Transcript Imaging Findings in the Injuries to the Neck Muscles

University of Massachusetts Medical School – UMASS
Worcester – MA - USA
Imaging Findings in the Injuries to
the Neck Muscles – Examples with
Review of Anatomy
E. Scortegagna Jr., MD
K. de Macedo Rodrigues, MD
A. Abayazeed, MD
S. K. Dundamadappa, MD
D. Takhtani, MD
eEdE-87
Disclosures
The authors have no actual or potential conflict
of interest in relation to this electronic exhibit
Objectives
• To review the anatomic aspects of the neck
muscles
• To review the imaging findings in the injuries to
the muscles of the neck
Introduction
• Most studies on trauma to the cervical spine have focused on
the injuries to the ligament, disc, bone, and the spinal cord.
There is hardly any report in the literature on the imaging
findings in the injuries to the muscles of the neck.
• The osseoligamentous system contributes 20% to the
mechanical stability of the cervical spine, while the remaining
80% is provided by the surrounding neck musculature.
• With increasing use of MRI in the patients with neck trauma,
we come across several examples of injury to the neck
muscles with or without fractures and ligament injuries.
Cervical spine/neck muscles
anatomy review
In the following slides, we present a focused review of
numerous muscles of the cervical region with examples
of injuries to some of them
Anatomy – anterior vertebral muscles
Muscle
Origin
Insertion
Ant. Surface of vertebral
column
Longus Colli
Three parts
Function
Flexes and rotates
the cervical portion
of the vertebral
column
Superior oblique
3/4/5th ant. Transv. Processes
Anterior arch of the atlas
Inferior oblique
First 2 or 3 ant vert. bodies
Anterior 5/6th cervical vertebrae
Front of upper 3 thoracic
bodies
2/3/4th cervical vertebrae
Longus Capitis
Anterior tubercles of anterior
transverse processes of the
3/4/5/6th cervical vertebrae
Inferior surface of the basilar
part of the occipital bone
Antagonist of the
muscles at the back.
Restores the head to its
natural position after
drawn backward. Also
flexes the head and
rotate it.
Rectus capitis
anterior
Located post. to the longus
colli
Anterior surface of lateral
mass of the atlas
Inferior surface of the jugular
process of the occipital bone
Similar to Longus
Capitis.
Rectus capitis
lateralis
Upper surface of the
transverse process of the
atlas
Under surface of the jugular
process of the occipital bone
Bends the head
laterally.
Vertical
Gray’s anatomy of the human body: Twentieth edition, Revised by Warren H. Lewis, New york: Bartleby.com, 2000
Anatomy – posterior vertebral
muscles
Muscle
Origin
Insertion
Function
Splenius capitis
Lower half of ligamentum
nuchae, from spinous
process of 7th and upper 3 or
4 cervical vertebrae
Mastoid process of the temporal
and occipital bones
Draw the head
backward, assisting
the trapezius and
semispinalis capitis.
Acting separately
they can draw the
back to one side and
slightly rotate
Splenius Cervicis
Spinous processes from 3rd to
6th thoracic vertebrae
Posterior tubercle of the
transverse processes of the 2 or
3 cervical vertebrae
Same as spleinus
capitis
Semispinalis
capitis
Transverse processes of the
upper 6 or 7 thoracic and 7th
cervical vertebrae, and
articular process of 3 cervical
vertebrae above
Between superior and inferior
nuchal lines of the occipital
bone
Head extension,
lateral flexion and
rotation of the
cervical spine
Multifidus
Articular processes of the
lower 4 cervical vertebrae
Into the spinous process of the
vertebrae above
Stabilization and
rotation of the spine
Gray’s anatomy of the human body: Twentieth edition, Revised by Warren H. Lewis, New york: Bartleby.com, 2000
Anatomy – posterior vertebral
muscles (cont.)
Muscle
Origin
Insertion
Function
Longissimus
cervicis
Transverse processes of the
4 or 5 thoracic vertebrae
Posterior tubercles of the
transverse processes from 2nd
to 6th cervical vertebrae
Bilaterally extends the
cervical spine.
Unilaterally produces
extension of the neck
to the same side
Longissimus
capitis
Transverse processes of the
4 o 5 thoracic vertebrae and
articular processes of lower
3 or 4 cervical vertebrae
Posterior margin of the
mastoid process
Bilaterally extends and
hyperextends the
head. Unilaterally
flexes and rotates the
head to the same side.
Gray’s anatomy of the human body: Twentieth edition, Revised by Warren H. Lewis, New york: Bartleby.com, 2000
Anatomy – lateral vertebral
muscles
Muscle
Origin
Insertion
Function
Scalenus anterior
Anterior tubercles of
anterior processes of
3/4/5/6th vertebrae
Inner board and upper surface
of the 1st rib
Elevate the first and
second ribs, acting
as inspiratory
muscle
Scalenus medius
Largest and longest of the
three. Arises from post.
Tubercles of transverse
processes of lower 6
vertebrae
Upper surface of the first rib
Similar to scalenus
anterior
Scalenus posterior
Posterior tubercles of
transverse processes of
lower 2 or 3 cervical
vertebrae
Outer surface of the 2nd rib,
behind the serratus anterior
Similar to scalenus
anterior
Gray’s anatomy of the human body: Twentieth edition, Revised by Warren H. Lewis, New york: Bartleby.com, 2000
Anatomy – lateral cervical muscles
Muscle
Origin
Insertion
Function
Sternocleidomastoideus
Sternum and clavicle (2
heads)
Sternum – medial head
-Anterior manubrium
sterni
Clavicle – lateral head Medial third of clavicle
Both heads are inserted into
the lateral surface of the
mastoid process and
superior nuchal line of the
occipital bone
Bilaterally it flexes
and extends the
head. Unilaterally
rotates to the
opposite side and
flexes to the same
side.
Trapezius
External occipital
protuberance and
medial third of superior
nuchal line of the
occipital bone,
ligamentum nuchae,
spinous process of the
7th cervical, and spinous
processes of all thoracic
vertebrae
Superior fibers are inserted
into the posterior border of
the lateral third clavicle.
Middle fibers into the medial
margin of the acromion and
superior lip of posterior
border of spine and scapula.
Inferior fibers converge near
the scapula and end in an
aponeurosis to be inserted
into a tubercle at the apex of
this smooth triangular
surface
Main function is to
stabilizes and move
the scapulae.
Gray’s anatomy of the human body: Twentieth edition, Revised by Warren H. Lewis, New york: Bartleby.com, 2000
Anatomy – superficial muscle
Muscle
Platysma
Origin
Insertion
Function
Fascia covering the upper
parts of the Pectoralis
major and Deltoideus,
extend superiorly along
the side of the neck
Some fibers insert in the
mandible, others into the skin
and subcutaneous of the lower
face. Fibers can insert partially
in the zygomaticus or orbicularis
oculi
Wrinkles the skin of
the neck. Also
serves to draw down
the lower lip and
angle the mouth in
expression of
melancholy.
Gray’s anatomy of the human body: Twentieth edition, Revised by Warren H. Lewis, New york: Bartleby.com, 2000
Image based anatomy
Longus capitis
Medial pterygoid
Digastric – posterior belly
Obliquus capitis inferior
Sternocleidomastoid
Splenius capitis
Semispinalis capitis
Trapezius
Rectus capitis posterior major
Image based anatomy
Sternocleidomastoid
Longus capitis
Longus colli
Levator scapulae
Trapezius
Splenius cervicis
Splenius capitis
Semispinalis cervicis
Multifidus
Image based anatomy
Longus colli
Scalenus anterior
Longus capitis
Scalenus medius
Levator scapulae
Semispinalis capitis
Trapezius
Rhomboid minor
Multifidus
Splenius capitis
Semispinalis cervicis
Image based anatomy
Longus colli
Scalenus medius
Scalenus posterior
Multifidus
Semispinalis cervicis
Levator scapulae
Rhomboid minor
Trapezius
Splenus capitis
Methods
• We have reviewed MRI scans of patients with traumatic
injuries to the neck over the past eight years to look for
injuries to the neck muscles.
• Routine MRI of the cervical spine for trauma in our
institution includes: Spin Echo T1 sagittal, Fast Spin
Echo T2 sagittal, Short Tau Inversion Recovery sagittal,
Fast Spin Echo T2 axial and Gradient T2 axial
sequences.
Patient #1
19-year-old female involved in a motor
vehicle accident with loss of consciousness
a
b
c
d
Figure 1: a,b: Axial STIR images demonstrate hyperintensity within the bilateral sternocleidomastoid muscles
(arrows) and bilateral scalene muscles (b: circles). c: Coronal STIR image demonstrating the extensive injury of the
scalene muscles (brackets) and d: Sagittal T2 sequence showing the extension of the left sternocleidomastoid injury
(arrows).
Patient #2
55-year-old female with history of fall at
home and loss of consciousness
a
b
c
d
Figure 2: a, b: Axial T2-weighted images showing T2 hyperintensity within the left longus colli muscle on the (arrows). c: Sagittal
STIR image demonstrating extensive T2 hyperintensity tracking along the left longus colli muscle (bracket) d: Sagittal STIR
images from the contralateral side, showing the normal aspect of the right longus colli muscle (arrowheads).
Patient #3
45 year-old male involved in a motor vehicle
accident as a pedestrian, with associated
loss of consciousness
a
b
Figure 3. a. Axial T2-weighted images demonstrating hyperintensity within the left multifidus muscle (arrows),
compatible with muscle injury/sprain.
b. Sagittal STIR image showing the same changes within the muscle (bracket).
Patient #4
34-year-old found unresponsive at home
and with persistent left arm deficit
a
b
c
d
Figure 4: a: Axial T2-weighted images demonstrate hyperintensity within the bilateral semispinalis cervicis (arrows), multifidus
and rotator cervicis muscles on the left (bracket); b: Axial T2-weighted images show hyperintensity within the left scalenus
anterior (arrows); c,d: Sagittal STIR images demonstrate the extent of the left posterior muscles involvement (circles).
Patient #5
10-year-old injured while performing
gymnastics
a
b
Figure 5: a,b: Axial T2-weighted images demonstrate hyperintensity within the bilateral
semispinalis cervicis muscles, left greater then right (arrows); c: Sagittal STIR images
demonstrates the extent of the injury (circle).
c
Patient #6
64-year-old with history of helmeted
motorcycle crash with multiple facial
fractures
a
*
b
*
c
Figure 6: a,b,c: Axial T2-weighted images demonstrating hyperintensity within the left levator scapulae muscle (arrows) and left
trapezius muscle (a,b) [asterisks].
Patient #7
71-year-old male found down in pulseless
electrical activity
Figure 7: axial T2-weighted image demonstrating hyperintensity within the right anterior
scalene muscle (arrows)
Patient #8
68-year-old female who fell down 15 stairs.
a
b
c
Figure 8: a,b: axial T2-weighted images demonstrating hyperintensity within the right longus
colli muscle (arrow). There is also hyperintensity within the left semispinalis cervicis on the left
side (a) [circle]. c: Sagittal STIR images demonstrating hyperintensity within the left
semispinalis cervicis muscle (circle). d: Sagittal STIR demonstrate the extent of the injury to the
right longus colli muscle shown on the axial images (arrows).
d
Patient #9
22-year-old male with history of motor
vehicle accident
*
a
c
*
b
d
Figure 9: a, b: Axial CT images showing contusions within the right semispinalis muscle (arrow),
splenius capitis (asterisk) . c, d: Coronal and Sagittal CT images demonstrate the contusions
described in the axial planes (arrows). Edema can also be seen tracking along the fascial
planes, better seen on the axial images.
Discussion
•
Plain films have a limited role in the injury to the neck. A subset of
patients with neck injury will even have normal CT. In one large metaanalysis involving 464 patients, MRI showed additional findings in
nearly 20% of patients that were not seen in the plain films with or
without CT [2].
•
In another large series of 174 patients who underwent MRI for occult
injuries of the cervical spine after their plain X-rays were normal, 36%
(62) patients had evidence of soft tissue injury. Both these studies
concluded that negative MRI should be a confirmation of cleared spine
[3].
•
American college of Radiology also advocates use of MRI in case of
suspected soft tissue injury.
Discussion
•
The injury to the soft tissues of the neck can involve the flexor or
extensor muscles depending on the nature of injury.
•
The flexion injuries cause sprain of the extensors whereas the whiplash
injuries damage the flexor group. There are also cases of direct injury to
the muscles causing contusion.
•
On MR imaging, the most common findings of muscle injury are
swelling of the muscle and edema (high T2 signal). In addition to this,
patients can present with rupture of muscle fibers, intramuscular
hematoma and bleeding, or reactive fluid in the adjacent soft tissues.
These changes are best seen on the short tau inversion recovery
(STIR) and FSET2 sequences.
Conclusion
Injuries to the neck muscles can be an important finding
on MRI, which in our opinion is often overlooked. Patient
with pain following neck trauma can greatly benefit from
correctly identifying various components of neck injury,
which can guide appropriate management and follow-up.
References
1. Panjabi MM, Cholewichi J, Nibu K, Grauer J, Babat LB,Dvorak J. Critical load of the human cervical spine:
an in vitro experimental study. Clin Biomech (Bristol, Avon). 1998 Jan;13(1):11-17.
2. Muchow RD, Resnick DK, Abdel MP, Munoz A, Anderson PA. Magnetic resonance imaging (MRI) in the
clearance of the cervical spine in blunt trauma: A meta-analysis. J Trauma. 2008;64(1):179-189.
3. Benzel EC, Hart BL, Ball PA, Baldwin NG, Orrison WW, Espinosa MC. Magnetic resonance imaging for the
evaluation of patients with occult cervical spine injury. J Neurosurg. 1996;85(5):824-829.
4. Branstetter BF 4th, Weissman JL. Normal anatomy of the neck with CT and MR imaging correlation. Radiol
Clin North Am. 2000 Sep;38(5):925-40, ix.
5. Gray’s anatomy of the human body: Twentieth edition, Revised by Warren H. Lewis, New york:
Bartleby.com, 2000
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