Society of Rural Physicians of Canada 26TH ANNUAL RURAL AND REMOTE MEDICINE COURSE ST. JOHN'S NEWFOUNDLAND AND LABRADOR APRIL 12-14, 2018 Dr. Peter Hutten-Czapski HAILEYBURY ON RURAL CRITICAL CARE C-SPINE INJURY This session will review radiographic injury patterns of the cervical spine. 1. At the conclusion of this activity, participants will be able to appropriately order and interpret cervical spine X-rays. 2. Participants will learn to identify appropriate patients for imaging based on NEXUS and Canadian C-Spine rules. 3. Participants will be able to practice a systematic approach to interpret C-Spine films. Common pitfalls will be identified. 4. Participants will develop some comfort in identifying films with normal findings and some common injury patterns. 5. Participants will also identify films that they would not be comfortable with and might require further imaging and/or radiologist evaluation.
C-Spine X-ray Interpretation Karl Stobbe MD Beamsville, ON Peter Hutten-Czapski MD New Liskeard, ON Neil Leslie MD Revelstoke, BC Trina Larsen Soles MD Golden, BC C-spine x-ray interpretation When to x-ray Accuracy of x-ray What s normal Cases 1
Abnormal x-rays are uncommon 4% of patients have c-spine fracture without neurological deficit 1% have spinal cord injury How accurate are x-rays? Mower et al Ann Emerg Med 2001 n=34,069 3 views missed 0.1% of fractures Only missed 0.008% of unstable injuries 30% of missed injuries due to inadequate films 2
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Patients excluded: Under 16 years old Unstable Acute paralysis Known vertebral disease: RA, spinal stenosis, etc. Injuries over 48 hrs old Minor injuries Pediatrics Epiphyses Fusion lines Pseudosubluxation Anterior wedging Predental space widening SCIWORA is more common Make interpretation difficult Canadian C-spine rules don t apply 4
What views to order Routine trauma series: Lat c-spine first proceed if normal A-P Odontoid view No data on obliques but some docs like them! Obliques can be helpful in seeing C7-T1 Flexion-extension views rarely or never show fracture when other views are normal In 30% of trauma cases, flex-ext is inadequate for diagnosis However, it is recommended ahead of MRI; can show ligamentous injury 5
What Is Normal? A B C T1 (4) (1) (2) (3) 6
Atlantodens interval 7
A-P view Unilateral facet dislocation 8
Open-mouth Odontoid view The standard C-spine trauma series 9
Patient 1 45 year old woman in a motor vehicle accident. She lost control of her car, slid into a ditch and rolled. Was brought to the hospital by ambulance with full c-spine immobilization. Vital signs stable, patient is alert but has no recall of the accident. She has facial lacerations, bruising on her shoulder and lower abdomen from the seat-belt, and abrasions on both her knees. She complains of neck pain. Chest exam shows good air entry bilaterally. Brief neurological exam is normal. 10
A-1-1 A1-2 11
A-1-3 A-1-4 12
After the x-ray No abnormality noted by ER physician. Facial lacerations were sutured, she was monitored overnight. X-ray reported as normal the next day by the radiologist. Patient sent home. Patient 2a 17 year old male, injured when a hay baler fell on his neck 13
A-2a-1 A-2a-2 14
A-2a-3 A-2a-4 15
The radiologist s report: C6 is subluxated anteriorly by 4mm with respect to C7. One small bone fragment measuring 1.2cm in length and 2mm in width is noted at the posterior aspect of the neural canal adjacent to the spinous process of C6 on the lateral view. This would suggest a fracture from a superior articular process of C7 but could also represent a fracture from an inferior articular facet of C6. On Oblique views there is asymmetry of the C6-7 intervertebral foramen on the right side and one small bone fragment is seen just above this which likely represents the previous described fragment. No other abnormality. Patient 3 24 year old female passenger on a motorcycle. Was wearing a helmet. Was thrown from the vehicle, landing on her head. 16
A-3-1 A-3-2 17
A-3-3 After the x-ray: Patient died in ER 18
Patient 4a 21 year old male, jumped from moving vehicle. Injured his head, briefly lost consciousness. Complaining of neck pain. A-4a 19
Radiologist s report: A complete study could not be done on this patient. Only A/P, odontoid view and a single crosstable projection showing the cervical spine to the level of C5 are available. There is seen to be a compression fracture of the body C4. This has resulted in anterior wedging of the body with loss of approximately 50 percent of its vertical body height. There appears to be at least one fracture line visible in the coronal plane. Other fracture sites cannot be excluded. There is a posterior extrusion of a portion of the body by approximately 3mm. The C3-4 interspace shows marked narrowing. The appearance of this suggests a hyperflexion injury. There does not appear to be any significant prevertebral edema. The cervical spine below C5 cannot be assessed on these films. Patient 5 17 year old male, was wrestling. Fell on the back of his head hyperflexion. Slept 4 hours woke with pain and stiffness in his neck. Was brought to hospital by his family. Examination was negative. 20
A-5-1 A-5-2 21
A-5-3 Radiologist s report: There is a flexion deformity of the cervical spine with loss of alignment at the C3 C4 level. The angulation at this point measures 15 degrees. This strongly suggests ligamentous injury, probably involving the posterior longitudinal ligament. 22
Patient 6 A 20 year-old female from a motorcycle accident. Complaining of neck pain. A-6-1 23
A-6-2 After the x-ray Transferred for surgery. Quadriplegic, but survived. 24
Patient 8 22 year-old male Hyperextension injury: stopped on highway, hit from behind by transport. Car demolished. A-8 25
Radiologist s report: There is a fracture-dislocation at the C2, C3 level with approximately 2 mm anterior displacement of C2 on C3. Patient 9 28 year old male complains of a sore neck the day after a fight in a bar. 26
A-9-1 A-9-2 27
A-9-3 Radiologist s report: There is a fracture through the spinous process of C7 with approximately 5mm posterior and caudad displacement of the fragment. Some mild degenerative arthritic changes can be seen at the intervertebral joints at C7-T1. The cervical spine appears otherwise unremarkable. Comment: Clay shovelers fracture spinous process C7. 28
C1-C2 anatomy Patient 10 87 year old male. MVA hit another vehicle pulling onto the road. Multiple injuries. Required IV fluids, intubation. C-spine lateral was ordered along with chest and pelvic x-rays prior to detailed examination. 29
B-11 After the x-ray Odontoid fracture Type II with posterior displacement. Transferred for surgery which was successful. Long and stormy post-op course, eventual death from sepsis. 30
Odontoid fracture, type II Odontoid fracture, type II 31
Patient 11 52 year old male; fall from a height. Bystanders thought his head bent forward. Patient has no recall of the fall. Complains of headache and neck pain. No neurological findings. Pain with neck movement. B-12-1 32
B-12-2 B-12-3 33
After the x-ray Patient complained of pain and tingling in his hands when flexion x-rays were done. Immobilized and transferred to referral centre. Surgical stabilization with good outcome. Rural MD was criticized for ordering too many x-rays when the abnormality was visible on the first 2 films. Patient 12 84 year old woman injured in MVA at 50 kph. She was the front seat passenger, wearing seat belt. She has no recall of the accident, appears slightly confused but in no distress, though complains of neck pain. 34
Patient 12 X-ray tech: very difficult patient to do. Did my best. B-13-1 35
B-13-2 B-13-3 36
B-13-4 B-13-5 37
B-13-6 B-13-7 38
After the x-rays Frustrated with the poor quality films, the rural ER doc has a last look. On one lateral film, he wonders about the odontoid. Decides to immobilize the patient s c-spine and talk to the nearest surgical centre. With much reluctance the patient is accepted in transfer. Radiologist s report: The cervical spine is very difficult to image in this patient due to her inability to co-operate and fairly marked cervical kyphosis. There is seen to be a moderately severe degree of osteoporosis throughout the cervical spine. Moderately advanced degenerative arthritic change is present with interspaces at C5-6 and C6-7 slightly narrowed suggesting degenerative disc disease. On one lateral projection there is seen to be a deformity of the odontoid process of C2. This appears to be angulated ventrally by approximately 15 degrees and a step deformity can be seen in both its anterior and posterior margins measuring approximately 3mm. The overall appearance is strongly suggestive of a fracture of the odontoid process (type III). 39
Patient 13 A young man was involved in a MVA. He arrives by ambulance in full spinal immobilization to Revelstoke hospital. He has neck pain spasm and tenderness. Neurological examination is normal. A cross table Xray was taken at 62 80KV and 3 msec IX-1 40
Radiology Report Fracture Odontoid with posterior displacement. Also note incidental fracture C7- T1. Clayshoveler s Fracture. Atlantodens interval 41
Atlantodens interval Patient 14 A 7-year-old male was diving off a ledge when he landed head first in shallow water. He was pulled semiconscious from the water by lifeguards. While maintaining his airway, the lifeguards placed the patient in full C-spine immobilization. When the patient became more alert, he complained of pain to his upper neck region. Paramedics transported the patient to the ED. Upon arrival, the patient is awake, alert, cooperative, and in C-spine immobilization. His vital signs are normal, and the neurologic exam is nonfocal. He continues to complain of upper neck pain. A cross table lateral neck radiograph is obtained. 42
II-1 Not so unusual Quality II-2 43
But it is enough II-3 Repeat View II-4 44
CT of our patient II-5 X-ray Report The lateral neck radiograph is suggestive of mild prevertebral soft tissue widening. Jefferson fracture (C1 ring) is demonstrated 45
Jefferson fracture Jefferson fracture 46
Jefferson fracture C-17 Atlantoaxial spondylolisthesis, type I 47
Atlantoaxial spondylolisthesis, type II Patient 15 A young male was involved in a MVA. He was dragged semi conscious up an embankment by his friend. A cross table Xray was done on arrival at the Revelstoke hospital. He has a lot of neck pain spasm and tenderness. Neurological examination is normal. 48
VII-1 After the X-ray Radiologist s first comment is Why are you taking post mortem Films? C2 Fracture/dislocation. Hangman type Neurosurgeon unable to reduce the dislocation so fused as is. 49
Hangman's fracture Atlantoaxial spondylolisthesis, type II 50
Patient 16 62 year old male. C-18-1 51
C-18-2 Radiologist s comments Hyper Extension injury Hangman s fracture Seen best with slight flexion Posterior laminar line C2-C3 Step deformity 52
Patient 17 Elderly female brought to ER from MVA. Found at the scene. Car badly damaged. She was the driver. Car flipped. Was wearing seat belt. C-19 53
Radiologist s report: There is a slight step deformity with approximately 3mm anterior displacement of the body of C2 on C3. Films are not of good quality, however, there appears to be a defect through the pedicles of C2 with slight displacement of the anterior and posterior fragments. There is a marked degree of swelling of the prevertebral soft tissues at this level. Comment: These findings are suggestive of hyperextension or Hangman s fracture. Crosstable lateral view only is available which demonstrates the cervical spine only to be to the level of C4. The cervical spine appears, otherwise, unremarkable. Patient 18 A 7-year-old female is brought in by paramedics in full C-spine immobilization after being involved in a motor vehicle accident. According to her parents, the unrestrained child was sitting in her restrained mother's lap on the passenger side when the passenger side of the car was broadsided by another vehicle. The child's head was thrown into the dashboard, and she sustained severe injuries to the face and scalp. Upon arrival at the hospital, the patient is crying and responsive to all stimuli. There are multiple facial lacerations, a large scalp laceration, and facial edema/ecchymosis. 54
V-1 The hangman's fracture is an unstable fracture of the C2 pedicles, with forward displacement of C1 and the body of C2 on C3. V-2 55
Hangman's fracture Patient 19 29 year old male, front-seat passenger. High-speed collision with parked vehicle in a residential neighbourhood. Driver has been airlifted to trauma centre. Patient is a happy drunk. Smiling, wandering around ER, uncooperative. Extremity bruises are his only obvious injuries. He has no complaints. Exam: midline tenderness over c-spine. 56
C-21-1 C-21-2 57
C-21-3 Patient 19 When told he has an unstable c-spine injury, the patient goes out for a smoke, refuses to believe diagnosis. Eventually he agrees to be immobilized and transferred. 58
Radiologist s comments: Unilateral Facet Dislocation C4-C5 Flexion rotation injury Patient 20 31 year old tourist from Calgary on snow machine tour. Hits a bump, thrown off snow machine into the air and hits a tree about 15 feet off the ground. Slides down, c/o neck pain. Brought to ER on spine board with full spinal precautions. Some tingling in R hand. 59
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Patient 21 79 year old woman. Known history of osteoporosis. Fell in the bathroom and hit face on the sink. C/O neck pain. Drove self to hospital. Arrived in ER with a towel wrapped around her neck 62
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A final word of caution SCIWORA Spinal Cord Injury WithOut Radiographic Abnormality (Treat the patient not the x-ray) 65