1、.,Cervical Spine fractures,.,Cervical Anatomy,Biomechanically Specialized Support of “l(fā)arge” Cranial mass Large range of motion Flexion/extension Axial rotation Unique osteological characteristics,.,C1 - Atlas,No body 2 articular pillars Flat articular surface Vertebral artery foramen 2 arches Anter

2、ior Posterior Vertebral artery groove,.,Function The Atlas,Transition zone between head and c-spine Important anatomical points Superior articular processes allow flex/ext Inferior articular processes are important for rotation Notch for vertebral artery is a common fracture site,.,C2 Anatomy,Dens E

3、mbriological C1 body Base poorly vascularized Osteoporotic Flat C1-2 joints Vertebral artery foramena Inferomedial to superolateral,.,Anatomy The Axis,Important transition point for forces within the c-spine Important anatomical points Superior and inferior articular processes are “offset” in the AP

4、 direction- due to different functions at each articulation Pars interarticularis- due to this transition is a frequent fracture site Odontoid process- the “pivot” for rotation,.,Anatomy The Ligaments,Allow for the wide ROM of upper C-spine while maintaining stability Classified according to locatio

5、n with respect to vertebral canal Internal: Tectorial membrane Cruciate ligament including transverse ligament Alar and apical ligaments External Anterior and posterior atlanto-occipital membranes Anterior and posterior atlanto-axial membranes Articular capsules and ligamentum nuchae,.,AtlantoAxial

6、Anatomy,Tectorial Membrane,.,AtlantoAxial Anatomy,occiput,C1,C2,Tranverse Ligament,C1-C2 joint,Alar Ligament,.,AtlantoAxial Anatomy,Transverse Ligament,Facet for Occipital Condyle,.,AtlantoAxial Anatomy,Vertebral Artery,.,APPROACH TO C-SPINE INJURIES,Following trauma or complaint of neck pain Obtain

7、 lateral AP, and odontoid views The lateral view is only adequate if T1 can be visualized If there is any doubt of fracture or prevertebral swelling , obtain oblique views and consider CT All patients with sign/symptoms of cord injury require MRI,.,Cervical Views,AP,Odontoid,Obliques,.,Swimmers View

8、,.,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. Spinolaminar line (post

9、erior margin of spinal canal) 5. Posterior spinous line (tips of the spinous processes),.,C1-C2,Predental 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 children Or less ring sign of C2,.,C3-C7,Anterior

10、 spinal, posterior spinal and spinolaminar lines: should be smooth lines Disc Spaces should be approximately same anterior narrowing = flexion injury. Widening = extension injury Facet joints should be parallel Interspinous distance should decrease from C3 to C7 Transverse process of C7 points downw

11、ard and T1 UPWARDS,INTERVERTEBRAL DISC SPACES,FACET JOINT,.,Prevertebral Soft Tissue Nasopharyngeal 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 anter

12、ior inferior body C6 ) c3-4 5mm from vertebral body is normal C4-7 20mm from vertebral body is normal,5mm,22mm,10mm,.,.,AP View,The 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

13、 midline and in good alignment.,.,Odontoid View,An 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 b

14、ilaterally. The tips of lateral mass 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.,.,Classification of Fractures of c-spine,HYPERFLEXION INJURIES Flexion teardrop fracture Hyp

15、er flexion Strain Wedge Compression fracture Bilateral facet Lock Unilateral facet dislocation Clay-shovelers fracture Hyper extention injuries Hangman fracture Extention teardrop fracture laminar fracture Pillar fracture Posterior arch of c1 fracture FRACTURE DUE TO AXIAL LOADING Jefferson fracture

16、 Burst fracture OTHER INJURIES Odontoid fracture Rotational Injuries,.,Hyperflexion,Distraction creates tensile forces in posterior column Can result in compression of body (anterior column) Most commonly results from MVC and falls,.,Compression,Result from axial loading Commonly from diving, footba

17、ll, MVA Injury pattern depends on initial head position May create burst, wedge or compression fxs,.,Hyperextension,Impaction of posterior arches and facet compression causing many types of fxs lamina spinous processes pedicles With distraction get disruption of ALL Evaluate carefully for stability

18、LOOK FOR CENTRAL CORD SYNDROME,.,Types of Injuries,.,Flexion Teardrop Fracture C5-6,fracture is the result of a combination of flexion and compression ,most commonly at C5-6 The teardrop fragment comes from the anteroinferior aspect of the vertebral body. The larger posterior part of the vertebral b

19、ody is displaced backward into the spinal canal. Best seen on lateral view It is an completely unstable fracture associated with complete disruption of ligaments and anterior cord syndrome and quadriplegia 70% of patients have neurologic deficit. common in MOTOR VECHICLE ACCIDENT,.,Signs: Prevertebr

20、al swelling associated with anterior longitudinal ligament tear. Teardrop 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.,.,Fracture of the

21、body of c5 with a small fragment anteriorly,Fracture of the spinous process of C4,Acute angulation at the level of C5C6 with displacement of C5 in posterior direction,.,.,.,.,.,Wedge fracture,Compression fracture resulting from flexion. Flexion compression injury Best seen on lateral view Stable Com

22、mon in Elderly patients with osteoporosis or osteogenesis imperfecta,.,.,Wedge shape vertebra,Antersuperior body fracture,.,Hangmans Fracture C-2,Fx through the pars interarticularis of C2 secondary to hyperextension Best seen on lateral view Hyperextention injury Stable fracture ?,.,.,.,The most co

23、mmon scenario would be frontal motor vehicle(hitting dash board) Hanging falls, diving injuries contact sports. Neurological involvement is rare,.,.,Classification of Hangman s fractures Type I (65%) hair-line fracture C2-3 disc normal Type II (28%) displaced C2 disrupted C2-3 disc ligamentous ruptu

24、re with instability C3 anterosuperior compression fracture Type III (7%) displaced C2 C2-3 Bilateral interfacet dislocation Severe instability,.,TYPE 1 HANGMAN FRACTURE,There is a hair-line fracture and there is no displacement. C23 NORMAL,.,HANGMAN FRACTURE TYPE 3,Anterior dislocation of the C2 ver

25、tebral body,BILATRAL C2 pars interarticularis fractures.,Prevertebral soft tissue swelling,.,The CT-images confirm the fracture-lines of the hangmans fracture. They run through the pars interarticularis resulting in a traumatic spondylolysis. In this case there was no neurologic deficit, because the

26、 spinal canal is widened at the level of the fracture.,.,.,Extention tear drop fracture,AVULSION FRACTURE of anterio inferior content of the axis resulting from hyperextention This injury is stable in flexion but highly unstable in extension. common in diving accidents It also may be associated with

27、 the central cord syndrome .,.,.,.,The CT confirms the displaced anteroinferior bony fragment. This fragment is a true avulsion, in contrast to the flexion teardrop fracture in which the fragment is produced by compression of the anterior vertebral aspect due to hyperflexion.,.,Jefferson Fracture C-

28、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 against the roof of a vehicle fall from playground equipments,Fracture is caused by a compressive downward force that is tra

29、nsmitted evenly through the occipital condyles to the superior articular surfaces of the lateral masses of C1. This process displaces the masses laterally and causes fractures of the anterior and posterior arches, along with possible disruption of the transverse ligament.,.,SIGNS ON XRAY: Displaceme

30、nt of the lateral masses of vertebrae C1 beyond the margins of the body of vertebra C2. T1 Best seen on lateral view Powerful Hyperflexion injury(shoveling) Stable fracture Common in motor vehicle accidents sudden muscle contraction direct blows to the spine,.,.,Ap view show ghost sign with 2 spinous processes ?,.,Case 1,5 yo girl Hit by car while riding bike VSA at scene Vitals recovered by EMS,Rose et al, Am J Surg 2003;185(4),.,Atlanto