Emergency Spinal Radiological Assessment

spine injury: location type neurologic sequelae 1. cervical . . . . . . brainstem, cord or root 2. thoracic . . . . . cord or root 3. lumbar . . . . . . conus or root T L

cord injury: deficit patterns 1. normal (no neurologic injury) 2. incomplete deficit (syndromes) a. central cord b. anterior cord c. Brown-Sequard d. posterior cord e. conus/epiconus 3. complete functional transection

spine injury: types stability: 1. stable 2. unstable muscular/ligamentous a. contusions b. strains c. sprains d. complete ligamentous disruption 2. fractures + / - dislocation stability: 1. stable 2. unstable

spinal Imaging after trauma - indications clinical indications a. spine-region pain b. neurologic deficit (1) radicular (2) cord c. severe multisystem injuries d. altered mental status clinical rationale a. prevent cord, root injury (neurologic stability) b. prevent incapacitating deformity and pain (mechanical instability)

Which patients need imaging of the cervical spine? Case 1: mild/moderate trauma patient no loss of consciousness normal mental status (and not intoxicated) no neck pain or tenderness no neurologic deficit no imaging needed

Which patients need imaging of the cervical spine? Case 2: mild/moderate trauma patient altered mental status (patient is obtunded and/or intoxicated) neck pain or tenderness neurologic symptoms or deficit

Which patients need imaging of the cervical spine? Case 3: severe multi-system trauma patient imaging needed

spinal Imaging after trauma – imaging tools bony - fractures/dislocations a. X-rays – AP, lateral, open-mouth odontoid b. CT scan ligamentous a. MRI scan b. flexion – extension lateral x-ray 3. disk injury b. CT/myelogram

cervical: 7 lordotic curve thoracic: 12 lumbar: 5 kyphotic curve

spine injury: alignment 1. pre-vertebral fascia 2. anterior marginal line 3. posterior marginal line 4. spino-laminar line 5. posterior spinous line 1 2 3 4 5 A. vertebral body width B. spinal canal diameter

ligamentous injury without fracture instability possible even with normal CT; early MRI helpful stabilize until neck pain resolves, assess competence of ligaments with flexion/extension X-rays or MRI

Bilateral facet fracture/dislocation: “jumped” or locked facets

C1 - Jefferson fracture axial loading often associated with C2 fractures assess transverse ligament

C2 - odontoid fractures/subluxations type I type II type III

C2 - Hangman’s fracture hyperextension/axial loading bilateral C2 pars interarticularis fracture unstable when: a. >3.5 mm subluxation of C2 on C3 b. >11 degrees angulation

Atlantoaxial subluxation Atlantodental interval (ADI) Left: Normal ADI ≤ 3 mm Right: C1-2 subluxation

Denis 3-column model - thoracolumbar spine one-column injury usually stable two-column injury usually unstable three-column injury unstable

Class A: vertebral body compression compression fracture Anterior column failure Middle and posterior columns intact Unstable if >50% compression or >20 degrees angulation burst fracture Anterior and middle column failure Retropulsion of bone into canal Often have neurologic deficit Unstable

Burst fracture

Class B: distraction (+ flexion/extension) Types Flexion/distraction (Chance, seat belt injury) Hyperextension Three-column injury: unstable

flexion/distraction posterior ligamentous injury

Class C: three-column injury with rotation fracture-dislocation shear injury unstable neurologic deficit

fracture-dislocation