Project: Ghana Emergency Medicine Collaborative
Document Title: The Role of Radiography in the Initial Evaluation of C-Spi...
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“The role of radiography in the
initial evaluation of C-Spine
Trauma”
Stephen Hartsell MD, FACEP
Director of Education
Div...
OBJECTIVES
§  Better understand normal radiographic anatomy
§  Standardized approach to reading c-spine
radiographs
§  ...
Normal Radiographic
Anatomy
5
Normal Lower Cervical Vertebra
6
Source Undetermined
ABCs of the C-Spine
§ Alignment, Adequacy
§ Bony Element
§ Cartilage Space, Connective Tissue
§ Soft Tissue
7
Cross Table Lateral View
Alignment/Adequacy
§  C7 –T1 thru post. F. Magnum
§  ALL & PLL
§  Spinolaminar Line
§  Tips o...
CTLV – Alignment
BDI, BAI <= 12mm
9
Source Undetermined
Pseudosubluxation C2
10
Source Undetermined
CTLV – Bony elements
Density & Symmetry
§  Ant. & post. Cortices body
§  Sup. & Inf. Endplates
§  Ring of C2
§  Transv...
Cartilage space and connective tissue
§  Intervertebral disc
§  Interfacetal joints
§  Interlaminal space
§  Interspin...
Soft Tissue
§  Retropharyngeal space
<= 6mm
§  Retrotracheal space
<= 22mm
§  Cervical esophagus at
C4-5
§  Absolute m...
Is This An
Adequate
CTLV ?
14
Source Undetermined
15
Source Undetermined
Anatomy of the cervicocranium
16
Source Undetermined
Odontoid view (open mouth)
Alignment
§  Odontoid process located between lat. masses of axis
§  Lateral margins of atlan...
Odontoid view w/ rotation
18
Source Undetermined
Odontoid view
Bony elements
§  Odontoid and artifacts
§  C1 lateral masses
§  C2 vertebral body
19
Source Undetermined
Odontoid view
Cartilage space
§  Interfacetal joints
20
Source Undetermined
A-P View
Alignment
§  Spinous processes midline
§  Tracheal air shadow
21
Source Undetermined
A-P View
Bony elements
§  Vertebral bodies
§  Sup. & Inf. Endplates
§  Uncinate processes
§  Articular masses
Lateral ...
A-P view
Cartilage space and connective tissue
§  Intervertebral disc space
§  Interspinous space
§  Joints of Luschka
...
Swimmer’s View
§  For evaluation of C7-T1
interface when CTLV is
inadequate
§  Posterior C7 not well visualized
§  Use ...
CSI by Mechanism
Hyperflexion
25
Hyperflexion Strain
§  Hyperkyphosis at level of injury
§  Ant. displacement Vertebral
Body > 2mm
§  Disruption post. L...
Hyperflexion Strain (cont)
27
Source Undetermined
Hyperflexion Strain (cont)
§  Soft Tissue Swelling may be only
evidence CSI.
§  Loss of cervical esophagus highly
suspic...
Hyperflexion Strain
MRI
§  Sagittal STIR image
§  Ruptured ALL
§  Ruptured PLL
§  Abnormal signal throughout
interspin...
Bilateral Facet Dislocation
§  Dislocation of bilat. facet joints
§  All ligamentous structures
disrupted
§  Ant. Displ...
Bilateral Facet Dislocation (cont)
31
Source Undetermined
Bilateral Facet Dislocation
CT
32
Source Undetermined
Flexion Teardrop Fracture
Marked prevertebral STS
Retropulsion of fragments
into spinal canal
Anterior Cord Syndrome
Quadr...
Hyperflexion with rotation
Unilateral Facet Dislocation
34
Unilateral Facet Dislocation
§  Ant. Subluxation of vertebral
body <= 25% AP diameter
§  Ant. Dislocation of one articul...
Unilateral Facet Dislocation (cont)
§  Dislocated Articular mass stuck in subjacent intervertebral
Foramina (locked)
§  ...
Unilateral Facet Dislocation (cont)
§  A-P view – spinous process
at level of dislocation
displaced towards
side of dislo...
Vertical Compression
38
Jefferson Fracture of C1
§  At least one Fracture through the ant. & post. Arch
§  Lateral expulsion of the lateral mass...
Jefferson Fracture C2 (cont)
§  Lat. displacement of C1 articular masses on odontoid view
§  Coronal CT reformations – d...
Jefferson Fracture (textbook)
Odontoid view and axial CT
41
Source Undetermined
Burst Fracture
Intrusion of NP into
vertebral body
Retropulsion fracture
fragments
Fracture on A-P view
42
Source Undeterm...
Hyperextension
43
Hangman’s Fracture
Traumatic Spondylolisthesis
§  Bilateral Pars Interarticularis Fx
§  Type I – III
§  Ant. Displaceme...
Hangman’s Fracture
45
Source Undetermined
Myelopathy and the
Cervicocranium
A-P diameter > at this level of the
C-spine
Auto decompression
46
Source Undetermined
Diverse Mechanisms
47
Odontoid Fracture
§  Hi (type II) Fracture
§  Soft Tissue Swelling
§  +/- Odontoid Displacement
§  Fracture at base of...
Odontoid Fracture
§  Low (Type III)
§  Disruption “ Ring of C2” on
CTLV
§  Fracture upper C2 vertebral
body
§  +/- pre...
NEXUS
National Emergency X-
Radiography Utilization Study
50
Validity Of A Set Of Clinical Criteria To
Rule Out Injury To The Cervical Spine In
Patients With Blunt Trauma
§  Hoffman ...
Patients considered Low Prob. Injury if :
Stable and met 5 Criteria
§  No Midline Cervical Tenderness
§  No Focal Neurol...
Performance of Clinical Criteria
§  818 patients (2.4%) x-ray documented
injury : missed 8
§  576 patients w/ clinically...
Conclusions
§  Confirms validity of a decision instrument
based on 5 clinical criteria for identifying
blunt trauma patie...
Sons of Nexus
§  Reliability of Standard 3- view series
§  Value of F/E views in acute blunt trauma
§  Distribution and...
Use of Plain Radiography to Screen for
Cervical Spine Injuries
§  Mower WR, et al. AnnEM. July 2001;38;1-7
§  34,069 pat...
Use of Plain Radiography (cont.)
35 missed CSI
§  3 ( 2 patients ) dx on MRI
§  8 ( 6 patients ) dx on Flex/Ext
§  29 (...
Use of Plain Radiography (cont.)
Conclusions
§  Standard 3-view reliable screen in most
blunt trauma patients.
§  On rar...
Use of Flexion-Extension Radiographs of
the Cervical Spine in Blunt Trauma
§  Pollack CV Jr,et al. AnnEMJuly2001;38:8-11
...
Use of Flex/Ext (cont.)
Conclusions
§  Largest prospective study; adds very little to
3-view supplemented when appropriat...
Distribution and Patterns of Blunt
Traumatic Cervical Spine Injury
§  Goldberg W,et al. Ann EM July
2001;38;17-21
§  34,...
Distributions and patterns (cont)
RESULTS
§  C2 most common site of fracture (23.9%)
§  C3 least likely to be injured
§...
Advanced Imaging
CT Scan
§  CT detects 97-100% of Fractures but
accuracy in detecting purely ligamentous
injury not docum...
Advanced Imaging
MRI
§  MRI highly sensitive in detection of
ligamentous injury but my be too sensitive
§  Much less sen...
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GEMC: The Role of Radiography in the Initial Evaluation of C-Spine Trauma

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This is a lecture by Dr. Stephen Hartsell from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.

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GEMC: The Role of Radiography in the Initial Evaluation of C-Spine Trauma

  1. 1. Project: Ghana Emergency Medicine Collaborative Document Title: The Role of Radiography in the Initial Evaluation of C-Spine Trauma Author(s): Stephen Hartsell (University of Utah), MD, FACEP 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1
  2. 2. Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2
  3. 3. “The role of radiography in the initial evaluation of C-Spine Trauma” Stephen Hartsell MD, FACEP Director of Education Division of Emergency Medicine University of Utah 3
  4. 4. OBJECTIVES §  Better understand normal radiographic anatomy §  Standardized approach to reading c-spine radiographs §  Review of common cervical spine injuries seen in the blunt trauma patient and their significance §  Discuss using NEXUS as a framework; who to x- ray, which studies needed to adequately screen for CSI and appropriate use of advanced imaging 4
  5. 5. Normal Radiographic Anatomy 5
  6. 6. Normal Lower Cervical Vertebra 6 Source Undetermined
  7. 7. ABCs of the C-Spine § Alignment, Adequacy § Bony Element § Cartilage Space, Connective Tissue § Soft Tissue 7
  8. 8. Cross Table Lateral View Alignment/Adequacy §  C7 –T1 thru post. F. Magnum §  ALL & PLL §  Spinolaminar Line §  Tips of Spinous Processes §  Predental Space <=3mm §  Basion Dental interval (BDI) §  Basion Axial Interval (BAI) 8 Source Undetermined
  9. 9. CTLV – Alignment BDI, BAI <= 12mm 9 Source Undetermined
  10. 10. Pseudosubluxation C2 10 Source Undetermined
  11. 11. CTLV – Bony elements Density & Symmetry §  Ant. & post. Cortices body §  Sup. & Inf. Endplates §  Ring of C2 §  Transverse processes §  Pedicles §  Articular Masses §  Sup. & Inf. Facets §  Laminae §  Spinous processes §  C1-2 and C5-7 11 Source Undetermined
  12. 12. Cartilage space and connective tissue §  Intervertebral disc §  Interfacetal joints §  Interlaminal space §  Interspinous space 12 Source Undetermined
  13. 13. Soft Tissue §  Retropharyngeal space <= 6mm §  Retrotracheal space <= 22mm §  Cervical esophagus at C4-5 §  Absolute measurement not reliable, sensitivity~5% lower C-spine 13 Source Undetermined
  14. 14. Is This An Adequate CTLV ? 14 Source Undetermined
  15. 15. 15 Source Undetermined
  16. 16. Anatomy of the cervicocranium 16 Source Undetermined
  17. 17. Odontoid view (open mouth) Alignment §  Odontoid process located between lat. masses of axis §  Lateral margins of atlanto-axial facet joints §  Bifid spinous process midline §  w/o tilt or rotation 17 Source Undetermined
  18. 18. Odontoid view w/ rotation 18 Source Undetermined
  19. 19. Odontoid view Bony elements §  Odontoid and artifacts §  C1 lateral masses §  C2 vertebral body 19 Source Undetermined
  20. 20. Odontoid view Cartilage space §  Interfacetal joints 20 Source Undetermined
  21. 21. A-P View Alignment §  Spinous processes midline §  Tracheal air shadow 21 Source Undetermined
  22. 22. A-P View Bony elements §  Vertebral bodies §  Sup. & Inf. Endplates §  Uncinate processes §  Articular masses Lateral columns 22 Source Undetermined
  23. 23. A-P view Cartilage space and connective tissue §  Intervertebral disc space §  Interspinous space §  Joints of Luschka 23 Source Undetermined
  24. 24. Swimmer’s View §  For evaluation of C7-T1 interface when CTLV is inadequate §  Posterior C7 not well visualized §  Use only when suspicion of injury is low 24 Source Undetermined
  25. 25. CSI by Mechanism Hyperflexion 25
  26. 26. Hyperflexion Strain §  Hyperkyphosis at level of injury §  Ant. displacement Vertebral Body > 2mm §  Disruption post. Ligamentous complex §  Interspinous & Interlaminal fanning §  Disc space widened post. And narrowed ant. 26 Source Undetermined
  27. 27. Hyperflexion Strain (cont) 27 Source Undetermined
  28. 28. Hyperflexion Strain (cont) §  Soft Tissue Swelling may be only evidence CSI. §  Loss of cervical esophagus highly suspicious of CSI §  Flexion film shows anterolisthesis C4 on C5 with upward and forward movement of inferior facet §  30% to 50% incidence delayed instability 28 Source Undetermined
  29. 29. Hyperflexion Strain MRI §  Sagittal STIR image §  Ruptured ALL §  Ruptured PLL §  Abnormal signal throughout interspinous and supraspinous ligaments 29 Source Undetermined
  30. 30. Bilateral Facet Dislocation §  Dislocation of bilat. facet joints §  All ligamentous structures disrupted §  Ant. Displacement => 50% A-P diameter subjacent vertebral body §  Purely soft tissue injury w/ pre - vertebral STS §  Unstable 30 Source Undetermined
  31. 31. Bilateral Facet Dislocation (cont) 31 Source Undetermined
  32. 32. Bilateral Facet Dislocation CT 32 Source Undetermined
  33. 33. Flexion Teardrop Fracture Marked prevertebral STS Retropulsion of fragments into spinal canal Anterior Cord Syndrome Quadriplegia loss pain, pinprick, temp preserve post. column (vib.,pressure, proprio) 33 Source Undetermined
  34. 34. Hyperflexion with rotation Unilateral Facet Dislocation 34
  35. 35. Unilateral Facet Dislocation §  Ant. Subluxation of vertebral body <= 25% AP diameter §  Ant. Dislocation of one articular mass inferior facet §  Rarely assoc. w/ neuro deficit of nerve root distribution §  Mechanically stable 35 Source Undetermined
  36. 36. Unilateral Facet Dislocation (cont) §  Dislocated Articular mass stuck in subjacent intervertebral Foramina (locked) §  Obliques to confirm site of dislocation 36 Source Undetermined
  37. 37. Unilateral Facet Dislocation (cont) §  A-P view – spinous process at level of dislocation displaced towards side of dislocation 37 Source Undetermined
  38. 38. Vertical Compression 38
  39. 39. Jefferson Fracture of C1 §  At least one Fracture through the ant. & post. Arch §  Lateral expulsion of the lateral masses of C1 §  TAL avulsion or rupture with increased AADI §  Retropharyngeal swelling 39 Source Undetermined
  40. 40. Jefferson Fracture C2 (cont) §  Lat. displacement of C1 articular masses on odontoid view §  Coronal CT reformations – disruption of occiputal-C1 articulation, displacement C1 lat. mass 40 Source Undetermined
  41. 41. Jefferson Fracture (textbook) Odontoid view and axial CT 41 Source Undetermined
  42. 42. Burst Fracture Intrusion of NP into vertebral body Retropulsion fracture fragments Fracture on A-P view 42 Source Undetermined
  43. 43. Hyperextension 43
  44. 44. Hangman’s Fracture Traumatic Spondylolisthesis §  Bilateral Pars Interarticularis Fx §  Type I – III §  Ant. Displacement C2 vertebral body §  Disruption intervertebral disc §  Dislocation C2-3 Facet Joints §  Displaced & angulated posterior arch §  STS §  Mechanically unstable 44 Source Undetermined
  45. 45. Hangman’s Fracture 45 Source Undetermined
  46. 46. Myelopathy and the Cervicocranium A-P diameter > at this level of the C-spine Auto decompression 46 Source Undetermined
  47. 47. Diverse Mechanisms 47
  48. 48. Odontoid Fracture §  Hi (type II) Fracture §  Soft Tissue Swelling §  +/- Odontoid Displacement §  Fracture at base of Odontoid §  Most common type §  Unstable, 26-36% nonunion 48 Source Undetermined
  49. 49. Odontoid Fracture §  Low (Type III) §  Disruption “ Ring of C2” on CTLV §  Fracture upper C2 vertebral body §  +/- prevertebral soft tissue swelling §  Unstable, better prognosis than Type II 49 Source Undetermined
  50. 50. NEXUS National Emergency X- Radiography Utilization Study 50
  51. 51. Validity Of A Set Of Clinical Criteria To Rule Out Injury To The Cervical Spine In Patients With Blunt Trauma §  Hoffman J., et al NEJM 2000;343:94-9 §  Prospective, Observational Multicenter Study §  34,069 patients w/ Blunt Trauma who underwent C-spine imaging §  Examined the performance of a set of 5 clinical criteria to identify patients who have a low probability of cervical spine injury 51
  52. 52. Patients considered Low Prob. Injury if : Stable and met 5 Criteria §  No Midline Cervical Tenderness §  No Focal Neurological Deficit §  Normal Alertness §  No Intoxication §  No Painful Distracting Injury 52
  53. 53. Performance of Clinical Criteria §  818 patients (2.4%) x-ray documented injury : missed 8 §  576 patients w/ clinically significant* injury : missed 2 §  Sensitivity 99.0, NPV 99.8; Specificity 12.9 PPV 2.7 §  Rate of missed CSI : 1 in 4000 patients §  * spinous, trans. process fx., wedge < 25%, osteophyte fx., type I odontoid, end-plate fx. 53
  54. 54. Conclusions §  Confirms validity of a decision instrument based on 5 clinical criteria for identifying blunt trauma patients who have extremely low probability of having CSI. §  Sensitivity ~ 100% for clinically significant injury §  Decrease in ordering of radiographs by 12.6% 54
  55. 55. Sons of Nexus §  Reliability of Standard 3- view series §  Value of F/E views in acute blunt trauma §  Distribution and Patterns of CSI 55
  56. 56. Use of Plain Radiography to Screen for Cervical Spine Injuries §  Mower WR, et al. AnnEM. July 2001;38;1-7 §  34,069 patients; 818 had total of 1,496 CSI (2.4%) §  Plain radiographs ; 932 CSI in 498 patients (1.4%) missed 564 CSI in 320 patients (.94%) §  Majority missed CSI; x-rays interpreted as abnormal but not dx or inadequate (.80%) §  23 patients (.07%) had 35 CSI (3 ? Unstable) not visualized on adequate plain films §  2.81% of all injured patients, 4.13% of 557 w/ adequate 3-view 56
  57. 57. Use of Plain Radiography (cont.) 35 missed CSI §  3 ( 2 patients ) dx on MRI §  8 ( 6 patients ) dx on Flex/Ext §  29 ( 18 patients ) dx on CT §  1 detected on risk management review §  Sensitivity adequate 3-view 89%, NPV 99% §  Lamina & Post. arch most common site §  C 6-7 (48%) most common level followed by C 2 (20%) 57
  58. 58. Use of Plain Radiography (cont.) Conclusions §  Standard 3-view reliable screen in most blunt trauma patients. §  On rare occasions will fail to detect unstable injuries. (.20% of injuries,.008% all patients) §  Difficult to obtain adequate plain radiographic imaging in a substantial # patients. ( 30%) 58
  59. 59. Use of Flexion-Extension Radiographs of the Cervical Spine in Blunt Trauma §  Pollack CV Jr,et al. AnnEMJuly2001;38:8-11 §  818 patients w/ CSI, F/E ordered in 86 §  6 patients w/ CSI not seen on 3-view,none clinically significant §  3 dislocations detected, all seen on 3-view §  15 of 16 subluxations detected, 4 missed on 3-view* 59
  60. 60. Use of Flex/Ext (cont.) Conclusions §  Largest prospective study; adds very little to 3-view supplemented when appropriate w/ CT, MRI. §  MRI preferable evaluate Lig. Instability §  CT better to evaluate for occult Fx. 60
  61. 61. Distribution and Patterns of Blunt Traumatic Cervical Spine Injury §  Goldberg W,et al. Ann EM July 2001;38;17-21 §  34,069 patients, 818 (2.4%) radiographic CSI §  1,195 Fractures & 231 Subluxations or dislocations 61
  62. 62. Distributions and patterns (cont) RESULTS §  C2 most common site of fracture (23.9%) §  C3 least likely to be injured §  C5-6 & C6-7 most common level of dislocation §  240 patients (29.3%) clinical insign. CSI §  32.3% patients > 50 years, had 45.3% of all atlantoaxial injuries 62
  63. 63. Advanced Imaging CT Scan §  CT detects 97-100% of Fractures but accuracy in detecting purely ligamentous injury not documented §  Limited in patients with severe degenerative disc disease §  Inability to detect axially oriented fractures, lig.injury and facet subluxation largely overcome on current scanners if thin cuts and multiplanar reformations (MPR). 63
  64. 64. Advanced Imaging MRI §  MRI highly sensitive in detection of ligamentous injury but my be too sensitive §  Much less sensitive than CT in detection of fractures to the posterior arch and injuries to the crainiocervical junction. §  In patients with neurologic deficits, MRI is the study of choice to define cord injury or impingement 64

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