Spinal Trauma Flashcards
must be cleared first for stability before
other views are attempted
Lateral cervical view
before ruling out
significant spinal injury don’t perform what views?
flexed and extended views
often required to fully
evaluate cervical spinal injury
Reconstructed CT scanning w/o contrast
Prevertebral (retropharyngeal & retrotracheal) soft tissues
evaluation
(significant indicator of underlying cervical injury)
Adults: no more than 22-mm at C6-C7 and no more than 7-mm at C2
soft tissue thickness at C2 should measure less than
50% of vertebral body width
At C6 or C7 soft tissues should measure less than the width of the
adjacent vertebral body
is loss of cervical lordosis is a reliable
indication of injury?
NO
seen in >20% of normal cervical radiographs
Absent lordosis
may cause flattening and/or reversal of lordosis
Post-traumatic cervical muscle spasm or
DDD
A reliable way to evaluate alignment of C/S is to look at what 4-lines?
- Anterior vertebral line
- Posterior (George’s) vertebral line
- Spinal laminar line
- Posterior spinous process line
may strongly indicate disruption of the
PLL, capsular and interspinous ligaments
Posterior disc space widening and fanning of the spinous
processes esp. at C3-C6
may indicate marked rotational
deformity and facet dislocation
Abrupt change in facet orientation
“double
SP sign” indicating
SP avulsion
C2-Odontoid normally it tilts ____ slightly
back
If the Odontoid leans more anterior, suspect
odontoid fracture
In adults C1-C2 distance on lateral view is approx.
2.5-mm
(should not
increase on flexion)
In children the C1-C2 distance may be up to
5-mm and may change by 1-2-mm in flexion
In children C1 lateral masses may slightly
overhang
what system can establish if the fracture is stable or unstable?
3-column Denis classification system
How can we establish if the fracture is stable or unstable?
stable fracture if only 1-column is injured
most spinal fractures may
involve some component of
flexion injury
S.C.I.W.O.R.A.
serious trauma including cord damage w/o radiographic
abnormality
posterior arch, Jefferson “burst” fracture, anterior arch lateral
mass fractures
C1-atlas
Hangman’s, Odontoid process, teardrop fracture
C2-axis
compression wedge or burst, flexion teardrop, pillar, isolated
lamina & TP, Clay Shoveler’s fractures
C3-C7
potentially unstable upper cervical injury
Occipital condyle fracture
x-ray may miss this
Occipital condyle fractures may be encountered more frequently due to
MVA injuries
Usually associated with severe injuries to facial skeleton and the
skull due to significant trauma
Occipitovertebral dissociation (less common but often fatal)
m/c fracture of the Atlas (>50%)
Bilateral fracture of the posterior arch of C1
Bilateral fracture of the posterior arch of C1 should not be confused with
Jefferson C1 fracture
mechanism of a bilateral fracture of the posterior arch of C1
extension/compression of the C1 arch by the occiput
• Relatively stable injury but may have >80% association with other
cervical fractures
Bilateral fracture of the posterior arch of C1
burst fracture of C1
Jefferson fracture
represents an osseous ring that ossifies between 3-6 years of
age (an may fracture)
burst fracture of C1 (Jefferson fracture)
“diving head first”, compression of occipital condyles
into lateral masses of C1
burst fracture of C1 (Jefferson fracture)
overhanging C1 masses, if >6-mm combined, suspect
transverse
ligament damage and marked instability
may occur due flexion or extension or a
combination of forces
Odontoid process fracture
less common, involves avulsion of the tip. May be unstable
contrary to some views
Type 1 - Odontoid process fracture
most common and most unstable through the base of the
odontoid process and may involve cruciate ligament.
(>23% missed cervical fractures)
Type 2 - Odontoid process fracture
through the base into the body and lateral masses.
Type 3- Odontoid process fracture
Can be
stable and carries best healing potential due to greater fracture surface
and vascularization.
Type 3- Odontoid process fracture
not to be confused with Dens fracture
Mach line (effect)
Not to be confused with Type 1 odontoid fracture.
Persistent ossiculum terminale.
traumatic spondylolisthesis of C2.
Hangman’s fracture
(Most cases
related to MVA)
Due to hyperextension and traction of the upper cervical spine leading to
b/l break of pars interarticularis of C2 and disruption of the discovertebral
junction
Hangman’s fracture
vertebral artery
damage may occur If fracture line extends to the
foramina intertransversaria
b/l break in pedicles and lamina of C2 and spondylolisthesis
of C2 body
spondylolisthesis of C2. (Hangman’s fracture)
A sliver of bone may be noted at anterior C2 body due to associated extension
teardrop fracture caused by
avulsion of the Anterior Longitudinal
Ligament attachment
hyperextension of the C/S may cause avulsion of the inferior-anterior corner of the
vertebral body
Extension teardrop fractures
unstable in extension
Extension teardrop fractures can be associated with Hangman’s fracture, especially
in older patients due to
spondylosis
one of the most severe injury of the cervical
spine, often causing anterior cervical cord syndrome and quadriplegia.
Flexion teardrop fracture (80% paralyzed on site)
typically occurs from severe flexion and
compression, most commonly at C5-6
Flexion teardrop fracture
Flexion teardrop fracture may cause
anterior cord damage due to posterior
displacement of vertebral body fragments
fracture of antero-inferior vertebral body
(teardrop sign)
Focal cervical kyphosis
fracture of antero-inferior vertebral body
- posterior cervical displacement above the level of injury
Fanning of interspinous processes
intervertebral disc space narrowing
disruption of the spinolaminar line
anterior dislocation of the facet joints
fracture of antero-inferior vertebral body (teardrop sign)
seen on lateral radiographs as an oblique lucency
through the spinous process, usually of C7.
Clay Shoveller Fracture
most typical mechanism of Clay Shoveller Fracture
sudden muscle contraction
occasionally direct blows to SP
Hyperflexion injuries to the vertebral body resulting from axial loading
Compression “Wedge fracture”
Compression “Wedge fracture” most commonly affecting the
anterior body aspect
wedge fractures are considered a
single-column (i.e. stable) fracture
Compression “Wedge fracture” may occur in the C/S but typically seen in the
thoracic and T/L region
no posterior body retropulsion, wedging of the anterior body
typically of superior end-plate impaction
Compression “Wedge fracture”
stable and no neuro
Compression “Wedge fracture” may share great
resemblance to
osteoporotic thoracic compression fracture
more common in the thoracolumbar region and
considered stable.
Simple wedge fractures
type of comminuted compression fracture which results
in disruption of the posterior vertebral body cortex with retropulsion of
fragments into spinal canal
Burst fractures
When burst fractures involve the thoracolumbar level, it tends to occur between
T9 and
L5 level.
result of high energy axial loading and nucleus is driven into the vertebral body below
burst fracture
All patients with burst fracture require a
CT to assess
burst of vertebral body fragments well demonstrated
on axial CT and
loss of posterior vertebral height on lateral radiographic views
burst fracture
retropulsed fragments in the spinal canal
burst fracture
Interpedicular distance widening
burst fracture
comminuted fracture often with posterior displacement (retropulsion)
of fragments and potential cord damage
Burst fracture
flexion distraction type of injury
Bilateral cervical facet dislocation
Results from hyperflexion & traction and also reported buckling force to be
involved
facet dislocation
If flexion/distraction injury occurs whilst cervical rotation is present- a
______ facet dislocation may occur.
unilateral
may tear capsular ligaments leading to facet of the
above vertebra overriding or perched on the one below
Flexion/distraction force
may be seen radiographically with
perched and dislocated facets
50% anterolisthesis of vertebral body
Overriding facets may typically produce _______ appearance due to sudden facet ______ on lateral cervical view
“bow tie”, rotation
Perched facet joint is a vertebral facet joint whose inferior articular
process appears to sit (perched) on the
ipsilateral superior articular
process of the vertebra below.
Any further anterior subluxation will result in dislocation, becoming locked in this position leading to
“Jumped facets”
will lead to overriding and “locked facets” frequently
seen in complete bilateral facet dislocation
“Jumped facets”
commonly at C4-C7 with C6 (40%) cases
Cervical articular pillar fracture
Fractures of the spinous process of a lower cervical vertebra (usually C7)
Clay-shoveler fracture
usually an avulsion-pull fracture
Clay-shoveler fracture
often goes unrecognized
seen on lateral views as an oblique lucency through the
spinous process, usually of C7
Clay-shoveler fracture
flexion-distraction type injury of the spine that extends through to involve all three spinal columns
Chance (seat-belt) fracture
Unstable injury and have a high association with intra-abdominal trauma
(esp. pancreatic and duodenal injury)
Chance (seat-belt) fracture
occurs from a flexion injury of the vertebral body and distraction
type injury of the posterior elements
Chance (seat-belt) fracture
back seat passenger restrained by a lap
seatbelt and involved in a motor vehicle accident or that of a person who
has fallen from a height
Chance (seat-belt) fracture
TL junction (T12-L1) contributes to ___ % of cases of chance fracture
50%
anterior wedge fracture of the vertebral body with horizontal
fracture through posterior elements or distraction of facet joints, disc and
spinous processes
chance (seat-belt) fracture
modality of choice for chance fracture
CT scanning
treatment for chance fracture
surgical or fibreglass plaster with some extension
Radiographically anterior body narrowing and fracture through posterior elements
Chance (seat belt)
Radiographic evaluation of “whiplash injury” is often
unrewarding
