Presented to: National Radiological Emergency Preparedness Conference
Emergency Spinal Radiological Assessment
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Transcript of Emergency Spinal Radiological Assessment
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
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T
L
cord injury: deficit patterns
1. normal (no neurologic injury)
2. incomplete deficit (syndromes)
a. central cordb. anterior cord c. Brown-Sequardd. posterior corde. conus/epiconus
3. complete functional transection
spine injury: types
1. muscular/ligamentous
a. contusionsb. strainsc. sprainsd. complete ligamentous disruption
2. fractures
+ / - dislocation
stability: 1. stable 2. unstable
spinal Imaging after trauma - indications
1. clinical indications
a. spine-region pain b. neurologic deficit
(1) radicular(2) cord
c. severe multisystem injuries d. altered mental status
2. 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
1. bony - fractures/dislocations
a. X-rays – AP, lateral, open-mouth odontoid b. CT scan
2. ligamentous
a. MRI scan b. flexion – extension lateral x-ray
3. disk injury
a. MRI scan b. CT/myelogram
cervical: 7 lordotic curve
thoracic: 12kyphotic curve
lumbar: 5lordotic curve
spine injury: alignment
1. pre-vertebral fascia
2. anterior marginal line
3. posterior marginal line
4. spino-laminar line
5. posterior spinous line
A. vertebral body width
B. spinal canal diameter
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ligamentous injury without fracture
instability possible even with normal CT; early MRI helpfulstabilize 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 loadingoften associated with
C2 fracturesassess transverse ligament
type I
type II
type III
C2 - odontoid fractures/subluxations
C2 - Hangman’s fracture
hyperextension/axial loading
bilateral C2 pars interarticularis fracture
unstable when:a. >3.5 mm subluxation of
C2 on C3b. >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 fractureAnterior column failureMiddle and posterior columns intactUnstable if >50% compression or
>20 degrees angulation
burst fractureAnterior and middle column failureRetropulsion of bone into canalOften have neurologic deficitUnstable
Burst fracture
Class B: distraction (+ flexion/extension)
Types Flexion/distraction (Chance, seat belt injury)Hyperextension
Three-column injury: unstable
flexion/distractionposterior ligamentous injury
Class C: three-column injury with rotation
fracture-dislocationshear injury
unstable
neurologic deficit
fracture-dislocation