1. X ray spine

2. SPINE TRAUMA
CERVICAL SPINE INJURY
THORACO-LUMBAR SPINE INJURY

3. CERVICAL SPINE INJURY

4. COMMON MECHANISMS OF INJURY
HYPERFLEXION- MVA, CAR COMES TO SUDDEN STOP
HYPEREXTENSION- MVA, CAR STRUCK FROM BEHIND
COMPRESSION- HEAD FIRST DIVE IN SHALLOW WATER

5. 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

6. CLINICAL PROCEDURE INVOLVING PTS WITH SUSPECTED SPINE INJURY
PATIENT KEPT IN CERVICAL COLLAR AND IMMOBILIZED ON SPINE BOARD
“ABCDEF” ER PROTOCOL FOLLOWED (AIRWAY, BREATHING, CIRCULATION, DISABILITY/DRUGS,
EXPOSURE, FOLEY CATHETER)
HISTORY AND PHYSICAL (PT HANDLED AS THOUGH SERIOUS INJURY PRESENT)
DECIDE IF IMAGING IS NECESSARY

7. CERVICAL VERTEBRAL ANATOMY:

8. ANT LONGITUDINAL LIG
POST LONGITUDINAL LIG
LIGAMENTA FLAVA
SUPRASPINOUS LIG

9. MENU OF IMAGING OPTIONS
CERVICAL SPINE PLAIN FILMS
ANTERO- POSTERIOR
AND
LATERAL VIEW
STANDARD FIRST LINE IMAGING MODALITY IN ASSESSING CERVICAL VERTEBRAL
INJURY
SWIMMER’S VIEW

10. Anteroposterior (A-P) View
Spinous process deviation
Lateral Translation
Coronal deformity

11. Open Mouth View Mostly C1-C2 lateral mass Occipital Condyles/CO-C1
Odontoid Process

12. Swimmer’s View Cervico-thoracic junction obliques sometimes helpful
CASETTE
X-ray BEAM

13. NORMAL C-SPINE VIEWS
LATERAL AP
ODONTOID

14. C-SPINE FILM INTERPRETATION 7 STEP PROCESS
1. COUNT VERTEBRAE
-C1 THROUGH C7
-IF T1 NOT SEEN 􀃆SWIMMER’S 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 JOINT
7. SOFT TISSUES

15. THE 4 CONTOUR LINES 1-ANT VERTEBRAL LINE 2-POST VERTEBRAL LINE
3-SPINOLAMINAL LINE
4-POST SPINAL LINE

16. Lower Cervical Detection
Spinous process gapping
Facet joint Apposition
Inter-vertebral Gapping
Angulation
Translation

17. Lower Cervical Detection
Spinous process gapping
Facet joint Apposition
Inter-vertebral Gapping
Angulation
Translation

18. Lower Cervical Detection
Spinous process gapping
Facet joint Apposition
Inter-vertebral Gapping
Angulation
Translation

19. Lower Cervical Detection
Spinous process gapping
Facet joint Apposition
Inter-vertebral Gapping
Angulation
Translation

20. Lower Cervical Detection
Spinous process gapping
Facet joint Apposition
Inter-vertebral Gapping
Angulation
Translation

21. Lower Cervical Detection
Spinous process gapping
Facet joint Apposition
Inter-vertebral Gapping
Angulation
Translation

22. JEFFERSON FRACTURE

23. HANGMAN’S FRACTURE

24. DENS FRACTURE FRACTURE OF THE BASE OF THE DENS (ODONTOID) OF C2
ANTERIOR OR POSTERIOR DISPLACEMENT OF THE DENS
CAN OCCUR AT VARIOUS LEVELS ON THE DENS
VIA HYPERFLEXION OR HYPEREXTENSION OF HEAD ON NECK
UNSTABLE IF DISPLACEMENT OCCURS

25. COMPRESSION FRACTURE
VARIABLE SEVERITY, FROM MINIMAL ANTERIOR WEDGING TO COMPLETE DISRUPTION OF VERTEBRAL BODY (BURST)
LOOK FOR LOSS OF VERTICAL HEIGHT OF VERTEBRAL BODY
DUE TO LONG AXIS COMPRESSION OR HYPERFLEXION
DIVING INTO SHALLOW POOL
STABLE 􀃆UNSTABLE

26. TEARDROP FRACTURE
AVULSION FRACTURE OF ANTERIOR MARGIN OF VERTEBRAL BODY
ANTERIOR LONGITUDINAL LIG INSTABILITY (RUPTURE, AVULSION)
HYPEREXTENSION INJURY
UNSTABLE INJURY
LAMINA MAY JAM TOGETHER CAUSING LIGAMENTA FLAVA TO BUCKLE INWARD AND COMPRESS/CONTUSE THE SPINAL CORD

27. CLAY SHOVELER’S FRACTURE
AVULSION FRACTURE OF SPINOUS PROCESS BY SUPRASPINOUS LIGAMENT
USUALLY OCCURRING FROM C6-T2
HYPERFLEXION; DIRECT TRAUMA; DOWNWARD FORCE VIA THORACOSCAPULAR MUSCLE (AS IN SHOVELING MOTION)
STABLE

28. THORACO-LUMBAR SPINE INJURY

29. Anatomy

30. MENU OF IMAGING OPTIONS
DORSAL SPINE PLAIN FILMS
ANTERO- POSTERIOR
AND
LATERAL VIEW
LUMBO SACCRAL SPINE

31. Thoracic Spine

32. Lumbar Spine

33. Determinants of Stability
T & L spines are more stable than C-spine
Strong ligaments
Stabilization by ribs
Bigger intervertebral discs
Larger facet joints
Less mobility
Fractures & dislocations tend to occur where curvature changes
T11-12 (thoracolumbar junction)
L5-S1 (lumbosacral junction)

34. Mechanisms of Injury Hyperflexion +/- rotation Shearing Hyperextension
Commonest
Usually see anterior wedge #’s or Chance #
Shearing
Ant or post translation
Hyperextension
Axial loading
Compression or burst #’s

35. 3 Column Model Anterior column Middle column Posterior column
Ant longitudinal lig
Ant annulus fibrosis
Ant vertebral body
Middle column
Post longitudinal lig
Post annulus fibrosis
Post vertebral body
Posterior column
Spinous processes
Transverse processes
Lamina
Facet joints
Pedicles
Post ligamentous complex
2 or more columns disrupted = unstable
Most disruption of middle columns are unstable

36. Stable or Unstable? Radiographic findings suggestive of instability
Vertebral body collapse w/ widening of pedicles
> 33% canal compromise on CT
> 2.5 mm translation b/w vertebral bodies in any plane
Bilateral facet dislocation
Abnormal widening b/w spinous processes or lamina and > 50% anterior collapse of vertebral body

37. Stable or Unstable? Checklist for Instability
Anterior elements disrupted 2 pts
Posterior elements disrupted 2 pts
Saggital plane translation > 2.5 mm 2 pts
Saggital plane rotation > 5o 2 pts
Spinal cord or cauda equina damage 2 pts
Disruption of costovertebral articulations 1 pt
Dangerous loading anticipated 2 pts
5 or more pts unstable until healed or surgically stabilized

38. Stable or Unstable? Risk of neurologic injury increases with
> 35% canal narrowing at T11-12
> 45% canal narrowing at L1
> 55% canal narrowing at L2 & below

39. Approach to T & L Spines A – adequacy & alignment B – bones
All vertebrae need to be visible
Ant & post longitudinal lines
Facet joints should lie on smooth curve
Normal kyphosis & lordosis
All spinous processes should lie in straight line
B – bones
Trace cortical margins of each vertebrae
Difference b/w ant & post body ht < 2 mm
Progressive increase in vertebral body ht moving down spine
Wink sign & interpedicular distance
Don’t forget to look at transverse processes
Exceptions: L5-S1 disc space is narrower than above ones
TP #’s are in and of themselves stable but markers for serious intraabdominal injury in ~20% of cases

40. Approach to T & L Spines C – cartilage S –soft tissue
Progressive increase in disc space moving down spine (except L5-S1)
Facet joint alignment
S –soft tissue
Look at paraspinal stripe and prevertebral space

41. Injury Detection Thoracic and Lumbar Spines
Same principles
Landmarks and Lines: Lateral View
Posterior VB line
Anterior VB line
Inter-spinous Distance
Translation

42. Injury Detection Thoracic and Lumbar Spines
Same principles
Landmarks and Lines: A-P View
Spinous process to Pedicles
Inter-pedicular Distance
Translation

43. Thoracic and Lumbar Injuries

44. Height Loss
Adjacent fracture

45. Transverse process fractures
of L2-4
Significance of transverse process
fractures is not the fractures in and
of themselves but rather the high
incidence of associated serious
intraabdominal injury (~20%)

46. Anterolisthesis
Of L4 on L5