Cervical spine fractures muhamma
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Cervical spine fractures muhamma

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  • displaced C2C2-3 Bilateral interfacet dislocationSevere instability
  • It also may be associated with the central cord syndrome due to buckling of the ligamenta flava into spinal canal during the hyperextension phase of injury
  • The CT confirms the displaced anteroinferior bony fragment. This fragment is a true avulsion, in contrast to the flexion teardrop fracture in which the fragment is produced by compression of the anterior vertebral aspect due to hyperflexion.
  • V can c the displacement of lateral masses of c1
  •    Soft tissue swelling can be recognized by an increase in the prevertebral soft tissue of greater than ½ the AP diameter of the C3 vertebral body at C3 or greater than the full AP diameter of the cervical vertebral body at C6
  • Frequent in children due to the relatively large head-to-spine ratio.
  • Type 2 poor healing cuz fracture is above the accessory ligament and vascular supply
  • AVULSION OF TIP OF DENS
  • racture through the base of the dens.Prevertebral soft tissue swelling.Rupture of C1C2 interspinous ligamentNo visualisation of lower C-spine
  • Ap view show ghost sign with 2 spinous processes ???

Cervical spine fractures muhamma Cervical spine fractures muhamma Presentation Transcript

  • Cervical Anatomy  Biomechanically Specialized  Support of “large” Cranial mass  Large range of motion ○ Flexion/extension ○ Axial rotation  Unique osteological characteristics
  • C1 - Atlas No body  2 articular pillars   Flat articular surface  Vertebral artery foramen  2 arches  Anterior  Posterior ○ Vertebral artery groove
  • C2 Anatomy  Dens  Embriological C1 body  Base poorly vascularized  Osteoporotic   Flat C1-2 joints Vertebral artery foramena  Inferomedial to superolateral
  • Anatomy – The Ligaments   Allow for the wide ROM of upper C-spine while maintaining stability Classified according to location with respect to vertebral canal  Internal: ○ Tectorial membrane ○ Cruciate ligament – including transverse ligament ○ Alar and apical ligaments  External ○ Anterior and posterior atlanto-occipital membranes ○ Anterior and posterior atlanto-axial membranes ○ Articular capsules and ligamentum nuchae
  • AtlantoAxial Anatomy Tectorial Membrane
  • AtlantoAxial Anatomy Tranverse Ligament occiput C1-C2 joint C1 C2 Alar Ligament
  • AtlantoAxial Anatomy Facet for Occipital Condyle Transverse Ligament
  • AtlantoAxial Anatomy Vertebral Artery
  • APPROACH TO C-SPINE INJURIES  Following trauma or complaint of neck pain  Obtain lateral  AP, and  odontoid views  The lateral view is only adequate if T1 can be visualized  If there is any doubt of fracture or prevertebral swelling , obtain oblique views and consider CT All patients with sign/symptoms of cord injury require MRI 
  • Cervical Views Odontoid AP
  • Swimmer’s View
  • LATERAL VIEW      1. Anterior vertebral line (anterior margin of vertebral bodies) 2. Posterior vertebral line (posterior margin of vertebral bodies) 3.Articular pillar (where superior and inferior articular processes of cervical vertebrae have fused on either or both sides) 4. Spinolaminar line (posterior margin of spinal canal) 5. Posterior spinous line (tips of the spinous processes)
  • C1-C2  Predental space (distance between posterior aspect of anterior arch of C1 and anterior aspect of odontoid process )  should be< 3mm In adult and less <5mm in children Or less  ring sign of C2
  • C3-C7  Anterior spinal, posterior spinal and spinolaminar lines: should be smooth lines  Disc Spaces should be approximately same anterior narrowing = flexion injury. Widening = extension injury  Facet joints should be parallel Interspinous distance should decrease from C3 to C7  Transverse process of C7 points downward and T1 UPWARDS  INTERVERT EBRAL DISC SPACE S
  •  Prevertebral Soft Tissue  Nasopharyngeal space (C1) - 10 mm (adult)  Retropharyngeal spaceC 2-C4 ( between posterior pharyngeal wall and anterior border of vertebrae). 10m m  5mm Retro tracheal space C5-7 (space between posterior tracheal wall and anterior inferior body C6 ) c3-4 5mm from vertebral body is normal C4-7 20mm from vertebral body is normal 22mm
  • AP View  The height of the cervical vertebral bodies should be approximately equal  The height of each joint space should be roughly equal at all levels.  Spinous process should be in midline and in good alignment.
  • Odontoid View An adequate film should include the entire odontoid and the lateral borders of C1-C2. Occipital condyles should line up with the lateral masses and superior articular facet of C1. The distance from the dens to the lateral masses of C1 should be equal bilaterally. The tips of lateral mass of C1 should line up with the lateral margins of the superior articular facet of C2. The odontoid should have uninterrupted cortical margins blending with the body of C2.
  • Classification of Fractures of c-spine  HYPERFLEXION INJURIES        Hyper extention injuries       Hangman fracture Extention teardrop fracture laminar fracture Pillar fracture Posterior arch of c1 fracture FRACTURE DUE TO AXIAL LOADING    Flexion teardrop fracture Hyper flexion Strain Wedge Compression fracture Bilateral facet Lock Unilateral facet dislocation Clay-shoveler’s fracture Jefferson fracture Burst fracture OTHER INJURIES   Odontoid fracture Rotational Injuries
  • Hyperflexion  Distraction creates tensile forces in posterior column  Can result in compression of body (anterior column)  Most commonly results from MVC and falls
  • Compression  Result from axial loading  Commonly from diving, football, MVA  Injury pattern depends on initial head position  May create burst, wedge or compression fx’s
  • Hyperextension  Impaction of posterior arches and facet compression causing many types of fx’s ○ lamina ○ spinous processes ○ pedicles  With distraction get disruption of ALL  Evaluate carefully for stability  LOOK FOR CENTRAL CORD SYNDROME
  • Types of Injuries
  • Flexion Teardrop Fracture C5-6 fracture is the result of a combination of flexion and compression ,most commonly at C5-6  The teardrop fragment comes from the anteroinferior aspect of the vertebral body. The larger posterior part of the vertebral body is displaced backward into the spinal canal.  Best seen on lateral view  It is an completely unstable fracture associated with complete disruption of ligaments and anterior cord syndrome and quadriplegia  70% of patients have neurologic deficit.  common in MOTOR VECHICLE ACCIDENT 
  • Signs: Prevertebral swelling associated with anterior longitudinal ligament tear. Teardrop fragment from anterior vertebral body avulsion fracture. Posterior vertebral body subluxation into the spinal canal. Spinal cord compression from vertebral body displacement. Fracture of the spinous process.
  • Fracture of the spinous process of C4 Fracture of the body of c5 with a small fragment anteriorly Acute angulation at the level of C5C6 with displacement of C5 in posterior direction
  • Wedge fracture  Compression fracture resulting from flexion. Flexion compression injury  Best seen on lateral view  Stable  Common in  Elderly patients with osteoporosis or osteogenesis imperfecta 
  • Wedge shape vertebra Antersuperio r body fracture
  • Hangman’s Fracture C-2  Fx through the pars interarticularis of C2 secondary to hyperextension  Best seen on lateral view Hyperextention injury Stable fracture ?  
  •   The most common scenario would be  frontal motor vehicle(hitting dash board)  Hanging  falls,  diving injuries  contact sports. Neurological involvement is rare
  •  Classification of Hangman' s fractures  Type I (65%)  hair-line fracture  C2-3 disc normal Type II (28%)  displaced C2  disrupted C2-3 disc  ligamentous rupture with instability  C3 anterosuperior compression fracture Type III (7%)  displaced C2  C2-3 Bilateral interfacet dislocation  Severe instability  
  • TYPE 1 HANGMAN FRACTURE There is a hair-line fracture and there is no displacement. C23 NORMAL
  •  HANGMAN FRACTURE TYPE 3 Prevertebral soft tissue swelling Anterior dislocation of the C2 vertebral body BILATRAL C2 pars interarticularis fractures.
  •  The CT-images confirm the fracture-lines of the hangman's fracture. They run through the pars interarticularis resulting in a traumatic spondylolysis. In this case there was no neurologic deficit, because the spinal canal is widened at the level of the fracture.
  • Extention tear drop fracture AVULSION FRACTURE of anterio inferior content of the axis resulting from hyperextention  This injury is    stable in flexion but highly unstable in extension. common in diving accidents  It also may be associated with the central cord syndrome . 
  • bony fragment. This fragment is a true avulsion, in contrast to the flexion teardrop fracture in which the fragment is produced by compression of the anterior vertebral aspect due to hyperflexion.
  • Jefferson Fracture C-1 Fracture is caused by a compressive downward force that is transmitted evenly through the occipital condyles to the superior articular surfaces of the lateral masses of C1. This process displaces the masses laterally and causes fractures of the anterior and posterior arches, along with possible disruption of the transverse ligament. • • • • Best seen on odontoid view Unstable fracture Fracture due to AXIAL LOADING frequently associated with • diving into shallow water(axial • • blow to the vertex of the head ) impact against the roof of a vehicle fall from playground equipments
  • SIGNS ON XRAY: Displacement of the lateral masses of vertebrae C1 beyond the margins of the body of vertebra C2. <2mm bilateral is always abnormal <1-2 mm or unilateral displacement can be due to head rotation
  • CT is required to 1. define the extent of fracture 2. detecting fragment in spinal cord
  • BURST FRACTURE C3-7       Same mechanism as jefferson fracture i.e axial compression but Located at c3-7 Stable fracture The intervertebral disc is driven into the vertebral body below. Posterior fragments dislocation common Require ct for fracture evaluation and bone fragment in spinal cord
  • Odontoid Fracture C2  Fracture of the odontoid (dens) of C2  3 categories, I-III  Best seen on open-mouth odontoid view or lateral radiograph result from blunt trauma to head leading to cervical hyperflexion or hyperextension Unstable fracture Occur in both elderly and young patients 75% cases are children    
  • Classification Type I: Avulsion of the tip of the dens where it is attached to C1. This is a rare fracture. It is potentially stable.? Type II: Through the base of the dens. Most common fracture. Always unstable and poor healing. Type III: Fracture through the body of the axis and sometimes facets. Can be unstable, but has a better prognosis than type II due to better healing of the fracture which runs through the metaphyseal body of C-2
  • Type 1 odontoid fracture
  • Type II
  • Type III
  • CT IMAGE
  • DENS Dens
  • The image through the lateral part of C2 nicely shows, that the fracture runs through the body of C2, i.e. a type III odontoid fracture. The posterior dura is in a normal position, but the anterior dura is displaced (arrow).
  • Showing Central location of spinal cord injury
  • Clay Shoveler’s Fracture Oblique avulsion fracture of a spinous process C6-T1  C7>C6>T1         Best seen on lateral view Powerful Hyperflexion injury(shoveling) Stable fracture Common in motor vehicle accidents sudden muscle contraction direct blows to the spine
  • Ap view show ghost sign with 2 spinous processes ???
  • Case 1 5 yo girl  Hit by car while riding bike  VSA at scene  Vitals recovered by EMS  Rose et al, Am J Surg 2003;185(4)
  • Atlanto-Occipital Dislocation     2.5 x more common in children than adults Due to small occipital condyles and horizontal atlanto-occipital joints Suspect if distance between occipital condyles and C1 is > 5mm at any point Usually have ++ soft tissue swelling
  • OccipitoAtlantal Dissociation (OAD) Commonly Fatal Present 6-20% of post mortem studies – Alker et al, 1978 – Bucholz & Burkhead,1979 – Adams et al, 1992 50% missed injury rate 1/3 Neurological Worsening – Davis et al, 1993
  • OccipitoAtlantal Dissociation (OAD) Symptoms/Findings – Wallenberg Syndrome Lower Cranial nerve deficits Horner’s syndrome Cerebellar ataxia Cruciate paralysis Contralateral loss of pain and temperature
  • Radiographic Lines Powers’ Ratio  BC/OA  >1 considered abnormal    Limited Usefulness Positive only in Anterior Translational injuries False Negative with pure distraction Powers et al, Neurosurg, 1979
  • QUESTIONS
  • REFERRENCES Text Book of Radiology and imaging (DAVID SUTTON)  Primer of Diagnostic Imaging  Radiology Review Manual(Dahnert) 
  • Thank You!