Radiological Evaluation of C-spine Flashcards by Kilani Gaston

3 main views for C-spine

AP
APOM
Lateral

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Swimmer’s lateral projection performed to assess:

Lower cervical segments and CT junction

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Most diagnostic view

lateral

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Oblique view assesses:

Neural Foramina: indicates radiculopathy

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Flexion/Extension stress views assess:

instability

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Best modality for viewing C spine Trauma

CT scan

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If neurological deficit is detected in C spine what modality should be used?

MRI: can view bony fragments as well as injury to spinal cord, disk, and soft tissue

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Two evidence based guidelines established by clinicians to decide whether or not to use radiographs:

Canadian C-Spine Rule

2. National Emergency X-Radiography Utilization Study(NEXUS)

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Canadian C-Spine Rule requires the patient to be___ and ___

alert and medically stable

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What are the 3 main questions of the C-spine rule?

Any high risk factors that mandate radiography?
Any low risk factors that allow safe assessment of ROM?
Is pt. able to rotate neck actively at least 45 degrees L and R?

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High risk factors that mandate radiography include?

Age over 65 years, dangerous MOI, parathesia in extremities

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Low risk factors that mandate radiography include?

Tenderness over midline of Cspine, pain with normal sitting, DOMS of neck, pt not being ambulatory at time of crach

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Canadian C-spine Rule has what sensitivity and specificity?

100% sensitivity and 43% specificity

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For NEXUS, radiographs are indicated following trauma unless pt meets all five criteria:

No post. midline cervical tenderness
No evidence of intoxication
Normal level or alertness and consciousness
No focal neurological deficit
No painful distracting injuries

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Nexus has a specificity of __ and a sensitivity of __

12.9%, 99.6%

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Evidence based guidelines point to patient having a radiograph if they meet the following criteria

Dangerus MOI
Over 65 years old
Paresthesia
Midline Tenderness over spine
Unable to rotate neck 45 degrees L or R

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ACR recommends that if pt meets criteria for CCR or NEXUS then this modality should be used with these 2 views

CT with sagittal and coronal reformatting

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ACR recommends that if pt meets criteria for CCR or NEXUS then these two modalities should be used as complementary studies

CT and MRI

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This view should be used first if the pt has had a history of trauma but has not be evaluated for trauma yet

Lateral: assess normal cervical alignment with series of parallel vertebral lines
-discontinuity or step offs indicate possible fracture/dislocation

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This view is used in severe trauma cases and functions as a preliminary diagnostic screen

Cross-table lateral View

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Radiology of C-spine evaluates:

soft tissue, vertebral alignment, joint characteristics

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Widening retropharyngeal or retrotracheal spaces should follow these distance rules

6mm at 2 and 22mm at 6

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Large IVD height indicates what kind of damage:

anterior tissue damage, rupture of posterior ligament

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Small IVD height indicates what kind of problem:

IVD problem such as rupture of disk, extrusion of nuclear material

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Loss of parallelism of Cspine indicates:

fracture, dislocation, or severe degenerative changes

Loss of lordosis of C-spine indicates:

muscle spasm in response to underlying injury

Acute Kyphotic angulation of the C spine indicates:

widened interpinous space indicating rupture of post. ligaments

Rotation of the vertebral bodies at the C-spine indicates:

unilateral facet dislocation, hyperextension fractures, muscle spasm, or disk capsular injury

APOM views what the best:

Lateral masses of C1 and the dens of C2

Normal overhang of the lateral masses of C1 over the body of C2 is:

1-2mm; any more is abnormal

A widened ADI indicates:

degeneration, stretching, or rupture of the transverse ligament

Widening of the interspinous process space indicates:

- Fanning | - rupture of interspinous and other posterior ligamanets

Loss of facet joint articulation indicates:

dislocation

Injuries to the spinal cord are broadly classified as ___ and ___

stable and unstable

These injuries are protected from significant bone or joint displacement by intact posterior spinal ligaments: answer stable or unstable

Stable | ex//compression fractures, disk herniations, unilateral facet dislocations

These types of injuries show significant displacement initially or have potential to become displaced with movement: answer stable or unstable

Unstable | ex//bilateral facet dislocations, fracture-dislocations

What are the most frequently injured levels of the C-spine?

C1-C2 and C6-C7

Adults mostly injure what levels of the C-spine

Lower levels

Children more frequently injure what levels of the C spine?

Upper | They have big heads, upper spine can't handle that much weight

C-spine fracture has __% incidence of associated neurological injury

40%

C-spine is __ of all spinal cord injuries?

2/3

What are the two most common MOI of the C-spine?

1. Flexion/extension | 2. Loaded flexion of C-spine

SCIWORA Syndrome stands for:

Spinal Cord Injury Without Radiographic Abnormalities

SCIWORA is predominant in what populations?

Children with inherent elastic pediatric spine | -cause ligamentous injury and cartilagenous vertebral endplate fracture

In adults, SCIWORA presents as:

acute disk prolapse and/or excessive buckling of the ligamentum flavum

Two main types of fractures of the C-spine include:

Avulsion and compression/impaction fracture

Definition: bone fragment pulled off by violent muscle contraction or passive resistance of ligament applied against an oppositely directed force

Avulsion Fracture

Definition: adjacent vertebrae forced together

Compression Fracture

In a compression fracture: Axial compression produces __ fracture of impacted vertebral body

burst

In a compression fracture: flexion forces compresses impacted body into an anterior __ shape

wedge

In a compression fracture: extension force compresses ___ __

articular pillars

A wedge fracture is caused by a ___ force

hyperflexion

This type of fracture occurs when the IVD is axially compressed and NP is driven through the adjacent vertebral endplate

Burst Fracture | -will see posterior displacement

True or False:Burst fracture may be stable or unstable

True | Depends on configuration of fracture.

Triangular fragment of bone becomes separated anterioinferior corner of vertebral body due to avulsion from hyperextension of compression from hyperflexion

Tear drop fracture

What is the most severe lower cervical fractures?

Flexion teardrop

Fracture from compressive hyperextension force combined with lateral flexion

Articular Pillar Fracture | -stable; normally at C6

Avulsion fracture of SP by hyperflexion or forceful contraction of traps/rhomboids

Clay Shoveler's fracture

Uncommon fracture at TVP in C7; usually a result from lateral flexion forces causing an avulsion at tip of contralateral TVP

Transverse process fracture

Most serious and life threatening injuries

Fractures associated with dislocations

Transient dislocation or subluxations are often referred to as:

self-reducing dislocations | -momentarily disengage articulations but return to normal alignment once force dissipates

Axial fractures associated with ant dislocation of C2 on C3

Hangmans fracture

Complete facet joint dislocations unilaterally occur due to what type of force?

Hyperflexion and rotation force

Complete facet joint dislocations occur bilaterally due to what type of force?

Hyperflexion Force

What are the components of a unilateral facet dislocation tear?

One facet capsule and posterior ligaments

If there is no vertebral body subluxation, is a unilateral facet dislocation stable or unstable?

Stable injury

Are bilateral facet joint dislocations considered stable or unstable?

Unstable due to extensive disruption of post ligaments, facet joint capsules, annulus fibrosis and sometimes ant longitudinal ligament

Which type of dislocation, unilateral or bilateral, would be most likely associated with spinal cord injuries?

Bilateral

Hyperflexion sprains disrupt ant or post ligament complex?

Posterior; obtain stress views

Hyperextension sprains disrupt ant or post ligament complex?

Anterior; may result in posterior subluxation

What treatment would you do for sprains?

Immobilization, pain management, rehab

What treatment options are there for dislocations?

Reduction(traction), Immobilization

Acute disk herniation resulting in nerve root compression in Cspine is common or uncommon?

Uncommon: inherent anatomic protection within C spine formed by ant positioned NP, posteriorly reinforced AF, wide double layers of PLL and unconvertable joints

Degenerative disk disease is due to the degeneration of:

IVD

Degenerative joint disease is due to:

Osteoarthritic changes at synovial facet joints

Foraminal encroachment is due to:

diminished dimensions of IVF secondary to degenerative changes in adjacent structures

Spondylosis is due to:

osteophyte formation at joint margins

Advanced spur formation from degeneration of vertebral bodies and AF contributes to:

Spondylosis Deformans

Ossification along ant vertebral bodies and disk spaces contributes to

Diffuse idiopathic skeletal hyperostosis(DISH)

What age group is at risk for Degenerative disk diseases

>60 years of age

Intervertebral herniation of NP through endplate into spongiosa of vertebral body is called

Schmorl's nodes

Nitrogen gas from extracellular spaces accumulating in degenerative dehydrated fissures of disk is called:

Vacuum Phenomenon

Hallmark of DDD is:

decreased disk height

Hallmark of DJD is:

decreased joint space, subchondral sclerosis, ostephytes

What view would be used to see foraminal encroachment?

Oblique

What levels of the C-spine would you most likely find osteophytes in response to DDD

C4-C5 and C5-C6

Would spondylosis deformans typically show a decrease in disk height?

This type of degenerative disease typically shows a claw-like formation, cupping toward the IVD

Spondylosis deformans

This type of degenerative disease has an unknown etiology but is often found in diabetic pt.

DISH(Diffuse idiopathic skeletal hyperostosis) | -also found in pt with growth hormones, vitamin A, retinoid derivatives, metabolic syndromes

In what age and gender demographic group would you typically see DISH

Age 40, male

3 criteria of DISH:

1. Flowing ossification of at least 4 contiguous vertebral bodies 2. Preservation of disk height 3. Absence of facet joint DJD