see also: [[Thoracic and lumbar trauma radiology]], [[Neck and spine trauma|c-spine trauma]] , [[SCIWORA]], [[paediatric c-spine]]
good [table in rosen](x-devonthink-item://949DFB87-DEB3-4BE2-818D-21D2B115168D?page=3) chpt 35 about MOI and stability , [A&E radiology - Cervical spine](x-devonthink-item://6D4FAD5A-4759-4128-ACFA-299C7E359B17?page=175)
#trauma #radiopaedia
> [!Key Points]
> - transverse foramen fracture is an indication for CT carotid angiogram if patient has not had it already, due to risk of vertebral artery traumatic occlusion (consider the [[Cervical spine trauma radiology#Blunt Cerebrovascular injury - Denver Criteria|Denver Criteria]] )
# Three columns
- applies to cervical spine same as to [[Thoracic and lumbar trauma radiology#Three columns of stability|thoracic and lumbar spine]]
![[Pasted image 20230420220647.png]]
# When to image?
see also: [C-spine clearance](https://davidlempert.com/medCMS/article/4#Spinal-Clearance-algorithm2)
## NEXUS
> can technically be used in kids, [[paediatric c-spine]] approach covers paediatric c spine in greater details
- midline cervical tenderness
- focal neurological deficit
- intoxication
- painful distracting injury
- altered mental status
*note, does not have mechanism of injury*
## Canadian C spine rule
age ≥ 16
- slightly better statistically
# X-Ray
- in general, do not perform in trauma patients
## evaluation
> [!info] Evaluation
> - **prevertebral thickness** - 7mm at C2, 2cm at C7 (*note, pre-vertebral fat can cause false positive*)
> - atlanto-dens interval <3mm
> - **alignment of vertebrae** (see pic below)
> - intervertebral disc spaces (check for widening)
> - facet joints alignment
> - interspinous distance
**ABCs of c-spine XR interpretation:**
***A - adequacy***
- C7 / T1 junction must be visible
***Alignment (4 lines)***
- anterior vertebral line
- posterior vertebral line
- spinolaminar line
- will sometimes show a slight step at the C2 level, particularly in children.
- Apply this rule: this step should not be more than 2 mm posterior to the smooth arc as it is traced upwards between C3 and C1 vertebrae.
- spinous process line
![[Pasted image 20250302225400.png|spinolaminar line in children]]
***B - bones***
- look at every vertebrae for fracture / collapse
- check anterior arch of c1 (looks like a small coffee bean in front of odontoid peg of c2)
- The gap between the Peg and the coffee bean should not exceed 3 mm in adults or 5 mm in children
![[Pasted image 20250302225131.png]]
![[Pasted image 20250302225001.png|normal lateral view]]
***C - cartilage (aka disc spaces)***
- symmetry
***S - soft tissue***
- check prevertebral swelling , ensure below maximal widths:
- C1-3: 1/3 vertebral body AP width (7mm)
- C4 down: ~1 VB (22mm)
***Pre-dental space (atlanto-dens interval)***
- damage to transverse ligament of atlas
- horizontal space between dens and anterior arch of atlas
- Normal: <3mm adults, <5mm children
***Power’s ratio***
- for atlanto-axial dislocation
- Normal = 1
- **\> 1 indicates anterior subluxation**
![[Pasted image 20250302223730.png]]
![[Pasted image 20230422123357.png]]
***Line of Swischuk***
- differentiates pseudosubluxation of C2 on C3 (normal) vs subluxation
- vertical line between C1 & C3 anterior spinous process
- anterior C2 spinous process should be <2mm from line
- \>2mm is subluxed, <2mm is pseudosubluxed
![[Pasted image 20250302223824.png]]
## Differences between paeds + adult C spine XR
- pseudo-subluxation of C2 on C3
- exaggerated atlanto-dens distance < 5mm
- variable anterior soft tissue width altering with head-positioning and crying;
- anterior wedging of the vertebral bodies (especially C3).
- Loss of normal C spine lordosis
## examples
![[Pasted image 20230422123715.png]]
^ anterior-superior corner fracture, angle to anterior-superior line. caused by flexion distraction injury in c-spine
![[Pasted image 20230422123804.png]]
^ increased inter-spinous distance
![[Pasted image 20230428213016.png]]
^ normal odontoid peg view
![[Pasted image 20230422122910.png]]
^ cranio-cervical dissociation
# CT Spine
>[!pearl] General Tidbits
>- on modern CT scanners, can do a fairly decent assessment of cord for signs of epidural haematoma
>- focus on cranio-cervical junction (easy to miss, eg occipital condyle fracture)
>- review each facet joint
>- Review axials, especially c1 and c2, review vertebral artery foramen, odontoid fracture, pedicle, laminae, transverse process fractures
## anatomy
### C1-C2 ligaments
*cruciate ligament* - hold dens in position and prevent pressure from dens on medulla
*alar ligaments* - from sides of dens to edge of foramen magnum, limit rotation
*tectorial membrane* - continuation of posterior longitudinal ligament
![[Pasted image 20250323074424.jpg]]
![[Pasted image 20250323074123.png]]
![[Pasted image 20230428212129.png]]
![[Pasted image 20250323074354.jpg]]
## Bone algorithm vs bone window
![[Pasted image 20230428210556.png]]
## paeds
keep in mind that ossificaiton centers have not fully fused, can be mistaken for a fracture
## Occipital condyle fracture
![[Pasted image 20230428211524.png]]
^ **potentially [[#Unstable C-spine fractures|unstable]].**
![[Pasted image 20230428211602.png]]
Concerning for alar ligament fracture
## atlanto-axial joint widening
![[Pasted image 20230428212400.png]]
\> 3mm
## cranio-cervical dissociation
![[Pasted image 20230428212511.png]]
## C1-C2 joint space widening
![[Pasted image 20230428212548.png]]
# Unstable C-spine fractures
see also: [[Neck and spine trauma#Unstable Fractures]]
## Jefferson's fracture (C1 burst fracture)
- look for evidence of any **avulsion fracture** of anterior band of the cruciate ligament , which can make these unstable.
![[Pasted image 20230428212914.png]]
^ note extra pre-vertebral soft tissue thickening
![[Pasted image 20230428213121.png]]
^ note anterior arch fracture and posterior arch fracture
![[Pasted image 20230428213354.png]]
^ note the **avulsion fragment** of the transverse portion of the the cruciate ligament
## odontoid peg fracture
> classification system does **not** correlate with stability; keep in strict spinal precautions until review by ortho/NSx
![[Pasted image 20230428213630.png]]
![[Pasted image 20230428213603.png]]
![[Pasted image 20230428213852.png]]
^ angulation and displacement of dens
*ligaments stabilise joints between C1 and C2*:
cruciate ligament - hold dens in position and prevent pressure from dens on medulla
alar ligaments- from sides of dens to edge of foramen magnum, limit rotation
tectorial membrane - continuation of posterior longitudinal ligament
2 lateral atlanto-axial joints (facet joints) are synovial joints, between inferior artericular facet of atlas and superior articular facet of axis on each side.
median atlanto-axial joint - synovial joint between anterior arch of C1 and dends, a pivot joint
![[Pasted image 20241026124112.jpg]]
![[Pasted image 20241026124126.jpg]]
![[Pasted image 20241026124139.jpg]]
## hangman's fracture (bilateral pedicle C2)
![[Pasted image 20230429205412.png]]
## Teardrop fractures
### hyperextension teardrop
- better of the two
- usually upper cervical spine
- isolated **anterior column injury**, middle column and posterior ligaments usually intact
- low association with cord injuries
-
![[Pasted image 20230429211210.png]]
### hyperflexion teardrop
- worse of the teardrop fractures
- middle column alignment disruption and dwidening of facet joint
![[Pasted image 20230429211320.png]]
![[Pasted image 20230429211445.png]]
^ very commonly have vertical fracture extending through middle of vertebral body . this patient also has bilateral laminae fractures
![[Pasted image 20230429211612.png]]
MRI of above patient: pre-vertebral haematoma, disruption of anterior disc, cord with high signal in cord and dark signal in the middle (haemorrhage), poor prognosis. slight tear in ligamentum flavum.
## bilateral facet displacement
![[Pasted image 20230430210938.png]]
^ C6-C7 anterior dislocation, there is a perched facet joint bilaterally (not seen in this study). also, occipital condyl fracture. warrents a carotid angiogram. Also lots of disc widening, suggesting complete rupture of disc and ligament structures
> if vertebral body displaced forward by 50%, need to have bilateral facet dislocations or fractures
![[Pasted image 20230430211531.png]]
^ same patient MRI. Note ligamentum flavum tear, as well as bad cord signal as seen in the [[Cervical spine trauma radiology#hyperflexion teardrop]] case. Also **epidural haematoma** same signal as cord that is pushing the dura in. Note a lot of disc materal behind injury impinging on cord
> MRI valuable prior to surgery to see if there is a lot of disc materal behind such that placing vertebral body back might cause further impingement on the cord
### epidural haematoma easier to see on T1 image
![[Pasted image 20230430212101.png]]
## Role of MRI
- Look for epidural haematoma
- look for disc herniation
- prognostication
- MRI is especially useful in older patients with degenerative disc disease
See: [[#literature on c-spine clearance]]
### example of MRI benefit
![[Pasted image 20230430212804.png]]
However, MRI shows anterior ligament tear and prevertebral fluid
![[Pasted image 20230430212844.png]]
BUT does this change management??
# Classification of spinal injury
see also: [Moore Trauma Chpt 23](x-devonthink-item://3673A856-E48F-44F0-83B7-25775BEEF8BF?page=480) , [Rosens chpt 35spinal trauma](x-devonthink-item://949DFB87-DEB3-4BE2-818D-21D2B115168D), [Cameron 3.3 Spinal trauma](x-devonthink-item://10DC3BB1-027C-40D6-BDB3-4AF0C6B160E6?page=104)
![[Pasted image 20230429203407.png]]
# Spinal cord syndromes
see: [Rosen Chpt 35](x-devonthink-item://949DFB87-DEB3-4BE2-818D-21D2B115168D?page=20) and [Moore's Trauma spinal cord syndromes](x-devonthink-item://3673A856-E48F-44F0-83B7-25775BEEF8BF?page=481&start=4281&length=20&search=Neurologic%20Syndromes) and [[Dermatomes#Spinal exam]]
| | motor | pain/temp | proprioception/light touch |
| :--- | :--- | :--- | :--- |
| brown-sequard | ipsilateral loss | contralateral loss | ipsilateral loss |
| anterior cord | loss below injury | loss below injury | preserved |
| central cord | upper loss > lower loss | upper loss > lower loss | preserved |
## anatomy of spinal cord
![[Pasted image 20230430214149.png]]
![[Pasted image 20230430214245.png]]
![[Pasted image 20230430214449.png]]
![[Pasted image 20230430215014.png]]
![[Pasted image 20230430215427.png]]
## central cord syndrome
- Traumatic central cord syndrome (TCCS) is associated with a contusion, ischemia or hemorrhage in the central portions of the spinal cord due to traumatic injury sustained in the cervical or upper thoracic spine.
- The syndrome is characterized by ==weakness in the arms with “burning hands”== and ==relative sparing of lower extremity motor function, associated with variable sensory loss.==
- TCCS typically results from a ==cervical hyperextension injury== in patients with preexisting degenerative changes and narrowing of the spinal canal.
- Clinically, the upper extremities are more involved than the lower extremities due to the more central location of the upper extremity axons within the spinal cord tracts.
- Patients typically regain the ability to walk, but have more limited return of function to the upper extremities.
## dorsal cord syndrome
**Dorsal cord syndrome** results from the bilateral involvement of the dorsal columns, the corticospinal tracts, and descending central autonomic tracts to bladder control centers in the sacral cord.
- Dorsal column symptoms include gait ataxia and paresthesias. Corticospinal tract dysfunction produces weakness that, if acute, is accompanied by muscle flaccidity and hyporeflexia and, if chronic, by muscle hypertonia and hyperreflexia. Extensor plantar responses and urinary incontinence may be present.
- **Causes of a dorsal cord syndrome** include multiple sclerosis (more typically the primary progressive form), tabes dorsalis, Friedreich ataxia, subacute combined degeneration, vascular malformations, epidural and intradural extramedullary tumors, cervical spondylotic myelopathy, and atlantoaxial subluxation.
# Blunt Cerebrovascular injury - Denver Criteria
See also [[Neck and spine trauma#Penetrating neck injury]]
**Criteria for carotids and vertebral arteries imaged:**
***Signs and symptoms:***
- arterial haemorrhage
- cervical bruit in patient < 50 years old
- expanding cervical haematoma
- focal neurological deficit
- neurological exam incongruous with head CT scan findings
- stroke on secondary CT scan
***Risk factors include high-energy transfer mechanism with:***
- Le fort fracture : type 2 or 3
- base of skull fractures involving the carotid canal
- diffuse axonal injury with a GCS <6
- cervical spine fractures that involve C1-3, and/or the transverse foramen fractures
- cervical spine subluxation
- near hanging with hypoxic-ischaemic brain injury
![[Pasted image 20230430215216.png]]
# literature on c-spine clearance
- [Evaluation of Cervical Spine Injuries](bookends://sonnysoftware.com/ref/DL/105196)
- Summary article
- Mentions their own meta-analysis [Utility of MRI for cervical spine clearance after blunt traumatic injury: a meta-analysis.](bookends://sonnysoftware.com/ref/DL/232173)
- mentions **Eastern trauma** research on safety in obtunded patients [Cervical spine collar clearance in the obtunded adult blunt trauma patient: a systematic review and practice management guideline from the Eastern Association for the Surgery of Trauma.](bookends://sonnysoftware.com/ref/DL/217578), which notes "There is a worst-case 9% (161 of 1,718 subjects in 11 studies) cumulative literature incidence of stable injuries and a 91% negative predictive value of no injury"
- See also: [Evaluation of Cervical Spine Clearance by Computed Tomographic Scan Alone in Intoxicated Patients With Blunt Trauma.](bookends://sonnysoftware.com/ref/DL/253981)
- mentions **western trauma** research unlikely to find clinically significant injury if negative CT [Cervical spinal clearance: A prospective Western Trauma Association Multi-institutional Trial.](bookends://sonnysoftware.com/ref/DL/93460), with 0.03% false negative CT for clinical signifigant injury, **all had neurology concerning for [[#central cord syndrome]]**, and two of three scans had severe degenerative disease. Overall take home is reasonable to do MRI if they have neurology
- [Magnetic resonance imaging cervical spine in trauma: A retrospective single-centre audit of patient outcomes.](bookends://sonnysoftware.com/ref/DL/99046)
- EMA article 2022
- Of 181 patients with negative CT who had MRI for midline tenderness only, 146 had negative MRI, 35 had positive (19%), for which 21 received no treatment and 14 had a rigid collar (7.7% of total CT negative patients with midline tenderness needed any treatment).
- Of 47 patients with neurology and negative CT, 36 had normal MRI (76%) and 11 had abnornal MRI (23%), of whom 2 needed surgery (4.2% of all ct negative with neurology) and 4 a rigid collar
- [Clinical significance of "positive" cervical spine MRI findings following a negative CT.](bookends://sonnysoftware.com/ref/DL/22476)
- Disscusses how ct good for issolated cervicalgia but MRI if neurology
- Good pictures
- Reviews ReConnect data from their hospital (see below for Reconnect trial)
- [Cervical spine MRI in patients with negative CT: A prospective, multicenter study of the Research Consortium of New England Centers for Trauma (ReCONECT).](bookends://sonnysoftware.com/ref/DL/248419)
- In a select population of patients, MRI identified additional injuries in 23.6% of patients despite a normal CSCT. It is uncertain if this is a true limitation of CT technology or represents subtle injuries missed in the interpretation of the scan. The clinical significance of these abnormal MRI findings cannot be determined from this study group.
- [Impact of MRI to clear the cervical spine after a negative CT for suspected spine trauma.](bookends://sonnysoftware.com/ref/DL/229152)
- discusses mechanisms of injury and costs
# Related Questions
## blunt cerebrovascular injury
- 3Q: [Blunt cerebrovascular injury](x-devonthink-item://9C485EF0-3985-4EBA-B9DC-9CDF8A6E2F45?page=5) -- [Answer](x-devonthink-item://A0D348CE-FCD4-4ECD-BE21-6CA73F6DE8CD?page=9)
## central cord syndrome
- 5Q: [Central Cord Syndrome](x-devonthink-item://EDAB8F09-3068-4C91-874B-E205EA17F631?page=19) -- [Answer](x-devonthink-item://E624826E-2062-41B8-96C9-ECEA0E1BDF54?page=10)
## cord syndromes
- 6Q: [Elderly patient with Neck Injury](x-devonthink-item://2CAEF14B-356F-45F8-834C-4766A58A56A9?page=2) -- [Answer](x-devonthink-item://98D17FA0-225B-4E94-B21C-4E36D5C76A7C?page=0)
## ct spine
- 8Q: [Hypotensive Trauma Patient](x-devonthink-item://73409C77-B2FA-4E0A-AEB3-5EB284457F0C?page=50) -- [Answer](x-devonthink-item://5A848952-80E3-4184-B553-368412A69917?page=33)
## hanging
- 14Q: [Hanging](x-devonthink-item://4BE7EDE1-1843-4BA0-B8D2-0DCEF50784D4?page=5) -- [Answer](x-devonthink-item://15F8F701-8EC8-4F9A-8DEC-5220C8561C8A?page=5)
## head ct
- 15Q: [Head Injury](x-devonthink-item://C1DDA3AB-2DA2-4922-A8A6-F597AB7E2558?page=1) -- [Answer](x-devonthink-item://A10DE51E-92FA-42D1-8AA0-7AE68C2FA743?page=11)
## imaging
- 16Q: [Imaging in trauma](x-devonthink-item://2F267333-5FEC-47E5-83D1-CC05B23EB91A?page=9) -- [Answer](x-devonthink-item://C6CAC39D-CAE8-4F76-9C45-689A0464D936?page=6)
## prognostication
- DUPLICATE Q: [Hanging](x-devonthink-item://4BE7EDE1-1843-4BA0-B8D2-0DCEF50784D4?page=5) -- [Answer](x-devonthink-item://15F8F701-8EC8-4F9A-8DEC-5220C8561C8A?page=5)
- 19Q: [Post Arrest](x-devonthink-item://EE0B8625-5F19-46CF-8208-56D79DC48BC5?page=1) -- [Answer](x-devonthink-item://6F751245-A36C-447A-8AE7-599AD5871C71?page=10)
## spinal injury
- 20Q: [Paralysis after Rugby Injury](x-devonthink-item://CDB16617-3785-40E5-B8BE-5668D2D7A3E7?page=4) -- [Answer](x-devonthink-item://A6CA01E8-9551-45E7-8617-441BE3DBB5D7?page=3)
## trauma
- 28Q: [Traumatic arrest](x-devonthink-item://1A14F7A1-E434-47A6-BC68-AF2DD1A7C090?page=16) -- [Answer](x-devonthink-item://736EC9CD-AC9C-4588-BA1E-F4AD190CBA47?page=38)
- 29Q: [Open ankle fracture](x-devonthink-item://09493372-578D-4C97-972A-EEC617B38B53?page=8) -- [Answer](x-devonthink-item://A0D348CE-FCD4-4ECD-BE21-6CA73F6DE8CD?page=4)
- 30Q: [Motorbike accident](x-devonthink-item://1A2C485F-D4AD-4821-AFF2-452BA753717F?page=46) -- [Answer](x-devonthink-item://FD716379-1A77-4B5B-B257-1154995ECA6E?page=30)
- 31Q: [Motorcycle Vs Kangaroo](x-devonthink-item://73409C77-B2FA-4E0A-AEB3-5EB284457F0C?page=36) -- [Answer](x-devonthink-item://5A848952-80E3-4184-B553-368412A69917?page=25)