Shreya Kangovi HMS III

Gillian Lieberman, MD

Cervical Spine Trauma

Shreya Kangovi
Radiology Core, BIDMC
July 25th, 2004
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Overview

-Menu of tests
-Anatomy Review
-Case Interpretation

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Menu Of Tests: Who and How?

Why not image every blunt trauma victim?

•Imaging of cervical spine in the United States cost
$4 billion in 1994.
•Prevalence of detected cervical spine injury in
screened patients is .2%-4.3%
•There was a clear need for clinical criteria to
identify patients who had a high enough probability
of injury to warrant imaging
F.A. Mann, et al. ‘Evidence-based approach to using CT in spinal trauma’. European Journal of Radiology, Vol 3
48, Usse 1, 10/03
Menu Of Tests: NEXUS

Radiography indicated if a patient meets ANYof criteria

• Posterior midline cervical tenderness
• Evidence of intoxication
• Abnormal level of alertness (GCS <14)
• Focal neurological deficit
• Painful distracting injuries

Hoffman et al., ‘Validity of a Set of clinical Criteria to Rule Out Injury to the Cervical Spine in patients with 4
Blunt Trauma. NEJM, Col 343; 13, July 2000
Menu Of Tests:
Canadian C-spine Rule
Any High-risk factors (age
>65, dangerous mechanisms, paresthesias)

No
Yes

Any Low-risk factors (Simple

rear-end, sitting/ambulatory in ED, delayed No Radiography
onset of pain, absence of midline tenderness)

Yes
No

Able to rotate neck actively

Yes

No radiography Stiell et al, The Canadian C-spine Rule vs NEXUS; NEJM Dec 25, 2003 5
Menu of Tests: How?

Screening Technique: CT vs Plain Film

•CT is more sensitive, specific and fast. But also more costly, so
doesn’t make sense to use for every case
•If pre-test probability of injury is greater than 10%, CT is actually
cost effective compared to plain film (less missed injury and follow-up
imaging)
•How can we isolate a population of patients with pre-test probability
of >10%?

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Menu of Tests: How?
High-risk criteria for use of screening CT
•Neurological deficit
•Head Injury
•High-energy mechanism
•Patients with any of these criteria have 12.8% risk of cervical injury

Indications for MRI

•Incomplete/progressive neurological deficit
•Level of edema for planning decompression
•Planning stabilization for ligament/disk injury
Blackmore et al; ‘Helical CT in the primary trauma evaluation of the C-spine: an evidence-based approach’. 7
Skeletal Radiology 29:632-639
Anatomy- Typical
Vertebrae
Transverse
foramen

Uncinate
Process

Pedicles,
articular
processes,
IV discs
•What is the distinguishing feature of cervical vertebrae?
•Which structure functions as a guiderail for vertebral
bodies to prevent lateral displacement?
•What are the boundaries of the neuroforamina? 8
 Anatomy- High Vertebrae
Anterior arch

Transverse
Lateral Masses Ligament
w/ 4 articular Body of C2
surfaces

Posterior arch Transverse

Processes

Lamina
Dens

Pedicle

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Living Anatomy

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Living Anatomy

Contours:
-Soft Tissue: look for swelling,
which is a sensitive indicator of
underlying injury of spine
-Anterior longitudinal ligament
-Posterior longitudinal ligament
-Spinolaminal line (corresponds to
Ligamentum Flavum)
-Supraspinous line
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Living Anatomy
Columns:
-Anterior column: contains anterior
longitudinal ligament, vertebral
body, intervertebral disk and
posterior longitudinal ligament
-Posterior column: contains
everything posterior to posterior
longitudinal ligament
-Two columns are affected
reciprocally by injury; e.g.
hyperflexion compresses anterior
column and distracts posterior 12
column
Patient 1:
Approach to C-Spine: Sagittal
A. Alignment
Contour Lines
Interlaminous/Interspinous Distances
Anterior atlantodense interval
B. Integrity
Osseous Integrity
Occipital condyles*
Lateral masses of C1*
*Better seen on parasagittal 13
Patient 1:

Approach to Cervical Spine: Axial

Further examine abnormalities seen on sagittal
Scan each level for intact body and posterior arch
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Patient 1:

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Patient 1: Teardrop Hyperflexion
fracture-dislocation

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Patient 2:

1. Contour Lines
2. Interlaminous/spinous
distances
3. Atlantodens interval
4. Osseous Integrity
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18
19
Patient 2: Fracture of the
dens...

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...and Jefferson Burst Fracture

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Patient 2: Fracture of the
dens + Jefferson Fracture

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Summary
-Menu of tests:
•NEXUS & Canadian C-Spine Rule

-Anatomy Review
•Typical Vertebrae
•Atypical Vertebrae

-Case Interpretation
•Hyperflexion Teardrop Fracture
•High Dens Fracture
•Jefferson Burst Fracture

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References:

1. F.A. Mann, et al. ‘Evidence-based approach to using CT in spinal trauma’. European Journal
of Radiology, Vol 48, Usse 1, 10/03
2. Hoffman et al., ‘Validity of a Set of clinical Criteria to Rule Out Injury to the Cervical Spine in
patients with Blunt Trauma. NEJM, Col 343; 13, July 2000
3. Stiell et al, The Canadian C-spine Rule vs NEXUS; NEJM Dec 25, 2003
4. Blackmore et al; ‘Helical CT in the primary trauma evaluation of the C-spine: an evidence-
based approach’. Skeletal Radiology 29:632-639
5. Harris J., Mirvis S. The Radiology of Acute Cervical Spine Trauma. Williams & Wilkins.
1996
6. Kricun R., Kricun M. MRI and CT of the Spine: Case Study Approach. Raven Press. 1994
7. Gehweiler, Osborne, Becker. The Radiology of Vertebral Trauma. W.B Saunders Company.
1980
8. Reynolds P., Abrahams P. ‘McMinn’s Interactive Clinical Anatomy: Head and Neck’ CD-
ROM. Mosby 1997
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Acknowledgments

•Dr. Ivan Pedrosa for providing all case images

•Dr. Barbara Appignani
•Dr. Gillian Lieberman
•Pamela Lepkowski
•Larry Barbaras

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