X ray spine SPINE TRAUMA CERVICAL SPINE INJURY

X ray spine

SPINE TRAUMA CERVICAL SPINE INJURY THORACO-LUMBAR SPINE INJURY

CERVICAL SPINE INJURY

COMMON MECHANISMS OF INJURY HYPERFLEXION- MVA, CAR COMES TO SUDDEN STOP HYPEREXTENSION- MVA, CAR STRUCK FROM BEHIND COMPRESSION- HEAD FIRST DIVE IN SHALLOW WATER

HIGH RISK FACTORS FOR SPINE INJURY HIGH-VELOCITY BLUNT TRAUMA MULTIPLE, SEVERE LONG BONE FRACTURES DIRECT CERVICAL REGION INJURY ALTERED MENTAL STATUS FALL FROM GREATER THAN 10 FEET DROWNING / HEAD FIRST DIVING ACCIDENT SIGNIFICANT HEAD OR FACIAL INJURY NECK PAIN, TENDERNESS, OR DEFORMITY ABNORMAL NEUROLOGICAL EXAMINATION THORACIC OR LUMBAR VERTEBRAL FRACTURE HXISTORY OF PRE-EXISTING VERTEBRAL DISEASE

CLINICAL PROCEDURE INVOLVING PTS WITH SUSPECTED SPINE INJURY PATIENT KEPT IN CERVICAL COLLAR AND IMMOBILIZED ON SPINE BOARD “ABCDEF” ER PROTOCOL FOLLOWED (AIRWAY, BREATHING, CIRCULATION, DISABILITY/DRUGS, EXPOSURE, FOLEY CATHETER) HISTORY AND PHYSICAL (PT HANDLED AS THOUGH SERIOUS INJURY PRESENT) DECIDE IF IMAGING IS NECESSARY

CERVICAL VERTEBRAL ANATOMY:

ANT LONGITUDINAL LIG POST LONGITUDINAL LIGAMENTA FLAVA SUPRASPINOUS LIG

MENU OF IMAGING OPTIONS CERVICAL SPINE PLAIN FILMS ANTERO- POSTERIOR AND LATERAL VIEW STANDARD FIRST LINE IMAGING MODALITY IN ASSESSING CERVICAL VERTEBRAL INJURY SWIMMER’S VIEW

Anteroposterior (A-P) View • Spinous process deviation • Lateral Translation • Coronal deformity

Open Mouth View • Mostly C 1 -C 2 lateral mass • Occipital Condyles/CO-C 1 • Odontoid Process

Swimmer’s View • Cervico-thoracic junction – obliques sometimes helpful CASETTE X-ray BEAM

NORMAL C-SPINE VIEWS LATERAL AP ODONTOID

C-SPINE FILM INTERPRETATION 7 STEP PROCESS 1. COUNT VERTEBRAE -C 1 THROUGH C 7 -IF T 1 NOT SEEN �� SWIMMER’S VIEW 2. ASSESS CURVATURE 3. ASSESS VERTEBRAL ALIGNMENT (4 LINES) -ANT VERTEBRAL LINE -POST VERTEBRAL LINE -SPINOLAMINAL LINE -POST SPINAL LINE 4. ASSESS BONY INTEGRITY 5. ASSESS INTERVERTEBRAL DISK SPACES 6. ASSESS OAA JOINT 7. SOFT TISSUES

THE 4 CONTOUR LINES 1 -ANT VERTEBRAL LINE 2 -POST VERTEBRAL LINE 3 -SPINOLAMINAL LINE 4 -POST SPINAL LINE

Lower Cervical Detection • Spinous process gapping • Facet joint Apposition • Inter-vertebral Gapping • Angulation • Translation

Lower Cervical Detection • Spinous process gapping • Facet joint Apposition • Inter-vertebral Gapping • Angulation • Translation

Lower Cervical Detection • Spinous process gapping • Facet joint Apposition • Inter-vertebral Gapping • Angulation • Translation

Lower Cervical Detection • Spinous process gapping • Facet joint Apposition • Inter-vertebral Gapping • Angulation • Translation

Lower Cervical Detection • Spinous process gapping • Facet joint Apposition • Inter-vertebral Gapping • Angulation • Translation

Lower Cervical Detection • Spinous process gapping • Facet joint Apposition • Inter-vertebral Gapping • Angulation • Translation

JEFFERSON FRACTURE

HANGMAN’S FRACTURE

DENS FRACTURE OF THE BASE OF THE DENS (ODONTOID) OF C 2 ANTERIOR OR POSTERIOR DISPLACEMENT OF THE DENS CAN OCCUR AT VARIOUS LEVELS ON THE DENS VIA HYPERFLEXION OR HYPEREXTENSION OF HEAD ON NECK UNSTABLE IF DISPLACEMENT OCCURS

COMPRESSION FRACTURE VARIABLE SEVERITY, FROM MINIMAL ANTERIOR WEDGING TO COMPLETE DISRUPTION OF VERTEBRAL BODY (BURST) LOOK FOR LOSS OF VERTICAL HEIGHT OF VERTEBRAL BODY DUE TO LONG AXIS COMPRESSION OR HYPERFLEXION DIVING INTO SHALLOW POOL STABLE �� UNSTABLE

TEARDROP FRACTURE AVULSION FRACTURE OF ANTERIOR MARGIN OF VERTEBRAL BODY ANTERIOR LONGITUDINAL LIG INSTABILITY (RUPTURE, AVULSION) HYPEREXTENSION INJURY UNSTABLE INJURY LAMINA MAY JAM TOGETHER CAUSING LIGAMENTA FLAVA TO BUCKLE INWARD AND COMPRESS/CONTUSE THE SPINAL CORD

CLAY SHOVELER’S FRACTURE AVULSION FRACTURE OF SPINOUS PROCESS BY SUPRASPINOUS LIGAMENT USUALLY OCCURRING FROM C 6 -T 2 HYPERFLEXION; DIRECT TRAUMA; DOWNWARD FORCE VIA THORACOSCAPULAR MUSCLE (AS IN SHOVELING MOTION) STABLE

THORACO-LUMBAR SPINE INJURY

Anatomy

MENU OF IMAGING OPTIONS DORSAL SPINE PLAIN FILMS ANTERO- POSTERIOR AND LATERAL VIEW LUMBO SACCRAL SPINE ANTERO- POSTERIOR AND LATERAL VIEW

Thoracic Spine

Lumbar Spine

Determinants of Stability • T & L spines are more stable than C-spine – – – Strong ligaments Stabilization by ribs Bigger intervertebral discs Larger facet joints Less mobility • Fractures & dislocations tend to occur where curvature changes – T 11 -12 (thoracolumbar junction) – L 5 -S 1 (lumbosacral junction)

Mechanisms of Injury • Hyperflexion +/- rotation – Commonest – Usually see anterior wedge #’s or Chance # • Shearing – Ant or post translation • Hyperextension • Axial loading – Compression or burst #’s

3 Column Model • Anterior column – Ant longitudinal lig – Ant annulus fibrosis – Ant vertebral body • Middle column – Post longitudinal lig – Post annulus fibrosis – Post vertebral body • Posterior column – – – Spinous processes Transverse processes Lamina Facet joints Pedicles Post ligamentous complex • 2 or more columns disrupted = unstable • Most disruption of middle columns are unstable

Stable or Unstable? • Radiographic findings suggestive of instability – – – Vertebral body collapse w/ widening of pedicles > 33% canal compromise on CT > 2. 5 mm translation b/w vertebral bodies in any plane Bilateral facet dislocation Abnormal widening b/w spinous processes or lamina and > 50% anterior collapse of vertebral body

Stable or Unstable? • Checklist for Instability – – – – Anterior elements disrupted Posterior elements disrupted 2 pts Saggital plane translation > 2. 5 mm 2 pts Saggital plane rotation > 5 o Spinal cord or cauda equina damage 2 pts Disruption of costovertebral articulations Dangerous loading anticipated 2 pts 1 pt – 5 or more pts unstable until healed or surgically stabilized

Stable or Unstable? • Risk of neurologic injury increases with – > 35% canal narrowing at T 11 -12 – > 45% canal narrowing at L 1 – > 55% canal narrowing at L 2 & below

Approach to T & L Spines • A – adequacy & alignment – – – All vertebrae need to be visible Ant & post longitudinal lines Facet joints should lie on smooth curve Normal kyphosis & lordosis All spinous processes should lie in straight line • B – bones – Trace cortical margins of each vertebrae – Difference b/w ant & post body ht < 2 mm – Progressive increase in vertebral body ht moving down spine – Wink sign & interpedicular distance – Don’t forget to look at transverse processes

Approach to T & L Spines • C – cartilage – Progressive increase in disc space moving down spine (except L 5 -S 1) – Facet joint alignment • S –soft tissue – Look at paraspinal stripe and prevertebral space

Injury Detection Thoracic and Lumbar Spines • Same principles • Landmarks and Lines: Lateral View – Posterior VB line – Anterior VB line – Inter-spinous Distance – Translation

Injury Detection Thoracic and Lumbar Spines • Same principles • Landmarks and Lines: A-P View – Spinous process to Pedicles – Inter-pedicular Distance – Translation

Thoracic and Lumbar Injuries

Height Loss Adjacent fracture

Transverse process fractures of L 2 -4 Significance of transverse process fractures is not the fractures in and of themselves but rather the high incidence of associated serious intraabdominal injury (~20%)

Anterolisthesis Of L 4 on L 5