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1 Cervical Spine Trauma Shreya Kangovi Radiology Core, BIDMC July 25th, 2004 Shreya Kangovi HMS III Gillian Lieberman, MD 2 Overview -Menu of tests -Anatomy Review -Case Interpretation 3 Menu Of Tests: Who and How? Why not image every blunt trauma victim? •Imaging of cervical spine in the United States cost $4 billion in 1994. •Prevalence of detected cervical spine injury in screened patients is .2%-4.3% •There was a clear need for clinical criteria to identify patients who had a high enough probability of injury to warrant imaging F.A. Mann, et al. ‘Evidence-based approach to using CT in spinal trauma’. European Journal of Radiology, Vol 48, Usse 1, 10/03 4 Menu Of Tests: NEXUS Radiography indicated if a patient meets ANYof criteria • Posterior midline cervical tenderness • Evidence of intoxication • Abnormal level of alertness (GCS <14) • Focal neurological deficit • Painful distracting injuries Hoffman et al., ‘Validity of a Set of clinical Criteria to Rule Out Injury to the Cervical Spine in patients with Blunt Trauma. NEJM, Col 343; 13, July 2000 5 Menu Of Tests: Canadian C-spine Rule Any High-risk factors (age >65, dangerous mechanisms, paresthesias) Any Low-risk factors (Simple rear-end, sitting/ambulatory in ED, delayed onset of pain, absence of midline tenderness) Able to rotate neck actively No radiography Radiography Yes No No Yes Yes No Stiell et al, The Canadian C-spine Rule vs NEXUS; NEJM Dec 25, 2003 6 Menu of Tests: How? Screening Technique: CT vs Plain Film •CT is more sensitive, specific and fast. But also more costly, so doesn’t make sense to use for every case •If pre-test probability of injury is greater than 10%, CT is actually cost effective compared to plain film (less missed injury and follow-up imaging) •How can we isolate a population of patients with pre-test probability of >10%? 7 Menu of Tests: How? High-risk criteria for use of screening CT •Neurological deficit •Head Injury •High-energy mechanism •Patients with any of these criteria have 12.8% risk of cervical injury Indications for MRI •Incomplete/progressive neurological deficit •Level of edema for planning decompression •Planning stabilization for ligament/disk injury Blackmore et al; ‘Helical CT in the primary trauma evaluation of the C-spine: an evidence-based approach’. Skeletal Radiology 29:632-639 8 Anatomy- Typical Vertebrae •What is the distinguishing feature of cervical vertebrae? •Which structure functions as a guiderail for vertebral bodies to prevent lateral displacement? •What are the boundaries of the neuroforamina? Transverse foramen Uncinate Process Pedicles, articular processes, IV discs 9 Anatomy- High Vertebrae Anterior arch Posterior arch Lateral Masses w/ 4 articular surfaces Dens Body of C2 Pedicle Lamina Transverse Processes Transverse Ligament 10 Living Anatomy 11 Living Anatomy Contours: -Soft Tissue: look for swelling, which is a sensitive indicator of underlying injury of spine -Anterior longitudinal ligament -Posterior longitudinal ligament -Spinolaminal line (corresponds to Ligamentum Flavum) -Supraspinous line 12 Living Anatomy Columns: -Anterior column: contains anterior longitudinal ligament, vertebral body, intervertebral disk and posterior longitudinal ligament -Posterior column: contains everything posterior to posterior longitudinal ligament -Two columns are affected reciprocally by injury; e.g. hyperflexion compresses anterior column and distracts posterior column 13 Patient 1: Approach to C-Spine: Sagittal A. Alignment �Contour Lines �Interlaminous/Interspinous Distances �Anterior atlantodense interval B. Integrity �Osseous Integrity �Occipital condyles* �Lateral masses of C1* *Better seen on parasagittal 14 Patient 1: Approach to Cervical Spine: Axial � Further examine abnormalities seen on sagittal � Scan each level for intact body and posterior arch 15 Patient 1: 16 Patient 1: Teardrop Hyperflexion fracture-dislocation 17 Patient 2: 1. Contour Lines 2. Interlaminous/spinous distances 3. Atlantodens interval 4. Osseous Integrity 18 19 20 Patient 2: Fracture of the dens... 21 ...and Jefferson Burst Fracture 22 Patient 2: Fracture of the dens + Jefferson Fracture 23 Summary -Menu of tests: •NEXUS & Canadian C-Spine Rule -Anatomy Review •Typical Vertebrae •Atypical Vertebrae -Case Interpretation •Hyperflexion Teardrop Fracture •High Dens Fracture •Jefferson Burst Fracture 24 References: 1. F.A. Mann, et al. ‘Evidence-based approach to using CT in spinal trauma’. European Journal of Radiology, Vol 48, Usse 1, 10/03 2. Hoffman et al., ‘Validity of a Set of clinical Criteria to Rule Out Injury to the Cervical Spine in patients with Blunt Trauma. NEJM, Col 343; 13, July 2000 3. Stiell et al, The Canadian C-spine Rule vs NEXUS; NEJM Dec 25, 2003 4. Blackmore et al; ‘Helical CT in the primary trauma evaluation of the C-spine: an evidence- based approach’. Skeletal Radiology 29:632-639 5. Harris J., Mirvis S. The Radiology of Acute Cervical Spine Trauma. Williams & Wilkins. 1996 6. Kricun R., Kricun M. MRI and CT of the Spine: Case Study Approach. Raven Press. 1994 7. Gehweiler, Osborne, Becker. The Radiology of Vertebral Trauma. W.B Saunders Company. 1980 8. Reynolds P., Abrahams P. ‘McMinn’s Interactive Clinical Anatomy: Head and Neck’ CD- ROM. Mosby 1997 25 Acknowledgments •Dr. Ivan Pedrosa for providing all case images •Dr. Barbara Appignani •Dr. Gillian Lieberman •Pamela Lepkowski •Larry Barbaras Cervical Spine Trauma Overview Menu Of Tests: Who and How? Menu Of Tests: NEXUS Menu Of Tests: �Canadian C-spine Rule Menu of Tests: How? Menu of Tests: How? Anatomy- Typical Vertebrae Anatomy- High Vertebrae Living Anatomy Living Anatomy Living Anatomy Patient 1: Patient 1: Patient 1: Patient 1: Teardrop Hyperflexion fracture-dislocation Patient 2: Slide Number 18 Slide Number 19 Patient 2: Fracture of the dens... ...and Jefferson Burst Fracture Patient 2: Fracture of the dens + Jefferson Fracture Summary References: Acknowledgments