Imaging & Diagnostics

Spinal Trauma Imaging Approach to Diagnosis Part I

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Imaging Diagnosis Management:

  • Cervical spinal trauma & radiographic variants simulating disease
  • Cervical spine
  • Arthritis
  • Neoplasms
  • Infection
  • Post-Surgical cervical spine
  • Cranio-cervical and upper cervical stability is dependent on transverse, superior and inferior bands of the C1-C2 ligament, alar ligaments, along with a few other ligaments

Cervical Trauma

  • The C/S is vulnerable to injury. Why?
  • Stability has been sacrificed for greater mobility
  • Cervical vertebrae are small and interrupted by multiple foraminae
  • The head is disproportionately heavy and acts as an abnormal lever especially when forces act against a rigid torso
  • Additionally, C/S is prone to degeneration which makes it more vulnerable to trauma
  • In young children, ligaments are more luxed vs. disproportionately large head size
  • In children, the fulcrum of movement is at C2/3 thus making injuries more common in the upper C/S and craniocervical junction. In children, S.C.I.W.O.R.A. may occur when no evidence of fracture present
  • In adults, the fulcrum of movement is at C5/6 thus making lower C/S more vulnerable to trauma especially during extremes of flexion
  • Cervical Trauma categorized according to mechanisms of injury (Harris & Mirvis classification)

Hyperflexion Injury: Stable vs. Unstable

  • Flexion teardrop Fx (most severe fracture, unstable)
  • Bilateral facet dislocation (severe injury w/o fracture, unstable)
  • Anterior subluxation (potentially unstable) can be very subtle injury
  • Clay Shoveller Fx (lower C/S SP avulsion, stable)
  • Simple wedge compression (most benign Fx, stable)
  • Hyperflexion-rotation with unilateral facet dislocation
  • Obtain a thorough history
  • Perform physical exam including a neurological exam
  • Consider NEXUS criteria (National Emergency X-radiography Utilization Study)

Imaging Techniques:

  • Begins with x-radiography especially in cases with no significant neurological compromise
  • Clear neutral lateral view first
  • If x-radiography is unrewarding but high probability of severe trauma and neurological deficit present, CT scanning w/o contrast is required
  • Consider CT scanning in patients with pre-existing changes: advance spondylosis, DISH, AS, RA, post-surgical spine, congenital abnormalities (Klippel-Feil syndrome, etc.)

Vertical compression:

  • Jefferson aka burst Atlas Fx (unstable especially if the Transverse ligament is torn, cord paralysis in 20-30% only)
  • Why? Due to fragments dissociation and canal widening
  • Burst Fx of the Thoracic or Lumbar spine (unstable, cord paralysis may occur)

How to Assess Spinal Radiographs in Trauma Cases:

  • Construct 5-lines on the lateral view
  • Note if facets are well-aligned and symmetrical
  • Ensure symmetry of the disc height
  • Note any widening or fanning of the inter-spinous distance
  • Carefully examine prevertebral soft tissues
  • Evaluate atlanto-dental interval (ADI)
  • In cases of trauma, evaluate and clear neutral lateral first
  • Do not perform flexed and extended views in acute cases before x-rays or CT scanning exclude significant instability
  • Pay extra attention to prevertebral soft tissues
  • If thicker than normal limits, consider severe post-traumatic bleed
  • Subtle asymmetry and widening of posterior disc height and facets with inter-spinous fanning may be a key feature of significant tearing of posterior ligaments

Hyperflexion Injuries (M/C Mechanism)

  • More frequent in sub-axial C/S C-3-C7)
  • Unstable injuries:
  • Flexion teardrop fracture (M/C C5 & C6) v. unstable
  • Key rad features:
  • Large โ€œteardropโ€ triangular anterior body fragment
  • Fanning of the SPs, posterior disc and facet widening indicating tearing of major spinal ligaments and instability
  • A posterior shift of the vertebral body fracture suggests direct anterior cord/vessels compression
  • Bulging prevertebral soft tissue >20-mm at C6-7
  • 80% of cases may be paralyzed on the spot or develop significant paralysis soon after

Acute Neck Trauma. What are the vital radiographic features? What is the diagnosis?

  • CT scanning w/o contrasts with sagittal reconstruction. Note C7 Flexion teardrop Fx.
  • CT may help with further delineation and preoperative planning
  • May follow with MR imaging and evaluation of the neurological injury
  • Fluid sensitive (T2) sagittal MRI slice of Flexion teardrop fracture at C4 and possibly C5
  • Note high signal intensity lesion in the cord and surrounding ligaments indicating cord edema and ischemia
  • Management: neurosurgical with spinal fusion
  • Complications:
  • Quadriplegia/paraplegia
  • Respiratory complications
  • Disability, changes in the quality of life
  • Decreased life expectancy
  • Bilateral facet dislocation (unstable)
  • Mechanism: Flexion-distraction injury
  • Key radiography: anteriorly displaced body 50% or more
  • Facets override and locked (can be perched left image)
  • Major tearing of ligaments
  • Chances of severe cord compression and paralysis
  • Patients with ligaments laxity and degenerative changes are at higher risk
  • Initial x-radiography is the first step

CT scanning w/o Contrast is Crucial:

  • Further delineation of this injury
  • Facet fractures, pedicle fracture
  • Management planning

Sagittal fluid sensitive MRI of bilateral C5 facet dislocation, large ischemic cord injury and posterior soft tissue injuries

  • Management:
  • X-radiography, then CT scanning then immediate closed reduction (esp. if the patient is conscious)
  • Followed in some more complicated cases by MRI and then surgical care
  • If the patient is awake and neurologically stable, CT and closed reduction are adequate
  • Complicated cases and failed closed reduction may require surgical stabilization
  • Complications: spinal cord injury and paralysis
  • Delayed ligamentous laxity and instability
  • Unilateral facet dislocation (flexion-rotation injury) less severe than bilateral dislocation
  • Most commonly missed unstable cervical injury on x-radiography
  • Key rad features: body anteriorly translated 25% facets appear misaligned and blurred, SPs rotated on frontal views
  • Clinically may be presented as one-sided radiculopathy esp. C6 or C7
  • CT scanning is required to evaluate further facet/pedicle fractures
  • Pre-reduction evaluation and care planning
  • Management: closed reduction esp. in a conscious patient
  • Complications: acute disc herniation/retropulsion, ligamentous laxity, neurological injury

Spinal Trauma Imaging Approach

Resources:

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The information herein on "Spinal Trauma Imaging Approach to Diagnosis Part I" is not intended to replace a one-on-one relationship with a qualified health care professional or licensed physician and is not medical advice. We encourage you to make healthcare decisions based on your research and partnership with a qualified healthcare professional.

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