1. Those are the Breaks: Don't-miss Cervical Spine Traumatic Injuries for Residents on Call eEdE-247 Ruth K. Gershon MD Nisha Swaminathan MD Ellen E. Parker MD University of Mississippi Medical Center

2. Disclosures Nothing to disclose

3. Cervical Spine CT Rapid and accurate diagnosis of fractures and other injuries Interpretation may be daunting for novice residents on call, particularly in the fast- paced setting of a busy level 1 trauma center

4. Test yourself and sharpen your skills on the following cases Recognize crucial findings and their clinical significance Communicate critical results

5. Case 1 26yF unrestrained passenger MVC Left Right Make your findings and diagnosis. Click next to check. Right

6. Case 1: Left occipital condyle fracture and right C1 lateral mass fracture Left Right What other imaging should be performed? Click next to check. Comminuted fx right C1 lateral mass Displaced fx left occipital condyle

7. MRI: to evaluate cord and ligaments CTA Focal right ICA dissection related to blunt force trauma CTA: to evaluate for vessel injury STIR No cord injury Disruption of anterior occipitoatlantal membrane and anterior atlantoaxial membrane with severe prevertebral edema Next case Clinical f/u: fractures healed with halo fixation; pt neurologically intact. ICA injury healed with conservative management.

8. Case 2: 42yF: MVC vs. tree Make your findings and diagnosis. Click next to check.

9. Case 2: 42yF: MVC vs. tree next case Nondisplaced avulsion fx of right occipital condyle Clinical f/u: healed with rigid collar OC fx: often isolated-- no other C spine fx-- Easy to overlook, especially if nondisplaced. Scrutinize occipital condyles on coronal images.

10. Case 3: 90yM s/p fall Make your findings and diagnosis. Click next to check.

11. Case 3: Hangman fracture with extension teardrop fracture Pt neurological exam intact. What other imaging should be performed? Click next to check. Hangman fx: traumatic spondylolisthesis of C2. linear fx through body of C2, bilateral pars interarticularis, and bilateral transverse foramina Extension teardrop fx of C2 inferior endplate

12. CTA: Right vertebral artery occlusion Retrograde filling distally next case Treatment plan: placed in rigid collar. ASA for vertebral artery occlusion.

13. Case 4: 57yM 10 ft fall from ladder Make your findings and diagnosis. Click next to check.

14. Case 4: Nondisplaced spinous process fx Pt has numbness and tinging in hands. What other imaging should be performed? Click next to check. Nondisplaced spinous process fx

15. Case 4 MRI: ligamentous injury and subtle central cord signal abnormality Edema of interspinous/ supraspinous ligaments Subtle T2 hyperintensity of the cord: central cord syndrome, related to blunt trauma in setting of congenital and degenerative spinal canal narrowing STIR T2 Trace prevertebral edema Clinical f/u: placed in rigid collar. Returned to neurologic baseline with resolution of numbness/tingling at 6 week f/u. next case

16. Case 5: 19yM playing basketball: fell, another player landed on him midlineleftright Make your findings and diagnosis. Click next to check.

17. midlineleftright Jumped right facet Interspinous widening Anteriolisthesis of C4 on C5 Perched left facet Case 5: Flexion-Distraction injury with C4-C5 fracture/dislocation Pt is neurologically intact. What other imaging should be performed? Click next to check.

18. MRI: evaluate cord, ligaments, disks T2 STIR Edema of supraspinous ligament & ligamentum nuchae Ligamentum flavum and interspinous ligament disruption Trace prevertebral edema Normal cord *pertinent negative: no traumatic disk herniation— Important to exclude prior to surgery! Clinical f/u: pt doing well at 3 month f/u s/p posterior decompression with anterior and posterior instrumented fusion

19. Case 6: 32yF MVC vs utility pole rightleft Make your findings and diagnosis. What is different about this case compared to the prior? Click next to check.

20. Case 6Flexion-Distraction injury with C4-C5 fracture/dislocation rightleft Severe anteriolisthesis of C4 on C5 Posterior elements relatively intact (compared to previous case) with severe spinal canal narrowing Cord is presumably transected or severely compressed Clinical f/u: at presentation, pt had complete spinal injury on exam with T2 sensory level and C5 motor level. Slow reduction of anterolisthesis with tongs followed by instrumented fusion. Jumped left facet Jumped right facet next case

21. Case 7: 18yM: ATV vs. tree midline left right Make your findings and diagnosis. Click next to check.

22. Case 7: Pseudofracture due to motion midline left right Pitfall: focal motion artifact at C4-5 perfectly mimics fracture-dislocation on sagittal images! Clue to artifact: focal soft tissue defect—if this were fx, there should be prevertebral edema Motion artifact is more apparent on axial images next

23. Case 7: C4-C5 Pseudofracture on CT: Normal MRI STIRT2 Pitfall: focal motion artifact on prior CT Perfectly mimicked flexion distraction injury. Followup imaging (either MRI or repeat CT) required to exclude possible subtle injury obscured by motion next case

24. Case 8: 13yM ejected from go-cart Make your findings and diagnosis. Click next to check.

25. Case 8: 13yM ejected from go-cart Nondisplaced linear dens fracture— Combination of Type I and Type II What do you expect the MRI to show? Click next to check. Type I: Avulsion fracture from tip of dens Type II: Transverse fracture through base of dens Type III: Oblique fracture extending from base of dens into body of C2

26. Dens Fracture: MRI STIRT1T2 Prevertebral edema Normal cord Fracture lines much more subtle on MRI than prior CT Clinical f/u: neurologically intact. Given component traversing the base of the dens (Type II), pt was placed in a halo next case

27. Case 9: 3yM MVC unrestrained lap passenger Make your findings and diagnosis. Click next to check

28. Normal CT of C and T spine What imaging should be performed? Click next to check. Negative CT of C and T spine SCIWORA: Spinal cord injury without radiologic abnormality Clinical exam: pt not moving upper or lower extremities, worrisome for spinal cord injury

29. SCIWORA—negative CT and plain films MRI: ligamentous injury and cord transection T1 T2 STIR Transection of the cord at the level of T2 with edema above and below ligamentum flavum disruption at C6-7 Edema of interspinous/ supraspinous ligaments linear dorsal epidural hemorrhage without cord compression next case

30. Case 10: 29yM: MVC, ejected Make your findings and diagnosis. Click next to check

31. Left C1 transverse process fx involving transverse foramen What other imaging should be performed? Click next to check

32. CTA: nonocclusive left vertebral artery injury Narrowing of Left vertebral artery Clinical f/u: neurologically intact. Placed on ASA. repeat CTA in 6 weeks normal

33. Case 11: 37yF ATV rollover, acute LE weakness/numbness Make your findings and diagnosis. Click next to check

34. Case 11: No fractures. Disk protrusions at C4-5 and C5-6 What other imaging should be performed? Click next to check Right paracentral protrusion at C4-5 Left paracentral protrusion at C5-6 Pearl: review soft tissue algorithm for disks!

35. Case 11 MRI: traumatic disk herniations with cord edema T2 GRE (Superimposed on chronic degenerative changes) Focal disk protrusion C4-5 C5-6 Focal disk protrusion Cord edema Clincal presentation --acute onset of symptoms following trauma--is key to this diagnosis Clinical f/u: pt had ACDF with improvement in symptoms next case

36. Case 12: 68yM 10 foot fall off roof Make your findings and diagnosis. Click next to check

37. Left C6 transverse process and superior articular process fractures Worsening neuro exam. CTA was obtained Acute fracture of the left C6 superior articular process Subtle fracture left C6 transverse process —not involving transverse foramen

38. CTA: left vertebral artery occlusion Left vertebral artery occlusion Distal filling via collaterals Congenital small right vertebral artery Continued worsening neuro exam. What do you think brain CT will show? Key concept: catastrophic arterial injury can occur even without direct fracture involvement of the transverse foramen

39. Clinical f/u: Pt died due to catastrophic posterior circulation infarcts Brain NCCT on admission—neg acute Brain NCCT 2 days later—diffuse posterior circulation infarcts Great work on those 12 cases!

40. Conclusion: Cervical Spine NCCT: It’s not all about the bones Note fractures AND be vigilant about non- osseous injury Don’t forget about vessels and spinal cord NCCT can provide important clues about vessels, cord, ligaments and disks— review soft tissue algorithm