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ECR 2013 / C-2110
Upper cervical trauma: study in acute phase and follow up
Congress: ECR 2013
Poster No.: C-2110
Type: Educational Exhibit
Keywords: Trauma, Outcomes, Acute, Screening, Instrumentation, Computer Applications-Detection, diagnosis, MR, CT-Angiography, CT, Neuroradiology spine, Emergency
Authors: E. Gómez Roselló, A. M. Quiles Granado, G. Laguillo Sala, S. Pedraza, S. Martín; Girona/ES
DOI:10.1594/ecr2013/C-2110

Imaging findings OR Procedure details

 

 

In acute trauma, CT is the most useful technique for high risk patients; thus, CT rather than cervical plain films should be the technique of choice. CT can also be useful in follow-up.

With the appropriate protocol and post-processing, MDCT improves the recognition, characterisation, and classification of traumatic cervical lesions for determining the appropriate treatment. Contrast agents can be administered in the same study to rule out damage to cervical arteries.

MRI provides essential additional information in spinal cord and ligament injuries.

For follow-up, plain films are still widely used. CT, and/or MRI can be used to complete the study. 

Fig. 1

 

Fig. 1
References: radiology, IDI, Josep Trueta - Girona/ES

1.  ANATOMY


Craniocervical juntion is composed by:

-bones: occipital bone condyles, atlas (anterior and posterior arch with no body) and axis (large body and superiorly projecting odontoid process)

-joints: atlantooccipital, median and lateral atlanto-axial joints

-ligaments (anterior to posterior): anterior atlanto-occipital membrane, odontoid ligaments apical and alar, cruciate ligaments, tectorial membrane and posterior atlanto-occipital membrane

Anatomic/funtional landmarks:

-Spine has and excellent continent/ content relation (1/3)

-Vertebral arteries are very resistant because of their elasticity

-Transverse ligament is the most important ligament in mantaining stability

Fig. 2-3


Fig. 2
References: radiology, IDI, Josep Trueta - Girona/ES



 

Fig. 3
References: radiology, IDI, Josep Trueta - Girona/ES

 

 

2. CLINICAL SETTING

 

a) Low risk patient. How to avoid the overuse of imaging?

Classifications like the Nexus or Canadian C-Spine Rule help determine whether plain films/CT are indicated. They avoid excessive irradiation and reduce costs, so they are progressively being included in clinical guidelines.

Fig. 4

Fig. 4
References: radiology, IDI, Josep Trueta - Girona/ES


 

b)  All multiple trauma patients in our center--> Body CT. When are patients considered multiple trauma patients?

Fig. 5

Fig. 5
References: radiology, IDI, Josep Trueta - Girona/ES


 

3- TECHNIQUE  

 

Plain films :

-Odontoid projection: Anteroposterior, mouth open as wide as possible. Correct examination must show the atlas, axis, and atlantoaxial articulation.

-Lateral projection: Strict lateral. Correct examination must show all the cervical vertebrae without rotation; the atlas and odontoid process must be clearly shown. Variants: hyperflexion and hyperextension.

 

CT:

Sagittal and coronal reconstructions are necessary for correct assessment. Traumatic cervical lesions suspected in a non polytraumatic patient can be ruled out by non-contrast CT. All multiple trauma patients should be screened with contrast-enhanced body CT using cervical reconstruction with bone filter.

   -Cervical CT: From the foramen magnum to T2. Standard acquisition with bone filter (C or D) and high matrix. Optionally, arterial phase CT angiography images can be obtained .

  -Body CT with cervical reconstruction: Two acquisitions: a) non-enhanced cranial CT, b) contrast-enhanced CT from skull base to pelvis. 50-second delay. For cervical reconstruction, a higher matrix and bone filter is used.

 

MRI

Sagittal T1-weighted // Sagittal T2-weighted TSE / short-inversion-time inversion recovery (STIR)// axial spin-echo T1- and T2-weighted sequences. Additional sequences in the neck to rule out arterial damage: Contrast-enhanced arterial study / Axial fat-suppression T1 and STIR.

 

 

4. CLASSIFICATION OF LESIONS AND THEIR TREATMENT

 

Classification is essential to characterise the lesion and determine the best treatment for every patient. Sometimes detection and classification are difficult due to multiple associated fractures.

 

Classification of traumatic occipitoatlantoaxial lesions by anatomical location

Atlantooccipital  luxation

Traynelis, 1986

Type I, anterior displacement of atlas masses

Type II, longitudinal occipitoatlantal displacement

Type III, posterior displacement of atlas masses

Occipital condyle fractures

Anderson & Montesano 1988

Type I, isolated fracture of occipital condyle

Type II, condyle fracture with extension to clivus or occipital bone

Type III, condyle avulsion

Atlantoaxoid rotatory luxation

Fielding & Hawkins 1977

Type I,  anterior rotation of atlas mass

Type II, rotation or anterior luxation of an atlas mass >3mm.

Type III, anterior luxation of both atlas masses >5 mm.

Tipo IV, posterior luxation of one or two atlas masses

Isolated rupture of transverse ligament of atlas

Dickman, 1996

Type I, medial rupture of transverse ligament of atlas

Type II, fracture or detachment of insertion tubercle from transverse ligament to atlas

Atlas fractures.

Jefferson, 1920

 

 

Type a, unilateral or bilateral fracture of anterior arch

Type b, unilateral or bilateral fracture of  posterior arch

Type c, simple fracture of an atlas lateral mass

Type d, comminute fracture of an atlas lateral mass

 Type e, bilateral fracture of anterior and posterior arches (Jefferson fracture)

Type f, linear or crossed fractures of anterior and posterior arches

Type g, isolated rupture of transverse ligament of atlas

Odontoid fractures. Martín-Ferrer, 1997

 

                                D´Alonzo, 1974

Apex fracture

Basis fracture

I, Apex

II, Basis

III, Fracture extends through the body of the axis

Axial pedicles of axis.

Levine-Effendi & Edwards, 1985

 

Type I, < 3mm displacement with no angulation of C2-C3

 Type II, > 3 mm displacement and angulation

C2-C3 < 11º

Type  IIa, > 3mm of separation and angulation C2-C3 > 11º

Type III, total luxation C2-C3 (hangman’s fracture)

Axis body fractures.

Benzel, 1994

Type I, coronal fracture

Type II, sagittal fracture

Type III,  transverse fracture

Chronic fractures (multiple possibilities)

 

Associated fractures  (multiple combinations)

 

Others

Marginal fractures of axis body, laminas, facets or spinous apophysis of axis, transverse apophysis of atlas or axis


Most frequent lesions. In order of frequency

Fig. 6

Fig. 6
References: radiology, IDI, Josep Trueta - Girona/ES



When surgery is indicated, it aims to liberate neurological structures and maintain stability, align vertebral segments, stabilize vertebral elements, prevent lesions from developing, and permit maximal functional recovery. In cases with associated fractures, every treatment indication should be evaluated separately.

 

Most frequent pathologies and their treatment.

Fig. 7

Fig. 7
References: radiology, IDI, Josep Trueta - Girona/ES

Most frequently used surgical techniques.

Fig.8

Fig. 8
References: radiology, IDI, Josep Trueta - Girona/ES


5. PRACTICAL CASES

 

 1. Quiz cases. "Classification of traumatic occipitoatlantoaxial lesions by anatomical location" table above might help you.

 2.  See description and evolution of patient.

  Fig. 9-46

Fig. 9: Arrow on perimedullary hematoma
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Fig. 10
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Fig. 11
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Fig. 12
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Fig. 13
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Fig. 14
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Fig. 15
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Fig. 16
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Fig. 17
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Fig. 18
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Fig. 19
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Fig. 20
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Fig. 21
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Fig. 22
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Fig. 23
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Fig. 24
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Fig. 25
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Fig. 26
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Fig. 27
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Fig. 28
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Fig. 29
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Fig. 30
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Fig. 31
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Fig. 32
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Fig. 33
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Fig. 34
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Fig. 35
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Fig. 36
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Fig. 37
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Fig. 38
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Fig. 39
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Fig. 40
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Fig. 41
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Fig. 42
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Fig. 43
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Fig. 44
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Fig. 45
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Fig. 46
References: radiology, IDI, Josep Trueta - Girona/ES


 

 

6.  DIFFERENTIAL DIAGNOSIS 

Fig. 47-50


 Watch out!  Differential diagnosis has to be stablished with:

 -    degenerative bone and articular disease in the elderly

 - congenital conditions like congenital fusion anomaly, os odontoideum or congenital ligament laxity

 -   pseudospread of C1-2 articular masses in physiological in young children

 

 

Fig. 48
References: radiology, IDI, Josep Trueta - Girona/ES

 

Fig. 47
References: radiology, IDI, Josep Trueta - Girona/ES

 

 

Fig. 49
References: radiology, IDI, Josep Trueta - Girona/ES

 

Fig. 50
References: radiology, IDI, Josep Trueta - Girona/ES


 

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