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CERVICAL SPINE FRACTURES…
Cervical Anatomy
Biomechanically SpecializedSupport of “large” Cranial massLarge range of motion
○ Flexion/extension○ Axial rotation
Unique osteological characteristics
C1 - Atlas
No body 2 articular pillars
Flat articular surfaceVertebral artery
foramen 2 arches
AnteriorPosterior
○ Vertebral artery groove
C2 Anatomy
Dens Embriological C1 body Base poorly vascularized Osteoporotic
Flat C1-2 joints Vertebral artery
foramena Inferomedial to
superolateral
Anatomy – The Ligaments Allow for the wide ROM of upper C-spine while
maintaining stability Classified according to location with respect to
vertebral canal Internal:
○ Tectorial membrane○ Cruciate ligament – including transverse ligament○ Alar and apical ligaments
External○ Anterior and posterior atlanto-occipital membranes○ Anterior and posterior atlanto-axial membranes○ Articular capsules and ligamentum nuchae
AtlantoAxial Anatomy
Tectorial Membrane
AtlantoAxial Anatomy
occiput
C1
C2
Tranverse Ligament
C1-C2 joint
Alar Ligament
AtlantoAxial Anatomy
TransverseLigamentFacet for
OccipitalCondyle
AtlantoAxial Anatomy
Vertebral Artery
APPROACH TO C-SPINE INJURIES
Following trauma or complaint of neck pain Obtain lateral AP, and odontoid views
The lateral view is only adequate if T1 can be visualized
If there is any doubt of fracture or prevertebral swelling , obtain oblique views and consider CT
All patients with sign/symptoms of cord injury require MRI
Cervical Views
AP
Odontoid
Obliques
Swimmer’s View
LATERAL VIEW
1. Anterior vertebral line (anterior margin of vertebral bodies)
2. Posterior vertebral line (posterior margin of vertebral bodies)
3.Articular pillar (where superior and inferior articular processes of cervical vertebrae have fused on either or both sides)
4. Spinolaminar line (posterior margin of spinal canal)
5. Posterior spinous line (tips of the spinous processes)
C1-C2 Predental space (distance between posterior
aspect of anterior arch of C1
and anterior aspect of
odontoid process )
should be< 3mm In adult
and less <5mm in children
Or less ring sign of C2
C3-C7
Anterior spinal, posterior spinal and
spinolaminar lines: should be
smooth lines Disc Spaces should be approximately same
anterior narrowing = flexion injury.
Widening = extension injury Facet joints should be parallel Interspinous distance should
decrease from C3 to C7 Transverse process of C7 points downward and
T1 UPWARDS
INTERVERTEBRAL DISC
SPACES
FACET JOINT
Prevertebral Soft Tissue
Nasopharyngeal space (C1) - 10 mm (adult)
Retropharyngeal spaceC 2-C4 ( between posterior pharyngeal wall and anterior border of vertebrae).
Retro tracheal space C5-7 (space between posterior tracheal wall and anterior inferior body C6 )
c3-4 5mm from vertebral body is normalC4-7 20mm from vertebral body is normal
5mm
22mm
10mm
AP View The height of the cervical
vertebral bodies should be approximately equal
The height of each joint space should be roughly equal at all levels.
Spinous process should be in midline and in good alignment.
Odontoid View An adequate film should include the
entire odontoid and the lateral borders of C1-C2.
Occipital condyles should line up with the lateral masses and superior articular facet of C1.
The distance from the dens to the lateral masses of C1 should be equal bilaterally.
The tips of lateral mass of C1 should line up with the lateral margins of the superior articular facet of C2.
The odontoid should have uninterrupted cortical margins blending with the body of C2.
Classification of Fractures of c-spine
HYPERFLEXION INJURIES Flexion teardrop fracture Hyper flexion Strain Wedge Compression fracture Bilateral facet Lock Unilateral facet dislocation Clay-shoveler’s fracture
Hyper extention injuries Hangman fracture Extention teardrop fracture laminar fracture Pillar fracture Posterior arch of c1 fracture
FRACTURE DUE TO AXIAL LOADING Jefferson fracture Burst fracture
OTHER INJURIES Odontoid fracture Rotational Injuries
Hyperflexion
Distraction creates tensile forces in posterior column
Can result in compression of body (anterior column)
Most commonly results from MVC and falls
Compression
Result from axial loading
Commonly from diving, football, MVA
Injury pattern depends on initial head position
May create burst, wedge or compression fx’s
Hyperextension
Impaction of posterior arches and facet compression causing many types of fx’s○ lamina○ spinous processes○ pedicles
With distraction get disruption of ALL
Evaluate carefully for stability
LOOK FOR CENTRAL CORD SYNDROME
Types of Injuries
Flexion Teardrop Fracture C5-6
fracture is the result of a combinationof flexion and compression ,most commonly at C5-6 The teardrop fragment comes from the anteroinferior aspect of the vertebral body. The larger posterior part of the vertebral body is displaced backward into the spinal canal.
Best seen on lateral view It is an completely unstable fracture associated with complete disruption of ligaments and anterior cord syndrome and quadriplegia 70% of patients have neurologic deficit. common in MOTOR VECHICLE ACCIDENT
Signs: Prevertebral swelling associated with anterior longitudinal ligament tear.
Teardrop fragment from anterior vertebral body avulsion fracture.
Posterior vertebral body subluxation into the spinal canal.
Spinal cord compression from vertebral body displacement.
Fracture of the spinous process.
Fracture of the body of c5 with a small fragment
anteriorly
Fracture of the spinous process of C4
Acute angulation at the level of C5C6 with displacement of C5 in posterior direction
Wedge fracture
Compression fracture resulting from flexion.
Flexion compression injury Best seen on lateral view Stable Common in Elderly patients with osteoporosis or
osteogenesis imperfecta
Wedge shape vertebra
Antersuperior body fracture
Hangman’s Fracture C-2
Fx through the pars interarticularis of C2 secondary to hyperextension
Best seen on lateral view
Hyperextention injury Stable fracture ?
The most common scenario would be frontal motor
vehicle(hitting dash board)
Hanging falls, diving injuries contact sports.
Neurological involvement is rare
Classification of Hangman' s fractures
Type I (65%) hair-line fracture C2-3 disc normal
Type II (28%) displaced C2 disrupted C2-3 disc ligamentous rupture with
instability C3 anterosuperior compression
fracture Type III (7%)
displaced C2 C2-3 Bilateral interfacet dislocation Severe instability
TYPE 1 HANGMAN FRACTURE There is a hair-line fracture and there is no displacement.C23 NORMAL
HANGMAN FRACTURE TYPE 3
Anterior dislocation of the C2 vertebral body
BILATRAL C2 pars interarticularis fractures.
Prevertebral soft tissue swelling
The CT-images confirm the fracture-lines of the hangman's fracture.They run through the pars interarticularis resulting in a traumatic spondylolysis.In this case there was no neurologic deficit, because the spinal canal is widened at the level of the fracture.
Extention tear drop fracture
AVULSION FRACTURE of anterio inferior content
of the axis resulting from hyperextention This injury is stable in flexion but highly unstable in extension.
common in diving accidents It also may be associated with the central cord
syndrome .
The CT confirms the displaced anteroinferior bony fragment. This fragment is a true avulsion, in contrast to the flexion teardrop fracture in which the fragment is produced by compression of the anterior vertebral aspect due to hyperflexion.
Jefferson Fracture C-1
• Best seen on odontoid view• Unstable fracture • Fracture due to AXIAL LOADING • frequently associated with
• diving into shallow water(axial blow to the vertex of the head )
• impact against the roof of a vehicle• fall from playground equipments
Fracture is caused by a compressive downward force that is transmitted evenly through the occipital condyles to the superior articular surfaces of the lateral masses of C1. This process displaces the masses laterally and causes fractures of the anterior and posterior arches, along with possible disruption of the transverse ligament.
SIGNS ON XRAY: Displacement of the lateral masses of vertebrae C1 beyond the margins of the body of vertebra C2.
<2mm bilateral is always abnormal<1-2 mm or unilateral displacement can be due to head rotation
CT is required to 1. define the extent of fracture 2. detecting fragment in spinal cord
BURST FRACTURE C3-7 Same mechanism as jefferson fracture i.e axial compression
but Located at c3-7 Stable fracture The intervertebral disc is driven into the vertebral body below. Posterior fragments dislocation common Require ct for fracture evaluation and bone fragment in spinal
cord
Odontoid Fracture C2 Fracture of the odontoid (dens) of C2
3 categories, I-III
Best seen on open-mouth odontoid view or lateral radiograph result from blunt trauma to head leading to cervical hyperflexion or
hyperextension Unstable fracture Occur in both elderly and young patients 75% cases are children
Classification
Type I: Avulsion of the tip of the dens where it is attached to C1.This is a rare fracture. It is potentially stable.?
Type II: Through the base of the dens. Most common fracture. Always unstable and poor healing.
Type III: Fracture through the body of the axis and sometimes facets.Can be unstable, but has a better prognosis than type II due to better healing of the fracture which runs through the metaphyseal body of C-2
Type 1 odontoid fracture
Type II
Type III
CT IMAGE
Dens
DENS
The image through the lateral part of C2 nicely shows, that the fracture runs through the body of C2, i.e. a type III odontoid fracture.The posterior dura is in a normal position, but the anterior dura is displaced (arrow).
Showing Central location of spinal cord injury
Clay Shoveler’s Fracture Oblique avulsion fracture of a spinous process C6-T1 C7>C6>T1
Best seen on lateral view Powerful Hyperflexion injury(shoveling) Stable fracture Common in motor vehicle accidents sudden muscle contraction direct blows to the spine
Ap view show ghost sign with 2 spinous processes ???
Case 1 5 yo girl Hit by car while
riding bike VSA at scene Vitals recovered
by EMS
Rose et al, Am J Surg 2003;185(4)
Atlanto-Occipital Dislocation 2.5 x more common in
children than adults Due to small occipital
condyles and horizontal atlanto-occipital joints
Suspect if distance between occipital condyles and C1 is > 5mm at any point
Usually have ++ soft tissue swelling
OccipitoAtlantal Dissociation (OAD)
Commonly FatalPresent 6-20% of post mortem studies– Alker et al, 1978– Bucholz & Burkhead,1979– Adams et al, 1992
50% missed injury rate1/3 Neurological Worsening– Davis et al, 1993
OccipitoAtlantal Dissociation (OAD)
Symptoms/Findings– Wallenberg Syndrome
Lower Cranial nerve deficitsHorner’s syndromeCerebellar ataxiaCruciate paralysisContralateral loss of pain and
temperature
Radiographic Lines
BC/OA >1 considered abnormal
Limited Usefulness Positive only in Anterior
Translational injuries False Negative with pure
distraction
Powers et al, Neurosurg, 1979
Powers’ Ratio
QUESTIONS
REFERRENCES
Text Book of Radiology and imaging
(DAVID SUTTON) Primer of Diagnostic Imaging Radiology Review Manual(Dahnert)
Thank You!