Cervical Spine Trauma: Interpretation of the C-Spine Film
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1 November 2000 Cervical Spine Trauma: Interpretation of the C-Spine Film Gerlock AJ, Heller RM, Kaye JJ, Kirchner SG: The Cervical Spine in Trauma. Advanced Exercises in Diagnostic Radiology, vol 11. W.B. Saunders, 1978 Anthony Powell, Harvard Medical School- Year III 1
2 Common Mechanisms of Injury Hyperflexion- MVA, car comes to sudden stop Hyperextension- MVA, car struck from behind Compression- Head first dive in shallow water 2
3 Clinical Procedure involving Pts with suspected spine injury Pt kept in cervical collar and immobilized on spine board ABCDEF ER protocol followed (airway, breathing, circulation, disability/drugs, exposure, Foley catheter) History and physical (pt handled as though serious injury present) Decide if imaging is necessary 3
4 Vandermark risk-tailored approach in assessing need for neck imaging No Risk- no hx or physical findings suggestive of neck injury Low Risk- pt has hx for a mechanism of injury unlikely to have exceeded physiologic range of cervical motion Medium Risk- pt has hx for mechanism of injury sufficient to have exceeded physiologic cervical ROM High Risk- pt has hx for mechanism of injury very likely to have exceeded physiologic ROM 4
5 High Risk Factors for cervical vertebral injury High-velocity blunt trauma Multiple, severe long bone fractures Direct cervical region injury Altered mental status Fall from greater than 10 feet Drowning / head first diving accident Significant head or facial injury Neck pain, tenderness, or deformity Abnormal neurological examination Thoracic or lumbar vertebral fracture Hx of pre-existing vertebral disease 5
6 Imaging Must Assess for Spinal Cord Stability Critical assessment which determines pt s management and handling Unstable- spinal canal is no longer protected by its ligament and bony supports Any movement of neck could result in permanent cord damage 6
7 Menu of Imaging Options Cervical Spine Plain Films -standard first line imaging modality in assessing cervical vertebral injury Cervical CT -to evaluate extent of injury with any definitive finding on plain film -delineating equivocal/uncertain findings on plain film Cervical MRI -pt with c-spine trauma who exhibits neurological signs and symptoms suggestive of cord injury 7
8 In order to recognize the abnormal, we need to know the normal appearance Let s review some c-spine anatomy: 8
9 Atlanto-axial joint Odontoid Anterior arch Superior articulating surface Lateral mass Posterior arch C1, Atlas C2, Axis Cervical spine Images: Netter, FH: Atlas of Human Anatomy, 2 nd ed. Novartis,
10 Occipito-Atlanto-Axial Joint Occipital condyle Odontiod C1 C2 Lateral mass C1 Lateral Mass C2 C2 Gerlock AJ, Heller RM, Kaye JJ, Kirchner SG: The Cervical Spine in Trauma. Advanced Exercises in Diagnostic Radiology, vol 11. W.B. Saunders,
11 Cervical Vertebrae Pedicle Vertebral body Facet Lamina Spinous process C7 Netter, FH: Atlas of Human Anatomy, 2 nd ed. Novartis, 1997 Gerlock AJ, Heller RM, Kaye JJ, Kirchner SG: The Cervical Spine in Trauma. Advanced Exercises in Diagnostic Radiology, vol 11. W.B. Saunders,
12 Radiograph Correlations Rotation effect on lateral view Apophyseal / facet joints Gerlock AJ, Heller RM, Kaye JJ, Kirchner SG: The Cervical Spine in Trauma. Advanced Exercises in Diagnostic Radiology, vol 11. W.B. Saunders,
13 Ligaments Ant Longitudinal lig Post Longitudinal lig Ligamenta Flava Supraspinous lig Netter, FH: Atlas of Human Anatomy, 2 nd ed. Novartis, Gerlock AJ, Heller RM, Kaye JJ, Kirchner SG: The Cervical Spine in Trauma. Advanced Exercises in Diagnostic Radiology, vol 11. W.B. Saunders, 1978
14 C-Spine Plain Films Standard 5 view series: Cross table lateral AP of lower cervical column Atlanto-axial AP (open mouth, odontiod) Bilateral supine trauma oblique views 14
15 Normal C-spine 5 view series Lateral AP Odontoid Right Oblique Left Oblique 15 Gerlock AJ, Heller RM, Kaye JJ, Kirchner SG: The Cervical Spine in Trauma. Advanced Exercises in Diagnostic Radiology, vol 11. W.B. Saunders, 1978 ; BIDMC
16 C-spine Film Interpretation 7 step process 1. Count Vertebrae (lateral) -C1 through C7 -If T1 not seen get a swimmer s view 2. Assess Curvature (frontal and lateral) 3. Assess Vertebral Alignment (on lateral: 4 lines) -ant vertebral line -post vertebral line -spinolaminar line -post spinal line 16
17 The 4 Contour Lines Gerlock AJ, Heller RM, Kaye JJ, Kirchner SG: The Cervical Spine in Trauma. Advanced Exercises in Diagnostic Radiology, vol 11. W.B. Saunders,
18 C-spine Film Interpretation 7 step process 1. Count Vertebrae -C1 through C7 -If T1 not seen Swimmer s view 2. Assess Curvature 3. Assess Vertebral Alignment (4 lines) -ant vertebral line -post vertebral line -spinolaminal line -post spinal line 4. Assess Bony Integrity 5. Assess Intervertebral Disk Spaces 6. Assess OAA joint 7. Soft Tissues 18
19 Patient 91 y.o. female who presents to ED with a laceration and contusion to her right eye, suffered when she fell out of her bed at the assisted living facility. Fall was not witnessed. Pt is also complaining of neck pain. Pt reports no loc, n/v, visual changes, headache, numbness or weakness. Exam reveals no focal or gross neurological deficits. Pt is secured in a hard cervical collar. Pt sent for plain films 19
20 Our patient s lateral c-spine Film findings: 1. C2 fracture through base of odontoid process 2. Approx 4mm posterior displacement of C1 on C2 Farrell, Susan MD. Teaching Files. BIDMC dept of Emergency Medicine,
21 Our patient s course An MRI confirmed the dens fx with no compromise of the spinal canal. Treatment: Due to pt s age and medical conditions, she was treated conservatively with hard collar immobilization. Interval x-rays were ordered to assess for odontoid mobility. 21
22 Let s review some other patients whose c-spine plain films demonstrate common cervical fractures 22
23 Hangman s Fracture Bilateral pedicle fractures of C2 (axis) Anterolisthesis of C2 on C3 Unstable fracture Hyperextension injury -fracture is identical to those occurring upon hanging -elderly may slip and strike chin on basin or counter -MVA in which chin strikes steering wheel 23
24 Hangman s Fracture 24 Gerlock AJ, Heller RM, Kaye JJ, Kirchner SG: The Cervical Spine in Trauma. Advanced Exercises in Diagnostic Radiology, vol 11. W.B. Saunders, 1978
25 Teardrop Fracture Avulsion fracture of anterior margin of vertebral body Anterior longitudinal lig instability (rupture, avulsion) Hyperextension injury Unstable injury Lamina may jam together causing ligamenta flava to buckle inward and compress/contuse the spinal cord 25
26 Teardrop Fracture Gerlock AJ, Heller RM, Kaye JJ, Kirchner SG: The Cervical Spine in Trauma. Advanced Exercises in Diagnostic Radiology, vol 11. W.B. Saunders,
27 Compression Fracture Variable severity, from minimal anterior wedging to complete disruption of vertebral body (burst) Look for loss of vertical height of vertebral body Due to long axis compression or hyperflexion -diving into shallow pool Stable unstable 27
28 Compression Fracture Gerlock AJ, Heller RM, Kaye JJ, Kirchner SG: The Cervical Spine in Trauma. Advanced Exercises in Diagnostic Radiology, vol 11. W.B. Saunders,
29 Jefferson Fracture Compression/bursting fracture of C1 ring Due to long axis compression forces Results in uni or bilateral displacement of C1 lateral masses with respect to C2 sup articulating facets Best seen on odontoid (open mouth) view Unstable if transverse ligament is disrupted, resulting in C1 anterolisthesis May be stable 29
30 Jefferson Fracture 30 Gerlock AJ, Heller RM, Kaye JJ, Kirchner SG: The Cervical Spine in Trauma. Advanced Exercises in Diagnostic Radiology, vol 11. W.B. Saunders, 1978
31 Clay Shoveler s Fracture Avulsion fracture of spinous process by supraspinous ligament Usually occurring from C6-T2 Hyperflexion; direct trauma; downward force via thoracoscapular muscle (as in shoveling motion) Stable 31
32 Anthony Powell Clay Shoveler s Fracture 32 Gerlock AJ, Heller RM, Kaye JJ, Kirchner SG: The Cervical Spine in Trauma. Advanced Exercises in Diagnostic Radiology, vol 11. W.B. Saunders, 1978
33 Dens Fracture Fracture of the base of the dens (odontoid) of C2 Anterior or posterior displacement of the dens Can occur at various levels on the dens Via hyperflexion or hyperextension of head on neck Unstable if displacement occurs 33
34 Dens Fracture Gerlock AJ, Heller RM, Kaye JJ, Kirchner SG: The Cervical Spine in Trauma. Advanced Exercises in Diagnostic Radiology, vol 11. W.B. Saunders,
35 References Daffner RH: Evaluation of cervical vertebral injuries. Seminars in Roentgenology 24: , 1992 Gerlock AJ, Heller RM, Kaye JJ, Kirchner SG: The Cervical Spine in Trauma. Advanced Exercises in Diagnostic Radiology, vol 11. W.B. Saunders, 1978 Vandermark RM: Radiology of the cervical spine in trauma patients: Practice pitfalls and recommendations for improving efficiency and communication. AJR 155: , 1990 Novelline, RA: Squire s Fundamentals of Radiology, ed 5. Harvard University Press, 1997 Farrell, Susan MD. Teaching Files. BIDMC dept of Emergency Medicine, 2000 Netter, FH: Atlas of Human Anatomy, 2 nd ed. Novartis, 1997 Gunderman, RB: Essential Radiology, clinical presentation, pathophysiology, imaging. Thieme,
36 Acknowledgements Beverlee Turner for her support and PowerPoint expertise. Susan Farrell MD 36
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