This document provides an overview of c-spine trauma, including the Nexus and Canadian c-spine rules for clinical assessment and imaging criteria. It discusses various c-spine injury types from different mechanisms of injury such as flexion teardrop fractures from hyperflexion and hangman's fractures from hyperextension. Imaging guidelines for radiography, CT, and MRI are provided. Examples of c-spine fractures are reviewed in quiz cases along with features to determine stability and need for further workup.

1. C-SPINE TRAUMA
JULIANA TSURUTA
Radiology Fellow
12/05/2016

2. TOPICS
• Clinical assessment
• Imaging
• Injuries
• Management
• Quiz

3. NEXUS CRITERIA
• Sensitivity(S) 99.6%
• No age cut-off however
– >65 y.o - S:66-84%
• Safely reduce imaging 12-36% - cost

4. NEXUS CRITERIA
• Midline cervical spine tenderness
• Focal neurological deficit
• Intoxication
• Painful distracting injury
• Altered mental status
– GCS < 15
– Disorientation in time, place, person or event
– Inability to recall 3 objects at 5 minutes
– Delayed or inappropriate response to stimulus

5. NEXUS CRITERIA
• If ALL criteria are negative:
– No need for imaging
• If positive:
– CT
– MRI

6. CANADIAN C-SPINE RULE (CCR)
• For all alert (GCS = 15) and stable trauma
patients where cervical spine injury is a
concern

8. Harborview criteria:
- Presence of significant head injury
- Presence of focal neurological deficit(s)
- Presence of pelvic or multiple extremity
fracture
- Combined impact of accident >50km/h
- Death at the scene of the MVA
- Accident involved a fall from a height ≥ 3m

10. IMAGING
• Radiography vs CT
– Low x high risk of CSI
– Accuracy
– Ionising radiation
– Cost

11. IMAGING
• Literature:
– Combined S of plain films 53% vs CT 98%
– Five-views plain films failed to identify 52% of
cervical spine fractures identified by CT imaging
– Choose CT
– 3 view plain film: If CT not available
• AP
• Lateral
• Odointoid
TC PLAIN FILMS
Se 97.4 44
Sp 100 100
PPV 100 100
NPV 99.7 93.2

12. IMAGING
• Obtunded/unexaminable patients:
– Flexion and extension fluoroscopy: inadequate
– MRI: despite negative CT, if clinical suspicious
persists
• Improved the probab of identifying significant CSI by
8%
• Controversial

13. IMAGING
• Signs of instability:
– More than one vertebral column involvement
– Increased or reduced intervertebral disc space
height
– Increased interspinous distance
– Facet joint widening
– Vertebral compression greater than 25%

14. IMAGING
• Normal

17. NORMAL PREDENTAL SPACE:
- < 3 mm in adults
- <5 mm in children
C1 C2

18. HARRIS’ RING:
- The ring should be complete
C1
C2

19. The spinolaminar line
should intersect the
opisthion

20. Basion-Dental Interval:
- Distance between the tip of
the clivus (basion) should be
<12mm (XR) and <8.5mm
(CT) from the tip of the dens

21. Posterior axial line:
-a line drawn along the
posterior VBs should be
<12mm from the basion

22. Lateral aspects of the lateral
masses should have <1-2mm of
malalignment
The atlanto-dental
spaces should be
symmetric
LATERAL MASS ALIGNMENT

23. Smooth contours of the 4
following lines:
- Anterior VB line
- Posterior VB line
- Articular pillars
- Spinolaminar line

24. Important: focal contour
abnormality!!
C2: <7mm
C3-C4: <5mm
C6: <22mm (adults) / <14mm
(children >15yo)

25. IMAGING
• Mechanism
– Hyperflexion: most common
• Flexion teardrop fracture
• Clay-shoveler fracture
• Facet dislocation
– Bilateral (no rotation)
– Unilateral (with rotation)
• Anterior subluxation

26. FLEXION TEARDROP FRACTURE
• Flexion and compression: C5/6
• Anterior cervical cord syndrome and quadriplegia
• Radiographic features:
– Sagittal fracture through the vertebral body (VB)
– Fracture of AI VB
– Loss of anterior height of VB
– Cervical kyphosis
– Posterior cervical displacement above the level of injury
– Widening of interspinous processes
– Intervertebral disc space narrowing
– Disruption of the spinolamellar line
– VB rotation with an AP diameter that appears smaller than on other
levels
– Anterior dislocation of facet joints

28. FLEXION TEARDROP FRACTURE
• DDX: extension teardrop fracture
• MRI for further spinal cord injury
• CTA for blunt cerebrovascular injury
• Unstable

29. CLAY-SHOVELER FRACTURE
• Fracture of spinous process of lower cervical
spine (C7)
• Usually a stress fracture
• Acute onset: MVA, muscle contraction and
direct blows to the spine
• Stable

31. FACET DISLOCATION
• Anterior displacement of one vertebral body
on another
• Forced flexion and distraction
• Bilateral: unstable (no rotation)
– Associated with significant spinal cord injury
– Bowtie sign
• Unilateral: stable (with rotation)
– Associated with monoradiculopathy that improves
with traction

33. ANTERIOR SUBLUXATION
• Hyperflexion sprain
• Ligamentous injury
– If not diagnosed: delayed instability
• Usually stable
• Radiographic features:
– Kyphotic deformity
– Widened spinous processes
– Widened of the posterior aspect of the involved disc
space
– May have associated wedge fracture

35. IMAGING
• Mechanism
– Hyperextension:
• Hangman fracture
• Extension teardrop fracture

36. HANGMAN FRACTURE
• Traumatic spondylolisthesis of axis
• Never seen in hanging
• High speed MVA
• Bilateral lamina and pedicle fracture at C2
• Usually associated with anterolisthesis of C2 on
C3
• If extension to transverse foramina: ?vertebral
artery injury
• Stable/unstable (if facet dislocation)

38. EXTENSION TEARDROP FRACTURE
• Avulsion of anteroinferior corner of the VB
• Unstable
• Older: C2
• Radiographic features:
– Avulsion fracture of the attachment of the
anterior longitudinal ligament
– Fragment is triangular in shape (teardrop)
– Vertical height of fragment is equal or greater
than width

39. C3
C2
C2

40. EXTENSION TEADROP FRACTURE
• Additional features are common: CT is
indicated in all cases

41. IMAGING
• Mechanism:
– Axial compression:
• Jefferson fracture
• Burst (compression) fracture

42. JEFFERSON FRACTURE
• Burst fracture of C1
• Diving head first into shallow water
• Not normally associated with neurological deficit
– Retropulsed fragment
• Associations:
– Other C-spine injuries (50%)
– C2 fracture (33%)
– Head injury (children 25-50%)
– BCVI – vertebral artery injury
– Extra-cranial nerve injury

43. JEFFERSON FRACTURE
• Radiographic features:
– Asymmetry in odontoid view:
• Displacement of lateral mass(es) away from dens
– Usually involves anterior and posterior arch
• Unstable

46. BURST FRACTURE
• High energy axial loading
• Disruption of posterior VB cortex with
retropulsion into the spinal canal
• Common: thoracolumbar transition zone
• Fall from significant height
• Unstable

47. BURST FRACTURE
• Radiographic features:
– Loss of vertebral height
– Disruption of posterior VB cortex
– Retropulsed fragments may occur
– Interpedicular widening
– Vertical fracture through posterior elements
• DDx:
– Wedge fracture
– Chance fracture
– Osteoporotic compression fracture

49. IMAGING
• Mechanism
– Complex injuries:
• Odontoid fracture
• Atlanto-occipital dissociation

50. ODONTOID FRACTURE
• Peg or dens fracture
• Flexion or extension with or without compression
• Common
• Classification:
– Anderson and D’Alonzo
• Most commonly used
• Level of fracture line
– Roy-Camille
• Better correlate with prognosis
• Plane of fracture and displacement

51. ODONTOID FRACTURE
Rare/stable
Common/unstable/po
or healing
Usually stable/better
prognosis than II

53. ODONTOID FRACTURE
• DDx:
– Os odontoideum
– Persistent ossiculum terminale
– Mach effect

54. MACH EFFECT
OS ODONTOIDEUM
PERSISTENT OSSICULUM
TERMINALE

55. ATLANTO-OCCIPITAL DISSOCIATION
• Atlanto-occipital dislocations and subluxations
• Unstable:
– Tectorial membrane and alar ligaments
• Uncommon
• Fatal
• More common in children: larger head
• Up to 50% are overlook initially

56. ATLANTO-OCCIPITAL DISSOCIATIONS
• Radiographic features:
– Disruption of normal alignment
– Basion-dens interval (BDI)> 10 mm in adults
– Basion-axial interval (BAI) > 12 mm in adults
– Atlantodental interval
• > 3 mm in adult males
• > 2.5 mm in adult females

57. BDI ADI BAI

59. QUIZ

60. CASE 1
• 31y.o male
• MVA

61. • What is the type of fracture?
• Any other associated injury?
• Unstable or stable?

63. • Hangman fracture
• Extension to the foramina
• CTA: left vertebral dissection
• Unstable

64. CASE 2
• 35 y.o
• Thrown off a horse
• Landed on head
• Hyperextension injury
• Was paralysed for 15 min. Normal now.

65. • Type of fracture?
• Unstable or stable?

67. • Type III odontoid peg fracture with up to 5
mm displacement of the superior fragment
posteriorly with some narrowing of the spinal
canal at this level.
• There is posterior subluxation of C1 lateral
masses on C2.
• Usually stable.

68. • After 3 months

70. CASE 3
• 22 y.o male
• Forced hyperflexion injury following tackle
during AFL
• Felt click
• Midline tenderness at C2-C4 with right
paravertebral spasm
• No focal neurology

71. • Type of injury?
• Stable or unstable?
• Other associated injuries?

73. • Unilateral facet-joint fracture-dislocation at
the right C3/4 level (perched)
• With comminuted fracture associated through
the inferior tip of the right inferior articular
facet of C3 with 5 mm superior displacement
• Anterolisthesis of C3 (4mm)
• Ligamentous/spinal cord injury – MRI
• Vertebral artery injury – CTA

74. CASE 4
• 85 y.o female
• Nursing home
• Unwitnessed fall
• Midline tenderness
• Recent C2-C6 fractures March 2014
• Left humerus and clavicular fracture

75. • Type of fracture?
• Complication?
• Stable or unstable?

78. • Type II odontoid peg fracture
• Minimal posterior displacement
• Unstable
• Non union is highly frequent

79. CASE 5
• 28 y.o. male
• MVA

80. • Type of fracture?
• Stable or unstable?

82. • Extension teardrop fracture
• Anteroinferior avulsion of C2 vertebral body

83. CASE 6
• 26 y.o. male
• MVA

84. • Mechanism of injury?
• Radiographic features?

86. • Hyperextension injury
• Radiographic features:
– Widened anterior disc space
– Anterior avulsion fracture
– Narrowing/impaction of posterior elements

87. • Anterior wedging of the C6 and C7 vertebral bodies
with widening of the C6/7 disc space
• Fracture lines extends through both C6 laminae
• Small osseous fragments are noted at the right C6/7
neural exit foramina
• Superior end plate fracture of C7 which extends to
traverse the right vertebral artery foramen
• The left vertebral artery foramen is also traversed by a
fracture line
• Ligamentous injury – MRI
• Vertebral artery injury – CTA

88. CASE 7
• 32 y.o. male
• Previous C1 fracture
• Assess fracture healing

89. • Type of fracture?
• Do you see any sign of healing?

91. • Jefferson fracture (burst fracture of C1)
• Oblique fractures of C2 and C7 again noted
• C1 fracture demonstrates interval bony
remodeling and bony bridging at the posterior
arch. The left anterior arch component
remains unfused with callus and bony
remodelling

92. References
• AFP vol 41 no 4 April 2012 pages 196-201
• ANZCOR Guideline 9.1.6 Jan 2016
• Trauma Victoria – Spinal Trauma Guideline
• NEXUS Criteria
• AANS – guidelines for the management of acute cervical spine and spinal
cord injuries
• Radiology: Volume 263: Number 3—June 2012
• RadioGraphics Volume 8,Number 4 }uly,1988
• http://www.imagingpathways.health.wa.gov.au/index.php/imaging-
pathways/musculoskeletal-trauma/bone-and-joint-trauma/cervical-spine-
injury#pathway
• Radiopaedia.org
• Radiologyassistant.nl
• Neurosurgery 72:54-72, 2013
• https://www.youtube.com/watch?v=skLoiQgzi5s