1. Elda Baptistelli de Carvalho, MD, PGY-3 University of Toronto
Cervical Spine Trauma
Elda Baptistelli de Carvalho, MD, PGY-3
University of Toronto

2. Objectives Clinical indication for each imaging modality
Identify anatomy of cervical spine
Approach to C-spine radiography interpretation
Classification of spine injuries

3. Who gets radiographs? Midline cervical tenderness
Focal neurologic deficits
Altered LOC
Evidence of intoxication
Painful distracting injury

4. Who gets CT? Dangerous mechanisms/high energy mechanisms:
-fall from elevation = or > 3 feet/5 stairs
-axial load to head (diving)
-MVC high speed (>100 km/h), ejection
-motorized recreational vehicles
-bicycle collision

5. Who gets MRI? Unexplained neurologic symptoms/signs
For visualizing soft tissues, neural elements and unsuspected disk herniation
To differentiate cord edema x hemorrhage x infarction
To better characterize epidural hematoma

6. Anatomy

7. Approach to C spine radiograph
ABC’S
-Adequacy

8. Approach to C spine radiograph
ABC’S
-Adequacy

9. Approach to C spine Radiograph
ABC’S
-Alignment

10. Approach to C spine Radiography
ABC’S
- Bones

11. Approach to C spine radiograph
ABC’S
- Cartilage

12. Approach to C spine radiograph
ABC’S
-Soft Tissue
Rule 2-6 (C2-6 mm)
6-2 (C6-2 cm)

13. Case 1

14. Case 1

15. Mechanism of Fractures
Hyperflexion Hyperextension Axial Compression

16. Classification

17. Classification By Mechanism of injury /Stability Type of Injury
Fractures
Stability
Flexion
Anterior subluxation 
Unilateral facet dislocation Bilateral facet dislocation Wedge compression fracture Flexion teardrop fracture Clay Shoveler's fracture
Odontoid
stable or delayed instability
stable unstable stable unstable stable
unstable
Extension
Hangman's fracture 
Compression
Jefferson fracture Burst fracture
unstable stable

18. Hyperflexion

19. Case 2

20. Clay shoveler fracture
Stable fracture
Hyperflexion ( shoveling snow)
Sudden exertion of muscular attachment
Avulsion # of spinous process of C7>C6>T1
Rule out extension to lamina, facet #, unilateral jump facet

21. Case 3

26. Unilateral Facet Dislocation
Hyperflexion + rotation
Superior facet slides over inferior facet and becomes locked
Anterior subluxation of superior vertebral body –25% AP diameter
Stable injury
30% with associated neurologic deficit
MRI: disk extrusion leading to cord compression

27. Case 4

31. Bilateral Facet Dislocation
Extreme hyperflexion
Anterior dislocation of articular masses (disruption of posterior ligament complex,PLL,disk and ALL.
Complete dislocation: dislocated vertebra anteriorly displaced ½ of AP diameter of vertebral body
Unstable ( high incidence of cord damage)

32. Case 5

36. Case 6

39. Flexion Tear Drop Flexion+compression (MVA)
Teardrop fragment comes from the anteroinferior aspect of the vertebral body
Larger posterior part displaced backward into the spinal canal
Facets joints and interspinous distances usually widened, disk space may be narrowed
70% of patients with neurologic injuries
Unstable fracture (complete disruption of ligaments and anterior cord syndrome)

40. Hyperextension

41. Case 7

42. Hangman’s fracture Most common cervical spine fracture
Usually hyperextension
Diving
Unstable, however seldom associated with cord injury (AP diameter of spinal canal greatest at C1/C2 level and # pedicles allow decompression)
Hangman’s + uni/bilateral facet dislocation: high rate of neurologic complications

43. Types of Hangman #

44. Case 8

47. Hyperextension injury
Widening of disk space anteriorly and narrowing posteriorly
“open book”
Central cord injury= disproportionated weakness in arms and normal strength in the legs
Injuries can be devastating, however are uncommon hemorrhagic

48. Case 9

51. Extension Teardrop Fracture
ALL pulls bony fragment away from inferior aspect of the vertebra because sudden extension
Fragment is true avulsion x fragment from flexion teardrop (compression)
Diving accidents
Lower cervical spine
Central cord syndrome (buckling of ligamenta flava into spinal canal)
Stable in flexion; highly unstable in extension

52. Case 10

54. Axial Compression

55. Jefferson Fracture Burst fracture of ring of C1
Axial loading in the occiput
No associated neuro deficts ( C1 ring is wide!)
Diving, MVA, fall onto height
> 2mm dislocation of lateral masses of C1 or odontoid view is diagnostic, 1-2 mm is equivocal ( rotation of head?)
Predental space > 3 mm: disruption of transverse ligament
1/3 associated with C2 fracture

56. Case 11

59. Atlanto-Occipital Dislocation
Very rare in surviving patients
More common in Kids
Hyperextension+distraction
Disruption of tectorial ligaments
CR: rule of 12: tip of dens-basion
Basion-post line< 12mm
Atlanto-occipital condyle distance<5mm

60. Summary Be systematic (follow ABC’S!!!!)
Know anatomy and mechanism of trauma
If dangerous mechanism-CT
Unexplained neuro symptoms-MRI
Don’t clear C spine on call if not sure!!

61. References http://www.wheelessonline.com/ortho
Emergency Radiology-Schwartz
Primer to Diagnostic Imaging