The document discusses cervical spine (C spine) injuries. It covers anatomy of the C spine including the atlas and axis vertebrae. It describes the three column concept for spinal stability. Imaging of the C spine including normal measurements and views is discussed. The roles of MRI and stretch testing are covered. Neurological assessment including the ASIA scale is explained. Pharmacological management including methylprednisolone is summarized. Neurogenic and spinal shock in spinal cord injuries are briefly defined.

1. C SPINE INJURIES
PRESENTER :Dr. Karthik S J
MODERATOR :
Dr. Anil Kumar Sakalecha
Dr. Arun Prasad P

2. C spine : Anatomy
The cervical spine is the most superior portion of the vertebral
column, lying between the cranium and the thoracic vertebrae.
It consists of seven distinct vertebrae, two of which are given unique
names:
The first cervical vertebrae (C1) is known as the atlas
The second cervical vertebrae (C2) is known as the axis

3. The cervical vertebrae have three main features
which distinguish them from other vertebrae:
Triangular vertebral foramen.
Bifid spinous process – this is where the
spinous process splits into two distally.
Transverse foramina – holes in the transverse
processes. They give passage to the vertebral
artery, vein and sympathetic nerve

4. ATLAS:
• The atlas is the first cervical vertebra and
articulates with the occiput of the head and the
axis (C2). Has no vertebral body and no spinous
process.
• Has lateral masses which are connected by an
anterior and posterior arch. Each lateral mass
contains a superior articular facet and an inferior
articular facet.
• The anterior arch contains a facet for articulation
with the dens of the axis.. The posterior arch has a
groove for the vertebral artery and C1 spinal
nerve.

5. AXIS:
• The axis (C2) is easily identifiable due to its
dens which extends superiorly from the
anterior portion of the vertebra.
• The dens articulates with the anterior arch
of the atlas, thus creating the medial
atlanto-axial joint. This allows for rotation
of the head independently of the torso.

6. • C7: has a much larger and singular spinous process, known as the
vertebra prominens, which is similar to those in the thoracic vertebra
• Action:
Nodding and lateral flexion movement occurs at atlanto occipital joint
Rotation of skull occurs at Atlanto axial joint around the dens which
acts as pivot

7. DENNIS THREE COLUMN CONCEPT :
If more than 2 columns are involved
fracture is unstable
This column applied below C 3 level
It does not apply to C1 C2 vertebra

8. JOINTS IN C SPINE:
• Intervertebral discs ( fibro cartilaginous joint )
• Facet joint (formed by the articulation of superior and inferior
articular processes from adjacent vertebrae)
• Unco vertebral joints
• Atlanto axial joint Unique to C spine
• Atlanto Occipital joint

9. LIGAMENTS:
6 ligaments to be considered in C spine:
Anterior and posterior longitudinal ligaments
Ligamentum flavum
Interspinous ligament
Nuchal ligament
Transverse ligament of the atlas

10. • Transverse ligament :
primary stabilizer of atlantoaxial junction
• Paired alar ligaments:
connect the odontoid to the occipital
condyles
• Apical ligament:
runs vertically between the odontoid and
foramen magnum
• Tectorial membrane:
• connects the posterior body of the axis
to the anterior foramen magnum

11. C SPINE RADIOGRAPHS : INDICATIONS
Cervical spine radiographs are indicated for a variety of settings
including:
• trauma
• infection
• atypical pain
• limb pain
• osteoporosis
• degenerative changes

12. In the absence of CT 5 views of the C-spine
should be performed
1. AP View:
anteroposterior projection of the cervical
spine demonstrating the vertebral bodies and
intervertebral spaces

13. 2. Lateral view:
Often utilized in trauma demonstrated
zygapophyseal joints
soft tissue structures around the
c spine
spinous processes
anterior-posterior relationship of
the vertebral bodies

14. 3. Odontoid view :
Also known as a 'peg' projection
It demonstrates the C1
(atlas) and C2 (axis)

15. 4. AP Oblique:
It demonstrates the
intervertebral foramina of the
side positioned farther from
the image receptor

16. 5. PA Oblique :
It demonstrates the intervertebral
foramina of the side positioned closer
to the image receptor

17. ADDITIONAL VIEWS:
Cervicothoracic view (swimmer's view)
• It is a modified lateral projection of the
cervical spine to visualize the C7/T1
junction

18. Flexion-extension lateral
• It is the specialized projections of the
cervical spine often requested to assess
for spinal stability.

19. Fuchs view
• It is a non-angled AP radiograph of
C1 and C2.
• It should not be used in a trauma
setting

20. NORMAL CERVICAL SOFT TISSUE
MEASUREMENTS
ADULT CHILD
Predental space ≤ 3mm ≤ 5 mm
Retropharyngeal space
Anterior to C3
≤ 7mm ≤ 7mm
Retro tracheal space
Anterior to C6
≤ 22 mm ≤ 14mm

21. LINES IN C SPINE

22. Wackenheims line
• Wackenheims line (also known as the clivus
canal line or basilar line) is formed by drawing
a line along the clivus and extending it inferiorly
to the upper cervical canal.
• Normally the tip of the dens is ventral and
tangential to this line. In basilar
invagination odontoid process transects this
line.
• In posterior atlantooccipital dislocation the line
will extend posterior to the odontoid process.
• In anterior atlantooccipital dislocation the line
will extent through the center of the odontoid
process or more anterior.

23. NEXUS CRITERIA:
• Neurological deficit
• Ethanol Intoxication
• eXtreme distracting Injury
• Unable to provide history ( Altered Mental Status )
• Spinal tenderness ( Midline )
Presence of any one of these indicates C-spine radiograph and
continuing C-spine immobilization.

24. CANADIAN C
SPINE RULE:

25. Factors for assessing and treating Spine
Injuries:
• Early recognition of the patient
• Prevention of neurologic deteroitation
• Optimisation of initial medical management
• Correct interpretation of all the diagnostic evaluation
• Delivery of appropriate medical care

26. ROLE OF MRI:
• MRI has a higher sensitivity for detecting soft tissue injuries either by
showing discontinuity of anatomic structures such as ligamentum
flavum and annulus fibrosus or haemorrhage and edema associated
with tissue disruption, which are not well demonstrated on CT
• MRI can detect a missed spinal column injury or neural compressive
pathologic process such as disc fragmentation, epidural hematoma, or
the presence of significant canal stenosis from other cause

27. The main indications of MRI in spinal trauma include
1.Radiographic and/or CT scan findings suggestive of ligamentous
injury, such as prevertebral hematoma, spondylolisthesis, asymmetric
disc space widening, facet joint widening or dislocations, and inter-
spinous space widening.
2.To look for epidural hematoma or disc herniation before attempting a
closed reduction of cervical facet dislocations.
3.To identify spinal cord abnormalities in patients with impaired
neurological status.
Kumar, Y., Hayashi, D. Role of magnetic resonance imaging in acute spinal trauma: a pictorial
review. BMC Musculoskelet Disord 17, 310 (2016). 1169-6

28. 4.To exclude clinically suspected ligamentous or occult bony injuries in
patients with negative radiographs.
5.To determine the stability of the cervical spine and assess the need
for cervical collar in obtunded trauma patients.
6.To differentiate between hemorrhagic and non-hemorrhagic spinal
cord injuries for the prognostic significance as the presence of
hemorrhage significantly worsens the final clinical outcome.
Kumar, Y., Hayashi, D. Role of magnetic resonance imaging in acute spinal trauma: a
pictorial review. BMC Musculoskelet Disord 17, 310 (2016). 1169-6

29. According to American College of Radiology (ACR) appropriateness
criteria, MRI of spine combined with CT scan is appropriate in the
setting of acute spinal trauma if :
1.National Emergency X-Radiography Utilization Study (NEXUS) or
Canadian Cervical-Spine Rule (CCR) criteria are met and there are
clinical findings of myelopathy.
2.NEXUS or CCR criteria are met and there are clinical or imaging
findings to suggest ligamentous injury.
3.NEXUS or CCR criteria indicate imaging and the mechanically unstable
spine is anticipated.
Kumar, Y., Hayashi, D. Role of magnetic resonance imaging in acute spinal trauma:
a pictorial review. BMC Musculoskelet Disord 17, 310 (2016). 1169-6

30. STRETCH TEST:
• This test allows measurement of displacement within a motion
segment under controlled condotions to identify soft tissue injuries
• Gardner-Wells tongs are applied before the test is performed
END POINTS:
Change in neurologic status
Increase of 1.7 mm between adjacent vertebra at any level
Angulatory change of 7.5 degree at any disc level
Reaching one third of body weight or weight limit of tongs, whichever
is less

31. Gardner-Wells tongs placed just
above ears, below greatest
diameter of skull

32. Neurological assessment
• Assessment of mental status using Glascow Coma Scale determines
the level of conciousness
• Using ASIA scale scoring is made
• ASIA scale should be assessed once in 4 to 6 hours for the initial 24
hours of injury

35. ASIA IMPAIRMENT SCALE:
• Grade A: The impairment is complete. There is no motor or sensory function left below
the level of injury.
• Grade B: The impairment is incomplete. Sensory function, but not motor function, is
preserved below the neurologic level and some sensation is preserved in the sacral
segments S4 and S5.
• Grade C: The impairment is incomplete. Motor function is preserved below the neurologic
level, but more than half of the key muscles below the neurologic level have a muscle
grade less than 3
• Grade D: The impairment is incomplete. Motor function is preserved below the neurologic
level, and at least half of the key muscles below the neurologic level have a muscle grade
of 3 or more
• Grade E: The patient's functions are normal. All motor and sensory functions are
unhindered.

36. PHARMACOLOGICAL MANAGEMENT:
• Methyl Prednisolone Sodium Succinate:
Within 3 hours of injury : 30mg/kg bolus + 5.4mg/kg/hr infusion for 24
hours
3 to 8 hours : 30mg/kg bolus + 5.4 mg/kg/hr infusion for 48 hours

37. SPINAL CORD INJURY:
NEUROGENIC SHOCK:
It refers to hemodynamic instability that occurs with rostral cord
injuries related to loss of sympathetic tone to the peripheral
vasculature of heart, the consequences are bradycardia, hypotension
and hypocoagulation
Aggressive treatment of hypotension of any cause is a priority in
patients with spinal cord injury

38. • SPINAL SHOCK :
It refers to the temporary dysfunction of spinal cord, with a loss of
sensorimotor dysfunction and reflexes caudal to the level of injury
It is manifested by loss of anal wink and bulbocavernous reflexes and
by flaccid paralysis. It is a temporary phenomenon and recovers
usually in 24 to 48 hours even in severe injuries
There is no specific treatment of spinal shock

39. • The secondary injury cascade refers to the additional neurologic
injury that results from cord ischemia, leading to electrolytes shifts
with cell membrane alterations and accumulation of neuro
transmitters and inflammatory mediators including further neural
tissue damage
• It occurs over a period of hours to days depending on the severity of
injury
• Spinal cord ischemia results in changes locally with loss of auto
regulation of spinal cord blood flow and changes to systemic
vasculature

40. Immediate spinal reduction:
• The primary objective for rapid cervical reduction and stabilisation is
to improve spinal cord blood flow and thus minimise the harmful
effects of ischemia
• There is still controversy exists regarding timing of cervical reduction
and the need for Cervical MRI, particularly in patients with unilaterl or
bilateral facet dislocations
• But many studies recommend for expeditious reduction without
obtaining MRI in an alert and awake patient

41. CLOSED RECUCTION TECHNIQUE:
• After placement of cervical tongs, reduction is same as that of stretch
test
• The injured segement should not not be distracted more than 1.7mm
• Once the reduction is achieved the traction is reduced to 10 to 15 lb
• The patient head is elevated to 30 degrees until definitive fixation is
planned

42. SPINAL CORD SYNDROMES:
• Central cord syndrome
• Brown sequard syndrome
• Anterior cord syndrome
• Posterior cord syndome
• Conus medullaris syndrome
• Cauda equina syndrome

43. CENTRAL CORD SYNDROME :
• Most common
• Injury to central area of spinal cord, including gray and white matter
• Centrally located upper extremity motor neurons are more affected
and lower extremiy motor neurons are less affected
• Patients have tetraparesis
• Patients have greater dynfunction in the extremities distally than
proximally
• Sensory sparing varies but usually sacral pin prick sensation is
preserved

45. BROWN SEQUARD SYNDROME
• It is injury to either side of spinal cord as a
result of unilateral laminar pedicle fracture,
penetrating injury or rotational injury resulting
in subluxation
• It is characterised by motor weakness on the
side of the lesion and contralateral loss of pain
and temperature sensation
• Prognosis is good with significant neurological
improvement

46. ANTERIOR CORD SYNDROME
• It is caused by hyper flexion injury in which
bone or disc fragments compress the anterior
spinal cord and artery
• Characterised by complete motor loss and
loss of pain and temperature discrimation
below the level of injury
• Posterior column is preseved to varying
degrees resulting in preservation of deep
touch, position sense and vibratory sensation
• Prognosis : Poor

47. POSTERIOR CORD SYNDROME:
• It involves the dorsal column of the spinal
cord and produces loss of proprioception
and vibratory sense while preserving other
sensory and motor functions,
• This syndrome is rare and usually is caused
by extension injury

48. CONUS MEDULLARIS SYNDROME
• Injury of the sacral cord and lumbar nerve roots within the spinal
canal usually resulting in areflexic bladder, bowel and lower
extremities
• Most of these injuries occur between T 11 and L 2 and result in flaccid
paralysis in lower extremities and loss of all bladder and peri anal
muscle control
• Persistent absence of the bulbo cavernous reflex and perianal wink

50. CAUDA EQUINA SYNDROME:
• Injury between the conus and the lumbo sacral nerve roots within the
spinal canal
• It can also result in an areflexic bladder, bowel and lower limbs
• With a complete cauda equina injury, all peripheral nerves to the
bladder, bowel, peri anal area and lower extremities are lost
• Bulbocavernous reflex, anal wink and all reflex acitivity in the lower
extremities are absent indicating absence of any function in cauda
equina

51. RADIOGRAPHIC EVALUATION PROTOCOL
• Helical CT scan is the imaging modality of choice for the diagnosis of
cervical fractures and dislocations.
• Axial images, sagittal reconstructions and coronal plane
reconstructions each provide optimal visualisation for particular
injuries
• Systemic and methodical routine for viewing these series is required
to detect injuries

52. Parasagittal image Midline image Coronal reconstruction
 Congruity of the occipital condyle-C1
joint, which should be concentric
and should not be more than 2 mm
wide laterally
 Relation of the Wackenheim line to
the dens
 Evaluating the Occiput- C1 joints
 Intact isthmus at the C2 level  Widening of the atlantodens interval
(normal < 3 mm; abnormal > 5 mm)
 C1-C2 joints
 Normal relationship at each facet
joint and intact lateral masses
 Soft-tissue swelling at the C3
midbody
 Bony integrity of the dens.
 Bony integrity of the dens
 Anterior vertebral body alignment
 Posterior vertebral body alignment
 Alignment of the spinolaminar line
 Assessment for excess angulation or
widening of each disc space

53. Atlantodental interval
• The atlantodental interval (ADI) is the horizontal distance between
the anterior arch of the atlas and the dens of the axis, used in the
diagnosis of atlanto-occipital dissociation injuries and injuries of the
atlas and axis.
• Radiographs
Adults
• males: <3 mm
• females: <2.5 mm
• children: <5 mm
• CT: adults: <2 mm

54. • Arrow a indicates normal occiput-C1
joint congruity.
• Arrow b indicates intact C2 isthmus.
• Bracket c indicates normal facet
relationships throughout the cervical
spine

55. • Arrow a indicates Wackenheim
line with normal relationship
between clivus and posterior
dens.
• Arrow b indicates atlantodens
interval, which is normal in
width.
• Arrow c indicates normal soft-
tissue density width less than 5
mm at C3 midbody

56. C SPINE FRACTURE CLASSIFICATION SYSTEMS
• Anderson and D'Alonzo classification (odontoid fracture)
• Levine and Edwards classification (for traumatic injuries to axis)
• Allen and Ferguson classification (subaxial spine injuries)
• Subaxial cervical spine injury classification (SLIC) system

57. OCCIPITO CERVICAL INJURY PATTERNS
• Atlantooccipital dislocations
• C1-C2dislocations
• Combinations of fractures and dislocations involving the occiput, atlas,
and the axis can disrupt the tectorial membrane, alar and apical
ligaments, transverse atlantal ligament
• Joint capsules at occiput-C1 or C1-C2

58. Harris method of calculation :
• The BAI/BDI method is the most
reliable method using lateral
radiographs for assessing occipito
cervical injuries
BAI : <12 mm
BDI : < 15 mm

60. HALO VEST APPLICATION
When applying halo ring,
pin sites should be 1 cm
above lateral one third of
eyebrows and same
distance above tops of ears
in occipital area

61. TRANSVERSE ATLANTIAL LIGAMENT RUPTURE
• Rupture of the transverse atlantal ligament or cruciform ligament
usually occurs from a force applied to the back of the head, such as
occurs in a fall.
TYPES PATTERN MANAGEMENT
TYPE 1 Disruptions of the
Substance of the ligament
Incapable of healing without internal
fixation and they should be treated
with early surgery
TYPE 2 Fractures and avulsions
Involving the tubercle insertion of
the transverse atlantal ligament
On the lateral mass of C1
Treated initially with a rigid cervical
orthosis
Anterior widening of the atlantodens interval of more than 3 mm on the midsagittal CT reconstruction or on a
flexion view suggests that the transverse ligament is incompetent.

62. RULE OF SPENCE:
• The rule of Spence is a radiographic method that attempts to
determine the integrity of the transverse ligament when doing an
open mouth (odontoid view) radiograph.
• If the combined measurement of the right and left lateral masses of
C1 hang over the lateral masses of C2 by more than 6.9 mm then
there should be concern for a possible transverse ligament injury and
the patient should get an MRI or flexion or extension imaging.

63. • The outer edges of the C1 lateral
masses should not extend over (or
"hang over") the outer edge of the C2
lateral masses.

64. BIMASTOID LINE:
• The bimastoid line is a line connecting the
tip of the right and left mastoid bones.
• The distance below this line to the tip of
the dens is used to assess for the
presence of basilar invagination. The
distance should be less than 10 mm
above this line

65. ATLAS FRACTURES : JEFFERSON FRACTURE
TYPE PATTERN MANAGEMENT
TYPE 1 Isolated anterior or posterior
Arch fractures
Use a rigid collar for nondisplaced
Type I fractures
TYPE 2 The anterior and posterior
portion of the ring
Halo vest is used for external
immobilization
TYPE 3 Involve the lateral mass with
or without a fracture of the
ring
Halo vest is used for external
immobilization

66. AXIS FRACTURES:
• Odontoid process fracture
• Isthmus fracture ( Hangman fracture )
It is fracture of the posterior element of axis through the isthmic
portion or pars inter articularis
Mechanism : Hyperextension and axial loading

67. Anderson and D'Alonzo classification
(odontoid fracture)
• Odontoid process fracture, also
known as a peg or dens
fracture, occurs where there is a
fracture through the odontoid
process of C2
• The mechanism of injury is
variable, and can occur both
during flexion or extension, and
with or without compression

68. MANAGEMENT OF ODONTOID FRACTURES
Types Management
Type 1 Rigid immobilization with halo vest
Type 2 Minimally displaced : Immobilization with Halo vest /
Rigid cervical collar
If reduction is not satisfactory after immobilization /
translation > 6mm : Surgical management – C1C2
fusion or Anterior osteosynthesis
Type 3 Rigid immobilization with halo vest

69. Levine and Edwards classification
(Traumatic injuries to axis)
• It is the most widely used
classification system of hangman
fractures of the C2.
• The injury, also known as traumatic
spondylolisthesis of the axis

70. Management :
Type Management
Type 1 Rigid collar
Type 2 Reduction with traction and immobilised with halo
vest
Type 2 a Should not be reduced with traction ;
Reduced with gentle manual extension and slight
compression
Type 3 Open reduction and fixation with C2 pedicle screws

71. Allen and Ferguson classification
(Subaxial spine injuries)
It is used to classify subaxial spine injuries. It is based on the
mechanism of injury and position of the neck during injury
flexion and compression
vertical compression
flexion and distraction (facet joint dislocation)
extension and compression
extension and distraction
lateral flexion

72. UNSTABLE SPINE:
• Supporting structures :
Two groups
Anterior
Posterior

73. Significant sagittal plane rotation (>11 degrees) suggests
instability.
Sagittal plane translation of more than 3.5 mm
suggests clinical instability

74. HYPER EXTENSION INJURY
• The patient may have diffuse idiopathic skeletal hyperostosis (DISH)
• Patients with an incomplete disc disruption usually can be treated
with immobilization.
• Patients with an annulus disruption that extends through the anterior
and posterior margins of the annulus fibrosus are treated with
anterior discectomy and fusion with bone graft and an anterior
locking plate

75. BURST FRACTURES:
• This injury is exemplified by shortening of
the vertebral body, with comminution
and retropulsion of the vertebral body
into the canal
• These injuries are usually treated with
corpectomy and anterior reconstruction
with a tricortical iliac bone graft, fibular
allograft, or cylindrical mesh cage packed
with the resected vertebral body and
anterior plating

76. FACET DISLOCATIONS:
• Bilateral facet dislocations are severe pure soft-tissue injuries with
disruption of the facet capsules which are the most important
posterior ligamentous stabilizers
• After failed or successful closed reduction, MRI is obtained.
• If there is a significant disc herniation present, anterior cervical
discectomy with fusion and bone graft is done.
• If reduction was accomplished preoperatively or at the time of
discectomy and fusion, an anterior locking plate is applied

78. Subaxial cervical spine
injury classification (SLIC)
system

79. TAKE HOME MESSAGE
1 to 5 % of C spine injuries are missed
If a spinal fracture is suspected at any level entire spine should be
examined with AP and lateral xrays before giving clearance
Before clearing the C spine, ligametous injuries, instability, Cervical
stenosis should be considered
Progressive neurological deficits needs early cord decompression