Cervical Spine Injury

Last Updated on by FRCEM Intermediate

X-ray Views

  • anterior-posterior (AP),
  • lateral and
  • peg views

For Imageshttps://www.radiologymasterclass.co.uk/tutorials/musculoskeletal/x-ray_trauma_spinal/x-ray_c-spine_normal

Lateral film

  • C-spine – Systematic approach
  • Coverage – Adequate? – Adequacy Visible base of skull to top of body of T1
  • Alignment – Anterior/Posterior/Spinolaminar
  • Bones – Cortical outline/Vertebral body height
  • Spacing – Discs/Spinous processes
  • Soft tissues – Pre-vertebral
    • C1-4 max of 7mm (30% of vertebral body width) <C4
    • C5-7 max of 22mm (100% of vertebral body width) >C4
  • PEG anterior arch of C1 no more than 3mm in adults (5mm in children) space between anterior arch of C1 and PEG

AP View

  • Spinous processes should be in a straight line except if bifid spinous process
  • The distance between spinous processes approximately equal

Odontoid Peg View

  • Lateral margins of C1 should lie within lateral margins of C2
  • Spaces on each side of peg should be equal slight variation if the neck is slightly rotated

Compression – C1’Jefferson’ fracture

  • burst # of atlas (C1)
  • combined anterior and posterior arch fractures
  • from axial compression of C1
  • can result from hyperextension causing a posterior arch #
  • typical history: diving head first into water, thrown against roof of car
  • unstable

Hyperflexion

  • Tear Drop Fracture
    • This fracture may occur at any level between C3 and C7.
    • It is a highly unstable injury with a high incidence of associated spinal cord injury.
  • Odontoid Peg Fracture
    • The C2 bone ‘ring’ is incomplete due to a fracture
    • The odontoid peg is displaced posteriorly
    • It is uncommon to see such an obvious fracture on the open mouth view – many fractures of the odontoid peg are more readily seen on the lateral view

Hyperextension –

  • C2 ‘hangman’ fracture
    • hyperextension fracture through pedicles of C2 following hyperextension with distraction or compression.
    • Results from judicial hanging (rather than suicidal which causes asphyxiation) or from striking chin on the steering wheel in a collision
    • Unstable
  • Extension teardrop’ fracture
    • A fracture fragment is seen at the anterior/inferior corner of C2 resembling a ‘teardrop’
    • Hyperextension may result in avulsion of the anterior corner of a vertebral body – most commonly C2.
    • The anterior longitudinal ligament remains attached to the bone fragment which is separated from the vertebral body.

Rotation

  • Facet joint dislocation
    • It is possible to sustain severe C-spine or spinal cord injury without evidence of a fracture
    • The pre-vertebral soft tissue is widened due to a haematoma

Pre-vertebral soft tissue

  • At the level of C3 the pre-vertebral soft tissue is thickened – ( >1/3rd the width of the vertebral body)
  • This soft tissue swelling is the only visible sign of injury

Children

  • Pseudosubluxation refers to the appearance of forward slippage of one vertebral body on another (see figure 7); pseudosubluxation of C2 on C3 occurs in 24% of under 8 year olds and of C3 on C4 in14% of under 8 year olds
  • SCIWORA (Spinal Cord Injury without radiological abnormality) which is defined as objective signs of myelopathy as a result of trauma with no evidence of fracture or ligamentous instability on plain radiographs or tomography.

Cervical spine protection is indicated in the following trauma settings

  • Neck pain or neurological symptoms
  • Altered level of consciousness
  • Significant blunt injury above the level of the clavicles

 Clearing C-spine Clinically

NEXUS LOW PROBABILITY CRITERIA

  • No midline cervical tenderness
  • No focal neurological deficit
  • Normal alertness
  • No intoxication
  • No painful distracting injury

Canadian C-spine rule

The person with suspected spine injury should be assessed as having high, low or no risk of cervical spine injury using the following rule:

  • the person is at high risk if they have at least one of the following high‑risk factors:
    • age 65 years or older
    • dangerous mechanism of injury (fall from a height of greater than 1 metre or 5 steps, axial load to the head – for example diving, high‑speed motor vehicle collision, rollover motor accident, ejection from a motor vehicle, accident involving motorised recreational vehicles, bicycle collision, horse riding accidents)
    • paraesthesia in the upper or lower limbs
  • the person is at low risk if they have no high-risk features and at least one of the following low‑risk factors:
    • involved in a minor rear‑end motor vehicle collision
    • comfortable in a sitting position
    • ambulatory at any time since the injury
    • no midline cervical spine tenderness
    • delayed onset of neck pain
  • the person remains at low risk if they are:
    • unable to actively rotate their neck 45 degrees to the left and right (the range of the neck can only be assessed safely if the person is at low risk and there are no high‑risk factors).
  • the person has no risk if they:
    • have one of the above low‑risk factors and
    • are able to actively rotate their neck 45 degrees to the left and right.

Applying the Canadian C‑spine rule to children is difficult and the child’s developmental stage should be taken into account.

When to add the CT C-spine in adults?

  • if you’re scanning other areas
  • if they’re going for urgent surgery
  • if GCS<13
  • intubation
  • if c-spine injury suspected and
    • any neuro signs or symptoms
    • dangerous mechanisms
    • age >65
  • if any issues with the c-spine film then CT

 When to add the CT C-spine in kids?

  • similar to above but without the dangerous mechanism bit
  • if dangerous MOI present then they encourage plain film first
    • note that dangerous MOI for paeds c-spine is 1 m fall but for head injury it’s 3m

Guidelines: https://www.nice.org.uk/guidance/cg176/resources/imaging-algorithm-pdf-498950893

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