Cranio-cervical and upper cervical stability is dependent on transverse, superior and inferior bands of the C1-C2 ligament, alar ligaments, along with a few other ligaments
Cervical Trauma
The C/S is vulnerable to injury. Why?
Stability has been sacrificed for greater mobility
Cervical vertebrae are small and interrupted by multiple foraminae
The head is disproportionately heavy and acts as an abnormal lever especially when forces act against a rigid torso
Additionally, C/S is prone to degeneration which makes it more vulnerable to trauma
In young children, ligaments are more luxed vs. disproportionately large head size
In children, the fulcrum of movement is at C2/3 thus making injuries more common in the upper C/S and craniocervical junction. In children, S.C.I.W.O.R.A. may occur when no evidence of fracture present
In adults, the fulcrum of movement is at C5/6 thus making lower C/S more vulnerable to trauma especially during extremes of flexion
Cervical Trauma categorized according to mechanisms of injury (Harris & Mirvis classification)
Hyperflexion Injury: Stable vs. Unstable
Flexion teardrop Fx (most severe fracture, unstable)
Begins with x-radiography especially in cases with no significant neurological compromise
Clear neutral lateral view first
If x-radiography is unrewarding but high probability of severe trauma and neurological deficit present, CT scanning w/o contrast is required
Consider CT scanning in patients with pre-existing changes: advance spondylosis, DISH, AS, RA, post-surgical spine, congenital abnormalities (Klippel-Feil syndrome, etc.)
Vertical compression:
Jefferson aka burst Atlas Fx (unstable especially if the Transverse ligament is torn, cord paralysis in 20-30% only)
Why? Due to fragments dissociation and canal widening
Burst Fx of the Thoracic or Lumbar spine (unstable, cord paralysis may occur)
How to Assess Spinal Radiographs in Trauma Cases:
Construct 5-lines on the lateral view
Note if facets are well-aligned and symmetrical
Ensure symmetry of the disc height
Note any widening or fanning of the inter-spinous distance
Carefully examine prevertebral soft tissues
Evaluate atlanto-dental interval (ADI)
In cases of trauma, evaluate and clear neutral lateral first
Do not perform flexed and extended views in acute cases before x-rays or CT scanning exclude significant instability
Pay extra attention to prevertebral soft tissues
If thicker than normal limits, consider severe post-traumatic bleed
Subtle asymmetry and widening of posterior disc height and facets with inter-spinous fanning may be a key feature of significant tearing of posterior ligaments
Hyperflexion Injuries (M/C Mechanism)
More frequent in sub-axial C/S C-3-C7)
Unstable injuries:
Flexion teardrop fracture (M/C C5 & C6) v. unstable
Key rad features:
Large "teardrop" triangular anterior body fragment
Fanning of the SPs, posterior disc and facet widening indicating tearing of major spinal ligaments and instability
A posterior shift of the vertebral body fracture suggests direct anterior cord/vessels compression
Bulging prevertebral soft tissue >20-mm at C6-7
80% of cases may be paralyzed on the spot or develop significant paralysis soon after
Acute Neck Trauma. What are the vital radiographic features? What is the diagnosis?
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Dr. Alex Jimenez DC, MSACP, CCST, IFMCP*, CIFM*, ATN*
email: coach@elpasofunctionalmedicine.com
phone: 915-850-0900
Licensed in: Texas & New Mexico*