Atls C Spine

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C-Spine Injury

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Atls C Spine

  1. 1. C-Spine Injury Radiology Challenge
  2. 2. Adequacy <ul><li>Skull base </li></ul><ul><li>C1-C7 </li></ul><ul><li>Upper T1 </li></ul>
  3. 3. Alignment <ul><li>Anterior spinal line </li></ul><ul><li>Posterior spinal line </li></ul><ul><li>Spinolaminal line </li></ul><ul><li>Spinous process tips </li></ul>
  4. 4. Bones <ul><li>Anterior components </li></ul><ul><ul><li>Vertebral body (cortices, endplates) </li></ul></ul><ul><ul><li>Transverse process </li></ul></ul><ul><li>Posterior components </li></ul><ul><ul><li>Articular masses and pedicles </li></ul></ul><ul><ul><li>Facet joints </li></ul></ul><ul><ul><li>Lamina </li></ul></ul><ul><ul><li>Spinous process </li></ul></ul>
  5. 5. Cartilage <ul><li>Intervertebral discs </li></ul><ul><li>Epiphyses (childhood) </li></ul><ul><ul><li>Subdental synchondrosis </li></ul></ul><ul><li>Ossification centers (childhood) </li></ul><ul><ul><li>Tapered anterior vertebrae </li></ul></ul><ul><ul><li>Absent C1 anterior ring </li></ul></ul>
  6. 6. Soft Tissue <ul><li>Cervicocranial </li></ul><ul><ul><li>Pd : Adenoid hypertrophy </li></ul></ul><ul><li>Predental </li></ul><ul><ul><li>Ad : < 3mm </li></ul></ul><ul><ul><li>Pd : < 5mm </li></ul></ul><ul><li>Prevertebral </li></ul><ul><ul><li>Ad : C3 < 5-7mm; C5 < 15-21mm (1 body) </li></ul></ul><ul><ul><li>Pd : C3 < 7mm; C5 < 14mm (2/3 body) </li></ul></ul>
  7. 7. Mechanism of Injury <ul><li>Types of c-spine injuries </li></ul><ul><ul><li>Axial loading </li></ul></ul><ul><ul><li>Flexion </li></ul></ul><ul><ul><li>Extension </li></ul></ul><ul><ul><li>Rotation </li></ul></ul><ul><ul><li>Lateral bending </li></ul></ul><ul><ul><li>Distraction. </li></ul></ul>
  8. 8. Jefferson fracture (C1) <ul><li>Blowout of the ring </li></ul><ul><li>Axial loading </li></ul><ul><li>Open-mouth (odontoid) view </li></ul><ul><li>1/3 associated with C-2 fracture </li></ul><ul><li>Unstable </li></ul><ul><li>Usually not associated with cord injury </li></ul><ul><li>Lateral offset of C1 lateral masses > 1mm from C2 vertebral body </li></ul>
  9. 9. Pseudo-Jefferson fracture <ul><li>Age < 4Y </li></ul><ul><li>90% (+) at 2 Y </li></ul><ul><li>C1 growth > C2; radiolucent cartilage </li></ul><ul><li>Normalizes by 4-6 Y </li></ul><ul><li>CT scan needed </li></ul>
  10. 10. C-1 Rotary Subluxation <ul><li>Odontoid not equidistant from lateral masses </li></ul><ul><li>Children </li></ul><ul><li>Torticolis (chin toward uninvolved side) </li></ul><ul><li>Immobilize in place </li></ul><ul><li>Consult NS </li></ul>
  11. 11. C-2 Odontoid Subluxation <ul><li>Ruptured transverse ligament </li></ul><ul><li>Odontoid fractures </li></ul><ul><li>Predental space : </li></ul><ul><ul><li>Ad > 3mm </li></ul></ul><ul><ul><li>Pd > 5mm (symptomatic if > 7-10mm) </li></ul></ul><ul><li>C1 spinal canal (Steel rule of 3) : </li></ul><ul><ul><li>Odontoid – Free space – Cord </li></ul></ul><ul><li>Unstable </li></ul>
  12. 12. C2 Odontoid Fractures <ul><li>Type I : Avulsion of tip </li></ul><ul><ul><li>Stable </li></ul></ul><ul><li>Type II : At the base </li></ul><ul><ul><li>Unstable </li></ul></ul><ul><ul><li>D/D : Synchondrosis if < 6Y </li></ul></ul><ul><li>Type III : Through vertebral body </li></ul><ul><ul><li>Unstable </li></ul></ul>
  13. 13. Hangman Fracture <ul><li>Traumatic spondylolisthesis of C2 </li></ul><ul><li>Mechanism : </li></ul><ul><ul><li>Extension + Distraction </li></ul></ul><ul><ul><li>Extension + Axial compression </li></ul></ul><ul><li>X-ray : C2/3 subluxation </li></ul><ul><li>Unstable </li></ul><ul><li>Traction contraindicated </li></ul>
  14. 14. C2/3 Subluxation <ul><li>C2 posterior spinal line v.s. Swischuk line </li></ul><ul><li>Pseudosubluxation (< 8-16Y) : </li></ul><ul><ul><li>Displacement < 1.5-2 mm </li></ul></ul><ul><li>Hangman fracture : </li></ul><ul><ul><li>Displacement > 1.5-2 mm </li></ul></ul>
  15. 15. Unstable Fractures <ul><li>Overriding of vertebra by > 3 mm </li></ul><ul><li>Angulation > 11 degrees </li></ul><ul><li>Flexion teardrop </li></ul><ul><li>Bilateral facet dislocation (BFD) </li></ul><ul><li>Atlanto-occipital dislocation </li></ul><ul><li>Atlanto-axial dislocation (flexion/extension/rotary) </li></ul><ul><li>Odontoid fracture </li></ul><ul><li>Jefferson fracture/posterior arch fracture of C1 </li></ul><ul><li>Hangman fracture </li></ul>
  16. 16. Stable Fractures <ul><li>Wedge fracture </li></ul><ul><li>Clay shoveler fracture </li></ul><ul><li>Transverse process fracture </li></ul><ul><li>Unilateral facet dislocation (UFD) </li></ul><ul><li>Burst vertebral body </li></ul><ul><li>Isolated fracture of articular pillar </li></ul><ul><li>Extension teardrop in flexion </li></ul>
  17. 17. Subluxation <ul><li>Angulation between two adjoining vertebrae > 11 degrees </li></ul><ul><li>Overriding of vertebra by > 3 mm </li></ul>
  18. 18. Facet Dislocation <ul><li>Unilateral (UFD) : </li></ul><ul><ul><li>Stable </li></ul></ul><ul><ul><li>< 25% translation </li></ul></ul><ul><li>Bilateral (BFD) : </li></ul><ul><ul><li>Unstable </li></ul></ul><ul><ul><li>> 50% translation </li></ul></ul>
  19. 19. Teardrop Fractures <ul><li>Extension teardrop : </li></ul><ul><ul><li>Stable in flexion, unstable in extension </li></ul></ul><ul><ul><li>Cortices : Same length </li></ul></ul><ul><li>Flexion teardrop : </li></ul><ul><ul><li>Extremely unstable </li></ul></ul><ul><ul><li>Cortices : Unequal length </li></ul></ul>
  20. 20. Hyperextension Injury <ul><li>Fracture of inferior endplate, being avulsed by the Sharpey fibers </li></ul><ul><li>Extension teardrop </li></ul><ul><li>Bilateral facet dislocation (BFD) </li></ul><ul><li>Severe prevertebral soft tissue swelling </li></ul><ul><li>Anteriorly displaced NG tube </li></ul>
  21. 21. Burst Vertebral Body <ul><li>Mechanically stable </li></ul><ul><li>Spinal cord injury can occur (even total transection) </li></ul>
  22. 22. Distraction Injuries <ul><li>Longitudinal stress (e.g. difficult delivery) </li></ul><ul><li>Atlanto-occipital dislocation </li></ul><ul><ul><li>Increased space between occiput and C1 </li></ul></ul><ul><li>Widening of IV disk without adjacent compression fracture </li></ul><ul><li>MRI </li></ul>
  23. 23. Spinal EDH <ul><li>Venous bleeds </li></ul><ul><li>Minor traumas </li></ul><ul><li>Ascending neurologic symptoms </li></ul><ul><li>Hours or days </li></ul><ul><li>MRI </li></ul>
  24. 24. SCIWORA <ul><li>67% of pediatric SCI </li></ul><ul><li>Mainly < 8 Y </li></ul><ul><li>Plain films/tomograms/CT (-) </li></ul><ul><li>May have transient neurologic symptoms and apparently recover then return 1d later with significant neurologic abnormalities </li></ul><ul><li>Poor prognosis </li></ul>
  25. 25. SCIWORA <ul><li>Etiology : </li></ul><ul><ul><li>Vascular injuries (occlusion, spasm, infarction) </li></ul></ul><ul><ul><li>Ligamentous injury </li></ul></ul><ul><ul><li>Disc impingement </li></ul></ul><ul><ul><li>Incomplete neuronal destruction </li></ul></ul>
  26. 26. Oblique C-spine <ul><li>Pedicles </li></ul><ul><li>Articular mass </li></ul><ul><li>Intervertebral foramen </li></ul><ul><li>Transverse process </li></ul><ul><li>Laminae - aligned in the fashion of shingles </li></ul>

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