Anthony Powell Gillian Lieberman, MD

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 Gillian Lieberman, MD

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Anthony Powell Gillian Lieberman, MD

Common Mechanisms of Injury

• Hyperflexion- MVA, car comes to sudden stop • Hyperextension- MVA, car struck from behind • Compression- Head first dive in shallow water

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Anthony Powell Gillian Lieberman, MD

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

Anthony Powell Gillian Lieberman, MD

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

Anthony Powell Gillian Lieberman, MD

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

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Anthony Powell Gillian Lieberman, MD

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

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Anthony Powell Gillian Lieberman, MD

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

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Anthony Powell Gillian Lieberman, MD

In order to recognize the abnormal, we need to know the normal appearance Let’s review some c-spine anatomy:

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Anthony Powell Gillian Lieberman, MD

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, 2nd ed. Novartis, 1997

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Anthony Powell Gillian Lieberman, MD

Occipito-Atlanto-Axial Joint Occipital condyle Odontiod Lateral mass C1 C2

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, 1978

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Anthony Powell Gillian Lieberman, MD

Cervical Vertebrae Vertebral body Pedicle

Facet

Lamina

Spinous process

C7 Netter, FH: Atlas of Human Anatomy, 2nd 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, 1978

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Anthony Powell Gillian Lieberman, MD

Radiograph Correlations

Rotation effect on lateral view

Apophyseal / facet joints

12 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 Gillian Lieberman, MD

Ligaments Ant Longitudinal lig

Post Longitudinal lig

Ligamenta Flava

Supraspinous lig

Netter, FH: Atlas of Human Anatomy, 2nd 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, 1978

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Anthony Powell Gillian Lieberman, MD

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

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Anthony Powell Gillian Lieberman, MD

Normal C-spine 5 view series

Lateral

AP

Right Oblique

Odontoid

Left Oblique

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

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Anthony Powell Gillian Lieberman, MD

C-spine Film Interpretation 7 step process 1. Count Vertebrae (lateral) -C1 through C7 -If T1 not seen Æ 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

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Anthony Powell Gillian Lieberman, MD

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, 1978

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Anthony Powell Gillian Lieberman, MD

C-spine Film Interpretation 7 step process 1. Count Vertebrae -C1 through C7 -If T1 not seen Æ Swimmer’s view

2. Assess Curvature 3. Assess Vertebral Alignment (4 lines) -ant vertebral line -post vertebral line -spinolaminal line -post spinal line

4. 5. 6. 7.

Assess Bony Integrity Assess Intervertebral Disk Spaces Assess OAA joint Soft Tissues

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Anthony Powell Gillian Lieberman, MD

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

Anthony Powell Gillian Lieberman, MD

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

20 •Farrell, Susan MD. Teaching Files. BIDMC dept of Emergency Medicine, 2000

Anthony Powell Gillian Lieberman, MD

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

Anthony Powell Gillian Lieberman, MD

Let’s review some other patients whose c-spine plain films demonstrate common cervical fractures

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Anthony Powell Gillian Lieberman, MD

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

Anthony Powell Gillian Lieberman, MD

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

Anthony Powell Gillian Lieberman, MD

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

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Anthony Powell Gillian Lieberman, MD

Teardrop Fracture

26 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 Gillian Lieberman, MD

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 Æ unstable

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Anthony Powell Gillian Lieberman, MD

Compression Fracture

28 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 Gillian Lieberman, MD

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

Anthony Powell Gillian Lieberman, MD

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

Anthony Powell Gillian Lieberman, MD

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

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Anthony Powell Gillian Lieberman, MD

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

Anthony Powell Gillian Lieberman, MD

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

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Anthony Powell Gillian Lieberman, MD

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, 1978

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Anthony Powell Gillian Lieberman, MD

References • •

•

• • • •

Daffner RH: Evaluation of cervical vertebral injuries. Seminars in Roentgenology 24:239-253, 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 155:465-472, 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, 2nd ed. Novartis, 1997 Gunderman, RB: Essential Radiology, clinical presentation, pathophysiology, imaging. Thieme, 1998 35

Anthony Powell Gillian Lieberman, MD

Acknowledgements • Beverlee Turner for her support and PowerPoint expertise. • Susan Farrell MD

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