Cervical Spine Imaging - Lieberman's eRadiology …eradiology.bidmc.harvard.edu/LearningLab/musculo/Kratz.pdf · Cervical Spine Imaging Johannes Kratz, Harvard Medical School Year

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Johannes Kratz, HMS IVGillian Lieberman, MD

Cervical Spine Imaging

Johannes Kratz, Harvard Medical School Year IV

Gillian Lieberman, MD

March 20, 2006

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Overview

• Background• Clinical Cases• Diagnostic Tests and a Decision-Tree Algorithm

• Examples of Cervical Spine Evaluations• Common C-spine fractures• Summary

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Cervical Spine Trauma

• 30,000 injuries to the spinal column every year in the US

• The majority of injuries are due to blunt trauma (motor vehicle accidents, falls, sports injuries, etc.)

• 2-3% of blunt trauma victims have cervical spine trauma

• 40-50% of spinal injuries produce a neurological deficit, often severe and sometimes fatal

• Costs of lifetime care and rehabilitation often exceed $1,000,000 per patient Souce: Bagley 2006

www.discoverchiropractichawaii.com

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BIDMC Cases

• Patient ND– 39 year old female s/p MVA. Awake, alert, no neck pain.

• Patient TN – 32 year old male s/p MVA. Awake, alert, complains of neck pain.

• Patient WD – 84 year old man s/p fall down 10-12 stairs at home. Awake, alert, “cannot move my arms”.

What kind of neck injuries might these patients have?

www.legeros.com

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Differential Diagnosis of Neck Pain s/p Trauma

• Cervical Spine Injuries– Cervical spine fracture– Spinal cord injury– Neck strain/Whiplash (ligaments, muscles, tendons)

• Epidural hematoma• Vertebral Artery Dissection• Atypical headache• Acute on Chronic neck pain (OA, radiculopathy, spinal stenosis, etc.)

How would you evaluate for the presence of c-spine injuries?

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Menu of Tests

What tests should be ordered and when?

Neck Trauma

No imaging is necessary or mandated

C-spine plain films C-spine CT

C-spine MRI

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Algorithm for C-spine imaging

Back to our patients…

Neurological Status

Patient is A&O x 3 Patient has ΔMS, focal neurological deficit or extremity paresthesia+ Neck Pain- Neck Pain

No imaging necessaryor mandated Plain films

Sources: Tins et al. 2004, NICE Guidelines 2003, Stiell et al. 2001.

CT (significant plain film finding OR negative plain film finding but

HIGH clinical suspicion)

MRI (ligamentousinjury suspected)

+/- +/-

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Patient ND39 year old female s/p MVA. Awake, alert,

no neck pain.

How about our second patient?

Patient is A&O x 3

- Neck Pain

No imaging necessaryor mandated

Patient has ΔMS, focal neurological deficit or

extremity paraesthesia+ Neck Pain

Plain films




+/- +/-

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Patient TN32 year old male s/p MVA. Awake, alert,

complains of neck pain.

A 3 view c-spine plain film series is ordered

Patient is A&O x 3

- Neck Pain

No imaging necessaryor mandated (XXX study)


extremity paraesthesia+ Neck Pain

Plain films




+/- +/-

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C-spine Anatomy: Atlas and Axis

How about the other cervical vertebrae?

Atlas (C1): superior view Axis (C2): posterosuperior

viewNetter 1997

Netter 1997

________

________

_____________________

____

____________

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C-spine Anatomy: 4th and 7th vetebrae

What holds the cervical vertebrae together?

Netter 1997

C4: superior view

Netter 1997

C3-C5: anterior view

________________________

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C-spine Anatomy: Cervical Spine Ligaments

How is this anatomy imaged?

Netter 1997 Atlantoaxial

joint: superior view

Netter 1997

Atlantooccipital

junction: midline sagittal

view

____________________________

______________________

___________

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3 View Plain Film C-spine Series

How do you interpret these films?lateral

A/P

Open Mouth

www.trauma.org

www.trauma.org

www.trauma.org

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Reading a Lateral C-spine Plain Film: 7 steps

What does TN’s lateral film look like?

• Quality Control• “See 7”. If can’t see C7, repeat

the film with the shoulders lowered.

• Evaluate 5 parallel lines• Prevertebral Line• Anterior Vertebral Line• Posterior Vertebral Line• Spinolaminal Line• Posterior Spinous Line

• Inspect the Dens• Dens-C1 body space <2.5mm (<5mm)

• Check the atlanto-occipital alignment• Check the bony landmarks• Check disc spaces• Check the soft tissue

www.trauma.org

normal

Sources: Brant and Helms 2004, Yao et al. 2000.

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TN’s Lateral C-spine Plain Film

What about the A/P film?normal TN

www.trauma.org PACS, BIDMC, courtesy of Dr. Lai

Non-displacedC1 fracture

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Reading an A/P C-spine Plain Film

What does TN’s A/P film look like?

• Quality Control• Evaluate 3 parallel lines

• Articular Pillar Line• Vertebral Body Line• Spinous Process Line

• Check the vertebral bodies• Check disc spaces

normal


www.trauma.org

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TN’s A/P C-spine Plain Film

What about the open mouth film?normal TN


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Reading an Open Mouth C-spine Plain Film

What does TN’s open mouth film look like?

• Quality Control• Examine the alignment

• Occipital condyles• Check the lateral dens

space• Check the lateral tips of

C1• Check the bony landmarks

normal


www.trauma.org

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TN’s Open Mouth C-spine Plain Film

What about our third patient?

normal TN


Lateral displacement of C1 massesaka “Jefferson Fracture”

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Patient WD84 year old man s/p fall down 10-12 stairs at

home. Awake, alert, “cannot move my arms”.

CT and MRI c-spine studies are ordered


extremity paraesthesia

Plain films

Patient is A&O x 3

- Neck Pain

No imaging necessaryor mandated (XXX study)

+ Neck Pain




+/- +/-

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Patient WD: Sagittal CT

Right of midline Midline Left of midline

PACS, BIDMC, courtesy of Drs. Sun and Zeikus

“Locked” facets “Perched” facetsOsteophytes

AnterolisthesisCongenital block vertebrae

Bone fragment

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Patient WD: Axial CT

Is there ligamentous injury?

Normal facetsPACS, BIDMC, courtesy of Drs. Sun and Zeikus

“Naked facet sign”

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Patient WD: MRI

What about other common cervical spine fractures?

T2 weighted MRI STIR MRI

PACS, BIDMC, courtesy of Drs. Sun and Zeikus

Hematomas

Ligament injury

Hematomas

Ligament injury

“Locked/Perched Facets w/ ligament damage”

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Hangman’s Fracture

www.emedicine.com

Caused by a hyperextension injury

Displacement of C2 body

Fracture of posterior C2 elements

Source: Brant and Helms 2004

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Clay Shoveler’s Fracture


www.gentili.net

Classically caused by shoveling sticky clay over shoulder

Fracture of C6 spinous

process

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Flexion-Teardrop Fracture

www.emedhome.com


Caused by severe c-spine flexion

Associated with spinal cord injury

“Teardrop” frature

of an anterior

vertebral body

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Summary

• Significance of detecting cervical spine fractures

• Diagnostic Tests and a Decision-Tree Algorithm

• Clinical Examples of Cervical Spine Evaluations

• Common c-spine fractures: Jefferson, Locked/Perched Facets, Hangman’s, Clay Shoveler’s, Flexion-Teardrop

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Acknowledgements• Dr. Maryellen Sun, BIDMC Radiology• Dr. Eric Zeikus, BIDMC Radiology• Dr. Ken Lai, BIDMC Radiology• Dr. Jim Wu, BIDMC Radiology• Dr. Gillian Lieberman, BIDMC Radiology• Pamela Lepkowski, BIDMC Radiology• Larry Barbaras, Webmaster

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ReferencesBagley, L. Imaging of Spinal Trauma. Radiol Clin North Am 2006; 44:1-12.Banit, DM et al. Management of the Acute Cervical Spine: A Management

Algorithm. J Trauma 2000; 49:450-456.Brant, WE and Helms, CA. Fundamentals of Diagnostic Radiology. Lippincott

1999: 886-895.Brohi, K. Initial Assessment of Spinal Trauma.

http://www.trauma.org/spine/cspine-eval.html 2002; 7:4.Daffner, RH. Controversies in cervical spine imaging in trauma patients.

Emerg Radiol 2004; 11:2-8.Lingawi, SS. The Naked Facet Sign. Radiology 2001; 219:366-367.National Institute for Clinical Excellence. Head injury: triage, assessment,

investigation and early management of head injury in infants, children and adults—NICE guideline; 2003.

Netter, F. Atlas of Human Anatomy. Havas Medi Media 1997; 2:12-16.Radiographic assessment of the cervical spine in asymptomatic trauma

patients. Neurosurgery 2002; 50:S30-35.Radiographic assessment of the cervical spine in symptomatic trauma patients.

Neurosurgery 2002; 50:S36-43.Stiell IG, Wells GA, Vandernheen KL, et al. The Canadian C-spine rule for

radiography in alert and stable trauma patients. JAMA 2001; 286: 1841- 1848.

Tins, BJ and Cassar-Pullicino VN. Imaging of acute cervical spine injuries: review and outlook. Clin Radiol 2004; 59:865-880.

Yao, LL et al. Imaging Evaluation of the Cervical Spine. http://www.med- ed.virginia.edu/courses/rad/cspine/ 2000.

Documents

Cervical Spine Imaging - Lieberman's eRadiology …eradiology.bidmc.harvard.edu/LearningLab/musculo/Kratz.pdf · Cervical Spine Imaging Johannes Kratz, Harvard Medical School Year