Cervical Spine Imaging

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1 March 20, 2006 Cervical Spine Imaging Johannes Kratz, Harvard Medical School Year IV 1

2 Overview Background Clinical Cases Diagnostic Tests and a Decision-Tree Algorithm Examples of Cervical Spine Evaluations Common C-spine fractures Summary 2

3 Cervical Spine Trauma 30,000 injuries to the spinal column every year in the US The majority of injuries are due to blunt trauma (motor vehicle accidents, falls, sports injuries, etc.) 2-3% of blunt trauma victims have cervical spine trauma 40-50% of spinal injuries produce a neurological deficit, often severe and sometimes fatal Costs of lifetime care and rehabilitation often exceed $1,000,000 per patient Souce: Bagley

4 BIDMC Cases Patient ND 39 year old female s/p MVA. Awake, alert, no neck pain. Patient TN 32 year old male s/p MVA. Awake, alert, complains of neck pain. Patient WD 84 year old man s/p fall down stairs at home. Awake, alert, cannot move my arms. What kind of neck injuries might these patients have? 4

5 Differential Diagnosis of Neck Pain s/p Trauma Cervical Spine Injuries Cervical spine fracture Spinal cord injury Neck strain/whiplash (ligaments, muscles, tendons) Epidural hematoma Vertebral Artery Dissection Atypical headache Acute on Chronic neck pain (OA, radiculopathy, spinal stenosis, etc.) How would you evaluate for the presence of c-spine injuries? 5

6 Menu of Tests Neck Trauma No imaging is necessary or mandated C-spine plain films C-spine CT C-spine MRI What tests should be ordered and when? 6

7 Algorithm for C-spine imaging Neurological Status -Neck Pain Patient is A&O x 3 + Neck Pain Patient has ΔMS, focal neurological deficit or extremity paresthesia No imaging necessary or mandated Plain films +/- +/- CT (significant plain film finding OR negative plain film finding but HIGH clinical suspicion) MRI (ligamentous injury suspected) Back to our patients Sources: Tins et al. 2004, NICE Guidelines 2003, Stiell et al

8 Patient ND 39 year old female s/p MVA. Awake, alert, no neck pain. Patient is A&O x 3 Patient has ΔMS, focal neurological deficit or -Neck Pain + Neck Pain extremity paraesthesia No imaging necessary or mandated Plain films +/- +/- CT (significant plain film finding OR negative plain film finding but HIGH clinical suspicion) MRI (ligamentous injury suspected) How about our second patient? 8

9 Patient TN 32 year old male s/p MVA. Awake, alert, complains of neck pain. Patient is A&O x 3 Patient has ΔMS, focal neurological deficit or -Neck Pain + Neck Pain extremity paraesthesia No imaging necessary or mandated (XXX study) Plain films +/- +/- CT (significant plain film finding OR negative plain film finding but HIGH clinical suspicion) MRI (ligamentous injury suspected) A 3 view c-spine plain film series is ordered 9

10 C-spine Anatomy: Atlas and Axis Netter 1997 Atlas (C1): superior view Netter 1997 Axis (C2): posterosuperior view How about the other cervical vertebrae? 10

11 C-spine Anatomy: 4th and 7th vetebrae Netter 1997 C4: superior view Netter 1997 C3-C5: anterior view What holds the cervical vertebrae together? 11

12 C-spine Anatomy: Cervical Spine Ligaments Netter 1997 Netter 1997 Atlantoaxial joint: superior view Atlantooccipital junction: midline sagittal view How is this anatomy imaged? 12

13 3 View Plain Film C-spine Series Open Mouth lateral A/P How do you interpret these films? 13

14 Reading a Lateral C-spine Plain Film: 7 steps Quality Control See 7. If can t see C7, repeat the film with the shoulders lowered. Evaluate 5 parallel lines Prevertebral Line Anterior Vertebral Line Posterior Vertebral Line Spinolaminal Line Posterior Spinous Line Inspect the Dens Dens-C1 body space <2.5mm (<5mm) Check the atlanto-occipital alignment Check the bony landmarks Check disc spaces Check the soft tissue normal Sources: Brant and Helms 2004, Yao et al What does TN s lateral film look like? 14

15 TN s Lateral C-spine Plain Film Non-displaced C1 fracture normal PACS, BIDMC, courtesy of Dr. Lai TN What about the A/P film? 15

16 Reading an A/P C-spine Plain Film Quality Control Evaluate 3 parallel lines Articular Pillar Line Vertebral Body Line Spinous Process Line Check the vertebral bodies Check disc spaces normal What does TN s A/P film look like? Sources: Brant and Helms 2004, Yao et al

17 TN s A/P C-spine Plain Film normal PACS, BIDMC, courtesy of Dr. Lai What about the open mouth film? TN 17

18 Reading an Open Mouth C-spine Plain Film normal Quality Control Examine the alignment Occipital condyles Check the lateral dens space Check the lateral tips of C1 Check the bony landmarks What does TN s open mouth film look like? Sources: Brant and Helms 2004, Yao et al

19 TN s Open Mouth C-spine Plain Film normal PACS, BIDMC, courtesy of Dr. Lai TN Lateral displacement of C1 masses aka Jefferson Fracture What about our third patient? 19

20 Patient WD 84 year old man s/p fall down stairs at home. Awake, alert, cannot move my arms. -Neck Pain Patient is A&O x 3 + Neck Pain Patient has ΔMS, focal neurological deficit or extremity paraesthesia No imaging necessary or mandated (XXX study) Plain films +/- +/- CT (significant plain film finding OR negative plain film finding but HIGH clinical suspicion) MRI (ligamentous injury suspected) CT and MRI c-spine studies are ordered 20

21 Patient WD: Sagittal CT Bone fragment Right of midline Midline Left of midline Locked facets Osteophytes Congenital block vertebrae Anterolisthesis PACS, BIDMC, courtesy of Drs. Sun and Zeikus Perched facets 21

22 Patient WD: Axial CT PACS, BIDMC, courtesy of Drs. Sun and Zeikus Normal facets Naked facet sign Is there ligamentous injury? 22

23 Patient WD: MRI Hematomas Hematomas Ligament injury Ligament injury PACS, BIDMC, courtesy of Drs. Sun and Zeikus T2 weighted MRI STIR MRI Locked/Perched Facets w/ ligament damage What about other common cervical spine fractures? 23

24 Hangman s Fracture Caused by a hyperextension injury Fracture of posterior C2 elements Displacement of C2 body Source: Brant and Helms

25 Clay Shoveler s Fracture Classically caused by shoveling sticky clay over shoulder Fracture of C6 spinous process Source: Brant and Helms

26 Flexion-Teardrop Fracture Caused by severe c-spine flexion Teardrop frature of an anterior vertebral body Associated with spinal cord injury Source: Brant and Helms

27 Summary Significance of detecting cervical spine fractures Diagnostic Tests and a Decision-Tree Algorithm Clinical Examples of Cervical Spine Evaluations Common c-spine fractures: Jefferson, Locked/Perched Facets, Hangman s, Clay Shoveler s, Flexion-Teardrop 27

28 Acknowledgements Dr. Maryellen Sun, BIDMC Radiology Dr. Eric Zeikus, BIDMC Radiology Dr. Ken Lai, BIDMC Radiology Dr. Jim Wu, BIDMC Radiology Dr. Gillian Lieberman, BIDMC Radiology Pamela Lepkowski, BIDMC Radiology Larry Barbaras, Webmaster 28

29 References Bagley, L. Imaging of Spinal Trauma. Radiol Clin North Am 2006; 44:1-12. Banit, DM et al. Management of the Acute Cervical Spine: A Management Algorithm. J Trauma 2000; 49: Brant, WE and Helms, CA. Fundamentals of Diagnostic Radiology. Lippincott 1999: Brohi, K. Initial Assessment of Spinal Trauma ; 7:4. Daffner, RH. Controversies in cervical spine imaging in trauma patients. Emerg Radiol 2004; 11:2-8. Lingawi, SS. The Naked Facet Sign. Radiology 2001; 219: National Institute for Clinical Excellence. Head injury: triage, assessment, investigation and early management of head injury in infants, children and adults NICE guideline; Netter, F. Atlas of Human Anatomy. Havas Medi Media 1997; 2: Radiographic assessment of the cervical spine in asymptomatic trauma patients. Neurosurgery 2002; 50:S Radiographic assessment of the cervical spine in symptomatic trauma patients. Neurosurgery 2002; 50:S Stiell IG, Wells GA, Vandernheen KL, et al. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA 2001; 286: Tins, BJ and Cassar-Pullicino VN. Imaging of acute cervical spine injuries: review and outlook. Clin Radiol 2004; 59: Yao, LL et al. Imaging Evaluation of the Cervical Spine

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