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C SPINE
Y A Mamoojee
Importance of Prompt Diagnosis
• Neck pain
– > quadriplegia
– > death
• Delayed recognition can lead to irreversible s.c
injury and permanent neurologic damage.
INDICATIONS
• Who needs XR
NEXUS
NO • Alcohol intoxication
• Focal neuro deficit
• Midline tenderness
• GCS 15
• Painful distracting injuries
CANADIAN C SPINE RULES
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?
WHAT VIEWS?
• LATERAL
• AP
• ODONTOID
• SWIMMERS
• FLEXION/EXTENSION?
ANATOMY OF NECK
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LIGAMENTS
BONES
MUSCLES
JOINTS
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Most important view
Can see 80-90% of injuries
Interpretation:
A - adequacy
A - alignment
B - bone
C - cartilage
D - disc
S – soft tissue
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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
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• Check :
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B - individual vertebrae
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C - cartilage
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D - disc
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S - soft tissue •
<7mm at C3
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<21mm at C7
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no more than vertebral body
width at C7
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Predental space –
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5mm child
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3mm adult
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Fanning of spinous processes
• Open mouth view
• Adequate if entire
Odontoid and lateral
borders of C1 and C2
visible
• Check :
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lateral masses of C1
must align with Odontoid
•
bilateral symmetry
• Important also for
Odontoid fractures
SWIMMER’S
AP
MECHANISM OF INJURY
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1. Flexion
2. flexion rotation
3. extension
4. axial compression
5. Other
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
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
• Mechanism –
Hyperflexion and
Compression –
Excessive flexion of the
neck in the sagittal
plane, disrupts
posterior ligament.
• Example – diving into
shallow pool
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.
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Stable but potentially unstable during flexion
Mechanism : hyperflexion
Disruption of posterior ligament complex,
anterior intact
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Stable –
loss of normal cervical lordosis
anterior displacement of body
fanning of interspinous distance
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Unstable –
anterior subluxation >4mm
assoc. compression fracture >25% of
affected body
increase or decrease in normal disc space
fanning of interspinous distance
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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.
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
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
EXTENSION INJURIES
• Excessive extension of
the neck in the sagittal
plane.
• E.g. hitting the dash
board in MVA
HANGMAN’S FRACTURE
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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.
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)
AXIAL COMPRESSION INJURIES
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
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
ATLANTO AXIAL SUBLUXATION
• Flexion and rotation causes the transverse
ligament to rupture
• Predental space >3.5mm in adults and >5mm
in children
• Unstable
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)