Transcript Those are the Breaks: Don`t-miss Cervical Spine

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