Cervical Spine Trauma

Edward C. Fritsch, D.C.

Assistant Professor of Radiology
Texas Chiropractic College
CERVICAL TRAUMA SERIES
■ Neutral Lateral
◆ Erect vs. cross-table

■ APOM & APL5

■ Bilateral Obliques
■ Flexion & Extension Lateral
■ Extra views
◆ Pillar views
◆ Lateral bending views
Cervical Spine
Neutral Lateral Cervical Spine
■ Prevertebral soft tissues:
◆ In adults:
✦ No more than 5mm at C3 & C4
✦ Less than 22 mm at C6

◆ In children:
✦ Two thirds of the width of C2 body at C3 and C4.
✦ Not more than 14 mm at C6.
Pre-vertebral Soft Tissues
Pre-vertebral Soft Tissues
Pre-vertebral
Soft Tissues
Neutral Lateral Cervical Spine
■ Cervical lordosis:
◆ Reversal - indicates myospasm
◆ Hypolordosis - may represent muscle spasm;
normally absent in 20% of patients
◆ It is absent in 70% of normal patients if the
chin is depressed only 1 inch.
Reversed Cervical Lordosis
Neutral Lateral Cervical Spine
■ Four continuous curves describe the normal
position of the bony elements:
◆ Anterior vertebral body line
◆ Posterior vertebral body line
◆ Spinal laminar line
◆ Posterior spinous process line
Neutral Lateral Cervical Spine
 Neutral Lateral Cervical Spine

■ Abnormal fanning of the spinous

■ Abrupt change in overlap of
facets indicates an abnormal
rotation.
■ Dens is normally tilted
posteriorly on the body of C2.
Neutral Lateral Cervical Spine

■ Atlantodental
interspace (ADI)
◆ Adults <3 mm and
does not change with
flexion
◆ Children = 5mm and
may change by 1 to 2
mm with flexion.
AP Cervical Spine
■ May provide a valuable clue to spinous
process avulsion.
■ The spinous processes should form a
continuous line .
■ Evaluate articular pillars.
Oblique Views
■ Used to evaluate posterior elements for
fracture and confirm normal overlap of
facets.
◆ Perched facets
◆ Articular pillar fractures
LPO / RAO RPO / LAO
AP Open-mouth View
■ Used to evaluate the odontoid process for
fracture.
■ Used also to evaluate the integrity of the
ring of the atlas (Jefferson’s Fracture).
Other films:
■ Lateral flexion & extension views:
◆ Help evaluate the extent of the injury and the
degree of stability
◆ The patient is allowed to flex and extend alone,
without force.
◆ A physician must supervise the filming, and the
patient should be awake, cooperative, and
neurologically intact.
Other films:
■ Pillar views:
◆ Used to profile the facets & articular pillars.
◆ Watch for facet compression or fracture,
especially in hypertension injury.
◆ Consider computed tomography

■ Swimmers view:
◆ Used to clear the cervicothroracic junction.
◆ Bilateral oblique films may do the same.
Anomalies & Variants.
■ Fusion or lack-of-segmentation anomalies
■ Occipitalization of the atlas.
■ Absence or lack of fusion of ossification
centers is especially confusing at C1 and
C2.
◆ Os terminale
◆ Os odontoideum
Os Odontodium
Os Odontodium
Fractures & Dislocations of
the Cervical Spine
Fracture Incidence of 400
Vertebral Trauma Patients

Vertebral Arch 50%

Vertebral Body 30%
Intervertebral Disc 20%
Posterior ligaments 10%
Dens 14%
Locked Facets 12%
Anterior ligaments 2%
Fracture Incidence of 400
Vertebral Trauma Patients
C1 6%
C2 27%
C3 10%
C4 10%
C5 18%
C6 27%
C7 18%
Radiographic Signs of Instability:
■ Spinous process fanning.
■ Widening of intervertebral disk space.
■ Horizontal displacement of one body on
another more than 3.5 mm.
■ Angulation greater than 11 degrees.
■ Disruption of facets.
■ Severe injury, such as multiple fractures at
one segment.
Classification System
■ Hyperflexion
■ Compression
■ Hyperextension
■ Unknown mechanism
Classification System
■ Hyperflexion
◆ Stable
✦ Anterior subluxation
✦ Anterior vertebral compression

✦ “Clay-shoveller” avulsion Fracture

◆ Unstable
✦ Anterior subluxation
✦ Bilateral facetal dislocation

✦ Flexion tear-drop fracture

Hyperflexion Injuries:
■ Hyperflexion sprain-anterior subluxation:
◆ Posterior ligamentous complex disrupted
◆ Localized increased height of intervertebral
disk space
◆ Fanning of spinous processes and a local
kyphotic angulation.
◆ May allow facet subluxation or locking.
◆ There is delayed instability in 20%!
 Hyperflexion Injuries:
■ Anterior wedge:
◆ Relatively minor injury,
not usually associated with
posterior retropulsion of
the body.
◆ Stable
◆ Neurologically intact
Hyperflexion Injuries:
Wedge Fracture at C-7

C-6
Hyperflexion Injuries:
Wedge Fracture at C-7

C-6

C-6
Hyperflexion Injuries:
CT Wedge Fracture at C-7
Hyperflexion Injuries
■ Bilateral locked facet:
◆ Due to flexion with enough distraction for
facets to become disarticulated.
◆ The vertical body is displaced approximately
50% of the body length on the lateral film.
◆ Both lateral and oblique films show the
"jumped," locked facets.
◆ High incidence of cord damage.
Bilateral Facet
Dislocation
 Hyperflexion Injuries
■ Clay-shoveler's fracture:
◆ Avulsion of the spinous processes (usually C6
or C7) due to flexion
◆ "Double" process seen on AP.
◆ May need swimmers view or oblique films to
confirm
Clay-shoveler's fracture
Clay-shoveler's Fracture
Clay-shoveler's Fracture
Hyperflexion Injuries
■ Teardrop burst fracture:
◆ Most severe flexion fracture
◆ Comminuted vertebral body fracture with
triangular fragment from the anterorinferior
border of the body.
◆ The posterior body is displaced into the canal
with high probability of neural damage.
◆ Anterior cord syndrome
Teardrop Burst Fracture
Teardrop Burst Fracture
Teardrop Burst Fracture
Classification System
■ Flexion-Rotation
◆ Stable
✦ Unilateral facet dislocation
■ Extension-Rotation
◆ Stable
✦ Fracture of articular mass (pillar fracture
■ Vertical Compression
◆ Stable or Unstable
✦ Jefferson fracture
✦ C3 - C7 burst fracture
Flexion-Rotation Injuries
■ Unilateral locked facet:
◆ Due to flexion, distraction and rotation.
◆ An abrupt change in amount of facet overlap on
lateral film and oblique films.
◆ Disruption of the posterior vertebral body line.
◆ Most common locations are C4-5 and C5-6.
◆ 35% are associated with fracture (usually
facet).
 Compression Injuries
■ Fractures of the Atlas (C1)
◆ Jefferson's fracture
◆ Compression mechanism
◆ Burst fracture both arches.
◆ Stable, and usually neurologically intact
Jefferson's Fracture
Jefferson's Fracture
Jefferson's Fracture

APOM AP Tomogram
Complex or Unknown Mechanism
■ Unstable
◆ Atlanto-occipital dislocation
◆ Ondontoid process fracture
Fractures of the Axis (C2)
■ Odontoid (dens) fracture:
■ Classification:
◆ Type 1: +
✦ Stable, Rare
✦ DDX from os terminale
◆ Type 2:
✦ Unstable, most common
✦ DDX os odontoidium
◆ Type 3:
✦ Stable, uncommon
Dens Fractures
Dens Fractures
Dens Fractures
Dens Fractures
Classification System
■ Hyperextension
◆ Stable
✦ Fracture of the posterior arch of atlas
✦ Avulsion fracture of anterior arch of atlas

✦ Laminar fracture

◆ Unstable
✦ Extension tear-droop fracture (C2 - C7)
✦ Hangman’s fracture

✦ Hyperextension dislocation +/- fracture

 Fractures of the Axis (C2)
■ Hangman's fracture:
◆ Traumatic spondylolisthesis
◆ Hyperextension injury resulting in
bilateral neural arch fractures.
◆ Initially neurologically intact but very
unstable
◆ The odontoid and its attachments are
intact; nerve damage is uncommon
owing to the width of the canal at this
level.
Hangman's Fracture
Hangman's Fracture
Hangman's Fracture
Extension Injuries:
■ Subtle findings
■ Prevertebral soft tissue swelling.
■ Posterior body displacement.
■ Widened anterior disc space.
■ Vacuum phenomenon:
◆ Highly suggestive of anterior soft tissue injury.
Extension Injuries:
■ Avulsion fracture from the anteroinferior
margin, especially of C2 or C3.
■ Facet (pillar) compression fracture:
◆ Bilateral or unilateral.
◆ Pillar views and/or CT.
◆ May result in nerve root compression.
Pediatric Cervical Spine Fractures
■ Parameters for evaluation are different.
■ Sites of involvement tend to be different:
◆ Teenagers have similar distribution to adults.
◆ Children under 12 years old involve mostly
occiput-C1 & C1-C2.