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Page 1: X ray spine. SPINE TRAUMA CERVICAL SPINE INJURY THORACO-LUMBAR SPINE INJURY

X ray spine

SPINE TRAUMA

CERVICAL SPINE INJURY

THORACO-LUMBAR SPINE INJURY

CERVICAL SPINE INJURY

COMMON MECHANISMS OF INJURY

HYPERFLEXION- MVA CAR COMES TO SUDDEN STOP

HYPEREXTENSION- MVA CAR STRUCK FROM BEHIND

COMPRESSION- HEAD FIRST DIVE IN SHALLOW WATER

HIGH RISK FACTORS FOR SPINE 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

HXISTORY OF PRE-EXISTING VERTEBRAL DISEASE

CLINICAL PROCEDURE INVOLVING PTS WITH SUSPECTED SPINE INJURY

PATIENT KEPT IN CERVICAL COLLAR AND IMMOBILIZED ON SPINE BOARD

ldquoABCDEFrdquo ER PROTOCOL FOLLOWED (AIRWAY BREATHING CIRCULATION DISABILITYDRUGS EXPOSURE FOLEY CATHETER)

HISTORY AND PHYSICAL (PT HANDLED AS THOUGH SERIOUS INJURY PRESENT)

DECIDE IF IMAGING IS NECESSARY

CERVICAL VERTEBRAL ANATOMY

ANT LONGITUDINAL LIG

POST LONGITUDINAL LIG

LIGAMENTA FLAVA

SUPRASPINOUS LIG

MENU OF IMAGING OPTIONS

CERVICAL SPINE PLAIN FILMS

ANTERO- POSTERIOR AND

LATERAL VIEW

STANDARD FIRST LINE IMAGING MODALITY IN ASSESSING CERVICAL VERTEBRAL INJURY

SWIMMERrsquoS VIEW

Anteroposterior (A-P) View

bull Spinous process deviationbull Lateral Translationbull Coronal deformity

Open Mouth View

bull Mostly C1-C2 lateral massbull Occipital CondylesCO-C1bull Odontoid Process

Swimmerrsquos View

bull Cervico-thoracic junctionndash obliques sometimes helpful

CASETTE

X-ray BEAM

NORMAL C-SPINE VIEWS

LATERALAP

ODONTOID

C-SPINE FILM INTERPRETATION 7 STEP PROCESS

1 COUNT VERTEBRAE

-C1 THROUGH C7-IF T1 NOT SEEN 1048774SWIMMERrsquoS VIEW

2 ASSESS CURVATURE

3 ASSESS VERTEBRAL ALIGNMENT (4 LINES)-ANT VERTEBRAL LINE-POST VERTEBRAL LINE-SPINOLAMINAL LINE-POST SPINAL LINE

4 ASSESS BONY INTEGRITY

5 ASSESS INTERVERTEBRAL DISK SPACES

6 ASSESS OAA JOINT7 SOFT TISSUES

THE 4 CONTOUR LINES

1-ANT VERTEBRAL LINE

2-POST VERTEBRAL LINE

3-SPINOLAMINAL LINE

4-POST SPINAL LINE

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

JEFFERSON FRACTURE

HANGMANrsquoS FRACTURE

DENS FRACTURE

FRACTURE OF THE BASE OF THE DENS (ODONTOID) OF C2ANTERIOR OR POSTERIOR DISPLACEMENT OF THE DENSCAN OCCUR AT VARIOUS LEVELS ON THE DENSVIA HYPERFLEXION OR HYPEREXTENSION OF HEAD ON NECKUNSTABLE IF DISPLACEMENT OCCURS

COMPRESSION FRACTURE

VARIABLE SEVERITY FROM MINIMAL ANTERIOR WEDGING TO COMPLETE DISRUPTION OF VERTEBRAL BODY (BURST)LOOK FOR LOSS OF VERTICAL HEIGHT OF VERTEBRAL BODYDUE TO LONG AXIS COMPRESSION OR HYPERFLEXIONDIVING INTO SHALLOW POOLSTABLE 1048774UNSTABLE

TEARDROP FRACTURE

AVULSION FRACTURE OF ANTERIOR MARGIN OF VERTEBRAL BODYANTERIOR LONGITUDINAL LIG INSTABILITY (RUPTURE AVULSION)HYPEREXTENSION INJURYUNSTABLE INJURYLAMINA MAY JAM TOGETHER CAUSING LIGAMENTA FLAVA TO BUCKLE INWARD AND COMPRESSCONTUSE THE SPINAL CORD

CLAY SHOVELERrsquoS FRACTURE

AVULSION FRACTURE OF SPINOUS PROCESS BY SUPRASPINOUS LIGAMENTUSUALLY OCCURRING FROM C6-T2HYPERFLEXION DIRECT TRAUMA DOWNWARD FORCE VIA THORACOSCAPULAR MUSCLE (AS IN SHOVELING MOTION)STABLE

THORACO-LUMBAR SPINE INJURY

Anatomy

MENU OF IMAGING OPTIONS

DORSAL SPINE PLAIN FILMS

ANTERO- POSTERIOR AND

LATERAL VIEW

LUMBO SACCRAL SPINE

ANTERO- POSTERIOR AND

LATERAL VIEW

Thoracic Spine

Lumbar Spine

Determinants of Stability

bull T amp L spines are more stable than C-spinendash Strong ligamentsndash Stabilization by ribsndash Bigger intervertebral discsndash Larger facet jointsndash Less mobility

bull Fractures amp dislocations tend to occur where curvature changesndash T11-12 (thoracolumbar junction)ndash L5-S1 (lumbosacral junction)

Mechanisms of Injury

bull Hyperflexion +- rotationndash Commonestndash Usually see anterior wedge rsquos or Chance

bull Shearingndash Ant or post translation

bull Hyperextensionbull Axial loading

ndash Compression or burst rsquos

3 Column Modelbull Anterior column

ndash Ant longitudinal ligndash Ant annulus fibrosisndash Ant vertebral body

bull Middle columnndash Post longitudinal ligndash Post annulus fibrosisndash Post vertebral body

bull Posterior columnndash Spinous processesndash Transverse processesndash Laminandash Facet jointsndash Pediclesndash Post ligamentous complex

bull 2 or more columns disrupted = unstablebull Most disruption of middle columns are

unstable

Stable or Unstable

bull Radiographic findings suggestive of instabilityndash Vertebral body collapse w widening of pediclesndash gt 33 canal compromise on CTndash gt 25 mm translation bw vertebral bodies in any planendash Bilateral facet dislocationndash Abnormal widening bw spinous processes or lamina and gt

50 anterior collapse of vertebral body

Stable or Unstable

bull Checklist for Instabilityndash Anterior elements disrupted 2 ptsndash Posterior elements disrupted 2 ptsndash Saggital plane translation gt 25 mm 2 ptsndash Saggital plane rotation gt 5o 2 ptsndash Spinal cord or cauda equina damage 2 ptsndash Disruption of costovertebral articulations 1 ptndash Dangerous loading anticipated 2 pts

ndash 5 or more pts unstable until healed or surgically stabilized

Stable or Unstable

bull Risk of neurologic injury increases withndash gt 35 canal narrowing

at T11-12ndash gt 45 canal narrowing

at L1ndash gt 55 canal narrowing

at L2 amp below

Approach to T amp L Spinesbull A ndash adequacy amp alignment

ndash All vertebrae need to be visiblendash Ant amp post longitudinal linesndash Facet joints should lie on smooth curvendash Normal kyphosis amp lordosisndash All spinous processes should lie in straight line

bull B ndash bonesndash Trace cortical margins of each vertebraendash Difference bw ant amp post body ht lt 2 mmndash Progressive increase in vertebral body ht moving down

spinendash Wink sign amp interpedicular distancendash Donrsquot forget to look at transverse processes

Approach to T amp L Spines

bull C ndash cartilagendash Progressive increase in disc space moving down

spine (except L5-S1)ndash Facet joint alignment

bull S ndashsoft tissuendash Look at paraspinal stripe and prevertebral space

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines

Lateral Viewndash Posterior VB linendash Anterior VB linendash Inter-spinous Distancendash Translation

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines A-P

Viewndash Spinous process to Pediclesndash Inter-pedicular Distancendash Translation

Thoracic and Lumbar Injuries

Height Loss

Adjacent fracture

Transverse process fracturesof L2-4

Significance of transverse processfractures is not the fractures in andof themselves but rather the high incidence of associated seriousintraabdominal injury (~20)

AnterolisthesisOf L4 on L5

  • X ray spine
  • SPINE TRAUMA
  • CERVICAL SPINE INJURY
  • Slide 4
  • Slide 5
  • Slide 6
  • Slide 7
  • Slide 8
  • Slide 9
  • Anteroposterior (A-P) View
  • Open Mouth View
  • Swimmerrsquos View
  • Slide 13
  • Slide 14
  • Slide 15
  • Lower Cervical Detection
  • Lower Cervical Detection (2)
  • Lower Cervical Detection (3)
  • Lower Cervical Detection (4)
  • Lower Cervical Detection (5)
  • Lower Cervical Detection (6)
  • Slide 22
  • Slide 23
  • Slide 24
  • Slide 25
  • Slide 26
  • Slide 27
  • THORACO-LUMBAR SPINE INJURY
  • Anatomy
  • Slide 30
  • Thoracic Spine
  • Lumbar Spine
  • Determinants of Stability
  • Mechanisms of Injury
  • 3 Column Model
  • Stable or Unstable
  • Stable or Unstable (2)
  • Stable or Unstable (3)
  • Approach to T amp L Spines
  • Approach to T amp L Spines (2)
  • Injury Detection Thoracic and Lumbar Spines
  • Injury Detection Thoracic and Lumbar Spines (2)
  • Thoracic and Lumbar Injuries
  • Height Loss
  • Slide 45
  • Slide 46
Page 2: X ray spine. SPINE TRAUMA CERVICAL SPINE INJURY THORACO-LUMBAR SPINE INJURY

SPINE TRAUMA

CERVICAL SPINE INJURY

THORACO-LUMBAR SPINE INJURY

CERVICAL SPINE INJURY

COMMON MECHANISMS OF INJURY

HYPERFLEXION- MVA CAR COMES TO SUDDEN STOP

HYPEREXTENSION- MVA CAR STRUCK FROM BEHIND

COMPRESSION- HEAD FIRST DIVE IN SHALLOW WATER

HIGH RISK FACTORS FOR SPINE 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

HXISTORY OF PRE-EXISTING VERTEBRAL DISEASE

CLINICAL PROCEDURE INVOLVING PTS WITH SUSPECTED SPINE INJURY

PATIENT KEPT IN CERVICAL COLLAR AND IMMOBILIZED ON SPINE BOARD

ldquoABCDEFrdquo ER PROTOCOL FOLLOWED (AIRWAY BREATHING CIRCULATION DISABILITYDRUGS EXPOSURE FOLEY CATHETER)

HISTORY AND PHYSICAL (PT HANDLED AS THOUGH SERIOUS INJURY PRESENT)

DECIDE IF IMAGING IS NECESSARY

CERVICAL VERTEBRAL ANATOMY

ANT LONGITUDINAL LIG

POST LONGITUDINAL LIG

LIGAMENTA FLAVA

SUPRASPINOUS LIG

MENU OF IMAGING OPTIONS

CERVICAL SPINE PLAIN FILMS

ANTERO- POSTERIOR AND

LATERAL VIEW

STANDARD FIRST LINE IMAGING MODALITY IN ASSESSING CERVICAL VERTEBRAL INJURY

SWIMMERrsquoS VIEW

Anteroposterior (A-P) View

bull Spinous process deviationbull Lateral Translationbull Coronal deformity

Open Mouth View

bull Mostly C1-C2 lateral massbull Occipital CondylesCO-C1bull Odontoid Process

Swimmerrsquos View

bull Cervico-thoracic junctionndash obliques sometimes helpful

CASETTE

X-ray BEAM

NORMAL C-SPINE VIEWS

LATERALAP

ODONTOID

C-SPINE FILM INTERPRETATION 7 STEP PROCESS

1 COUNT VERTEBRAE

-C1 THROUGH C7-IF T1 NOT SEEN 1048774SWIMMERrsquoS VIEW

2 ASSESS CURVATURE

3 ASSESS VERTEBRAL ALIGNMENT (4 LINES)-ANT VERTEBRAL LINE-POST VERTEBRAL LINE-SPINOLAMINAL LINE-POST SPINAL LINE

4 ASSESS BONY INTEGRITY

5 ASSESS INTERVERTEBRAL DISK SPACES

6 ASSESS OAA JOINT7 SOFT TISSUES

THE 4 CONTOUR LINES

1-ANT VERTEBRAL LINE

2-POST VERTEBRAL LINE

3-SPINOLAMINAL LINE

4-POST SPINAL LINE

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

JEFFERSON FRACTURE

HANGMANrsquoS FRACTURE

DENS FRACTURE

FRACTURE OF THE BASE OF THE DENS (ODONTOID) OF C2ANTERIOR OR POSTERIOR DISPLACEMENT OF THE DENSCAN OCCUR AT VARIOUS LEVELS ON THE DENSVIA HYPERFLEXION OR HYPEREXTENSION OF HEAD ON NECKUNSTABLE IF DISPLACEMENT OCCURS

COMPRESSION FRACTURE

VARIABLE SEVERITY FROM MINIMAL ANTERIOR WEDGING TO COMPLETE DISRUPTION OF VERTEBRAL BODY (BURST)LOOK FOR LOSS OF VERTICAL HEIGHT OF VERTEBRAL BODYDUE TO LONG AXIS COMPRESSION OR HYPERFLEXIONDIVING INTO SHALLOW POOLSTABLE 1048774UNSTABLE

TEARDROP FRACTURE

AVULSION FRACTURE OF ANTERIOR MARGIN OF VERTEBRAL BODYANTERIOR LONGITUDINAL LIG INSTABILITY (RUPTURE AVULSION)HYPEREXTENSION INJURYUNSTABLE INJURYLAMINA MAY JAM TOGETHER CAUSING LIGAMENTA FLAVA TO BUCKLE INWARD AND COMPRESSCONTUSE THE SPINAL CORD

CLAY SHOVELERrsquoS FRACTURE

AVULSION FRACTURE OF SPINOUS PROCESS BY SUPRASPINOUS LIGAMENTUSUALLY OCCURRING FROM C6-T2HYPERFLEXION DIRECT TRAUMA DOWNWARD FORCE VIA THORACOSCAPULAR MUSCLE (AS IN SHOVELING MOTION)STABLE

THORACO-LUMBAR SPINE INJURY

Anatomy

MENU OF IMAGING OPTIONS

DORSAL SPINE PLAIN FILMS

ANTERO- POSTERIOR AND

LATERAL VIEW

LUMBO SACCRAL SPINE

ANTERO- POSTERIOR AND

LATERAL VIEW

Thoracic Spine

Lumbar Spine

Determinants of Stability

bull T amp L spines are more stable than C-spinendash Strong ligamentsndash Stabilization by ribsndash Bigger intervertebral discsndash Larger facet jointsndash Less mobility

bull Fractures amp dislocations tend to occur where curvature changesndash T11-12 (thoracolumbar junction)ndash L5-S1 (lumbosacral junction)

Mechanisms of Injury

bull Hyperflexion +- rotationndash Commonestndash Usually see anterior wedge rsquos or Chance

bull Shearingndash Ant or post translation

bull Hyperextensionbull Axial loading

ndash Compression or burst rsquos

3 Column Modelbull Anterior column

ndash Ant longitudinal ligndash Ant annulus fibrosisndash Ant vertebral body

bull Middle columnndash Post longitudinal ligndash Post annulus fibrosisndash Post vertebral body

bull Posterior columnndash Spinous processesndash Transverse processesndash Laminandash Facet jointsndash Pediclesndash Post ligamentous complex

bull 2 or more columns disrupted = unstablebull Most disruption of middle columns are

unstable

Stable or Unstable

bull Radiographic findings suggestive of instabilityndash Vertebral body collapse w widening of pediclesndash gt 33 canal compromise on CTndash gt 25 mm translation bw vertebral bodies in any planendash Bilateral facet dislocationndash Abnormal widening bw spinous processes or lamina and gt

50 anterior collapse of vertebral body

Stable or Unstable

bull Checklist for Instabilityndash Anterior elements disrupted 2 ptsndash Posterior elements disrupted 2 ptsndash Saggital plane translation gt 25 mm 2 ptsndash Saggital plane rotation gt 5o 2 ptsndash Spinal cord or cauda equina damage 2 ptsndash Disruption of costovertebral articulations 1 ptndash Dangerous loading anticipated 2 pts

ndash 5 or more pts unstable until healed or surgically stabilized

Stable or Unstable

bull Risk of neurologic injury increases withndash gt 35 canal narrowing

at T11-12ndash gt 45 canal narrowing

at L1ndash gt 55 canal narrowing

at L2 amp below

Approach to T amp L Spinesbull A ndash adequacy amp alignment

ndash All vertebrae need to be visiblendash Ant amp post longitudinal linesndash Facet joints should lie on smooth curvendash Normal kyphosis amp lordosisndash All spinous processes should lie in straight line

bull B ndash bonesndash Trace cortical margins of each vertebraendash Difference bw ant amp post body ht lt 2 mmndash Progressive increase in vertebral body ht moving down

spinendash Wink sign amp interpedicular distancendash Donrsquot forget to look at transverse processes

Approach to T amp L Spines

bull C ndash cartilagendash Progressive increase in disc space moving down

spine (except L5-S1)ndash Facet joint alignment

bull S ndashsoft tissuendash Look at paraspinal stripe and prevertebral space

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines

Lateral Viewndash Posterior VB linendash Anterior VB linendash Inter-spinous Distancendash Translation

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines A-P

Viewndash Spinous process to Pediclesndash Inter-pedicular Distancendash Translation

Thoracic and Lumbar Injuries

Height Loss

Adjacent fracture

Transverse process fracturesof L2-4

Significance of transverse processfractures is not the fractures in andof themselves but rather the high incidence of associated seriousintraabdominal injury (~20)

AnterolisthesisOf L4 on L5

  • X ray spine
  • SPINE TRAUMA
  • CERVICAL SPINE INJURY
  • Slide 4
  • Slide 5
  • Slide 6
  • Slide 7
  • Slide 8
  • Slide 9
  • Anteroposterior (A-P) View
  • Open Mouth View
  • Swimmerrsquos View
  • Slide 13
  • Slide 14
  • Slide 15
  • Lower Cervical Detection
  • Lower Cervical Detection (2)
  • Lower Cervical Detection (3)
  • Lower Cervical Detection (4)
  • Lower Cervical Detection (5)
  • Lower Cervical Detection (6)
  • Slide 22
  • Slide 23
  • Slide 24
  • Slide 25
  • Slide 26
  • Slide 27
  • THORACO-LUMBAR SPINE INJURY
  • Anatomy
  • Slide 30
  • Thoracic Spine
  • Lumbar Spine
  • Determinants of Stability
  • Mechanisms of Injury
  • 3 Column Model
  • Stable or Unstable
  • Stable or Unstable (2)
  • Stable or Unstable (3)
  • Approach to T amp L Spines
  • Approach to T amp L Spines (2)
  • Injury Detection Thoracic and Lumbar Spines
  • Injury Detection Thoracic and Lumbar Spines (2)
  • Thoracic and Lumbar Injuries
  • Height Loss
  • Slide 45
  • Slide 46
Page 3: X ray spine. SPINE TRAUMA CERVICAL SPINE INJURY THORACO-LUMBAR SPINE INJURY

CERVICAL SPINE INJURY

COMMON MECHANISMS OF INJURY

HYPERFLEXION- MVA CAR COMES TO SUDDEN STOP

HYPEREXTENSION- MVA CAR STRUCK FROM BEHIND

COMPRESSION- HEAD FIRST DIVE IN SHALLOW WATER

HIGH RISK FACTORS FOR SPINE 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

HXISTORY OF PRE-EXISTING VERTEBRAL DISEASE

CLINICAL PROCEDURE INVOLVING PTS WITH SUSPECTED SPINE INJURY

PATIENT KEPT IN CERVICAL COLLAR AND IMMOBILIZED ON SPINE BOARD

ldquoABCDEFrdquo ER PROTOCOL FOLLOWED (AIRWAY BREATHING CIRCULATION DISABILITYDRUGS EXPOSURE FOLEY CATHETER)

HISTORY AND PHYSICAL (PT HANDLED AS THOUGH SERIOUS INJURY PRESENT)

DECIDE IF IMAGING IS NECESSARY

CERVICAL VERTEBRAL ANATOMY

ANT LONGITUDINAL LIG

POST LONGITUDINAL LIG

LIGAMENTA FLAVA

SUPRASPINOUS LIG

MENU OF IMAGING OPTIONS

CERVICAL SPINE PLAIN FILMS

ANTERO- POSTERIOR AND

LATERAL VIEW

STANDARD FIRST LINE IMAGING MODALITY IN ASSESSING CERVICAL VERTEBRAL INJURY

SWIMMERrsquoS VIEW

Anteroposterior (A-P) View

bull Spinous process deviationbull Lateral Translationbull Coronal deformity

Open Mouth View

bull Mostly C1-C2 lateral massbull Occipital CondylesCO-C1bull Odontoid Process

Swimmerrsquos View

bull Cervico-thoracic junctionndash obliques sometimes helpful

CASETTE

X-ray BEAM

NORMAL C-SPINE VIEWS

LATERALAP

ODONTOID

C-SPINE FILM INTERPRETATION 7 STEP PROCESS

1 COUNT VERTEBRAE

-C1 THROUGH C7-IF T1 NOT SEEN 1048774SWIMMERrsquoS VIEW

2 ASSESS CURVATURE

3 ASSESS VERTEBRAL ALIGNMENT (4 LINES)-ANT VERTEBRAL LINE-POST VERTEBRAL LINE-SPINOLAMINAL LINE-POST SPINAL LINE

4 ASSESS BONY INTEGRITY

5 ASSESS INTERVERTEBRAL DISK SPACES

6 ASSESS OAA JOINT7 SOFT TISSUES

THE 4 CONTOUR LINES

1-ANT VERTEBRAL LINE

2-POST VERTEBRAL LINE

3-SPINOLAMINAL LINE

4-POST SPINAL LINE

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

JEFFERSON FRACTURE

HANGMANrsquoS FRACTURE

DENS FRACTURE

FRACTURE OF THE BASE OF THE DENS (ODONTOID) OF C2ANTERIOR OR POSTERIOR DISPLACEMENT OF THE DENSCAN OCCUR AT VARIOUS LEVELS ON THE DENSVIA HYPERFLEXION OR HYPEREXTENSION OF HEAD ON NECKUNSTABLE IF DISPLACEMENT OCCURS

COMPRESSION FRACTURE

VARIABLE SEVERITY FROM MINIMAL ANTERIOR WEDGING TO COMPLETE DISRUPTION OF VERTEBRAL BODY (BURST)LOOK FOR LOSS OF VERTICAL HEIGHT OF VERTEBRAL BODYDUE TO LONG AXIS COMPRESSION OR HYPERFLEXIONDIVING INTO SHALLOW POOLSTABLE 1048774UNSTABLE

TEARDROP FRACTURE

AVULSION FRACTURE OF ANTERIOR MARGIN OF VERTEBRAL BODYANTERIOR LONGITUDINAL LIG INSTABILITY (RUPTURE AVULSION)HYPEREXTENSION INJURYUNSTABLE INJURYLAMINA MAY JAM TOGETHER CAUSING LIGAMENTA FLAVA TO BUCKLE INWARD AND COMPRESSCONTUSE THE SPINAL CORD

CLAY SHOVELERrsquoS FRACTURE

AVULSION FRACTURE OF SPINOUS PROCESS BY SUPRASPINOUS LIGAMENTUSUALLY OCCURRING FROM C6-T2HYPERFLEXION DIRECT TRAUMA DOWNWARD FORCE VIA THORACOSCAPULAR MUSCLE (AS IN SHOVELING MOTION)STABLE

THORACO-LUMBAR SPINE INJURY

Anatomy

MENU OF IMAGING OPTIONS

DORSAL SPINE PLAIN FILMS

ANTERO- POSTERIOR AND

LATERAL VIEW

LUMBO SACCRAL SPINE

ANTERO- POSTERIOR AND

LATERAL VIEW

Thoracic Spine

Lumbar Spine

Determinants of Stability

bull T amp L spines are more stable than C-spinendash Strong ligamentsndash Stabilization by ribsndash Bigger intervertebral discsndash Larger facet jointsndash Less mobility

bull Fractures amp dislocations tend to occur where curvature changesndash T11-12 (thoracolumbar junction)ndash L5-S1 (lumbosacral junction)

Mechanisms of Injury

bull Hyperflexion +- rotationndash Commonestndash Usually see anterior wedge rsquos or Chance

bull Shearingndash Ant or post translation

bull Hyperextensionbull Axial loading

ndash Compression or burst rsquos

3 Column Modelbull Anterior column

ndash Ant longitudinal ligndash Ant annulus fibrosisndash Ant vertebral body

bull Middle columnndash Post longitudinal ligndash Post annulus fibrosisndash Post vertebral body

bull Posterior columnndash Spinous processesndash Transverse processesndash Laminandash Facet jointsndash Pediclesndash Post ligamentous complex

bull 2 or more columns disrupted = unstablebull Most disruption of middle columns are

unstable

Stable or Unstable

bull Radiographic findings suggestive of instabilityndash Vertebral body collapse w widening of pediclesndash gt 33 canal compromise on CTndash gt 25 mm translation bw vertebral bodies in any planendash Bilateral facet dislocationndash Abnormal widening bw spinous processes or lamina and gt

50 anterior collapse of vertebral body

Stable or Unstable

bull Checklist for Instabilityndash Anterior elements disrupted 2 ptsndash Posterior elements disrupted 2 ptsndash Saggital plane translation gt 25 mm 2 ptsndash Saggital plane rotation gt 5o 2 ptsndash Spinal cord or cauda equina damage 2 ptsndash Disruption of costovertebral articulations 1 ptndash Dangerous loading anticipated 2 pts

ndash 5 or more pts unstable until healed or surgically stabilized

Stable or Unstable

bull Risk of neurologic injury increases withndash gt 35 canal narrowing

at T11-12ndash gt 45 canal narrowing

at L1ndash gt 55 canal narrowing

at L2 amp below

Approach to T amp L Spinesbull A ndash adequacy amp alignment

ndash All vertebrae need to be visiblendash Ant amp post longitudinal linesndash Facet joints should lie on smooth curvendash Normal kyphosis amp lordosisndash All spinous processes should lie in straight line

bull B ndash bonesndash Trace cortical margins of each vertebraendash Difference bw ant amp post body ht lt 2 mmndash Progressive increase in vertebral body ht moving down

spinendash Wink sign amp interpedicular distancendash Donrsquot forget to look at transverse processes

Approach to T amp L Spines

bull C ndash cartilagendash Progressive increase in disc space moving down

spine (except L5-S1)ndash Facet joint alignment

bull S ndashsoft tissuendash Look at paraspinal stripe and prevertebral space

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines

Lateral Viewndash Posterior VB linendash Anterior VB linendash Inter-spinous Distancendash Translation

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines A-P

Viewndash Spinous process to Pediclesndash Inter-pedicular Distancendash Translation

Thoracic and Lumbar Injuries

Height Loss

Adjacent fracture

Transverse process fracturesof L2-4

Significance of transverse processfractures is not the fractures in andof themselves but rather the high incidence of associated seriousintraabdominal injury (~20)

AnterolisthesisOf L4 on L5

  • X ray spine
  • SPINE TRAUMA
  • CERVICAL SPINE INJURY
  • Slide 4
  • Slide 5
  • Slide 6
  • Slide 7
  • Slide 8
  • Slide 9
  • Anteroposterior (A-P) View
  • Open Mouth View
  • Swimmerrsquos View
  • Slide 13
  • Slide 14
  • Slide 15
  • Lower Cervical Detection
  • Lower Cervical Detection (2)
  • Lower Cervical Detection (3)
  • Lower Cervical Detection (4)
  • Lower Cervical Detection (5)
  • Lower Cervical Detection (6)
  • Slide 22
  • Slide 23
  • Slide 24
  • Slide 25
  • Slide 26
  • Slide 27
  • THORACO-LUMBAR SPINE INJURY
  • Anatomy
  • Slide 30
  • Thoracic Spine
  • Lumbar Spine
  • Determinants of Stability
  • Mechanisms of Injury
  • 3 Column Model
  • Stable or Unstable
  • Stable or Unstable (2)
  • Stable or Unstable (3)
  • Approach to T amp L Spines
  • Approach to T amp L Spines (2)
  • Injury Detection Thoracic and Lumbar Spines
  • Injury Detection Thoracic and Lumbar Spines (2)
  • Thoracic and Lumbar Injuries
  • Height Loss
  • Slide 45
  • Slide 46
Page 4: X ray spine. SPINE TRAUMA CERVICAL SPINE INJURY THORACO-LUMBAR SPINE INJURY

COMMON MECHANISMS OF INJURY

HYPERFLEXION- MVA CAR COMES TO SUDDEN STOP

HYPEREXTENSION- MVA CAR STRUCK FROM BEHIND

COMPRESSION- HEAD FIRST DIVE IN SHALLOW WATER

HIGH RISK FACTORS FOR SPINE 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

HXISTORY OF PRE-EXISTING VERTEBRAL DISEASE

CLINICAL PROCEDURE INVOLVING PTS WITH SUSPECTED SPINE INJURY

PATIENT KEPT IN CERVICAL COLLAR AND IMMOBILIZED ON SPINE BOARD

ldquoABCDEFrdquo ER PROTOCOL FOLLOWED (AIRWAY BREATHING CIRCULATION DISABILITYDRUGS EXPOSURE FOLEY CATHETER)

HISTORY AND PHYSICAL (PT HANDLED AS THOUGH SERIOUS INJURY PRESENT)

DECIDE IF IMAGING IS NECESSARY

CERVICAL VERTEBRAL ANATOMY

ANT LONGITUDINAL LIG

POST LONGITUDINAL LIG

LIGAMENTA FLAVA

SUPRASPINOUS LIG

MENU OF IMAGING OPTIONS

CERVICAL SPINE PLAIN FILMS

ANTERO- POSTERIOR AND

LATERAL VIEW

STANDARD FIRST LINE IMAGING MODALITY IN ASSESSING CERVICAL VERTEBRAL INJURY

SWIMMERrsquoS VIEW

Anteroposterior (A-P) View

bull Spinous process deviationbull Lateral Translationbull Coronal deformity

Open Mouth View

bull Mostly C1-C2 lateral massbull Occipital CondylesCO-C1bull Odontoid Process

Swimmerrsquos View

bull Cervico-thoracic junctionndash obliques sometimes helpful

CASETTE

X-ray BEAM

NORMAL C-SPINE VIEWS

LATERALAP

ODONTOID

C-SPINE FILM INTERPRETATION 7 STEP PROCESS

1 COUNT VERTEBRAE

-C1 THROUGH C7-IF T1 NOT SEEN 1048774SWIMMERrsquoS VIEW

2 ASSESS CURVATURE

3 ASSESS VERTEBRAL ALIGNMENT (4 LINES)-ANT VERTEBRAL LINE-POST VERTEBRAL LINE-SPINOLAMINAL LINE-POST SPINAL LINE

4 ASSESS BONY INTEGRITY

5 ASSESS INTERVERTEBRAL DISK SPACES

6 ASSESS OAA JOINT7 SOFT TISSUES

THE 4 CONTOUR LINES

1-ANT VERTEBRAL LINE

2-POST VERTEBRAL LINE

3-SPINOLAMINAL LINE

4-POST SPINAL LINE

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

JEFFERSON FRACTURE

HANGMANrsquoS FRACTURE

DENS FRACTURE

FRACTURE OF THE BASE OF THE DENS (ODONTOID) OF C2ANTERIOR OR POSTERIOR DISPLACEMENT OF THE DENSCAN OCCUR AT VARIOUS LEVELS ON THE DENSVIA HYPERFLEXION OR HYPEREXTENSION OF HEAD ON NECKUNSTABLE IF DISPLACEMENT OCCURS

COMPRESSION FRACTURE

VARIABLE SEVERITY FROM MINIMAL ANTERIOR WEDGING TO COMPLETE DISRUPTION OF VERTEBRAL BODY (BURST)LOOK FOR LOSS OF VERTICAL HEIGHT OF VERTEBRAL BODYDUE TO LONG AXIS COMPRESSION OR HYPERFLEXIONDIVING INTO SHALLOW POOLSTABLE 1048774UNSTABLE

TEARDROP FRACTURE

AVULSION FRACTURE OF ANTERIOR MARGIN OF VERTEBRAL BODYANTERIOR LONGITUDINAL LIG INSTABILITY (RUPTURE AVULSION)HYPEREXTENSION INJURYUNSTABLE INJURYLAMINA MAY JAM TOGETHER CAUSING LIGAMENTA FLAVA TO BUCKLE INWARD AND COMPRESSCONTUSE THE SPINAL CORD

CLAY SHOVELERrsquoS FRACTURE

AVULSION FRACTURE OF SPINOUS PROCESS BY SUPRASPINOUS LIGAMENTUSUALLY OCCURRING FROM C6-T2HYPERFLEXION DIRECT TRAUMA DOWNWARD FORCE VIA THORACOSCAPULAR MUSCLE (AS IN SHOVELING MOTION)STABLE

THORACO-LUMBAR SPINE INJURY

Anatomy

MENU OF IMAGING OPTIONS

DORSAL SPINE PLAIN FILMS

ANTERO- POSTERIOR AND

LATERAL VIEW

LUMBO SACCRAL SPINE

ANTERO- POSTERIOR AND

LATERAL VIEW

Thoracic Spine

Lumbar Spine

Determinants of Stability

bull T amp L spines are more stable than C-spinendash Strong ligamentsndash Stabilization by ribsndash Bigger intervertebral discsndash Larger facet jointsndash Less mobility

bull Fractures amp dislocations tend to occur where curvature changesndash T11-12 (thoracolumbar junction)ndash L5-S1 (lumbosacral junction)

Mechanisms of Injury

bull Hyperflexion +- rotationndash Commonestndash Usually see anterior wedge rsquos or Chance

bull Shearingndash Ant or post translation

bull Hyperextensionbull Axial loading

ndash Compression or burst rsquos

3 Column Modelbull Anterior column

ndash Ant longitudinal ligndash Ant annulus fibrosisndash Ant vertebral body

bull Middle columnndash Post longitudinal ligndash Post annulus fibrosisndash Post vertebral body

bull Posterior columnndash Spinous processesndash Transverse processesndash Laminandash Facet jointsndash Pediclesndash Post ligamentous complex

bull 2 or more columns disrupted = unstablebull Most disruption of middle columns are

unstable

Stable or Unstable

bull Radiographic findings suggestive of instabilityndash Vertebral body collapse w widening of pediclesndash gt 33 canal compromise on CTndash gt 25 mm translation bw vertebral bodies in any planendash Bilateral facet dislocationndash Abnormal widening bw spinous processes or lamina and gt

50 anterior collapse of vertebral body

Stable or Unstable

bull Checklist for Instabilityndash Anterior elements disrupted 2 ptsndash Posterior elements disrupted 2 ptsndash Saggital plane translation gt 25 mm 2 ptsndash Saggital plane rotation gt 5o 2 ptsndash Spinal cord or cauda equina damage 2 ptsndash Disruption of costovertebral articulations 1 ptndash Dangerous loading anticipated 2 pts

ndash 5 or more pts unstable until healed or surgically stabilized

Stable or Unstable

bull Risk of neurologic injury increases withndash gt 35 canal narrowing

at T11-12ndash gt 45 canal narrowing

at L1ndash gt 55 canal narrowing

at L2 amp below

Approach to T amp L Spinesbull A ndash adequacy amp alignment

ndash All vertebrae need to be visiblendash Ant amp post longitudinal linesndash Facet joints should lie on smooth curvendash Normal kyphosis amp lordosisndash All spinous processes should lie in straight line

bull B ndash bonesndash Trace cortical margins of each vertebraendash Difference bw ant amp post body ht lt 2 mmndash Progressive increase in vertebral body ht moving down

spinendash Wink sign amp interpedicular distancendash Donrsquot forget to look at transverse processes

Approach to T amp L Spines

bull C ndash cartilagendash Progressive increase in disc space moving down

spine (except L5-S1)ndash Facet joint alignment

bull S ndashsoft tissuendash Look at paraspinal stripe and prevertebral space

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines

Lateral Viewndash Posterior VB linendash Anterior VB linendash Inter-spinous Distancendash Translation

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines A-P

Viewndash Spinous process to Pediclesndash Inter-pedicular Distancendash Translation

Thoracic and Lumbar Injuries

Height Loss

Adjacent fracture

Transverse process fracturesof L2-4

Significance of transverse processfractures is not the fractures in andof themselves but rather the high incidence of associated seriousintraabdominal injury (~20)

AnterolisthesisOf L4 on L5

  • X ray spine
  • SPINE TRAUMA
  • CERVICAL SPINE INJURY
  • Slide 4
  • Slide 5
  • Slide 6
  • Slide 7
  • Slide 8
  • Slide 9
  • Anteroposterior (A-P) View
  • Open Mouth View
  • Swimmerrsquos View
  • Slide 13
  • Slide 14
  • Slide 15
  • Lower Cervical Detection
  • Lower Cervical Detection (2)
  • Lower Cervical Detection (3)
  • Lower Cervical Detection (4)
  • Lower Cervical Detection (5)
  • Lower Cervical Detection (6)
  • Slide 22
  • Slide 23
  • Slide 24
  • Slide 25
  • Slide 26
  • Slide 27
  • THORACO-LUMBAR SPINE INJURY
  • Anatomy
  • Slide 30
  • Thoracic Spine
  • Lumbar Spine
  • Determinants of Stability
  • Mechanisms of Injury
  • 3 Column Model
  • Stable or Unstable
  • Stable or Unstable (2)
  • Stable or Unstable (3)
  • Approach to T amp L Spines
  • Approach to T amp L Spines (2)
  • Injury Detection Thoracic and Lumbar Spines
  • Injury Detection Thoracic and Lumbar Spines (2)
  • Thoracic and Lumbar Injuries
  • Height Loss
  • Slide 45
  • Slide 46
Page 5: X ray spine. SPINE TRAUMA CERVICAL SPINE INJURY THORACO-LUMBAR SPINE INJURY

HIGH RISK FACTORS FOR SPINE 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

HXISTORY OF PRE-EXISTING VERTEBRAL DISEASE

CLINICAL PROCEDURE INVOLVING PTS WITH SUSPECTED SPINE INJURY

PATIENT KEPT IN CERVICAL COLLAR AND IMMOBILIZED ON SPINE BOARD

ldquoABCDEFrdquo ER PROTOCOL FOLLOWED (AIRWAY BREATHING CIRCULATION DISABILITYDRUGS EXPOSURE FOLEY CATHETER)

HISTORY AND PHYSICAL (PT HANDLED AS THOUGH SERIOUS INJURY PRESENT)

DECIDE IF IMAGING IS NECESSARY

CERVICAL VERTEBRAL ANATOMY

ANT LONGITUDINAL LIG

POST LONGITUDINAL LIG

LIGAMENTA FLAVA

SUPRASPINOUS LIG

MENU OF IMAGING OPTIONS

CERVICAL SPINE PLAIN FILMS

ANTERO- POSTERIOR AND

LATERAL VIEW

STANDARD FIRST LINE IMAGING MODALITY IN ASSESSING CERVICAL VERTEBRAL INJURY

SWIMMERrsquoS VIEW

Anteroposterior (A-P) View

bull Spinous process deviationbull Lateral Translationbull Coronal deformity

Open Mouth View

bull Mostly C1-C2 lateral massbull Occipital CondylesCO-C1bull Odontoid Process

Swimmerrsquos View

bull Cervico-thoracic junctionndash obliques sometimes helpful

CASETTE

X-ray BEAM

NORMAL C-SPINE VIEWS

LATERALAP

ODONTOID

C-SPINE FILM INTERPRETATION 7 STEP PROCESS

1 COUNT VERTEBRAE

-C1 THROUGH C7-IF T1 NOT SEEN 1048774SWIMMERrsquoS VIEW

2 ASSESS CURVATURE

3 ASSESS VERTEBRAL ALIGNMENT (4 LINES)-ANT VERTEBRAL LINE-POST VERTEBRAL LINE-SPINOLAMINAL LINE-POST SPINAL LINE

4 ASSESS BONY INTEGRITY

5 ASSESS INTERVERTEBRAL DISK SPACES

6 ASSESS OAA JOINT7 SOFT TISSUES

THE 4 CONTOUR LINES

1-ANT VERTEBRAL LINE

2-POST VERTEBRAL LINE

3-SPINOLAMINAL LINE

4-POST SPINAL LINE

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

JEFFERSON FRACTURE

HANGMANrsquoS FRACTURE

DENS FRACTURE

FRACTURE OF THE BASE OF THE DENS (ODONTOID) OF C2ANTERIOR OR POSTERIOR DISPLACEMENT OF THE DENSCAN OCCUR AT VARIOUS LEVELS ON THE DENSVIA HYPERFLEXION OR HYPEREXTENSION OF HEAD ON NECKUNSTABLE IF DISPLACEMENT OCCURS

COMPRESSION FRACTURE

VARIABLE SEVERITY FROM MINIMAL ANTERIOR WEDGING TO COMPLETE DISRUPTION OF VERTEBRAL BODY (BURST)LOOK FOR LOSS OF VERTICAL HEIGHT OF VERTEBRAL BODYDUE TO LONG AXIS COMPRESSION OR HYPERFLEXIONDIVING INTO SHALLOW POOLSTABLE 1048774UNSTABLE

TEARDROP FRACTURE

AVULSION FRACTURE OF ANTERIOR MARGIN OF VERTEBRAL BODYANTERIOR LONGITUDINAL LIG INSTABILITY (RUPTURE AVULSION)HYPEREXTENSION INJURYUNSTABLE INJURYLAMINA MAY JAM TOGETHER CAUSING LIGAMENTA FLAVA TO BUCKLE INWARD AND COMPRESSCONTUSE THE SPINAL CORD

CLAY SHOVELERrsquoS FRACTURE

AVULSION FRACTURE OF SPINOUS PROCESS BY SUPRASPINOUS LIGAMENTUSUALLY OCCURRING FROM C6-T2HYPERFLEXION DIRECT TRAUMA DOWNWARD FORCE VIA THORACOSCAPULAR MUSCLE (AS IN SHOVELING MOTION)STABLE

THORACO-LUMBAR SPINE INJURY

Anatomy

MENU OF IMAGING OPTIONS

DORSAL SPINE PLAIN FILMS

ANTERO- POSTERIOR AND

LATERAL VIEW

LUMBO SACCRAL SPINE

ANTERO- POSTERIOR AND

LATERAL VIEW

Thoracic Spine

Lumbar Spine

Determinants of Stability

bull T amp L spines are more stable than C-spinendash Strong ligamentsndash Stabilization by ribsndash Bigger intervertebral discsndash Larger facet jointsndash Less mobility

bull Fractures amp dislocations tend to occur where curvature changesndash T11-12 (thoracolumbar junction)ndash L5-S1 (lumbosacral junction)

Mechanisms of Injury

bull Hyperflexion +- rotationndash Commonestndash Usually see anterior wedge rsquos or Chance

bull Shearingndash Ant or post translation

bull Hyperextensionbull Axial loading

ndash Compression or burst rsquos

3 Column Modelbull Anterior column

ndash Ant longitudinal ligndash Ant annulus fibrosisndash Ant vertebral body

bull Middle columnndash Post longitudinal ligndash Post annulus fibrosisndash Post vertebral body

bull Posterior columnndash Spinous processesndash Transverse processesndash Laminandash Facet jointsndash Pediclesndash Post ligamentous complex

bull 2 or more columns disrupted = unstablebull Most disruption of middle columns are

unstable

Stable or Unstable

bull Radiographic findings suggestive of instabilityndash Vertebral body collapse w widening of pediclesndash gt 33 canal compromise on CTndash gt 25 mm translation bw vertebral bodies in any planendash Bilateral facet dislocationndash Abnormal widening bw spinous processes or lamina and gt

50 anterior collapse of vertebral body

Stable or Unstable

bull Checklist for Instabilityndash Anterior elements disrupted 2 ptsndash Posterior elements disrupted 2 ptsndash Saggital plane translation gt 25 mm 2 ptsndash Saggital plane rotation gt 5o 2 ptsndash Spinal cord or cauda equina damage 2 ptsndash Disruption of costovertebral articulations 1 ptndash Dangerous loading anticipated 2 pts

ndash 5 or more pts unstable until healed or surgically stabilized

Stable or Unstable

bull Risk of neurologic injury increases withndash gt 35 canal narrowing

at T11-12ndash gt 45 canal narrowing

at L1ndash gt 55 canal narrowing

at L2 amp below

Approach to T amp L Spinesbull A ndash adequacy amp alignment

ndash All vertebrae need to be visiblendash Ant amp post longitudinal linesndash Facet joints should lie on smooth curvendash Normal kyphosis amp lordosisndash All spinous processes should lie in straight line

bull B ndash bonesndash Trace cortical margins of each vertebraendash Difference bw ant amp post body ht lt 2 mmndash Progressive increase in vertebral body ht moving down

spinendash Wink sign amp interpedicular distancendash Donrsquot forget to look at transverse processes

Approach to T amp L Spines

bull C ndash cartilagendash Progressive increase in disc space moving down

spine (except L5-S1)ndash Facet joint alignment

bull S ndashsoft tissuendash Look at paraspinal stripe and prevertebral space

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines

Lateral Viewndash Posterior VB linendash Anterior VB linendash Inter-spinous Distancendash Translation

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines A-P

Viewndash Spinous process to Pediclesndash Inter-pedicular Distancendash Translation

Thoracic and Lumbar Injuries

Height Loss

Adjacent fracture

Transverse process fracturesof L2-4

Significance of transverse processfractures is not the fractures in andof themselves but rather the high incidence of associated seriousintraabdominal injury (~20)

AnterolisthesisOf L4 on L5

  • X ray spine
  • SPINE TRAUMA
  • CERVICAL SPINE INJURY
  • Slide 4
  • Slide 5
  • Slide 6
  • Slide 7
  • Slide 8
  • Slide 9
  • Anteroposterior (A-P) View
  • Open Mouth View
  • Swimmerrsquos View
  • Slide 13
  • Slide 14
  • Slide 15
  • Lower Cervical Detection
  • Lower Cervical Detection (2)
  • Lower Cervical Detection (3)
  • Lower Cervical Detection (4)
  • Lower Cervical Detection (5)
  • Lower Cervical Detection (6)
  • Slide 22
  • Slide 23
  • Slide 24
  • Slide 25
  • Slide 26
  • Slide 27
  • THORACO-LUMBAR SPINE INJURY
  • Anatomy
  • Slide 30
  • Thoracic Spine
  • Lumbar Spine
  • Determinants of Stability
  • Mechanisms of Injury
  • 3 Column Model
  • Stable or Unstable
  • Stable or Unstable (2)
  • Stable or Unstable (3)
  • Approach to T amp L Spines
  • Approach to T amp L Spines (2)
  • Injury Detection Thoracic and Lumbar Spines
  • Injury Detection Thoracic and Lumbar Spines (2)
  • Thoracic and Lumbar Injuries
  • Height Loss
  • Slide 45
  • Slide 46
Page 6: X ray spine. SPINE TRAUMA CERVICAL SPINE INJURY THORACO-LUMBAR SPINE INJURY

CLINICAL PROCEDURE INVOLVING PTS WITH SUSPECTED SPINE INJURY

PATIENT KEPT IN CERVICAL COLLAR AND IMMOBILIZED ON SPINE BOARD

ldquoABCDEFrdquo ER PROTOCOL FOLLOWED (AIRWAY BREATHING CIRCULATION DISABILITYDRUGS EXPOSURE FOLEY CATHETER)

HISTORY AND PHYSICAL (PT HANDLED AS THOUGH SERIOUS INJURY PRESENT)

DECIDE IF IMAGING IS NECESSARY

CERVICAL VERTEBRAL ANATOMY

ANT LONGITUDINAL LIG

POST LONGITUDINAL LIG

LIGAMENTA FLAVA

SUPRASPINOUS LIG

MENU OF IMAGING OPTIONS

CERVICAL SPINE PLAIN FILMS

ANTERO- POSTERIOR AND

LATERAL VIEW

STANDARD FIRST LINE IMAGING MODALITY IN ASSESSING CERVICAL VERTEBRAL INJURY

SWIMMERrsquoS VIEW

Anteroposterior (A-P) View

bull Spinous process deviationbull Lateral Translationbull Coronal deformity

Open Mouth View

bull Mostly C1-C2 lateral massbull Occipital CondylesCO-C1bull Odontoid Process

Swimmerrsquos View

bull Cervico-thoracic junctionndash obliques sometimes helpful

CASETTE

X-ray BEAM

NORMAL C-SPINE VIEWS

LATERALAP

ODONTOID

C-SPINE FILM INTERPRETATION 7 STEP PROCESS

1 COUNT VERTEBRAE

-C1 THROUGH C7-IF T1 NOT SEEN 1048774SWIMMERrsquoS VIEW

2 ASSESS CURVATURE

3 ASSESS VERTEBRAL ALIGNMENT (4 LINES)-ANT VERTEBRAL LINE-POST VERTEBRAL LINE-SPINOLAMINAL LINE-POST SPINAL LINE

4 ASSESS BONY INTEGRITY

5 ASSESS INTERVERTEBRAL DISK SPACES

6 ASSESS OAA JOINT7 SOFT TISSUES

THE 4 CONTOUR LINES

1-ANT VERTEBRAL LINE

2-POST VERTEBRAL LINE

3-SPINOLAMINAL LINE

4-POST SPINAL LINE

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

JEFFERSON FRACTURE

HANGMANrsquoS FRACTURE

DENS FRACTURE

FRACTURE OF THE BASE OF THE DENS (ODONTOID) OF C2ANTERIOR OR POSTERIOR DISPLACEMENT OF THE DENSCAN OCCUR AT VARIOUS LEVELS ON THE DENSVIA HYPERFLEXION OR HYPEREXTENSION OF HEAD ON NECKUNSTABLE IF DISPLACEMENT OCCURS

COMPRESSION FRACTURE

VARIABLE SEVERITY FROM MINIMAL ANTERIOR WEDGING TO COMPLETE DISRUPTION OF VERTEBRAL BODY (BURST)LOOK FOR LOSS OF VERTICAL HEIGHT OF VERTEBRAL BODYDUE TO LONG AXIS COMPRESSION OR HYPERFLEXIONDIVING INTO SHALLOW POOLSTABLE 1048774UNSTABLE

TEARDROP FRACTURE

AVULSION FRACTURE OF ANTERIOR MARGIN OF VERTEBRAL BODYANTERIOR LONGITUDINAL LIG INSTABILITY (RUPTURE AVULSION)HYPEREXTENSION INJURYUNSTABLE INJURYLAMINA MAY JAM TOGETHER CAUSING LIGAMENTA FLAVA TO BUCKLE INWARD AND COMPRESSCONTUSE THE SPINAL CORD

CLAY SHOVELERrsquoS FRACTURE

AVULSION FRACTURE OF SPINOUS PROCESS BY SUPRASPINOUS LIGAMENTUSUALLY OCCURRING FROM C6-T2HYPERFLEXION DIRECT TRAUMA DOWNWARD FORCE VIA THORACOSCAPULAR MUSCLE (AS IN SHOVELING MOTION)STABLE

THORACO-LUMBAR SPINE INJURY

Anatomy

MENU OF IMAGING OPTIONS

DORSAL SPINE PLAIN FILMS

ANTERO- POSTERIOR AND

LATERAL VIEW

LUMBO SACCRAL SPINE

ANTERO- POSTERIOR AND

LATERAL VIEW

Thoracic Spine

Lumbar Spine

Determinants of Stability

bull T amp L spines are more stable than C-spinendash Strong ligamentsndash Stabilization by ribsndash Bigger intervertebral discsndash Larger facet jointsndash Less mobility

bull Fractures amp dislocations tend to occur where curvature changesndash T11-12 (thoracolumbar junction)ndash L5-S1 (lumbosacral junction)

Mechanisms of Injury

bull Hyperflexion +- rotationndash Commonestndash Usually see anterior wedge rsquos or Chance

bull Shearingndash Ant or post translation

bull Hyperextensionbull Axial loading

ndash Compression or burst rsquos

3 Column Modelbull Anterior column

ndash Ant longitudinal ligndash Ant annulus fibrosisndash Ant vertebral body

bull Middle columnndash Post longitudinal ligndash Post annulus fibrosisndash Post vertebral body

bull Posterior columnndash Spinous processesndash Transverse processesndash Laminandash Facet jointsndash Pediclesndash Post ligamentous complex

bull 2 or more columns disrupted = unstablebull Most disruption of middle columns are

unstable

Stable or Unstable

bull Radiographic findings suggestive of instabilityndash Vertebral body collapse w widening of pediclesndash gt 33 canal compromise on CTndash gt 25 mm translation bw vertebral bodies in any planendash Bilateral facet dislocationndash Abnormal widening bw spinous processes or lamina and gt

50 anterior collapse of vertebral body

Stable or Unstable

bull Checklist for Instabilityndash Anterior elements disrupted 2 ptsndash Posterior elements disrupted 2 ptsndash Saggital plane translation gt 25 mm 2 ptsndash Saggital plane rotation gt 5o 2 ptsndash Spinal cord or cauda equina damage 2 ptsndash Disruption of costovertebral articulations 1 ptndash Dangerous loading anticipated 2 pts

ndash 5 or more pts unstable until healed or surgically stabilized

Stable or Unstable

bull Risk of neurologic injury increases withndash gt 35 canal narrowing

at T11-12ndash gt 45 canal narrowing

at L1ndash gt 55 canal narrowing

at L2 amp below

Approach to T amp L Spinesbull A ndash adequacy amp alignment

ndash All vertebrae need to be visiblendash Ant amp post longitudinal linesndash Facet joints should lie on smooth curvendash Normal kyphosis amp lordosisndash All spinous processes should lie in straight line

bull B ndash bonesndash Trace cortical margins of each vertebraendash Difference bw ant amp post body ht lt 2 mmndash Progressive increase in vertebral body ht moving down

spinendash Wink sign amp interpedicular distancendash Donrsquot forget to look at transverse processes

Approach to T amp L Spines

bull C ndash cartilagendash Progressive increase in disc space moving down

spine (except L5-S1)ndash Facet joint alignment

bull S ndashsoft tissuendash Look at paraspinal stripe and prevertebral space

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines

Lateral Viewndash Posterior VB linendash Anterior VB linendash Inter-spinous Distancendash Translation

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines A-P

Viewndash Spinous process to Pediclesndash Inter-pedicular Distancendash Translation

Thoracic and Lumbar Injuries

Height Loss

Adjacent fracture

Transverse process fracturesof L2-4

Significance of transverse processfractures is not the fractures in andof themselves but rather the high incidence of associated seriousintraabdominal injury (~20)

AnterolisthesisOf L4 on L5

  • X ray spine
  • SPINE TRAUMA
  • CERVICAL SPINE INJURY
  • Slide 4
  • Slide 5
  • Slide 6
  • Slide 7
  • Slide 8
  • Slide 9
  • Anteroposterior (A-P) View
  • Open Mouth View
  • Swimmerrsquos View
  • Slide 13
  • Slide 14
  • Slide 15
  • Lower Cervical Detection
  • Lower Cervical Detection (2)
  • Lower Cervical Detection (3)
  • Lower Cervical Detection (4)
  • Lower Cervical Detection (5)
  • Lower Cervical Detection (6)
  • Slide 22
  • Slide 23
  • Slide 24
  • Slide 25
  • Slide 26
  • Slide 27
  • THORACO-LUMBAR SPINE INJURY
  • Anatomy
  • Slide 30
  • Thoracic Spine
  • Lumbar Spine
  • Determinants of Stability
  • Mechanisms of Injury
  • 3 Column Model
  • Stable or Unstable
  • Stable or Unstable (2)
  • Stable or Unstable (3)
  • Approach to T amp L Spines
  • Approach to T amp L Spines (2)
  • Injury Detection Thoracic and Lumbar Spines
  • Injury Detection Thoracic and Lumbar Spines (2)
  • Thoracic and Lumbar Injuries
  • Height Loss
  • Slide 45
  • Slide 46
Page 7: X ray spine. SPINE TRAUMA CERVICAL SPINE INJURY THORACO-LUMBAR SPINE INJURY

CERVICAL VERTEBRAL ANATOMY

ANT LONGITUDINAL LIG

POST LONGITUDINAL LIG

LIGAMENTA FLAVA

SUPRASPINOUS LIG

MENU OF IMAGING OPTIONS

CERVICAL SPINE PLAIN FILMS

ANTERO- POSTERIOR AND

LATERAL VIEW

STANDARD FIRST LINE IMAGING MODALITY IN ASSESSING CERVICAL VERTEBRAL INJURY

SWIMMERrsquoS VIEW

Anteroposterior (A-P) View

bull Spinous process deviationbull Lateral Translationbull Coronal deformity

Open Mouth View

bull Mostly C1-C2 lateral massbull Occipital CondylesCO-C1bull Odontoid Process

Swimmerrsquos View

bull Cervico-thoracic junctionndash obliques sometimes helpful

CASETTE

X-ray BEAM

NORMAL C-SPINE VIEWS

LATERALAP

ODONTOID

C-SPINE FILM INTERPRETATION 7 STEP PROCESS

1 COUNT VERTEBRAE

-C1 THROUGH C7-IF T1 NOT SEEN 1048774SWIMMERrsquoS VIEW

2 ASSESS CURVATURE

3 ASSESS VERTEBRAL ALIGNMENT (4 LINES)-ANT VERTEBRAL LINE-POST VERTEBRAL LINE-SPINOLAMINAL LINE-POST SPINAL LINE

4 ASSESS BONY INTEGRITY

5 ASSESS INTERVERTEBRAL DISK SPACES

6 ASSESS OAA JOINT7 SOFT TISSUES

THE 4 CONTOUR LINES

1-ANT VERTEBRAL LINE

2-POST VERTEBRAL LINE

3-SPINOLAMINAL LINE

4-POST SPINAL LINE

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

JEFFERSON FRACTURE

HANGMANrsquoS FRACTURE

DENS FRACTURE

FRACTURE OF THE BASE OF THE DENS (ODONTOID) OF C2ANTERIOR OR POSTERIOR DISPLACEMENT OF THE DENSCAN OCCUR AT VARIOUS LEVELS ON THE DENSVIA HYPERFLEXION OR HYPEREXTENSION OF HEAD ON NECKUNSTABLE IF DISPLACEMENT OCCURS

COMPRESSION FRACTURE

VARIABLE SEVERITY FROM MINIMAL ANTERIOR WEDGING TO COMPLETE DISRUPTION OF VERTEBRAL BODY (BURST)LOOK FOR LOSS OF VERTICAL HEIGHT OF VERTEBRAL BODYDUE TO LONG AXIS COMPRESSION OR HYPERFLEXIONDIVING INTO SHALLOW POOLSTABLE 1048774UNSTABLE

TEARDROP FRACTURE

AVULSION FRACTURE OF ANTERIOR MARGIN OF VERTEBRAL BODYANTERIOR LONGITUDINAL LIG INSTABILITY (RUPTURE AVULSION)HYPEREXTENSION INJURYUNSTABLE INJURYLAMINA MAY JAM TOGETHER CAUSING LIGAMENTA FLAVA TO BUCKLE INWARD AND COMPRESSCONTUSE THE SPINAL CORD

CLAY SHOVELERrsquoS FRACTURE

AVULSION FRACTURE OF SPINOUS PROCESS BY SUPRASPINOUS LIGAMENTUSUALLY OCCURRING FROM C6-T2HYPERFLEXION DIRECT TRAUMA DOWNWARD FORCE VIA THORACOSCAPULAR MUSCLE (AS IN SHOVELING MOTION)STABLE

THORACO-LUMBAR SPINE INJURY

Anatomy

MENU OF IMAGING OPTIONS

DORSAL SPINE PLAIN FILMS

ANTERO- POSTERIOR AND

LATERAL VIEW

LUMBO SACCRAL SPINE

ANTERO- POSTERIOR AND

LATERAL VIEW

Thoracic Spine

Lumbar Spine

Determinants of Stability

bull T amp L spines are more stable than C-spinendash Strong ligamentsndash Stabilization by ribsndash Bigger intervertebral discsndash Larger facet jointsndash Less mobility

bull Fractures amp dislocations tend to occur where curvature changesndash T11-12 (thoracolumbar junction)ndash L5-S1 (lumbosacral junction)

Mechanisms of Injury

bull Hyperflexion +- rotationndash Commonestndash Usually see anterior wedge rsquos or Chance

bull Shearingndash Ant or post translation

bull Hyperextensionbull Axial loading

ndash Compression or burst rsquos

3 Column Modelbull Anterior column

ndash Ant longitudinal ligndash Ant annulus fibrosisndash Ant vertebral body

bull Middle columnndash Post longitudinal ligndash Post annulus fibrosisndash Post vertebral body

bull Posterior columnndash Spinous processesndash Transverse processesndash Laminandash Facet jointsndash Pediclesndash Post ligamentous complex

bull 2 or more columns disrupted = unstablebull Most disruption of middle columns are

unstable

Stable or Unstable

bull Radiographic findings suggestive of instabilityndash Vertebral body collapse w widening of pediclesndash gt 33 canal compromise on CTndash gt 25 mm translation bw vertebral bodies in any planendash Bilateral facet dislocationndash Abnormal widening bw spinous processes or lamina and gt

50 anterior collapse of vertebral body

Stable or Unstable

bull Checklist for Instabilityndash Anterior elements disrupted 2 ptsndash Posterior elements disrupted 2 ptsndash Saggital plane translation gt 25 mm 2 ptsndash Saggital plane rotation gt 5o 2 ptsndash Spinal cord or cauda equina damage 2 ptsndash Disruption of costovertebral articulations 1 ptndash Dangerous loading anticipated 2 pts

ndash 5 or more pts unstable until healed or surgically stabilized

Stable or Unstable

bull Risk of neurologic injury increases withndash gt 35 canal narrowing

at T11-12ndash gt 45 canal narrowing

at L1ndash gt 55 canal narrowing

at L2 amp below

Approach to T amp L Spinesbull A ndash adequacy amp alignment

ndash All vertebrae need to be visiblendash Ant amp post longitudinal linesndash Facet joints should lie on smooth curvendash Normal kyphosis amp lordosisndash All spinous processes should lie in straight line

bull B ndash bonesndash Trace cortical margins of each vertebraendash Difference bw ant amp post body ht lt 2 mmndash Progressive increase in vertebral body ht moving down

spinendash Wink sign amp interpedicular distancendash Donrsquot forget to look at transverse processes

Approach to T amp L Spines

bull C ndash cartilagendash Progressive increase in disc space moving down

spine (except L5-S1)ndash Facet joint alignment

bull S ndashsoft tissuendash Look at paraspinal stripe and prevertebral space

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines

Lateral Viewndash Posterior VB linendash Anterior VB linendash Inter-spinous Distancendash Translation

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines A-P

Viewndash Spinous process to Pediclesndash Inter-pedicular Distancendash Translation

Thoracic and Lumbar Injuries

Height Loss

Adjacent fracture

Transverse process fracturesof L2-4

Significance of transverse processfractures is not the fractures in andof themselves but rather the high incidence of associated seriousintraabdominal injury (~20)

AnterolisthesisOf L4 on L5

  • X ray spine
  • SPINE TRAUMA
  • CERVICAL SPINE INJURY
  • Slide 4
  • Slide 5
  • Slide 6
  • Slide 7
  • Slide 8
  • Slide 9
  • Anteroposterior (A-P) View
  • Open Mouth View
  • Swimmerrsquos View
  • Slide 13
  • Slide 14
  • Slide 15
  • Lower Cervical Detection
  • Lower Cervical Detection (2)
  • Lower Cervical Detection (3)
  • Lower Cervical Detection (4)
  • Lower Cervical Detection (5)
  • Lower Cervical Detection (6)
  • Slide 22
  • Slide 23
  • Slide 24
  • Slide 25
  • Slide 26
  • Slide 27
  • THORACO-LUMBAR SPINE INJURY
  • Anatomy
  • Slide 30
  • Thoracic Spine
  • Lumbar Spine
  • Determinants of Stability
  • Mechanisms of Injury
  • 3 Column Model
  • Stable or Unstable
  • Stable or Unstable (2)
  • Stable or Unstable (3)
  • Approach to T amp L Spines
  • Approach to T amp L Spines (2)
  • Injury Detection Thoracic and Lumbar Spines
  • Injury Detection Thoracic and Lumbar Spines (2)
  • Thoracic and Lumbar Injuries
  • Height Loss
  • Slide 45
  • Slide 46
Page 8: X ray spine. SPINE TRAUMA CERVICAL SPINE INJURY THORACO-LUMBAR SPINE INJURY

ANT LONGITUDINAL LIG

POST LONGITUDINAL LIG

LIGAMENTA FLAVA

SUPRASPINOUS LIG

MENU OF IMAGING OPTIONS

CERVICAL SPINE PLAIN FILMS

ANTERO- POSTERIOR AND

LATERAL VIEW

STANDARD FIRST LINE IMAGING MODALITY IN ASSESSING CERVICAL VERTEBRAL INJURY

SWIMMERrsquoS VIEW

Anteroposterior (A-P) View

bull Spinous process deviationbull Lateral Translationbull Coronal deformity

Open Mouth View

bull Mostly C1-C2 lateral massbull Occipital CondylesCO-C1bull Odontoid Process

Swimmerrsquos View

bull Cervico-thoracic junctionndash obliques sometimes helpful

CASETTE

X-ray BEAM

NORMAL C-SPINE VIEWS

LATERALAP

ODONTOID

C-SPINE FILM INTERPRETATION 7 STEP PROCESS

1 COUNT VERTEBRAE

-C1 THROUGH C7-IF T1 NOT SEEN 1048774SWIMMERrsquoS VIEW

2 ASSESS CURVATURE

3 ASSESS VERTEBRAL ALIGNMENT (4 LINES)-ANT VERTEBRAL LINE-POST VERTEBRAL LINE-SPINOLAMINAL LINE-POST SPINAL LINE

4 ASSESS BONY INTEGRITY

5 ASSESS INTERVERTEBRAL DISK SPACES

6 ASSESS OAA JOINT7 SOFT TISSUES

THE 4 CONTOUR LINES

1-ANT VERTEBRAL LINE

2-POST VERTEBRAL LINE

3-SPINOLAMINAL LINE

4-POST SPINAL LINE

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

JEFFERSON FRACTURE

HANGMANrsquoS FRACTURE

DENS FRACTURE

FRACTURE OF THE BASE OF THE DENS (ODONTOID) OF C2ANTERIOR OR POSTERIOR DISPLACEMENT OF THE DENSCAN OCCUR AT VARIOUS LEVELS ON THE DENSVIA HYPERFLEXION OR HYPEREXTENSION OF HEAD ON NECKUNSTABLE IF DISPLACEMENT OCCURS

COMPRESSION FRACTURE

VARIABLE SEVERITY FROM MINIMAL ANTERIOR WEDGING TO COMPLETE DISRUPTION OF VERTEBRAL BODY (BURST)LOOK FOR LOSS OF VERTICAL HEIGHT OF VERTEBRAL BODYDUE TO LONG AXIS COMPRESSION OR HYPERFLEXIONDIVING INTO SHALLOW POOLSTABLE 1048774UNSTABLE

TEARDROP FRACTURE

AVULSION FRACTURE OF ANTERIOR MARGIN OF VERTEBRAL BODYANTERIOR LONGITUDINAL LIG INSTABILITY (RUPTURE AVULSION)HYPEREXTENSION INJURYUNSTABLE INJURYLAMINA MAY JAM TOGETHER CAUSING LIGAMENTA FLAVA TO BUCKLE INWARD AND COMPRESSCONTUSE THE SPINAL CORD

CLAY SHOVELERrsquoS FRACTURE

AVULSION FRACTURE OF SPINOUS PROCESS BY SUPRASPINOUS LIGAMENTUSUALLY OCCURRING FROM C6-T2HYPERFLEXION DIRECT TRAUMA DOWNWARD FORCE VIA THORACOSCAPULAR MUSCLE (AS IN SHOVELING MOTION)STABLE

THORACO-LUMBAR SPINE INJURY

Anatomy

MENU OF IMAGING OPTIONS

DORSAL SPINE PLAIN FILMS

ANTERO- POSTERIOR AND

LATERAL VIEW

LUMBO SACCRAL SPINE

ANTERO- POSTERIOR AND

LATERAL VIEW

Thoracic Spine

Lumbar Spine

Determinants of Stability

bull T amp L spines are more stable than C-spinendash Strong ligamentsndash Stabilization by ribsndash Bigger intervertebral discsndash Larger facet jointsndash Less mobility

bull Fractures amp dislocations tend to occur where curvature changesndash T11-12 (thoracolumbar junction)ndash L5-S1 (lumbosacral junction)

Mechanisms of Injury

bull Hyperflexion +- rotationndash Commonestndash Usually see anterior wedge rsquos or Chance

bull Shearingndash Ant or post translation

bull Hyperextensionbull Axial loading

ndash Compression or burst rsquos

3 Column Modelbull Anterior column

ndash Ant longitudinal ligndash Ant annulus fibrosisndash Ant vertebral body

bull Middle columnndash Post longitudinal ligndash Post annulus fibrosisndash Post vertebral body

bull Posterior columnndash Spinous processesndash Transverse processesndash Laminandash Facet jointsndash Pediclesndash Post ligamentous complex

bull 2 or more columns disrupted = unstablebull Most disruption of middle columns are

unstable

Stable or Unstable

bull Radiographic findings suggestive of instabilityndash Vertebral body collapse w widening of pediclesndash gt 33 canal compromise on CTndash gt 25 mm translation bw vertebral bodies in any planendash Bilateral facet dislocationndash Abnormal widening bw spinous processes or lamina and gt

50 anterior collapse of vertebral body

Stable or Unstable

bull Checklist for Instabilityndash Anterior elements disrupted 2 ptsndash Posterior elements disrupted 2 ptsndash Saggital plane translation gt 25 mm 2 ptsndash Saggital plane rotation gt 5o 2 ptsndash Spinal cord or cauda equina damage 2 ptsndash Disruption of costovertebral articulations 1 ptndash Dangerous loading anticipated 2 pts

ndash 5 or more pts unstable until healed or surgically stabilized

Stable or Unstable

bull Risk of neurologic injury increases withndash gt 35 canal narrowing

at T11-12ndash gt 45 canal narrowing

at L1ndash gt 55 canal narrowing

at L2 amp below

Approach to T amp L Spinesbull A ndash adequacy amp alignment

ndash All vertebrae need to be visiblendash Ant amp post longitudinal linesndash Facet joints should lie on smooth curvendash Normal kyphosis amp lordosisndash All spinous processes should lie in straight line

bull B ndash bonesndash Trace cortical margins of each vertebraendash Difference bw ant amp post body ht lt 2 mmndash Progressive increase in vertebral body ht moving down

spinendash Wink sign amp interpedicular distancendash Donrsquot forget to look at transverse processes

Approach to T amp L Spines

bull C ndash cartilagendash Progressive increase in disc space moving down

spine (except L5-S1)ndash Facet joint alignment

bull S ndashsoft tissuendash Look at paraspinal stripe and prevertebral space

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines

Lateral Viewndash Posterior VB linendash Anterior VB linendash Inter-spinous Distancendash Translation

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines A-P

Viewndash Spinous process to Pediclesndash Inter-pedicular Distancendash Translation

Thoracic and Lumbar Injuries

Height Loss

Adjacent fracture

Transverse process fracturesof L2-4

Significance of transverse processfractures is not the fractures in andof themselves but rather the high incidence of associated seriousintraabdominal injury (~20)

AnterolisthesisOf L4 on L5

  • X ray spine
  • SPINE TRAUMA
  • CERVICAL SPINE INJURY
  • Slide 4
  • Slide 5
  • Slide 6
  • Slide 7
  • Slide 8
  • Slide 9
  • Anteroposterior (A-P) View
  • Open Mouth View
  • Swimmerrsquos View
  • Slide 13
  • Slide 14
  • Slide 15
  • Lower Cervical Detection
  • Lower Cervical Detection (2)
  • Lower Cervical Detection (3)
  • Lower Cervical Detection (4)
  • Lower Cervical Detection (5)
  • Lower Cervical Detection (6)
  • Slide 22
  • Slide 23
  • Slide 24
  • Slide 25
  • Slide 26
  • Slide 27
  • THORACO-LUMBAR SPINE INJURY
  • Anatomy
  • Slide 30
  • Thoracic Spine
  • Lumbar Spine
  • Determinants of Stability
  • Mechanisms of Injury
  • 3 Column Model
  • Stable or Unstable
  • Stable or Unstable (2)
  • Stable or Unstable (3)
  • Approach to T amp L Spines
  • Approach to T amp L Spines (2)
  • Injury Detection Thoracic and Lumbar Spines
  • Injury Detection Thoracic and Lumbar Spines (2)
  • Thoracic and Lumbar Injuries
  • Height Loss
  • Slide 45
  • Slide 46
Page 9: X ray spine. SPINE TRAUMA CERVICAL SPINE INJURY THORACO-LUMBAR SPINE INJURY

MENU OF IMAGING OPTIONS

CERVICAL SPINE PLAIN FILMS

ANTERO- POSTERIOR AND

LATERAL VIEW

STANDARD FIRST LINE IMAGING MODALITY IN ASSESSING CERVICAL VERTEBRAL INJURY

SWIMMERrsquoS VIEW

Anteroposterior (A-P) View

bull Spinous process deviationbull Lateral Translationbull Coronal deformity

Open Mouth View

bull Mostly C1-C2 lateral massbull Occipital CondylesCO-C1bull Odontoid Process

Swimmerrsquos View

bull Cervico-thoracic junctionndash obliques sometimes helpful

CASETTE

X-ray BEAM

NORMAL C-SPINE VIEWS

LATERALAP

ODONTOID

C-SPINE FILM INTERPRETATION 7 STEP PROCESS

1 COUNT VERTEBRAE

-C1 THROUGH C7-IF T1 NOT SEEN 1048774SWIMMERrsquoS VIEW

2 ASSESS CURVATURE

3 ASSESS VERTEBRAL ALIGNMENT (4 LINES)-ANT VERTEBRAL LINE-POST VERTEBRAL LINE-SPINOLAMINAL LINE-POST SPINAL LINE

4 ASSESS BONY INTEGRITY

5 ASSESS INTERVERTEBRAL DISK SPACES

6 ASSESS OAA JOINT7 SOFT TISSUES

THE 4 CONTOUR LINES

1-ANT VERTEBRAL LINE

2-POST VERTEBRAL LINE

3-SPINOLAMINAL LINE

4-POST SPINAL LINE

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

JEFFERSON FRACTURE

HANGMANrsquoS FRACTURE

DENS FRACTURE

FRACTURE OF THE BASE OF THE DENS (ODONTOID) OF C2ANTERIOR OR POSTERIOR DISPLACEMENT OF THE DENSCAN OCCUR AT VARIOUS LEVELS ON THE DENSVIA HYPERFLEXION OR HYPEREXTENSION OF HEAD ON NECKUNSTABLE IF DISPLACEMENT OCCURS

COMPRESSION FRACTURE

VARIABLE SEVERITY FROM MINIMAL ANTERIOR WEDGING TO COMPLETE DISRUPTION OF VERTEBRAL BODY (BURST)LOOK FOR LOSS OF VERTICAL HEIGHT OF VERTEBRAL BODYDUE TO LONG AXIS COMPRESSION OR HYPERFLEXIONDIVING INTO SHALLOW POOLSTABLE 1048774UNSTABLE

TEARDROP FRACTURE

AVULSION FRACTURE OF ANTERIOR MARGIN OF VERTEBRAL BODYANTERIOR LONGITUDINAL LIG INSTABILITY (RUPTURE AVULSION)HYPEREXTENSION INJURYUNSTABLE INJURYLAMINA MAY JAM TOGETHER CAUSING LIGAMENTA FLAVA TO BUCKLE INWARD AND COMPRESSCONTUSE THE SPINAL CORD

CLAY SHOVELERrsquoS FRACTURE

AVULSION FRACTURE OF SPINOUS PROCESS BY SUPRASPINOUS LIGAMENTUSUALLY OCCURRING FROM C6-T2HYPERFLEXION DIRECT TRAUMA DOWNWARD FORCE VIA THORACOSCAPULAR MUSCLE (AS IN SHOVELING MOTION)STABLE

THORACO-LUMBAR SPINE INJURY

Anatomy

MENU OF IMAGING OPTIONS

DORSAL SPINE PLAIN FILMS

ANTERO- POSTERIOR AND

LATERAL VIEW

LUMBO SACCRAL SPINE

ANTERO- POSTERIOR AND

LATERAL VIEW

Thoracic Spine

Lumbar Spine

Determinants of Stability

bull T amp L spines are more stable than C-spinendash Strong ligamentsndash Stabilization by ribsndash Bigger intervertebral discsndash Larger facet jointsndash Less mobility

bull Fractures amp dislocations tend to occur where curvature changesndash T11-12 (thoracolumbar junction)ndash L5-S1 (lumbosacral junction)

Mechanisms of Injury

bull Hyperflexion +- rotationndash Commonestndash Usually see anterior wedge rsquos or Chance

bull Shearingndash Ant or post translation

bull Hyperextensionbull Axial loading

ndash Compression or burst rsquos

3 Column Modelbull Anterior column

ndash Ant longitudinal ligndash Ant annulus fibrosisndash Ant vertebral body

bull Middle columnndash Post longitudinal ligndash Post annulus fibrosisndash Post vertebral body

bull Posterior columnndash Spinous processesndash Transverse processesndash Laminandash Facet jointsndash Pediclesndash Post ligamentous complex

bull 2 or more columns disrupted = unstablebull Most disruption of middle columns are

unstable

Stable or Unstable

bull Radiographic findings suggestive of instabilityndash Vertebral body collapse w widening of pediclesndash gt 33 canal compromise on CTndash gt 25 mm translation bw vertebral bodies in any planendash Bilateral facet dislocationndash Abnormal widening bw spinous processes or lamina and gt

50 anterior collapse of vertebral body

Stable or Unstable

bull Checklist for Instabilityndash Anterior elements disrupted 2 ptsndash Posterior elements disrupted 2 ptsndash Saggital plane translation gt 25 mm 2 ptsndash Saggital plane rotation gt 5o 2 ptsndash Spinal cord or cauda equina damage 2 ptsndash Disruption of costovertebral articulations 1 ptndash Dangerous loading anticipated 2 pts

ndash 5 or more pts unstable until healed or surgically stabilized

Stable or Unstable

bull Risk of neurologic injury increases withndash gt 35 canal narrowing

at T11-12ndash gt 45 canal narrowing

at L1ndash gt 55 canal narrowing

at L2 amp below

Approach to T amp L Spinesbull A ndash adequacy amp alignment

ndash All vertebrae need to be visiblendash Ant amp post longitudinal linesndash Facet joints should lie on smooth curvendash Normal kyphosis amp lordosisndash All spinous processes should lie in straight line

bull B ndash bonesndash Trace cortical margins of each vertebraendash Difference bw ant amp post body ht lt 2 mmndash Progressive increase in vertebral body ht moving down

spinendash Wink sign amp interpedicular distancendash Donrsquot forget to look at transverse processes

Approach to T amp L Spines

bull C ndash cartilagendash Progressive increase in disc space moving down

spine (except L5-S1)ndash Facet joint alignment

bull S ndashsoft tissuendash Look at paraspinal stripe and prevertebral space

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines

Lateral Viewndash Posterior VB linendash Anterior VB linendash Inter-spinous Distancendash Translation

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines A-P

Viewndash Spinous process to Pediclesndash Inter-pedicular Distancendash Translation

Thoracic and Lumbar Injuries

Height Loss

Adjacent fracture

Transverse process fracturesof L2-4

Significance of transverse processfractures is not the fractures in andof themselves but rather the high incidence of associated seriousintraabdominal injury (~20)

AnterolisthesisOf L4 on L5

  • X ray spine
  • SPINE TRAUMA
  • CERVICAL SPINE INJURY
  • Slide 4
  • Slide 5
  • Slide 6
  • Slide 7
  • Slide 8
  • Slide 9
  • Anteroposterior (A-P) View
  • Open Mouth View
  • Swimmerrsquos View
  • Slide 13
  • Slide 14
  • Slide 15
  • Lower Cervical Detection
  • Lower Cervical Detection (2)
  • Lower Cervical Detection (3)
  • Lower Cervical Detection (4)
  • Lower Cervical Detection (5)
  • Lower Cervical Detection (6)
  • Slide 22
  • Slide 23
  • Slide 24
  • Slide 25
  • Slide 26
  • Slide 27
  • THORACO-LUMBAR SPINE INJURY
  • Anatomy
  • Slide 30
  • Thoracic Spine
  • Lumbar Spine
  • Determinants of Stability
  • Mechanisms of Injury
  • 3 Column Model
  • Stable or Unstable
  • Stable or Unstable (2)
  • Stable or Unstable (3)
  • Approach to T amp L Spines
  • Approach to T amp L Spines (2)
  • Injury Detection Thoracic and Lumbar Spines
  • Injury Detection Thoracic and Lumbar Spines (2)
  • Thoracic and Lumbar Injuries
  • Height Loss
  • Slide 45
  • Slide 46
Page 10: X ray spine. SPINE TRAUMA CERVICAL SPINE INJURY THORACO-LUMBAR SPINE INJURY

Anteroposterior (A-P) View

bull Spinous process deviationbull Lateral Translationbull Coronal deformity

Open Mouth View

bull Mostly C1-C2 lateral massbull Occipital CondylesCO-C1bull Odontoid Process

Swimmerrsquos View

bull Cervico-thoracic junctionndash obliques sometimes helpful

CASETTE

X-ray BEAM

NORMAL C-SPINE VIEWS

LATERALAP

ODONTOID

C-SPINE FILM INTERPRETATION 7 STEP PROCESS

1 COUNT VERTEBRAE

-C1 THROUGH C7-IF T1 NOT SEEN 1048774SWIMMERrsquoS VIEW

2 ASSESS CURVATURE

3 ASSESS VERTEBRAL ALIGNMENT (4 LINES)-ANT VERTEBRAL LINE-POST VERTEBRAL LINE-SPINOLAMINAL LINE-POST SPINAL LINE

4 ASSESS BONY INTEGRITY

5 ASSESS INTERVERTEBRAL DISK SPACES

6 ASSESS OAA JOINT7 SOFT TISSUES

THE 4 CONTOUR LINES

1-ANT VERTEBRAL LINE

2-POST VERTEBRAL LINE

3-SPINOLAMINAL LINE

4-POST SPINAL LINE

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

JEFFERSON FRACTURE

HANGMANrsquoS FRACTURE

DENS FRACTURE

FRACTURE OF THE BASE OF THE DENS (ODONTOID) OF C2ANTERIOR OR POSTERIOR DISPLACEMENT OF THE DENSCAN OCCUR AT VARIOUS LEVELS ON THE DENSVIA HYPERFLEXION OR HYPEREXTENSION OF HEAD ON NECKUNSTABLE IF DISPLACEMENT OCCURS

COMPRESSION FRACTURE

VARIABLE SEVERITY FROM MINIMAL ANTERIOR WEDGING TO COMPLETE DISRUPTION OF VERTEBRAL BODY (BURST)LOOK FOR LOSS OF VERTICAL HEIGHT OF VERTEBRAL BODYDUE TO LONG AXIS COMPRESSION OR HYPERFLEXIONDIVING INTO SHALLOW POOLSTABLE 1048774UNSTABLE

TEARDROP FRACTURE

AVULSION FRACTURE OF ANTERIOR MARGIN OF VERTEBRAL BODYANTERIOR LONGITUDINAL LIG INSTABILITY (RUPTURE AVULSION)HYPEREXTENSION INJURYUNSTABLE INJURYLAMINA MAY JAM TOGETHER CAUSING LIGAMENTA FLAVA TO BUCKLE INWARD AND COMPRESSCONTUSE THE SPINAL CORD

CLAY SHOVELERrsquoS FRACTURE

AVULSION FRACTURE OF SPINOUS PROCESS BY SUPRASPINOUS LIGAMENTUSUALLY OCCURRING FROM C6-T2HYPERFLEXION DIRECT TRAUMA DOWNWARD FORCE VIA THORACOSCAPULAR MUSCLE (AS IN SHOVELING MOTION)STABLE

THORACO-LUMBAR SPINE INJURY

Anatomy

MENU OF IMAGING OPTIONS

DORSAL SPINE PLAIN FILMS

ANTERO- POSTERIOR AND

LATERAL VIEW

LUMBO SACCRAL SPINE

ANTERO- POSTERIOR AND

LATERAL VIEW

Thoracic Spine

Lumbar Spine

Determinants of Stability

bull T amp L spines are more stable than C-spinendash Strong ligamentsndash Stabilization by ribsndash Bigger intervertebral discsndash Larger facet jointsndash Less mobility

bull Fractures amp dislocations tend to occur where curvature changesndash T11-12 (thoracolumbar junction)ndash L5-S1 (lumbosacral junction)

Mechanisms of Injury

bull Hyperflexion +- rotationndash Commonestndash Usually see anterior wedge rsquos or Chance

bull Shearingndash Ant or post translation

bull Hyperextensionbull Axial loading

ndash Compression or burst rsquos

3 Column Modelbull Anterior column

ndash Ant longitudinal ligndash Ant annulus fibrosisndash Ant vertebral body

bull Middle columnndash Post longitudinal ligndash Post annulus fibrosisndash Post vertebral body

bull Posterior columnndash Spinous processesndash Transverse processesndash Laminandash Facet jointsndash Pediclesndash Post ligamentous complex

bull 2 or more columns disrupted = unstablebull Most disruption of middle columns are

unstable

Stable or Unstable

bull Radiographic findings suggestive of instabilityndash Vertebral body collapse w widening of pediclesndash gt 33 canal compromise on CTndash gt 25 mm translation bw vertebral bodies in any planendash Bilateral facet dislocationndash Abnormal widening bw spinous processes or lamina and gt

50 anterior collapse of vertebral body

Stable or Unstable

bull Checklist for Instabilityndash Anterior elements disrupted 2 ptsndash Posterior elements disrupted 2 ptsndash Saggital plane translation gt 25 mm 2 ptsndash Saggital plane rotation gt 5o 2 ptsndash Spinal cord or cauda equina damage 2 ptsndash Disruption of costovertebral articulations 1 ptndash Dangerous loading anticipated 2 pts

ndash 5 or more pts unstable until healed or surgically stabilized

Stable or Unstable

bull Risk of neurologic injury increases withndash gt 35 canal narrowing

at T11-12ndash gt 45 canal narrowing

at L1ndash gt 55 canal narrowing

at L2 amp below

Approach to T amp L Spinesbull A ndash adequacy amp alignment

ndash All vertebrae need to be visiblendash Ant amp post longitudinal linesndash Facet joints should lie on smooth curvendash Normal kyphosis amp lordosisndash All spinous processes should lie in straight line

bull B ndash bonesndash Trace cortical margins of each vertebraendash Difference bw ant amp post body ht lt 2 mmndash Progressive increase in vertebral body ht moving down

spinendash Wink sign amp interpedicular distancendash Donrsquot forget to look at transverse processes

Approach to T amp L Spines

bull C ndash cartilagendash Progressive increase in disc space moving down

spine (except L5-S1)ndash Facet joint alignment

bull S ndashsoft tissuendash Look at paraspinal stripe and prevertebral space

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines

Lateral Viewndash Posterior VB linendash Anterior VB linendash Inter-spinous Distancendash Translation

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines A-P

Viewndash Spinous process to Pediclesndash Inter-pedicular Distancendash Translation

Thoracic and Lumbar Injuries

Height Loss

Adjacent fracture

Transverse process fracturesof L2-4

Significance of transverse processfractures is not the fractures in andof themselves but rather the high incidence of associated seriousintraabdominal injury (~20)

AnterolisthesisOf L4 on L5

  • X ray spine
  • SPINE TRAUMA
  • CERVICAL SPINE INJURY
  • Slide 4
  • Slide 5
  • Slide 6
  • Slide 7
  • Slide 8
  • Slide 9
  • Anteroposterior (A-P) View
  • Open Mouth View
  • Swimmerrsquos View
  • Slide 13
  • Slide 14
  • Slide 15
  • Lower Cervical Detection
  • Lower Cervical Detection (2)
  • Lower Cervical Detection (3)
  • Lower Cervical Detection (4)
  • Lower Cervical Detection (5)
  • Lower Cervical Detection (6)
  • Slide 22
  • Slide 23
  • Slide 24
  • Slide 25
  • Slide 26
  • Slide 27
  • THORACO-LUMBAR SPINE INJURY
  • Anatomy
  • Slide 30
  • Thoracic Spine
  • Lumbar Spine
  • Determinants of Stability
  • Mechanisms of Injury
  • 3 Column Model
  • Stable or Unstable
  • Stable or Unstable (2)
  • Stable or Unstable (3)
  • Approach to T amp L Spines
  • Approach to T amp L Spines (2)
  • Injury Detection Thoracic and Lumbar Spines
  • Injury Detection Thoracic and Lumbar Spines (2)
  • Thoracic and Lumbar Injuries
  • Height Loss
  • Slide 45
  • Slide 46
Page 11: X ray spine. SPINE TRAUMA CERVICAL SPINE INJURY THORACO-LUMBAR SPINE INJURY

Open Mouth View

bull Mostly C1-C2 lateral massbull Occipital CondylesCO-C1bull Odontoid Process

Swimmerrsquos View

bull Cervico-thoracic junctionndash obliques sometimes helpful

CASETTE

X-ray BEAM

NORMAL C-SPINE VIEWS

LATERALAP

ODONTOID

C-SPINE FILM INTERPRETATION 7 STEP PROCESS

1 COUNT VERTEBRAE

-C1 THROUGH C7-IF T1 NOT SEEN 1048774SWIMMERrsquoS VIEW

2 ASSESS CURVATURE

3 ASSESS VERTEBRAL ALIGNMENT (4 LINES)-ANT VERTEBRAL LINE-POST VERTEBRAL LINE-SPINOLAMINAL LINE-POST SPINAL LINE

4 ASSESS BONY INTEGRITY

5 ASSESS INTERVERTEBRAL DISK SPACES

6 ASSESS OAA JOINT7 SOFT TISSUES

THE 4 CONTOUR LINES

1-ANT VERTEBRAL LINE

2-POST VERTEBRAL LINE

3-SPINOLAMINAL LINE

4-POST SPINAL LINE

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

JEFFERSON FRACTURE

HANGMANrsquoS FRACTURE

DENS FRACTURE

FRACTURE OF THE BASE OF THE DENS (ODONTOID) OF C2ANTERIOR OR POSTERIOR DISPLACEMENT OF THE DENSCAN OCCUR AT VARIOUS LEVELS ON THE DENSVIA HYPERFLEXION OR HYPEREXTENSION OF HEAD ON NECKUNSTABLE IF DISPLACEMENT OCCURS

COMPRESSION FRACTURE

VARIABLE SEVERITY FROM MINIMAL ANTERIOR WEDGING TO COMPLETE DISRUPTION OF VERTEBRAL BODY (BURST)LOOK FOR LOSS OF VERTICAL HEIGHT OF VERTEBRAL BODYDUE TO LONG AXIS COMPRESSION OR HYPERFLEXIONDIVING INTO SHALLOW POOLSTABLE 1048774UNSTABLE

TEARDROP FRACTURE

AVULSION FRACTURE OF ANTERIOR MARGIN OF VERTEBRAL BODYANTERIOR LONGITUDINAL LIG INSTABILITY (RUPTURE AVULSION)HYPEREXTENSION INJURYUNSTABLE INJURYLAMINA MAY JAM TOGETHER CAUSING LIGAMENTA FLAVA TO BUCKLE INWARD AND COMPRESSCONTUSE THE SPINAL CORD

CLAY SHOVELERrsquoS FRACTURE

AVULSION FRACTURE OF SPINOUS PROCESS BY SUPRASPINOUS LIGAMENTUSUALLY OCCURRING FROM C6-T2HYPERFLEXION DIRECT TRAUMA DOWNWARD FORCE VIA THORACOSCAPULAR MUSCLE (AS IN SHOVELING MOTION)STABLE

THORACO-LUMBAR SPINE INJURY

Anatomy

MENU OF IMAGING OPTIONS

DORSAL SPINE PLAIN FILMS

ANTERO- POSTERIOR AND

LATERAL VIEW

LUMBO SACCRAL SPINE

ANTERO- POSTERIOR AND

LATERAL VIEW

Thoracic Spine

Lumbar Spine

Determinants of Stability

bull T amp L spines are more stable than C-spinendash Strong ligamentsndash Stabilization by ribsndash Bigger intervertebral discsndash Larger facet jointsndash Less mobility

bull Fractures amp dislocations tend to occur where curvature changesndash T11-12 (thoracolumbar junction)ndash L5-S1 (lumbosacral junction)

Mechanisms of Injury

bull Hyperflexion +- rotationndash Commonestndash Usually see anterior wedge rsquos or Chance

bull Shearingndash Ant or post translation

bull Hyperextensionbull Axial loading

ndash Compression or burst rsquos

3 Column Modelbull Anterior column

ndash Ant longitudinal ligndash Ant annulus fibrosisndash Ant vertebral body

bull Middle columnndash Post longitudinal ligndash Post annulus fibrosisndash Post vertebral body

bull Posterior columnndash Spinous processesndash Transverse processesndash Laminandash Facet jointsndash Pediclesndash Post ligamentous complex

bull 2 or more columns disrupted = unstablebull Most disruption of middle columns are

unstable

Stable or Unstable

bull Radiographic findings suggestive of instabilityndash Vertebral body collapse w widening of pediclesndash gt 33 canal compromise on CTndash gt 25 mm translation bw vertebral bodies in any planendash Bilateral facet dislocationndash Abnormal widening bw spinous processes or lamina and gt

50 anterior collapse of vertebral body

Stable or Unstable

bull Checklist for Instabilityndash Anterior elements disrupted 2 ptsndash Posterior elements disrupted 2 ptsndash Saggital plane translation gt 25 mm 2 ptsndash Saggital plane rotation gt 5o 2 ptsndash Spinal cord or cauda equina damage 2 ptsndash Disruption of costovertebral articulations 1 ptndash Dangerous loading anticipated 2 pts

ndash 5 or more pts unstable until healed or surgically stabilized

Stable or Unstable

bull Risk of neurologic injury increases withndash gt 35 canal narrowing

at T11-12ndash gt 45 canal narrowing

at L1ndash gt 55 canal narrowing

at L2 amp below

Approach to T amp L Spinesbull A ndash adequacy amp alignment

ndash All vertebrae need to be visiblendash Ant amp post longitudinal linesndash Facet joints should lie on smooth curvendash Normal kyphosis amp lordosisndash All spinous processes should lie in straight line

bull B ndash bonesndash Trace cortical margins of each vertebraendash Difference bw ant amp post body ht lt 2 mmndash Progressive increase in vertebral body ht moving down

spinendash Wink sign amp interpedicular distancendash Donrsquot forget to look at transverse processes

Approach to T amp L Spines

bull C ndash cartilagendash Progressive increase in disc space moving down

spine (except L5-S1)ndash Facet joint alignment

bull S ndashsoft tissuendash Look at paraspinal stripe and prevertebral space

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines

Lateral Viewndash Posterior VB linendash Anterior VB linendash Inter-spinous Distancendash Translation

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines A-P

Viewndash Spinous process to Pediclesndash Inter-pedicular Distancendash Translation

Thoracic and Lumbar Injuries

Height Loss

Adjacent fracture

Transverse process fracturesof L2-4

Significance of transverse processfractures is not the fractures in andof themselves but rather the high incidence of associated seriousintraabdominal injury (~20)

AnterolisthesisOf L4 on L5

  • X ray spine
  • SPINE TRAUMA
  • CERVICAL SPINE INJURY
  • Slide 4
  • Slide 5
  • Slide 6
  • Slide 7
  • Slide 8
  • Slide 9
  • Anteroposterior (A-P) View
  • Open Mouth View
  • Swimmerrsquos View
  • Slide 13
  • Slide 14
  • Slide 15
  • Lower Cervical Detection
  • Lower Cervical Detection (2)
  • Lower Cervical Detection (3)
  • Lower Cervical Detection (4)
  • Lower Cervical Detection (5)
  • Lower Cervical Detection (6)
  • Slide 22
  • Slide 23
  • Slide 24
  • Slide 25
  • Slide 26
  • Slide 27
  • THORACO-LUMBAR SPINE INJURY
  • Anatomy
  • Slide 30
  • Thoracic Spine
  • Lumbar Spine
  • Determinants of Stability
  • Mechanisms of Injury
  • 3 Column Model
  • Stable or Unstable
  • Stable or Unstable (2)
  • Stable or Unstable (3)
  • Approach to T amp L Spines
  • Approach to T amp L Spines (2)
  • Injury Detection Thoracic and Lumbar Spines
  • Injury Detection Thoracic and Lumbar Spines (2)
  • Thoracic and Lumbar Injuries
  • Height Loss
  • Slide 45
  • Slide 46
Page 12: X ray spine. SPINE TRAUMA CERVICAL SPINE INJURY THORACO-LUMBAR SPINE INJURY

Swimmerrsquos View

bull Cervico-thoracic junctionndash obliques sometimes helpful

CASETTE

X-ray BEAM

NORMAL C-SPINE VIEWS

LATERALAP

ODONTOID

C-SPINE FILM INTERPRETATION 7 STEP PROCESS

1 COUNT VERTEBRAE

-C1 THROUGH C7-IF T1 NOT SEEN 1048774SWIMMERrsquoS VIEW

2 ASSESS CURVATURE

3 ASSESS VERTEBRAL ALIGNMENT (4 LINES)-ANT VERTEBRAL LINE-POST VERTEBRAL LINE-SPINOLAMINAL LINE-POST SPINAL LINE

4 ASSESS BONY INTEGRITY

5 ASSESS INTERVERTEBRAL DISK SPACES

6 ASSESS OAA JOINT7 SOFT TISSUES

THE 4 CONTOUR LINES

1-ANT VERTEBRAL LINE

2-POST VERTEBRAL LINE

3-SPINOLAMINAL LINE

4-POST SPINAL LINE

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

JEFFERSON FRACTURE

HANGMANrsquoS FRACTURE

DENS FRACTURE

FRACTURE OF THE BASE OF THE DENS (ODONTOID) OF C2ANTERIOR OR POSTERIOR DISPLACEMENT OF THE DENSCAN OCCUR AT VARIOUS LEVELS ON THE DENSVIA HYPERFLEXION OR HYPEREXTENSION OF HEAD ON NECKUNSTABLE IF DISPLACEMENT OCCURS

COMPRESSION FRACTURE

VARIABLE SEVERITY FROM MINIMAL ANTERIOR WEDGING TO COMPLETE DISRUPTION OF VERTEBRAL BODY (BURST)LOOK FOR LOSS OF VERTICAL HEIGHT OF VERTEBRAL BODYDUE TO LONG AXIS COMPRESSION OR HYPERFLEXIONDIVING INTO SHALLOW POOLSTABLE 1048774UNSTABLE

TEARDROP FRACTURE

AVULSION FRACTURE OF ANTERIOR MARGIN OF VERTEBRAL BODYANTERIOR LONGITUDINAL LIG INSTABILITY (RUPTURE AVULSION)HYPEREXTENSION INJURYUNSTABLE INJURYLAMINA MAY JAM TOGETHER CAUSING LIGAMENTA FLAVA TO BUCKLE INWARD AND COMPRESSCONTUSE THE SPINAL CORD

CLAY SHOVELERrsquoS FRACTURE

AVULSION FRACTURE OF SPINOUS PROCESS BY SUPRASPINOUS LIGAMENTUSUALLY OCCURRING FROM C6-T2HYPERFLEXION DIRECT TRAUMA DOWNWARD FORCE VIA THORACOSCAPULAR MUSCLE (AS IN SHOVELING MOTION)STABLE

THORACO-LUMBAR SPINE INJURY

Anatomy

MENU OF IMAGING OPTIONS

DORSAL SPINE PLAIN FILMS

ANTERO- POSTERIOR AND

LATERAL VIEW

LUMBO SACCRAL SPINE

ANTERO- POSTERIOR AND

LATERAL VIEW

Thoracic Spine

Lumbar Spine

Determinants of Stability

bull T amp L spines are more stable than C-spinendash Strong ligamentsndash Stabilization by ribsndash Bigger intervertebral discsndash Larger facet jointsndash Less mobility

bull Fractures amp dislocations tend to occur where curvature changesndash T11-12 (thoracolumbar junction)ndash L5-S1 (lumbosacral junction)

Mechanisms of Injury

bull Hyperflexion +- rotationndash Commonestndash Usually see anterior wedge rsquos or Chance

bull Shearingndash Ant or post translation

bull Hyperextensionbull Axial loading

ndash Compression or burst rsquos

3 Column Modelbull Anterior column

ndash Ant longitudinal ligndash Ant annulus fibrosisndash Ant vertebral body

bull Middle columnndash Post longitudinal ligndash Post annulus fibrosisndash Post vertebral body

bull Posterior columnndash Spinous processesndash Transverse processesndash Laminandash Facet jointsndash Pediclesndash Post ligamentous complex

bull 2 or more columns disrupted = unstablebull Most disruption of middle columns are

unstable

Stable or Unstable

bull Radiographic findings suggestive of instabilityndash Vertebral body collapse w widening of pediclesndash gt 33 canal compromise on CTndash gt 25 mm translation bw vertebral bodies in any planendash Bilateral facet dislocationndash Abnormal widening bw spinous processes or lamina and gt

50 anterior collapse of vertebral body

Stable or Unstable

bull Checklist for Instabilityndash Anterior elements disrupted 2 ptsndash Posterior elements disrupted 2 ptsndash Saggital plane translation gt 25 mm 2 ptsndash Saggital plane rotation gt 5o 2 ptsndash Spinal cord or cauda equina damage 2 ptsndash Disruption of costovertebral articulations 1 ptndash Dangerous loading anticipated 2 pts

ndash 5 or more pts unstable until healed or surgically stabilized

Stable or Unstable

bull Risk of neurologic injury increases withndash gt 35 canal narrowing

at T11-12ndash gt 45 canal narrowing

at L1ndash gt 55 canal narrowing

at L2 amp below

Approach to T amp L Spinesbull A ndash adequacy amp alignment

ndash All vertebrae need to be visiblendash Ant amp post longitudinal linesndash Facet joints should lie on smooth curvendash Normal kyphosis amp lordosisndash All spinous processes should lie in straight line

bull B ndash bonesndash Trace cortical margins of each vertebraendash Difference bw ant amp post body ht lt 2 mmndash Progressive increase in vertebral body ht moving down

spinendash Wink sign amp interpedicular distancendash Donrsquot forget to look at transverse processes

Approach to T amp L Spines

bull C ndash cartilagendash Progressive increase in disc space moving down

spine (except L5-S1)ndash Facet joint alignment

bull S ndashsoft tissuendash Look at paraspinal stripe and prevertebral space

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines

Lateral Viewndash Posterior VB linendash Anterior VB linendash Inter-spinous Distancendash Translation

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines A-P

Viewndash Spinous process to Pediclesndash Inter-pedicular Distancendash Translation

Thoracic and Lumbar Injuries

Height Loss

Adjacent fracture

Transverse process fracturesof L2-4

Significance of transverse processfractures is not the fractures in andof themselves but rather the high incidence of associated seriousintraabdominal injury (~20)

AnterolisthesisOf L4 on L5

  • X ray spine
  • SPINE TRAUMA
  • CERVICAL SPINE INJURY
  • Slide 4
  • Slide 5
  • Slide 6
  • Slide 7
  • Slide 8
  • Slide 9
  • Anteroposterior (A-P) View
  • Open Mouth View
  • Swimmerrsquos View
  • Slide 13
  • Slide 14
  • Slide 15
  • Lower Cervical Detection
  • Lower Cervical Detection (2)
  • Lower Cervical Detection (3)
  • Lower Cervical Detection (4)
  • Lower Cervical Detection (5)
  • Lower Cervical Detection (6)
  • Slide 22
  • Slide 23
  • Slide 24
  • Slide 25
  • Slide 26
  • Slide 27
  • THORACO-LUMBAR SPINE INJURY
  • Anatomy
  • Slide 30
  • Thoracic Spine
  • Lumbar Spine
  • Determinants of Stability
  • Mechanisms of Injury
  • 3 Column Model
  • Stable or Unstable
  • Stable or Unstable (2)
  • Stable or Unstable (3)
  • Approach to T amp L Spines
  • Approach to T amp L Spines (2)
  • Injury Detection Thoracic and Lumbar Spines
  • Injury Detection Thoracic and Lumbar Spines (2)
  • Thoracic and Lumbar Injuries
  • Height Loss
  • Slide 45
  • Slide 46
Page 13: X ray spine. SPINE TRAUMA CERVICAL SPINE INJURY THORACO-LUMBAR SPINE INJURY

NORMAL C-SPINE VIEWS

LATERALAP

ODONTOID

C-SPINE FILM INTERPRETATION 7 STEP PROCESS

1 COUNT VERTEBRAE

-C1 THROUGH C7-IF T1 NOT SEEN 1048774SWIMMERrsquoS VIEW

2 ASSESS CURVATURE

3 ASSESS VERTEBRAL ALIGNMENT (4 LINES)-ANT VERTEBRAL LINE-POST VERTEBRAL LINE-SPINOLAMINAL LINE-POST SPINAL LINE

4 ASSESS BONY INTEGRITY

5 ASSESS INTERVERTEBRAL DISK SPACES

6 ASSESS OAA JOINT7 SOFT TISSUES

THE 4 CONTOUR LINES

1-ANT VERTEBRAL LINE

2-POST VERTEBRAL LINE

3-SPINOLAMINAL LINE

4-POST SPINAL LINE

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

JEFFERSON FRACTURE

HANGMANrsquoS FRACTURE

DENS FRACTURE

FRACTURE OF THE BASE OF THE DENS (ODONTOID) OF C2ANTERIOR OR POSTERIOR DISPLACEMENT OF THE DENSCAN OCCUR AT VARIOUS LEVELS ON THE DENSVIA HYPERFLEXION OR HYPEREXTENSION OF HEAD ON NECKUNSTABLE IF DISPLACEMENT OCCURS

COMPRESSION FRACTURE

VARIABLE SEVERITY FROM MINIMAL ANTERIOR WEDGING TO COMPLETE DISRUPTION OF VERTEBRAL BODY (BURST)LOOK FOR LOSS OF VERTICAL HEIGHT OF VERTEBRAL BODYDUE TO LONG AXIS COMPRESSION OR HYPERFLEXIONDIVING INTO SHALLOW POOLSTABLE 1048774UNSTABLE

TEARDROP FRACTURE

AVULSION FRACTURE OF ANTERIOR MARGIN OF VERTEBRAL BODYANTERIOR LONGITUDINAL LIG INSTABILITY (RUPTURE AVULSION)HYPEREXTENSION INJURYUNSTABLE INJURYLAMINA MAY JAM TOGETHER CAUSING LIGAMENTA FLAVA TO BUCKLE INWARD AND COMPRESSCONTUSE THE SPINAL CORD

CLAY SHOVELERrsquoS FRACTURE

AVULSION FRACTURE OF SPINOUS PROCESS BY SUPRASPINOUS LIGAMENTUSUALLY OCCURRING FROM C6-T2HYPERFLEXION DIRECT TRAUMA DOWNWARD FORCE VIA THORACOSCAPULAR MUSCLE (AS IN SHOVELING MOTION)STABLE

THORACO-LUMBAR SPINE INJURY

Anatomy

MENU OF IMAGING OPTIONS

DORSAL SPINE PLAIN FILMS

ANTERO- POSTERIOR AND

LATERAL VIEW

LUMBO SACCRAL SPINE

ANTERO- POSTERIOR AND

LATERAL VIEW

Thoracic Spine

Lumbar Spine

Determinants of Stability

bull T amp L spines are more stable than C-spinendash Strong ligamentsndash Stabilization by ribsndash Bigger intervertebral discsndash Larger facet jointsndash Less mobility

bull Fractures amp dislocations tend to occur where curvature changesndash T11-12 (thoracolumbar junction)ndash L5-S1 (lumbosacral junction)

Mechanisms of Injury

bull Hyperflexion +- rotationndash Commonestndash Usually see anterior wedge rsquos or Chance

bull Shearingndash Ant or post translation

bull Hyperextensionbull Axial loading

ndash Compression or burst rsquos

3 Column Modelbull Anterior column

ndash Ant longitudinal ligndash Ant annulus fibrosisndash Ant vertebral body

bull Middle columnndash Post longitudinal ligndash Post annulus fibrosisndash Post vertebral body

bull Posterior columnndash Spinous processesndash Transverse processesndash Laminandash Facet jointsndash Pediclesndash Post ligamentous complex

bull 2 or more columns disrupted = unstablebull Most disruption of middle columns are

unstable

Stable or Unstable

bull Radiographic findings suggestive of instabilityndash Vertebral body collapse w widening of pediclesndash gt 33 canal compromise on CTndash gt 25 mm translation bw vertebral bodies in any planendash Bilateral facet dislocationndash Abnormal widening bw spinous processes or lamina and gt

50 anterior collapse of vertebral body

Stable or Unstable

bull Checklist for Instabilityndash Anterior elements disrupted 2 ptsndash Posterior elements disrupted 2 ptsndash Saggital plane translation gt 25 mm 2 ptsndash Saggital plane rotation gt 5o 2 ptsndash Spinal cord or cauda equina damage 2 ptsndash Disruption of costovertebral articulations 1 ptndash Dangerous loading anticipated 2 pts

ndash 5 or more pts unstable until healed or surgically stabilized

Stable or Unstable

bull Risk of neurologic injury increases withndash gt 35 canal narrowing

at T11-12ndash gt 45 canal narrowing

at L1ndash gt 55 canal narrowing

at L2 amp below

Approach to T amp L Spinesbull A ndash adequacy amp alignment

ndash All vertebrae need to be visiblendash Ant amp post longitudinal linesndash Facet joints should lie on smooth curvendash Normal kyphosis amp lordosisndash All spinous processes should lie in straight line

bull B ndash bonesndash Trace cortical margins of each vertebraendash Difference bw ant amp post body ht lt 2 mmndash Progressive increase in vertebral body ht moving down

spinendash Wink sign amp interpedicular distancendash Donrsquot forget to look at transverse processes

Approach to T amp L Spines

bull C ndash cartilagendash Progressive increase in disc space moving down

spine (except L5-S1)ndash Facet joint alignment

bull S ndashsoft tissuendash Look at paraspinal stripe and prevertebral space

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines

Lateral Viewndash Posterior VB linendash Anterior VB linendash Inter-spinous Distancendash Translation

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines A-P

Viewndash Spinous process to Pediclesndash Inter-pedicular Distancendash Translation

Thoracic and Lumbar Injuries

Height Loss

Adjacent fracture

Transverse process fracturesof L2-4

Significance of transverse processfractures is not the fractures in andof themselves but rather the high incidence of associated seriousintraabdominal injury (~20)

AnterolisthesisOf L4 on L5

  • X ray spine
  • SPINE TRAUMA
  • CERVICAL SPINE INJURY
  • Slide 4
  • Slide 5
  • Slide 6
  • Slide 7
  • Slide 8
  • Slide 9
  • Anteroposterior (A-P) View
  • Open Mouth View
  • Swimmerrsquos View
  • Slide 13
  • Slide 14
  • Slide 15
  • Lower Cervical Detection
  • Lower Cervical Detection (2)
  • Lower Cervical Detection (3)
  • Lower Cervical Detection (4)
  • Lower Cervical Detection (5)
  • Lower Cervical Detection (6)
  • Slide 22
  • Slide 23
  • Slide 24
  • Slide 25
  • Slide 26
  • Slide 27
  • THORACO-LUMBAR SPINE INJURY
  • Anatomy
  • Slide 30
  • Thoracic Spine
  • Lumbar Spine
  • Determinants of Stability
  • Mechanisms of Injury
  • 3 Column Model
  • Stable or Unstable
  • Stable or Unstable (2)
  • Stable or Unstable (3)
  • Approach to T amp L Spines
  • Approach to T amp L Spines (2)
  • Injury Detection Thoracic and Lumbar Spines
  • Injury Detection Thoracic and Lumbar Spines (2)
  • Thoracic and Lumbar Injuries
  • Height Loss
  • Slide 45
  • Slide 46
Page 14: X ray spine. SPINE TRAUMA CERVICAL SPINE INJURY THORACO-LUMBAR SPINE INJURY

C-SPINE FILM INTERPRETATION 7 STEP PROCESS

1 COUNT VERTEBRAE

-C1 THROUGH C7-IF T1 NOT SEEN 1048774SWIMMERrsquoS VIEW

2 ASSESS CURVATURE

3 ASSESS VERTEBRAL ALIGNMENT (4 LINES)-ANT VERTEBRAL LINE-POST VERTEBRAL LINE-SPINOLAMINAL LINE-POST SPINAL LINE

4 ASSESS BONY INTEGRITY

5 ASSESS INTERVERTEBRAL DISK SPACES

6 ASSESS OAA JOINT7 SOFT TISSUES

THE 4 CONTOUR LINES

1-ANT VERTEBRAL LINE

2-POST VERTEBRAL LINE

3-SPINOLAMINAL LINE

4-POST SPINAL LINE

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

JEFFERSON FRACTURE

HANGMANrsquoS FRACTURE

DENS FRACTURE

FRACTURE OF THE BASE OF THE DENS (ODONTOID) OF C2ANTERIOR OR POSTERIOR DISPLACEMENT OF THE DENSCAN OCCUR AT VARIOUS LEVELS ON THE DENSVIA HYPERFLEXION OR HYPEREXTENSION OF HEAD ON NECKUNSTABLE IF DISPLACEMENT OCCURS

COMPRESSION FRACTURE

VARIABLE SEVERITY FROM MINIMAL ANTERIOR WEDGING TO COMPLETE DISRUPTION OF VERTEBRAL BODY (BURST)LOOK FOR LOSS OF VERTICAL HEIGHT OF VERTEBRAL BODYDUE TO LONG AXIS COMPRESSION OR HYPERFLEXIONDIVING INTO SHALLOW POOLSTABLE 1048774UNSTABLE

TEARDROP FRACTURE

AVULSION FRACTURE OF ANTERIOR MARGIN OF VERTEBRAL BODYANTERIOR LONGITUDINAL LIG INSTABILITY (RUPTURE AVULSION)HYPEREXTENSION INJURYUNSTABLE INJURYLAMINA MAY JAM TOGETHER CAUSING LIGAMENTA FLAVA TO BUCKLE INWARD AND COMPRESSCONTUSE THE SPINAL CORD

CLAY SHOVELERrsquoS FRACTURE

AVULSION FRACTURE OF SPINOUS PROCESS BY SUPRASPINOUS LIGAMENTUSUALLY OCCURRING FROM C6-T2HYPERFLEXION DIRECT TRAUMA DOWNWARD FORCE VIA THORACOSCAPULAR MUSCLE (AS IN SHOVELING MOTION)STABLE

THORACO-LUMBAR SPINE INJURY

Anatomy

MENU OF IMAGING OPTIONS

DORSAL SPINE PLAIN FILMS

ANTERO- POSTERIOR AND

LATERAL VIEW

LUMBO SACCRAL SPINE

ANTERO- POSTERIOR AND

LATERAL VIEW

Thoracic Spine

Lumbar Spine

Determinants of Stability

bull T amp L spines are more stable than C-spinendash Strong ligamentsndash Stabilization by ribsndash Bigger intervertebral discsndash Larger facet jointsndash Less mobility

bull Fractures amp dislocations tend to occur where curvature changesndash T11-12 (thoracolumbar junction)ndash L5-S1 (lumbosacral junction)

Mechanisms of Injury

bull Hyperflexion +- rotationndash Commonestndash Usually see anterior wedge rsquos or Chance

bull Shearingndash Ant or post translation

bull Hyperextensionbull Axial loading

ndash Compression or burst rsquos

3 Column Modelbull Anterior column

ndash Ant longitudinal ligndash Ant annulus fibrosisndash Ant vertebral body

bull Middle columnndash Post longitudinal ligndash Post annulus fibrosisndash Post vertebral body

bull Posterior columnndash Spinous processesndash Transverse processesndash Laminandash Facet jointsndash Pediclesndash Post ligamentous complex

bull 2 or more columns disrupted = unstablebull Most disruption of middle columns are

unstable

Stable or Unstable

bull Radiographic findings suggestive of instabilityndash Vertebral body collapse w widening of pediclesndash gt 33 canal compromise on CTndash gt 25 mm translation bw vertebral bodies in any planendash Bilateral facet dislocationndash Abnormal widening bw spinous processes or lamina and gt

50 anterior collapse of vertebral body

Stable or Unstable

bull Checklist for Instabilityndash Anterior elements disrupted 2 ptsndash Posterior elements disrupted 2 ptsndash Saggital plane translation gt 25 mm 2 ptsndash Saggital plane rotation gt 5o 2 ptsndash Spinal cord or cauda equina damage 2 ptsndash Disruption of costovertebral articulations 1 ptndash Dangerous loading anticipated 2 pts

ndash 5 or more pts unstable until healed or surgically stabilized

Stable or Unstable

bull Risk of neurologic injury increases withndash gt 35 canal narrowing

at T11-12ndash gt 45 canal narrowing

at L1ndash gt 55 canal narrowing

at L2 amp below

Approach to T amp L Spinesbull A ndash adequacy amp alignment

ndash All vertebrae need to be visiblendash Ant amp post longitudinal linesndash Facet joints should lie on smooth curvendash Normal kyphosis amp lordosisndash All spinous processes should lie in straight line

bull B ndash bonesndash Trace cortical margins of each vertebraendash Difference bw ant amp post body ht lt 2 mmndash Progressive increase in vertebral body ht moving down

spinendash Wink sign amp interpedicular distancendash Donrsquot forget to look at transverse processes

Approach to T amp L Spines

bull C ndash cartilagendash Progressive increase in disc space moving down

spine (except L5-S1)ndash Facet joint alignment

bull S ndashsoft tissuendash Look at paraspinal stripe and prevertebral space

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines

Lateral Viewndash Posterior VB linendash Anterior VB linendash Inter-spinous Distancendash Translation

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines A-P

Viewndash Spinous process to Pediclesndash Inter-pedicular Distancendash Translation

Thoracic and Lumbar Injuries

Height Loss

Adjacent fracture

Transverse process fracturesof L2-4

Significance of transverse processfractures is not the fractures in andof themselves but rather the high incidence of associated seriousintraabdominal injury (~20)

AnterolisthesisOf L4 on L5

  • X ray spine
  • SPINE TRAUMA
  • CERVICAL SPINE INJURY
  • Slide 4
  • Slide 5
  • Slide 6
  • Slide 7
  • Slide 8
  • Slide 9
  • Anteroposterior (A-P) View
  • Open Mouth View
  • Swimmerrsquos View
  • Slide 13
  • Slide 14
  • Slide 15
  • Lower Cervical Detection
  • Lower Cervical Detection (2)
  • Lower Cervical Detection (3)
  • Lower Cervical Detection (4)
  • Lower Cervical Detection (5)
  • Lower Cervical Detection (6)
  • Slide 22
  • Slide 23
  • Slide 24
  • Slide 25
  • Slide 26
  • Slide 27
  • THORACO-LUMBAR SPINE INJURY
  • Anatomy
  • Slide 30
  • Thoracic Spine
  • Lumbar Spine
  • Determinants of Stability
  • Mechanisms of Injury
  • 3 Column Model
  • Stable or Unstable
  • Stable or Unstable (2)
  • Stable or Unstable (3)
  • Approach to T amp L Spines
  • Approach to T amp L Spines (2)
  • Injury Detection Thoracic and Lumbar Spines
  • Injury Detection Thoracic and Lumbar Spines (2)
  • Thoracic and Lumbar Injuries
  • Height Loss
  • Slide 45
  • Slide 46
Page 15: X ray spine. SPINE TRAUMA CERVICAL SPINE INJURY THORACO-LUMBAR SPINE INJURY

THE 4 CONTOUR LINES

1-ANT VERTEBRAL LINE

2-POST VERTEBRAL LINE

3-SPINOLAMINAL LINE

4-POST SPINAL LINE

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

JEFFERSON FRACTURE

HANGMANrsquoS FRACTURE

DENS FRACTURE

FRACTURE OF THE BASE OF THE DENS (ODONTOID) OF C2ANTERIOR OR POSTERIOR DISPLACEMENT OF THE DENSCAN OCCUR AT VARIOUS LEVELS ON THE DENSVIA HYPERFLEXION OR HYPEREXTENSION OF HEAD ON NECKUNSTABLE IF DISPLACEMENT OCCURS

COMPRESSION FRACTURE

VARIABLE SEVERITY FROM MINIMAL ANTERIOR WEDGING TO COMPLETE DISRUPTION OF VERTEBRAL BODY (BURST)LOOK FOR LOSS OF VERTICAL HEIGHT OF VERTEBRAL BODYDUE TO LONG AXIS COMPRESSION OR HYPERFLEXIONDIVING INTO SHALLOW POOLSTABLE 1048774UNSTABLE

TEARDROP FRACTURE

AVULSION FRACTURE OF ANTERIOR MARGIN OF VERTEBRAL BODYANTERIOR LONGITUDINAL LIG INSTABILITY (RUPTURE AVULSION)HYPEREXTENSION INJURYUNSTABLE INJURYLAMINA MAY JAM TOGETHER CAUSING LIGAMENTA FLAVA TO BUCKLE INWARD AND COMPRESSCONTUSE THE SPINAL CORD

CLAY SHOVELERrsquoS FRACTURE

AVULSION FRACTURE OF SPINOUS PROCESS BY SUPRASPINOUS LIGAMENTUSUALLY OCCURRING FROM C6-T2HYPERFLEXION DIRECT TRAUMA DOWNWARD FORCE VIA THORACOSCAPULAR MUSCLE (AS IN SHOVELING MOTION)STABLE

THORACO-LUMBAR SPINE INJURY

Anatomy

MENU OF IMAGING OPTIONS

DORSAL SPINE PLAIN FILMS

ANTERO- POSTERIOR AND

LATERAL VIEW

LUMBO SACCRAL SPINE

ANTERO- POSTERIOR AND

LATERAL VIEW

Thoracic Spine

Lumbar Spine

Determinants of Stability

bull T amp L spines are more stable than C-spinendash Strong ligamentsndash Stabilization by ribsndash Bigger intervertebral discsndash Larger facet jointsndash Less mobility

bull Fractures amp dislocations tend to occur where curvature changesndash T11-12 (thoracolumbar junction)ndash L5-S1 (lumbosacral junction)

Mechanisms of Injury

bull Hyperflexion +- rotationndash Commonestndash Usually see anterior wedge rsquos or Chance

bull Shearingndash Ant or post translation

bull Hyperextensionbull Axial loading

ndash Compression or burst rsquos

3 Column Modelbull Anterior column

ndash Ant longitudinal ligndash Ant annulus fibrosisndash Ant vertebral body

bull Middle columnndash Post longitudinal ligndash Post annulus fibrosisndash Post vertebral body

bull Posterior columnndash Spinous processesndash Transverse processesndash Laminandash Facet jointsndash Pediclesndash Post ligamentous complex

bull 2 or more columns disrupted = unstablebull Most disruption of middle columns are

unstable

Stable or Unstable

bull Radiographic findings suggestive of instabilityndash Vertebral body collapse w widening of pediclesndash gt 33 canal compromise on CTndash gt 25 mm translation bw vertebral bodies in any planendash Bilateral facet dislocationndash Abnormal widening bw spinous processes or lamina and gt

50 anterior collapse of vertebral body

Stable or Unstable

bull Checklist for Instabilityndash Anterior elements disrupted 2 ptsndash Posterior elements disrupted 2 ptsndash Saggital plane translation gt 25 mm 2 ptsndash Saggital plane rotation gt 5o 2 ptsndash Spinal cord or cauda equina damage 2 ptsndash Disruption of costovertebral articulations 1 ptndash Dangerous loading anticipated 2 pts

ndash 5 or more pts unstable until healed or surgically stabilized

Stable or Unstable

bull Risk of neurologic injury increases withndash gt 35 canal narrowing

at T11-12ndash gt 45 canal narrowing

at L1ndash gt 55 canal narrowing

at L2 amp below

Approach to T amp L Spinesbull A ndash adequacy amp alignment

ndash All vertebrae need to be visiblendash Ant amp post longitudinal linesndash Facet joints should lie on smooth curvendash Normal kyphosis amp lordosisndash All spinous processes should lie in straight line

bull B ndash bonesndash Trace cortical margins of each vertebraendash Difference bw ant amp post body ht lt 2 mmndash Progressive increase in vertebral body ht moving down

spinendash Wink sign amp interpedicular distancendash Donrsquot forget to look at transverse processes

Approach to T amp L Spines

bull C ndash cartilagendash Progressive increase in disc space moving down

spine (except L5-S1)ndash Facet joint alignment

bull S ndashsoft tissuendash Look at paraspinal stripe and prevertebral space

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines

Lateral Viewndash Posterior VB linendash Anterior VB linendash Inter-spinous Distancendash Translation

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines A-P

Viewndash Spinous process to Pediclesndash Inter-pedicular Distancendash Translation

Thoracic and Lumbar Injuries

Height Loss

Adjacent fracture

Transverse process fracturesof L2-4

Significance of transverse processfractures is not the fractures in andof themselves but rather the high incidence of associated seriousintraabdominal injury (~20)

AnterolisthesisOf L4 on L5

  • X ray spine
  • SPINE TRAUMA
  • CERVICAL SPINE INJURY
  • Slide 4
  • Slide 5
  • Slide 6
  • Slide 7
  • Slide 8
  • Slide 9
  • Anteroposterior (A-P) View
  • Open Mouth View
  • Swimmerrsquos View
  • Slide 13
  • Slide 14
  • Slide 15
  • Lower Cervical Detection
  • Lower Cervical Detection (2)
  • Lower Cervical Detection (3)
  • Lower Cervical Detection (4)
  • Lower Cervical Detection (5)
  • Lower Cervical Detection (6)
  • Slide 22
  • Slide 23
  • Slide 24
  • Slide 25
  • Slide 26
  • Slide 27
  • THORACO-LUMBAR SPINE INJURY
  • Anatomy
  • Slide 30
  • Thoracic Spine
  • Lumbar Spine
  • Determinants of Stability
  • Mechanisms of Injury
  • 3 Column Model
  • Stable or Unstable
  • Stable or Unstable (2)
  • Stable or Unstable (3)
  • Approach to T amp L Spines
  • Approach to T amp L Spines (2)
  • Injury Detection Thoracic and Lumbar Spines
  • Injury Detection Thoracic and Lumbar Spines (2)
  • Thoracic and Lumbar Injuries
  • Height Loss
  • Slide 45
  • Slide 46
Page 16: X ray spine. SPINE TRAUMA CERVICAL SPINE INJURY THORACO-LUMBAR SPINE INJURY

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

JEFFERSON FRACTURE

HANGMANrsquoS FRACTURE

DENS FRACTURE

FRACTURE OF THE BASE OF THE DENS (ODONTOID) OF C2ANTERIOR OR POSTERIOR DISPLACEMENT OF THE DENSCAN OCCUR AT VARIOUS LEVELS ON THE DENSVIA HYPERFLEXION OR HYPEREXTENSION OF HEAD ON NECKUNSTABLE IF DISPLACEMENT OCCURS

COMPRESSION FRACTURE

VARIABLE SEVERITY FROM MINIMAL ANTERIOR WEDGING TO COMPLETE DISRUPTION OF VERTEBRAL BODY (BURST)LOOK FOR LOSS OF VERTICAL HEIGHT OF VERTEBRAL BODYDUE TO LONG AXIS COMPRESSION OR HYPERFLEXIONDIVING INTO SHALLOW POOLSTABLE 1048774UNSTABLE

TEARDROP FRACTURE

AVULSION FRACTURE OF ANTERIOR MARGIN OF VERTEBRAL BODYANTERIOR LONGITUDINAL LIG INSTABILITY (RUPTURE AVULSION)HYPEREXTENSION INJURYUNSTABLE INJURYLAMINA MAY JAM TOGETHER CAUSING LIGAMENTA FLAVA TO BUCKLE INWARD AND COMPRESSCONTUSE THE SPINAL CORD

CLAY SHOVELERrsquoS FRACTURE

AVULSION FRACTURE OF SPINOUS PROCESS BY SUPRASPINOUS LIGAMENTUSUALLY OCCURRING FROM C6-T2HYPERFLEXION DIRECT TRAUMA DOWNWARD FORCE VIA THORACOSCAPULAR MUSCLE (AS IN SHOVELING MOTION)STABLE

THORACO-LUMBAR SPINE INJURY

Anatomy

MENU OF IMAGING OPTIONS

DORSAL SPINE PLAIN FILMS

ANTERO- POSTERIOR AND

LATERAL VIEW

LUMBO SACCRAL SPINE

ANTERO- POSTERIOR AND

LATERAL VIEW

Thoracic Spine

Lumbar Spine

Determinants of Stability

bull T amp L spines are more stable than C-spinendash Strong ligamentsndash Stabilization by ribsndash Bigger intervertebral discsndash Larger facet jointsndash Less mobility

bull Fractures amp dislocations tend to occur where curvature changesndash T11-12 (thoracolumbar junction)ndash L5-S1 (lumbosacral junction)

Mechanisms of Injury

bull Hyperflexion +- rotationndash Commonestndash Usually see anterior wedge rsquos or Chance

bull Shearingndash Ant or post translation

bull Hyperextensionbull Axial loading

ndash Compression or burst rsquos

3 Column Modelbull Anterior column

ndash Ant longitudinal ligndash Ant annulus fibrosisndash Ant vertebral body

bull Middle columnndash Post longitudinal ligndash Post annulus fibrosisndash Post vertebral body

bull Posterior columnndash Spinous processesndash Transverse processesndash Laminandash Facet jointsndash Pediclesndash Post ligamentous complex

bull 2 or more columns disrupted = unstablebull Most disruption of middle columns are

unstable

Stable or Unstable

bull Radiographic findings suggestive of instabilityndash Vertebral body collapse w widening of pediclesndash gt 33 canal compromise on CTndash gt 25 mm translation bw vertebral bodies in any planendash Bilateral facet dislocationndash Abnormal widening bw spinous processes or lamina and gt

50 anterior collapse of vertebral body

Stable or Unstable

bull Checklist for Instabilityndash Anterior elements disrupted 2 ptsndash Posterior elements disrupted 2 ptsndash Saggital plane translation gt 25 mm 2 ptsndash Saggital plane rotation gt 5o 2 ptsndash Spinal cord or cauda equina damage 2 ptsndash Disruption of costovertebral articulations 1 ptndash Dangerous loading anticipated 2 pts

ndash 5 or more pts unstable until healed or surgically stabilized

Stable or Unstable

bull Risk of neurologic injury increases withndash gt 35 canal narrowing

at T11-12ndash gt 45 canal narrowing

at L1ndash gt 55 canal narrowing

at L2 amp below

Approach to T amp L Spinesbull A ndash adequacy amp alignment

ndash All vertebrae need to be visiblendash Ant amp post longitudinal linesndash Facet joints should lie on smooth curvendash Normal kyphosis amp lordosisndash All spinous processes should lie in straight line

bull B ndash bonesndash Trace cortical margins of each vertebraendash Difference bw ant amp post body ht lt 2 mmndash Progressive increase in vertebral body ht moving down

spinendash Wink sign amp interpedicular distancendash Donrsquot forget to look at transverse processes

Approach to T amp L Spines

bull C ndash cartilagendash Progressive increase in disc space moving down

spine (except L5-S1)ndash Facet joint alignment

bull S ndashsoft tissuendash Look at paraspinal stripe and prevertebral space

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines

Lateral Viewndash Posterior VB linendash Anterior VB linendash Inter-spinous Distancendash Translation

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines A-P

Viewndash Spinous process to Pediclesndash Inter-pedicular Distancendash Translation

Thoracic and Lumbar Injuries

Height Loss

Adjacent fracture

Transverse process fracturesof L2-4

Significance of transverse processfractures is not the fractures in andof themselves but rather the high incidence of associated seriousintraabdominal injury (~20)

AnterolisthesisOf L4 on L5

  • X ray spine
  • SPINE TRAUMA
  • CERVICAL SPINE INJURY
  • Slide 4
  • Slide 5
  • Slide 6
  • Slide 7
  • Slide 8
  • Slide 9
  • Anteroposterior (A-P) View
  • Open Mouth View
  • Swimmerrsquos View
  • Slide 13
  • Slide 14
  • Slide 15
  • Lower Cervical Detection
  • Lower Cervical Detection (2)
  • Lower Cervical Detection (3)
  • Lower Cervical Detection (4)
  • Lower Cervical Detection (5)
  • Lower Cervical Detection (6)
  • Slide 22
  • Slide 23
  • Slide 24
  • Slide 25
  • Slide 26
  • Slide 27
  • THORACO-LUMBAR SPINE INJURY
  • Anatomy
  • Slide 30
  • Thoracic Spine
  • Lumbar Spine
  • Determinants of Stability
  • Mechanisms of Injury
  • 3 Column Model
  • Stable or Unstable
  • Stable or Unstable (2)
  • Stable or Unstable (3)
  • Approach to T amp L Spines
  • Approach to T amp L Spines (2)
  • Injury Detection Thoracic and Lumbar Spines
  • Injury Detection Thoracic and Lumbar Spines (2)
  • Thoracic and Lumbar Injuries
  • Height Loss
  • Slide 45
  • Slide 46
Page 17: X ray spine. SPINE TRAUMA CERVICAL SPINE INJURY THORACO-LUMBAR SPINE INJURY

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

JEFFERSON FRACTURE

HANGMANrsquoS FRACTURE

DENS FRACTURE

FRACTURE OF THE BASE OF THE DENS (ODONTOID) OF C2ANTERIOR OR POSTERIOR DISPLACEMENT OF THE DENSCAN OCCUR AT VARIOUS LEVELS ON THE DENSVIA HYPERFLEXION OR HYPEREXTENSION OF HEAD ON NECKUNSTABLE IF DISPLACEMENT OCCURS

COMPRESSION FRACTURE

VARIABLE SEVERITY FROM MINIMAL ANTERIOR WEDGING TO COMPLETE DISRUPTION OF VERTEBRAL BODY (BURST)LOOK FOR LOSS OF VERTICAL HEIGHT OF VERTEBRAL BODYDUE TO LONG AXIS COMPRESSION OR HYPERFLEXIONDIVING INTO SHALLOW POOLSTABLE 1048774UNSTABLE

TEARDROP FRACTURE

AVULSION FRACTURE OF ANTERIOR MARGIN OF VERTEBRAL BODYANTERIOR LONGITUDINAL LIG INSTABILITY (RUPTURE AVULSION)HYPEREXTENSION INJURYUNSTABLE INJURYLAMINA MAY JAM TOGETHER CAUSING LIGAMENTA FLAVA TO BUCKLE INWARD AND COMPRESSCONTUSE THE SPINAL CORD

CLAY SHOVELERrsquoS FRACTURE

AVULSION FRACTURE OF SPINOUS PROCESS BY SUPRASPINOUS LIGAMENTUSUALLY OCCURRING FROM C6-T2HYPERFLEXION DIRECT TRAUMA DOWNWARD FORCE VIA THORACOSCAPULAR MUSCLE (AS IN SHOVELING MOTION)STABLE

THORACO-LUMBAR SPINE INJURY

Anatomy

MENU OF IMAGING OPTIONS

DORSAL SPINE PLAIN FILMS

ANTERO- POSTERIOR AND

LATERAL VIEW

LUMBO SACCRAL SPINE

ANTERO- POSTERIOR AND

LATERAL VIEW

Thoracic Spine

Lumbar Spine

Determinants of Stability

bull T amp L spines are more stable than C-spinendash Strong ligamentsndash Stabilization by ribsndash Bigger intervertebral discsndash Larger facet jointsndash Less mobility

bull Fractures amp dislocations tend to occur where curvature changesndash T11-12 (thoracolumbar junction)ndash L5-S1 (lumbosacral junction)

Mechanisms of Injury

bull Hyperflexion +- rotationndash Commonestndash Usually see anterior wedge rsquos or Chance

bull Shearingndash Ant or post translation

bull Hyperextensionbull Axial loading

ndash Compression or burst rsquos

3 Column Modelbull Anterior column

ndash Ant longitudinal ligndash Ant annulus fibrosisndash Ant vertebral body

bull Middle columnndash Post longitudinal ligndash Post annulus fibrosisndash Post vertebral body

bull Posterior columnndash Spinous processesndash Transverse processesndash Laminandash Facet jointsndash Pediclesndash Post ligamentous complex

bull 2 or more columns disrupted = unstablebull Most disruption of middle columns are

unstable

Stable or Unstable

bull Radiographic findings suggestive of instabilityndash Vertebral body collapse w widening of pediclesndash gt 33 canal compromise on CTndash gt 25 mm translation bw vertebral bodies in any planendash Bilateral facet dislocationndash Abnormal widening bw spinous processes or lamina and gt

50 anterior collapse of vertebral body

Stable or Unstable

bull Checklist for Instabilityndash Anterior elements disrupted 2 ptsndash Posterior elements disrupted 2 ptsndash Saggital plane translation gt 25 mm 2 ptsndash Saggital plane rotation gt 5o 2 ptsndash Spinal cord or cauda equina damage 2 ptsndash Disruption of costovertebral articulations 1 ptndash Dangerous loading anticipated 2 pts

ndash 5 or more pts unstable until healed or surgically stabilized

Stable or Unstable

bull Risk of neurologic injury increases withndash gt 35 canal narrowing

at T11-12ndash gt 45 canal narrowing

at L1ndash gt 55 canal narrowing

at L2 amp below

Approach to T amp L Spinesbull A ndash adequacy amp alignment

ndash All vertebrae need to be visiblendash Ant amp post longitudinal linesndash Facet joints should lie on smooth curvendash Normal kyphosis amp lordosisndash All spinous processes should lie in straight line

bull B ndash bonesndash Trace cortical margins of each vertebraendash Difference bw ant amp post body ht lt 2 mmndash Progressive increase in vertebral body ht moving down

spinendash Wink sign amp interpedicular distancendash Donrsquot forget to look at transverse processes

Approach to T amp L Spines

bull C ndash cartilagendash Progressive increase in disc space moving down

spine (except L5-S1)ndash Facet joint alignment

bull S ndashsoft tissuendash Look at paraspinal stripe and prevertebral space

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines

Lateral Viewndash Posterior VB linendash Anterior VB linendash Inter-spinous Distancendash Translation

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines A-P

Viewndash Spinous process to Pediclesndash Inter-pedicular Distancendash Translation

Thoracic and Lumbar Injuries

Height Loss

Adjacent fracture

Transverse process fracturesof L2-4

Significance of transverse processfractures is not the fractures in andof themselves but rather the high incidence of associated seriousintraabdominal injury (~20)

AnterolisthesisOf L4 on L5

  • X ray spine
  • SPINE TRAUMA
  • CERVICAL SPINE INJURY
  • Slide 4
  • Slide 5
  • Slide 6
  • Slide 7
  • Slide 8
  • Slide 9
  • Anteroposterior (A-P) View
  • Open Mouth View
  • Swimmerrsquos View
  • Slide 13
  • Slide 14
  • Slide 15
  • Lower Cervical Detection
  • Lower Cervical Detection (2)
  • Lower Cervical Detection (3)
  • Lower Cervical Detection (4)
  • Lower Cervical Detection (5)
  • Lower Cervical Detection (6)
  • Slide 22
  • Slide 23
  • Slide 24
  • Slide 25
  • Slide 26
  • Slide 27
  • THORACO-LUMBAR SPINE INJURY
  • Anatomy
  • Slide 30
  • Thoracic Spine
  • Lumbar Spine
  • Determinants of Stability
  • Mechanisms of Injury
  • 3 Column Model
  • Stable or Unstable
  • Stable or Unstable (2)
  • Stable or Unstable (3)
  • Approach to T amp L Spines
  • Approach to T amp L Spines (2)
  • Injury Detection Thoracic and Lumbar Spines
  • Injury Detection Thoracic and Lumbar Spines (2)
  • Thoracic and Lumbar Injuries
  • Height Loss
  • Slide 45
  • Slide 46
Page 18: X ray spine. SPINE TRAUMA CERVICAL SPINE INJURY THORACO-LUMBAR SPINE INJURY

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

JEFFERSON FRACTURE

HANGMANrsquoS FRACTURE

DENS FRACTURE

FRACTURE OF THE BASE OF THE DENS (ODONTOID) OF C2ANTERIOR OR POSTERIOR DISPLACEMENT OF THE DENSCAN OCCUR AT VARIOUS LEVELS ON THE DENSVIA HYPERFLEXION OR HYPEREXTENSION OF HEAD ON NECKUNSTABLE IF DISPLACEMENT OCCURS

COMPRESSION FRACTURE

VARIABLE SEVERITY FROM MINIMAL ANTERIOR WEDGING TO COMPLETE DISRUPTION OF VERTEBRAL BODY (BURST)LOOK FOR LOSS OF VERTICAL HEIGHT OF VERTEBRAL BODYDUE TO LONG AXIS COMPRESSION OR HYPERFLEXIONDIVING INTO SHALLOW POOLSTABLE 1048774UNSTABLE

TEARDROP FRACTURE

AVULSION FRACTURE OF ANTERIOR MARGIN OF VERTEBRAL BODYANTERIOR LONGITUDINAL LIG INSTABILITY (RUPTURE AVULSION)HYPEREXTENSION INJURYUNSTABLE INJURYLAMINA MAY JAM TOGETHER CAUSING LIGAMENTA FLAVA TO BUCKLE INWARD AND COMPRESSCONTUSE THE SPINAL CORD

CLAY SHOVELERrsquoS FRACTURE

AVULSION FRACTURE OF SPINOUS PROCESS BY SUPRASPINOUS LIGAMENTUSUALLY OCCURRING FROM C6-T2HYPERFLEXION DIRECT TRAUMA DOWNWARD FORCE VIA THORACOSCAPULAR MUSCLE (AS IN SHOVELING MOTION)STABLE

THORACO-LUMBAR SPINE INJURY

Anatomy

MENU OF IMAGING OPTIONS

DORSAL SPINE PLAIN FILMS

ANTERO- POSTERIOR AND

LATERAL VIEW

LUMBO SACCRAL SPINE

ANTERO- POSTERIOR AND

LATERAL VIEW

Thoracic Spine

Lumbar Spine

Determinants of Stability

bull T amp L spines are more stable than C-spinendash Strong ligamentsndash Stabilization by ribsndash Bigger intervertebral discsndash Larger facet jointsndash Less mobility

bull Fractures amp dislocations tend to occur where curvature changesndash T11-12 (thoracolumbar junction)ndash L5-S1 (lumbosacral junction)

Mechanisms of Injury

bull Hyperflexion +- rotationndash Commonestndash Usually see anterior wedge rsquos or Chance

bull Shearingndash Ant or post translation

bull Hyperextensionbull Axial loading

ndash Compression or burst rsquos

3 Column Modelbull Anterior column

ndash Ant longitudinal ligndash Ant annulus fibrosisndash Ant vertebral body

bull Middle columnndash Post longitudinal ligndash Post annulus fibrosisndash Post vertebral body

bull Posterior columnndash Spinous processesndash Transverse processesndash Laminandash Facet jointsndash Pediclesndash Post ligamentous complex

bull 2 or more columns disrupted = unstablebull Most disruption of middle columns are

unstable

Stable or Unstable

bull Radiographic findings suggestive of instabilityndash Vertebral body collapse w widening of pediclesndash gt 33 canal compromise on CTndash gt 25 mm translation bw vertebral bodies in any planendash Bilateral facet dislocationndash Abnormal widening bw spinous processes or lamina and gt

50 anterior collapse of vertebral body

Stable or Unstable

bull Checklist for Instabilityndash Anterior elements disrupted 2 ptsndash Posterior elements disrupted 2 ptsndash Saggital plane translation gt 25 mm 2 ptsndash Saggital plane rotation gt 5o 2 ptsndash Spinal cord or cauda equina damage 2 ptsndash Disruption of costovertebral articulations 1 ptndash Dangerous loading anticipated 2 pts

ndash 5 or more pts unstable until healed or surgically stabilized

Stable or Unstable

bull Risk of neurologic injury increases withndash gt 35 canal narrowing

at T11-12ndash gt 45 canal narrowing

at L1ndash gt 55 canal narrowing

at L2 amp below

Approach to T amp L Spinesbull A ndash adequacy amp alignment

ndash All vertebrae need to be visiblendash Ant amp post longitudinal linesndash Facet joints should lie on smooth curvendash Normal kyphosis amp lordosisndash All spinous processes should lie in straight line

bull B ndash bonesndash Trace cortical margins of each vertebraendash Difference bw ant amp post body ht lt 2 mmndash Progressive increase in vertebral body ht moving down

spinendash Wink sign amp interpedicular distancendash Donrsquot forget to look at transverse processes

Approach to T amp L Spines

bull C ndash cartilagendash Progressive increase in disc space moving down

spine (except L5-S1)ndash Facet joint alignment

bull S ndashsoft tissuendash Look at paraspinal stripe and prevertebral space

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines

Lateral Viewndash Posterior VB linendash Anterior VB linendash Inter-spinous Distancendash Translation

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines A-P

Viewndash Spinous process to Pediclesndash Inter-pedicular Distancendash Translation

Thoracic and Lumbar Injuries

Height Loss

Adjacent fracture

Transverse process fracturesof L2-4

Significance of transverse processfractures is not the fractures in andof themselves but rather the high incidence of associated seriousintraabdominal injury (~20)

AnterolisthesisOf L4 on L5

  • X ray spine
  • SPINE TRAUMA
  • CERVICAL SPINE INJURY
  • Slide 4
  • Slide 5
  • Slide 6
  • Slide 7
  • Slide 8
  • Slide 9
  • Anteroposterior (A-P) View
  • Open Mouth View
  • Swimmerrsquos View
  • Slide 13
  • Slide 14
  • Slide 15
  • Lower Cervical Detection
  • Lower Cervical Detection (2)
  • Lower Cervical Detection (3)
  • Lower Cervical Detection (4)
  • Lower Cervical Detection (5)
  • Lower Cervical Detection (6)
  • Slide 22
  • Slide 23
  • Slide 24
  • Slide 25
  • Slide 26
  • Slide 27
  • THORACO-LUMBAR SPINE INJURY
  • Anatomy
  • Slide 30
  • Thoracic Spine
  • Lumbar Spine
  • Determinants of Stability
  • Mechanisms of Injury
  • 3 Column Model
  • Stable or Unstable
  • Stable or Unstable (2)
  • Stable or Unstable (3)
  • Approach to T amp L Spines
  • Approach to T amp L Spines (2)
  • Injury Detection Thoracic and Lumbar Spines
  • Injury Detection Thoracic and Lumbar Spines (2)
  • Thoracic and Lumbar Injuries
  • Height Loss
  • Slide 45
  • Slide 46
Page 19: X ray spine. SPINE TRAUMA CERVICAL SPINE INJURY THORACO-LUMBAR SPINE INJURY

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

JEFFERSON FRACTURE

HANGMANrsquoS FRACTURE

DENS FRACTURE

FRACTURE OF THE BASE OF THE DENS (ODONTOID) OF C2ANTERIOR OR POSTERIOR DISPLACEMENT OF THE DENSCAN OCCUR AT VARIOUS LEVELS ON THE DENSVIA HYPERFLEXION OR HYPEREXTENSION OF HEAD ON NECKUNSTABLE IF DISPLACEMENT OCCURS

COMPRESSION FRACTURE

VARIABLE SEVERITY FROM MINIMAL ANTERIOR WEDGING TO COMPLETE DISRUPTION OF VERTEBRAL BODY (BURST)LOOK FOR LOSS OF VERTICAL HEIGHT OF VERTEBRAL BODYDUE TO LONG AXIS COMPRESSION OR HYPERFLEXIONDIVING INTO SHALLOW POOLSTABLE 1048774UNSTABLE

TEARDROP FRACTURE

AVULSION FRACTURE OF ANTERIOR MARGIN OF VERTEBRAL BODYANTERIOR LONGITUDINAL LIG INSTABILITY (RUPTURE AVULSION)HYPEREXTENSION INJURYUNSTABLE INJURYLAMINA MAY JAM TOGETHER CAUSING LIGAMENTA FLAVA TO BUCKLE INWARD AND COMPRESSCONTUSE THE SPINAL CORD

CLAY SHOVELERrsquoS FRACTURE

AVULSION FRACTURE OF SPINOUS PROCESS BY SUPRASPINOUS LIGAMENTUSUALLY OCCURRING FROM C6-T2HYPERFLEXION DIRECT TRAUMA DOWNWARD FORCE VIA THORACOSCAPULAR MUSCLE (AS IN SHOVELING MOTION)STABLE

THORACO-LUMBAR SPINE INJURY

Anatomy

MENU OF IMAGING OPTIONS

DORSAL SPINE PLAIN FILMS

ANTERO- POSTERIOR AND

LATERAL VIEW

LUMBO SACCRAL SPINE

ANTERO- POSTERIOR AND

LATERAL VIEW

Thoracic Spine

Lumbar Spine

Determinants of Stability

bull T amp L spines are more stable than C-spinendash Strong ligamentsndash Stabilization by ribsndash Bigger intervertebral discsndash Larger facet jointsndash Less mobility

bull Fractures amp dislocations tend to occur where curvature changesndash T11-12 (thoracolumbar junction)ndash L5-S1 (lumbosacral junction)

Mechanisms of Injury

bull Hyperflexion +- rotationndash Commonestndash Usually see anterior wedge rsquos or Chance

bull Shearingndash Ant or post translation

bull Hyperextensionbull Axial loading

ndash Compression or burst rsquos

3 Column Modelbull Anterior column

ndash Ant longitudinal ligndash Ant annulus fibrosisndash Ant vertebral body

bull Middle columnndash Post longitudinal ligndash Post annulus fibrosisndash Post vertebral body

bull Posterior columnndash Spinous processesndash Transverse processesndash Laminandash Facet jointsndash Pediclesndash Post ligamentous complex

bull 2 or more columns disrupted = unstablebull Most disruption of middle columns are

unstable

Stable or Unstable

bull Radiographic findings suggestive of instabilityndash Vertebral body collapse w widening of pediclesndash gt 33 canal compromise on CTndash gt 25 mm translation bw vertebral bodies in any planendash Bilateral facet dislocationndash Abnormal widening bw spinous processes or lamina and gt

50 anterior collapse of vertebral body

Stable or Unstable

bull Checklist for Instabilityndash Anterior elements disrupted 2 ptsndash Posterior elements disrupted 2 ptsndash Saggital plane translation gt 25 mm 2 ptsndash Saggital plane rotation gt 5o 2 ptsndash Spinal cord or cauda equina damage 2 ptsndash Disruption of costovertebral articulations 1 ptndash Dangerous loading anticipated 2 pts

ndash 5 or more pts unstable until healed or surgically stabilized

Stable or Unstable

bull Risk of neurologic injury increases withndash gt 35 canal narrowing

at T11-12ndash gt 45 canal narrowing

at L1ndash gt 55 canal narrowing

at L2 amp below

Approach to T amp L Spinesbull A ndash adequacy amp alignment

ndash All vertebrae need to be visiblendash Ant amp post longitudinal linesndash Facet joints should lie on smooth curvendash Normal kyphosis amp lordosisndash All spinous processes should lie in straight line

bull B ndash bonesndash Trace cortical margins of each vertebraendash Difference bw ant amp post body ht lt 2 mmndash Progressive increase in vertebral body ht moving down

spinendash Wink sign amp interpedicular distancendash Donrsquot forget to look at transverse processes

Approach to T amp L Spines

bull C ndash cartilagendash Progressive increase in disc space moving down

spine (except L5-S1)ndash Facet joint alignment

bull S ndashsoft tissuendash Look at paraspinal stripe and prevertebral space

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines

Lateral Viewndash Posterior VB linendash Anterior VB linendash Inter-spinous Distancendash Translation

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines A-P

Viewndash Spinous process to Pediclesndash Inter-pedicular Distancendash Translation

Thoracic and Lumbar Injuries

Height Loss

Adjacent fracture

Transverse process fracturesof L2-4

Significance of transverse processfractures is not the fractures in andof themselves but rather the high incidence of associated seriousintraabdominal injury (~20)

AnterolisthesisOf L4 on L5

  • X ray spine
  • SPINE TRAUMA
  • CERVICAL SPINE INJURY
  • Slide 4
  • Slide 5
  • Slide 6
  • Slide 7
  • Slide 8
  • Slide 9
  • Anteroposterior (A-P) View
  • Open Mouth View
  • Swimmerrsquos View
  • Slide 13
  • Slide 14
  • Slide 15
  • Lower Cervical Detection
  • Lower Cervical Detection (2)
  • Lower Cervical Detection (3)
  • Lower Cervical Detection (4)
  • Lower Cervical Detection (5)
  • Lower Cervical Detection (6)
  • Slide 22
  • Slide 23
  • Slide 24
  • Slide 25
  • Slide 26
  • Slide 27
  • THORACO-LUMBAR SPINE INJURY
  • Anatomy
  • Slide 30
  • Thoracic Spine
  • Lumbar Spine
  • Determinants of Stability
  • Mechanisms of Injury
  • 3 Column Model
  • Stable or Unstable
  • Stable or Unstable (2)
  • Stable or Unstable (3)
  • Approach to T amp L Spines
  • Approach to T amp L Spines (2)
  • Injury Detection Thoracic and Lumbar Spines
  • Injury Detection Thoracic and Lumbar Spines (2)
  • Thoracic and Lumbar Injuries
  • Height Loss
  • Slide 45
  • Slide 46
Page 20: X ray spine. SPINE TRAUMA CERVICAL SPINE INJURY THORACO-LUMBAR SPINE INJURY

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

JEFFERSON FRACTURE

HANGMANrsquoS FRACTURE

DENS FRACTURE

FRACTURE OF THE BASE OF THE DENS (ODONTOID) OF C2ANTERIOR OR POSTERIOR DISPLACEMENT OF THE DENSCAN OCCUR AT VARIOUS LEVELS ON THE DENSVIA HYPERFLEXION OR HYPEREXTENSION OF HEAD ON NECKUNSTABLE IF DISPLACEMENT OCCURS

COMPRESSION FRACTURE

VARIABLE SEVERITY FROM MINIMAL ANTERIOR WEDGING TO COMPLETE DISRUPTION OF VERTEBRAL BODY (BURST)LOOK FOR LOSS OF VERTICAL HEIGHT OF VERTEBRAL BODYDUE TO LONG AXIS COMPRESSION OR HYPERFLEXIONDIVING INTO SHALLOW POOLSTABLE 1048774UNSTABLE

TEARDROP FRACTURE

AVULSION FRACTURE OF ANTERIOR MARGIN OF VERTEBRAL BODYANTERIOR LONGITUDINAL LIG INSTABILITY (RUPTURE AVULSION)HYPEREXTENSION INJURYUNSTABLE INJURYLAMINA MAY JAM TOGETHER CAUSING LIGAMENTA FLAVA TO BUCKLE INWARD AND COMPRESSCONTUSE THE SPINAL CORD

CLAY SHOVELERrsquoS FRACTURE

AVULSION FRACTURE OF SPINOUS PROCESS BY SUPRASPINOUS LIGAMENTUSUALLY OCCURRING FROM C6-T2HYPERFLEXION DIRECT TRAUMA DOWNWARD FORCE VIA THORACOSCAPULAR MUSCLE (AS IN SHOVELING MOTION)STABLE

THORACO-LUMBAR SPINE INJURY

Anatomy

MENU OF IMAGING OPTIONS

DORSAL SPINE PLAIN FILMS

ANTERO- POSTERIOR AND

LATERAL VIEW

LUMBO SACCRAL SPINE

ANTERO- POSTERIOR AND

LATERAL VIEW

Thoracic Spine

Lumbar Spine

Determinants of Stability

bull T amp L spines are more stable than C-spinendash Strong ligamentsndash Stabilization by ribsndash Bigger intervertebral discsndash Larger facet jointsndash Less mobility

bull Fractures amp dislocations tend to occur where curvature changesndash T11-12 (thoracolumbar junction)ndash L5-S1 (lumbosacral junction)

Mechanisms of Injury

bull Hyperflexion +- rotationndash Commonestndash Usually see anterior wedge rsquos or Chance

bull Shearingndash Ant or post translation

bull Hyperextensionbull Axial loading

ndash Compression or burst rsquos

3 Column Modelbull Anterior column

ndash Ant longitudinal ligndash Ant annulus fibrosisndash Ant vertebral body

bull Middle columnndash Post longitudinal ligndash Post annulus fibrosisndash Post vertebral body

bull Posterior columnndash Spinous processesndash Transverse processesndash Laminandash Facet jointsndash Pediclesndash Post ligamentous complex

bull 2 or more columns disrupted = unstablebull Most disruption of middle columns are

unstable

Stable or Unstable

bull Radiographic findings suggestive of instabilityndash Vertebral body collapse w widening of pediclesndash gt 33 canal compromise on CTndash gt 25 mm translation bw vertebral bodies in any planendash Bilateral facet dislocationndash Abnormal widening bw spinous processes or lamina and gt

50 anterior collapse of vertebral body

Stable or Unstable

bull Checklist for Instabilityndash Anterior elements disrupted 2 ptsndash Posterior elements disrupted 2 ptsndash Saggital plane translation gt 25 mm 2 ptsndash Saggital plane rotation gt 5o 2 ptsndash Spinal cord or cauda equina damage 2 ptsndash Disruption of costovertebral articulations 1 ptndash Dangerous loading anticipated 2 pts

ndash 5 or more pts unstable until healed or surgically stabilized

Stable or Unstable

bull Risk of neurologic injury increases withndash gt 35 canal narrowing

at T11-12ndash gt 45 canal narrowing

at L1ndash gt 55 canal narrowing

at L2 amp below

Approach to T amp L Spinesbull A ndash adequacy amp alignment

ndash All vertebrae need to be visiblendash Ant amp post longitudinal linesndash Facet joints should lie on smooth curvendash Normal kyphosis amp lordosisndash All spinous processes should lie in straight line

bull B ndash bonesndash Trace cortical margins of each vertebraendash Difference bw ant amp post body ht lt 2 mmndash Progressive increase in vertebral body ht moving down

spinendash Wink sign amp interpedicular distancendash Donrsquot forget to look at transverse processes

Approach to T amp L Spines

bull C ndash cartilagendash Progressive increase in disc space moving down

spine (except L5-S1)ndash Facet joint alignment

bull S ndashsoft tissuendash Look at paraspinal stripe and prevertebral space

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines

Lateral Viewndash Posterior VB linendash Anterior VB linendash Inter-spinous Distancendash Translation

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines A-P

Viewndash Spinous process to Pediclesndash Inter-pedicular Distancendash Translation

Thoracic and Lumbar Injuries

Height Loss

Adjacent fracture

Transverse process fracturesof L2-4

Significance of transverse processfractures is not the fractures in andof themselves but rather the high incidence of associated seriousintraabdominal injury (~20)

AnterolisthesisOf L4 on L5

  • X ray spine
  • SPINE TRAUMA
  • CERVICAL SPINE INJURY
  • Slide 4
  • Slide 5
  • Slide 6
  • Slide 7
  • Slide 8
  • Slide 9
  • Anteroposterior (A-P) View
  • Open Mouth View
  • Swimmerrsquos View
  • Slide 13
  • Slide 14
  • Slide 15
  • Lower Cervical Detection
  • Lower Cervical Detection (2)
  • Lower Cervical Detection (3)
  • Lower Cervical Detection (4)
  • Lower Cervical Detection (5)
  • Lower Cervical Detection (6)
  • Slide 22
  • Slide 23
  • Slide 24
  • Slide 25
  • Slide 26
  • Slide 27
  • THORACO-LUMBAR SPINE INJURY
  • Anatomy
  • Slide 30
  • Thoracic Spine
  • Lumbar Spine
  • Determinants of Stability
  • Mechanisms of Injury
  • 3 Column Model
  • Stable or Unstable
  • Stable or Unstable (2)
  • Stable or Unstable (3)
  • Approach to T amp L Spines
  • Approach to T amp L Spines (2)
  • Injury Detection Thoracic and Lumbar Spines
  • Injury Detection Thoracic and Lumbar Spines (2)
  • Thoracic and Lumbar Injuries
  • Height Loss
  • Slide 45
  • Slide 46
Page 21: X ray spine. SPINE TRAUMA CERVICAL SPINE INJURY THORACO-LUMBAR SPINE INJURY

Lower Cervical Detection

bull Spinous process gapping

bull Facet joint Apposition

bull Inter-vertebral Gapping

bull Angulationbull Translation

JEFFERSON FRACTURE

HANGMANrsquoS FRACTURE

DENS FRACTURE

FRACTURE OF THE BASE OF THE DENS (ODONTOID) OF C2ANTERIOR OR POSTERIOR DISPLACEMENT OF THE DENSCAN OCCUR AT VARIOUS LEVELS ON THE DENSVIA HYPERFLEXION OR HYPEREXTENSION OF HEAD ON NECKUNSTABLE IF DISPLACEMENT OCCURS

COMPRESSION FRACTURE

VARIABLE SEVERITY FROM MINIMAL ANTERIOR WEDGING TO COMPLETE DISRUPTION OF VERTEBRAL BODY (BURST)LOOK FOR LOSS OF VERTICAL HEIGHT OF VERTEBRAL BODYDUE TO LONG AXIS COMPRESSION OR HYPERFLEXIONDIVING INTO SHALLOW POOLSTABLE 1048774UNSTABLE

TEARDROP FRACTURE

AVULSION FRACTURE OF ANTERIOR MARGIN OF VERTEBRAL BODYANTERIOR LONGITUDINAL LIG INSTABILITY (RUPTURE AVULSION)HYPEREXTENSION INJURYUNSTABLE INJURYLAMINA MAY JAM TOGETHER CAUSING LIGAMENTA FLAVA TO BUCKLE INWARD AND COMPRESSCONTUSE THE SPINAL CORD

CLAY SHOVELERrsquoS FRACTURE

AVULSION FRACTURE OF SPINOUS PROCESS BY SUPRASPINOUS LIGAMENTUSUALLY OCCURRING FROM C6-T2HYPERFLEXION DIRECT TRAUMA DOWNWARD FORCE VIA THORACOSCAPULAR MUSCLE (AS IN SHOVELING MOTION)STABLE

THORACO-LUMBAR SPINE INJURY

Anatomy

MENU OF IMAGING OPTIONS

DORSAL SPINE PLAIN FILMS

ANTERO- POSTERIOR AND

LATERAL VIEW

LUMBO SACCRAL SPINE

ANTERO- POSTERIOR AND

LATERAL VIEW

Thoracic Spine

Lumbar Spine

Determinants of Stability

bull T amp L spines are more stable than C-spinendash Strong ligamentsndash Stabilization by ribsndash Bigger intervertebral discsndash Larger facet jointsndash Less mobility

bull Fractures amp dislocations tend to occur where curvature changesndash T11-12 (thoracolumbar junction)ndash L5-S1 (lumbosacral junction)

Mechanisms of Injury

bull Hyperflexion +- rotationndash Commonestndash Usually see anterior wedge rsquos or Chance

bull Shearingndash Ant or post translation

bull Hyperextensionbull Axial loading

ndash Compression or burst rsquos

3 Column Modelbull Anterior column

ndash Ant longitudinal ligndash Ant annulus fibrosisndash Ant vertebral body

bull Middle columnndash Post longitudinal ligndash Post annulus fibrosisndash Post vertebral body

bull Posterior columnndash Spinous processesndash Transverse processesndash Laminandash Facet jointsndash Pediclesndash Post ligamentous complex

bull 2 or more columns disrupted = unstablebull Most disruption of middle columns are

unstable

Stable or Unstable

bull Radiographic findings suggestive of instabilityndash Vertebral body collapse w widening of pediclesndash gt 33 canal compromise on CTndash gt 25 mm translation bw vertebral bodies in any planendash Bilateral facet dislocationndash Abnormal widening bw spinous processes or lamina and gt

50 anterior collapse of vertebral body

Stable or Unstable

bull Checklist for Instabilityndash Anterior elements disrupted 2 ptsndash Posterior elements disrupted 2 ptsndash Saggital plane translation gt 25 mm 2 ptsndash Saggital plane rotation gt 5o 2 ptsndash Spinal cord or cauda equina damage 2 ptsndash Disruption of costovertebral articulations 1 ptndash Dangerous loading anticipated 2 pts

ndash 5 or more pts unstable until healed or surgically stabilized

Stable or Unstable

bull Risk of neurologic injury increases withndash gt 35 canal narrowing

at T11-12ndash gt 45 canal narrowing

at L1ndash gt 55 canal narrowing

at L2 amp below

Approach to T amp L Spinesbull A ndash adequacy amp alignment

ndash All vertebrae need to be visiblendash Ant amp post longitudinal linesndash Facet joints should lie on smooth curvendash Normal kyphosis amp lordosisndash All spinous processes should lie in straight line

bull B ndash bonesndash Trace cortical margins of each vertebraendash Difference bw ant amp post body ht lt 2 mmndash Progressive increase in vertebral body ht moving down

spinendash Wink sign amp interpedicular distancendash Donrsquot forget to look at transverse processes

Approach to T amp L Spines

bull C ndash cartilagendash Progressive increase in disc space moving down

spine (except L5-S1)ndash Facet joint alignment

bull S ndashsoft tissuendash Look at paraspinal stripe and prevertebral space

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines

Lateral Viewndash Posterior VB linendash Anterior VB linendash Inter-spinous Distancendash Translation

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines A-P

Viewndash Spinous process to Pediclesndash Inter-pedicular Distancendash Translation

Thoracic and Lumbar Injuries

Height Loss

Adjacent fracture

Transverse process fracturesof L2-4

Significance of transverse processfractures is not the fractures in andof themselves but rather the high incidence of associated seriousintraabdominal injury (~20)

AnterolisthesisOf L4 on L5

  • X ray spine
  • SPINE TRAUMA
  • CERVICAL SPINE INJURY
  • Slide 4
  • Slide 5
  • Slide 6
  • Slide 7
  • Slide 8
  • Slide 9
  • Anteroposterior (A-P) View
  • Open Mouth View
  • Swimmerrsquos View
  • Slide 13
  • Slide 14
  • Slide 15
  • Lower Cervical Detection
  • Lower Cervical Detection (2)
  • Lower Cervical Detection (3)
  • Lower Cervical Detection (4)
  • Lower Cervical Detection (5)
  • Lower Cervical Detection (6)
  • Slide 22
  • Slide 23
  • Slide 24
  • Slide 25
  • Slide 26
  • Slide 27
  • THORACO-LUMBAR SPINE INJURY
  • Anatomy
  • Slide 30
  • Thoracic Spine
  • Lumbar Spine
  • Determinants of Stability
  • Mechanisms of Injury
  • 3 Column Model
  • Stable or Unstable
  • Stable or Unstable (2)
  • Stable or Unstable (3)
  • Approach to T amp L Spines
  • Approach to T amp L Spines (2)
  • Injury Detection Thoracic and Lumbar Spines
  • Injury Detection Thoracic and Lumbar Spines (2)
  • Thoracic and Lumbar Injuries
  • Height Loss
  • Slide 45
  • Slide 46
Page 22: X ray spine. SPINE TRAUMA CERVICAL SPINE INJURY THORACO-LUMBAR SPINE INJURY

JEFFERSON FRACTURE

HANGMANrsquoS FRACTURE

DENS FRACTURE

FRACTURE OF THE BASE OF THE DENS (ODONTOID) OF C2ANTERIOR OR POSTERIOR DISPLACEMENT OF THE DENSCAN OCCUR AT VARIOUS LEVELS ON THE DENSVIA HYPERFLEXION OR HYPEREXTENSION OF HEAD ON NECKUNSTABLE IF DISPLACEMENT OCCURS

COMPRESSION FRACTURE

VARIABLE SEVERITY FROM MINIMAL ANTERIOR WEDGING TO COMPLETE DISRUPTION OF VERTEBRAL BODY (BURST)LOOK FOR LOSS OF VERTICAL HEIGHT OF VERTEBRAL BODYDUE TO LONG AXIS COMPRESSION OR HYPERFLEXIONDIVING INTO SHALLOW POOLSTABLE 1048774UNSTABLE

TEARDROP FRACTURE

AVULSION FRACTURE OF ANTERIOR MARGIN OF VERTEBRAL BODYANTERIOR LONGITUDINAL LIG INSTABILITY (RUPTURE AVULSION)HYPEREXTENSION INJURYUNSTABLE INJURYLAMINA MAY JAM TOGETHER CAUSING LIGAMENTA FLAVA TO BUCKLE INWARD AND COMPRESSCONTUSE THE SPINAL CORD

CLAY SHOVELERrsquoS FRACTURE

AVULSION FRACTURE OF SPINOUS PROCESS BY SUPRASPINOUS LIGAMENTUSUALLY OCCURRING FROM C6-T2HYPERFLEXION DIRECT TRAUMA DOWNWARD FORCE VIA THORACOSCAPULAR MUSCLE (AS IN SHOVELING MOTION)STABLE

THORACO-LUMBAR SPINE INJURY

Anatomy

MENU OF IMAGING OPTIONS

DORSAL SPINE PLAIN FILMS

ANTERO- POSTERIOR AND

LATERAL VIEW

LUMBO SACCRAL SPINE

ANTERO- POSTERIOR AND

LATERAL VIEW

Thoracic Spine

Lumbar Spine

Determinants of Stability

bull T amp L spines are more stable than C-spinendash Strong ligamentsndash Stabilization by ribsndash Bigger intervertebral discsndash Larger facet jointsndash Less mobility

bull Fractures amp dislocations tend to occur where curvature changesndash T11-12 (thoracolumbar junction)ndash L5-S1 (lumbosacral junction)

Mechanisms of Injury

bull Hyperflexion +- rotationndash Commonestndash Usually see anterior wedge rsquos or Chance

bull Shearingndash Ant or post translation

bull Hyperextensionbull Axial loading

ndash Compression or burst rsquos

3 Column Modelbull Anterior column

ndash Ant longitudinal ligndash Ant annulus fibrosisndash Ant vertebral body

bull Middle columnndash Post longitudinal ligndash Post annulus fibrosisndash Post vertebral body

bull Posterior columnndash Spinous processesndash Transverse processesndash Laminandash Facet jointsndash Pediclesndash Post ligamentous complex

bull 2 or more columns disrupted = unstablebull Most disruption of middle columns are

unstable

Stable or Unstable

bull Radiographic findings suggestive of instabilityndash Vertebral body collapse w widening of pediclesndash gt 33 canal compromise on CTndash gt 25 mm translation bw vertebral bodies in any planendash Bilateral facet dislocationndash Abnormal widening bw spinous processes or lamina and gt

50 anterior collapse of vertebral body

Stable or Unstable

bull Checklist for Instabilityndash Anterior elements disrupted 2 ptsndash Posterior elements disrupted 2 ptsndash Saggital plane translation gt 25 mm 2 ptsndash Saggital plane rotation gt 5o 2 ptsndash Spinal cord or cauda equina damage 2 ptsndash Disruption of costovertebral articulations 1 ptndash Dangerous loading anticipated 2 pts

ndash 5 or more pts unstable until healed or surgically stabilized

Stable or Unstable

bull Risk of neurologic injury increases withndash gt 35 canal narrowing

at T11-12ndash gt 45 canal narrowing

at L1ndash gt 55 canal narrowing

at L2 amp below

Approach to T amp L Spinesbull A ndash adequacy amp alignment

ndash All vertebrae need to be visiblendash Ant amp post longitudinal linesndash Facet joints should lie on smooth curvendash Normal kyphosis amp lordosisndash All spinous processes should lie in straight line

bull B ndash bonesndash Trace cortical margins of each vertebraendash Difference bw ant amp post body ht lt 2 mmndash Progressive increase in vertebral body ht moving down

spinendash Wink sign amp interpedicular distancendash Donrsquot forget to look at transverse processes

Approach to T amp L Spines

bull C ndash cartilagendash Progressive increase in disc space moving down

spine (except L5-S1)ndash Facet joint alignment

bull S ndashsoft tissuendash Look at paraspinal stripe and prevertebral space

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines

Lateral Viewndash Posterior VB linendash Anterior VB linendash Inter-spinous Distancendash Translation

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines A-P

Viewndash Spinous process to Pediclesndash Inter-pedicular Distancendash Translation

Thoracic and Lumbar Injuries

Height Loss

Adjacent fracture

Transverse process fracturesof L2-4

Significance of transverse processfractures is not the fractures in andof themselves but rather the high incidence of associated seriousintraabdominal injury (~20)

AnterolisthesisOf L4 on L5

  • X ray spine
  • SPINE TRAUMA
  • CERVICAL SPINE INJURY
  • Slide 4
  • Slide 5
  • Slide 6
  • Slide 7
  • Slide 8
  • Slide 9
  • Anteroposterior (A-P) View
  • Open Mouth View
  • Swimmerrsquos View
  • Slide 13
  • Slide 14
  • Slide 15
  • Lower Cervical Detection
  • Lower Cervical Detection (2)
  • Lower Cervical Detection (3)
  • Lower Cervical Detection (4)
  • Lower Cervical Detection (5)
  • Lower Cervical Detection (6)
  • Slide 22
  • Slide 23
  • Slide 24
  • Slide 25
  • Slide 26
  • Slide 27
  • THORACO-LUMBAR SPINE INJURY
  • Anatomy
  • Slide 30
  • Thoracic Spine
  • Lumbar Spine
  • Determinants of Stability
  • Mechanisms of Injury
  • 3 Column Model
  • Stable or Unstable
  • Stable or Unstable (2)
  • Stable or Unstable (3)
  • Approach to T amp L Spines
  • Approach to T amp L Spines (2)
  • Injury Detection Thoracic and Lumbar Spines
  • Injury Detection Thoracic and Lumbar Spines (2)
  • Thoracic and Lumbar Injuries
  • Height Loss
  • Slide 45
  • Slide 46
Page 23: X ray spine. SPINE TRAUMA CERVICAL SPINE INJURY THORACO-LUMBAR SPINE INJURY

HANGMANrsquoS FRACTURE

DENS FRACTURE

FRACTURE OF THE BASE OF THE DENS (ODONTOID) OF C2ANTERIOR OR POSTERIOR DISPLACEMENT OF THE DENSCAN OCCUR AT VARIOUS LEVELS ON THE DENSVIA HYPERFLEXION OR HYPEREXTENSION OF HEAD ON NECKUNSTABLE IF DISPLACEMENT OCCURS

COMPRESSION FRACTURE

VARIABLE SEVERITY FROM MINIMAL ANTERIOR WEDGING TO COMPLETE DISRUPTION OF VERTEBRAL BODY (BURST)LOOK FOR LOSS OF VERTICAL HEIGHT OF VERTEBRAL BODYDUE TO LONG AXIS COMPRESSION OR HYPERFLEXIONDIVING INTO SHALLOW POOLSTABLE 1048774UNSTABLE

TEARDROP FRACTURE

AVULSION FRACTURE OF ANTERIOR MARGIN OF VERTEBRAL BODYANTERIOR LONGITUDINAL LIG INSTABILITY (RUPTURE AVULSION)HYPEREXTENSION INJURYUNSTABLE INJURYLAMINA MAY JAM TOGETHER CAUSING LIGAMENTA FLAVA TO BUCKLE INWARD AND COMPRESSCONTUSE THE SPINAL CORD

CLAY SHOVELERrsquoS FRACTURE

AVULSION FRACTURE OF SPINOUS PROCESS BY SUPRASPINOUS LIGAMENTUSUALLY OCCURRING FROM C6-T2HYPERFLEXION DIRECT TRAUMA DOWNWARD FORCE VIA THORACOSCAPULAR MUSCLE (AS IN SHOVELING MOTION)STABLE

THORACO-LUMBAR SPINE INJURY

Anatomy

MENU OF IMAGING OPTIONS

DORSAL SPINE PLAIN FILMS

ANTERO- POSTERIOR AND

LATERAL VIEW

LUMBO SACCRAL SPINE

ANTERO- POSTERIOR AND

LATERAL VIEW

Thoracic Spine

Lumbar Spine

Determinants of Stability

bull T amp L spines are more stable than C-spinendash Strong ligamentsndash Stabilization by ribsndash Bigger intervertebral discsndash Larger facet jointsndash Less mobility

bull Fractures amp dislocations tend to occur where curvature changesndash T11-12 (thoracolumbar junction)ndash L5-S1 (lumbosacral junction)

Mechanisms of Injury

bull Hyperflexion +- rotationndash Commonestndash Usually see anterior wedge rsquos or Chance

bull Shearingndash Ant or post translation

bull Hyperextensionbull Axial loading

ndash Compression or burst rsquos

3 Column Modelbull Anterior column

ndash Ant longitudinal ligndash Ant annulus fibrosisndash Ant vertebral body

bull Middle columnndash Post longitudinal ligndash Post annulus fibrosisndash Post vertebral body

bull Posterior columnndash Spinous processesndash Transverse processesndash Laminandash Facet jointsndash Pediclesndash Post ligamentous complex

bull 2 or more columns disrupted = unstablebull Most disruption of middle columns are

unstable

Stable or Unstable

bull Radiographic findings suggestive of instabilityndash Vertebral body collapse w widening of pediclesndash gt 33 canal compromise on CTndash gt 25 mm translation bw vertebral bodies in any planendash Bilateral facet dislocationndash Abnormal widening bw spinous processes or lamina and gt

50 anterior collapse of vertebral body

Stable or Unstable

bull Checklist for Instabilityndash Anterior elements disrupted 2 ptsndash Posterior elements disrupted 2 ptsndash Saggital plane translation gt 25 mm 2 ptsndash Saggital plane rotation gt 5o 2 ptsndash Spinal cord or cauda equina damage 2 ptsndash Disruption of costovertebral articulations 1 ptndash Dangerous loading anticipated 2 pts

ndash 5 or more pts unstable until healed or surgically stabilized

Stable or Unstable

bull Risk of neurologic injury increases withndash gt 35 canal narrowing

at T11-12ndash gt 45 canal narrowing

at L1ndash gt 55 canal narrowing

at L2 amp below

Approach to T amp L Spinesbull A ndash adequacy amp alignment

ndash All vertebrae need to be visiblendash Ant amp post longitudinal linesndash Facet joints should lie on smooth curvendash Normal kyphosis amp lordosisndash All spinous processes should lie in straight line

bull B ndash bonesndash Trace cortical margins of each vertebraendash Difference bw ant amp post body ht lt 2 mmndash Progressive increase in vertebral body ht moving down

spinendash Wink sign amp interpedicular distancendash Donrsquot forget to look at transverse processes

Approach to T amp L Spines

bull C ndash cartilagendash Progressive increase in disc space moving down

spine (except L5-S1)ndash Facet joint alignment

bull S ndashsoft tissuendash Look at paraspinal stripe and prevertebral space

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines

Lateral Viewndash Posterior VB linendash Anterior VB linendash Inter-spinous Distancendash Translation

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines A-P

Viewndash Spinous process to Pediclesndash Inter-pedicular Distancendash Translation

Thoracic and Lumbar Injuries

Height Loss

Adjacent fracture

Transverse process fracturesof L2-4

Significance of transverse processfractures is not the fractures in andof themselves but rather the high incidence of associated seriousintraabdominal injury (~20)

AnterolisthesisOf L4 on L5

  • X ray spine
  • SPINE TRAUMA
  • CERVICAL SPINE INJURY
  • Slide 4
  • Slide 5
  • Slide 6
  • Slide 7
  • Slide 8
  • Slide 9
  • Anteroposterior (A-P) View
  • Open Mouth View
  • Swimmerrsquos View
  • Slide 13
  • Slide 14
  • Slide 15
  • Lower Cervical Detection
  • Lower Cervical Detection (2)
  • Lower Cervical Detection (3)
  • Lower Cervical Detection (4)
  • Lower Cervical Detection (5)
  • Lower Cervical Detection (6)
  • Slide 22
  • Slide 23
  • Slide 24
  • Slide 25
  • Slide 26
  • Slide 27
  • THORACO-LUMBAR SPINE INJURY
  • Anatomy
  • Slide 30
  • Thoracic Spine
  • Lumbar Spine
  • Determinants of Stability
  • Mechanisms of Injury
  • 3 Column Model
  • Stable or Unstable
  • Stable or Unstable (2)
  • Stable or Unstable (3)
  • Approach to T amp L Spines
  • Approach to T amp L Spines (2)
  • Injury Detection Thoracic and Lumbar Spines
  • Injury Detection Thoracic and Lumbar Spines (2)
  • Thoracic and Lumbar Injuries
  • Height Loss
  • Slide 45
  • Slide 46
Page 24: X ray spine. SPINE TRAUMA CERVICAL SPINE INJURY THORACO-LUMBAR SPINE INJURY

DENS FRACTURE

FRACTURE OF THE BASE OF THE DENS (ODONTOID) OF C2ANTERIOR OR POSTERIOR DISPLACEMENT OF THE DENSCAN OCCUR AT VARIOUS LEVELS ON THE DENSVIA HYPERFLEXION OR HYPEREXTENSION OF HEAD ON NECKUNSTABLE IF DISPLACEMENT OCCURS

COMPRESSION FRACTURE

VARIABLE SEVERITY FROM MINIMAL ANTERIOR WEDGING TO COMPLETE DISRUPTION OF VERTEBRAL BODY (BURST)LOOK FOR LOSS OF VERTICAL HEIGHT OF VERTEBRAL BODYDUE TO LONG AXIS COMPRESSION OR HYPERFLEXIONDIVING INTO SHALLOW POOLSTABLE 1048774UNSTABLE

TEARDROP FRACTURE

AVULSION FRACTURE OF ANTERIOR MARGIN OF VERTEBRAL BODYANTERIOR LONGITUDINAL LIG INSTABILITY (RUPTURE AVULSION)HYPEREXTENSION INJURYUNSTABLE INJURYLAMINA MAY JAM TOGETHER CAUSING LIGAMENTA FLAVA TO BUCKLE INWARD AND COMPRESSCONTUSE THE SPINAL CORD

CLAY SHOVELERrsquoS FRACTURE

AVULSION FRACTURE OF SPINOUS PROCESS BY SUPRASPINOUS LIGAMENTUSUALLY OCCURRING FROM C6-T2HYPERFLEXION DIRECT TRAUMA DOWNWARD FORCE VIA THORACOSCAPULAR MUSCLE (AS IN SHOVELING MOTION)STABLE

THORACO-LUMBAR SPINE INJURY

Anatomy

MENU OF IMAGING OPTIONS

DORSAL SPINE PLAIN FILMS

ANTERO- POSTERIOR AND

LATERAL VIEW

LUMBO SACCRAL SPINE

ANTERO- POSTERIOR AND

LATERAL VIEW

Thoracic Spine

Lumbar Spine

Determinants of Stability

bull T amp L spines are more stable than C-spinendash Strong ligamentsndash Stabilization by ribsndash Bigger intervertebral discsndash Larger facet jointsndash Less mobility

bull Fractures amp dislocations tend to occur where curvature changesndash T11-12 (thoracolumbar junction)ndash L5-S1 (lumbosacral junction)

Mechanisms of Injury

bull Hyperflexion +- rotationndash Commonestndash Usually see anterior wedge rsquos or Chance

bull Shearingndash Ant or post translation

bull Hyperextensionbull Axial loading

ndash Compression or burst rsquos

3 Column Modelbull Anterior column

ndash Ant longitudinal ligndash Ant annulus fibrosisndash Ant vertebral body

bull Middle columnndash Post longitudinal ligndash Post annulus fibrosisndash Post vertebral body

bull Posterior columnndash Spinous processesndash Transverse processesndash Laminandash Facet jointsndash Pediclesndash Post ligamentous complex

bull 2 or more columns disrupted = unstablebull Most disruption of middle columns are

unstable

Stable or Unstable

bull Radiographic findings suggestive of instabilityndash Vertebral body collapse w widening of pediclesndash gt 33 canal compromise on CTndash gt 25 mm translation bw vertebral bodies in any planendash Bilateral facet dislocationndash Abnormal widening bw spinous processes or lamina and gt

50 anterior collapse of vertebral body

Stable or Unstable

bull Checklist for Instabilityndash Anterior elements disrupted 2 ptsndash Posterior elements disrupted 2 ptsndash Saggital plane translation gt 25 mm 2 ptsndash Saggital plane rotation gt 5o 2 ptsndash Spinal cord or cauda equina damage 2 ptsndash Disruption of costovertebral articulations 1 ptndash Dangerous loading anticipated 2 pts

ndash 5 or more pts unstable until healed or surgically stabilized

Stable or Unstable

bull Risk of neurologic injury increases withndash gt 35 canal narrowing

at T11-12ndash gt 45 canal narrowing

at L1ndash gt 55 canal narrowing

at L2 amp below

Approach to T amp L Spinesbull A ndash adequacy amp alignment

ndash All vertebrae need to be visiblendash Ant amp post longitudinal linesndash Facet joints should lie on smooth curvendash Normal kyphosis amp lordosisndash All spinous processes should lie in straight line

bull B ndash bonesndash Trace cortical margins of each vertebraendash Difference bw ant amp post body ht lt 2 mmndash Progressive increase in vertebral body ht moving down

spinendash Wink sign amp interpedicular distancendash Donrsquot forget to look at transverse processes

Approach to T amp L Spines

bull C ndash cartilagendash Progressive increase in disc space moving down

spine (except L5-S1)ndash Facet joint alignment

bull S ndashsoft tissuendash Look at paraspinal stripe and prevertebral space

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines

Lateral Viewndash Posterior VB linendash Anterior VB linendash Inter-spinous Distancendash Translation

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines A-P

Viewndash Spinous process to Pediclesndash Inter-pedicular Distancendash Translation

Thoracic and Lumbar Injuries

Height Loss

Adjacent fracture

Transverse process fracturesof L2-4

Significance of transverse processfractures is not the fractures in andof themselves but rather the high incidence of associated seriousintraabdominal injury (~20)

AnterolisthesisOf L4 on L5

  • X ray spine
  • SPINE TRAUMA
  • CERVICAL SPINE INJURY
  • Slide 4
  • Slide 5
  • Slide 6
  • Slide 7
  • Slide 8
  • Slide 9
  • Anteroposterior (A-P) View
  • Open Mouth View
  • Swimmerrsquos View
  • Slide 13
  • Slide 14
  • Slide 15
  • Lower Cervical Detection
  • Lower Cervical Detection (2)
  • Lower Cervical Detection (3)
  • Lower Cervical Detection (4)
  • Lower Cervical Detection (5)
  • Lower Cervical Detection (6)
  • Slide 22
  • Slide 23
  • Slide 24
  • Slide 25
  • Slide 26
  • Slide 27
  • THORACO-LUMBAR SPINE INJURY
  • Anatomy
  • Slide 30
  • Thoracic Spine
  • Lumbar Spine
  • Determinants of Stability
  • Mechanisms of Injury
  • 3 Column Model
  • Stable or Unstable
  • Stable or Unstable (2)
  • Stable or Unstable (3)
  • Approach to T amp L Spines
  • Approach to T amp L Spines (2)
  • Injury Detection Thoracic and Lumbar Spines
  • Injury Detection Thoracic and Lumbar Spines (2)
  • Thoracic and Lumbar Injuries
  • Height Loss
  • Slide 45
  • Slide 46
Page 25: X ray spine. SPINE TRAUMA CERVICAL SPINE INJURY THORACO-LUMBAR SPINE INJURY

COMPRESSION FRACTURE

VARIABLE SEVERITY FROM MINIMAL ANTERIOR WEDGING TO COMPLETE DISRUPTION OF VERTEBRAL BODY (BURST)LOOK FOR LOSS OF VERTICAL HEIGHT OF VERTEBRAL BODYDUE TO LONG AXIS COMPRESSION OR HYPERFLEXIONDIVING INTO SHALLOW POOLSTABLE 1048774UNSTABLE

TEARDROP FRACTURE

AVULSION FRACTURE OF ANTERIOR MARGIN OF VERTEBRAL BODYANTERIOR LONGITUDINAL LIG INSTABILITY (RUPTURE AVULSION)HYPEREXTENSION INJURYUNSTABLE INJURYLAMINA MAY JAM TOGETHER CAUSING LIGAMENTA FLAVA TO BUCKLE INWARD AND COMPRESSCONTUSE THE SPINAL CORD

CLAY SHOVELERrsquoS FRACTURE

AVULSION FRACTURE OF SPINOUS PROCESS BY SUPRASPINOUS LIGAMENTUSUALLY OCCURRING FROM C6-T2HYPERFLEXION DIRECT TRAUMA DOWNWARD FORCE VIA THORACOSCAPULAR MUSCLE (AS IN SHOVELING MOTION)STABLE

THORACO-LUMBAR SPINE INJURY

Anatomy

MENU OF IMAGING OPTIONS

DORSAL SPINE PLAIN FILMS

ANTERO- POSTERIOR AND

LATERAL VIEW

LUMBO SACCRAL SPINE

ANTERO- POSTERIOR AND

LATERAL VIEW

Thoracic Spine

Lumbar Spine

Determinants of Stability

bull T amp L spines are more stable than C-spinendash Strong ligamentsndash Stabilization by ribsndash Bigger intervertebral discsndash Larger facet jointsndash Less mobility

bull Fractures amp dislocations tend to occur where curvature changesndash T11-12 (thoracolumbar junction)ndash L5-S1 (lumbosacral junction)

Mechanisms of Injury

bull Hyperflexion +- rotationndash Commonestndash Usually see anterior wedge rsquos or Chance

bull Shearingndash Ant or post translation

bull Hyperextensionbull Axial loading

ndash Compression or burst rsquos

3 Column Modelbull Anterior column

ndash Ant longitudinal ligndash Ant annulus fibrosisndash Ant vertebral body

bull Middle columnndash Post longitudinal ligndash Post annulus fibrosisndash Post vertebral body

bull Posterior columnndash Spinous processesndash Transverse processesndash Laminandash Facet jointsndash Pediclesndash Post ligamentous complex

bull 2 or more columns disrupted = unstablebull Most disruption of middle columns are

unstable

Stable or Unstable

bull Radiographic findings suggestive of instabilityndash Vertebral body collapse w widening of pediclesndash gt 33 canal compromise on CTndash gt 25 mm translation bw vertebral bodies in any planendash Bilateral facet dislocationndash Abnormal widening bw spinous processes or lamina and gt

50 anterior collapse of vertebral body

Stable or Unstable

bull Checklist for Instabilityndash Anterior elements disrupted 2 ptsndash Posterior elements disrupted 2 ptsndash Saggital plane translation gt 25 mm 2 ptsndash Saggital plane rotation gt 5o 2 ptsndash Spinal cord or cauda equina damage 2 ptsndash Disruption of costovertebral articulations 1 ptndash Dangerous loading anticipated 2 pts

ndash 5 or more pts unstable until healed or surgically stabilized

Stable or Unstable

bull Risk of neurologic injury increases withndash gt 35 canal narrowing

at T11-12ndash gt 45 canal narrowing

at L1ndash gt 55 canal narrowing

at L2 amp below

Approach to T amp L Spinesbull A ndash adequacy amp alignment

ndash All vertebrae need to be visiblendash Ant amp post longitudinal linesndash Facet joints should lie on smooth curvendash Normal kyphosis amp lordosisndash All spinous processes should lie in straight line

bull B ndash bonesndash Trace cortical margins of each vertebraendash Difference bw ant amp post body ht lt 2 mmndash Progressive increase in vertebral body ht moving down

spinendash Wink sign amp interpedicular distancendash Donrsquot forget to look at transverse processes

Approach to T amp L Spines

bull C ndash cartilagendash Progressive increase in disc space moving down

spine (except L5-S1)ndash Facet joint alignment

bull S ndashsoft tissuendash Look at paraspinal stripe and prevertebral space

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines

Lateral Viewndash Posterior VB linendash Anterior VB linendash Inter-spinous Distancendash Translation

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines A-P

Viewndash Spinous process to Pediclesndash Inter-pedicular Distancendash Translation

Thoracic and Lumbar Injuries

Height Loss

Adjacent fracture

Transverse process fracturesof L2-4

Significance of transverse processfractures is not the fractures in andof themselves but rather the high incidence of associated seriousintraabdominal injury (~20)

AnterolisthesisOf L4 on L5

  • X ray spine
  • SPINE TRAUMA
  • CERVICAL SPINE INJURY
  • Slide 4
  • Slide 5
  • Slide 6
  • Slide 7
  • Slide 8
  • Slide 9
  • Anteroposterior (A-P) View
  • Open Mouth View
  • Swimmerrsquos View
  • Slide 13
  • Slide 14
  • Slide 15
  • Lower Cervical Detection
  • Lower Cervical Detection (2)
  • Lower Cervical Detection (3)
  • Lower Cervical Detection (4)
  • Lower Cervical Detection (5)
  • Lower Cervical Detection (6)
  • Slide 22
  • Slide 23
  • Slide 24
  • Slide 25
  • Slide 26
  • Slide 27
  • THORACO-LUMBAR SPINE INJURY
  • Anatomy
  • Slide 30
  • Thoracic Spine
  • Lumbar Spine
  • Determinants of Stability
  • Mechanisms of Injury
  • 3 Column Model
  • Stable or Unstable
  • Stable or Unstable (2)
  • Stable or Unstable (3)
  • Approach to T amp L Spines
  • Approach to T amp L Spines (2)
  • Injury Detection Thoracic and Lumbar Spines
  • Injury Detection Thoracic and Lumbar Spines (2)
  • Thoracic and Lumbar Injuries
  • Height Loss
  • Slide 45
  • Slide 46
Page 26: X ray spine. SPINE TRAUMA CERVICAL SPINE INJURY THORACO-LUMBAR SPINE INJURY

TEARDROP FRACTURE

AVULSION FRACTURE OF ANTERIOR MARGIN OF VERTEBRAL BODYANTERIOR LONGITUDINAL LIG INSTABILITY (RUPTURE AVULSION)HYPEREXTENSION INJURYUNSTABLE INJURYLAMINA MAY JAM TOGETHER CAUSING LIGAMENTA FLAVA TO BUCKLE INWARD AND COMPRESSCONTUSE THE SPINAL CORD

CLAY SHOVELERrsquoS FRACTURE

AVULSION FRACTURE OF SPINOUS PROCESS BY SUPRASPINOUS LIGAMENTUSUALLY OCCURRING FROM C6-T2HYPERFLEXION DIRECT TRAUMA DOWNWARD FORCE VIA THORACOSCAPULAR MUSCLE (AS IN SHOVELING MOTION)STABLE

THORACO-LUMBAR SPINE INJURY

Anatomy

MENU OF IMAGING OPTIONS

DORSAL SPINE PLAIN FILMS

ANTERO- POSTERIOR AND

LATERAL VIEW

LUMBO SACCRAL SPINE

ANTERO- POSTERIOR AND

LATERAL VIEW

Thoracic Spine

Lumbar Spine

Determinants of Stability

bull T amp L spines are more stable than C-spinendash Strong ligamentsndash Stabilization by ribsndash Bigger intervertebral discsndash Larger facet jointsndash Less mobility

bull Fractures amp dislocations tend to occur where curvature changesndash T11-12 (thoracolumbar junction)ndash L5-S1 (lumbosacral junction)

Mechanisms of Injury

bull Hyperflexion +- rotationndash Commonestndash Usually see anterior wedge rsquos or Chance

bull Shearingndash Ant or post translation

bull Hyperextensionbull Axial loading

ndash Compression or burst rsquos

3 Column Modelbull Anterior column

ndash Ant longitudinal ligndash Ant annulus fibrosisndash Ant vertebral body

bull Middle columnndash Post longitudinal ligndash Post annulus fibrosisndash Post vertebral body

bull Posterior columnndash Spinous processesndash Transverse processesndash Laminandash Facet jointsndash Pediclesndash Post ligamentous complex

bull 2 or more columns disrupted = unstablebull Most disruption of middle columns are

unstable

Stable or Unstable

bull Radiographic findings suggestive of instabilityndash Vertebral body collapse w widening of pediclesndash gt 33 canal compromise on CTndash gt 25 mm translation bw vertebral bodies in any planendash Bilateral facet dislocationndash Abnormal widening bw spinous processes or lamina and gt

50 anterior collapse of vertebral body

Stable or Unstable

bull Checklist for Instabilityndash Anterior elements disrupted 2 ptsndash Posterior elements disrupted 2 ptsndash Saggital plane translation gt 25 mm 2 ptsndash Saggital plane rotation gt 5o 2 ptsndash Spinal cord or cauda equina damage 2 ptsndash Disruption of costovertebral articulations 1 ptndash Dangerous loading anticipated 2 pts

ndash 5 or more pts unstable until healed or surgically stabilized

Stable or Unstable

bull Risk of neurologic injury increases withndash gt 35 canal narrowing

at T11-12ndash gt 45 canal narrowing

at L1ndash gt 55 canal narrowing

at L2 amp below

Approach to T amp L Spinesbull A ndash adequacy amp alignment

ndash All vertebrae need to be visiblendash Ant amp post longitudinal linesndash Facet joints should lie on smooth curvendash Normal kyphosis amp lordosisndash All spinous processes should lie in straight line

bull B ndash bonesndash Trace cortical margins of each vertebraendash Difference bw ant amp post body ht lt 2 mmndash Progressive increase in vertebral body ht moving down

spinendash Wink sign amp interpedicular distancendash Donrsquot forget to look at transverse processes

Approach to T amp L Spines

bull C ndash cartilagendash Progressive increase in disc space moving down

spine (except L5-S1)ndash Facet joint alignment

bull S ndashsoft tissuendash Look at paraspinal stripe and prevertebral space

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines

Lateral Viewndash Posterior VB linendash Anterior VB linendash Inter-spinous Distancendash Translation

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines A-P

Viewndash Spinous process to Pediclesndash Inter-pedicular Distancendash Translation

Thoracic and Lumbar Injuries

Height Loss

Adjacent fracture

Transverse process fracturesof L2-4

Significance of transverse processfractures is not the fractures in andof themselves but rather the high incidence of associated seriousintraabdominal injury (~20)

AnterolisthesisOf L4 on L5

  • X ray spine
  • SPINE TRAUMA
  • CERVICAL SPINE INJURY
  • Slide 4
  • Slide 5
  • Slide 6
  • Slide 7
  • Slide 8
  • Slide 9
  • Anteroposterior (A-P) View
  • Open Mouth View
  • Swimmerrsquos View
  • Slide 13
  • Slide 14
  • Slide 15
  • Lower Cervical Detection
  • Lower Cervical Detection (2)
  • Lower Cervical Detection (3)
  • Lower Cervical Detection (4)
  • Lower Cervical Detection (5)
  • Lower Cervical Detection (6)
  • Slide 22
  • Slide 23
  • Slide 24
  • Slide 25
  • Slide 26
  • Slide 27
  • THORACO-LUMBAR SPINE INJURY
  • Anatomy
  • Slide 30
  • Thoracic Spine
  • Lumbar Spine
  • Determinants of Stability
  • Mechanisms of Injury
  • 3 Column Model
  • Stable or Unstable
  • Stable or Unstable (2)
  • Stable or Unstable (3)
  • Approach to T amp L Spines
  • Approach to T amp L Spines (2)
  • Injury Detection Thoracic and Lumbar Spines
  • Injury Detection Thoracic and Lumbar Spines (2)
  • Thoracic and Lumbar Injuries
  • Height Loss
  • Slide 45
  • Slide 46
Page 27: X ray spine. SPINE TRAUMA CERVICAL SPINE INJURY THORACO-LUMBAR SPINE INJURY

CLAY SHOVELERrsquoS FRACTURE

AVULSION FRACTURE OF SPINOUS PROCESS BY SUPRASPINOUS LIGAMENTUSUALLY OCCURRING FROM C6-T2HYPERFLEXION DIRECT TRAUMA DOWNWARD FORCE VIA THORACOSCAPULAR MUSCLE (AS IN SHOVELING MOTION)STABLE

THORACO-LUMBAR SPINE INJURY

Anatomy

MENU OF IMAGING OPTIONS

DORSAL SPINE PLAIN FILMS

ANTERO- POSTERIOR AND

LATERAL VIEW

LUMBO SACCRAL SPINE

ANTERO- POSTERIOR AND

LATERAL VIEW

Thoracic Spine

Lumbar Spine

Determinants of Stability

bull T amp L spines are more stable than C-spinendash Strong ligamentsndash Stabilization by ribsndash Bigger intervertebral discsndash Larger facet jointsndash Less mobility

bull Fractures amp dislocations tend to occur where curvature changesndash T11-12 (thoracolumbar junction)ndash L5-S1 (lumbosacral junction)

Mechanisms of Injury

bull Hyperflexion +- rotationndash Commonestndash Usually see anterior wedge rsquos or Chance

bull Shearingndash Ant or post translation

bull Hyperextensionbull Axial loading

ndash Compression or burst rsquos

3 Column Modelbull Anterior column

ndash Ant longitudinal ligndash Ant annulus fibrosisndash Ant vertebral body

bull Middle columnndash Post longitudinal ligndash Post annulus fibrosisndash Post vertebral body

bull Posterior columnndash Spinous processesndash Transverse processesndash Laminandash Facet jointsndash Pediclesndash Post ligamentous complex

bull 2 or more columns disrupted = unstablebull Most disruption of middle columns are

unstable

Stable or Unstable

bull Radiographic findings suggestive of instabilityndash Vertebral body collapse w widening of pediclesndash gt 33 canal compromise on CTndash gt 25 mm translation bw vertebral bodies in any planendash Bilateral facet dislocationndash Abnormal widening bw spinous processes or lamina and gt

50 anterior collapse of vertebral body

Stable or Unstable

bull Checklist for Instabilityndash Anterior elements disrupted 2 ptsndash Posterior elements disrupted 2 ptsndash Saggital plane translation gt 25 mm 2 ptsndash Saggital plane rotation gt 5o 2 ptsndash Spinal cord or cauda equina damage 2 ptsndash Disruption of costovertebral articulations 1 ptndash Dangerous loading anticipated 2 pts

ndash 5 or more pts unstable until healed or surgically stabilized

Stable or Unstable

bull Risk of neurologic injury increases withndash gt 35 canal narrowing

at T11-12ndash gt 45 canal narrowing

at L1ndash gt 55 canal narrowing

at L2 amp below

Approach to T amp L Spinesbull A ndash adequacy amp alignment

ndash All vertebrae need to be visiblendash Ant amp post longitudinal linesndash Facet joints should lie on smooth curvendash Normal kyphosis amp lordosisndash All spinous processes should lie in straight line

bull B ndash bonesndash Trace cortical margins of each vertebraendash Difference bw ant amp post body ht lt 2 mmndash Progressive increase in vertebral body ht moving down

spinendash Wink sign amp interpedicular distancendash Donrsquot forget to look at transverse processes

Approach to T amp L Spines

bull C ndash cartilagendash Progressive increase in disc space moving down

spine (except L5-S1)ndash Facet joint alignment

bull S ndashsoft tissuendash Look at paraspinal stripe and prevertebral space

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines

Lateral Viewndash Posterior VB linendash Anterior VB linendash Inter-spinous Distancendash Translation

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines A-P

Viewndash Spinous process to Pediclesndash Inter-pedicular Distancendash Translation

Thoracic and Lumbar Injuries

Height Loss

Adjacent fracture

Transverse process fracturesof L2-4

Significance of transverse processfractures is not the fractures in andof themselves but rather the high incidence of associated seriousintraabdominal injury (~20)

AnterolisthesisOf L4 on L5

  • X ray spine
  • SPINE TRAUMA
  • CERVICAL SPINE INJURY
  • Slide 4
  • Slide 5
  • Slide 6
  • Slide 7
  • Slide 8
  • Slide 9
  • Anteroposterior (A-P) View
  • Open Mouth View
  • Swimmerrsquos View
  • Slide 13
  • Slide 14
  • Slide 15
  • Lower Cervical Detection
  • Lower Cervical Detection (2)
  • Lower Cervical Detection (3)
  • Lower Cervical Detection (4)
  • Lower Cervical Detection (5)
  • Lower Cervical Detection (6)
  • Slide 22
  • Slide 23
  • Slide 24
  • Slide 25
  • Slide 26
  • Slide 27
  • THORACO-LUMBAR SPINE INJURY
  • Anatomy
  • Slide 30
  • Thoracic Spine
  • Lumbar Spine
  • Determinants of Stability
  • Mechanisms of Injury
  • 3 Column Model
  • Stable or Unstable
  • Stable or Unstable (2)
  • Stable or Unstable (3)
  • Approach to T amp L Spines
  • Approach to T amp L Spines (2)
  • Injury Detection Thoracic and Lumbar Spines
  • Injury Detection Thoracic and Lumbar Spines (2)
  • Thoracic and Lumbar Injuries
  • Height Loss
  • Slide 45
  • Slide 46
Page 28: X ray spine. SPINE TRAUMA CERVICAL SPINE INJURY THORACO-LUMBAR SPINE INJURY

THORACO-LUMBAR SPINE INJURY

Anatomy

MENU OF IMAGING OPTIONS

DORSAL SPINE PLAIN FILMS

ANTERO- POSTERIOR AND

LATERAL VIEW

LUMBO SACCRAL SPINE

ANTERO- POSTERIOR AND

LATERAL VIEW

Thoracic Spine

Lumbar Spine

Determinants of Stability

bull T amp L spines are more stable than C-spinendash Strong ligamentsndash Stabilization by ribsndash Bigger intervertebral discsndash Larger facet jointsndash Less mobility

bull Fractures amp dislocations tend to occur where curvature changesndash T11-12 (thoracolumbar junction)ndash L5-S1 (lumbosacral junction)

Mechanisms of Injury

bull Hyperflexion +- rotationndash Commonestndash Usually see anterior wedge rsquos or Chance

bull Shearingndash Ant or post translation

bull Hyperextensionbull Axial loading

ndash Compression or burst rsquos

3 Column Modelbull Anterior column

ndash Ant longitudinal ligndash Ant annulus fibrosisndash Ant vertebral body

bull Middle columnndash Post longitudinal ligndash Post annulus fibrosisndash Post vertebral body

bull Posterior columnndash Spinous processesndash Transverse processesndash Laminandash Facet jointsndash Pediclesndash Post ligamentous complex

bull 2 or more columns disrupted = unstablebull Most disruption of middle columns are

unstable

Stable or Unstable

bull Radiographic findings suggestive of instabilityndash Vertebral body collapse w widening of pediclesndash gt 33 canal compromise on CTndash gt 25 mm translation bw vertebral bodies in any planendash Bilateral facet dislocationndash Abnormal widening bw spinous processes or lamina and gt

50 anterior collapse of vertebral body

Stable or Unstable

bull Checklist for Instabilityndash Anterior elements disrupted 2 ptsndash Posterior elements disrupted 2 ptsndash Saggital plane translation gt 25 mm 2 ptsndash Saggital plane rotation gt 5o 2 ptsndash Spinal cord or cauda equina damage 2 ptsndash Disruption of costovertebral articulations 1 ptndash Dangerous loading anticipated 2 pts

ndash 5 or more pts unstable until healed or surgically stabilized

Stable or Unstable

bull Risk of neurologic injury increases withndash gt 35 canal narrowing

at T11-12ndash gt 45 canal narrowing

at L1ndash gt 55 canal narrowing

at L2 amp below

Approach to T amp L Spinesbull A ndash adequacy amp alignment

ndash All vertebrae need to be visiblendash Ant amp post longitudinal linesndash Facet joints should lie on smooth curvendash Normal kyphosis amp lordosisndash All spinous processes should lie in straight line

bull B ndash bonesndash Trace cortical margins of each vertebraendash Difference bw ant amp post body ht lt 2 mmndash Progressive increase in vertebral body ht moving down

spinendash Wink sign amp interpedicular distancendash Donrsquot forget to look at transverse processes

Approach to T amp L Spines

bull C ndash cartilagendash Progressive increase in disc space moving down

spine (except L5-S1)ndash Facet joint alignment

bull S ndashsoft tissuendash Look at paraspinal stripe and prevertebral space

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines

Lateral Viewndash Posterior VB linendash Anterior VB linendash Inter-spinous Distancendash Translation

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines A-P

Viewndash Spinous process to Pediclesndash Inter-pedicular Distancendash Translation

Thoracic and Lumbar Injuries

Height Loss

Adjacent fracture

Transverse process fracturesof L2-4

Significance of transverse processfractures is not the fractures in andof themselves but rather the high incidence of associated seriousintraabdominal injury (~20)

AnterolisthesisOf L4 on L5

  • X ray spine
  • SPINE TRAUMA
  • CERVICAL SPINE INJURY
  • Slide 4
  • Slide 5
  • Slide 6
  • Slide 7
  • Slide 8
  • Slide 9
  • Anteroposterior (A-P) View
  • Open Mouth View
  • Swimmerrsquos View
  • Slide 13
  • Slide 14
  • Slide 15
  • Lower Cervical Detection
  • Lower Cervical Detection (2)
  • Lower Cervical Detection (3)
  • Lower Cervical Detection (4)
  • Lower Cervical Detection (5)
  • Lower Cervical Detection (6)
  • Slide 22
  • Slide 23
  • Slide 24
  • Slide 25
  • Slide 26
  • Slide 27
  • THORACO-LUMBAR SPINE INJURY
  • Anatomy
  • Slide 30
  • Thoracic Spine
  • Lumbar Spine
  • Determinants of Stability
  • Mechanisms of Injury
  • 3 Column Model
  • Stable or Unstable
  • Stable or Unstable (2)
  • Stable or Unstable (3)
  • Approach to T amp L Spines
  • Approach to T amp L Spines (2)
  • Injury Detection Thoracic and Lumbar Spines
  • Injury Detection Thoracic and Lumbar Spines (2)
  • Thoracic and Lumbar Injuries
  • Height Loss
  • Slide 45
  • Slide 46
Page 29: X ray spine. SPINE TRAUMA CERVICAL SPINE INJURY THORACO-LUMBAR SPINE INJURY

Anatomy

MENU OF IMAGING OPTIONS

DORSAL SPINE PLAIN FILMS

ANTERO- POSTERIOR AND

LATERAL VIEW

LUMBO SACCRAL SPINE

ANTERO- POSTERIOR AND

LATERAL VIEW

Thoracic Spine

Lumbar Spine

Determinants of Stability

bull T amp L spines are more stable than C-spinendash Strong ligamentsndash Stabilization by ribsndash Bigger intervertebral discsndash Larger facet jointsndash Less mobility

bull Fractures amp dislocations tend to occur where curvature changesndash T11-12 (thoracolumbar junction)ndash L5-S1 (lumbosacral junction)

Mechanisms of Injury

bull Hyperflexion +- rotationndash Commonestndash Usually see anterior wedge rsquos or Chance

bull Shearingndash Ant or post translation

bull Hyperextensionbull Axial loading

ndash Compression or burst rsquos

3 Column Modelbull Anterior column

ndash Ant longitudinal ligndash Ant annulus fibrosisndash Ant vertebral body

bull Middle columnndash Post longitudinal ligndash Post annulus fibrosisndash Post vertebral body

bull Posterior columnndash Spinous processesndash Transverse processesndash Laminandash Facet jointsndash Pediclesndash Post ligamentous complex

bull 2 or more columns disrupted = unstablebull Most disruption of middle columns are

unstable

Stable or Unstable

bull Radiographic findings suggestive of instabilityndash Vertebral body collapse w widening of pediclesndash gt 33 canal compromise on CTndash gt 25 mm translation bw vertebral bodies in any planendash Bilateral facet dislocationndash Abnormal widening bw spinous processes or lamina and gt

50 anterior collapse of vertebral body

Stable or Unstable

bull Checklist for Instabilityndash Anterior elements disrupted 2 ptsndash Posterior elements disrupted 2 ptsndash Saggital plane translation gt 25 mm 2 ptsndash Saggital plane rotation gt 5o 2 ptsndash Spinal cord or cauda equina damage 2 ptsndash Disruption of costovertebral articulations 1 ptndash Dangerous loading anticipated 2 pts

ndash 5 or more pts unstable until healed or surgically stabilized

Stable or Unstable

bull Risk of neurologic injury increases withndash gt 35 canal narrowing

at T11-12ndash gt 45 canal narrowing

at L1ndash gt 55 canal narrowing

at L2 amp below

Approach to T amp L Spinesbull A ndash adequacy amp alignment

ndash All vertebrae need to be visiblendash Ant amp post longitudinal linesndash Facet joints should lie on smooth curvendash Normal kyphosis amp lordosisndash All spinous processes should lie in straight line

bull B ndash bonesndash Trace cortical margins of each vertebraendash Difference bw ant amp post body ht lt 2 mmndash Progressive increase in vertebral body ht moving down

spinendash Wink sign amp interpedicular distancendash Donrsquot forget to look at transverse processes

Approach to T amp L Spines

bull C ndash cartilagendash Progressive increase in disc space moving down

spine (except L5-S1)ndash Facet joint alignment

bull S ndashsoft tissuendash Look at paraspinal stripe and prevertebral space

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines

Lateral Viewndash Posterior VB linendash Anterior VB linendash Inter-spinous Distancendash Translation

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines A-P

Viewndash Spinous process to Pediclesndash Inter-pedicular Distancendash Translation

Thoracic and Lumbar Injuries

Height Loss

Adjacent fracture

Transverse process fracturesof L2-4

Significance of transverse processfractures is not the fractures in andof themselves but rather the high incidence of associated seriousintraabdominal injury (~20)

AnterolisthesisOf L4 on L5

  • X ray spine
  • SPINE TRAUMA
  • CERVICAL SPINE INJURY
  • Slide 4
  • Slide 5
  • Slide 6
  • Slide 7
  • Slide 8
  • Slide 9
  • Anteroposterior (A-P) View
  • Open Mouth View
  • Swimmerrsquos View
  • Slide 13
  • Slide 14
  • Slide 15
  • Lower Cervical Detection
  • Lower Cervical Detection (2)
  • Lower Cervical Detection (3)
  • Lower Cervical Detection (4)
  • Lower Cervical Detection (5)
  • Lower Cervical Detection (6)
  • Slide 22
  • Slide 23
  • Slide 24
  • Slide 25
  • Slide 26
  • Slide 27
  • THORACO-LUMBAR SPINE INJURY
  • Anatomy
  • Slide 30
  • Thoracic Spine
  • Lumbar Spine
  • Determinants of Stability
  • Mechanisms of Injury
  • 3 Column Model
  • Stable or Unstable
  • Stable or Unstable (2)
  • Stable or Unstable (3)
  • Approach to T amp L Spines
  • Approach to T amp L Spines (2)
  • Injury Detection Thoracic and Lumbar Spines
  • Injury Detection Thoracic and Lumbar Spines (2)
  • Thoracic and Lumbar Injuries
  • Height Loss
  • Slide 45
  • Slide 46
Page 30: X ray spine. SPINE TRAUMA CERVICAL SPINE INJURY THORACO-LUMBAR SPINE INJURY

MENU OF IMAGING OPTIONS

DORSAL SPINE PLAIN FILMS

ANTERO- POSTERIOR AND

LATERAL VIEW

LUMBO SACCRAL SPINE

ANTERO- POSTERIOR AND

LATERAL VIEW

Thoracic Spine

Lumbar Spine

Determinants of Stability

bull T amp L spines are more stable than C-spinendash Strong ligamentsndash Stabilization by ribsndash Bigger intervertebral discsndash Larger facet jointsndash Less mobility

bull Fractures amp dislocations tend to occur where curvature changesndash T11-12 (thoracolumbar junction)ndash L5-S1 (lumbosacral junction)

Mechanisms of Injury

bull Hyperflexion +- rotationndash Commonestndash Usually see anterior wedge rsquos or Chance

bull Shearingndash Ant or post translation

bull Hyperextensionbull Axial loading

ndash Compression or burst rsquos

3 Column Modelbull Anterior column

ndash Ant longitudinal ligndash Ant annulus fibrosisndash Ant vertebral body

bull Middle columnndash Post longitudinal ligndash Post annulus fibrosisndash Post vertebral body

bull Posterior columnndash Spinous processesndash Transverse processesndash Laminandash Facet jointsndash Pediclesndash Post ligamentous complex

bull 2 or more columns disrupted = unstablebull Most disruption of middle columns are

unstable

Stable or Unstable

bull Radiographic findings suggestive of instabilityndash Vertebral body collapse w widening of pediclesndash gt 33 canal compromise on CTndash gt 25 mm translation bw vertebral bodies in any planendash Bilateral facet dislocationndash Abnormal widening bw spinous processes or lamina and gt

50 anterior collapse of vertebral body

Stable or Unstable

bull Checklist for Instabilityndash Anterior elements disrupted 2 ptsndash Posterior elements disrupted 2 ptsndash Saggital plane translation gt 25 mm 2 ptsndash Saggital plane rotation gt 5o 2 ptsndash Spinal cord or cauda equina damage 2 ptsndash Disruption of costovertebral articulations 1 ptndash Dangerous loading anticipated 2 pts

ndash 5 or more pts unstable until healed or surgically stabilized

Stable or Unstable

bull Risk of neurologic injury increases withndash gt 35 canal narrowing

at T11-12ndash gt 45 canal narrowing

at L1ndash gt 55 canal narrowing

at L2 amp below

Approach to T amp L Spinesbull A ndash adequacy amp alignment

ndash All vertebrae need to be visiblendash Ant amp post longitudinal linesndash Facet joints should lie on smooth curvendash Normal kyphosis amp lordosisndash All spinous processes should lie in straight line

bull B ndash bonesndash Trace cortical margins of each vertebraendash Difference bw ant amp post body ht lt 2 mmndash Progressive increase in vertebral body ht moving down

spinendash Wink sign amp interpedicular distancendash Donrsquot forget to look at transverse processes

Approach to T amp L Spines

bull C ndash cartilagendash Progressive increase in disc space moving down

spine (except L5-S1)ndash Facet joint alignment

bull S ndashsoft tissuendash Look at paraspinal stripe and prevertebral space

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines

Lateral Viewndash Posterior VB linendash Anterior VB linendash Inter-spinous Distancendash Translation

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines A-P

Viewndash Spinous process to Pediclesndash Inter-pedicular Distancendash Translation

Thoracic and Lumbar Injuries

Height Loss

Adjacent fracture

Transverse process fracturesof L2-4

Significance of transverse processfractures is not the fractures in andof themselves but rather the high incidence of associated seriousintraabdominal injury (~20)

AnterolisthesisOf L4 on L5

  • X ray spine
  • SPINE TRAUMA
  • CERVICAL SPINE INJURY
  • Slide 4
  • Slide 5
  • Slide 6
  • Slide 7
  • Slide 8
  • Slide 9
  • Anteroposterior (A-P) View
  • Open Mouth View
  • Swimmerrsquos View
  • Slide 13
  • Slide 14
  • Slide 15
  • Lower Cervical Detection
  • Lower Cervical Detection (2)
  • Lower Cervical Detection (3)
  • Lower Cervical Detection (4)
  • Lower Cervical Detection (5)
  • Lower Cervical Detection (6)
  • Slide 22
  • Slide 23
  • Slide 24
  • Slide 25
  • Slide 26
  • Slide 27
  • THORACO-LUMBAR SPINE INJURY
  • Anatomy
  • Slide 30
  • Thoracic Spine
  • Lumbar Spine
  • Determinants of Stability
  • Mechanisms of Injury
  • 3 Column Model
  • Stable or Unstable
  • Stable or Unstable (2)
  • Stable or Unstable (3)
  • Approach to T amp L Spines
  • Approach to T amp L Spines (2)
  • Injury Detection Thoracic and Lumbar Spines
  • Injury Detection Thoracic and Lumbar Spines (2)
  • Thoracic and Lumbar Injuries
  • Height Loss
  • Slide 45
  • Slide 46
Page 31: X ray spine. SPINE TRAUMA CERVICAL SPINE INJURY THORACO-LUMBAR SPINE INJURY

Thoracic Spine

Lumbar Spine

Determinants of Stability

bull T amp L spines are more stable than C-spinendash Strong ligamentsndash Stabilization by ribsndash Bigger intervertebral discsndash Larger facet jointsndash Less mobility

bull Fractures amp dislocations tend to occur where curvature changesndash T11-12 (thoracolumbar junction)ndash L5-S1 (lumbosacral junction)

Mechanisms of Injury

bull Hyperflexion +- rotationndash Commonestndash Usually see anterior wedge rsquos or Chance

bull Shearingndash Ant or post translation

bull Hyperextensionbull Axial loading

ndash Compression or burst rsquos

3 Column Modelbull Anterior column

ndash Ant longitudinal ligndash Ant annulus fibrosisndash Ant vertebral body

bull Middle columnndash Post longitudinal ligndash Post annulus fibrosisndash Post vertebral body

bull Posterior columnndash Spinous processesndash Transverse processesndash Laminandash Facet jointsndash Pediclesndash Post ligamentous complex

bull 2 or more columns disrupted = unstablebull Most disruption of middle columns are

unstable

Stable or Unstable

bull Radiographic findings suggestive of instabilityndash Vertebral body collapse w widening of pediclesndash gt 33 canal compromise on CTndash gt 25 mm translation bw vertebral bodies in any planendash Bilateral facet dislocationndash Abnormal widening bw spinous processes or lamina and gt

50 anterior collapse of vertebral body

Stable or Unstable

bull Checklist for Instabilityndash Anterior elements disrupted 2 ptsndash Posterior elements disrupted 2 ptsndash Saggital plane translation gt 25 mm 2 ptsndash Saggital plane rotation gt 5o 2 ptsndash Spinal cord or cauda equina damage 2 ptsndash Disruption of costovertebral articulations 1 ptndash Dangerous loading anticipated 2 pts

ndash 5 or more pts unstable until healed or surgically stabilized

Stable or Unstable

bull Risk of neurologic injury increases withndash gt 35 canal narrowing

at T11-12ndash gt 45 canal narrowing

at L1ndash gt 55 canal narrowing

at L2 amp below

Approach to T amp L Spinesbull A ndash adequacy amp alignment

ndash All vertebrae need to be visiblendash Ant amp post longitudinal linesndash Facet joints should lie on smooth curvendash Normal kyphosis amp lordosisndash All spinous processes should lie in straight line

bull B ndash bonesndash Trace cortical margins of each vertebraendash Difference bw ant amp post body ht lt 2 mmndash Progressive increase in vertebral body ht moving down

spinendash Wink sign amp interpedicular distancendash Donrsquot forget to look at transverse processes

Approach to T amp L Spines

bull C ndash cartilagendash Progressive increase in disc space moving down

spine (except L5-S1)ndash Facet joint alignment

bull S ndashsoft tissuendash Look at paraspinal stripe and prevertebral space

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines

Lateral Viewndash Posterior VB linendash Anterior VB linendash Inter-spinous Distancendash Translation

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines A-P

Viewndash Spinous process to Pediclesndash Inter-pedicular Distancendash Translation

Thoracic and Lumbar Injuries

Height Loss

Adjacent fracture

Transverse process fracturesof L2-4

Significance of transverse processfractures is not the fractures in andof themselves but rather the high incidence of associated seriousintraabdominal injury (~20)

AnterolisthesisOf L4 on L5

  • X ray spine
  • SPINE TRAUMA
  • CERVICAL SPINE INJURY
  • Slide 4
  • Slide 5
  • Slide 6
  • Slide 7
  • Slide 8
  • Slide 9
  • Anteroposterior (A-P) View
  • Open Mouth View
  • Swimmerrsquos View
  • Slide 13
  • Slide 14
  • Slide 15
  • Lower Cervical Detection
  • Lower Cervical Detection (2)
  • Lower Cervical Detection (3)
  • Lower Cervical Detection (4)
  • Lower Cervical Detection (5)
  • Lower Cervical Detection (6)
  • Slide 22
  • Slide 23
  • Slide 24
  • Slide 25
  • Slide 26
  • Slide 27
  • THORACO-LUMBAR SPINE INJURY
  • Anatomy
  • Slide 30
  • Thoracic Spine
  • Lumbar Spine
  • Determinants of Stability
  • Mechanisms of Injury
  • 3 Column Model
  • Stable or Unstable
  • Stable or Unstable (2)
  • Stable or Unstable (3)
  • Approach to T amp L Spines
  • Approach to T amp L Spines (2)
  • Injury Detection Thoracic and Lumbar Spines
  • Injury Detection Thoracic and Lumbar Spines (2)
  • Thoracic and Lumbar Injuries
  • Height Loss
  • Slide 45
  • Slide 46
Page 32: X ray spine. SPINE TRAUMA CERVICAL SPINE INJURY THORACO-LUMBAR SPINE INJURY

Lumbar Spine

Determinants of Stability

bull T amp L spines are more stable than C-spinendash Strong ligamentsndash Stabilization by ribsndash Bigger intervertebral discsndash Larger facet jointsndash Less mobility

bull Fractures amp dislocations tend to occur where curvature changesndash T11-12 (thoracolumbar junction)ndash L5-S1 (lumbosacral junction)

Mechanisms of Injury

bull Hyperflexion +- rotationndash Commonestndash Usually see anterior wedge rsquos or Chance

bull Shearingndash Ant or post translation

bull Hyperextensionbull Axial loading

ndash Compression or burst rsquos

3 Column Modelbull Anterior column

ndash Ant longitudinal ligndash Ant annulus fibrosisndash Ant vertebral body

bull Middle columnndash Post longitudinal ligndash Post annulus fibrosisndash Post vertebral body

bull Posterior columnndash Spinous processesndash Transverse processesndash Laminandash Facet jointsndash Pediclesndash Post ligamentous complex

bull 2 or more columns disrupted = unstablebull Most disruption of middle columns are

unstable

Stable or Unstable

bull Radiographic findings suggestive of instabilityndash Vertebral body collapse w widening of pediclesndash gt 33 canal compromise on CTndash gt 25 mm translation bw vertebral bodies in any planendash Bilateral facet dislocationndash Abnormal widening bw spinous processes or lamina and gt

50 anterior collapse of vertebral body

Stable or Unstable

bull Checklist for Instabilityndash Anterior elements disrupted 2 ptsndash Posterior elements disrupted 2 ptsndash Saggital plane translation gt 25 mm 2 ptsndash Saggital plane rotation gt 5o 2 ptsndash Spinal cord or cauda equina damage 2 ptsndash Disruption of costovertebral articulations 1 ptndash Dangerous loading anticipated 2 pts

ndash 5 or more pts unstable until healed or surgically stabilized

Stable or Unstable

bull Risk of neurologic injury increases withndash gt 35 canal narrowing

at T11-12ndash gt 45 canal narrowing

at L1ndash gt 55 canal narrowing

at L2 amp below

Approach to T amp L Spinesbull A ndash adequacy amp alignment

ndash All vertebrae need to be visiblendash Ant amp post longitudinal linesndash Facet joints should lie on smooth curvendash Normal kyphosis amp lordosisndash All spinous processes should lie in straight line

bull B ndash bonesndash Trace cortical margins of each vertebraendash Difference bw ant amp post body ht lt 2 mmndash Progressive increase in vertebral body ht moving down

spinendash Wink sign amp interpedicular distancendash Donrsquot forget to look at transverse processes

Approach to T amp L Spines

bull C ndash cartilagendash Progressive increase in disc space moving down

spine (except L5-S1)ndash Facet joint alignment

bull S ndashsoft tissuendash Look at paraspinal stripe and prevertebral space

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines

Lateral Viewndash Posterior VB linendash Anterior VB linendash Inter-spinous Distancendash Translation

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines A-P

Viewndash Spinous process to Pediclesndash Inter-pedicular Distancendash Translation

Thoracic and Lumbar Injuries

Height Loss

Adjacent fracture

Transverse process fracturesof L2-4

Significance of transverse processfractures is not the fractures in andof themselves but rather the high incidence of associated seriousintraabdominal injury (~20)

AnterolisthesisOf L4 on L5

  • X ray spine
  • SPINE TRAUMA
  • CERVICAL SPINE INJURY
  • Slide 4
  • Slide 5
  • Slide 6
  • Slide 7
  • Slide 8
  • Slide 9
  • Anteroposterior (A-P) View
  • Open Mouth View
  • Swimmerrsquos View
  • Slide 13
  • Slide 14
  • Slide 15
  • Lower Cervical Detection
  • Lower Cervical Detection (2)
  • Lower Cervical Detection (3)
  • Lower Cervical Detection (4)
  • Lower Cervical Detection (5)
  • Lower Cervical Detection (6)
  • Slide 22
  • Slide 23
  • Slide 24
  • Slide 25
  • Slide 26
  • Slide 27
  • THORACO-LUMBAR SPINE INJURY
  • Anatomy
  • Slide 30
  • Thoracic Spine
  • Lumbar Spine
  • Determinants of Stability
  • Mechanisms of Injury
  • 3 Column Model
  • Stable or Unstable
  • Stable or Unstable (2)
  • Stable or Unstable (3)
  • Approach to T amp L Spines
  • Approach to T amp L Spines (2)
  • Injury Detection Thoracic and Lumbar Spines
  • Injury Detection Thoracic and Lumbar Spines (2)
  • Thoracic and Lumbar Injuries
  • Height Loss
  • Slide 45
  • Slide 46
Page 33: X ray spine. SPINE TRAUMA CERVICAL SPINE INJURY THORACO-LUMBAR SPINE INJURY

Determinants of Stability

bull T amp L spines are more stable than C-spinendash Strong ligamentsndash Stabilization by ribsndash Bigger intervertebral discsndash Larger facet jointsndash Less mobility

bull Fractures amp dislocations tend to occur where curvature changesndash T11-12 (thoracolumbar junction)ndash L5-S1 (lumbosacral junction)

Mechanisms of Injury

bull Hyperflexion +- rotationndash Commonestndash Usually see anterior wedge rsquos or Chance

bull Shearingndash Ant or post translation

bull Hyperextensionbull Axial loading

ndash Compression or burst rsquos

3 Column Modelbull Anterior column

ndash Ant longitudinal ligndash Ant annulus fibrosisndash Ant vertebral body

bull Middle columnndash Post longitudinal ligndash Post annulus fibrosisndash Post vertebral body

bull Posterior columnndash Spinous processesndash Transverse processesndash Laminandash Facet jointsndash Pediclesndash Post ligamentous complex

bull 2 or more columns disrupted = unstablebull Most disruption of middle columns are

unstable

Stable or Unstable

bull Radiographic findings suggestive of instabilityndash Vertebral body collapse w widening of pediclesndash gt 33 canal compromise on CTndash gt 25 mm translation bw vertebral bodies in any planendash Bilateral facet dislocationndash Abnormal widening bw spinous processes or lamina and gt

50 anterior collapse of vertebral body

Stable or Unstable

bull Checklist for Instabilityndash Anterior elements disrupted 2 ptsndash Posterior elements disrupted 2 ptsndash Saggital plane translation gt 25 mm 2 ptsndash Saggital plane rotation gt 5o 2 ptsndash Spinal cord or cauda equina damage 2 ptsndash Disruption of costovertebral articulations 1 ptndash Dangerous loading anticipated 2 pts

ndash 5 or more pts unstable until healed or surgically stabilized

Stable or Unstable

bull Risk of neurologic injury increases withndash gt 35 canal narrowing

at T11-12ndash gt 45 canal narrowing

at L1ndash gt 55 canal narrowing

at L2 amp below

Approach to T amp L Spinesbull A ndash adequacy amp alignment

ndash All vertebrae need to be visiblendash Ant amp post longitudinal linesndash Facet joints should lie on smooth curvendash Normal kyphosis amp lordosisndash All spinous processes should lie in straight line

bull B ndash bonesndash Trace cortical margins of each vertebraendash Difference bw ant amp post body ht lt 2 mmndash Progressive increase in vertebral body ht moving down

spinendash Wink sign amp interpedicular distancendash Donrsquot forget to look at transverse processes

Approach to T amp L Spines

bull C ndash cartilagendash Progressive increase in disc space moving down

spine (except L5-S1)ndash Facet joint alignment

bull S ndashsoft tissuendash Look at paraspinal stripe and prevertebral space

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines

Lateral Viewndash Posterior VB linendash Anterior VB linendash Inter-spinous Distancendash Translation

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines A-P

Viewndash Spinous process to Pediclesndash Inter-pedicular Distancendash Translation

Thoracic and Lumbar Injuries

Height Loss

Adjacent fracture

Transverse process fracturesof L2-4

Significance of transverse processfractures is not the fractures in andof themselves but rather the high incidence of associated seriousintraabdominal injury (~20)

AnterolisthesisOf L4 on L5

  • X ray spine
  • SPINE TRAUMA
  • CERVICAL SPINE INJURY
  • Slide 4
  • Slide 5
  • Slide 6
  • Slide 7
  • Slide 8
  • Slide 9
  • Anteroposterior (A-P) View
  • Open Mouth View
  • Swimmerrsquos View
  • Slide 13
  • Slide 14
  • Slide 15
  • Lower Cervical Detection
  • Lower Cervical Detection (2)
  • Lower Cervical Detection (3)
  • Lower Cervical Detection (4)
  • Lower Cervical Detection (5)
  • Lower Cervical Detection (6)
  • Slide 22
  • Slide 23
  • Slide 24
  • Slide 25
  • Slide 26
  • Slide 27
  • THORACO-LUMBAR SPINE INJURY
  • Anatomy
  • Slide 30
  • Thoracic Spine
  • Lumbar Spine
  • Determinants of Stability
  • Mechanisms of Injury
  • 3 Column Model
  • Stable or Unstable
  • Stable or Unstable (2)
  • Stable or Unstable (3)
  • Approach to T amp L Spines
  • Approach to T amp L Spines (2)
  • Injury Detection Thoracic and Lumbar Spines
  • Injury Detection Thoracic and Lumbar Spines (2)
  • Thoracic and Lumbar Injuries
  • Height Loss
  • Slide 45
  • Slide 46
Page 34: X ray spine. SPINE TRAUMA CERVICAL SPINE INJURY THORACO-LUMBAR SPINE INJURY

Mechanisms of Injury

bull Hyperflexion +- rotationndash Commonestndash Usually see anterior wedge rsquos or Chance

bull Shearingndash Ant or post translation

bull Hyperextensionbull Axial loading

ndash Compression or burst rsquos

3 Column Modelbull Anterior column

ndash Ant longitudinal ligndash Ant annulus fibrosisndash Ant vertebral body

bull Middle columnndash Post longitudinal ligndash Post annulus fibrosisndash Post vertebral body

bull Posterior columnndash Spinous processesndash Transverse processesndash Laminandash Facet jointsndash Pediclesndash Post ligamentous complex

bull 2 or more columns disrupted = unstablebull Most disruption of middle columns are

unstable

Stable or Unstable

bull Radiographic findings suggestive of instabilityndash Vertebral body collapse w widening of pediclesndash gt 33 canal compromise on CTndash gt 25 mm translation bw vertebral bodies in any planendash Bilateral facet dislocationndash Abnormal widening bw spinous processes or lamina and gt

50 anterior collapse of vertebral body

Stable or Unstable

bull Checklist for Instabilityndash Anterior elements disrupted 2 ptsndash Posterior elements disrupted 2 ptsndash Saggital plane translation gt 25 mm 2 ptsndash Saggital plane rotation gt 5o 2 ptsndash Spinal cord or cauda equina damage 2 ptsndash Disruption of costovertebral articulations 1 ptndash Dangerous loading anticipated 2 pts

ndash 5 or more pts unstable until healed or surgically stabilized

Stable or Unstable

bull Risk of neurologic injury increases withndash gt 35 canal narrowing

at T11-12ndash gt 45 canal narrowing

at L1ndash gt 55 canal narrowing

at L2 amp below

Approach to T amp L Spinesbull A ndash adequacy amp alignment

ndash All vertebrae need to be visiblendash Ant amp post longitudinal linesndash Facet joints should lie on smooth curvendash Normal kyphosis amp lordosisndash All spinous processes should lie in straight line

bull B ndash bonesndash Trace cortical margins of each vertebraendash Difference bw ant amp post body ht lt 2 mmndash Progressive increase in vertebral body ht moving down

spinendash Wink sign amp interpedicular distancendash Donrsquot forget to look at transverse processes

Approach to T amp L Spines

bull C ndash cartilagendash Progressive increase in disc space moving down

spine (except L5-S1)ndash Facet joint alignment

bull S ndashsoft tissuendash Look at paraspinal stripe and prevertebral space

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines

Lateral Viewndash Posterior VB linendash Anterior VB linendash Inter-spinous Distancendash Translation

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines A-P

Viewndash Spinous process to Pediclesndash Inter-pedicular Distancendash Translation

Thoracic and Lumbar Injuries

Height Loss

Adjacent fracture

Transverse process fracturesof L2-4

Significance of transverse processfractures is not the fractures in andof themselves but rather the high incidence of associated seriousintraabdominal injury (~20)

AnterolisthesisOf L4 on L5

  • X ray spine
  • SPINE TRAUMA
  • CERVICAL SPINE INJURY
  • Slide 4
  • Slide 5
  • Slide 6
  • Slide 7
  • Slide 8
  • Slide 9
  • Anteroposterior (A-P) View
  • Open Mouth View
  • Swimmerrsquos View
  • Slide 13
  • Slide 14
  • Slide 15
  • Lower Cervical Detection
  • Lower Cervical Detection (2)
  • Lower Cervical Detection (3)
  • Lower Cervical Detection (4)
  • Lower Cervical Detection (5)
  • Lower Cervical Detection (6)
  • Slide 22
  • Slide 23
  • Slide 24
  • Slide 25
  • Slide 26
  • Slide 27
  • THORACO-LUMBAR SPINE INJURY
  • Anatomy
  • Slide 30
  • Thoracic Spine
  • Lumbar Spine
  • Determinants of Stability
  • Mechanisms of Injury
  • 3 Column Model
  • Stable or Unstable
  • Stable or Unstable (2)
  • Stable or Unstable (3)
  • Approach to T amp L Spines
  • Approach to T amp L Spines (2)
  • Injury Detection Thoracic and Lumbar Spines
  • Injury Detection Thoracic and Lumbar Spines (2)
  • Thoracic and Lumbar Injuries
  • Height Loss
  • Slide 45
  • Slide 46
Page 35: X ray spine. SPINE TRAUMA CERVICAL SPINE INJURY THORACO-LUMBAR SPINE INJURY

3 Column Modelbull Anterior column

ndash Ant longitudinal ligndash Ant annulus fibrosisndash Ant vertebral body

bull Middle columnndash Post longitudinal ligndash Post annulus fibrosisndash Post vertebral body

bull Posterior columnndash Spinous processesndash Transverse processesndash Laminandash Facet jointsndash Pediclesndash Post ligamentous complex

bull 2 or more columns disrupted = unstablebull Most disruption of middle columns are

unstable

Stable or Unstable

bull Radiographic findings suggestive of instabilityndash Vertebral body collapse w widening of pediclesndash gt 33 canal compromise on CTndash gt 25 mm translation bw vertebral bodies in any planendash Bilateral facet dislocationndash Abnormal widening bw spinous processes or lamina and gt

50 anterior collapse of vertebral body

Stable or Unstable

bull Checklist for Instabilityndash Anterior elements disrupted 2 ptsndash Posterior elements disrupted 2 ptsndash Saggital plane translation gt 25 mm 2 ptsndash Saggital plane rotation gt 5o 2 ptsndash Spinal cord or cauda equina damage 2 ptsndash Disruption of costovertebral articulations 1 ptndash Dangerous loading anticipated 2 pts

ndash 5 or more pts unstable until healed or surgically stabilized

Stable or Unstable

bull Risk of neurologic injury increases withndash gt 35 canal narrowing

at T11-12ndash gt 45 canal narrowing

at L1ndash gt 55 canal narrowing

at L2 amp below

Approach to T amp L Spinesbull A ndash adequacy amp alignment

ndash All vertebrae need to be visiblendash Ant amp post longitudinal linesndash Facet joints should lie on smooth curvendash Normal kyphosis amp lordosisndash All spinous processes should lie in straight line

bull B ndash bonesndash Trace cortical margins of each vertebraendash Difference bw ant amp post body ht lt 2 mmndash Progressive increase in vertebral body ht moving down

spinendash Wink sign amp interpedicular distancendash Donrsquot forget to look at transverse processes

Approach to T amp L Spines

bull C ndash cartilagendash Progressive increase in disc space moving down

spine (except L5-S1)ndash Facet joint alignment

bull S ndashsoft tissuendash Look at paraspinal stripe and prevertebral space

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines

Lateral Viewndash Posterior VB linendash Anterior VB linendash Inter-spinous Distancendash Translation

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines A-P

Viewndash Spinous process to Pediclesndash Inter-pedicular Distancendash Translation

Thoracic and Lumbar Injuries

Height Loss

Adjacent fracture

Transverse process fracturesof L2-4

Significance of transverse processfractures is not the fractures in andof themselves but rather the high incidence of associated seriousintraabdominal injury (~20)

AnterolisthesisOf L4 on L5

  • X ray spine
  • SPINE TRAUMA
  • CERVICAL SPINE INJURY
  • Slide 4
  • Slide 5
  • Slide 6
  • Slide 7
  • Slide 8
  • Slide 9
  • Anteroposterior (A-P) View
  • Open Mouth View
  • Swimmerrsquos View
  • Slide 13
  • Slide 14
  • Slide 15
  • Lower Cervical Detection
  • Lower Cervical Detection (2)
  • Lower Cervical Detection (3)
  • Lower Cervical Detection (4)
  • Lower Cervical Detection (5)
  • Lower Cervical Detection (6)
  • Slide 22
  • Slide 23
  • Slide 24
  • Slide 25
  • Slide 26
  • Slide 27
  • THORACO-LUMBAR SPINE INJURY
  • Anatomy
  • Slide 30
  • Thoracic Spine
  • Lumbar Spine
  • Determinants of Stability
  • Mechanisms of Injury
  • 3 Column Model
  • Stable or Unstable
  • Stable or Unstable (2)
  • Stable or Unstable (3)
  • Approach to T amp L Spines
  • Approach to T amp L Spines (2)
  • Injury Detection Thoracic and Lumbar Spines
  • Injury Detection Thoracic and Lumbar Spines (2)
  • Thoracic and Lumbar Injuries
  • Height Loss
  • Slide 45
  • Slide 46
Page 36: X ray spine. SPINE TRAUMA CERVICAL SPINE INJURY THORACO-LUMBAR SPINE INJURY

Stable or Unstable

bull Radiographic findings suggestive of instabilityndash Vertebral body collapse w widening of pediclesndash gt 33 canal compromise on CTndash gt 25 mm translation bw vertebral bodies in any planendash Bilateral facet dislocationndash Abnormal widening bw spinous processes or lamina and gt

50 anterior collapse of vertebral body

Stable or Unstable

bull Checklist for Instabilityndash Anterior elements disrupted 2 ptsndash Posterior elements disrupted 2 ptsndash Saggital plane translation gt 25 mm 2 ptsndash Saggital plane rotation gt 5o 2 ptsndash Spinal cord or cauda equina damage 2 ptsndash Disruption of costovertebral articulations 1 ptndash Dangerous loading anticipated 2 pts

ndash 5 or more pts unstable until healed or surgically stabilized

Stable or Unstable

bull Risk of neurologic injury increases withndash gt 35 canal narrowing

at T11-12ndash gt 45 canal narrowing

at L1ndash gt 55 canal narrowing

at L2 amp below

Approach to T amp L Spinesbull A ndash adequacy amp alignment

ndash All vertebrae need to be visiblendash Ant amp post longitudinal linesndash Facet joints should lie on smooth curvendash Normal kyphosis amp lordosisndash All spinous processes should lie in straight line

bull B ndash bonesndash Trace cortical margins of each vertebraendash Difference bw ant amp post body ht lt 2 mmndash Progressive increase in vertebral body ht moving down

spinendash Wink sign amp interpedicular distancendash Donrsquot forget to look at transverse processes

Approach to T amp L Spines

bull C ndash cartilagendash Progressive increase in disc space moving down

spine (except L5-S1)ndash Facet joint alignment

bull S ndashsoft tissuendash Look at paraspinal stripe and prevertebral space

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines

Lateral Viewndash Posterior VB linendash Anterior VB linendash Inter-spinous Distancendash Translation

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines A-P

Viewndash Spinous process to Pediclesndash Inter-pedicular Distancendash Translation

Thoracic and Lumbar Injuries

Height Loss

Adjacent fracture

Transverse process fracturesof L2-4

Significance of transverse processfractures is not the fractures in andof themselves but rather the high incidence of associated seriousintraabdominal injury (~20)

AnterolisthesisOf L4 on L5

  • X ray spine
  • SPINE TRAUMA
  • CERVICAL SPINE INJURY
  • Slide 4
  • Slide 5
  • Slide 6
  • Slide 7
  • Slide 8
  • Slide 9
  • Anteroposterior (A-P) View
  • Open Mouth View
  • Swimmerrsquos View
  • Slide 13
  • Slide 14
  • Slide 15
  • Lower Cervical Detection
  • Lower Cervical Detection (2)
  • Lower Cervical Detection (3)
  • Lower Cervical Detection (4)
  • Lower Cervical Detection (5)
  • Lower Cervical Detection (6)
  • Slide 22
  • Slide 23
  • Slide 24
  • Slide 25
  • Slide 26
  • Slide 27
  • THORACO-LUMBAR SPINE INJURY
  • Anatomy
  • Slide 30
  • Thoracic Spine
  • Lumbar Spine
  • Determinants of Stability
  • Mechanisms of Injury
  • 3 Column Model
  • Stable or Unstable
  • Stable or Unstable (2)
  • Stable or Unstable (3)
  • Approach to T amp L Spines
  • Approach to T amp L Spines (2)
  • Injury Detection Thoracic and Lumbar Spines
  • Injury Detection Thoracic and Lumbar Spines (2)
  • Thoracic and Lumbar Injuries
  • Height Loss
  • Slide 45
  • Slide 46
Page 37: X ray spine. SPINE TRAUMA CERVICAL SPINE INJURY THORACO-LUMBAR SPINE INJURY

Stable or Unstable

bull Checklist for Instabilityndash Anterior elements disrupted 2 ptsndash Posterior elements disrupted 2 ptsndash Saggital plane translation gt 25 mm 2 ptsndash Saggital plane rotation gt 5o 2 ptsndash Spinal cord or cauda equina damage 2 ptsndash Disruption of costovertebral articulations 1 ptndash Dangerous loading anticipated 2 pts

ndash 5 or more pts unstable until healed or surgically stabilized

Stable or Unstable

bull Risk of neurologic injury increases withndash gt 35 canal narrowing

at T11-12ndash gt 45 canal narrowing

at L1ndash gt 55 canal narrowing

at L2 amp below

Approach to T amp L Spinesbull A ndash adequacy amp alignment

ndash All vertebrae need to be visiblendash Ant amp post longitudinal linesndash Facet joints should lie on smooth curvendash Normal kyphosis amp lordosisndash All spinous processes should lie in straight line

bull B ndash bonesndash Trace cortical margins of each vertebraendash Difference bw ant amp post body ht lt 2 mmndash Progressive increase in vertebral body ht moving down

spinendash Wink sign amp interpedicular distancendash Donrsquot forget to look at transverse processes

Approach to T amp L Spines

bull C ndash cartilagendash Progressive increase in disc space moving down

spine (except L5-S1)ndash Facet joint alignment

bull S ndashsoft tissuendash Look at paraspinal stripe and prevertebral space

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines

Lateral Viewndash Posterior VB linendash Anterior VB linendash Inter-spinous Distancendash Translation

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines A-P

Viewndash Spinous process to Pediclesndash Inter-pedicular Distancendash Translation

Thoracic and Lumbar Injuries

Height Loss

Adjacent fracture

Transverse process fracturesof L2-4

Significance of transverse processfractures is not the fractures in andof themselves but rather the high incidence of associated seriousintraabdominal injury (~20)

AnterolisthesisOf L4 on L5

  • X ray spine
  • SPINE TRAUMA
  • CERVICAL SPINE INJURY
  • Slide 4
  • Slide 5
  • Slide 6
  • Slide 7
  • Slide 8
  • Slide 9
  • Anteroposterior (A-P) View
  • Open Mouth View
  • Swimmerrsquos View
  • Slide 13
  • Slide 14
  • Slide 15
  • Lower Cervical Detection
  • Lower Cervical Detection (2)
  • Lower Cervical Detection (3)
  • Lower Cervical Detection (4)
  • Lower Cervical Detection (5)
  • Lower Cervical Detection (6)
  • Slide 22
  • Slide 23
  • Slide 24
  • Slide 25
  • Slide 26
  • Slide 27
  • THORACO-LUMBAR SPINE INJURY
  • Anatomy
  • Slide 30
  • Thoracic Spine
  • Lumbar Spine
  • Determinants of Stability
  • Mechanisms of Injury
  • 3 Column Model
  • Stable or Unstable
  • Stable or Unstable (2)
  • Stable or Unstable (3)
  • Approach to T amp L Spines
  • Approach to T amp L Spines (2)
  • Injury Detection Thoracic and Lumbar Spines
  • Injury Detection Thoracic and Lumbar Spines (2)
  • Thoracic and Lumbar Injuries
  • Height Loss
  • Slide 45
  • Slide 46
Page 38: X ray spine. SPINE TRAUMA CERVICAL SPINE INJURY THORACO-LUMBAR SPINE INJURY

Stable or Unstable

bull Risk of neurologic injury increases withndash gt 35 canal narrowing

at T11-12ndash gt 45 canal narrowing

at L1ndash gt 55 canal narrowing

at L2 amp below

Approach to T amp L Spinesbull A ndash adequacy amp alignment

ndash All vertebrae need to be visiblendash Ant amp post longitudinal linesndash Facet joints should lie on smooth curvendash Normal kyphosis amp lordosisndash All spinous processes should lie in straight line

bull B ndash bonesndash Trace cortical margins of each vertebraendash Difference bw ant amp post body ht lt 2 mmndash Progressive increase in vertebral body ht moving down

spinendash Wink sign amp interpedicular distancendash Donrsquot forget to look at transverse processes

Approach to T amp L Spines

bull C ndash cartilagendash Progressive increase in disc space moving down

spine (except L5-S1)ndash Facet joint alignment

bull S ndashsoft tissuendash Look at paraspinal stripe and prevertebral space

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines

Lateral Viewndash Posterior VB linendash Anterior VB linendash Inter-spinous Distancendash Translation

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines A-P

Viewndash Spinous process to Pediclesndash Inter-pedicular Distancendash Translation

Thoracic and Lumbar Injuries

Height Loss

Adjacent fracture

Transverse process fracturesof L2-4

Significance of transverse processfractures is not the fractures in andof themselves but rather the high incidence of associated seriousintraabdominal injury (~20)

AnterolisthesisOf L4 on L5

  • X ray spine
  • SPINE TRAUMA
  • CERVICAL SPINE INJURY
  • Slide 4
  • Slide 5
  • Slide 6
  • Slide 7
  • Slide 8
  • Slide 9
  • Anteroposterior (A-P) View
  • Open Mouth View
  • Swimmerrsquos View
  • Slide 13
  • Slide 14
  • Slide 15
  • Lower Cervical Detection
  • Lower Cervical Detection (2)
  • Lower Cervical Detection (3)
  • Lower Cervical Detection (4)
  • Lower Cervical Detection (5)
  • Lower Cervical Detection (6)
  • Slide 22
  • Slide 23
  • Slide 24
  • Slide 25
  • Slide 26
  • Slide 27
  • THORACO-LUMBAR SPINE INJURY
  • Anatomy
  • Slide 30
  • Thoracic Spine
  • Lumbar Spine
  • Determinants of Stability
  • Mechanisms of Injury
  • 3 Column Model
  • Stable or Unstable
  • Stable or Unstable (2)
  • Stable or Unstable (3)
  • Approach to T amp L Spines
  • Approach to T amp L Spines (2)
  • Injury Detection Thoracic and Lumbar Spines
  • Injury Detection Thoracic and Lumbar Spines (2)
  • Thoracic and Lumbar Injuries
  • Height Loss
  • Slide 45
  • Slide 46
Page 39: X ray spine. SPINE TRAUMA CERVICAL SPINE INJURY THORACO-LUMBAR SPINE INJURY

Approach to T amp L Spinesbull A ndash adequacy amp alignment

ndash All vertebrae need to be visiblendash Ant amp post longitudinal linesndash Facet joints should lie on smooth curvendash Normal kyphosis amp lordosisndash All spinous processes should lie in straight line

bull B ndash bonesndash Trace cortical margins of each vertebraendash Difference bw ant amp post body ht lt 2 mmndash Progressive increase in vertebral body ht moving down

spinendash Wink sign amp interpedicular distancendash Donrsquot forget to look at transverse processes

Approach to T amp L Spines

bull C ndash cartilagendash Progressive increase in disc space moving down

spine (except L5-S1)ndash Facet joint alignment

bull S ndashsoft tissuendash Look at paraspinal stripe and prevertebral space

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines

Lateral Viewndash Posterior VB linendash Anterior VB linendash Inter-spinous Distancendash Translation

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines A-P

Viewndash Spinous process to Pediclesndash Inter-pedicular Distancendash Translation

Thoracic and Lumbar Injuries

Height Loss

Adjacent fracture

Transverse process fracturesof L2-4

Significance of transverse processfractures is not the fractures in andof themselves but rather the high incidence of associated seriousintraabdominal injury (~20)

AnterolisthesisOf L4 on L5

  • X ray spine
  • SPINE TRAUMA
  • CERVICAL SPINE INJURY
  • Slide 4
  • Slide 5
  • Slide 6
  • Slide 7
  • Slide 8
  • Slide 9
  • Anteroposterior (A-P) View
  • Open Mouth View
  • Swimmerrsquos View
  • Slide 13
  • Slide 14
  • Slide 15
  • Lower Cervical Detection
  • Lower Cervical Detection (2)
  • Lower Cervical Detection (3)
  • Lower Cervical Detection (4)
  • Lower Cervical Detection (5)
  • Lower Cervical Detection (6)
  • Slide 22
  • Slide 23
  • Slide 24
  • Slide 25
  • Slide 26
  • Slide 27
  • THORACO-LUMBAR SPINE INJURY
  • Anatomy
  • Slide 30
  • Thoracic Spine
  • Lumbar Spine
  • Determinants of Stability
  • Mechanisms of Injury
  • 3 Column Model
  • Stable or Unstable
  • Stable or Unstable (2)
  • Stable or Unstable (3)
  • Approach to T amp L Spines
  • Approach to T amp L Spines (2)
  • Injury Detection Thoracic and Lumbar Spines
  • Injury Detection Thoracic and Lumbar Spines (2)
  • Thoracic and Lumbar Injuries
  • Height Loss
  • Slide 45
  • Slide 46
Page 40: X ray spine. SPINE TRAUMA CERVICAL SPINE INJURY THORACO-LUMBAR SPINE INJURY

Approach to T amp L Spines

bull C ndash cartilagendash Progressive increase in disc space moving down

spine (except L5-S1)ndash Facet joint alignment

bull S ndashsoft tissuendash Look at paraspinal stripe and prevertebral space

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines

Lateral Viewndash Posterior VB linendash Anterior VB linendash Inter-spinous Distancendash Translation

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines A-P

Viewndash Spinous process to Pediclesndash Inter-pedicular Distancendash Translation

Thoracic and Lumbar Injuries

Height Loss

Adjacent fracture

Transverse process fracturesof L2-4

Significance of transverse processfractures is not the fractures in andof themselves but rather the high incidence of associated seriousintraabdominal injury (~20)

AnterolisthesisOf L4 on L5

  • X ray spine
  • SPINE TRAUMA
  • CERVICAL SPINE INJURY
  • Slide 4
  • Slide 5
  • Slide 6
  • Slide 7
  • Slide 8
  • Slide 9
  • Anteroposterior (A-P) View
  • Open Mouth View
  • Swimmerrsquos View
  • Slide 13
  • Slide 14
  • Slide 15
  • Lower Cervical Detection
  • Lower Cervical Detection (2)
  • Lower Cervical Detection (3)
  • Lower Cervical Detection (4)
  • Lower Cervical Detection (5)
  • Lower Cervical Detection (6)
  • Slide 22
  • Slide 23
  • Slide 24
  • Slide 25
  • Slide 26
  • Slide 27
  • THORACO-LUMBAR SPINE INJURY
  • Anatomy
  • Slide 30
  • Thoracic Spine
  • Lumbar Spine
  • Determinants of Stability
  • Mechanisms of Injury
  • 3 Column Model
  • Stable or Unstable
  • Stable or Unstable (2)
  • Stable or Unstable (3)
  • Approach to T amp L Spines
  • Approach to T amp L Spines (2)
  • Injury Detection Thoracic and Lumbar Spines
  • Injury Detection Thoracic and Lumbar Spines (2)
  • Thoracic and Lumbar Injuries
  • Height Loss
  • Slide 45
  • Slide 46
Page 41: X ray spine. SPINE TRAUMA CERVICAL SPINE INJURY THORACO-LUMBAR SPINE INJURY

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines

Lateral Viewndash Posterior VB linendash Anterior VB linendash Inter-spinous Distancendash Translation

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines A-P

Viewndash Spinous process to Pediclesndash Inter-pedicular Distancendash Translation

Thoracic and Lumbar Injuries

Height Loss

Adjacent fracture

Transverse process fracturesof L2-4

Significance of transverse processfractures is not the fractures in andof themselves but rather the high incidence of associated seriousintraabdominal injury (~20)

AnterolisthesisOf L4 on L5

  • X ray spine
  • SPINE TRAUMA
  • CERVICAL SPINE INJURY
  • Slide 4
  • Slide 5
  • Slide 6
  • Slide 7
  • Slide 8
  • Slide 9
  • Anteroposterior (A-P) View
  • Open Mouth View
  • Swimmerrsquos View
  • Slide 13
  • Slide 14
  • Slide 15
  • Lower Cervical Detection
  • Lower Cervical Detection (2)
  • Lower Cervical Detection (3)
  • Lower Cervical Detection (4)
  • Lower Cervical Detection (5)
  • Lower Cervical Detection (6)
  • Slide 22
  • Slide 23
  • Slide 24
  • Slide 25
  • Slide 26
  • Slide 27
  • THORACO-LUMBAR SPINE INJURY
  • Anatomy
  • Slide 30
  • Thoracic Spine
  • Lumbar Spine
  • Determinants of Stability
  • Mechanisms of Injury
  • 3 Column Model
  • Stable or Unstable
  • Stable or Unstable (2)
  • Stable or Unstable (3)
  • Approach to T amp L Spines
  • Approach to T amp L Spines (2)
  • Injury Detection Thoracic and Lumbar Spines
  • Injury Detection Thoracic and Lumbar Spines (2)
  • Thoracic and Lumbar Injuries
  • Height Loss
  • Slide 45
  • Slide 46
Page 42: X ray spine. SPINE TRAUMA CERVICAL SPINE INJURY THORACO-LUMBAR SPINE INJURY

Injury DetectionThoracic and Lumbar Spines

bull Same principlesbull Landmarks and Lines A-P

Viewndash Spinous process to Pediclesndash Inter-pedicular Distancendash Translation

Thoracic and Lumbar Injuries

Height Loss

Adjacent fracture

Transverse process fracturesof L2-4

Significance of transverse processfractures is not the fractures in andof themselves but rather the high incidence of associated seriousintraabdominal injury (~20)

AnterolisthesisOf L4 on L5

  • X ray spine
  • SPINE TRAUMA
  • CERVICAL SPINE INJURY
  • Slide 4
  • Slide 5
  • Slide 6
  • Slide 7
  • Slide 8
  • Slide 9
  • Anteroposterior (A-P) View
  • Open Mouth View
  • Swimmerrsquos View
  • Slide 13
  • Slide 14
  • Slide 15
  • Lower Cervical Detection
  • Lower Cervical Detection (2)
  • Lower Cervical Detection (3)
  • Lower Cervical Detection (4)
  • Lower Cervical Detection (5)
  • Lower Cervical Detection (6)
  • Slide 22
  • Slide 23
  • Slide 24
  • Slide 25
  • Slide 26
  • Slide 27
  • THORACO-LUMBAR SPINE INJURY
  • Anatomy
  • Slide 30
  • Thoracic Spine
  • Lumbar Spine
  • Determinants of Stability
  • Mechanisms of Injury
  • 3 Column Model
  • Stable or Unstable
  • Stable or Unstable (2)
  • Stable or Unstable (3)
  • Approach to T amp L Spines
  • Approach to T amp L Spines (2)
  • Injury Detection Thoracic and Lumbar Spines
  • Injury Detection Thoracic and Lumbar Spines (2)
  • Thoracic and Lumbar Injuries
  • Height Loss
  • Slide 45
  • Slide 46
Page 43: X ray spine. SPINE TRAUMA CERVICAL SPINE INJURY THORACO-LUMBAR SPINE INJURY

Thoracic and Lumbar Injuries

Height Loss

Adjacent fracture

Transverse process fracturesof L2-4

Significance of transverse processfractures is not the fractures in andof themselves but rather the high incidence of associated seriousintraabdominal injury (~20)

AnterolisthesisOf L4 on L5

  • X ray spine
  • SPINE TRAUMA
  • CERVICAL SPINE INJURY
  • Slide 4
  • Slide 5
  • Slide 6
  • Slide 7
  • Slide 8
  • Slide 9
  • Anteroposterior (A-P) View
  • Open Mouth View
  • Swimmerrsquos View
  • Slide 13
  • Slide 14
  • Slide 15
  • Lower Cervical Detection
  • Lower Cervical Detection (2)
  • Lower Cervical Detection (3)
  • Lower Cervical Detection (4)
  • Lower Cervical Detection (5)
  • Lower Cervical Detection (6)
  • Slide 22
  • Slide 23
  • Slide 24
  • Slide 25
  • Slide 26
  • Slide 27
  • THORACO-LUMBAR SPINE INJURY
  • Anatomy
  • Slide 30
  • Thoracic Spine
  • Lumbar Spine
  • Determinants of Stability
  • Mechanisms of Injury
  • 3 Column Model
  • Stable or Unstable
  • Stable or Unstable (2)
  • Stable or Unstable (3)
  • Approach to T amp L Spines
  • Approach to T amp L Spines (2)
  • Injury Detection Thoracic and Lumbar Spines
  • Injury Detection Thoracic and Lumbar Spines (2)
  • Thoracic and Lumbar Injuries
  • Height Loss
  • Slide 45
  • Slide 46
Page 44: X ray spine. SPINE TRAUMA CERVICAL SPINE INJURY THORACO-LUMBAR SPINE INJURY

Height Loss

Adjacent fracture

Transverse process fracturesof L2-4

Significance of transverse processfractures is not the fractures in andof themselves but rather the high incidence of associated seriousintraabdominal injury (~20)

AnterolisthesisOf L4 on L5

  • X ray spine
  • SPINE TRAUMA
  • CERVICAL SPINE INJURY
  • Slide 4
  • Slide 5
  • Slide 6
  • Slide 7
  • Slide 8
  • Slide 9
  • Anteroposterior (A-P) View
  • Open Mouth View
  • Swimmerrsquos View
  • Slide 13
  • Slide 14
  • Slide 15
  • Lower Cervical Detection
  • Lower Cervical Detection (2)
  • Lower Cervical Detection (3)
  • Lower Cervical Detection (4)
  • Lower Cervical Detection (5)
  • Lower Cervical Detection (6)
  • Slide 22
  • Slide 23
  • Slide 24
  • Slide 25
  • Slide 26
  • Slide 27
  • THORACO-LUMBAR SPINE INJURY
  • Anatomy
  • Slide 30
  • Thoracic Spine
  • Lumbar Spine
  • Determinants of Stability
  • Mechanisms of Injury
  • 3 Column Model
  • Stable or Unstable
  • Stable or Unstable (2)
  • Stable or Unstable (3)
  • Approach to T amp L Spines
  • Approach to T amp L Spines (2)
  • Injury Detection Thoracic and Lumbar Spines
  • Injury Detection Thoracic and Lumbar Spines (2)
  • Thoracic and Lumbar Injuries
  • Height Loss
  • Slide 45
  • Slide 46
Page 45: X ray spine. SPINE TRAUMA CERVICAL SPINE INJURY THORACO-LUMBAR SPINE INJURY

Transverse process fracturesof L2-4

Significance of transverse processfractures is not the fractures in andof themselves but rather the high incidence of associated seriousintraabdominal injury (~20)

AnterolisthesisOf L4 on L5

  • X ray spine
  • SPINE TRAUMA
  • CERVICAL SPINE INJURY
  • Slide 4
  • Slide 5
  • Slide 6
  • Slide 7
  • Slide 8
  • Slide 9
  • Anteroposterior (A-P) View
  • Open Mouth View
  • Swimmerrsquos View
  • Slide 13
  • Slide 14
  • Slide 15
  • Lower Cervical Detection
  • Lower Cervical Detection (2)
  • Lower Cervical Detection (3)
  • Lower Cervical Detection (4)
  • Lower Cervical Detection (5)
  • Lower Cervical Detection (6)
  • Slide 22
  • Slide 23
  • Slide 24
  • Slide 25
  • Slide 26
  • Slide 27
  • THORACO-LUMBAR SPINE INJURY
  • Anatomy
  • Slide 30
  • Thoracic Spine
  • Lumbar Spine
  • Determinants of Stability
  • Mechanisms of Injury
  • 3 Column Model
  • Stable or Unstable
  • Stable or Unstable (2)
  • Stable or Unstable (3)
  • Approach to T amp L Spines
  • Approach to T amp L Spines (2)
  • Injury Detection Thoracic and Lumbar Spines
  • Injury Detection Thoracic and Lumbar Spines (2)
  • Thoracic and Lumbar Injuries
  • Height Loss
  • Slide 45
  • Slide 46
Page 46: X ray spine. SPINE TRAUMA CERVICAL SPINE INJURY THORACO-LUMBAR SPINE INJURY

AnterolisthesisOf L4 on L5

  • X ray spine
  • SPINE TRAUMA
  • CERVICAL SPINE INJURY
  • Slide 4
  • Slide 5
  • Slide 6
  • Slide 7
  • Slide 8
  • Slide 9
  • Anteroposterior (A-P) View
  • Open Mouth View
  • Swimmerrsquos View
  • Slide 13
  • Slide 14
  • Slide 15
  • Lower Cervical Detection
  • Lower Cervical Detection (2)
  • Lower Cervical Detection (3)
  • Lower Cervical Detection (4)
  • Lower Cervical Detection (5)
  • Lower Cervical Detection (6)
  • Slide 22
  • Slide 23
  • Slide 24
  • Slide 25
  • Slide 26
  • Slide 27
  • THORACO-LUMBAR SPINE INJURY
  • Anatomy
  • Slide 30
  • Thoracic Spine
  • Lumbar Spine
  • Determinants of Stability
  • Mechanisms of Injury
  • 3 Column Model
  • Stable or Unstable
  • Stable or Unstable (2)
  • Stable or Unstable (3)
  • Approach to T amp L Spines
  • Approach to T amp L Spines (2)
  • Injury Detection Thoracic and Lumbar Spines
  • Injury Detection Thoracic and Lumbar Spines (2)
  • Thoracic and Lumbar Injuries
  • Height Loss
  • Slide 45
  • Slide 46