x ray spine. spine trauma cervical spine injury thoraco-lumbar spine injury

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X ray spine

SPINE TRAUMA CERVICAL SPINE INJURY

THORACO-LUMBAR SPINE INJURYCERVICAL SPINE INJURYCOMMON MECHANISMS OF INJURY

HYPERFLEXION- MVA, CAR COMES TO SUDDEN STOP

HYPEREXTENSION- MVA, CAR STRUCK FROM BEHIND

COMPRESSION- HEAD FIRST DIVE IN SHALLOW WATERHIGH RISK FACTORS FOR SPINE INJURY

HIGH-VELOCITY BLUNT TRAUMA

MULTIPLE, SEVERE LONG BONE FRACTURES

DIRECT CERVICAL REGION INJURY

ALTERED MENTAL STATUS

FALL FROM GREATER THAN 10 FEET

DROWNING / HEAD FIRST DIVING ACCIDENT

SIGNIFICANT HEAD OR FACIAL INJURY

NECK PAIN, TENDERNESS, OR DEFORMITY

ABNORMAL NEUROLOGICAL EXAMINATION

THORACIC OR LUMBAR VERTEBRAL FRACTURE

HXISTORY OF PRE-EXISTING VERTEBRAL DISEASECLINICAL PROCEDURE INVOLVING PTS WITH SUSPECTED SPINE INJURY

PATIENT KEPT IN CERVICAL COLLAR AND IMMOBILIZED ON SPINE BOARD

ABCDEF ER PROTOCOL FOLLOWED (AIRWAY, BREATHING, CIRCULATION, DISABILITY/DRUGS, EXPOSURE, FOLEY CATHETER)

HISTORY AND PHYSICAL (PT HANDLED AS THOUGH SERIOUS INJURY PRESENT)

DECIDE IF IMAGING IS NECESSARY CERVICAL VERTEBRAL ANATOMY:

ANT LONGITUDINAL LIGPOST LONGITUDINAL LIGLIGAMENTA FLAVASUPRASPINOUS LIGMENU OF IMAGING OPTIONS

CERVICAL SPINE PLAIN FILMS

ANTERO- POSTERIOR AND

LATERAL VIEW

STANDARD FIRST LINE IMAGING MODALITY IN ASSESSING CERVICAL VERTEBRAL INJURY

SWIMMERS VIEW

Anteroposterior (A-P) ViewSpinous process deviationLateral TranslationCoronal deformityOpen Mouth ViewMostly C1-C2 lateral massOccipital Condyles/CO-C1Odontoid Process

Swimmers ViewCervico-thoracic junctionobliques sometimes helpfulCASETTEX-ray BEAMNORMAL C-SPINE VIEWS

LATERALAPODONTOIDC-SPINE FILM INTERPRETATION 7 STEP PROCESS

1. COUNT VERTEBRAE

-C1 THROUGH C7-IF T1 NOT SEEN SWIMMERS VIEW

2. ASSESS CURVATURE

3. ASSESS VERTEBRAL ALIGNMENT (4 LINES)-ANT VERTEBRAL LINE-POST VERTEBRAL LINE-SPINOLAMINAL LINE-POST SPINAL LINE

4. ASSESS BONY INTEGRITY

5. ASSESS INTERVERTEBRAL DISK SPACES

6. ASSESS OAA JOINT7. SOFT TISSUES

THE 4 CONTOUR LINES

1-ANT VERTEBRAL LINE

2-POST VERTEBRAL LINE

3-SPINOLAMINAL LINE

4-POST SPINAL LINE

Lower Cervical DetectionSpinous process gappingFacet joint AppositionInter-vertebral GappingAngulationTranslationLower Cervical DetectionSpinous process gappingFacet joint AppositionInter-vertebral GappingAngulationTranslation

Lower Cervical DetectionSpinous process gappingFacet joint AppositionInter-vertebral GappingAngulationTranslation

Lower Cervical DetectionSpinous process gappingFacet joint AppositionInter-vertebral GappingAngulationTranslation

Lower Cervical DetectionSpinous process gappingFacet joint AppositionInter-vertebral GappingAngulationTranslation

Lower Cervical DetectionSpinous process gappingFacet joint AppositionInter-vertebral GappingAngulationTranslation

JEFFERSON FRACTURE

HANGMANS FRACTURE DENS FRACTURE

FRACTURE OF THE BASE OF THE DENS (ODONTOID) OF C2ANTERIOR OR POSTERIOR DISPLACEMENT OF THE DENSCAN OCCUR AT VARIOUS LEVELS ON THE DENSVIA HYPERFLEXION OR HYPEREXTENSION OF HEAD ON NECKUNSTABLE IF DISPLACEMENT OCCURS

COMPRESSION FRACTURE

VARIABLE SEVERITY, FROM MINIMAL ANTERIOR WEDGING TO COMPLETE DISRUPTION OF VERTEBRAL BODY (BURST)LOOK FOR LOSS OF VERTICAL HEIGHT OF VERTEBRAL BODYDUE TO LONG AXIS COMPRESSION OR HYPERFLEXIONDIVING INTO SHALLOW POOLSTABLE UNSTABLE

TEARDROP FRACTURE

AVULSION FRACTURE OF ANTERIOR MARGIN OF VERTEBRAL BODYANTERIOR LONGITUDINAL LIG INSTABILITY (RUPTURE, AVULSION)HYPEREXTENSION INJURYUNSTABLE INJURYLAMINA MAY JAM TOGETHER CAUSING LIGAMENTA FLAVA TO BUCKLE INWARD AND COMPRESS/CONTUSE THE SPINAL CORD

CLAY SHOVELERS FRACTURE

AVULSION FRACTURE OF SPINOUS PROCESS BY SUPRASPINOUS LIGAMENTUSUALLY OCCURRING FROM C6-T2HYPERFLEXION; DIRECT TRAUMA; DOWNWARD FORCE VIA THORACOSCAPULAR MUSCLE (AS IN SHOVELING MOTION)STABLE

THORACO-LUMBAR SPINE INJURY

AnatomyMENU OF IMAGING OPTIONS

DORSAL SPINE PLAIN FILMS

ANTERO- POSTERIOR AND

LATERAL VIEW

LUMBO SACCRAL SPINE

ANTERO- POSTERIOR AND

LATERAL VIEW

Thoracic Spine

Lumbar Spine

Determinants of StabilityT & L spines are more stable than C-spineStrong ligamentsStabilization by ribsBigger intervertebral discsLarger facet jointsLess mobilityFractures & dislocations tend to occur where curvature changesT11-12 (thoracolumbar junction)L5-S1 (lumbosacral junction)Mechanisms of InjuryHyperflexion +/- rotationCommonestUsually see anterior wedge #s or Chance #ShearingAnt or post translationHyperextensionAxial loadingCompression or burst #s3 Column ModelAnterior columnAnt longitudinal ligAnt annulus fibrosisAnt vertebral bodyMiddle columnPost longitudinal ligPost annulus fibrosisPost vertebral bodyPosterior columnSpinous processesTransverse processesLaminaFacet jointsPediclesPost ligamentous complex

2 or more columns disrupted = unstableMost disruption of middle columns are unstable

Stable or Unstable?Radiographic findings suggestive of instabilityVertebral body collapse w/ widening of pedicles> 33% canal compromise on CT> 2.5 mm translation b/w vertebral bodies in any planeBilateral facet dislocationAbnormal widening b/w spinous processes or lamina and > 50% anterior collapse of vertebral bodyStable or Unstable?Checklist for InstabilityAnterior elements disrupted2 ptsPosterior elements disrupted2 ptsSaggital plane translation > 2.5 mm2 ptsSaggital plane rotation > 5o2 ptsSpinal cord or cauda equina damage2 ptsDisruption of costovertebral articulations1 ptDangerous loading anticipated2 pts

5 or more pts unstable until healed or surgically stabilizedStable or Unstable?Risk of neurologic injury increases with> 35% canal narrowing at T11-12> 45% canal narrowing at L1> 55% canal narrowing at L2 & below

Approach to T & L SpinesA adequacy & alignmentAll vertebrae need to be visibleAnt & post longitudinal linesFacet joints should lie on smooth curveNormal kyphosis & lordosisAll spinous processes should lie in straight lineB bonesTrace cortical margins of each vertebraeDifference b/w ant & post body ht < 2 mmProgressive increase in vertebral body ht moving down spineWink sign & interpedicular distanceDont forget to look at transverse processes39Exceptions: L5-S1 disc space is narrower than above onesTP #s are in and of themselves stable but markers for serious intraabdominal injury in ~20% of casesApproach to T & L SpinesC cartilageProgressive increase in disc space moving down spine (except L5-S1)Facet joint alignmentS soft tissueLook at paraspinal stripe and prevertebral spaceInjury DetectionThoracic and Lumbar SpinesSame principlesLandmarks and Lines: Lateral ViewPosterior VB lineAnterior VB lineInter-spinous DistanceTranslation

Injury DetectionThoracic and Lumbar SpinesSame principlesLandmarks and Lines: A-P ViewSpinous process to PediclesInter-pedicular DistanceTranslation

Thoracic and Lumbar Injuries

Height Loss

Adjacent fracture

Transverse process fracturesof L2-4Significance of transverse processfractures is not the fractures in andof themselves but rather the high incidence of associated seriousintraabdominal injury (~20%)

AnterolisthesisOf L4 on L5