Imaging & Diagnostics

Spinal Trauma Imaging Approach to Diagnosis Part II

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Hyperextension Injury

  • Hangman’s Fx aka traumatic spondylolisthesis of C2 with a fracture of pars interarticularis or pedicles (unstable)
  • MVA is the most common cause
  • Mechanism: acute hyperextension of upper C/S similar to judicial hanging (never actually seen and most deaths are due to asphyxiation)
  • Secondary flexion may tear PLL and disc
  • Associated injuries: 30% have other c-spine fx especially Extension teardrop at C2 or C3 due to avulsion by ALL
  • Cord paralysis may only present in 25% due to bony fragments dissociation and canal widening
  • Hangman fx and extension teardrop
  • Cervical degeneration and previous fusion is a key predisposing factor due to the lack of mobility and suppleness, rendering C/S easy to fracture
  • Imaging: initial x-radiography then CT that helps to delineate another injury such as facet/pedicle Fx further. MRI may help if complicated by Vertebral A. damage
  • Management: if type 1 injury then closed reduction and rigid collar for 4-6 weeks, halo bracing if type 2 (>3-5mm displacement) Fx/instability, anterior or posterior spinal fusion at C2-3 if type 3 Fx (>5-mm displacement)
  • Extension teardrop Fx (stable) potentially unstable if put in extension
  • Avulsion of an inferior anterior body by ALL. More seen in elderly with superimposed C/S spondylosis
  • Key radiography: a smaller anterior-inferior body corner, no disruption of ligamentous alignment. Typically at C2 or C3 due to sudden hyperextension and ALL avulsion
  • Complication: central cord syndrome (m/c incomplete cord injury) esp. in superimposed spondylosis and canal stenosis by the laxity of ligamentum flavum and osteophytes
  • Management: hard collar isolation

Vertical (axial) Compression Injury

  • Jefferson Fx (named after British neurosurgeon who defined it) (unstable but neurologically intact Fx) 7% of all C/S injuries. Stability is dependent if the transverse ligament is intact or torn, which can be noted by overhanging of C1 lateral masses over C2 >5-mm combined (left image)
  • Mechanism: C1 compression (e.g., diving into shallow waters) causing burst Fx-classically 4-parts of the anterior and posterior arch of C1. Variations exist.
  • Complications: 50% show other C/S Fx, 40% show Odontoid C2 Fx esp. if extension and axial loading occur
  • Imaging: x-radiography followed by CT scanning to evaluate subaxial injury and complexity of C1 injury. Note Jefferson Fx with pillar and transverse foramina fx requiring posterior occipital-cervical fusion (below right image).
  • Management: rigid collar immobilization if the transverse ligament is intact. Halo brace or fusion if the transverse ligament is ruptured

Cervical Injuries With Variable Mechanisms of Trauma

  • Odontoid process fractures:
  • These occur with a variety of mechanisms, flexion, extension, lateral flexion. Elderly with superimposed spondylosis are at higher risk.
  • Anderson & D’Alonzo classification (below). Type 2 is the most common and most unstable. Type 3 has the best chance of healing d/t more massive bleed into C2 body and better healing potential.
  • Imaging: x-radiography can miss some Fx. CT scanning is essential.
  • On x-radiography note tilting of the Dens on lateral and APOM views. CT will reveal the injury and classify it.
  • Complications: cord injury, non-union
  • CT scanning: type 2 odontoid fracture (unstable)
  • Management: type 1 (alar ligament avulsion) most stable observed and treated with rigid collar.
  • In young patients, Halo brace is used to treat type 2
  • Older patients do not tolerate Halo
  • Operative C1-2 fusion if unstable is Dx and cord signs or other complicating factors are present

Normal Radiographic Variants & Anomalies Simulating Pathology

  • Pediatric spine appears different especially in children younger than 10-years old.
  • Normal variations; ADI 5-mm and may increase or decrease on flexed/extended views by 1-2-mm
  • C2-3 may appear as pseudo-subluxation due to normal ligamentous laxity in children (below arrow)
  • Pediatric vertebral bodies usually are narrower and anteriorly wedged due to the presence of cartilaginous tissue
  • APOM view appears different in children, and some asymmetry of C1 articular masses is normal (below top image) and should not be confused with Jefferson Fx
  • In adults, any asymmetry or “overhanging” of C1 articular masses is pathological and may indicate Jefferson fx
  • Standard ossification centers of the Atlas synchondrosis in children should not be mistaken for fractures
  • Persistent ossiculum terminal of Bergman is a typical variant/anomaly of tenacious un-united ossification center and should not be confused with type odontoid fx
  • Os odontoideum
  • Un-united growth center that currently considered as an un-noticed injury that disturbed normal growth in a child younger than 5-years-old
  • It may be a cause of C1-2 instability and should be evaluated with flexed and extended cervical views
  • Should not be confused with type 2 Dens fracture because it typically more demonstrates greater mineralization of bone
  • Incomplete bilateral agenesis of the C1 posterior arch
  • Anomalous closure of C1 posterior arch
  • Should not be confused with a fracture
  • However, local or cord symptoms may develop after trauma in some cases
  • Relatively rare anomaly developing due to failed chondrogenesis and ossification of posterior ossification centers of the Atlas
  • Patients with Down syndrome may suffer from increased ligamentous laxity and other abnormalities
  • Increased risk of subluxation at C1-2
  • Burst Fx (unstable) 2-columns are damaged
  • Mechanism: axial loading with frequent flexion after falls and MVAs
  • The thoracolumbar region is the most vulnerable due to the increased fulcrum of motion
  • Key radiography: acute compression fracture and collapse of body height, retropulsion of posterior body and acute kyphotic deformity on the lateral view
  • On the frontal view: interpedicular widening (below yellow arrow), regional soft tissue swelling (below green arrow)
  • Imaging: x-radiography should be followed by CT scanning w/o contrast
  • MRI if neurologically unstable due to cord or conus injury
  • Complications: cord damage by acutely retropulsed bone fragments
  • Management: non-operative if neurologically intact and <50% body retropulsed with minimal kyphosis
  • Operative (fusion) if 50% or more body retropulsed, laminar/pedicle Fx, neuro compromised

18-Year Old Female Following Trampoline Accident

  • AP & lateral L/S views
  • Note acute compression fracture, a vertebral body extending to posterior elements
  • Widening of the inter-spinous distance between T11-T12 (below arrow)
  • Radiolucent fracture line is seen through the T12 body on the AP projection
  • CT scanning was performed
  • Sagittal reconstructed Thoracic and Lumbar CT slices in bone window
  • Note acute compression fracture, the T12 body extending into pedicle and lamin
  • Dx: Chance fracture of T12
  • MR imaging was performed
  • T2 Wl sagittal MRI
  • Findings: acute compression fracture T12 body extending to posterior elements causing rapture of interspinous and flavum ligaments
  • Mild compression of the distal cord above the conus is noted with a minimal signal abnormality
  • Dx: Chance fracture
  • Chance Fx aka (Seatbelt Fx) – is a flexion-distraction injury (unstable)
  • M/C in lower thoracic-upper lumbar
  • All 3-columns fail: column 3 torn by distraction, columns 1 and 2 fail on compression (Denis classification)
  • Causes: MVA, falls
  • Imaging: initial x-radiography should be followed by CT scanning w/o contrast to assess bone fragments retropulsion/canal compression. MRI may help to evaluate potential cord damage and ligaments tearing
  • Management: non-operative immobilization if neuro intact
  • Operative decompression and fusion

Spinal Trauma Imaging Approach

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