RathoGraphlcsindexterms:

Imaging

of adult

cervical

spine

SPINE

trauma

Myelography Myelography,

technology

Thomas

H. Berquist,

M.D.

Introduction Approximately

63% of spinal

cord

injuries

involve

the cervical

spine

(f,). In adults, approximately 75% of injuries occur cervical spine (C3-C7). The average number of injuries

in the lower is 2.2 per

patient (2,8). In addition, upper and lower cervical

there is a significant incidence of combined spine injuries (15-25%) and of cervical injury associated with thoracolumbar fractures (5-17%) (2,4,8). The goals of spinal imaging should include the identification of all lesions, the determination of the stability of any injury, and the detection of any encroachment on the neural foramina on spinal canal. The morbidity of these injuries can be reduced if diagnosis is accurate and complete and if proper therapy is instituted promptly. Acutely injured patients with suspected spine trauma must be properly immobilized until radiographic assessment of the injury can be completed and treatment instituted. Efficient radiographic evaluation requires close communication between the radiologist and clinician (orthopedist. neurosurgeon. emergency room physician).

procedures

This is particularly

that

may

important

be employed

with

(Table

the

numerous

diagnostic

I).

THE CATEGORICAL EXHIBIT WAS INTRODUCED AT THE 1985 ANNUAL MEETING OF THE RSNA AS A NEW FEATURE OF THE SCIENTIFIC EXHIBIT AREA. THE CONCEPT OF A COMPREHENSIVE. GRAPHIC REVIEW OF A SHARPLY FOCUSSED SUBJECT COINCIDES WITH THE OBJECTIVES OF RADIOGRAPHICS. AND WE ARE PLEASED TO REPRODUCE THIS EXCELLENT EXHIBIT FROM THE 1987 ANNUAL MEETING HERE.

From the Department of Diagnostic Radiology, Mayo Clinic,

Rochester,

Minnesota.

Address reprint requests to 1. H. Berquist. M.D., Department of Diagnostic Radiology, Mayo Clinic, Rochester, MN 55905. Volume

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Routin#{149}Radiography Routine nadiognaphs remain the most effective screening technique for detection of significant cervical spine injuries. Radiographs also serve to assist in selecting the most appropriate special technique to be employed when more information is needed (1-3,5,6). The standard trauma series includes AP,

lateral, oblique and open mouth odontoid views (2,8,10,11) (Table I). In certain cases, pilIan views are obtained, but the patient’s head is usually rotated to obtain pillar views. Therefore, the initial series of radiographs must be reviewed to be certain this can be accomplished safely (2).

THE LATERAL The lateral view is the most important in the routine trauma series. Ninety percent of significant injuries can be identified on this view (28). It is essential that all seven cervical and the first thoracic vertebrae be clearly displayed (Figures 1 and 2) (Table II) (2,8,10,11). Several methods have been used to include the entire cervical spine on the lateral view. Pulling downward on the arms is frequently advocated. This, however, can cause hypenextension of the cervical spine and exaggerate

VIEW

an unstable

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he should

before

be certain

one uses that

the

physical and clinical findings indicate a low probability of significant or unstable injury. We prefer the swimmer’s view (Figure 3) unless shoulder injury prohibits this maneuver. If these techniques do not provide adequate visualization

of C7 and

TI, we use lateral

tomograms.

C-arm tomognaphic trauma table allows obtain lateral, AP and oblique tomognams without moving the patient.

Figure 1 Normal cervical spine-lateral view Note the nonmal cervical lordotic curve with uninterrupted postenor, anterior and spinolaminar lines. The prevertebral fat stripe (dotted line) can be useful in detection of subtle hyperextension injuries; its antenor displacement on partial obliteration may indicate hematoma formation (2, 17).

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injury. Therefore,

this technique,

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Figure 2 Upper cervical spine relationships The tip of the clivus (anterior doffed line) should point to the junction of the anterior and middle thirds of the odontoid tip. The distance between the odontoid and the antenon ring of Cl at the lower margin (arrow) should not exceed 2.5 mm in adults. The posterior lamina of Cl should align (doffed line) with the fonamen magnum (2).

I

1

____i

Tablell Factors

to be Evaluated

on the Lateral

Upper Cervical Spine (Occiput to C2) (See Figure 2) A. Does the tip of the cilvus point to the odontoid tip at the Junction of its anterior and middle thirds? B. Are the Cl laminae aligned with the posterior foramen magnum? C. Does the distance from the anterior ring of CI to the odontoid at the lower margin of CI = 2-2.5 mm in the adult or 4-4.5 mm In the child? D. Does the distance from the posterior pharyngeal wall to the anterior inferior bodyofC2= 7 mm?’

.

There

may

In dIstInguIshIng

be overlap normal

from

between abnormal

normal

and

view of the Cervical

Lower Cervical Spine (C3-C7) (See Figures 1, 4-6) A. Is the prevertebral fat stripe present and uniform along the anterior margin of the vertebrae from C2 to the C6 level? B. Does the retrotracheal space (the distance from the posterior wall of the trachea to the anterior inferior aspect of C6 = 22 mm In adults or 14 mm In children?’ C. Is the anterior spinal line smooth (free from abrupt discontinuity)? D. Is the posterior spinal line smooth (free from abrupt discontinuity)? E. Is the spinolaminar line smooth? F. Are the disk spaces normal in shape and approximately equal in height? G. Are the facetJolnts smooth and regular? H. Does the interspinous distance decrease in height regularly from superior to inferior?

abnormal

In thIs sefflng

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Spine (2,8,16)

measurements.

The prevertebral

fat stripe

can

be useful

(2,16,17).

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a) >1

a a)

4-

a

1

view (B) shows racic vertebrae.

all seven cervical

When evaluating cervical spine trauma, normal

variants

and

patients with suspected one must be aware of potential

pitfalls.

Soft

tis-

sue measurements in the prevertebral region may be inaccurate and can vary with slight upward or downward positioning of the mandible (2,16). Slight subluxation of C2 on C3 or C3 on C4 may

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be evident

in normal

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age 20 (2) (Figure 4). The endplates of the yentebrae vary in size; specifically, C7 is smaller than TI. This can mimic subluxation, especially when C7 is partially obscured (Figure 4). jury

When assessing fractures and soft tissue on the lateral view, it is important to

search for signs indicating and 6) (Table Ill).

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instability

(Figures

in-

5

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.

--

IC

a)

:,.‘:

Figure 4 Physiologic subluxation This normal lateral view of the cervical spine includes all cervical and the upper two thonacic vertebrae There is slight physiologic subluxation of C2 and C3 (arrow) in this 18 year old man. Note the “step-off” at C7-T1 (open arrows) owing to the difference in size of the vertebral bodies. This should not be confused with subluxation.

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Figure 5 True subluxation secondary to facet arthrosis This is the lateral view of the cervical spine of a 60 year old man with facet arthnosis at C7Ti resulting in slight subluxation (doffed lines). Both the anterior and posterior vertebral lines are displaced. In Figure 4 the anterior line was intact. The step-off in the posterior line was due only to the difference in the sizes of the vertebral bodies in that case.

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Table Ill FindIngson the Lateral View Indicating Unstable Injuries’ (2,7,8) A. Vertebral compression >25% B. Subluxation 3 mm C. Angulation (>1 2#{176}) and disk abnormalities (widened or narrowed) D. Increased interspinous distance (Injury of both middle (midbody to postenor longitudinal ligament) and posterior (posterior arch and ligaments) columns indicates instability) (7) *

Figure 6 Distractive hyperflexion injury This is the lateral view of a cervical spine following a distractive hyperflexion injury. There is widening of the interspinous distance (postenior arrow), facet joints (curved arrow), and narrowing of the anterior C4 disk space due to an unstable two-column injury.

ANTEROPOSTERIOR

VIEW

The information available on the AP view is important, especially in assessing soft tissue injuries which may produce only subtle changes on the lateral view. The AP view may also provide valuable clues in evaluating the cenvicothoracic region (Figures 7-10) (2,10,13).

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a) 0 V 0 0

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Normal cervical spine-AP view The articular pillans have a smooth undulating contour. The spinous processes (arrowheads) are midline and equidistant apart. The uncinate processes (small arrowheads) are cleanly demonstrated. C2 and Cl are obscuned by the mandible. The mid cervical spinous processes are frequently bifid.

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p .,r ligament disruption There is increased interspinous distance between C4 and C5 because of posterior ligament disruption. The distance between the C5-C7 spinous processes is normal.

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spine showing

shift (lateral

displacement)

of

the C5 spinous process (bifid) owing to a flexion rotation injury (unilateral locked facet).

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Figure 10 Sput0t5 process fracture AP view of the cervical spine with a double spinous process (arrows) because of a spinous process fracture at C7.

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OBLIQUE The oblique

gling

the tube

notating trauma

the unit.

view

can

be obtained

on conventional

by an-

equipment

or

arm on a C-arm tomographic This view is important for evaluat-

ing the posterior

structures

Figure 1 1 Normal cervical spine-oblique

and especially

view demon-

strating the intervertebral foramina, pedicles, laminae, and normal vertebral alignment

of adult

cervical

spine

trauma

VIEW

detecting subtle perching or locking of the facets (Figures 1 1 and 12). Subtle subluxations can also be identified. Note the smooth contour

of the

posterior

spinal

line

in Figure

I I.

for

Figure 12 Locked facet unilateral

Localized oblique view demonstrating

locked

facet. The superior

facet,

a

s, is located

posterior to the inferior, i, facet.

(lines).

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OPEN MOUTH

ODONTOID

VIEW

This view is useful in evaluating the odontoid and the relationships of CI-C2 (Figures 13-15). In some patients, it is difficult to visualize the entire odontoid. Angling the tube as would be done for an AP Waters view (Figure 14) is often successful in providing

complete

I

_

visualization

of the odontoid.

iv

Normal open mouth odontold view

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l4A Figure 14 Odontoid views In the AP open mouth odontoid view (A), the upper odontoid is obscured by overlying osseous structures. When the tube is angled 400 toward the head (B), the entire odontoid is cleanly demonstrated.

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a. 0 Figure 15 Jefferson fracture This AP view demonstrates lateral displacement of the lateral masses of Ci (arrows) due to a Jefferson fracture.

PILLAR

VIEWS

The patient’s head must be rotated to obtain pillar views. This necessitates review of the views described above to be certain that no significant or unstable lesion is evident prior

to moving

These views

the

head.

are difficult

to

obtain if the technologist not experienced. Proper

is

alignment of each set of pillars is not always possible using a single tube angle (usually the tube is angled 20-30#{176} caudad) (Figure 16). The pillar view is useful in evaluating the articular pillars and lamina (Figure 17).

Figure 16 Lateral view showing the variability of the articular angles

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Figure 17 Normal cervical spine-pillar

views Normal pillar views with the head rotated to the left and to the right Note the variation in height of the pillars due to degenerative changes and variation in articular angles. Care should be taken not to consider slight variation in height a fracture. If no fracture line is evident but injury is suspected clinically, it may be best to obtain tomography or CT to evaluate the area of concern.

.Iight 17B

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MOTION

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(FLEXION,

Fluoroscopically positioned flexion and extension views are important in assessing soft tissue

injury

and

potential

instability

(Figure

18). Generally, this study should be reserved for those patients without fracture. Motion views can displace a fracture. In the immediate post injury period, patients with soft tissue injury may have significant muscle spasm lead-

EXTENSION)

VIEWS

ing to limitation of physiological motion and a false negative examination. For this reason, we find it is best to support the neck in a rigid colIan for 48 hours in patients with questionable soft tissue injuny. The flexion and extension views can be more accurately performed aften the muscle spasm has subsided.

Figure 18 Posterior ligament tear The neutral lateral view (A) shows increased interspinous distance (arrow) between C3 and C4. This may be a normal variant in some patients at this level; the disk space, however, is also narrowed anteriorly suggesting posterior ligament cornplex disruption. The flexion view (B) shows marked increase in the interspinous distance and subluxation of C3 and C4 confirming the presence of a posterior ligament tear.

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Special

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sus computed tomography depends on the type of injury suspected, clinical status of the patient, and equipment available (Table IV). Table V summarizes the most frequent applications of CT and conventional tomography (2, 12,14,15). -

.

.,

Table V Applications of Conventional and Computed Tomography (2, 12, 14, 15)

Table IV

Factors to Consider in Choosing Conventional versus Computed Tomography (2,12,14,15) Patient status Pain Neurolo9ic deficit Mechanism of injury

Conventional

Tomography

Computed Tomography

Confirm or exclude fractures in suspicious areas Odontoid fractures’ Posterior elements1 Facet fracture Perched or locked facets1

Location of injury

Upper cervical spine Lower cervical spine Anterior vs posterior structures Availability of equipment

Classification

Type of CT scanner tomography

trauma

Studies

In certain situations, conventional tomognaphy, computed tomography on magnetic resonance imaging is useful to define the natune of an injury completely. The latter is currently not commonly used in the acute setting, but the use of MRI in acute spine injuries is evolving (9). The choice of conventional yen-

C-arm vs conventional

spine

of the

mechanism

(The patient

(contiguous

does not have to be moved with C-arm equipment.)

Spinal cord assessment Bone fragments Hematoma Dural tears (CT with metrizamide) Soft tissue injury Operative planning Potential for 3-D

of injury segments

reconstruction

can be more easily demonstrated) 1

Basics of Cervical and Technique The mechanism of cervical spine injury is rarely pure, but an understanding of the mechanisms of injury and the predictable radiographic patterns associated with them is important in determining the extent, stability and prognosis of an injury. Most injuries are due to

Volume

Partial

volume

effect

can be a problem

with

CT.

Spine Trauma Applications hypenflexion, hyperextension, rotational, or shearing forces (Table VI). The lateral view is particularly valuable in determining the mechanism of an injury (only 10% could not be easily characterized in our evaluation of 420 patients) (2).

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C

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.-

TableVi (2,6,8,9) Mechanism, Types of injury

I’-

Fractures

a.

Incidence,

and

U)

a U

Mechanism

(incidence)

Type of Injury or Radiographic Findings

Hyperfiexlon

(46-79%)’

Odontoid fracture Compression or burst fracture of vertebra Tear drop fracture Anterior subluxation Locked facets (unilateral with rotation force) Disk space narrowing Widened interspinous distance Spinous process fractures Widened disk space (anteriorly) Prevertebral swelling Anterior Inferior chip fractures Tear drop fractures Neural arch fracture Subluxation (anterior or posterior with normal Interspinous distance) Hangman’s fracture Unilateral locked facets Jefferson fracture Burst fractures Uncinate fractures Isolated pillar fractures Transverse process fractures Lateral vertebral compression

a)

0

0 0 U 0

a

Hyperextension

(20-38%)’

Flexion-rotatlon (12%)’ Vertical Compression (4%)’ Lateral flexion or shearing (4-6%)’

‘

L within

Numbers a series.

vary

to multiple

due

UPPER CERVICAL (OCCIPITAL In adults,

19-25%

of injuries

per cervical spine. Occipital are rare injuries (2,8,10,11,13). Figure

19 was

injured

dent and presented radiographs (Figure

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involve

the

vehicle

up-

acci-

with occipital pain. Skull 19A) and head CT includ-

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SPINE TRAUMA

CONDYLE-C2)

condyle fractures The patient in

in a motor

series

ing the

upper

cervical

enal tomograms verse fracture of was not seen on ume effect. This shearing forces.

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were

normal.

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(Figure 19B) showed a transthe occipital condyle. This CT because of the partial volinjury was produced by lateral

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Figure 19 Occipital condyle fracture Patient with occipital pain following a moton vehicle accident The routine skull series (A) and CT scan of the head were negative. Lateral tomograms (B) demonstrate a horizontal fracture of the occipital condyle (open arrow). This was overlooked on CT images because the fracture line was in the plane of the sections.

Figure 20 Compression fracture This AP tomograrn of the upper cervical spine following a vertical compression-lateral

rotation

injury demon-

strates compression of the left lateral mass of Cl (arrow). This was not evident

CI fractures CI fractures are associated with our experience, pedicle fractures (Figures 20 and

on CT.

make up about 4% of cervical spine injuries (2,8,13). usually produced by vertical compression (alone or lateral compression) or by hypertension injuries. In 25% have associated C7 fractures, 15% have C2 and 58% have fractures in extraspinal locations (2) 21).

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21A Figure 21 Vertical compression injury The lateral view of the cervical spine (A) shows a double density in the anterior ring of Ci (arrowheads). Only the upper five vertebrae are seen. An AP tomogram (B) dernonstrates lateral displacement of the left lateral mass of Cl and a chip fracture (arrowhead) near the tubercle. Computed tomography (C) more clearly demonstrates the fracture and tubencle avulsion on the night.

21C

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Six percent

in our series (420 cases) involved the odontoid (2). Odontoid fractures are due to extension, flexion, or lateral shearing forces. Eight percent have as-

sociated

of spine

CI fractures.

fractures

There

are three

types

odontoid fractures (Anderson and D’Alonzo classification) (Figure 22). A Type III fracture most always heals and has a good prognosis.

of al-

Type I lesions are difficult to detect without tomograms and are uncommon (2). Type II fractures are most prone to complications, specifically nonunion (Table VII). The orientation of the fracture line in a Type II fracture is such that conventional tomography is usually more useful than CT (Figures 23 and 24).

a)

0 a)

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a U)

V 3 a)

a C

3 a

TYPE

I Table VII Incidence of Odontold Fractures (2,8, 13) Type I 8% Typell’ 59% Typelll *

TYPE

Nonunion

33%

54-67%

Ill

Figure 22 The three types of odontoid fractures This figure lustrates the Anderson and D’Alonzo classification (2).

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Figure 23 Type II odontold fracture This patient had suboccipital pain following a motor vehicle accident. CT images (3 mm thick slices) of the odontoid (A) are negative. A lateral tomognam (B) demonstrates a Type II odontoid fracture.

23B

24A

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Figure 24 “Upper-lower” combination injury This 53 year old man had neck pain following a plane crash. AP (A) and lateral (B) views of the cervical spine show a questionable fracture in the odontoid region (annow). C7 was not seen on the lateral view and a cIaviculan fracture made a swimmer’s view difficult to obtain. Therefore, tomograms were obtained of the odontoid and lower cervical spine. A lateral odontoid tomognam (C) shows a Type Ill odontoid fracture (arrowheads). Lower cervical spine tomogram (D) shows a hyperextension injury at C6-C7 with widening of the interspace. Combination injuries in the upper and lower cervical spine are common. 24B

24C

24D

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LOWER Seventy-five injuries involve

and degree Special (Figures

the

Berquist

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CERVICAL

SPINE

to eighty-one percent lower cervical spine

of instability

studies are 25-2 7).

can usually

indicated

in certain

Figure 25 Disruptive hyperflexion injury

Forces applied to the occiput leading to hyperflexion often cause postenor ligament injury with little compression of the anterior column. A lateral view shows widening of the C4-C5 facet joints (posterior curved arrow) and interspinous distance with narrowing of the disk

space (arrow) anteriorly. (2).

TRAUMA

No compression

(C3-C7)

of adult

clinical

settings,

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This lateral view of the cervical spine demonstrates anterior widening of the C6-C7 interspace and an avulsion fracture (arrow) anteriorly.

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Figure 26 Hyperextension injury

are evident

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cervical

(2,8). The mechanism of injury be assessed using routine views.

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29A

29B Figure 29 Flexion compression Injury C7 was not seen on the plain lateral view. A tomogram in the midline (A) shows distraction of the spinous process secondary to ligament injury and compression of the anterior margin of C7 (arrowhead). A tomognam at the facet joint level (B) shows a fracture of the superior facet of C7 (arrow). The laffer finding indicates

that shearing

pression mechanism

forces

were associated

with the flexion

corn-

of injury.

CT images are useful in evaluating the spinal canal and assessing fragment position and cord involvement (Figures 21, 30 and 31). Keep in mind that subtle or undisplaced honizontal fractures may be overlooked because of partial volume effects, but CT does allow one to obtain thin slices for 3-D reconstruction. Such reconstructions can be useful in surgical

acute setting. This technique, however, shows potential in the evaluation of the cord and the relationship of the cord to the bony stnuctunes (9) (Figure 32). Flexion and extension studies can be obtained quickly using fast scan techniques. Though ligament and muscle tears can be identified in many locations, currently there

planning.

MRI in patients with suspected jury in the cervical spine.

Currently.

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Figure 30 Normal metrizamide CT of the mid cervical spine The facet joints (arrows) should not be mistaken forfractures.

F.,,. Burst fracture This CT scan of the lower cervical spine demonstrates a burst fracture with displacement of the lamina and narrowing of the spinal canal.

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F_. MRI of compression fracture Sagiffal Ti weighted (TRITE = 500/20) MR image shows an old compression fracture of C7 and narrowing of the spinal canal. There is slight associated

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COMBINATION The average number of injuries in patients with cervical spine trauma is 2.2 (2,8). One should be aware of the possibility of separate injuries in the cervical region as demonstrated in Figure 24. Distant injuries in the thoracic or lumbar spine occur in 5-15% of patients (2,4,8). Therefore, when a cervical fracture or

INJURIES fracture dislocation is identified, the entire spine should be studied. The reverse should also be considered. Routine radiographs are usually sufficient in this regard, but on occasion CT or conventional tomography may be required (Figures 33 and 34).

Figure 33

Combination skull and spine injury This lateral view of the skull shows a skull fracture (small arrowheads) with an anteriorly displaced Type Ill odontoid fracture (large arrowhead).

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34A Figure 34 Combination cervical and thoracic spine injuries These are lateral views of the cervical (A) and thoracic spine (B) of a patient who had been in a severe motor vehicle accident. (A) There are fractures of the posterior ring of Ci and of the pedicles of C2 (arrows) with distraction of the C2-C3 disk space. (B) Fracture dislocation racic spine with cord transection is demonstrated.

of the mid tho-

Conclusion The radiologist plays a significant role in the complete evaluation of spinal injuries. This necessitates an awareness of the mechanisms of injury, their radiographic pattern and the effects specific injuries may have on present and future

patient

be aware that

may

morbidity.

Specifically,

of the potentially lead

to further

one

unstable neurological

lesions dam-

age. Routine

screening

radiography

technique

remains

for evaluating

the

must

major

cervical

Volume

spine injury. Though routine views cannot onstrate all fractures (CT and tomography may be more accurate), they are useful

sessing

the mechanism

demin as-

of injury and determin-

ing which additional techniques may be most useful. Optimal communication with clinicians and the proper use of imaging techniques will help to assure that all lesions are identified, stability assessed and encroachment on the spinal canal or nerve roots completely evaluated.

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References 1. Acheson MB. Livingston RR, Richardson ML. Stimac GK. High-resolution CT scanning in the evaluation of cervical spine fractures: Comparison with plain film examinations.AJR 1987; 148:1179-1185. 2. Berquist TH. Imaging of orthopedic trauma and surgery. Philadelphia: Saunders. 1986. 3. Brackman R. Penning L. Injuries of the cervical spine. London: Excerpta Medica. 1970. 4. Calenoff L. Chessare JW. Rogers LF, Toerge J. Rosen JS. Multiple level spinal injuries: Importance of early recognition. AJR 1978; 130:665-669. 5. Christensen PC. Radiographic study of the normal spine. Radiol Clin North Am 1977; 15:133-154. 6. Daffner RH. Deeb ZL. Rothfus WE. “Fingerprints” of vertebral trauma: A unifying concept based on mechanisms. Skeletal Radiol 1986; 15:518-525. 7. Denis F. The three column spine and its significance in classification of acute thoracolumbar spinal injuries. Spine 1983; 8:817-831. 8. Gehweiler JA. Osborn RL, Becker FG. The radiology of vertebral trauma. Philadelphia: Saunders, 1980. 9. Goldberg L. Rothfus WE. Deeb ZL. et al. The impact of magnetic resonance on diagnostic evaluation of acute cervicothoracic spinal trauma. Skeletal Radiol 1988; 17:89-95.

10. Harris JH Jr. Acute injuries of the spine. Semin Roentgenol 1978; 13:53-68. I 1. Harris JH, Edeiken-Monroe B. Radiology of acute cervical spine trauma. Baltimore: Williams & Wilkins. 1987. 12. Keene JS, Goletz TH, Lilleas F, Alter AJ. Sackett JF. Diagnosis of vertebral fractures: A comparison of conventional radiography. conventional tomography and computed axial tomography. J Bone Joint Surg (Am) 1982; 64:586-594. 13. Miller MD. Gehweiler JA. Martinez S. Charlton OP. Daffner RH. Significant new observations on cervical spine trauma. AJR 1978; 130:659-663. 14. Pech P. Kilgore DP. Pojunas KW. Haughton VM. Cervical spinal fractures: CT detection. Radiology 1985; 157:117-120. 15. Roub LW. Drayer BP. Spinal computed tomography: Limitations and applications. AJR 1979; 133:267-273. 16. Templeton PA. Young JWR. Mirvis SE, Buddemeyer EU. Value of retropharyngeal soft tissue measurements in trauma of the adult cervical spine. Skeletal Radiol 1987; 16:98-104. 17. Whalen JP. Woodruff CL. The cervical prevertebral fat stripe: A new aid in evaluating the cervical prevertebral soft tissue space. AJR 1970; 109:445-451.

Figures 1. 2. 22. and 25 previously appeared trauma and surgery. Philadelphia. WB Saunders.

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