1. C SPINE
Y A Mamoojee

2. Importance of Prompt Diagnosis
Neck pain
> quadriplegia
> death
Delayed recognition can lead to irreversible s.c injury and permanent neurologic damage.

3. INDICATIONS
Who needs XR

4. NEXUS NO - Alcohol intoxication Focal neuro deficit Midline tenderness
GCS 15
Painful distracting injuries

5. CANADIAN C SPINE RULES

6. CASE DISCUSSION
A person arrives by ambulance to ED on a backboard and a cervical collar after an MVA.
Speed of 50km/hr
No LOC, no other injuries, no midline tenderness, BAL 0.20.
Does he need imaging?

7. WHAT VIEWS?

8. LATERAL AP
ODONTOID
SWIMMERS
FLEXION/EXTENSION?

9. ANATOMY OF NECK
LIGAMENTS
BONES
MUSCLES
JOINTS

10. Most important view
Can see 80-90% of injuries
Interpretation:
A - adequacy
A - alignment
B - bone
C - cartilage
D - disc
S – soft tissue
A - Must have a view of C7 – T1
A - Use 3 lines
1. anterior vertebral line
2. posterior vertebral line
3. spino laminar line (base of spinous processes)
4th line can be used ie. Tips of spinous processes

11. Check :
B - individual vertebrae
C - cartilage
D - disc
S - soft tissue -
<7mm at C3
<21mm at C7
no more than vertebral body width at C7
Predental space –
5mm child
3mm adult
Fanning of spinous processes

12. Open mouth view
Adequate if entire Odontoid and lateral borders of C1 and C2 visible
Check :
lateral masses of C1 must align with Odontoid
bilateral symmetry
Important also for Odontoid fractures

13. SWIMMER’S AP

14. MECHANISM OF INJURY 1. Flexion 2. flexion rotation 3. extension
4. axial compression
5. Other

16. WEDGE FRACTURE STABLE Compression fracture resulting from flexion
Features –
Buckled anterior cortex
Loss of height of anterior part of body
Anterosuperior fracture of vertebral body

18. FLEXION TEARDROP FRACTURE
UNSTABLE
Posterior ligament disruption and anterior compression fracture of the vertebral body
Prevertebral swelling
Tear drop fragment
Posterior vertebral body subluxation into the spinal canal
Spinal cord compression
Fracture of spinous process

19. Mechanism – Hyperflexion and Compression – Excessive flexion of the neck in the sagittal plane, disrupts posterior ligament.
Example – diving into shallow pool

21. ANTERIOR SUBLUXATION
Disruption of the posterior ligament complex. Anterior subluxation of C4 on C5 is characterized by widening of the interspinous space (arrowhead), subluxation of the C4-C5 interfacetal joints (arrows), and anterior rotation of the C4 vertebra relative to C5.

22. Stable but potentially unstable during flexion
Mechanism : hyperflexion
Disruption of posterior ligament complex, anterior intact
Stable –
loss of normal cervical lordosis
anterior displacement of body
fanning of interspinous distance
Unstable –
anterior subluxation >4mm
assoc. compression fracture >25% of affected body
increase or decrease in normal disc space

24. BILATERAL FACET JOINT DISLOCATION
Complete anterior dislocation of the vertebral body
Mechanism – extreme hyperflexion of head and neck without axial compression
Unstable – very high risk of cord damage
Features –
complete anterior dislocation >50% of vertebral body diameter
Disruption of the posterior ligament complex and anterior longitudinal ligament
“Bow tie” appearance of the locked facets.

26. CLAY SHOVELLER’S FRACTURE
Fracture of spinous process C6-T1
Mechanism – powerful hyperflexion, usually combined with contraction of paraspinous muscles pulling on spinous processes
(e.g. shovelling).
Features –
spinous process fracture on lateral view
Ghost sign on AP – double spinous process of C6/C7 due to displaced fractured spinous process

28. UNILATERAL FACET JOINT DISLOCATION
Stable
Mechanism – simultaneous flexion and rotation
Facet joint dislocation and rupture of the apophyseal joint ligaments
FEATURES :
Anterior dislocation of vertebral body by <50% of the diameter
Discordant rotation above and below involved level
Facet within intervertebral foramen on oblique view
“Bow tie” appearance of the overriding locked facets

29. EXTENSION INJURIES
Excessive extension of the neck in the sagittal plane.
E.g. hitting the dash board in MVA

31. HANGMAN’S FRACTURE Fractures through pars interaticularis of the axis
Unstable if occurs with facet dislocation
Mechanism – hyperextension
Features –
Prevertebral soft tissue swelling
Avulsion of anterior inferior corner of C2 assoc. with rupture of the ant. Longitudinal ligament
Anterior dislocation of C2 body
Bilateral C2 pedicle fractures.

33. C1 POSTERIOR ARCH FRACTURE
Hyperextended head
C1 arch is compressed by occiput and C2 spinous process
Odontoid process is normal
Stable
Distinguish from Jefferson fracture (unstable)

34. AXIAL COMPRESSION INJURIES

36. BURST FRACTURE Fracture of C3-C7 that results from axial compression
Spinal cord injury secondary to displacement of posterior fragments is common.
Mechanism – Axial compression
>25% loss of height of vertebral body
Stable
Needs CT or MRI

39. JEFFERSON FRACTURE Burst type fracture of C1
Lateral displacement of C1 masses
Fracture of anterior and posterior arches on both sides – quadruple fracture
Unstable – transverse ligament rupture
Soft tissue swelling is marked on Xray

43. ATLANTO AXIAL SUBLUXATION
Flexion and rotation causes the transverse ligament to rupture
Predental space >3.5mm in adults and >5mm in children
Unstable

46. ODONTOID FRACTURES 3 Types :
I Avulsion of tip at alar ligament (stable)
II Base of dens (unstable) – common, non union is a complication
III Involves body of C2 (unstable)