SPINAL TRAUMA

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SPINAL TRAUMA

• Presented by
• Michael Whitehead, D.C., DACBR

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Spinal Trauma

• Most cervical spine trauma is secondary to MVAs
  and falls.
• Most common sites of spinal fractures
• C1-C2
• C5-C7
• T12-L1
• Compression forces ? fractures
• Rotational and shearing forces disrupt ligaments.

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Biomechanics

• Three column theory of spinal stability by Denis
  (modified Holdsworths concept)
• Anterior
• ALL, anterior annulus fibrosis, anterior body.
• Middle
• PLL, posterior annulus fibrosis, posterior body.
• Posterior
• Neural arch and intervening soft tissues.

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Pathomechanics of Injury

• Usually results from indirect forces
• Flexion, extension, distraction, compression,
  shearing, and rotation
• Flexion is the most common force

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Classification of Injuries

• Classification of spinal injuries by mechanism.
• Families of injuries result from similar
  mechanisms
• Direct relationship exits between magnitude of
  forces and severity of injury.

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Classification of Injuries

• Hyperflexion Injuries
• Bilateral facet dislocation
• Clay-Shovelers fracture
• Hyperflexion sprain or strain
• Odontoid process fracture
• Simple wedge fracture
• Flexion teardrop fracture

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Classification of Injuries

• Hyperextension Injuries
• Extension teardrop fractures
• Fracture of the posterior arch of C1
• Hangmans fracture
• Articular pillar/facet fractures
• Spinous process fractures
• Hyperextension sprain or strain

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Classification of Injuries

• Compression Injuries
• Jeffersons fracture
• Burst fracture

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Classification of Injuries

• Rotation Injuries
• Lamina or facet fractures (extension)
• Transverse process fractures
• Unilateral facet dislocation (flexion)
• Rotary atlantoaxial fixation
• Lateral Flexion Injuries
• Uncinate process fractures
• Transverse process fractures (m/c)

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Classification of Injuries

• Shearing Injuries
• Fracture/ dislocations in thoracic and lumbar
  spine
• Atlanto-occipital dislocation
• Distraction Injuries
• Hyperflexion strain
• Chance fractures
• Atlanto-occipital dislocation

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Classification of Injuries

• Findings suggestive of instability according to
  Rockwood and Green.
• Increased angulation between vertebral bodies
  that is at least 11 degrees gt adjacent segments.
• Anterior or posterior translation gt 3.5mm.
• Segmental spinous process widening.
• Facet joint widening.
• Lateral tilting of vertebral bodies.

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Cervical Spine Trauma

• Majority of signs of cervical trauma can be
  visualized on the neutral lateral view.
• Must demonstrate C7 and if possible T1
• Developed and reviewed prior to additional views
• Check for the following
• Soft tissue swelling
• Abnormal vertebral alignment
• Abnormal joints

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Cervical Spine Trauma

• Three view cervical (minimum)
• APOM, APLC neutral lateral
• Five view cervical
• Minimum plus obliques
• Seven view cervical
• Five view plus flexion and extension
• Additional views
• Fuchs, pillar view, swim lateral

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Hyperextension Injuries

• Fracture posterior arch of C1
• Hangmans fracture
• Extension teardrop fractures
• Articular pillar/facet fractures
• Spinous process fractures
• Hyperextension sprain/strain

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Posterior Arch Fracture of Atlas

• Most common fracture of C1
• Mechanism
• Hyperextension
• Compresses neural arch between occiput and C2
• Stable
• Radiographic Features
• Bilateral vertical fractures through the neural
  arch
• Lateral cervical best view

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Hangmans Fracture

• AKA Traumatic spondylolisthesis
• Acute hyperextension MVAs
• 40 of axis fractures
• Bilateral fractures located just anterior to the
  inferior facets of C2.
• Clinical Features
• Upper neck pain
• Neurological manifestations are minimal

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Hangmans Fracture

• Radiographic Features
• Oblique fractures extending through the pedicles
• Anterior displacement of C2
• May see avulsion of the anterior inferior margin
  of C2 or anterior superior margin of C3
• Increased RPI
• Best view Lateral Cervical or CT
• Unstable

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Hangmans Fracture

• Management
• Vertebral artery injury ?delayed neurologic signs
• Immobilization
• Fusion

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Extension Teardrop Fracture

• Avulsion of a triangular-shaped fragment from the
  anterior inferior vertebral body margin
• Acute hyperextension
• Location M/C at C2 or C3
• May accompany a Hangmans fracture
• Best view Lateral cervical
• Stable

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Articular Pillar/Facet Fracture

• Among the most frequently missed cervical spine
  fractures
• Acute cervical radiculopathy ?important clue
• Pillar formed by superior and inferior articular
  processes
• M/C due to hyperextension, unilateral fractures
  typically have lateral flexion component
• C4-C6 m/c locations, C6

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Articular Pillar/Facet Fracture

• Radiographic Features
• May demonstrate compression or wedging with or
  with out radiolucencies
• Anterolisthesis
• Horizontal facet sign
• Best View Pillar projection
• Unstable

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Articular Pillar/Facet Fracture

• Management
• Immobilization (Halo)
• Decompression if neuro compression exists
• Steroids for cord edema if present
• Prognosis depends on presence / degree of
  neurologic compromise

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Compression Injuries

• Jeffersons fracture
• Burst fracture

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Jeffersons Fracture

• A.k.a. Bursting fracture of the atlas
• Auto accidents, falls and blows to the vertex
• Comminuted fracture involving both the posterior
  and anterior arches
• Mechanism Blow on the vertex transmitting forces
  through the occipital condyles
• Clinical
• Neck pain, occipital headaches

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Jeffersons Fracture

• Radiographic Features
• Best view APOM
• Bilateral offset or spreading of the lateral
  masses
• Overlap Sign
• Increased peridontoid spaces
• Transverse ligament may be disrupted ?ADI
  ?instability
• Stable if transverse ligament is intact

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Jeffersons Fracture

• Differential considerations
• Pseudo spread of C1 on C2
• Developmental defects in the neural arch
• Management
• Stable fracture with healing in majority of cases
• Immobilization, fusion if gross instability

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Burst Fracture

• Axial compressive forces
• Nucleus pulposus implodes through the superior
  endplate of the vertebra resulting in a
  comminuted fracture
• Severe neck pain
• Posteriorly displaced fragments may produce
  spinal cord injury
• M/C at C3-C7

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Burst Fracture

• Radiographic Features
• Lateral view shows comminution
• AP may demonstrate a vertical fracture line
• CT is most revealing

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Burst Fracture

• Management
• Can be stable or unstable
• Surgical stabilization
• Canal decompression if needed
• Bed rest may be sufficient with immobilization if
  comminution is minimal

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Hyperflexion Injuries

• Flexion teardrop fracture
• Simple wedge fracture
• Clay-Shovelers fracture
• Bilateral facet dislocation
• Odontoid process fracture
• Hyperflexion sprain or strain
• Transverse ligament disruption

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Flexion Teardrop Fracture

• Specific form of the burst fracture
• Combination of flexion and compressive forces
• Posterior displacement of vertebra into the
  spinal canal
• Avulsed teardrop fragment
• Unstable
• Acute anterior cord syndrome

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Flexion Teardrop Fracture

• Radiographic Features
• Best view Lateral cervical, CT, MRI
• Spine flexed above the level of the injury
• Posteriorly displaced body
• Teardrop fragment
• Increased interspinous space
• Possible fractures / dislocations of posterior
  elements

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Simple Wedge Fracture

• Forceful hyperflexion
• Compressing vertebra between adjacent vertebral
  bodies
• Location M/C at C5, C6 and C7
• Stable

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Simple Wedge Fracture

• Radiographic features
• Decrease of anterior body height.
• Zone of impaction.
• Occasionally a fragment from anterior superior
  body margin.

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Clay-Shovelers Fracture

• Avulsion injury of the spinous process by sudden
  force placed on ligamentum nuchae
• MVA, wrestling, diving
• Mechanism Abrupt flexion, direct blow
  extension
• Location M/C at C7 (C6-T1)
• Stable

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Clay-Shovelers Fracture

• Radiographic features
• Lateral
• Oblique radiolucent line with rough margins
• Distal fragment displaced inferiorly
• DDx. Nuchal bone, ununited ossification center
• Frontal
• Double spinous process sign

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Hyperflexion Strain

• AKA Traumatic anterior subluxation
• Combination of distraction and flexion forces
• Disruption of capsular and posterior ligaments
• Intact anterior longitudinal ligament
• Unstable
• Delayed dislocation
• Generally requires posterior fusion

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Hyperflexion Strain

• Radiographic Features
• Focal angulation
• Increased space between adjacent spinous process
  and facets
• Anterolisthesis

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Bilateral Facet Dislocation

• Severe hyperflexion and distraction
• Location M/C at C4-C7
• B.I.D. primarily involves soft tissue
• Unstable
• Spinal cord injuries are frequent
• Arthrodesis usually required

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Bilateral Facet Dislocation

• Radiographic features
• Involved segment displaced anteriorly gt ½ AP
  diameter of the body below
• Facets lie anterior to facets of vertebra below,
  within the IVF
• May see facet fractures
• AP may reveal widened interspinous space

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Transverse Ligament Disruption

• Hyperflexion may play a role
• Isolated posttraumatic rupture is infrequent
• Unstable
• Downs syndrome, inflammatory arthritides,
  Jefferson fx
• Cord compression can occur
• Radiographic Features
• Increased ADI
• Disrupted posterior spinal line

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Odontoid Process Fractures

• Type I (Anderson and dAlonzo)
• Avulsion fracture of the tip of the odontoid
  process
• Apical or alar ligament stress
• Stable
• Usually an oblique fracture line
• DDx
• Os terminale
• Space between front incisors

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Odontoid Process Fractures

• Type II (Anderson and dAlonzo)
• Most common type
• Hyperflexion or hyperextension
• Transverse fracture base of the dens
• Unstable
• Often complicated by nonunion

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Odontoid Process Fractures

• Radiographic Features
• Transverse radiolucency at base of dens
• May see posterior or anterior displacement
• Lateral tilting of the dens
• DDx
• Os odontoideum, mach effect

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Odontoid Process Fractures

• Type III (Anderson and dAlonzo)
• Hyperflexion or hyperextension
• Common
• Oblique fracture at the base of the odontoid
  process that extends into the body
• May see disruption of the ring of the axis on the
  lateral projection.
• Stable.

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Rotation and Lateral Flexion Injuries

• Rotation Injuries
• Unilateral facet dislocation (flexion)
• Lamina or facet fractures (extension)
• Transverse process fractures
• Rotary atlantoaxial fixation
• Lateral Flexion Injuries
• Uncinate process fractures
• Transverse process fractures (m/c)

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Unilateral Facet Dislocation

• Secondary to flexion, rotation and distraction
• M/C levels C5/C6 and C6/C7
• Locked facet on side of spinous rotation with
  inferior facet resting in IVF
• Disruption of various posterior ligaments
• Stable

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Unilateral Facet Dislocation

• Lateral view
• Bow-tie or butterfly appearance
• Approximately 25 anterior displacement.
• AP view
• Spinous process rotates up and away.
• Oblique view
• Demonstrates the dislocated facet.

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Lamina Fractures

• Usually secondary to hyperextension
• Mid and lower cervical spine m/c at C5 and C6
• Best demonstrated by CT

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Transverse Process Fractures

• Not common
• M/C due to lateral flexion
• M/C at C7
• Fracture usually located at its junction with the
  pedicle

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Rotary Atlantoaxial Fixation

• M/C in children
• Etiologies
• Spontaneous
• Trauma
• Inflammatory arthritides
• Oral surgery

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Rotary Atlantoaxial Fixation

• Clinical Presentation
• Acute patient? torticollis
• (lateral flexion, rotation to opposite side,
  slight flexion)
• Prominent neck pain
• Some follow a chronic course

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Rotary Atlantoaxial Fixation

• Radiographic Features
• Four types based on anterior atlas translation
• Type 1 Rotary fixation w/o anterior translation
  m/c
• Lateral mass wider and closer to dens on side of
  anterior rotation
• Rt and Lt rotation and lateral flexion views
• Lateral may demo increased ADI