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Spinal Trauma

Hifz-ur-Rahman Aniq Royal Liverpool University Hospital

Honorary lecturer, University of Liverpool 2

Cervical Spine

The most vulnerable yet most common site of injury. Data from the UK (1993-95) 44% of all spine trauma occurs at the cervical level

Causes of cervical spinal injury (UK)

Fall 37% RTA 36%

Sports 20%

Assault 6.5%

Cervical Trauma ! RTA – young age

! Falls - after age 45

! Average age at time of injury is 33.4 years

! 82%: male, 18%: female ! Devastating injury

Cervical Injury

!  1-3 % of all trauma cases

!  2/3 of spinal cord injuries

! Missing 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

Accurate confirmation of absence of

cervical spine injury

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Aim of imaging

! Is there spinal trauma

! Spinal stability

! Level and Extent of injury

! Follow up

Cervical Trauma ! Is any imaging required?

! Investigation of choice

! Normal anatomy

! Mechanism of injury

! Imaging Algorithm

Is any imaging required?

National Emergency X-Radiography Utilization Study (NEXUS) study criteria !  No Xray Needed

!  No posterior midline cervical spine tenderness

!  No evidence of intoxication

!  Normal level of alertness

!  No focal neurologic deficit

!  No painful distracting injuries

Hoffman et al, N Eng J Med 2000

Canadian C spine (CSS) Rule

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Any High Risk which mandates immobilization •  Age > 65yrs •  Dangerous mechanism •  Numbness or tingling in the extremities

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

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

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

IMAGING REQUIRED

NO IMAGING REQUIRED Stiell et al, JAMA, 2001

NO

YES

YES

YES

YES

NO

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! Both are powerful predictor of cervical spine injury

! Sensitivity 98.1%

! Negative predictive value 99.8%

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NEXUS vs CSS rule

Anderson et all, J orth Trauma 2010

Plain Xrays

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Plain films

! AP

! Lateral

! Open mouth

! Both obliques

Optional views •  Swimmers view •  Flexion and extension

ABC’S of C spine

! A Alignment

! B Bones

! C Cartilage

! S Soft tissues

Adequacy Alignment

Anterior Spinal Line

Posterior spinal line

Spino-laminar line

Posterior spinous line

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Bones & Cartilage

Atlanto axial Space Children 5 mm Adults 3 mm

Retropharangeal space C2-5 5mm

Retro tracheal space C6-7 22 mm

Soft Tissues

CT Scan

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CT Scan ! Routine isotropic imaging

! Reformats and 3D Images

! Comprehensive display of bony anatomy

! High sensitivity to fractures

! Simultaneous assessment of vascular injuries

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Cervical spine CT

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CT scan cannot rule out ligament injuries Plain Xrays vs CT scan

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Cervical Injury – Plain Films ! Sensitivity for fractures – 43 - 52%

!  1/3rd fractures are unstable

! Audit - Average 5 views performed to achieve

satisfactory images

! Open mouth and swimmer views – difficult to

perform in patients with cervical stabilisation

and intubation

•  Nunez et al, Emerg Radiology, 1994

•  Griffin et al, J Trauma, 2003

Cervical Injury – CT scan ! Sensitivity for fracture – 98.5%

! Even a fracture was missed but did not affect

management

! Negative predictive value

! Ligament injury – 99%

! Unstable cervical spine – 100%

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•  Como et al, J Trauma 2007

•  Hennessy et al, J Trauma, 2010

Cervical injury - CT scan

! Reduced trauma work up time

!  Increased disposition of patients from trauma bay

! Plain Xrays have no role in cervical screening

29 Daffner et al, J Am College Radiol, 2007

Plain Radiography vs CT scan ! Cost effective

! CT – Moderate to severe Trauma "  Paralysis prevention

! Low risk group ! Plain Xrays – Old studies

! New studies – Suggested if any imaging is required for cevical spine spine clearance it should be CT

30 Bailitz et al, J Trauma 2005

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! Radiation ! 14 fold increase compared to PF trauma series

! Single slice scanner

! Increase radiation dose to thyroid ! Over-utilization

! Cost and radiation ! Consistent application of NEXUS criteria

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Cervical Injury – CT scan Plain Radiography vs CT Scan

! If NEXUS criteria is applied - 20 % reduction in the unnecessary exams

32 Griffiths et al, RSNA, 2010

Obtunded patient

! Plain Xrays – Not recommended

! CT- First line of investigation

! In case of normal CT ! Keep patient in collar immobilization until clinical

exam can be performed

! Remove collar

! Perform MR

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! Prolonged immobilization ! Respiratory deterioration, pressure ulceration,

thromboembolism

! Increase health care cost

! Unstable c spine injuries with normal CT scan is exceedingly low

34 Hangan et al, Radiology 2005 Harris et al, spine 2008

Obtunded patient

CT in obtunded patients ! Hogan et al

! Prospective study ! MR of 366 obtunded patient with negative CT

! 96.7% Normal, 1.9% cord contusion, 1.1 ligament injury, 0.8% disc injury

! Negative predictive value ! Ligament injury – 98.9%

! Unstable spine – 100%

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Indications of MRI ! Unstable spine on CT

!  Extent of bony or ligament injury

! Progressive neurologic deficit

! Severe 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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Mechanism of Spine injury

Mechanisms of injury ! Hyperflexion injury

! Hyperextension injury

! Vertical compression

! Flexion Rotation Injury

! 10-20% combination of more than one

Hyperflexion injury 50-70%

! Anterior wedge fracture

! Flexion teardrop fracture

! Anterior subluxation

! Bilateral facet locking

! Spinous process fracture

! Odontoid fracture

Flexion Strain

! No fracture

! Spinous process widening

! Flexion views needed

! Anterolisthesis 3mm

! Stable

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Wedge fracture Flexion tear drop

!  Most devastating cervical injury

!  Great flexion / compression force

!  Marked ligamentous damage

!  C5 – 7 level

!  Unstable

!  Instant quadriplegia or acute cord syndrome

!  70 % have neurological deficit

Flexion tear drop Perched facets

C5/6 Bilateral Locked facets

! Hyperflexion injury

! More than 50% of forward slip

! 85% have neurological deficit

! Unstable

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49 50

Odontoid fracture I

! 5%

! Difficult to detect

! Stable

! D/D !  Os Odentoideum

Odontoid fracture Type II

! 65%

! Unstable

! Cx Non Union

! MR

Odontoid fracture Type III

! 30%

! Good prognosis

! Unstable

Odontoid fracture type II

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Odontoid fracture Type III Vertical Compression (4%)

! Jefferson Fracture

! Burst fracture

Jefferson Fracture

! Comminuted Fracture of C1

! Mechanism

!  Axial loading – Anterior arch

!  Hyperextension – Posterior arch

! Lateral displacement of lateral masses

! Unstable

Jefferson Fracture

Burst fracture ! Axial Loading

! C3-C7

! Posterior Ligament can be disrupted than it is unstable

! Retro pulsed fragment – Can cause spinal cord injury

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! Hangman fracture

! Extension tear drop

! Neural Arch fracture of C1

! Ant / post dislocation

Hyperextension injuries 20-35% Hangman's Fracture

Hangman's Fracture

! Most common C - spine injury

! Bilateral pars defect of C2 with or without forward slip

! Associated teardrop Fracture of C2 / C3

! Unstable

Hangman's Fracture

Hangman fracture

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Hangman's Fracture Extension tear drop

! Usually at C2-3 level

! Associated with fractures of spinous processes

! Elderly people

! Stable

Extensor teardrop Flexion - Rotation injury (10%)

! Unilateral locked facet

Unilateral Facet Locking

! Flexion Rotation Mechanism

! 25 - 50% forward slip ! 30% present with neurological

deficit

! Associated with nerve root injuries

Unifacet locking

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Unifacet locking Cervical spine trauma

! In 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

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Whole Spine MR

Suspected spinal Trauma

Can spine be cleared clinically? Nexus study

Canadian C spine rule Yes

Evidence of C spine injury ?

MRI C Spine

Remove collar

CT Scan

Continue spinal stabilization Spine consultation

Neck pain or Neurologic deficit

Evidence of C spine injury

NO

YES

NO

YES

NO

Thoracic & Lumbar spine

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Anterior column

Middle column

Posterior column

Fractures Two column - Unstable One column - Stable

Lumbar spine

Burst Fracture

Axial compression

Axial compression

Chance fracture ! Flexion, distraction mechanism

! Usually associated with seat belt

! Fractures are subtle

! 40% present with intrabadominal injuries

! Thoracolumbar junction

! Usually no neurology

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

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Chance Fracture

! Imaging

! Increased intraspinous distance

! Empty vertebral body

! Fracture through pedicle, laminae, disc

! Unstable – Three column involved

Chance fracture

! Thoracolumbar junction

! 35 -50% have intra-abdominal injuries ! Pancreas

! Duodenum

! Mesentery

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

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Empty Vertebral sign

Epidural haematoma Summary ! Moderate to severe spinal injury - CT

Straight away

! Low risk Injury – Plain X rays / CT scan

! MRI

! Occult injuries

! Acute disc / ligament injuries – Normal CT

! Neurological deficit

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Thank You