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Cervical trauma
- 1. Cervical spine trauma DR ALI JIWANI JNMC WARDHA
- 3. • Axis
- 4. • C4 of typical cervical vertebra (c3 – c7)
- 10. Various views of cervical spine • THE LATERAL VIEW: • The lateral view is the most important in the routine trauma series. • It is essential that all seven cervical and the first thoracic vertebrae be clearly displayed • Pulling downward on the arms is frequently advocated. • Swimmers view can be taken if no shoulder injury • Lateral tomogram can be taken in cases of unsatisfactory conventional radiography
- 13. Vertebral lines
- 14. Three column -- denis
- 18. C2- 7mm or less C6- 22mm or less 14mm or less
- 20. ANTEROPOSTERIOR VIEW • The information available on the AP view is important, especially in assessing soft tissue injuries which may produce only subtle changes on the lateral view. • The AP view may also provide valuable clues in evaluating the cervicothoracic region
- 23. OBLIQUE VIEW • The oblique view can be obtained by angling the tube on conventional equipment or rotating the arm on a C-arm tomographic trauma unit. • This view is important for evaluating the posterior structures and especially for detecting subtle perching or locking of the facets
- 25. OPEN MOUTH ODONTOID VIEW • This view is useful in evaluating the odontoid and the relationships of CI-C2 • In some patients, it is difficult to visualize the entire odontoid. Angling the tube as would be done for an AP Waters view
- 29. PILLAR VIEWS • The patient’s head must be rotated to obtain pillar views. • Proper alignment of each set of pillars is not always possible using a single tube angle (usually the tube is angled 20-30 degree. The pillar view is useful in evaluating the articular pillars and lamina .
- 31. MOTION (FLEXION, EXTENSION) VIEWS • Fluoroscopically positioned flexion and extension views are important in assessing soft tissue injury and potential instability • this study should be reserved for those patients without fracture. • Post traumatic muscular spasm and underlying bony injury is great challenge for this study
- 33. CT • CT scan is not mandatory for every patient with cervical spine injury. Most injuries can be diagnosed by plain films. However, if there is a question on the radiograph, CT of the cervical spine should be obtained. • CT scan are particularly useful in fractures that result in neurologic deficit and in fractures of the posterior elements of the cervical canal (e.g. Jefferson's fracture) because the axial display eliminates the superimposition of bony structures.
- 34. • The advantages of CT are: • 1. CT is excellent for characterizing fractures and identifying osseous compromise of the vertebral canal because of the absence of superimposition from the transverse view. The higher contrast resolution of CT also provides improved visualization of subtle fractures. • 2. CT provides patient comfort by being able to reconstruct images in the axial, sagittal, coronal, and oblique planes from one patient positioning.
- 35. • The limitations of CT are: • 1. difficult to identify those fractures oriented in axial plane (e.g. dens fractures). • 2. unable to show ligamentous injuries. • 3. relatively high costs.
- 37. MRI • MRI is indicated in cervical fractures that have spinal canal involvement, clinical neurologic deficits or ligamentous injuries. MRI provides the best visualization of the soft tissues, including ligaments, intervertebral disks, spinal cord, and epidural hematomas.
- 38. • The advantages of MRI are: • 1. excellent soft tissue constrast, making it the study of choice for spinal cord survey, hematoma, and ligamentous injuries. • 2. provides good general overview because of its ability to show information in different planes (e.g. sagital, coronal, etc.). • 3. ability to demostrate vertebral arteries, which is useful in evaluating fractures involving the course of the vertebral arteries. • 4. no ionizing radiation.
- 39. • The disadvantages of MRI are: • 1. loss of bony details. • 2. relatively high cost.
- 45. Hyper extension
- 46. Cervical spine fractures Fractures of the Atlas • Jefferson’s Fracture (Bursting Fracture of the Atlas): • A bursting fracture of the ring of the atlas, with fractures through the anterior and posterior arches, • Jefferson’s fracture is a compression injury created by a forceful blow on the skull vertex, which is transmitted through the occipital condyles to the lateral masses of the atlas.
- 47. • The force displaces the lateral masses laterally, classically producing the fractures on each side of the anterior and posterior arches of the atlas. CT has since demonstrated variations in this fracture pattern • Death or significant neurological deficit is uncommon, though approximately 50% of cases will have persistent neck pain, stiffness, and occipital dysesthesia
- 48. • Radiographic features: the key radiographic view is the AP open mouth, which shows displacement of the lateral masses of vertebrae C1 beyond the margins of the body of vertebra C2. A lateral displacement of >2 mm or unilateral displacement may be indicative of a C1 fracture. CT is required to define the extent of fracture and to detect fragments in the spinal canal.
- 51. • Simulation of a Jefferson’s fracture (pseudo-spread) may occur in four circumstances. In children < 10 years of age, • most commonly around 4 years, the atlas may grow at a greater rate than the axis. • Developmental anomalies of the atlas, such as localized lateral mass malformation or combined anteroposterior (AP) spina bifida of the atlas, can produce a similar appearance. Rotary atlantoaxial subluxation and torticollis may also mimic a Jefferson’s fracture. Such variations usually do not produce lateral offset of > 2 mm, whereas a Jefferson’s fracture typically exceeds 3 mm.
- 53. Posterior Arch Fracture of the Atlas. • The most common fracture of the atlas is the posterior arch fracture, accounting for at least 50% of all atlas fractures • The fracture is usually a bilateral vertical fracture through the neural arch, • This fracture occurs as a result of the posterior arch of the atlas being compressed between the occiput and the large posterior arch of the axis during severe hyperextension..
- 54. • best seen on the lateral projection • Serious complications are unusual, though associated cervical fractures may precipitate spinal cord injury. • Close anatomic proximity of the vertebral artery to the fracture site may occasionally lead to serious vascular injury.
- 56. Rupture of the Transverse Ligament • Isolated traumatic disruption of the transverse ligament is infrequent • Rupture of the ligament is common in association with Jefferson’s fracture, inflammatory arthritis (e.g., rheumatoid arthritis, psoriasis, ankylosing spondylitis, and Reiter’s syndrome)
- 57. • A key radiologic feature of a ruptured transverse ligament is an abnormally wide atlantodental interspace (ADI) (> 3 mm in adults and 5 mm in children), most pronounced in flexion • The posterior cervical line will also be disrupted Cord compression may not be clinically apparent until considerable anterior displacement of the atlas (up to 10 mm) has occurred
- 59. Fractures of the Axis • Hangman’s Fracture (Traumatic Spondylolisthesis). • Fractures of the neural arch of the axis are among the most common injuries of the cervical spine • They are usually the results of automobile accidents in which there is abrupt deceleration from a high speed, though the fracture occurs during hyperextension
- 60. • The distribution of the fracture is similar to that resulting from judicial hanging • The fracture occurs as a bilateral disruption through the pedicles of the axis. • The fracture lines are best seen on CT or the lateral view just anterior to the inferior facet, usually in association with anterior displacement of C2 on C3.
- 61. • An avulsion of the anteroinferior corner of the vertebral body (teardrop fracture) often occurs simultaneously. • Extension of the fracture into the transverse foramen may precipitate vertebral artery injury.
- 62. • Classification of Hangman' s fractures • Type I (65%) 1. hair-line fracture 2. C2-3 disc normal • Type II (28%) 1. displaced C2 2. disrupted C2-3 disc 3. ligamentous rupture with instability 4. C3 anterosuperior compression fracture • Type III (7%) 1. displaced C2 2. C2-3 Bilateral interfacet dislocation 3. Severe instability
- 65. Teardrop Fracture. • The teardrop fracture is an avulsion of a triangular-shaped fragment from the anteroinferior corner of the axis body • Although teardrop fractures can occur at any cervical body, the lesion is most common at the axis. At this level an acute hyperextension is the usual mechanism of injury, which explains its common occurrence in combination with a hangman’s fracture
- 67. Odontoid Process Fracture • Fractures of the odontoid process are common traumatic injuries of the cervical spine • Pathologic fracture may complicate metastatic carcinoma, multiple myeloma and other tumors, rheumatoid arthritis, and ankylosing spondylitis as well as other causes for osteopenia
- 68. • Type I. • Type I is an avulsion of the tip of the odontoid process as a result of apical or alar ligament stress. It is an uncommon injury and is rarely complicated by non-union
- 69. • Type II. A fracture at the junction of the odontoid process and the body of the axis. This is the most common odontoid process fracture and the one that most frequently results in non-union owing to reduced vascularity of the separated fragment.
- 70. • During union, hypertrophic callus may induce myelopathy. Post-fracture osteolysis of the dens has been recorded. • Patients with dislocation of > 5 mm should be evaluated for surgical intervention
- 71. • Type III:In type III fractures, the fracture is found deep within the vertebral body, below the base of attachment of the odontoid process to the body. This type is almost as common as type II, though it heals more readily • The most reliable imaging findings consist of the fracture line, odontoid displacement, disrupted axis (Harris) ring, enlargement of C2 body, and retropharyngeal swelling
- 72. • Displacement of the odontoid in either the anterior or posterior position is usually < 3 mm • This displacement creates an offset of the posterior cervical line (PCL) of the atlas as it relates to the normally positioned axis. Impingement on the spinal cord occurs in isolated rupture of the transverse ligament with an intact odontoid process, creating a guillotine, or pincers, effect on the cord. A lateral tilt of the odontoid process > 5° indicates an underlying fracture.
- 74. • Os odontoideum represents a developmental failure of the dens to unite with the body of the odontoid but exhibits distinctive radiographic features that allow differentiation from acute fracture
- 75. Os Odontoideum • Wide Zone of separation • Round, smooth, sclerotic margins • Vertical Odontoid orientation • Interrupted Posterior cervical line • Increased Anterior tubercle size or density
- 77. Vertebral Body Compression Fractures • Wedge Fracture:A wedge fracture occurs as a result of mechanical compression of the involved vertebra between the adjacent vertebral bodies from forced hyperflexion • This is a stable fracture • The lateral radiograph is diagnostic • If the anterior height of a vertebral body measures at least 3 mm less than the posterior height, a fracture of the vertebral body can be assumed.
- 79. Burst Fracture. • A burst fracture is precipitated by vertical compression to the head propelling the nucleus pulposus through the endplate into the vertebral body. • The force fractures the vertebra vertically, causing a comminution of the vertebral body with the fragments migrating centrifugally. • The lateral radiograph reveals a comminuted vertebral body, which is usually flattened centrally
- 81. Clay Shoveler’s Fracture • Clay shoveler’s fracture (coal-miner’s or root- puller’s fracture) is an avulsive injury of the spinous process • It results from abrupt flexion of the head, such as is found in automobile accidents, diving, or wrestling injuries or from repeated stress caused by the pull of the trapezius and rhomboid muscles on the spinous process • The spinous avulsion most commonly occurs at C7, with C6 and T1 also frequently involved.
- 83. Lamina and Transverse Process Fractures • Laminar fractures occur in the middle to lower cervical spine, with C5 and C6 being the most common sites. While difficult to see on standard views, they are readily depicted on CT images • Severe trauma with lateral flexion is necessary, and, as such, these often coexist with other cervical fractures and brachial plexus lesions • The fracture line tends to localize near its junction with the pedicle and, if in continuity with the transverse foramen, may produce vertebral artery injury.
- 84. Lamina and Transverse Process Fractures
- 85. Thank you
Editor's Notes
- These images show a superior view and lateral view of C4, a typical cervical vertebra of C3 - C7. The vertebral body is equal in height anteriorly and posteriorly. The vertebra articulates with the next vertebra at the body and the articular processes. Vertebral artery passes through the transverse foramen. Also, notice that the spinous process is bifid.
- Fig. 2.- A , Ligamentous structures of normal cervical spine. Supraspinous ligament (a); interspinous ligament (b); capsule of interfacetal joint, (c); posterior longitudinal ligament (d); intervertebral disc (e); anterior longitudinal ligament (I). Ligamentum flavum not depicted. Together, supra- and interspinous ligaments,ligamentumflavum,andcapsuleofinter/acetaljointsconstitute"posteriorligamentcomplex." B, Pathology of anterior subluxation; disruption of supra- and interspinous ligaments, capsule of interfacetal joints, posterior longitudinal ligament, and short tear of posterior aspect of intervertebral disc. Ligamentum flavum, not demonstrated here, is torn as well. (Reprinted from [4].)
- Upper cervical spine relationships The tip of the clivus (anterior doffed line) should point to the junction of the anterior and middle thirds of the odontoid tip. The distance between the odontoid and the antenon ring of Cl at the lower margin (arrow) should not exceed 2.5 mm in adults. The posterior lamina of Cl should align (doffed line) with the fonamen magnum (2).
- Figure 4 Physiologic subluxation This normal lateral view of the cervical spine includes all cervical and the upper two thonacic vertebrae There is slight physiologic subluxation of C2 and C3 (arrow) in this 18 year old man. Note the “step-off” at C7-T1 (open arrows) owing to the difference in size of the vertebral bodies. This should not be confused with subluxation. True subluxation secondary to facet arthrosis This is the lateral view of the cervical spine of a 60 year old man with facet arthnosis at C7- Ti resulting in slight subluxation (doffed lines). Both the anterior and posterior vertebral lines are displaced. In Figure 4 the anterior line was intact. The step-off in the posterior line was due only to the difference in the sizes of the vertebral bodies in that case.
- This is the lateral view of a cervical spine following a distractive hyperflexion injury. There is widening of the interspinous distance (postenior arrow), facet joints (curved arrow), and narrowing of the anterior C4 disk space due to an unstable two-column injury.
- lıuı Normal cervical spine-AP view The articular pillans have a smooth undulating contour. The spinous processes (arrowheads) are midline and equidistant apart. The uncinate processes (small arrowheads) are cleanly demonstrated. C2 and Cl are obscuned by the mandible. The mid cervical spinous processes are frequently bifid. pı .ı,r ligament disruption There is increased interspinous distance between C4 and C5 because of posterior ligament disruption. The distance between the C5-C7 spinous processes is normal.
- spine showing shift (lateral displacement) of Figure 10 the C5 spinous process (bifid) owing to a Sputı0tı5 process fracture AP view of the cervical flexion rotation injury (unilateral locked facet). spine with a double spinous process (arrows) because of a spinous process fracture at C7.
- Normal cervical spine-oblique view demonstrating the intervertebral foramina, pedicles, laminae, and normal vertebral alignment (lines). Localized oblique view demonstrating a unilateral locked facet. The superior facet, s, is located posterior to the inferior, i, facet.
- Odontoid views In the AP open mouth odontoid view (A), the upper odontoid is obscured by overlying osseous structures. When the tube is angled 400 toward the head (B), the entire odontoid is cleanly demonstrated.
- Normal cervical spine-pillar views Normal pillar views with the head rotated to the left and to the right Note the variation in height of the pillars due to degenerative changes and variation in articular angles. Care should be taken not to consider slight variation in height a fracture. If no fracture line is evident but injury is suspected clinically, it may be best to obtain tomography or CT to evaluate the area of concern.
- Posterior ligament tear The neutral lateral view (A) shows increased interspinous distance (arrow) between C3 and C4. This may be a normal variant in some patients at this level; the disk space, however, is also narrowed anteriorly suggesting posterior ligament cornplex disruption. The flexion view (B) shows marked increase in the interspinous distance and subluxation of C3 and C4 confirming the presence of a posterior ligament tear.
- (The red arrows demostrate a fracture on the C2 vertebral body)
- example of a MRI image of the cervical spine demostrating a ligamentous injury. Notice that the spinal cord is also very well delinated. A dens fracture is not obvious on the lateral film, but is clearly revealed on MRI.
- Hyperflexion refers to excessive flexion of the neck in the sagital plane. It results in disruption of the posterior ligament. A common cause of hyperflexion injury is diving in shallow water, which may result in flexion tear drop fracture. Hyperextension refers to excessive extension of the neck in the sagital plane. A common cause of hyperextension injury is hitting the dash board in MVA, which may result in Hangman's fracture. Axial compression refers to force applied directly over the vertex in the caudal direction. This compression force "like smashing a cracker" may result in Jefferson fracture, a bursting fracture on the atlas.
- In the above odontoid view, the lateral displacement of C1 indicates a Jefferson fracture.
- PSEUDO-SPREAD OF THE ATLAS. Observe the bilateral overhang of the atlas lateral masses in relation to the axis (arrows). COMMENT: This is a normal variation in some children, which is identical to the appearance of a Jefferson’s fracture. It is most frequently found at around age 4. (Courtesy of Appa L. Anderson, DC, DACBR, Fellow, ACCR, Portland, Oregon.)
- POSTERIOR ARCH FRACTURE. Atlas. Observe the bilateral fracture lines at the junction of the posterior arch with the lateral masses (arrow). Observe the close proximity of the fracture lines to the course of the vertebral artery, which may be injured in this fracture.
- Figure 9-31 RUPTURE OF THE TRANSVERSE LIGAMENT. A. Flexion Lateral Cervical Spine. Note that in flexion the atlantodental interspace increases to approximately 7 mm (arrows), a radiologic sign of transverse ligament instability. B. Transverse Ligament Instability. Anterior displacement of the atlas on the axis owing to rupture of the transverse ligament may result in significant cord compression with entrapment between the posterior tubercle and odontoid process (guillotine mechanism). C. CT, Through the C1-C2 Articulation. Note the relationship of the odontoid (O), spinal cord (C), and soft tissues surrounding the cord (S). D. The C1-C2 Articulation. Approximately one third of the atlas ring is occupied by the odontoid (O), one third by the spinal cord (C), and the remaining third by the space surrounding the cord (S). This anatomic division explains why patients with anterior atlas displacement may be relatively asymptomatic until a large degree of translation has occurred (Steele’s Rule of Thirds).
- HANGMAN’S FRACTURE. A. Mechanism of Injury. During judicial hangings, a hyperextension and rotatory force to the neck directs the impact to the pedicle regions of the C2 segment, resulting in fracture. B. Radiologic Manifestations. An irregular fracture line (arrow) is seen to extend through the pedicle of the axis. Minimal anterior displacement of the C2 segment on C3 is also apparent. C. Diagram. In addition to the fracture through the pedicle region, disruption at the discovertebral junction may result in vertebral displacement.
- TEARDROP FRACTURE. A. Lateral Cervical B. Diagram, C2. Observe the anteroinferior corner of C2, which has been avulsed, creating a free triangular fragment (teardrop) (arrows).
- GUILLOTINE EFFECT OF ANTERIOR ATLAS DISPLACEMENT. A. Transverse Ligament. Transverse ligament rupture creates a potential for cord compression between the approximated posterior arch and odontoid process. B. Odontoid Process. Odontoid process fractures result in less compression of the spinal cord because the odontoid process and atlas move as a unit. C. Lateral Cervical Spine. Note the type III odontoid process fracture (arrows), which has disrupted the axis ring and the anterior cortex, with anterior displacement of the atlas and fractured odontoid complex (arrowheads). COMMENT: The incidence of isolated transverse ligament rupture after trauma is much less than odontoid process fractures because the transverse ligament is stronger than the odontoid attachment. However, a transverse ligament rupture represents a more life-threatening situation as a result of the guillotine effect.
- DIFFERENTIATION OF ODONTOID FRACTURES AND OS ODONTOIDEUM. A. Odontoid Fracture, Lateral Cervical Spine. Note the type II fracture of the odontoid process with posterior displacement of the atlas. Observe the increase in the prevertebral soft tissue space (arrow) secondary to hemorrhage in association with an irregular fracture line (arrowhead) at the base of the odontoid process. Observe the normal size and shape of the anterior tubercle of C1. B. Os Odontoideum, Lateral Cervical Spine. Note that the small bony ossicle represents the separated odontoid process (arrow). The smooth and sclerotic margins (arrowhead) and the radiolucent space between the odontoid process and the base of the axis are distinctive. Significant enlargement and increased density of the anterior tubercle (crossed arrow) is also a frequent finding in os odontoideum. COMMENT: The enlargement of the anterior tubercle with an increase in density is a stress response secondary to chronic upper cervical instability. This radiographic sign is found in chronic instability and is not seen in acute fractures. Close observation of the posterior surface of the anterior tubercle reveals an angular surface with its apex directed posteriorly
- WEDGE COMPRESSION FRACTURE OF THE C7 VERTEBRAL BODY. Note the characteristic wedge-type deformity with loss of intervertebral height and preservation of the posterior vertebral margins secondary to a hyperflexion injury. COMMENT: The lower cervical spine in the C5-C7 area is the most common location for these fractures.
- BURST FRACTURE OF THE VERTEBRAL BODY. A. Lateral Cervical Spine. Note the multiple fracture fragments of the C7 vertebral body (arrow) that have been displaced in various directions. B. CT, C7. Observe the displaced fracture fragments extending posteriorly, which has resulted in significant spinal stenosis (arrow). This demonstrates the clinical value of CT in vertebral body fractures.
- CLAY SHOVELER’S FRACTURE. A. Acute Fracture, Lateral Cervical Spine. Note the avulsion fracture of the spinous process of C7 with inferior displacement of the distal fragment (arrow). Observe the fracture line, which is irregular and exhibits no sclerosis. B. CT Scan, Acute Fracture. Observe the sites of fracture at the base of the spinous process (arrows). C. Old Fracture. Note the presence of smooth and sclerotic opposing margins, indicating an old clay shoveler’s fracture. (Panel B courtesy of Steven P. Brownstein, MD, Springfield, New Jersey. Panel C courtesy of Peter Christensson, DC, Rome, Italy.)
- VERTEBRAL BODY AND ASSOCIATED NEURAL ARCH FRACTURE. A. Lateral Cervical Spine, C7 Fracture. Note the anterior compression fracture with a step defect at the anterosuperior corner of the body of C7 (arrow). B. CT, C7 Fracture. Note that the fracture line extends through the vertebral body, pedicle, and base of the transverse process (arrows). The extension into the posterior arch could not be appreciated on the plain film radiographs. (Courtesy of Reed B. Phillips, DC, DACBR, PhD, Los Angeles, California.)