The CERVICAL SPINE

Imaging the Traumatized Patient

MI Zucker, MD

A dr Z Lecture
on imaging cervical
spine trauma.
With much gratitude to
Jack Harris, MD.

Michael I. Zucker, MD
Professor, Dept. of
Radiology
Faculty, Dept. of
Emergency Medicine
UCLA Medical Center,
David Geffen School
of Medicine at UCLA

10,000 spinal cord injuries per

year in USA
Two-thirds are cervical cord.
The monetary, physical and emotional
losses are great.
Our goal: Early detection of injuries to
prevent or decrease neurological and
mechanical damage to the spinal column.

STABILITY: A Word or Two

We talk about it, but what is it?
A useful definition: An injury is STABLE if
putting the spinal column through normal
range of motion does not increase
neurological or mechanical deficits.

Three Column Theory of Denis

Spinal column divided
into an ANTERIOR,
MIDDLE and
POSTERIOR column.
Injury to one column
is stable, two or three
are unstable.

ANTERIOR COLUMN
The anterior
longitudinal ligament,
anterior 2/3 of the
body and disc.

MIDDLE COLUMN
Posterior longitudinal
ligament and posterior
1/3 of body and disc.

POSTERIOR COLUMN
The posterior osseous
arch and ligaments.

DOES IT WORK?
If two or three columns injured, lesion is
unstable: Works well for C3 to T1.
Does not work so well for C1-2, so consider
most or all injuries here unstable.

HOW DO YOU IMAGE THE

CERVICAL SPINE?
Plain films?
CT?
MRI?
A combination of modalities?
Is there a consensus?

NO
(But were headed toward one)

My Opinion:
O*pin*ion: A belief held with confidence,
but not substantiated by proof.

Imaging Minor Trauma

LATERAL view from skull base through at
least the top one-half of T1. May need to
supplement with Swimmers view.
Anterior-posterior (AP)
Open Mouth Odontoid (OMO)
If patient is not in cervical collar: Adding
Oblique views is an option.

MINOR TRAUMA: Views

Imaging Major Blunt Trauma

Cross-table
LATERAL plain film
in Trauma Suite.
CT entire cervical
spine.
MRI also in selected
cases.

If you wish, AP,

OMO, and Swimmers
views also -- IF they
DO NOT cause delay.
CT: Axial sections
base of skull through
T1- AND- Sagittal
(like a lateral) and
Coronal (like AP and
OMO) reformatting.

MAJOR TRAUMA: Imaging

Cross-table Lateral in
Trauma Suite

CT Base of skull
through T1

Swimmers View in Major

Trauma
A SUPPLEMENTARY
view to see C7-T1 in
lateral projection. NOT a
substitute for a bad lateral.
One arm must be elevated,
so THEORETICALLY
could worsen a
mechanical or
neurological injury.
A state-of-the-art CT
sagittal reformat is
preferable: dont need to
move patient and imaging
easier and better.

CT
Axial sections from
base of skull through
T1.
ALWAYS do the
ENTIRE cervical
spine.
DONT do selective
imaging with modern
scanners.

CT: Sagittal Reformatting

Reconstructed by
computer from axial
data: no additional
imaging needed.
Outstanding
lateral/swimmers
imaging.

CT: Coronal Reformatting

Excellent OMO

Excellent AP

MRI
Gold standard for
cord, thecal sac, nerve
root and disc injuries.
Very good for
ligament injuries.
Fairly good for
fractures, but does
miss some. CT much
better.

NEUROLOGIC DEFICIT
In my view, ANY neurologic deficit,
extant or transient, is MAJOR
trauma, and will need CT followed by
MRI.

Any abnormality on Plain Films

or worrisome examination:
do CT!
Remember: Fractures often come in
2s and 3s. The more serious injury
may be the one that is occult.

ARE THERE RISKS?

Ionizing radiation can damage cells. Younger
people are more susceptible than older people.
Their cells are more sensitive and they have longer
to manifest somatic or genetic damage.
The radiation dose is significantly higher in CT
than in plain films.
As in most decisions in medicine, one must weigh
the risks versus the benefits.

My Approach to Success in
Image Interpretation
Know what to order.
Know what an optimal imaging series is and
dont accept less.
Read by check list.
Know the common lesions.
Know the commonly MISSED lesions.

Remember: The lesions are the

SAME regardless of the imaging
modality
Plain films are still the most common
modality.
If you learn on them, you can
translate your knowledge to CT and
MRI.

PLAIN FILM Series

LATERAL
ANTERIOR-POSTERIOR (AP)
OPEN MOUTH ODONTOID (OMO)
*REVERSE WATERS
*SWIMMERS
*OBLIQUES

THE CHECK LIST

View by view

LATERAL view
This is your MAIN view
where 90% of injuries are
detected.
You MUST see T1. If not
seen, do Swimmers view,
unless not safe to do so.
You did lateral and
Swimmers and still no
luck? DONT QUIT: DO
CT! Once you start an
exam you must complete
it.

LATERAL View: First Survey

Look for gross
fracture or dislocation.
Count vertebrae.
Look at skull, entire
airway and adjacent
soft tissues.

LATERAL View: Prevertebral

Soft Tissues
Contour is more
important than
measurements:
straight or concave
anteriorly, except at
larynx.
Top normal limits: C2
6mm; C6 22mm for
adult, 14mm for young
child.

LATERAL View: Alignment

Anterior body line.
Posterior body line.
Spino-laminar line
(called posterior
cervical line at C1-3).

LATERAL View: Alignment

Turning the lateral view HORIZONTALLY can

help detect subtle malalignment.

LATERAL View: Spaces

Disc spaces: too wide,
too narrow, not
uniform?
Facet joints: too wide,
not uniform?
Interspinous distances:
too wide, too narrow,
not uniform?

LATERAL View: C1 and C2

Basion-dens distance:
average 8mm, top
normal 12mm.
C1: Anterior and
posterior arch.
C2: Dens, Harris ring,
body especially ant/inf
corner, pars and
posterior arch.

LATERAL VIEW:
Predental Space
In an adult, upper
normal is 2.5mm.
Space is parallel or
narrow V shape.
In a young child,
upper normal is
4.5mm.

LATERAL VIEW: Predental

Space

LATERAL View: C3-T1

Body: loss of straight
or concave anterior
contour, loss of
height?
Posterior arch: subtle
cortical irregularity,
overt fracture line?

LATERAL VIEW: Child

Vertebral bodies are bullet
shaped.
Physiologic
pseudosubluxations are
common, especially C2-4.
Predental space is wider.
Lymphoid tissue makes
soft tissues more
prominent.

SWIMMERS View
A supplemental view
to see C7-T1.
Must raise one arm.
Probably not a good
idea if neurologic
deficit, altered level of
consciousness, upper
arm injury. Could
worsen an injury.

ANTERIOR-POSTERIOR View
Look at first few ribs,
sterno-clavicle junction,
lung apices.
Contour of lateral margins
of lateral masses.
Uncovertebral joints.
Alignment and contour of
spinous processes.
Position and contour of
trachea.

The ODONTOID Views

Open Mouth Odontoid
(OMO) is main view.

Reverse Waters view

is supplementary, to
see top half of dens
ONLY.

OMO
C1-2 lateral mass alignment
of lateral margins.
Dens: cortical margin
irregularities, fracture
lines, tilt.
Upper body of C2 for
fracture lines.
Mach lines can be confusing.

The INJURIES
C1 and C2: by anatomic location
C3 to T1: by mechanism of injury

(Modified from the classification of John

Harris, et al.)

The Atlas and the Axis

C1 and C2 injuries differ from the rest of
the cervical spine and are considered
separately.
Although controversial, best to consider
ALL C1 and C2 injuries as UNSTABLE in
the acute trauma setting.

Occipital-atlantic Injuries
Occipital condyle
fractures: lateral
bending, uncommon,
seen only on CT.
Occipital-atlantic
dissociation (OAD):
rare distraction injury,
usually fatal. Basiondens distance is
abnormal, 12+mm.

The ATLAS: C1
Anterior arch fracture: extension,
uncommon.
Posterior arch fracture: extension, more
common.
JEFFERSON fracture: axial load, common

C1: Isolated Arch Fractures

Anterior arch
Posterior arch
CAUTION: You may
be dealing with a
Jefferson fracture with
occult components:
Best to CT all C1
fractures.

JEFFERSON Fracture: C1
Axial load (burst) injury
Pure (4) or variant (2 or 3)
fractures, involving both
ant. & post. arches of C1
Cord injury in 15%
Lateral view: anterior and
posterior arch fractures
OMO view: lateral
displacement of C1 lateral
masses

JEFFERSON Fracture: C1
The lateral masses of C1
and C2 must be aligned on
the OMO view.
1-2mm of lateral
displacement on one side
and an EQUAL medial
displacement on the other
is head rotation.
ANY other pattern: lateral
displacement on both
sides or lateral on one
side, and none on the
other is abnormal.

JEFFERSON Fracture
CT
Classical Jefferson: 4
fractures, 2 ant./2 post.
Jefferson variants: 2
or 3 fractures, but at
least 1 ant. & 1 post.

The AXIS: C2
Dens fractures
Pars fractures
Extension teardrop
fractures

DENS Fractures
Type I: alar ligament
avulsion of the tip; rare.
Type II: the dens
excluding the tip; 2/3.
Type III: high C2 body;
1/3.
Mechanism of Type II and
III is controversial.

TYPE II Dens Fracture

Interrupted cortical
margin, lucent fracture
line, tilt especially
anterior
Cord injury in 15%
Delayed or non-union
50+%

TYPE II Dens Fracture

CT axial

TYPE III Dens Fracture

Interrupted Harris
ring, fat C2, lucent
fracture line, tilt
especially ant.
Cord injury in 15%
Heals well.

C2: PARS Fracture

Called Hangmans or
pedicle fracture, both
wrong.
Extension injury.
Cord injury in 15%.
Non-displaced,
displaced, subluxed.

C2: Extension Teardrop Fracture

Avulsion by the
anterior longitudinal
ligament of the
anterior-inferior
corner of the body.
Extension mechanism.
Cord injury is low.

C3 to T1
These levels are so similar they will
be considered as a unit.
The injuries are grouped by
mechanism into families.

The FAMILIES
Flexion
Flexion-rotation
Extension
Axial loading

FAMILY FLEXION
Motto: Anterior impaction,
posterior distraction.
Family members:

Wedge compression fracture

Hyperflexion sprain
Bilateral interfacetal dislocation
Hyperflexion teardrop fracture-dislocation
Spinous process fracture

Wedge Compression Fracture

Anterior-superior margin
of the body is fractured.
If loss of height less than
50%, one column injury
and so stable.
If height loss greater than
50%, posterior ligaments
presumed torn and so 3
column unstable injury.
If 3 bodies fractured,
unstable even if less than
50% height loss each.

Hyperflexion Sprain
Tear of the posterior
(stable), posterior/ middle
(unstable) and posterior/
middle/ anterior (unstable)
ligaments without
fracture.
One column stable, 2 or 3
unstable.
Delay in healing with
eventual surgical fusion
fairly common.
Can be a difficult
diagnosis.

Flexion-Extension Films
May be helpful in
ligament injuries
-but are-

Frequently useless due

to muscle spasm

Flexion-Extension films
Rules: Patient must be
alert, awake, not
intoxicated, able to sit
or stand, able to
understand commands,
and without
neurologic deficit.

It is an Active, patient-generated
STRESS TEST
NEVER help the
patient to improve
ROM.
NEVER do passive
ROM: this is a
neurosurgical
procedure done under
fluoroscopic control
and is controversial.

MRI
Gold Standard for
spinal canal, cord, disc
lesions.
Silver Standard for
ligament injuries, but
there is no Gold and
much better than plain
films, CT, and
flexion/extension.

Bilateral Interfacetal Dislocation

BID, also called locked
facets is anything but
locked. It is a severe 3
column injury that is
completely unstable.
Cord is injured in 2/3.
Body is subluxed
anteriorly at least 50%.
Marked posterior
distraction.

Hyperflexion Teardrop Fracturedislocation

Among the worst
survivable injuries,
with nearly 100%
severe cord lesion.
Completely unstable.
Little chance of
neurologic
improvement.

Hyperflexion Teardrop Fracturedislocation

CT Sagittal Reformat

Spinous Process Fracture

The clay shovelers
fracture.
Usually flexion, but
can be extension or
direct blow.
Stable if isolated, but
do CT to look for
associated posterior
arch fractures.

Spinous Process Fracture

CT Sagittal Reformat

FLEXION-ROTATION
Injuries
Unilateral Interfacetal Dislocation
and Fracture-dislocation

Unilateral Interfacetal
Dislocation
UID is not stable, as the
contralateral capsule
ligaments are torn.
Cord injury is uncommon,
but root injury is common,
and HNP also occurs.
Findings can be subtle:
less than 50% subluxation,
malalignment of spinous
processes.

CT: This is a normal facet joint,

normal hamburger sign

UID
CT: UID has
reversed hamburger
sign of facet joint.
CT is also more
sensitive for
associated lateral mass
fractures.

UID
Oblique view

CT Sagittal Reformat

EXTENSION Injuries
Family motto: Anterior
distraction, posterior impaction.
Posterior arch fractures
Extension teardrop fractures
Extension fracture-dislocations

Posterior Arch Fractures

Plain films are insensitive,
CT is outstanding.
Isolated: pedicle, lateral
mass, lamina or spinous
process.
Multiple fractures are
common. Pedicle/lamina
fractures cause freefloating lateral mass.
May be additional element
of lateral bending.
Stability depends on what
is fractured.

Extension Teardrop Fracture

Avulsion fracture caused
by anterior longitudinal
ligament.
Vertical narrow fracture of
anterior-inferior corner of
body.
Most common site is C2.
Unstable.

EXTENSION Fracturedislocation
More severe force
fractures the body
along end plate and
causes subluxation,
usually posterior.
Fracture is oriented
longitudinally, and
there is malalignment
of the bodies.

AXIAL Loading
Burst fractures
explode the body.
All are very unstable
and cause cord injury
in 2/3 (except C1).
There is usually an
element of flexion
also.

BURST Fractures
On lateral, body is
compressed anteriorly,
inferior end plate often
fractured, posterior
body contour is
convex.
On AP, body fracture
is vertical or oblique
and pedicles spread.

BURST Fractures
CT more accurately
displays the fracture
pattern and the very
important degree of
narrowing of the
spinal canal.

REMEMBER:
CT is much more sensitive for
fractures than plain films.
MRI is the standard for soft tissue
injuries.

GOODBYE AND GOOD

IMAGING!
Copyright 2004
M. I. Zucker