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Practical approach to Cervical Spine Trauma






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Practical approach to Cervical Spine Trauma. Dr. Donald E. Olofsson. Acknowledgments . A sincere and special thanks to Dr. Tudor Hughes for his inspiration, outstanding teaching and for his images. Without Tudors help. A box of crayons and a few ideas. Hmmm. We put our heads together.
Practical approach to Cervical Spine Trauma

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Practical approach to cervical spine trauma l.jpgSlide 1

Practical approach to Cervical Spine Trauma

  • Dr. Donald E. Olofsson

Acknowledgments l.jpgSlide 2

Acknowledgments

  • A sincere and special thanks to Dr. Tudor Hughes for his inspiration, outstanding teaching and for his images.

Without tudors help l.jpgSlide 3

Without Tudors help

  • A box of crayons and a few ideas.

Hmmm...

We put our heads together l.jpgSlide 4

We put our heads together.

This was my best attempt l.jpgSlide 5

This was my best attempt.

With tudors help l.jpgSlide 6

With Tudors help.

  • Very professional.

Overview l.jpgSlide 7

Overview

Overview8 l.jpgSlide 8

Overview

  • Readout

  • Anatomy

  • Technique

  • Trauma

Overview9 l.jpgSlide 9

Overview

  • The scout view and reconstruction.

  • Plain films: In and out of collar, flexion and Extension views

  • CT, series included and reconstructions

  • Stable vs. unstable

  • A few classifications

Overview10 l.jpgSlide 10

Overview

  • Reading Algorithm

Reading algorithm l.jpgSlide 11

Reading Algorithm

  • The scout view.

  • Soft tissues including brain,tubes and lines.

  • Bony alignment.

  • Facet joint alignment.

  • Look at common sites of fractures and the second fracture.

  • Other bones, and maximal STS.

The scout view the hidden view l.jpgSlide 12

The scout view (The hidden view)

  • Also known at the Naval Hospital as…The staff view, the overview, the First view.

  • Almost always included…Not always pushed to PACS and not always viewed.

The scout view l.jpgSlide 13

The scout view

  • Within voice recognition (AGFA Talk) template you can add. [The scout view is unremarkable.]

There may be a free lateral view l.jpgSlide 14

There may be a free lateral view.

A nice frontal view l.jpgSlide 15

A nice frontal view.

You may find the cause of pain l.jpgSlide 16

You may find the cause of pain.

Scout view with humeral fractures l.jpgSlide 17

Scout view with humeral fractures

These were known fractures l.jpgSlide 18

These were known fractures.

Scout view unremarkable l.jpgSlide 19

Scout view unremarkable

You can window and level the scout the scout view l.jpgSlide 20

You can window and level the scout. The Scout View

You will have to select the window/level from a different image.

You can enlarge the scout the scout view l.jpgSlide 21

You can enlarge the scout. The Scout View

Discover unexpected findings the scout view l.jpgSlide 22

Discover unexpected findings. The Scout View

Pneumothorax

Cxr several hours prior to ct with chest tube the scout view l.jpgSlide 23

CXR several hours prior to CT with Chest tube. The Scout View

  • The lung was up prior to CT. The tube was either clamped for CT or not functioning.

  • No AM CXR ordered.

  • Ward team notified.

  • Note: all of these scout views are from the same morning.

Pulling the scout view on agfa l.jpgSlide 24

Pulling the scout view on AGFA

  • Including the statement [The scout view is unremarkable.] in your template may help remembering to do this.

  • You are responsible for the image anyway so the statement will not hurt you, and it may serve as a reminder to pull and look at the image.

What the scout view can show l.jpgSlide 25

What the scout view can show.

  • Fractures/Dislocations

  • Tubes and lines

  • Associated injuries

  • Pneumothorax

  • Foreign bodies

Reconstructing the ct images l.jpgSlide 26

Reconstructing the CT images

  • Bring up the CT.

  • Reconstruct the thin axial images.

  • Bring up the sagittal images.

  • Rotate to create a true axial.

Reconstructing the ct images27 l.jpgSlide 27

Reconstructing the CT images

  • Level the axial from the coronal view.

  • Double click the axial image to enlarge.

  • Scroll the axial images C1 to about C3.

  • Rotate off the sagittal for C4.

  • Scroll

  • Rotate off the sagittal for C5-T1.

Anatomy l.jpgSlide 28

Anatomy

Anatomy29 l.jpgSlide 29

Anatomy

  • The anatomy of C3-C6 is basically the same.

  • The anatomy of C1,C2 and C7 are special.

Normal c spine the atlas axis l.jpgSlide 30

Normal C-SPINEThe Atlas & Axis

  • C1 the Atlas:

  • Anterior and posterior arch & Lat Masses, Small transverse process (contains transverse foramen)

  • C2 the Axis:

  • Body, lat masses, lamina, spinous process and Ondontoid process (dens).

Craniocervical ligaments l.jpgSlide 31

Craniocervical Ligaments

Netter

C3 c6 l.jpgSlide 32

C3-C6

  • Body

  • Lamina

  • Spinous Process

  • Transverse process

  • Pedicle & Transverse process

  • Articulating facets

Anatomy33 l.jpgSlide 33

Anatomy

C spine ap l.jpgSlide 34

C-Spine AP

Lateral view anatomy l.jpgSlide 35

Lateral view: Anatomy

Oblique view anatomy l.jpgSlide 36

Oblique View: Anatomy

Greenspan

Oblique view anatomy37 l.jpgSlide 37

Oblique View: Anatomy

Technique l.jpgSlide 38

Technique

Technique routine l.jpgSlide 39

Technique - Routine

Lateral view technique l.jpgSlide 40

Lateral view: Technique

C7

30M MVA Thought to be paraplegic

Slide41 l.jpgSlide 41

Lateral view: Technique

C7

C7

C7

C7-T1 Fracture Dislocation

30M MVA Thought to be paraplegic

Technique flexion extension l.jpgSlide 42

Technique - Flexion / Extension

Open C1 posterior arch

Technique flexion extension43 l.jpgSlide 43

Technique - Flexion / Extension

30F post trauma acute films

Technique flexion extension44 l.jpgSlide 44

Technique - Flexion / Extension

30F post trauma 8d later

Flexion and extension l.jpgSlide 45

Flexion and Extension

Extension

Peg # hard to see 37M

Flexion and extension46 l.jpgSlide 46

Flexion and Extension

Flexion

Peg # hard to see 37M

Technique ct l.jpgSlide 47

Technique - CT

  • Excellent visualization of fractures

  • Must be optimized

    • Thin slices 1 - 1.25 - 2mm

    • Bone and soft tissue algorithm / window

    • Orthogonal planes

      • Thin recons

    • Use workstation

    • 3D for alignment

Bifacet Dislocation

Technique mri l.jpgSlide 48

Technique - MRI

  • Poor visualization of fractures

  • Good for soft tissue injury

  • Good for spinal cord injury assessment

  • Good for spinal cord injury prognosis

  • Good for root avulsion

C7

Romanoff Fracture

Slide49 l.jpgSlide 49

C-5 facet fracture not well seen on plain films

Technique - CT

C5

5

Slide50 l.jpgSlide 50

C-5 facet fracture not well seen on plain films Technique - MR

C5

Sag T2FS

5

Ct type l odontoid fracture technique ct l.jpgSlide 51

CT: Type l Odontoid Fracture Technique - CT

2.5mm Standard algorithm 2.5mm Bone 1.25mm Bone

3

Optimizing ct l.jpgSlide 52

Optimizing CT

  • Half axial acquisition.

  • Reducing dose.

  • Altering pitch.

  • Slice thickness.

Fractures l.jpgSlide 53

Fractures

Life lines l.jpgSlide 54

Life lines

Reading algorithm life lines l.jpgSlide 55

Reading AlgorithmLife Lines

  • Anterior vertebral body line

  • Posterior vertebral body line

  • Spinolamina line

  • Posterior spinous process line

Evaluate C1-C2 Area

Adults: <3mm

Child: <5mm

Greenspan

Slide56 l.jpgSlide 56

Stable vs. Unstable

Compression fractures l.jpgSlide 57

Stable

Burst fracture

Unstable

Jefferson fracture

Compression Fractures

Flexion stable vs unstable l.jpgSlide 58

Stable

Unilateral facet dislocation

Wedge Compression

Clay Shovel's

Unstable

Bilateral facet dislocation

Flexion: stable vs. unstable

Extension stable vs unstable l.jpgSlide 59

Posterior arch C1

Laminar

Pilar

Extension tear drop

Hangman’s

Hyperextension dislocation fracture

Extension: stable vs. unstable

Pseudo physiologic subluxation l.jpgSlide 60

Pseudo (physiologic) Subluxation

C1

  • In children

  • Ligament laxity

  • Check Posterior Spinal (cervical) Line

  • More than 2-3mm offset (SLL anterior to PSL at C2) must be considered traumatic.

C3

C2

Caffey and Swischuk

Atlas l.jpgSlide 61

Atlas

  • Atlanto Occipital Dislocation

Atlanto occipital dislocation l.jpgSlide 62

Atlanto Occipital Dislocation

  • 40% missed dx at presentation

  • STS +/- Retropharyngeal air

  • Avulsion fractures occipital condyle or lower tip of clivus

  • Classification:

Normal

I

II

III

Atlanto occipital dislocation63 l.jpgSlide 63

Atlanto Occipital Dislocation

Causes:

  • Traumatic

  • Nontraumatic

    • RA

    • Congenital Skeletal Abnormalities

    • Down’s

    • Infection

    • CPPD

  • Prognosis not good

    • (but 20% may have no deficit!)

  • Atlantooccipital subluxation l.jpgSlide 64

    Atlantooccipital subluxation

    • BDI (Basion Dental Interval)

      • Vertical distance of basion above dens <12 mm

    • BAI (Basion Axial Interval)

      • Anterior distance of basion from PSL 4 – 12 mm

    • Powers ratio:

      • Basion to C1 Posterior lamina line / Opisthion to posterior cortex of the anterior C1 tubercle <1

    • X method of Lee

    • Clival line

    Occipito atlas separation power s ratio l.jpgSlide 65

    Occipito atlas separation Power’s ratio

    BC should be less than AO

    Powers B, et al. Neurosurgery. 1979 Jan;4(1):12-7.

    Traumatic anterior Atlanto-occipital dislocation.

    The x line l.jpgSlide 66

    The X-line

    X

    Occipito atlas separation x line l.jpgSlide 67

    Occipito atlas separation X Line

    Lee C, et al       AJNR Am J Neuroradiol. 1994 May;15(5):990.Evaluation of traumatic atlantooccipital dislocations.

    Occipito atlas separation clival line normal l.jpgSlide 68

    Occipito atlas separation Clival Line - Normal

    Occipito atlas separation basion axial interval l.jpgSlide 69

    Occipito atlas separation Basion Axial Interval

    Harris JH Jr

    AJR Am J Roentgenol. 1994 Apr;162(4):887-92.

    Radiologic diagnosis of traumatic occipitovertebral dissociation:

    Atlanto occipital dislocation70 l.jpgSlide 70

    Atlanto-occipital Dislocation.

    B

    O

    C

    A

    Powers B, et al. Neurosurgery. 1979 Jan;4(1):12-7.

    Traumatic anterior Atlanto-occipital dislocation.

    Atlanto axial and cranial

    atlas separation 32M

    Powers

    Atlanto occipital dislocation71 l.jpgSlide 71

    Atlanto-occipital Dislocation.

    Lee C, et al       AJNR Am J Neuroradiol. 1994 May;15(5):990.Evaluation of traumatic atlantooccipital dislocations.

    Atlanto axial and cranial

    atlas separation 32M

    X method

    Atlanto occipital dislocation72 l.jpgSlide 72

    Atlanto-occipital Dislocation.

    Clival line

    Atlanto axial and cranial atlas separation 32M

    Atlanto occipital dislocation73 l.jpgSlide 73

    Atlanto-occipital Dislocation.

    Harris JH Jr AJR Am J Roentgenol. 1994 Apr;162(4):887-92.

    Radiologic diagnosis of traumatic occipitovertebral dissociation:

    Basion Dens interval

    Atlanto axial and cranial atlas separation 32M

    Atlanto occipital dislocation74 l.jpgSlide 74

    Atlanto-occipital Dislocation.

    13 y.o girl s/p MVA unconscious

    Atlanto occipital dislocation75 l.jpgSlide 75

    Atlanto-occipital Dislocation.

    3

    28M MCA

    Atlantooccipital subluxation76 l.jpgSlide 76

    Atlantooccipital subluxation

    Atlas77 l.jpgSlide 77

    Atlas

    Fractures

    • Jefferson

    • Isolated posterior arch

      Subluxation

    • Atlanto axial

    • Rotary

    Atlas c1 l.jpgSlide 78

    Atlas – C1

    • Jefferson Fracture

    Jefferson fracture l.jpgSlide 79

    Jefferson Fracture

    Jefferson fracture burst fracture of c1 l.jpgSlide 80

    Jefferson Fracture (Burst Fracture of C1)

    • Compression to vertex

    • Diving injury

    • Rx. Halo for 3m

    Jefferson fracture burst fracture of c181 l.jpgSlide 81

    Jefferson Fracture (Burst Fracture of C1)

    • Radiographic findings

      • AP open mouth is key

      • C1 lateral masses laterally displaced

      • >2mm bilaterally always abnormal

      • 1-2mm unilaterally may be head tilt

    Slide82 l.jpgSlide 82

    Jefferson Fracture

    (Burst Fracture of C1)

    Vertical Compression – Unstable

    • Unilateral or Bilat FX’s of both ant and post arches of C1

    • Displacement of lateral masses.

    • CT required for defining full extent of fracture and detecting fragments in spinal cord/canal

    • Treatment: Halo placement for 3 months

    Greenspan

    Slide83 l.jpgSlide 83

    Jefferson Fracture

    (Burst Fracture of C1)

    Vertical Compression – Unstable

    • Unilateral or Bilat FX’s of both ant and post arches of C1

    • Displacement of lateral masses.

    • CT required for defining full extent of fracture and detecting fragments in spinal cord/canal

    • Treatment: Halo placement for 3 months

    Normal

    Direction of forces

    Jefferson fracture84 l.jpgSlide 84

    Jefferson Fracture

    • Axial loading

    • Often 4 part Fx, or single both side fractures

    • Splaying of lateral masses

    • Disruption of transverse ligament

    • Best seen on AP odontoid and axial CT

    Jefferson fracture85 l.jpgSlide 85

    Jefferson Fracture

    Atlanto axial distance l.jpgSlide 86

    Atlanto Axial Distance

    • Females < 2mm

    • Males < 3mm

    • Children < 4mm

    Hinck 1966

    Slide87 l.jpgSlide 87

    Axis

    • Odontoid Fracture

    Dens fractures l.jpgSlide 88

    Dens Fractures

    TYPE 1 - Avulsion fx of the tip.

    Considered Stable

    TYPE II - Fx at Base of Dens.

    Most Common

    Poor blood supply

    Unstable

    TYPE III - Fx into body of axis

    Best Prognosis

    Unstable

    Greenspan

    Anderson and D’Alonzo

    Type l odontoid fracture l.jpgSlide 89

    Type l Odontoid Fracture

    6

    22M MVA

    Type l odontoid fracture90 l.jpgSlide 90

    Type l Odontoid Fracture

    4

    22M MVA

    Slide91 l.jpgSlide 91

    Axis

    • Type 2

    • Odontoid Fracture

    Type ll odontoid fracture l.jpgSlide 92

    Type ll Odontoid Fracture

    73M

    Type ll odontoid fracture93 l.jpgSlide 93

    Type ll Odontoid Fracture

    S p mva l.jpgSlide 94

    Type ll Odontoid Fracture

    S/P MVA

    Mac band l.jpgSlide 95

    ? Type ll Odontoid Fracture

    Mac band

    Slide96 l.jpgSlide 96

    Axis

    • Type 3

    • Odontoid Fracture

    Displaced type 3 odontoid fx l.jpgSlide 97

    Displaced type 3 odontoid fx

    18M

    Low type lll odontoid fracture l.jpgSlide 98

    Low Type lll Odontoid fracture

    26M

    Type lll odontoid fracture l.jpgSlide 99

    Type lll Odontoid Fracture

    57M

    Type lll odontoid fracture100 l.jpgSlide 100

    Type lll Odontoid Fracture

    Slide101 l.jpgSlide 101

    Axis

    • Hangman Fracture

    Hangman fracture unstable l.jpgSlide 102

    Hangman Fracture - Unstable

    • Traumatic Spondylolisthesis of the Axis

    • Bilateral C2 pars (common) or Pedicle (less common)

    • Hyperextension and traction injury of C2

      • MVA (chin to dashboard)

      • Hanging

    • The odontoid and its attachments are intact.

    • Nerve damage is uncommon owing to the width of the canal at this level.

    Hangman fracture unstable103 l.jpgSlide 103

    Hangman Fracture - Unstable

    • Traumatic Spondylolisthesis of the Axis

    • Bilateral C2 pars (common) or Pedicle (less common)

    • Hyperextension and traction injury of C2

      • MVA (chin to dashboard)

      • Hanging

    • The odontoid and its attachments are intact.

    • Nerve damage is uncommon owing to the width of the canal at this level.

    Slide104 l.jpgSlide 104

    Hangman Fracture - Unstable

    Effendi classification

    Grade 1: extension injury, displacement < 2mm. Rx flexion.

    Grade 2: extension injury, displacement >2mm and angulation. Rx flexion.

    Grade 3: flexion injury, C2-3 facet joint subluxation/ dislocation. Rx extension.

    Slide105 l.jpgSlide 105

    Hangman Fracture - Unstable

    • Effendi classification

    • Type I: bilateral pars fractures, normal C2/C3 disc space and minimal / no displacement of C2 body. LE1

    • Type II: displacement of anterior fragment, abnormal C2/C3 disc LE2b

    • Type III: anterior displacement of the anterior fragment, body of C2 in flexed position, bilateral facet dislocation

    • LE2a/LE3

    Slide106 l.jpgSlide 106

    Hangman Fracture - Unstable

    Levin and Edward’s

    Type 1: Neural arch fracture, < 3mm displacement, no angulation

    Type 2: A; + angulation

    Type 2: B; + >3mm displacement

    Type 3: + bilateral facet dislocation C2-3

    Slide107 l.jpgSlide 107

    • Hangman Effendi 1

    Hangman fx l.jpgSlide 108

    Hangman Fx

    20M

    32 y o drunk fell off cliff l.jpgSlide 109

    Hangman Fracture – Effendi l

    32 Y.O. Drunk, fell off cliff

    Slide110 l.jpgSlide 110

    • Hangman effendi 2

    Hangman fracture effendi ll le2a l.jpgSlide 111

    Hangman Fracture – Effendi ll – LE2a

    Posterior arch C1 Fx

    Slide112 l.jpgSlide 112

    Hangman Fracture – Effendi lll – LE3

    Slide113 l.jpgSlide 113

    Fractures

    Tear drop

    Flexion

    Extension

    Posterior

    Burst

    Posterior arch

    Clayshoveller’s Fracture

    Dislocations

    Unifacet

    Bifacet

    Fracture Dislocations

    Unilateral

    Bilateral

    Floating lateral mass

    C3-7

    Slide114 l.jpgSlide 114

    C3-7

    • Wedge

    • Compression

    Wedge compression fracture l.jpgSlide 115

    Wedge Compression Fracture

    • Usually stable

    • Loss of height anterior vertebral body

    • Buckled anterior cortex

    • Anterosuperior fracture of body

    • Differentiate from Burst

      • Lack of vertical fracture component

      • Posterior cortex intact

    Slide116 l.jpgSlide 116

    C3-7

    • Flexion Teardrop

    Flexion teardrop l.jpgSlide 117

    Flexion Teardrop

    • Flexion Fracture Dislocation

    • Unstable

    • Most severe Cervical spine injury

    • Anterior cord syndrome

      • Quadriplegia

      • Loss of anterior column senses

      • Retention of posterior column senses

    • Associated with Tx or Lx spine Fx in 10%

    Flexion teardrop118 l.jpgSlide 118

    Flexion Teardrop

    • Teardrop fracture – anteroinferior

    • All ligaments disrupted

    • Posterior subluxation of vertebral body

    • Bilateral subluxated or dislocated facets

    • Spinal canal compromise

    C5 c6 flexion distraction teardrop l.jpgSlide 119

    C5-C6 Flexion Distraction Teardrop

    C5

    C6

    35M MVA

    C4 flexion teardrop l.jpgSlide 120

    C4 Flexion Teardrop

    C4

    Tear drop 2 level dislocation

    C5 and c7 tear drop fractures l.jpgSlide 121

    C5 and C7 tear drop fractures

    1+32+3+5

    21M

    C5 and c7 tear drop fractures122 l.jpgSlide 122

    C5 and C7 tear drop fractures

    C5

    C7

    2+5

    21M

    Slide123 l.jpgSlide 123

    C6 Flexion Teardrop

    • Significant Prevert ST Swelling

    • Comminuted Fx of body of C6 with Anterior displacement of a teardrop fracture fragment.

    19y.o s/p mva

    Slide124 l.jpgSlide 124

    C3-7

    • Extension Teardrop

    Extension teardrop fracture l.jpgSlide 125

    Extension Teardrop Fracture

    • Avulsion fracture of anteroinferior corner of C2>C3>C4

    • Radiographic findings

      • Teardrop pulled off by ALL

      • Vertical height of fragment >= width

    C2 extension teardrop l.jpgSlide 126

    C2 Extension Teardrop

    C3 extension teardrop l.jpgSlide 127

    C3 Extension Teardrop

    Slide128 l.jpgSlide 128

    C5 Extension Teardrop

    Slide129 l.jpgSlide 129

    C3-7

    • ALL

    • Rupture

    Slide130 l.jpgSlide 130

    Anterior Longitudinal Ligament Rupture

    C6-7

    Slide131 l.jpgSlide 131

    C3-7

    • Posterior Teardrop

    C6 posterior teardrop l.jpgSlide 132

    C6 Posterior Teardrop

    C6 posterior teardrop133 l.jpgSlide 133

    C6 Posterior Teardrop

    C6

    C6 posterior teardrop134 l.jpgSlide 134

    C6 Posterior Teardrop

    C6

    Slide135 l.jpgSlide 135

    C3-7

    • Burst Fracture

    Burst fractures l.jpgSlide 136

    Burst Fractures

    • Same mechanism as Jefferson Fx but located at C3-C7.

    • Injury to spinal cord (due to displacement of posterior fragments) is common.

    • Requires CT to evaluate.

    • Stable

    C5 burst fracture l.jpgSlide 137

    C5 Burst Fracture

    48 y o s p mva with quadriplegia l.jpgSlide 138

    Burst FX of C5 Flexion teardrop mechanism

    48 y.o s/p mva with quadriplegia

    • Prevert ST Swelling

    • Comminuted FX of C5 w/slight retrolisthesis of C5/6

    • Extension of Fx into the posterior elements

    Ct burst fx of c5 l.jpgSlide 139

    CT, Burst FX of C5

    48 y.o s/p mva with quadriplegia

    Slide140 l.jpgSlide 140

    C3-7

    • Facet Dislocation

    Facet dislocation subluxations l.jpgSlide 141

    Facet Dislocation - Subluxations

    • Anterior subluxation (hyperflexion strain)

      • The Posterior Ligament complex is disrupted. (30-50% can show delayed instability)

    • Unilateral facet dislocation (stable)

      • Results from simultaneous flexion and rotation

    • Bilateral Facet Dislocation (unstable)

      • Results from extreme flexion of head and neck without axial compression

    Greenspan

    Facet dislocation subluxations142 l.jpgSlide 142

    Facet Dislocation - Subluxations

    • Anterior subluxation (hyperflexion strain)

      • The Posterior Ligament complex is disrupted. (30-50% can show delayed instability)

    • Unilateral facet dislocation (stable)

      • Results from simultaneous flexion and rotation

    • Bilateral Facet Dislocation (unstable)

      • Results from extreme flexion of head and neck without axial compression

    Facet dislocation subluxations143 l.jpgSlide 143

    Facet Dislocation - Subluxations

    • Anterior subluxation (hyperflexion strain)

      • The Posterior Ligament complex is disrupted. (30-50% can show delayed instability)

    • Unilateral facet dislocation (stable)

      • Results from simultaneous flexion and rotation

    • Bilateral Facet Dislocation (unstable)

      • Results from extreme flexion of head and neck without axial compression

    Slide144 l.jpgSlide 144

    C3-7

    • Unilateral

    • Facet Dislocation

    Unilateral facet dislocation l.jpgSlide 145

    Unilateral Facet Dislocation

    • Simultaneous flexion and rotation

    • Best seen on lateral and oblique views

    • Vertebral body subluxation < ½ of AP width

    • Disrupted “shingles on a roof” on oblique view

    • Facet within foramen on oblique view

    • Disrupted posterior ligaments

    • Disrupted SP line on AP

    • Butterfly appears

    33 y o s p mva l.jpgSlide 146

    Rotational Subluxation

    33 y.o. s/p MVA

    • Prevert ST Normal

    • Normal Alignment

    • Abrupt change in rotation at level of C4-C5.

    • Facets superimposed at C5-6-7.

    Rotational subluxation l.jpgSlide 147

    Rotational Subluxation

    33 y.o. s/p MVA

    C2 3 unilateral jumped facet l.jpgSlide 148

    C2-3 Unilateral jumped facet

    40F

    C6 7 unilateral jumped facet l.jpgSlide 149

    C6-7 Unilateral jumped facet

    C6

    7

    Butterfly

    C5 6 unilateral jumped facet l.jpgSlide 150

    C5-6 Unilateral jumped facet

    Slide151 l.jpgSlide 151

    C5-6 Unilateral jumped facet

    C5 6 unilateral locked facet l.jpgSlide 152

    C5-6 Unilateral locked facet

    Lost Hamburger sign

    33 y.o s/p MVA

    22 y o s p mva l.jpgSlide 153

    C6-7 Unilateral locked facet

    22 Y.O. S /P MVA

    • Prevert ST Normal

    • Gd I anterolisthesis of C6 on C7

    • Facets of C7 and T1 superimposed while facets of C6 are abruptly obliqued on C7

    Unilateral facet lock c6 on c7 l.jpgSlide 154

    Unilateral facet lock, C6 on C7

    22 Y.O. S /P MVA

    Slide155 l.jpgSlide 155

    C3-7

    • Bifacet Dislocation

    Bifacet dislocation l.jpgSlide 156

    Bifacet Dislocation

    • Extreme flexion without compression

    • Unstable

    • Vertebral body anterolisthesis > ½ AP body

    • Batwing or bowtie appearance of adjacent facets

    • Wide SP on AP view

    • Disrupted ALL, disc and posterior ligaments

    C7 t1 bifacet dislocations l.jpgSlide 157

    C7-T1 Bifacet dislocations

    46F

    C7 t1 bifacet dislocations158 l.jpgSlide 158

    C7-T1 Bifacet dislocations

    Sag T1 Sag T2 Sag STIR

    46F

    Slide159 l.jpgSlide 159

    C3-7

    • Unifacet Fracture Dislocation

    Unifacet fracture dislocation l.jpgSlide 160

    Unifacet Fracture Dislocation

    • More common than pure dislocation

    • Signs as before + fracture

    • Fracture of facet often not seen on radiographs

    C5 6 uni facet fracture subluxation l.jpgSlide 161

    C5-6 Uni Facet Fracture Subluxation

    C5

    C5

    C6

    C6

    C5

    C6

    61M MVA

    1+4+6+3+1

    C5 6 uni facet fracture subluxation162 l.jpgSlide 162

    C5-6 Uni Facet Fracture Subluxation

    C6

    C5

    C6

    61M MVA

    3+6+3+1

    C5 6 uni facet fracture subluxation163 l.jpgSlide 163

    C5-6 Uni Facet Fracture Subluxation

    C5

    C6

    C6

    61M MVA

    6+3+1

    C4 5 fracture dislocation l.jpgSlide 164

    C4-5 Fracture Dislocation

    C4

    C4

    22M

    C4 5 fracture dislocation165 l.jpgSlide 165

    C4-5 Fracture Dislocation

    C4

    22M

    C4 5 fracture dislocation166 l.jpgSlide 166

    C4-5 Fracture Dislocation

    C4

    C5

    22M

    C4 5 fracture dislocation167 l.jpgSlide 167

    C4-5 Fracture Dislocation

    Sag T1 Sag T2

    1

    22M

    C6 7 fx subluxation l.jpgSlide 168

    C6-7 Fx subluxation

    1+11+18

    25M MVA

    C5 6 uni fx dis with post op unstable c4 5 l.jpgSlide 169

    C5-6 Uni Fx dis with post op unstable C4-5

    C5

    C6

    C5

    C6

    17M

    C5 6 uni fx dis with post op unstable c4 5170 l.jpgSlide 170

    C5-6 Uni Fx dis with post op unstable C4-5

    17M

    Slide171 l.jpgSlide 171

    C3-7

    • Bifacet Fracture Dislocation

    Bifacet fracture dislocation l.jpgSlide 172

    Bifacet Fracture Dislocation

    • Higher energy than bifacet dislocation

    • MVA

    Slide173 l.jpgSlide 173

    C3-7

    • Facet Fracture

    Hyperextension fracture dislocation l.jpgSlide 174

    Hyperextension fracture dislocation

    • Severe circular hyperextension force

      • Impact on forehead

    • Anterior vertebral displacement

    • Unstable

    Hyperextension fracture dislocation175 l.jpgSlide 175

    Hyperextension fracture dislocation

    • Radiographic findings

      • Mild anterior subluxation

      • Comminuted articular mass fracture

      • Contralateral facet subluxation

      • Disrupted ALL, PLL

    Hyperextension fracture dislocation176 l.jpgSlide 176

    Hyperextension fracture dislocation

    Clay shovlers l.jpgSlide 177

    Clay Shovlers

    • The shoveler: Special power shoveling.

    • Weakness: Spinous process fractures.

    • http://www.imdb.com/title/tt0132347/

    The mystery men l.jpgSlide 178

    The Mystery Men

    Slide179 l.jpgSlide 179

    C3-7

    • Clay Shoveler’s Fracture

    Clay shoveler s fracture l.jpgSlide 180

    Clay Shoveler’s Fracture

    • Oblique avulsion fx of spinous process

    • C7 > C6 > T1 levels

    • Due to powerful hyperflexion

    Clay shoveler s fracture181 l.jpgSlide 181

    Clay Shoveler’s Fracture

    • Best seen on lateral view

    • Double spinous process on AP

    28 y o construction worker l.jpgSlide 182

    Clay Shoveler’s Fx

    28 y.o construction worker

    • Oblique avulsion fx of the spinous process (C7 > C6 > T1)

    • Mechanism: Hyperflexion

    • Stable

    Old c6 clay shoveler s l.jpgSlide 183

    Old C6 clay shoveler’s

    2

    41F

    Slide184 l.jpgSlide 184

    C3-7

    • Flexion Subluxation

    Anterior subluxation l.jpgSlide 185

    Anterior Subluxation

    • Hyperflexion sprain

    • Posterior ligament complex disrupted

    • 20-50% show delayed instability

    Anterior subluxation186 l.jpgSlide 186

    Anterior Subluxation

    • Radiographic findings

      • Localized kyphotic angle

      • Fanning

        • Widened interspinous/interlaminar distance

      • Posterior widening of disc space

      • Subluxation of facet joints

      • Anterior subluxation

    Facet dislocation subluxations187 l.jpgSlide 187

    Facet Dislocation - Subluxations

    • Anterior subluxation (hyperflexion strain)

      • The Posterior Ligament complex is disrupted. (30-50% can show delayed instability)

    • Unilateral facet dislocation (stable)

      • Results from simultaneous flexion and rotation

    • Bilateral Facet Dislocation (unstable)

      • Results from extreme flexion of head and neck without axial compression

    Greenspan

    C3 4 flexion subluxation injury l.jpgSlide 188

    C3-4 Flexion subluxation injury

    Slide189 l.jpgSlide 189

    Unstable Posterior Ligamentous Injury at C5-C6

    27 y.o. female 3 mo s/p trauma with more recent “neck crackings” by chiropractor.

    Slide190 l.jpgSlide 190

    Unstable Posterior Ligamentous Injury at C5-C6

    27 y.o. female 3 mo s/p trauma with more recent “neck crackings” by chiropractor.

    Stability l.jpgSlide 191

    Stability

    Cx spine stability l.jpgSlide 192

    Cx-Spine - Stability

    • Stability is a function of ligamentous injury

    • Can be inferred from radiographs for certain fracture patterns

    • Not 100% accurate

      • Eg. Flexion subluxation

    Cx spine stability193 l.jpgSlide 193

    Cx-Spine - Stability

    An unstable injury, is one which can progress and cause cord injury.

    Greenspan

    Slide194 l.jpgSlide 194

    Stability

    Cervical spine stability l.jpgSlide 195

    Cervical Spine - Stability

    • MRI

      • Shows

        • Edema of soft tissues

        • Paravertebral hematoma

        • Ligamentous disruption

      • Still does not indicate instability

      • Negative study does not indicate stability

    Cx spine stability196 l.jpgSlide 196

    Cx-Spine - Stability

    • Flexion Extension views

      • Patient should be erect

      • Should wait 2w for spasm to resolve

      • Must see to T1

      • Must move > 30 degrees

    Cx spine signs of instability on flex ex l.jpgSlide 197

    Cx-Spine signs of instability on Flex/Ex.

    • Subluxation greater than 3.5mm

    • Angular deformity of more than 11 deg.

    • Compression fx more than 25% loss of height

    • Narrowing of the disk space.

    • Widening of the interspinous distance 1.5X

    • Facet joint widening

    Pearls l.jpgSlide 198

    PEARLS

    • One view is no view.

    • 20% of spinal fractures are multiple

    • 5% of spinal fractures are at discontinuous levels

    • Most spinal fractures occur in upper (C1-C2) or lower (C5-C7) regions

    Pearls cont l.jpgSlide 199

    PEARLS (Cont)

    • Spinal cord injury occurs

      • At time of trauma 84%

      • As a late complication 15%

    • Any signs/symptoms of cord injury require MRI.

    • Get CT in patients with unexplained prevertebral soft tissue swelling.

    Online credits l.jpgSlide 200

    Online credits:

    • www.crayola.com

    • www.rad.washington.edu

    • www.ispub.com

    • www.radiographicceu.com

    • http://www.imdb.com/title/tt0132347/

    If your head comes away from your neck it s over l.jpgSlide 201

    If your head comes away from your neck, it’s over!

    The Highlander http://www.imdb.com


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