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1、整理课件Cervical Spine fractures整理课件 Cervical AnatomyBiomechanically SpecializedSupport of“large”Cranial massLarge range of motionFlexion/extensionAxial rotationUnique osteological characteristics整理课件C1-AtlasNo body2 articular pillarsFlat articular surfaceVertebral artery foramen2 archesAnteriorPosterio

2、rVertebral artery groove整理课件Function The AtlasTransition zone between head and c-spineImportant anatomical pointsSuperior articular processes allow flex/extInferior articular processes are important for rotationNotch for vertebral artery is a common fracture site整理课件C2 AnatomyDensEmbriological C1 bo

3、dyBase poorly vascularizedOsteoporoticFlat C1-2 jointsVertebral artery foramenaInferomedial to superolateral整理课件Anatomy The AxisImportant transition point for forces within the c-spineImportant anatomical pointsSuperior and inferior articular processes are“offset”in the AP direction-due to different

4、 functions at each articulationPars interarticularis-due to this transition is a frequent fracture siteOdontoid process-the“pivot”for rotation整理课件Anatomy The LigamentsAllow for the wide ROM of upper C-spine while maintaining stabilityClassified according to location with respect to vertebral canalIn

5、ternal:Tectorial membraneCruciate ligament including transverse ligamentAlar and apical ligamentsExternalAnterior and posterior atlanto-occipital membranesAnterior and posterior atlanto-axial membranesArticular capsules and ligamentum nuchae整理课件AtlantoAxial AnatomyAtlantoAxial AnatomyTectorial Membr

6、ane整理课件AtlantoAxial AnatomyAtlantoAxial AnatomyocciputC1C2Tranverse LigamentC1-C2 jointAlar Ligament整理课件AtlantoAxial AnatomyAtlantoAxial AnatomyTransverseLigamentFacet forOccipitalCondyle整理课件AtlantoAxial AnatomyAtlantoAxial AnatomyVertebral Artery整理课件APPROACH TO C-SPINE INJURIES Following trauma or

7、complaint of neck painObtain lateralAP,and odontoid viewsThe lateral view is only adequate if T1 can be visualizedIf there is any doubt of fracture or prevertebral swelling,obtain oblique views and consider CTAll patients with sign/symptoms of cord injury require MRI整理课件Cervical ViewsAPOdontoidObliq

8、ues整理课件Swimmers View整理课件LATERAL VIEW 1.Anterior vertebral line(anterior margin of vertebral bodies)2.Posterior vertebral line(posterior margin of vertebral bodies)3.Articular pillar(where superior and inferior articular processes of cervical vertebrae have fused on either or both sides)4.Spinolamina

9、r line(posterior margin of spinal canal)5.Posterior spinous line(tips of the spinous processes)整理课件C1-C2Predental space(distance between posterior aspect of anterior arch of C1 and anterior aspect of odontoid process)should be 3mm In adult and less 5mm in childrenOr lessring sign of C2整理课件C3-C7Anter

10、ior spinal,posterior spinal and spinolaminar lines:should be smooth lines Disc Spaces should be approximately same anterior narrowing=flexion injury.Widening=extension injuryFacet joints should be parallelInterspinous distance should decrease from C3 to C7Transverse process of C7 points downward and

11、 T1 UPWARDS INTERVERTEBRAL DISC SPACES 整理课件Prevertebral Soft TissueNasopharyngeal space(C1)-10 mm(adult)Retropharyngeal spaceC 2-C4(between posterior pharyngeal wall and anterior border of vertebrae).Retro tracheal space C5-7(space between posterior tracheal wall and anterior inferior body C6)c3-4 5

12、mm from vertebral body is normalC4-7 20mm from vertebral body is normal5mm 22mm 10mm整理课件整理课件AP ViewThe height of the cervical vertebral bodies should be approximately equal The height of each joint space should be roughly equal at all levels.Spinous process should be in midline and in good alignment

13、.整理课件Odontoid ViewAn adequate film should include the entire odontoid and the lateral borders of C1-C2.Occipital condyles should line up with the lateral masses and superior articular facet of C1.The distance from the dens to the lateral masses of C1 should be equal bilaterally.The tips of lateral m

14、ass of C1 should line up with the lateral margins of the superior articular facet of C2.The odontoid should have uninterrupted cortical margins blending with the body of C2.整理课件Classification of Fractures of c-spine HYPERFLEXION INJURIES Flexion teardrop fracture Hyper flexion Strain Wedge Compressi

15、on fracture Bilateral facet LockUnilateral facet dislocationClay-shovelers fractureHyper extention injuries Hangman fracture Extention teardrop fracture laminar fracture Pillar fracture Posterior arch of c1 fracture FRACTURE DUE TO AXIAL LOADING Jefferson fracture Burst fracture OTHER INJURIES Odont

16、oid fracture Rotational Injuries整理课件HyperflexionDistraction creates tensile forces in posterior columnCan result in compression of body(anterior column)Most commonly results from MVC and falls整理课件CompressionResult from axial loadingCommonly from diving,football,MVAInjury pattern depends on initial h

17、ead positionMay create burst,wedge or compression fxs整理课件HyperextensionImpaction of posterior arches and facet compression causing many types of fxslaminaspinous processespediclesWith distraction get disruption of ALLEvaluate carefully for stabilityLOOK FOR CENTRAL CORD SYNDROME整理课件Types of Injuries

18、整理课件Flexion Teardrop Fracture C5-6fracture is the result of a combinationof flexion and compression,most commonly at C5-6The teardrop fragment comes from the anteroinferior aspect of the vertebral body.The larger posterior part of the vertebral body is displaced backward into the spinal canal.Best s

19、een on lateral viewIt is an completely unstable fracture associated with complete disruption of ligaments and anterior cord syndrome and quadriplegia 70%of patients have neurologic mon in MOTOR VECHICLE ACCIDENT 整理课件Signs:Prevertebral swelling associated with anterior longitudinal ligament tear.Tear

20、drop fragment from anterior vertebral body avulsion fracture.Posterior vertebral body subluxation into the spinal canal.Spinal cord compression from vertebral body displacement.Fracture of the spinous process.整理课件Fracture of the body Fracture of the body of c5 with a small of c5 with a small fragmen

21、t fragment anteriorlyFracture of the spinous process of C4Acute angulation at the level of Acute angulation at the level of C5C6 with displacement of C5 in C5C6 with displacement of C5 in posterior directionposterior direction整理课件整理课件整理课件整理课件整理课件Wedge fracture Compression fracture resulting from fle

22、xion.Flexion compression injury Best seen on lateral viewStableCommon in Elderly patients with osteoporosis or osteogenesis imperfecta整理课件整理课件Wedge shape vertebraAntersuperior body fracture整理课件Hangmans Fracture C-2Fx through the pars interarticularis of C2 secondary to hyperextensionBest seen on lat

23、eral viewHyperextention injury Stable fracture?整理课件整理课件整理课件 The most common scenario would be frontal motor vehicle(hitting dash board)Hanging falls,diving injuriescontact sports.Neurological involvement is rare 整理课件整理课件Classification of Hangman s fractures Type I(65%)hair-line fractureC2-3 disc nor

24、malType II(28%)displaced C2disrupted C2-3 discligamentous rupture with instabilityC3 anterosuperior compression fractureType III(7%)displaced C2C2-3 Bilateral interfacet dislocationSevere instability整理课件TYPE 1 HANGMAN FRACTURE There is a hair-line fracture and there is no displacement.C23 NORMAL 整理课

25、件HANGMAN FRACTURE TYPE 3 Anterior dislocation of the C2 vertebral bodyBILATRAL C2 pars BILATRAL C2 pars interarticularis interarticularis fractures.fractures.Prevertebral soft Prevertebral soft tissue swelling tissue swelling 整理课件The CT-images confirm the fracture-lines of the hangmans fracture.They

26、 run through the pars interarticularis resulting in a traumatic spondylolysis.In this case there was no neurologic deficit,because the spinal canal is widened at the level of the fracture.整理课件整理课件Extention tear drop fracture AVULSION FRACTURE of anterio inferior content of the axis resulting from hy

27、perextentionThis injury is stable in flexion but highly unstable in mon in diving accidents It also may be associated with the central cord syndrome.整理课件整理课件整理课件The CT confirms the displaced anteroinferior bony fragment.This fragment is a true avulsion,in contrast to the flexion teardrop fracture in

28、 which the fragment is produced by compression of the anterior vertebral aspect due to hyperflexion.整理课件Jefferson Fracture C-1 Best seen on odontoid view Unstable fracture Fracture due to AXIAL LOADING frequently associated with diving into shallow water(axial blow to the vertex of the head)impact a

29、gainst the roof of a vehicle fall from playground equipments Fracture is caused by a a compressive compressive downward forcedownward force that is transmitted evenly through the occipital condyles to the superior articular surfaces of the lateral masses of C1.This process displaces the masses later

30、ally and causes fractures of the anterior and posterior arches,along with possible disruption of the transverse ligament.整理课件SIGNS ON XRAY:Displacement of the lateral masses of vertebrae C1 beyond the margins of the body of vertebra C2.2mm bilateral is always abnormalC6T1Best seen on lateral viewPow

31、erful Hyperflexion injury(shoveling)Stable fracture Common in motor vehicle accidentssudden muscle contractiondirect blows to the spine 整理课件整理课件Ap view show ghost sign with 2 spinous processes?整理课件Case 15 yo girlHit by car while riding bikeVSA at sceneVitals recovered by EMSRose et al,Am J Surg 2003

32、;185(4)整理课件Atlanto-Occipital Dislocation2.5 x more common in children than adultsDue to small occipital condyles and horizontal atlanto-occipital jointsSuspect if distance between occipital condyles and C1 is 5mm at any pointUsually have+soft tissue swelling整理课件OccipitoAtlantal Dissociation (OAD)Com

33、monly FatalPresent 6-20%of post mortem studies Alker et al,1978 Bucholz&Burkhead,1979 Adams et al,199250%missed injury rate1/3 Neurological Worsening Davis et al,1993整理课件OccipitoAtlantal Dissociation (OAD)Symptoms/Findings Wallenberg SyndromeLower Cranial nerve deficitsHorners syndromeCerebellar ata

34、xiaCruciate paralysisContralateral loss of pain and temperature整理课件Radiographic LinesRadiographic LinesBC/OA1 considered abnormalLimited UsefulnessPositive only in Anterior Translational injuriesFalse Negative with pure distractionPowers et al,Neurosurg,1979 Powers Ratio整理课件QUESTIONS整理课件REFERRENCESText Book of Radiology and imaging(DAVID SUTTON)Primer of Diagnostic ImagingRadiology Review Manual(Dahnert)整理课件