Cervical Spine Trauma

Summarized by: Vineeth Bhogadi, M.D.

Reviewed by: Prasaanthan Gopee-Ramanan, M.D.

Original publication details

Authors: Mark P. Bernstein, Alexander B. Baxter

Reference: Bernstein, M. P., & Baxter, A. B. (2012). Cervical spine trauma: pearls and pitfalls. Pitfalls in Clinical Imaging. The American Roentgen Ray Society, 21-5.

Key features on MDCT

Axial images

Key components to assess

  1. Vertebral integrity and alignment

  2. Cervical soft tissues

  3. Spinal canal diameter

  4. Neuroforaminal patency

Sagittal images

Midline Sagittal Images Key Measurements

Paravertebral Soft Tissues

Abnormal if < 5mm at C2 or > 15mm at C5.

Normal 

Dens-Basion distance ≤ 9.5mm;

Line drawn vertically along dorsal body of C2 (posterior axial line) < 5.5mm posterior to basion.

Atlantodental interval < 3mm in adults

C1-2 interspinous distance at the spinolaminal line < 7.8mm

Parasagittal Images

Assess 

Occipital condyles, 

Alignment and congruency of facets, 

Atlantooccipital and atlantoaxial articulations

Coronal images

Dens centered between lateral masses of C1, occipital condyles, C1, C2 should be intact + aligned.

Atlas Injuries: Jefferson Fracture and variants

Imaging appearance

Classic Jefferson Fracture

4 part fracture along the anterior and posterior junctions of the arches and lateral masses; radial displacement of fracture fragments.

Stable mechanically and neurologically if isolated injury.

Atypical Jefferson Fracture

< 4 fractures of C1 ring

Unstable if evidence of transverse ligament injury, allows for C1-C2 subluxation.

Rule of Spence: Transverse separation of fracture fragments 7mm or more = transverse ligament injury/instability.

Other signs of instability: avulsion of C1 tubercle, two anterior ring fractures, atlantodental interval >3mm in adults or 5mm in children.

Axis Injuries: Hangman’s Fractures

Imaging appearance

Hangman’s Fracture

Traumatic spondylolisthesis of C2 due to bilateral pars interarticularis fractures.

Effendi Classification:

Type 1

Bilateral parts fractures without angulation of significant translation. Considered to be stable.

Paravertebral soft-tissue swelling often present, spinolaminar line may show posterior displacement.

Fractures involving transverse foramen require follow-up angiography.

Type 2

Include disruption of the C2-3 disk with anterior translocation of C2 body. Unstable.

Type 2A

C2 angulation but no translation; Unstable.

Type 3

Anterior translation and angulation with facet subluxation or frank dislocation. Highly Unstable

Type 2A and 3 require surgical reduction and internal fixation.

Subaxial Cervical Spine

Hyperflexion

Look for fanning of spinous processes or interspinous widening, uncovered facets, widened posterior disk space, focal kyphosis, and anterior subluxation.

Hyperextension-Dislocation

Mild anterior intervertebral disk space widening, anterior vertebral body avulsion fragments and facet malalignment.

MRI T2 weighted images show ligamentous disruption, soft-tissue edema, disk protrusion and cord injuries.

Citation

Bernstein, M. P., & Baxter, A. B. (2012). Cervical spine trauma: pearls and pitfalls. Pitfalls in Clinical Imaging. The American Roentgen Ray Society, 21-5.