Transcript iv. Emergency Spinal Radiological Assessment

Emergency
Spinal
Radiological Assessment
C
spine injury: location
type
neurologic sequelae
T
1. cervical . . . . . . brainstem, cord or root
2. thoracic . . . . . cord or root
L
3. lumbar . . . . . . conus or root
cord injury: deficit patterns
1. normal (no neurologic injury)
2. incomplete deficit (syndromes)
a.
b.
c.
d.
e.
central cord
anterior cord
Brown-Sequard
posterior cord
conus/epiconus
3. complete functional transection
spine injury: types
1. muscular/ligamentous
a.
b.
c.
d.
contusions
+ / - dislocation
strains
sprains
complete ligamentous disruption
2. fractures
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: 12
kyphotic curve
lumbar: 5
lordotic curve
spine injury: alignment
1. pre-vertebral fascia
1
2. anterior marginal line
3. posterior marginal line
3
4. spino-laminar line
5. posterior spinous line
5
A. vertebral body width
B. spinal canal diameter
4
2
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