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CERVICAL SPINE

FRACTURES

Cervical Anatomy

Biomechanically Specialized
Support of large Cranial mass
Large range of motion
Flexion/extension
Axial rotation

Unique osteological characteristics

C1 - Atlas

No body
2 articular pillars
Flat articular surface
Vertebral artery

foramen

2 arches
Anterior
Posterior
Vertebral artery groove

C2 Anatomy

Dens
Embriological C1 body
Base poorly vascularized
Osteoporotic

Flat C1-2 joints


Vertebral artery
foramena
Inferomedial to

superolateral

Anatomy The Ligaments

Allow for the wide ROM of upper C-spine while


maintaining stability
Classified according to location with respect to
vertebral canal
Internal:
Tectorial membrane
Cruciate ligament including transverse ligament
Alar and apical ligaments
External
Anterior and posterior atlanto-occipital membranes
Anterior and posterior atlanto-axial membranes
Articular capsules and ligamentum nuchae

AtlantoAxial Anatomy
TectorialMembrane

AtlantoAxial Anatomy
TranverseLigament

C1C2joint

occiput
C1
C2

AlarLigament

AtlantoAxial Anatomy

Facetfor
Occipital
Condyle

Transverse
Ligament

AtlantoAxial Anatomy

Vertebral
Artery

APPROACH TO C-SPINE INJURIES

Following trauma or complaint of neck pain


Obtain lateral
AP, and
odontoid views
The lateral view is only adequate if T1 can be
visualized

If there is any doubt of fracture or prevertebral


swelling , obtain oblique views and consider CT
All patients with sign/symptoms of cord injury require
MRI

Cervical Views

ue
q
i
l
Ob

Odontoid
AP

Swimmers View

LATERAL VIEW

1. Anterior vertebral line (anterior


margin of vertebral bodies)
2. Posterior vertebral line
(posterior margin of vertebral
bodies)
3.Articular pillar (where superior
and inferior articular processes of
cervical vertebrae have fused on
either or both sides)
4. Spinolaminar line (posterior
margin of spinal canal)
5. Posterior spinous line (tips of
the spinous processes)

C1-C2

Predental space

(distance between posterior


aspect of anterior arch of C1
and anterior aspect of
odontoid process )

should be< 3mm In adult


and less <5mm in children
Or less
ring sign of C2

C3-C7

Anterior spinal, posterior spinal and


spinolaminar lines: should be
smooth lines

Disc Spaces should be approximately same


anterior narrowing = flexion injury.
Widening = extension injury

Facet joints should be parallel

Interspinous distance should


decrease from C3 to C7

Transverse process of C7 points downward and


T1 UPWARDS

FACE
T
JOINT
INTERVERT
EBRAL
DISC

SPACE
S

Prevertebral Soft
Tissue

10m
m

Nasopharyngeal space (C1) - 10 mm

(adult)
Retropharyngeal spaceC 2-C4

5mm

( between posterior pharyngeal wall


and anterior border of vertebrae).

Retro tracheal space C5-7 (space


between posterior tracheal wall and
anterior inferior body C6 )
c3-4 5mm from vertebral body is normal
C4-7 20mm from vertebral body is normal

22mm

AP View

The height of the cervical


vertebral bodies should
be approximately equal

The height of each joint


space should be roughly
equal at all levels.

Spinous process should


be in midline and in good
alignment.

Odontoid View
An adequate film should include the
entire odontoid and the lateral borders
of C1-C2.
Occipital condyles should line up with
the lateral masses and superior
articular facet of C1.
The distance from the dens to the
lateral masses of C1 should be equal
bilaterally.
The tips of lateral mass of C1 should
line up with the lateral margins of the
superior articular facet of C2.
The odontoid should have
uninterrupted cortical margins
blending with the body of C2.

Classification of
Fractures of c-spine
HYPERFLEXION

INJURIES

Flexion teardrop fracture


Hyper flexion Strain
Wedge Compression fracture
Bilateral facet Lock
Unilateral facet dislocation
Clay-shovelers fracture
Hyper

extention injuries

Hangman fracture
Extention teardrop fracture
laminar fracture
Pillar fracture
Posterior arch of c1 fracture
FRACTURE

DUE TO AXIAL LOADING

Jefferson fracture
Burst fracture
OTHER

INJURIES

Odontoid fracture
Rotational Injuries

Hyperflexion
Distraction creates

tensile forces in
posterior column
Can result in
compression of
body (anterior
column)
Most commonly
results from MVC
and falls

Compression
Result from axial

loading
Commonly from
diving, football, MVA
Injury pattern
depends on initial
head position
May create burst,
wedge or
compression fxs

Hyperextension
Impaction of posterior

arches and facet


compression causing many
types of fxs
lamina
spinous processes
pedicles

With distraction get

disruption of ALL
Evaluate carefully for
stability
LOOK FOR CENTRAL
CORD SYNDROME

Types of Injuries

Flexion Teardrop Fracture C5-6


fracture is the result of a combination
of flexion and compression ,most commonly at C5-6

The teardrop fragment comes from the


anteroinferior aspect of the vertebral body. The
larger posterior part of the vertebral body
is displaced backward into the spinal canal.

Best seen on lateral view


It is an completely unstable fracture associated with
complete disruption of ligaments and anterior cord
syndrome and quadriplegia

70% of patients have neurologic deficit.

common in MOTOR VECHICLE ACCIDENT

Signs:

Prevertebral swelling
associated with anterior
longitudinal ligament tear.
Teardrop fragment from
anterior vertebral body
avulsion fracture.
Posterior vertebral body
subluxation into the spinal
canal.
Spinal cord compression
from vertebral body
displacement.
Fracture of the spinous
process.

Fracture of
the spinous
process of
C4

Fracture of the body


of c5 with a small
fragment

anteriorly

Acute angulation at the level of C5C6


with displacement of C5 in posterior
direction

Wedge fracture

Compression fracture resulting from


flexion.

Flexion compression injury


Best seen on lateral view
Stable
Common in
Elderly patients with osteoporosis or
osteogenesis imperfecta

Wedge shape
vertebra

Antersuperio
r body
fracture

Hangmans Fracture C-2


Fx

through the pars


interarticularis of C2
secondary to
hyperextension

Best

seen on lateral

view
Hyperextention injury
Stable fracture ?

The most common scenario


would be
frontal motor
vehicle(hitting dash
board)
Hanging
falls,
diving injuries
contact sports.
Neurological involvement is
rare

Classification of Hangman' s fractures

Type I (65%)
hair-line fracture
C2-3 disc normal
Type II (28%)
displaced C2
disrupted C2-3 disc
ligamentous rupture with
instability
C3 anterosuperior compression
fracture
Type III (7%)
displaced C2
C2-3 Bilateral interfacet dislocation
Severe instability

TYPE 1 HANGMAN FRACTURE


There is a hair-line fracture and there is no displacement.
C23 NORMAL

Prevertebral soft
tissue swelling

Anterior

HANGMAN
TYPE
dislocation of FRACTURE
the
3 C2 vertebral body

BILATRAL C2 pars
interarticularis
fractures.

The CT-images
confirm the
fracture-lines of
the hangman's
fracture.
They run through
the pars
interarticularis
resulting in a
traumatic
spondylolysis.
In this case there
was no neurologic
deficit, because
the spinal canal is
widened at the
level of the
fracture.

Extention tear drop


fracture

AVULSION FRACTURE of anterio inferior content


of the axis resulting from hyperextention

This injury is

stable in flexion
but highly unstable in extension.

common in diving accidents

It also may be associated with the central cord


syndrome .

The CT confirms the


displaced
anteroinferior bony
fragment.
This fragment is a
true avulsion, in
contrast to the
flexion teardrop
fracture in which the
fragment is
produced by
compression of the
anterior vertebral
aspect due to
hyperflexion.

Jefferson Fracture C-1


Fracture is caused by a compressive
downward force that is transmitted evenly
through the occipital condyles to the superior
articular surfaces of the lateral masses of C1.
This process displaces the masses laterally and
causes fractures of the anterior and posterior
arches, along with possible disruption of the
transverse ligament.

Best seen on odontoid view


Unstable fracture
Fracture due to AXIAL LOADING
frequently associated with

diving into sha llow wa ter(a xia l blow

im pa ct aga inst the roof of a ve hicle


fa ll from pla yground e quipme nts

to the verte x of the hea d )

SIGNS ON XRAY:
Displacement of the
lateral masses of
vertebrae C1 beyond the
margins of the body of
vertebra C2.
<2mm bilateral is always
abnormal
<1-2 mm or unilateral
displacement can be due
to head rotation

CT is required to
1. define the extent of fracture
2. detecting fragment in spinal cord

BURST FRACTURE C3-7

Same mechanism as jefferson fracture i.e axial compression


but
Located at c3-7
Stable fracture
The intervertebral disc is driven into the vertebral body below.
Posterior fragments dislocation common
Require ct for fracture evaluation and bone fragment in spinal
cord

Odontoid Fracture C2

Fracture of the odontoid (dens) of C2


3 categories, I-III

Best seen on open-mouth odontoid view or lateral radiograph


result from blunt trauma to head leading to cervical hyperflexion or
hyperextension
Unstable fracture
Occur in both elderly and young patients
75% cases are children

Classification
Type I: Avulsion of the tip of
the dens where it is attached
to C1.
This is a rare fracture.
It is potentially stable.?
Type II: Through the base of
the dens.
Most common fracture.
Always unstable and poor
healing.
Type III: Fracture through the
body of the axis and
sometimes facets.
Can be unstable, but has a
better prognosis than type II
due to better healing of the
fracture which runs through
the metaphyseal body of C-2

Type 1 odontoid fracture

Type II

Type III

CT IMAGE

DENS

Dens

The image through the lateral part of C2 nicely shows, that the fracture runs
through the body of C2, i.e. a type III odontoid fracture.
The posterior dura is in a normal position, but the anterior dura is displaced
(arrow).

Showing Central location of spinal cord injury

Clay Shovelers Fracture

Oblique avulsion fracture of a spinous process C6-T1


C7>C6>T1
Best seen on lateral view
Powerful Hyperflexion injury(shoveling)
Stable fracture
Common in
motor vehicle accidents
sudden muscle contraction
direct blows to the spine

Ap view show ghost sign with 2 spinous processes ???

Case 1

5 yo girl
Hit by car while
riding bike
VSA at scene
Vitals recovered
by EMS

Rose et al, Am J Surg 2003;185(4)

Atlanto-Occipital
Dislocation

2.5 x more common in


children than adults
Due to small occipital
condyles and horizontal
atlanto-occipital joints
Suspect if distance
between occipital
condyles and C1 is
> 5mm at any point
Usually have ++ soft
tissue swelling

OccipitoAtlantal Dissociation (OAD)


Commonly Fatal
Present 6-20% of post mortem studies
Alker et al, 1978
Bucholz & Burkhead,1979
Adams et al, 1992

50% missed injury rate


1/3 Neurological Worsening
Davis et al, 1993

OccipitoAtlantal Dissociation (OAD)


Symptoms/Findings
Wallenberg Syndrome
Lower Cranial nerve deficits
Horners syndrome
Cerebellar ataxia
Cruciate paralysis
Contralateral loss of pain and
temperature

Radiographic Lines
Powers Ratio

BC/OA
>1 considered abnormal

Limited Usefulness
Positive only in Anterior
Translational injuries
False Negative with pure
distraction

Powers et al, Neurosurg, 1979

QUESTIONS

REFERRENCES
Text Book of Radiology and imaging
(DAVID SUTTON)
Primer of Diagnostic Imaging
Radiology Review Manual(Dahnert)

Thank You!