22/04/2014

Spinal Trauma
Hifz-ur-Rahman Aniq
Royal Liverpool University Hospital
Honorary lecturer, University of Liverpool

Cervical Spine

Causes of
cervical spinal
injury (UK)

The most vulnerable yet most common

Cervical Trauma
! RTA

young age

! Falls

- after age 45

! 82%:

age at time of injury is 33.4 years

male, 18%: female

! Devastating

injury

37%

RTA

36%

Sports

20%

Assault

6.5%

Cervical Injury
!

1-3 % of all trauma cases

2/3 of spinal cord injuries

! Missing
! Average

Fall

trauma - instability and quadriplegia

! Associated

with Other injuries

Head (70%)

Rest of spine (10%)

Chest (35%)

Pelvis (15%)

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Cervical Spine Clearance

Aim of imaging
!Is

Accurate confirmation of absence of

there spinal trauma

!Spinal

cervical spine injury

!Level

stability

and Extent of injury

!Follow

up

Cervical Trauma
!Is

any imaging required?

!Investigation
!Normal

of choice

anatomy

!Mechanism
!Imaging

of injury

Algorithm

National Emergency X-Radiography

No Xray Needed
!

No posterior midline cervical spine tenderness

No evidence of intoxication

Normal level of alertness

No focal neurologic deficit

Is any imaging required?

No painful distracting injuries

Canadian C spine (CSS) Rule

YES

NO
Any low factor which allows safe assessment
of the range of movement
Simple rear-end RTA
Ambulatory at any time of scene
No neck pain at the time of injury
Absence of midline tenderness

NO

YES
Pt voluntarily able to rotate neck 45 both
sides regardless of pain

YES
Hoffman et al, N Eng J Med 2000

IMAGING REQUIRED

NO IMAGING REQUIRED
Stiell et al, JAMA, 2001

YES
Dangerous Mechanism
Fall from height 3 Ft or 5 stairs
Axial loading to head e.g diving
RTA-100 km/hr, rollover, ejection
Bicycle collision
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NEXUS vs CSS rule

are powerful predictor of cervical

Plain Xrays
!Sensitivity
!Negative

98.1%

predictive value 99.8%

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Plain films

Optional views
Swimmers view
Flexion and extension

ABCS of C spine

! AP

!A

! Lateral

!B

Bones

! Open

!C

Cartilage

!S

Soft tissues

! Both

mouth

obliques

Adequacy

Alignment

Alignment
Anterior Spinal Line
Posterior spinal line
Spino-laminar line
Posterior spinous line

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Bones & Cartilage

Soft Tissues
Atlanto axial Space
Children 5 mm
Adults 3 mm

CT Scan

Retropharangeal space
C2-5 5mm

Retro tracheal space

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Cervical spine CT

CT Scan
! Routine

isotropic imaging

! Reformats

and 3D Images

! Comprehensive
! High

display of bony anatomy

sensitivity to fractures

! Simultaneous

assessment of vascular injuries

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CT scan cannot rule out ligament

Plain Xrays vs CT scan

injuries

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Cervical Injury Plain Films

Cervical Injury CT scan

! Sensitivity

! Sensitivity

! 1/3rd

! Audit

for fractures 43 - 52%

fractures are unstable

! Even

- Average 5 views performed to achieve

a fracture was missed but did not affect

management

satisfactory images
! Open

for fracture 98.5%

! Negative

mouth and swimmer views difficult to

perform in patients with cervical stabilisation

predictive value

! Ligament

injury 99%

! Unstable

cervical spine 100%

and intubation
Como et al, J Trauma 2007
Nunez et al, Emerg Radiology, 1994

Hennessy et al, J Trauma, 2010

Griffin et al, J Trauma, 2003

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Cervical injury - CT scan

Plain Radiography vs CT scan

trauma work up time

! CT

! Increased
! Plain

disposition of patients from trauma bay

effective
Moderate to severe Trauma
"

! Low

Xrays have no role in cervical screening

Paralysis prevention

risk group

Plain Xrays Old studies

New studies Suggested if any imaging is

Daffner et al, J Am College Radiol, 2007

Bailitz et al, J Trauma 2005

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Cervical Injury CT scan

Plain Radiography vs CT Scan

! Radiation
! 14
!

fold increase compared to PF trauma series

! Increase

! If

NEXUS criteria is applied - 20 %

reduction in the unnecessary exams

radiation dose to thyroid

! Over-utilization
! Cost

and radiation

! Consistent

application of NEXUS criteria

Obtunded patient
!Plain
!CT!In

Obtunded patient

Xrays Not recommended

!Prolonged

deterioration, pressure ulceration,

case of normal CT
patient in collar immobilization until clinical

exam can be performed

collar

! Perform

MR

immobilization

! Respiratory

First line of investigation

! Keep

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! Increase

health care cost

!Unstable

c spine injuries with normal CT

Harris et al, spine 2008

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CT in obtunded patients
!Hogan

!MR

Indications of MRI

et al

!Prospective

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! Unstable

study

spine on CT

Extent of bony or ligament injury

of 366 obtunded patient with negative CT

! Progressive

96.7% Normal, 1.9% cord contusion, 1.1 ligament

! Severe

!Negative

predictive value

! Ligament

injury 98.9%

! Unstable

spine 100%

neurologic deficit

pain

Epidural haematoma

Acute Traumatic disc herniation

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MR protocol
Whole spine
!Sagittal

T1

!Sagittal

STIR

!Axial

T2

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Mechanisms of injury
! Hyperflexion

Mechanism of Spine injury

Hyperflexion injury 50-70%

wedge fracture
teardrop fracture

! Anterior

subluxation

! Bilateral

facet locking

! Spinous

process fracture

! Odontoid

injury

! Hyperextension

injury

! Vertical

compression

! Flexion

Rotation Injury

! 10-20%

combination of more than one

Flexion Strain
! No

fracture

! Spinous
! Flexion

process widening

views needed

! Anterolisthesis

3mm

! Stable

fracture

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Wedge fracture

Flexion tear drop

devastating cervical injury

! Great

flexion / compression force

! Marked
! C5

ligamentous damage

7 level

! Unstable
! Instant
! 70

Flexion tear drop

C5/6

quadriplegia or acute cord syndrome

% have neurological deficit

Perched facets

Bilateral Locked facets

injury

than 50% of forward slip

! Unstable

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Odontoid fracture I
! 5%

50

Odontoid fracture Type II

! Difficult

to detect

! Unstable

! Stable

! Cx

! D/D

! MR

Non Union

Os Odentoideum

Odontoid fracture Type III

Odontoid fracture type II

! 30%
! Good

prognosis

! Unstable

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Odontoid fracture Type III

Vertical Compression (4%)

Jefferson Fracture
! Comminuted

Fracture

fracture

Jefferson Fracture

Fracture of C1

! Mechanism
!

Axial loading Anterior arch

Hyperextension Posterior arch

! Lateral

displacement of lateral masses

! Unstable

Burst fracture
! Axial

Loading

! C3-C7
! Posterior

Ligament can be

disrupted than it is unstable

pulsed fragment Can

cause spinal cord injury

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Hyperextension injuries 20-35%

fracture

! Extension

tear drop

! Neural
! Ant

Hangman's Fracture

Arch fracture of C1

/ post dislocation

Hangman's Fracture
!Most

Hangman's Fracture

common C - spine injury

!Bilateral

pars defect of C2 with or without

forward slip
!Associated

teardrop Fracture of C2 / C3

!Unstable

Hangman fracture

66

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Hangman's Fracture

Extension tear drop

at C2-3 level

! Associated

with fractures of

spinous processes
! Elderly

people

! Stable

Extensor teardrop

Flexion - Rotation injury (10%)

Unilateral Facet Locking

locked facet

Unifacet locking

Rotation Mechanism

- 50% forward slip

!30%

present with neurological

!Associated

with nerve root

injuries

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Unifacet locking

Cervical spine trauma

case of cervical spine fracture

!50%

have a fracture at an adjacent level

!15%

have a fracture in another part of the

cervical spine
!10%

have fractures in thoracic/ lumbar

spine

Whole
Spine MR

75

Suspected spinal Trauma

Yes
NO

Can spine be cleared clinically?

CT Scan

Evidence of
C spine injury ?

Thoracic & Lumbar spine

Continue spinal stabilization

NO

Neck pain or
Neurologic deficit

YES

MRI C Spine

NO
Remove collar

Evidence of
C spine injury

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Lumbar
spine
Anterior column
Middle column

Posterior column
Fractures
Two column - Unstable
One column - Stable

Burst Fracture

Axial
compression

Axial compression

Chance fracture
!Flexion,

distraction mechanism

!Usually

associated with seat belt

!Fractures
!40%

are subtle

present with intrabadominal injuries

!Thoracolumbar
!Usually

junction

no neurology

Mark et al, AJR, Oct 2006; 187: 859 - 868

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Chance Fracture

Chance fracture

!Imaging

!Thoracolumbar

! Increased
! Empty

!35

intraspinous distance

! Unstable

-50% have intra-abdominal injuries

! Pancreas

vertebral body

! Fracture

junction

! Duodenum

through pedicle, laminae, disc

! Mesentery

Three column involved

Tyroch AH et al, Am Surg. 2005 May;71(5):434-8.

Empty Vertebral sign

87

Epidural haematoma

Summary
!Moderate

to severe spinal injury - CT

Straight away
!Low

risk Injury Plain X rays / CT scan

!MRI
! Occult
! Acute

injuries
disc / ligament injuries Normal CT

! Neurological

deficit

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Thank You

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