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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 Disclosures • Nothing to disclose Cervical Spine CT • Rapid and accurate diagnosis of fractures and other injuries • Interpretation may be daunting for novice residents on call, particularly in the fastpaced setting of a busy level 1 trauma center Test yourself and sharpen your skills on the following cases • Recognize crucial findings and their clinical significance • Communicate critical results Case 1 26yF unrestrained passenger MVC Right Right Left Make your findings and diagnosis. Click next to check. Case 1: Left occipital condyle fracture and right C1 lateral mass fracture Comminuted fx right C1 lateral mass Right Displaced fx left occipital condyle Left What other imaging should be performed? Click next to check. CTA: to evaluate for vessel injury MRI: to evaluate cord and ligaments Focal right ICA dissection related to blunt force trauma No cord injury Disruption of anterior occipitoatlantal membrane and anterior atlantoaxial membrane with severe prevertebral edema STIR CTA Clinical f/u: fractures healed with halo fixation; pt neurologically intact. ICA injury healed with conservative management. Next case Case 2: 42yF: MVC vs. tree Make your findings and diagnosis. Click next to check. Case 2: 42yF: MVC vs. tree Nondisplaced avulsion fx of right occipital condyle OC fx: often isolated-- no other C spine fx-Easy to overlook, especially if nondisplaced. Scrutinize occipital condyles on coronal images. Clinical f/u: healed with rigid collar next case Case 3: 90yM s/p fall Make your findings and diagnosis. Click next to check. Case 3: Hangman fracture with extension teardrop fracture 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 Pt neurological exam intact. What other imaging should be performed? Click next to check. CTA: Right vertebral artery occlusion Retrograde filling distally Treatment plan: placed in rigid collar. ASA for vertebral artery occlusion. next case Case 4: 57yM 10 ft fall from ladder Make your findings and diagnosis. Click next to check. Case 4: Nondisplaced spinous process fx Nondisplaced spinous process fx Pt has numbness and tinging in hands. What other imaging should be performed? Click next to check. Case 4 MRI: ligamentous injury and subtle central cord signal abnormality Trace prevertebral edema T2 T2 Edema of interspinous/ supraspinous ligaments STIR Subtle T2 hyperintensity of the cord: central cord syndrome, related to blunt trauma in setting of congenital and degenerative spinal canal narrowing Clinical f/u: placed in rigid collar. Returned to neurologic baseline with resolution of numbness/tingling at 6 week f/u. next case Case 5: 19yM playing basketball: fell, another player landed on him right midline left Make your findings and diagnosis. Click next to check. Case 5: Flexion-Distraction injury with C4-C5 fracture/dislocation Jumped right facet Perched left facet Interspinous widening Anteriolisthesis of C4 on C5 right midline left Pt is neurologically intact. What other imaging should be performed? Click next to check. MRI: evaluate cord, ligaments, disks Edema of supraspinous ligament & ligamentum nuchae Trace prevertebral edema Ligamentum flavum and interspinous ligament disruption Normal cord T2 STIR Clinical f/u: pt doing well at 3 month f/u s/p posterior decompression with anterior and posterior instrumented fusion *pertinent negative: no traumatic disk herniation— Important to exclude prior to surgery! Case 6: 32yF MVC vs utility pole right left Make your findings and diagnosis. What is different about this case compared to the prior? Click next to check. Case 6Flexion-Distraction injury with C4-C5 fracture/dislocation Jumped right facet Severe anteriolisthesis of C4 on C5 right Posterior elements relatively intact (compared to previous case) with severe spinal canal narrowing Cord is presumably transected or severely compressed Jumped left facet left 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. next case Case 7: 18yM: ATV vs. tree right midline left Make your findings and diagnosis. Click next to check. Case 7: Pseudofracture due to motion Pitfall: focal motion artifact at C4-5 perfectly mimics fracture-dislocation on sagittal images! right midline Clue to artifact: focal soft tissue defect—if this were fx, there should be prevertebral edema left Motion artifact is more apparent on axial images next Case 7: C4-C5 Pseudofracture on CT: Normal MRI Pitfall: focal motion artifact on prior CT Perfectly mimicked flexion distraction injury. STIR T2 Followup imaging (either MRI or repeat CT) required to exclude possible subtle injury obscured by motion next case Case 8: 13yM ejected from go-cart Make your findings and diagnosis. Click next to check. Case 8: 13yM ejected from go-cart Nondisplaced linear dens fracture— Combination of Type I and Type II •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 What do you expect the MRI to show? Click next to check. Dens Fracture: MRI Prevertebral edema Normal cord Fracture lines much more subtle on MRI than prior CT STIR T1 Clinical f/u: neurologically intact. Given component traversing the base of the dens (Type II), pt was placed in a halo T2 next case Case 9: 3yM MVC unrestrained lap passenger Make your findings and diagnosis. Click next to check Normal CT of C and T spine Clinical exam: pt not moving upper or lower extremities, worrisome for spinal cord injury Negative CT of C and T spine SCIWORA: Spinal cord injury without radiologic abnormality What imaging should be performed? Click next to check. SCIWORA—negative CT and plain films MRI: ligamentous injury and cord transection ligamentum flavum disruption at C6-7 Edema of interspinous/ supraspinous ligaments T2 T1 Transection of the cord at the level of T2 with edema above and below STIR linear dorsal epidural hemorrhage without cord compression next case Case 10: 29yM: MVC, ejected Make your findings and diagnosis. Click next to check Left C1 transverse process fx involving transverse foramen What other imaging should be performed? Click next to check 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 Case 11: 37yF ATV rollover, acute LE weakness/numbness Make your findings and diagnosis. Click next to check Case 11: No fractures. Disk protrusions at C4-5 and C5-6 Right paracentral protrusion at C4-5 Pearl: review soft tissue algorithm for disks! Left paracentral protrusion at C5-6 What other imaging should be performed? Click next to check Case 11 MRI: traumatic disk herniations (Superimposed on chronic with cord edema degenerative changes) C4-5 Focal disk protrusion Cord edema T2 T2 C5-6 GRE Focal disk protrusion Cord edema T2 T2 Clincal presentation --acute onset of symptoms following trauma--is key to this diagnosis GRE Clinical f/u: pt had ACDF with improvement in symptoms next case Case 12: 68yM 10 foot fall off roof Make your findings and diagnosis. Click next to check Left C6 transverse process and superior articular process fractures Acute fracture of the left C6 superior articular process Subtle fracture left C6 transverse process —not involving transverse foramen Worsening neuro exam. CTA was obtained CTA: left vertebral artery occlusion Key concept: catastrophic arterial injury can occur even without direct fracture involvement of the transverse foramen Distal filling via collaterals Congenital small right vertebral artery Left vertebral artery occlusion Continued worsening neuro exam. What do you think brain CT will show? Brain NCCT on admission—neg acute Brain NCCT 2 days later—diffuse posterior circulation infarcts Clinical f/u: Pt died due to catastrophic posterior circulation infarcts Great work on those 12 cases! Conclusion: Cervical Spine NCCT: • It’s not all about the bones • Note fractures AND be vigilant about nonosseous injury • Don’t forget about vessels and spinal cord • NCCT can provide important clues about vessels, cord, ligaments and disks— review soft tissue algorithm