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State-of-the-Art Emergency and Trauma Radiology 45

Keywords: CT, mechanisms of injury,


radiography, spine, trauma, vertebral injuries
1
Department of Diagnostic Radiology, Allegheny
General Hospital, 320 E North Ave., Pittsburgh,
PA 15212-4772. Address correspondence to
R. H. Daffner (rhdaffner@netscape.net).
Vertebral injuries, like those to the peripheral skeleton, occur in a specic
and predictable pattern that is strictly dependent on the mechanism of injury.
The pattern may be easily recognized by the changes that the injury produces on
imaging studies. These patterns are referred to as the ngerprints of the in-
jury. Injuries due to a particular mechanism produce the same imaging changes
regardless of the location. Recognizing the pattern of the injury allows one to
predict the full extent of that injury.
All skeletal injuries occur in a specic and predictable pattern that is solely
dependent on the mechanism of injury. Injuries to the vertebral column obey
the same mechanical principles as those that occur in the peripheral skeleton.
The pattern of the injury is recognizable by the radiographic or CT changes pro-
duced. I refer to these patterns as the ngerprints of the injury [14]. Injuries
due to any particular mechanism will produce the same radiographic changes
regardless of the location. It matters not whether the injury has occurred in the
cervical portion of the vertebral column or in the thoracic or lumbar regions.
The changes due to a particular mechanism will be identical regardless of the
location (cervical, thoracic, or lumbar). It is important to recognize the pattern
because then it is easy to predict the full extent of that injury. The radiographic
changes that an injury produces are typically referred to as the footprints of
the injury. The ngerprints identify the extent of injury [14].
The diagnosis of vertebral injuries also relies on the same principles as those
used for peripheral injuries. It is important to completely study the suspected
bone(s) involved. In the peripheral skeleton, that means including the joint
above and below all suspected levels of injury. The vertebral column, although
consisting of 33 separate bones, functions as a single long bone. This means
that to completely study the spine it is necessary to include all structures be-
tween the skull and the sacroiliac joints (the joints above and below). This is of
practical experience when one considers that multiple noncontiguous vertebral
injuries occur in approximately 25% of patients [1].
Mechanisms of Injury and Their Radiographic Fingerprints
There are four basic mechanisms of vertebral injuries: exion, extension,
shearing, and rotary. Shearing and rotary injuries are frequently associated with
some degree of exion. Flexion injuries occur throughout the vertebral column.
Extension injuries occur primarily in the cervical region. Shearing and rotary in-
juries typically occur in the thoracolumbar junction and lumbar region [5, 6].
Flexion Injuries
Flexion injuries are the most common injuries to the vertebral column; they
occur in four varieties: simple, burst, distraction, and dislocation [14, 7, 8].
Injury Patterns in
Vertebral Trauma
Richard H. Daffner
1
46 2008 ARRS Categorical Course
Dafner
All are based on a similar mechanism. The type and extent of
injury depends on the forces involved, including the degree
of exion and the amount of axial loading. The typical injury
results from forward exion when the fulcrum of motion is
approximately through the posterior third of the intervertebral
disk [1]. In the least severe injury, anterior compression occurs
along the superior portion of the vertebral body immediately
beneath the exing vertebra. This produces anterior compres-
sion of various degrees. Typically, the fracture line propagates
posteriorly with or without communication to the interverte-
bral disk space. These fractures are referred to as simple frac-
tures and involve no injury to the posterior structures or to the
posterior third of the disk.
With an increase in the exion force or an increase in the
degree of axial loading, the vertebra literally explodes, driv-
ing fragments posteriorly into the vertebral canal to produce
the burst fracture. A variant of this fracture occurs when the
force is sufcient to split the vertebra sagittally, both anteriorly
and posteriorly (Fig. 1). If the fulcrum of forward exion is
moved anteriorly, as occurs in individuals wearing a lap-type
seat belt only, the primary injuring force is directed at the pos-
terior structures, with rupture of the interspinous ligaments,
facet ligaments, ligamenta ava, and, ultimately, the posterior
longitudinal ligament.
Distraction injuries may take two forms. The rst is severe
posterior ligament damage with subsequent widening of the
D
Fig. 1Burst fracture of L3 vertebra in 52-year-old woman.
A, Lateral radiograph shows compression of superior aspect of L3 and displacement of bone fragment anteriorly. In addition, segment of superior
aspect of posterior vertebral body line has been displaced posteriorly (arrow).
B, Frontal radiograph shows widening of interpedicle space of L3 (double arrow).
C, Sagittal reconstructed CT image shows this displaced fragment encroaching on vertebral canal (arrow).
D, Axial CT image shows displaced fragment in vertebral canal (asterisk).
E, Axial image slightly lower than D shows sagittal cleavage through spinous process (arrow).
E
A C B
State-of-the-Art Emergency and Trauma Radiology 47
Vertebral Trauma
interlaminar (or interspinous) space. This pattern is typical of
the hyperexion sprain [1, 3] (Fig. 2). Alternatively, the frac-
ture may extend in a horizontal fashion through the posterior
elements and through the vertebral body to produce the so-
called Chance-type fracture [9, 10] (Fig. 3). Finally, severely
forceful exion injuries can produce a dislocation, which may
occur with or without associated fractures.
Unilateral (Fig. 4) or bilateral facet locks occur as a result
of exion mechanisms. Anterolisthesis resulting from exion
injuries is always associated with widening of the interlaminar
A
Fig. 2Hyperfexion sprain in 22-year-old
man.
A, Lateral radiograph shows slight
anterolisthesis of C4 on C5 and widening of
interlaminar space (asterisk).
B, T2-weighted MR image shows rupture of
posteriorlongitudinal ligament and disk
herniation (arrow).
B
A C
Fig. 3Chance fracture of L1 in 40-year-old man.
A, Frontal view shows widening of interspinous space (asterisk). Note fracture through pedicle of L1 on left that extends into transverse process (arrow).
B, Lateral radiograph shows anterior compression of L1 and posterior distraction.
C, Axial CT image shows compression of anterior portion of vertebral body and naked facet on right side (arrow). Contiguous sections above and
below this image (not shown) showed similar naked facets. Note fragmentation of pedicle on left.
B
48 2008 ARRS Categorical Course
Dafner
space, widening of the facet joints (including naked facets),
and abnormal alignment of the spinolaminar line [1, 3].
Facet abnormalities are common in exion injuries. Nor-
mally, on a CT scan, the facet joints have the appearance of a
hamburger. Unilateral or bilateral facet dislocations result in
the reverse hamburger bun sign [11]. Naked facets may be
easily recognized on CT scans as unopposed bony structures
posteriorly, where one would normally expect to see the adja-
cent vertebra. This appearance should never occur normally on
more than one single slice.
Flexion injuries produce the following changes that may be
seen on radiographs or on CT scans: compression, fragmenta-
tion, and burst fractures of vertebral bodies; anterolisthesis;
wide interlaminar space; teardrop fragments typically from
the anteroinferior margin of the vertebral bodies; facet abnor-
malities that include fractures or unilateral or bilateral blocks;
an abnormal posterior vertebral body line [12]; and narrowing
of the disk space above the level of injury [14]. These nd-
ings are summarized in Appendix 1.
Extension Injuries
Extension injuries occur in three distinct varieties: simple,
distraction, and dislocation [14, 13, 14]. Extension mecha-
nisms are far more common in the cervical region but may
be seen in the thoracic and lumbar regions. It is not rare to
encounter the latter in patients with rigid spine disease (anky-
losing spondylitis or diffuse idiopathic skeletal hyperostosis
[DISH]) [15] (Fig. 5). Important cervical extension injuries
include the hangmans fracture of C2 and the extension sprain
[1, 13, 14] (Fig. 6).
All extension injuries have in common disruption of the
anterior longitudinal ligament with or without association of
fracture and a varying degree of injury to the intervertebral
disk. The most important imaging nding that may be seen on
either radiographs or CT scans is widening of the disk space
(Figs. 5 and 6). This nding is so important that whenever it is
encountered, patients should be suspected of having an exten-
sion injury through that level until proven otherwise. Other ra-
diographic ndings include small triangular avulsion fractures
from the anterior disk margins of the vertebra either above or
below the level of injury.
Retrolisthesis is typical in severe injuries. In a severe but
rare form of extension injury, fractures occur through the neu-
ral arch. Often these are associated with anterolisthesis. This
may lead to some confusion because anterolisthesis is more
typical of exion injuries [1, 13, 14]. However, the mechanism
should be clear when the anterolisthesis is accompanied by
a normal spinolaminar line and normal interlaminar distance.
These two anatomic landmarks are typically abnormal in the
more common exion-type of injury. Appendix 2 summarizes
the ngerprints of extension injury.
Shearing Injuries
Thoracolumbar injuries typically cluster between T11 and
L2. The reason for this is the facet reorientation that occurs
from the coronal plane to the sagittal plane. Indeed, at L1, the
facet joints are oriented at 90, which strongly resists any kind
of side-to-side or rotary motion [16]. In addition, the change
from the kyphotic thoracic curve to the lordotic lumbar curve
and the loss of the stabilizing effects of the ribs increase the
A C
Fig. 4Unilateral facet lock at C5C6 in 73-year-old woman.
A, Lateral radiograph shows anterolisthesis of C5 on C6 (arrow). Note widening of interlaminar space (asterisk).
B, Axial CT image shows locked facet on right (arrow). Note that appearance is that of a reversed hamburger bun.
C, Sagittal reconstructed CT image shows facet lock (arrow).
B
State-of-the-Art Emergency and Trauma Radiology 49
Vertebral Trauma
A
C
Fig. 5Extension injuries in patients with rigid spine
disease.
A, Lateral radiograph in 44-year-old man with ankylosing
spondylitis shows widening of T9 disk space (asterisk). Note
anterior ankylosis and kyphotic angulation at T11T12.
B, Sagittal reconstructed CT image in same patient as in
A shows wide disk space (arrow). Kyphotic angulation at
T11T12 is due to fexion injury at that level.
C and D, Lateral radiograph (C) and sagittal reconstructed
image (D) in 72-year-old man with difuse idiopathic
skeletal hyperostosis (DISH) show widening of T8 disk space
(asterisk). Wide disk space is hallmark of extension injury.
B
D
mechanical vulnerability of the region to all de-
grees of motion.
Shearing injuries are the result of horizontal
or obliquely directed forces with associated for-
ward or lateral exion [1, 3, 5, 6, 13]. The most
common cause that we encounter in our practice
is ejection from a motor vehicle in which the indi-
vidual strikes the upper or lower part of the body
while the other half of the body continues moving
in the same direction as the initial ejection. The
result of shearing injuries is a pattern that is quite
different from that seen with either exion or ex-
tension injuries.
Shearing injuries typically produce imaging
features of lateral distraction and lateral disloca-
tion. The vertebrae may have a windswept appear-
ance (Fig. 7). In addition, this mechanism produces
transverse process or rib fractures. Anterolisthesis
is also typically present. Lateral fragmentation
that is linear in the direction of the deforming
force may be seen on a CT scan (Fig. 7C).
The importance of recognizing shearing frac-
tures is that the injury initially may resemble a
burst fracture. Because these injuries are typically
unstable (see the following text), the treatment is
radically different. Treatment of burst fractures
is directed at providing stability along the sagit-
tal plane. Treatment of shearing injuries must be
directed toward reestablishing stability not only in
the sagittal plane but also in the oblique planes.
It is not difcult to differentiate shearing inju-
ries from burst fractures when one knows the typi-
cal signs produced by each. Shearing injuries typi-
cally have a greater degree of lateral displacement
and a tendency for lateral dislocation. Transverse
process or rib fractures are also hallmarks of this
injury (and of rotary injuries). Furthermore, the
linear oblique and windswept appearance on both
radiographs and CT scans is also typical. Burst
fractures, on the other hand, have little tendency
to dislocate, even along the sagittal plane. If the
50 2008 ARRS Categorical Course
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vertebra has been split along the sagittal plane, there will be
widening of the interpedicle distance reecting that (Fig. 1).
Finally, on CT, there is a linear sagittal distribution of frag-
ments [1, 3]. The ngerprints of shearing injuries are listed in
Appendix 3.
Rotary Injuries
Rotary injuries may be seen in two locations. The most com-
mon location is at the thoracolumbar junction. Once again, the
unique anatomy of that region sets the stage for these injuries
to occur when the right mechanism is applied [16]. The second
location for rotary injuries is the atlantoaxial region, where
patients may suffer a pure ligamentous injury referred to as
atlantoaxial rotary subluxation or frank dislocation in atlanto-
axial rotary xation [17]. Rotary injuries to the thoracolumbar
region are most frequently the result of motor vehicle crashes
in which an individual is ejected. The mechanism of injury is
an obliquely directed force to the upper torso with twisting
of the lower torso accompanied by lateral deection. There is
generally some degree of forward or lateral exion in addition
to the twisting mechanism [1, 3].
The imaging ndings of rotary injuries are distinct and sug-
gestive. There is severe fragmentation of the vertebral body.
Often, a fragment of bone from the inferior vertebra is torn
from the anterosuperior margin of the vertebral body (Fig. 8).
Because of the severe fragmentation, the vertebra is frequent-
ly pulverized, leading to the designation of these injuries as
grinding. Disruption of the posterior vertebral body line of-
ten leads to this injury being confused with burst fractures.
Consequently, there is canal encroachment. Like shearing
injuries, transverse process or rib fractures typically occur.
These features alone serve to differentiate this injury from
burst fractures. There is usually anterolisthesis, frequently
posterior distraction, and facet distraction. On CT, the bone
fragments are displayed in a circular or concentric fashion.
Because of the rotary mechanism, one facet joint is displaced
anteriorly and the other is displaced posteriorly, allowing the
viewer to determine the exact direction in which the rotation
occurred (Fig. 8C).
As with shearing injuries, it is important to differentiate
rotary injuries from burst fractures because the treatment is
different. Treatment of burst fractures, as previously mentioned,
A C
Fig. 6Cervical extension sprains.
A, Lateral radiograph shows widening of C5 disk space (asterisk) in 76-year-old man. Note small avulsed bone fragment from anteroinferior margin of C5
(arrow).
B, Lateral radiograph in 62-year-old man shows widening of C3 disk space (asterisk) and retrolisthesis of C3 on C4.
C, Autopsy specimen from patient in B shows torn anterior disk space at C3 and signifcant cord hemorrhage (arrow). These injuries typically produce
severe central cord syndrome.
B
State-of-the-Art Emergency and Trauma Radiology 51
Vertebral Trauma
is directed to reestablishing stability in the sagittal plane. On
the other hand, treatment of rotary injuries is directed to re-
establishing stability in the sagittal, axial, and coronal planes.
Rotary injuries have a greater degree of separation and a
greater tendency to dislocate. Transverse process or rib frac-
tures are characteristic. Most characteristic is the concentric
distribution of the bone fragments on a CT. On MRI, the soft-
tissue injury from rotary mechanisms is much more exten-
sive. Burst fractures, on the other hand, have little tendency
to dislocate. They may have widening of the interpedicle dis-
tance, and, on CT, have a linear and sagittal distribution of
bone fragments. The ngerprints of rotary injury are listed in
Appendix 4.
Radiographic Assessment
of Vertebral Stability
Stability of the vertebral column is dened as the ability of
the bones and ligaments that make up the column to protect
the spinal cord under normal function [1, 18, 19]. Stability de-
pends on the integrity of certain anatomic structures that will
not permit excessive motion to allow compromise of either
the spinal cord or the nerves. In 1983, Denis [20] created the
concept of the three-column spine. He dened the anterior col-
umn as those structures beginning at the anterior longitudinal
ligament and extending posteriorly to an imaginary line ap-
proximately two thirds of the way through the vertebral body
and intervertebral disk. The middle column extended from that
A
C
Fig. 7Shearing injury at L4L5 in 68-year-old
man.
A, Frontal radiograph shows windswept
appearance of spine at L4L5. Note loss of
normal anatomic boundaries between the two
vertebrae.
B, Lateral radiograph shows anterolisthesis of
L4 on L5. Note indistinctness of inferior margin
of body of L4.
C and D, Axial CT images show linear
oblique distribution of bone fragments. Note
transverse process fracture on left. Windswept
appearance is characteristic of shearing
injuries.
B
D
52 2008 ARRS Categorical Course
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line to the posterior longitudinal ligament. The posterior col-
umn extended from the posterior longitudinal ligament to the
supraspinous ligament. Denis was able to show, through bio-
mechanical experiments, that the integrity of the middle col-
umn was key to overall anatomic stability in the spine. From a
practical standpoint, disruption of two contiguous zones (an-
terior and middle columns or middle and posterior columns)
produced instability. Disruption of a single column (anterior or
posterior) did not result in instability.
What, then, are the radiographic signs of instability? There
are ve, and they may be seen on radiographs, CT, or MRI:
displacement, widening of the interlaminar (interspinous)
space, widening of the facet joint, widening of the interpedicle
distance, and an abnormal posterior vertebral body line [1, 18,
19]. Displacement (Fig. 8) generally results in disruption of all
three columns. Widening of the interlaminar space and widen-
ing of the facet joint are the result of disruption posteriorly (Fig.
2). Unless the posterior third of the disk has been torn, widening
of the interlaminar space cannot occur, nor can facet joint wid-
ening. Widening of the interpedicle distance indicates that the
vertebra has been split along the sagittal plane (Fig. 1). This may
occur with or without an intracanalicular displaced fragment.
Finally, an abnormality of the posterovertebral body line (Fig.
1) indicates a disruption to the posterior third of the vertebra and
the disk. This may occur from a variety of mechanisms.
Although most of these signs of instability occur in combi-
nation with one another, the presence of only one is sufcient
to make the diagnosis [1, 18, 19]. Indeed, the presence of these
signs also indicates that the patient has suffered a major injury.
Major injuries are dened as those that produce neurologic
D
Fig. 8Rotary injury of L1 in 56-year-old man.
A, Frontal radiograph shows severe disruption
of body of L1. Fracture extends through pedicle
and transverse process on left (arrow).
B, Lateral radiograph shows anterolisthesis of
T12 on L1. Note severe fragmentation of L1.
C, Sagittal reconstructed CT image shows
anterolisthesis (arrow) of T12 on L1. Note small
bone fragment from anterosuperior aspect of
L1 in its normal anatomic position.
D, Axial CT image shows naked facet on left
side (arrow). Note concentric distribution of
bone fragments anteriorly.
E, Axial CT image slightly lower shows
widening of left facet (arrow).
E
A C B
State-of-the-Art Emergency and Trauma Radiology 53
Vertebral Trauma
decits or have the potential to do so, or produce instability or
have the potential to do so. They require surgical intervention.
Minor injuries, on the other hand, require only symptomatic
and supportive treatment. Examples of major injuries are burst
fractures, rotary (grinding) injuries, and shearing injuries. Ex-
amples of minor injuries are spinous process fractures, isolat-
ed articular pillar fractures, and simple compression fractures
[21]. Appendix 5 is a more complete compendium of major
injuries, and Appendix 6 lists minor injuries. Although this
concept was developed for cervical injuries, the principles are
identical for thoracic and lumbar injuries as well.
Conclusion
Vertebral injuries occur in a predictable pattern that depends
on the mechanism of injury. That pattern constitutes the nger-
prints of the injury. The imaging ndings, or ngerprints from
any particular mechanism, are identical no matter where they
occur in the vertebral column. It is important to recognize the
types of injuries because the treatment will be radically differ-
ent for each type.
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APPENDIX 1: Fingerprints of Flexion Injuries
1. Compression, fragmentation, burst of vertebral bodies
2. Teardrop fragments
3. Anterolisthesis
4. Disrupted posterior vertebral body line
5. Wide interlaminar (interspinous) space
6. Locked facets
7. Narrow disk space above involved vertebra
APPENDIX 2: Fingerprints of Extension Injuries
1. Wide disk space below involved vertebra
2. Triangular avulsion fracture anteriorly
3. Retrolisthesis
4. Neural arch or pillar fracture
5. Anterolisthesis with normal interlaminar space and
spinolaminar line
APPENDIX 3: Fingerprints of Shearing Injuries
1. Windswept appearance
2. Lateral distraction
3. Lateral dislocation
4. Transverse process or rib fracture
5. Linear oblique (windswept) array of fragments on CT
APPENDIX 4: Fingerprints of Rotary Injuries
1. Rotation
2. Dislocation
3. Disrupted posterior vertebral body line
4. Facet or pillar fracture or dislocation
5. Transverse process or rib fracture
6. Spinous process fracture
7. Rotary array of fragments on CT
54 2008 ARRS Categorical Course
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APPENDIX 5: Major Injuries
1. Hyperfexion
a. Hyperfexion sprain
b. Hyperfexion dislocation
(1) Without facet lock
(2) With unilateral or bilateral facet lock
c. Comminuted (teardrop) body fracture
d. Burst fracture
e. Chance-type fracture
f. Hyperfexion fracturedislocation
g. Occipitoatlantal dislocation or subluxation
h. Atlantoaxial dislocation
i. Anterior fracturedislocation of dens
j. Lateral fracturedislocation of dens
2. Hyperextension
a. Hangmans fracture
b. Hyperextension sprain
c. Hyperextension dislocation
d. Posterior atlantoaxial dislocation
3. Shearing injury
a. Thoracolumbar shear injury
4. Rotary injury
a. Rotary atlantoaxial dislocation (fxation)
b. Rotary atlantoaxial subluxation
c. Rotary (grinding) thoracolumbar injury
5. Cervical axial compression
a. Bursting Jefersons fracture
b. Vertical and oblique fractures of axis body
c. Occipital condyle type 3 fracture
APPENDIX 6: Minor Injuries
1. Hyperfexion
a. Spinous process fracture
b. Wedge-like compression of body (simple fracture)
c. Transverse process fracture (isolated)
d. Uncinate process fracture (isolated)
e. Articular pillar fracture (isolated)
f. Laminar fracture
g. Lateral wedge fracture of body
2. Hyperextension
a. Horizontal fracture of anterior arch of atlas
b. Anterior inferior margin of C2 (teardrop)
c. Spinous process fracture
d. Posterior arch of atlas fracture (isolated)
3. Shearing injury None
4. Rotary injury None
5. Axial compression
a. Lateral mass of atlas (isolated)
b. Occipital condyle types 1 and 2 fractures