|ECR 2013 / C-2110|
|Upper cervical trauma: study in acute phase and follow up|
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.
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
-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
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.
b) All multiple trauma patients in our center--> Body CT. When are patients considered multiple trauma patients?
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.
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.
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
Most frequent lesions.
In order of frequency
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.
Most frequently used surgical techniques.
1. Quiz cases. "Classification of traumatic occipitoatlantoaxial lesions by anatomical location" table above might help you.
2. See description and evolution of patient.
6. DIFFERENTIAL DIAGNOSIS
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
Thematically related posters
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ECR 2013 / C-0589
Infectious complications after thoracic major trauma: peculiar aspects at Multidetector-CT's follow-up.