This document discusses radiological imaging of spinal trauma and spinal cord injuries. It describes the common mechanisms of spinal injury including flexion, extension, axial loading, and rotation injuries. It outlines the aims of the radiologist in evaluating spinal trauma to define the extent and type of injury and guide management. The document then focuses on cervical spine trauma, providing details on imaging modalities, injury patterns, classifications of fractures and dislocations, and specific cervical spine injuries associated with different mechanisms. It also discusses thoracolumbar trauma including force vectors, stability considerations, basic fracture patterns, and specific injuries.

1. Radiological imaging of Spinal
Trauma and Spinal Cord Injury.
Dr/ ABD ALLAH NAZEER. MD.

2. MECHANISMS OF SPINAL INJURY:
• FLEXION INJURY: leading to anterior wedging of vertebral
body with posterior longitudinal ligament/ interspinous
ligament disruption.
• EXTENSION INJURY: more common in cervical spine leading
to posterior element fracture, anterior longitudinal ligament
rupture and subluxation.
• AXIAL LOADING: Diving & jumping injury leading to burst
fracture and lateral element fracture.
• ROTATION INJURY: leads to lateral mass fracture and
facet subluxation.
AIM OF RADIOLOGIST:
• Define complete extent and type of injury.
• Guide management options conservative vs surgical.

3. IMAGING OF CERVICAL SPINE TRAUMA:
Cervical Spine Trauma Demographics.
Most common spinal injury.
Responsible for 65% of all spinal injuries.
Mechanism: MVA/Fall/Sport Injury:
Spinal Cord Injury: 40% (10,000 annually).
Cervical Spine Trauma Patterns.
Areas most commonly involved
C1-2 (particularly in children).
C5-7.
Other fractures 20%.
Particular association of low cervical fracture with
high thoracic and thoracolumbar injury.

4. Imaging modalities for spinal trauma.
Radiography.
Conventional films
Flexion – Extension views
• CT-Scan.
Single slice vs Multislice
Importance of reformatted images
Protocol at the MGH
CT Angiography
• MRI.
Modality of choice for soft tissues
SC edema vs contusion vs hemorrhage
Contra-indications

5. Normal Anatomy.

12. C-spine Injuries.
Mechanism:
•Vector of forces causing injury.
•Classification system.
Location:
Upper cervical injuries: Include injuries to the
base of the skull(Occipital condyles, C1 and
C2 vertebra.
Lower cervical injuries(sub-axial): Include
injures from C3 through C7 vertebra.

13. Mechanism.
• Hyperflexion.
• Hyperflexion/Rotation.
• Vertical Compression.
• Hyperextension.
• Hyperextension/Rotation.
• Lateral Flexion.
• Others.

15. Hyperflexion Injuries
1. Hyperflexion Sprain (Anterior Subluxation).
2. Bilateral Interfacetal Dislocation.
3. Simple Wedge Compression fracture.
4. Clay Shoveler’s fracture.
5. Flexion Teardrop fracture.
Distraction of posterior elements and
compression of the anterior column

16. Anterior Subluxation
(Hyperflexion Sprain).
• Classic “whiplash” injury.
– abrupt deceleration <30mph.
– rear ending a stopped car
• Posterior ligament complex injury.
• Posterior annulus fibrosis & disc can be
disrupted.
• STABLE, Initially.
– 21-50% incidence of delayed instability.

19. Bilateral Interfacetal
Dislocations (BIID)
• Soft tissue injury.
• Disrupted ALL, PLL, Intervertebral
disc and post ligament complex.
• Articular masses pass superiorly and
anteriorly.
• High risk of cord damage.
• UNSTABLE.

25. Simple Wedge Compression Fracture.
• Mid to lower cervical spine.
• Impacted superior endplate.
• No vertical fracture.
• ALL and disc intact.
• initially STABLE, however: delayed
instability if post ligament complex
is injured and does not heal.

28. Flexion Teardrop Fracture
• Most devastating c-spine injury
compatible with life.
• Severe flexion with disruption of all
ligaments and disc + VB FX.
• UNSTABLE
Acute anterior cord syndrome
1. Complete paralysis.
2. Hypoesthesia and hypalgesia to level injury
3. Preservation touch, motion, position and
vibration sense.

30. Teardrop Fracture.

33. Hyperflexion Injury with Rotation.
1. Unilateral Interfacetal Dislocation:
– Dislocation of facet joint opposite that of the
direction of rotation.
– Posterior ligament complex and articular
joint capsule are disrupted.
– ALL, disc and PLL intact.
– Most common at C5-6, C6-7.
– Impaction fractures tip of either articular
mass (up to 70%).
– STABLE, unless FX isolates articular process.

40. Vertical Compression(Axial Load).
•Force delivered to top of skull
through the occipital condyles to
the cervical spine at the instant
that the cervical spine is straight
• Injury Patterns:
1. Jefferson fracture.
2. Burst fracture.

41. Jefferson Fracture:
• Splitting of C1 ring with fracture of both the
anterior and posterior arch
– may result from a single break in each arch
(anterior and posterior)
– bilateral or unilateral
• Centripetal displacement fragments
• 50% associated fractures
– 33% = axis fractures
• no neurologic deficit
• Transverse atlantal ligament intact or not
• UNSTABLE

46. Burst Fracture.
• C3-C7.
• Theory - compressed disc bulges into
inferior endplate causing VB to
explode from the inside.
• Usually with injury to spinal canal.
• ALL, disc, posterior column intact.
• STABLE.

49. Hyperextension Injuries:
1. Hangman’s fracture.
2. Hyperextension dislocation.
3. Anterior arch avulsion of the Atlas.
4. Posterior arch fracture of the Atlas
5. Extension teardrop fracture.
6. Laminar fracture.

50. Hangman's Fracture:
• 4-7% of all cervical FXs and/or dislocations.
• Most frequent FX in fatal traffic accidents
(Alker).
• Clinical cases result from hyperextension.
• Neurologic involvement is rare.
• Predictive factors for neurologic injury:
– Type II and III.
– Locked facets.
– Involvement transverse foramina with osseous
fragment:
• Dissection.
• Embolization.

55. Hyperextension Dislocation
• Soft tissue injury with disruption of ALL,
disc and PLL.
• Posterior column severely lordotic.
• Compression of cord anteriorly by VB and
posteriorly by ligaments.
• spontaneously reduction when force gone.
• Paralyzed patient with “normal” C-spine.
• Spondylosis a predisposing factor.
• UNSTABLE.

56. Hyperextension Dislocation:
Triad:
1. Facial injuries.
2. Diffuse soft-tissue swelling with normally
aligned vertebrae on lateral radiograph.
3. Acute Central Cervical Cord Syndrome
hemorrhage into central cord range of
Sxs from upper extremity paralysis to
quadriplegia (motor tracts to arms are
located centrally).

65. Hyperextension/Rotation
• Upward force on the forehead
or upper face with head rotated.
• Force which is not central is
applied to forehead or upper face.
• Injury Patterns.
1. Pillar Fracture.
2. Pedicolaminar Fracture-Separation

67. Pedicolaminar
Fracture - Separation
Fracture through ipsilateral pedicle and lamina free
floating lateral mass.
• Articular pillar fragment frequently rotated
horizontalized facet.
• Anterior displacement of vertebral body (similar
to hyperflexion injuries).
• If FX extends into foramen transversarium, then
possible vertebral artery injury.
• Best seen on oblique images
• UNSTABLE - if associated with contralateral
interfacetal dislocation.

68. Pedicolaminar
Fracture - Separation
Type I - Articular mass FX fragment.
Type II - FX + anterior subluxation.
Type III - Type II + disc narrowing.
Type IV - Bilateral involvement with
interfacetal dislocation.
contralaterally.

71. Lateral Flexion Injury.
• Tilt in the
coronal plane.
• Associated with
vertebral artery
injury.
• Best seen on
AP view and CT.
FXs:
– uncinate process.
– occipital condyles.
– transverse process.
– odontoid.
– lateral wedge
compression.
– eccentric atlas burst
fracture.

74. Other Fractures/Injuries:
• Rotary fixation of C1/C2 – torticollis.
• Odontoid fractures.
• Transverse atlantal ligament rupture.
• Occipitoatlantal dissociation.

75. Rotary Atlantoaxial Dissociation
(Rotary Fixation of C1/C2):
• Usually secondary to mild trauma.
– sleeping in an unusual position.
– torticollis.
• Rotation and lateral tilt at the
atlantoaxial joint.
• Fixation occurs when symptoms not
resolved in a few days.

78. Odontoid (Dens) Fractures:
• 11-13% c-spine injuries (up to 27% in some
series).
– 75% of cases are children.
• Classification
– Anderson & D’Alonzo (I, II and III).
• Associations
– atlantoaxial dislocations.
– Jefferson FX.
• Radiography may be subtle.
• Prevertebral STS nasopharynx.

85. Transverse Atlantal
Ligament Rupture:
• Increased atlantodental space.
• Anterior translation of atlas and skull.
• Associated with Jefferson fracture.

87. Thoracolumbar Trauma:
• Anatomy.
• Stability / instability.
• Basic trauma vectors.
• Fracture patterns.

88. Thoracolumbar spine injuries are commonly related
to high energy accidents including falls or motor
vehicle accidents. Patients with thoracolumbar injuries
commonly have other injuries including injuries to the
abdomen, chest, extremities, or other spinal injuries.
The typical “ABC” (airway, breathing, and circulation)
evaluation is needed for all patients seen in the
emergency room after a thoracolumbar spine trauma.
Appropriate evaluation of the thoracolumbar spine
trauma requires complete and thorough clinical and
radiographic examination, which begins only after
ensuring the patient’s other vital organ systems are
intact.

97. Force Vectors
• Most spine injuries: MVA or fall.
• Complex combination of forces.
• Force vectors applied to certain
areas of the spine result in
predictable patterns of fracture.
• Understanding of basic vectors aids
radiologic interpretation.

98. Basic Spine Trauma Forces
• Axial load.
• Flexion / compression.
• Flexion / rotation.
• Flexion / distraction.
• Lateral compression.
• Shear.
• Extension.

100. Axial Load
• T-L junction - most common site
of injury
• T-spine - may result in flexion force,
anterior wedge compression or burst
• 43% fx at another level
• 10% non-contiguous: need to survey
whole spine

107. Coronal T2W image dorso lumbar spine of a 29 yr old male
patient showing burst fracture(arrow) of L3 vertebra.

108. Burst fracture.

109. Burst
fracture.

110. Burst vs. Anterior Wedge Fx:
• Anterior wedge - anterior column – stable.
• Burst - 2-3 columns – unstable.
• Important to differentiate.
– Look for posterior vertebral concavity.
– CT for evaluation of posterior vertebral body,
fracture of posterior elements.
– As many as 20% of burst fractures may be
missed if radiographs alone are used.
– MRI for ligamentous disruption / neuro sx.

112. Sagittal T2W
image of 23yr
old male
showing burst
fracture with
anterior
wedging(arrow)
of L1 vertebra.

114. Flexion / Compression
• Anterior wedge compression vs.
burst fracture.
• Higher risk of posterior
ligamentous disruption.
• Loss of height anterior > posterior.

117. Flexion / Compression:
• Posterior ligamentous disruption
may not be apparent radiographically.
– CT or MRI.
– On X ray: if anterior compression 50% or
greater, assume posterior lig disruption
and instability.
• If unrecognized.
– progressive anterior collapse, deformity
(middle column - fulcrum).

121. Sagittal T2W images of dorsal spine showing
complete cord transection (arrow).

122. Flexion / Rotation:
• T/L junction.
• Flexion vector: anterior wedge or burst.
• Rotation: addition of this vector tends
to result in instability.
– disruption of posterior ligaments.
– posterior element fracture.
– can lead to dislocation.
• High incidence of neurologic deficit.

126. Coronal and sagittal T2W images of dorsal spine of a 35yr old male patient
showing antero-lateral subluxation with cord transection at D6-D7 vertebral level.

127. Flexion / Distraction
• Axis of flexion is moved anteriorly
(seatbelt injury).
• Results in distractive force as flexion is
applied, posterior > anterior.
• Neuro usually preserved (approx. 10%
with neuro deficit).
• Chance fracture and variants.
– pure osseous.
– combined osseous and ligamentous.
– pure disc / ligamentous.

129. Classic Chance Fracture
• Pure osseous.
– Most common (approx. 50%).
– Technically unstable.
– But excellent prognosis for healing / long
term stability.
• X-ray: horizontal split - spinous process,
lamina, pedicles, vertebral body with
distraction posterior > anterior.

130. Chance Variants
• Combined osseous / ligamentous.
• Pure ligamentous / discal.
• Both with worse prognosis for
healing/stability than pure osseous.
• Mechanism: abdominal organ injury.

135. Lateral Flexion/Compression
• Similar to flexion injury, but force is
applied to lateral aspect of vertebra.
• Loss of height of lateral vertebral body
with acute scoliotic deformity.
• Posterior elements often fractured.
• Asymmetric burst fracture.

139. Shear Injury:
• Results in severe ligamentous disruption.
• Listhesis, anterior / posterior or lateral.
• Fracture of posterior elements common,
especially at facets.
• Can result in dislocation.
• Severe neurologic compromise common.

143. Extension:
• Anterior distraction.
– ALL, anterior annular fibers injured
– avulsion anterior endplate
• Posterior compression.
– ‘crush’ fracture
• Usually neuro intact, but with more severe
injury - retrolisthesis, posterior crush.
– ‘lumberjack fracture / dislocation’
• X-ray: anterior disc widening - can be
subtle -CT for posterior element fx.

148. Transverse process fracture:
• Often at multiple adjacent levels.
• If isolated, stable - usually a result of
avulsive stress from psoas / paraspinal
muscle contraction.
• Can signify more severe injury.
– L5 transverse process fracture
associated with sacral fracture.
– nerve root injury (esp. L5).

155. Thank You.