Download Cervical Spine Trauma and Relevant Imaging Modalities

Taylor Lloyd, HMS 3
Gillian Lieberman, MD
Cervical Spine Trauma and Relevant Imaging Modalities
Taylor Lloyd, Harvard Medical School III
Dr. Gillian Lieberman, MD
November 2011
Taylor Lloyd, HMS 3
Gillian Lieberman, MD
Outline
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Case Presentation
Mechanisms of Injury
Differential Diagnoses
Imaging Modalities
Anatomy
Film Interpretation
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Taylor Lloyd, HMS 3
Gillian Lieberman, MD
Case 1
• 43 year old female restrained driver in motor
vehicle crash at 40mph
• Airbag deployed
• Felt immediate neck pain without radiation
• No weakness of extremities, bowel, or
bladder dysfunction
• Also experiencing some hip pain
• What are the structures of concern?
• What is the role of imaging?
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Taylor Lloyd, HMS 3
Gillian Lieberman, MD
Mechanisms of Spinal Injury
Each type of force theoretically produces a characteristic
injury
Rogers LF et al. “Skeletal Trauma.” In Grainger & Allison's Diagnostic Radiology, 5th ed., 1016. Orlando: Churchill
Livingston, 2008.
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Taylor Lloyd, HMS 3
Gillian Lieberman, MD
Differential Diagnosis
(Structures of Concern)
• Spinal cord injury
• Compression (hemorrhage, edema, spondylolethisis)
• Transection
• Vertebral fracture
• Unstable
• Stable
• Ligamentous injury
• Unstable
• Vascular injuries
• Vertebral arterial injury: in some case series, up to 46%
of patients with MAJOR blunt cervical trauma
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Taylor Lloyd, HMS 3
Gillian Lieberman, MD
NEXUS guidelines :
To image or not to image..
Based on prospective, observational study,
n=34,069
High sensitivity, 99.0% (95% CI 98-99.6%)
Low specificity, 12.9%
Cervical spine radiography is indicated unless
✗ the patient meets ALL 5 criteria:
✔–
✔–
✔–
✗ –
No posterior midline cervical tenderness
No evidence of intoxication
Normal level of alertness
No focal neurologic deficit
– No painful distracting injury
Hoffman JR. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X‐Radiography Utilization Study Group. N Engl J Med. 2000;343(2):94.
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Taylor Lloyd, HMS 3
Gillian Lieberman, MD
Menu of Tests
• Plain Film
– 3 views (lateral, odontoid, AP)
• CT
– With sagittal and coronal reconstructions
• MRI
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Taylor Lloyd, HMS 3
Gillian Lieberman, MD
To CT or not CT..
Based on meta-analysis of
7 randomized control trials and cohort studies, wherein
3 studies n >1000
Study inclusion criteria: CT and plain films in the setting
of blunt cervical spine trauma.
Gold standard varied
CT pooled sensitivity, 98% (95% CI, 96-99%)
Plain film pooled sensitivity, 52% (95% CI, 47-56%)
Recommendations:
– CT is preferred modality for high-risk patients
– Insufficient evidence that CT should replace plain
films in patients at low risk of C-spine injury
Holmes JF, Akkinepalli R. Computed tomography versus plain radiography to screen for cervical spine
injury: a meta-analysis. J Trauma. 2005;58(5):902
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Taylor Lloyd, HMS 3
Gillian Lieberman, MD
Anatomy – The Cervical Spine
C1 (atlas)
C2 (axis)
Primal Pictures. “Interactive Head and Neck Anatomy.” Accessed November 11, 2011.
http://anatomy.tv/interactivehead.
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Taylor Lloyd, HMS 3
Gillian Lieberman, MD
Anatomy – The Cervical Spine
Moore KL and Dalley AF, Clinically Oriented Anatomy, 5th edition (Baltimore, MD: Lippincott Williams and Wilkins, 2006), 505.
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Taylor Lloyd, HMS 3
Gillian Lieberman, MD
Anatomy – The Cervical Spine
Vertebral
Artery
(superior to
C1)
Primal Pictures. “Interactive Head and Neck Anatomy.” Accessed November 11, 2011.
http://anatomy.tv/interactivehead.
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Taylor Lloyd, HMS 3
Gillian Lieberman, MD
Anatomy
Moore KL and Dalley AF, Clinically Oriented Anatomy, 5th edition (Baltimore, MD: Lippincott Williams and Wilkins, 2006), 507.
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Taylor Lloyd, HMS 3
Gillian Lieberman, MD
Anatomy
Moore KL and Dalley AF, Clinically Oriented Anatomy, 5th edition (Baltimore, MD: Lippincott Williams and Wilkins, 2006), 507.
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Taylor Lloyd, HMS 3
Gillian Lieberman, MD
Anatomy
Anterior views with cross-section of occipital condyles, atlas (C1), and axis (C2)
Moore KL and Dalley AF, Clinically Oriented Anatomy, 5th edition (Baltimore, MD: Lippincott Williams and Wilkins, 2006), 487.
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Taylor Lloyd, HMS 3
Gillian Lieberman, MD
Steele’s Rule
Superior View of Atlanto-Occipital Joint
Anterior
Posterior
Moore KL and Dalley AF, Clinically Oriented Anatomy, 5th edition (Baltimore, MD: Lippincott Williams and Wilkins, 2006), 510.
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Taylor Lloyd, HMS 3
Gillian Lieberman, MD
Case 1
Status-Post MVA
Fracture
CT Coronal and Sagittal Planes Cross-Referenced
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Taylor Lloyd, HMS 3
Gillian Lieberman, MD
Case 1
Status-Post MVA
Fracture
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Taylor Lloyd, HMS 3
Gillian Lieberman, MD
Hangman’s Fracture:
Traumatic spondylolysis of C2: often a result of head hyperextension UPON the neck
Posterosuperior view of hangman’s fracture of C2
vertebra
Moore KL and Dalley AF, Clinically Oriented Anatomy, 5th edition (Baltimore, MD: Lippincott Williams and Wilkins, 2006), 488.
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Taylor Lloyd, HMS 3
Gillian Lieberman, MD
Hangman’s Fracture
Moore KL and Dalley AF, Clinically Oriented Anatomy, 5th edition (Baltimore, MD: Lippincott Williams and Wilkins, 2006), 488.
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Taylor Lloyd, HMS 3
Gillian Lieberman, MD
MRI Findings
T2 Weighted MRI, Sagittal Cross‐Section
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Taylor Lloyd, HMS 3
Gillian Lieberman, MD
Undisplaced Hangman’s Fracture
Fracture of the
pars interarticularis
Rogers LF et al. “Skeletal Trauma.” In Grainger & Allison's Diagnostic Radiology, 5th ed., 1018. Orlando: Churchill
Livingston, 2008.
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Taylor Lloyd, HMS 3
Gillian Lieberman, MD
Hangman’s Fracture with Subluxation
Widely displaced
neural arch
fracture
Subluxation
of C2 upon
C3
Rogers LF et al. “Skeletal Trauma.” In Grainger & Allison's Diagnostic Radiology, 5th ed., 1018. Orlando: Churchill
Livingston, 2008.
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Taylor Lloyd, HMS 3
Gillian Lieberman, MD
Widely Displaced Hangman’s Fracture
Fragment
anterior and
inferior to
C2 vertebral
body
Wide separation of
fracture fragments
Locking of C2 facets
anterior to C3
Rogers LF et al. “Skeletal Trauma.” In Grainger & Allison's Diagnostic Radiology, 5th ed., 1018. Orlando: Churchill
Livingston, 2008.
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Taylor Lloyd, HMS 3
Gillian Lieberman, MD
Our Patient
Halo brace
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Taylor Lloyd, HMS 3
Gillian Lieberman, MD
Acknowledgements:
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Dr. Ammar Sarwar
Dr. Karen Lee
Dr. Gunjan Senapat
Dr. Gillian Lieberman
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