颈椎骨折-英文.ppt

CervicalSpinefractures1.CervicalAnatomyBiomechanicallySpecializedSupportof“large”CranialmassLargerangeofmotionFlexion/extensionAxialrotationUniqueosteologicalcharacteristics2.C1-AtlasNobody2articularpillarsFlatarticularsurfaceVertebralarteryforamen2archesAnteriorPosteriorVertebralarterygroove3.C2AnatomyDensEmbriologicalC1bodyBasepoorlyvascularizedOsteoporoticFlatC1-2jointsVertebralarteryforamenaInferomedialtosuperolateral5.AnatomyTheLigamentsAllowforthewideROMofupperC-spinewhilemaintainingstabilityClassifiedaccordingtolocationwithrespecttovertebralcanalInternal:TectorialmembraneCruciateligamentincludingtransverseligamentAlarandapicalligamentsExternalAnteriorandposterioratlanto-occipitalmembranesAnteriorandposterioratlanto-axialmembranesArticularcapsulesandligamentumnuchae7.AtlantoAxial AnatomyTectorial Membrane8.AtlantoAxial AnatomyocciputC1C2Tranverse LigamentC1-C2 jointAlar Ligament9.AtlantoAxial AnatomyTransverseLigamentFacet forOccipitalCondyle10.AtlantoAxial AnatomyVertebral Artery11.APPROACHTOC-SPINEINJURIESFollowingtraumaorcomplaintofneckpainObtainlateralAP,andodontoidviewsThelateralviewisonlyadequateifT1canbevisualizedIfthereisanydoubtoffractureorprevertebralswelling,obtainobliqueviewsandconsiderCTAllpatientswithsign/symptomsofcordinjuryrequireMRI12.CervicalViewsAPOdontoidObliques13.SwimmersView14.LATERALVIEW1.Anteriorvertebralline(anteriormarginofvertebralbodies)2.Posteriorvertebralline(posteriormarginofvertebralbodies)3.Articularpillar(wheresuperiorandinferiorarticularprocessesofcervicalvertebraehavefusedoneitherorbothsides)4.Spinolaminarline(posteriormarginofspinalcanal)5.Posteriorspinousline(tipsofthespinousprocesses)15.C1-C2Predental space(distancebetweenposterioraspectofanteriorarchofC1andanterioraspectofodontoidprocess)shouldbe3mmInadultandless5mminchildrenOrlessringsignofC216.C3-C7Anterior spinal,posterior spinal and spinolaminar lines:should be smooth lines Disc Spaces shouldbeapproximatelysame anteriornarrowing=flexioninjury.Widening=extension injuryFacet joints should be parallelInterspinous distance should decrease from C3 to C7Transverse process of C7 points downward and T1 UPWARDS INTERVERTEBRALDISCSPACESFACEFACETTJOINTJOINT17.PrevertebralSoftTissueNasopharyngealspace(C1)-10mm(adult)RetropharyngealspaceC2-C4(betweenposteriorpharyngealwallandanteriorborderofvertebrae).RetrotrachealspaceC5-7(spacebetweenposteriortrachealwallandanteriorinferiorbodyC6)c3-4 5mm from vertebral body is normalC4-7 20mm from vertebral body is normal5mm22mm10mm18.19.APViewTheheightofthecervicalvertebralbodiesshouldbeapproximatelyequalTheheightofeachjointspaceshouldberoughlyequalatalllevels.Spinousprocessshouldbeinmidlineandingoodalignment.20.OdontoidViewAnadequatefilmshouldincludetheentireodontoidandthelateralbordersofC1-C2.OccipitalcondylesshouldlineupwiththelateralmassesandsuperiorarticularfacetofC1.ThedistancefromthedenstothelateralmassesofC1shouldbeequalbilaterally.ThetipsoflateralmassofC1shouldlineupwiththelateralmarginsofthesuperiorarticularfacetofC2.TheodontoidshouldhaveuninterruptedcorticalmarginsblendingwiththebodyofC2.21.ClassificationofFracturesofc-spineHYPERFLEXION INJURIES FlexionteardropfractureHyperflexionStrainWedgeCompressionfractureBilateralfacetLockUnilateralfacetdislocationClay-shovelersfractureHyper extention injuries HangmanfractureExtentionteardropfracturelaminarfracturePillarfracturePosteriorarchofc1fractureFRACTURE DUE TO AXIAL LOADING JeffersonfractureBurstfractureOTHER INJURIES OdontoidfractureRotationalInjuries22.HyperflexionDistractioncreatestensileforcesinposteriorcolumnCanresultincompressionofbody(anteriorcolumn)MostcommonlyresultsfromMVCandfalls23.CompressionResultfromaxialloadingCommonlyfromdiving,football,MVAInjurypatterndependsoninitialheadpositionMaycreateburst,wedgeorcompressionfxs24.HyperextensionImpactionofposteriorarchesandfacetcompressioncausingmanytypesoffxslaminaspinousprocessespediclesWithdistractiongetdisruptionofALLEvaluatecarefullyforstabilityLOOKFORCENTRALCORDSYNDROME25.TypesofInjuries26.FlexionTeardropFractureC5-6fractureistheresultofacombinationofflexionandcompression,mostcommonlyat C5-6Theteardropfragmentcomesfromtheanteroinferioraspectofthevertebralbody.Thelargerposteriorpartofthevertebralbodyisdisplacedbackwardintothespinalcanal.Bestseenon lateral viewItisancompletelyunstablefractureassociatedwithcompletedisruptionofligamentsandanteriorcordsyndromeandquadriplegia70%ofpatientshave neurologic moninMOTOR VECHICLE ACCIDENT 27.Signs:Prevertebralswellingassociatedwithanteriorlongitudinalligamenttear.Teardropfragmentfromanteriorvertebralbodyavulsionfracture.Posteriorvertebralbodysubluxationintothespinalcanal.Spinalcordcompressionfromvertebralbodydisplacement.Fractureofthespinousprocess.28.Fracture of the body of c5 with a small fragment anteriorlyFracture of the spinous process of C4Acute angulation at the level of C5C6 with displacement of C5 in posterior direction29.30.31.32.33.WedgefractureCompressionfractureresultingfromflexion.FlexioncompressioninjuryBestseenonlateralviewStableCommoninElderlypatientswithosteoporosisorosteogenesisimperfecta34.35.WedgeshapevertebraAntersuperiorbodyfracture36.HangmansFractureC-2FxthroughtheparsinterarticularisofC2secondarytohyperextensionBestseenonlateral viewHyperextentioninjuryStablefracture?37.38.39.Themostcommonscenariowouldbe frontal motor vehicle(hitting dash board)Hangingfalls,divinginjuriescontactsports.Neurologicalinvolvementisrare40.41.Classification of Hangman s fracturesType I(65%)hair-linefractureC2-3discnormalType II(28%)displacedC2disruptedC2-3discligamentousrupturewithinstabilityC3anterosuperiorcompressionfractureType III(7%)displacedC2C2-3BilateralinterfacetdislocationSevereinstability42.TYPE1HANGMANFRACTUREThereisahair-linefractureandthereisnodisplacement.C23NORMAL43.HANGMAN FRACTURE TYPE 3 AnteriordislocationoftheC2vertebralbodyBILATRAL C2 pars interarticularis fractures.Prevertebral soft tissue swelling 44.TheCT-imagesconfirmthefracture-linesofthehangmansfracture.Theyrunthroughtheparsinterarticularisresultinginatraumaticspondylolysis.Inthiscasetherewasnoneurologicdeficit,becausethespinalcanaliswidenedatthelevelofthefracture.45.46.ExtentionteardropfractureAVULSION FRACTURE of anterio inferior content of the axis resulting from hyperextentionThis injury is stable in flexion but highly unstable in monindiving accidents Italsomaybeassociatedwiththecentralcordsyndrome.47.48.49.TheCTconfirmsthedisplacedanteroinferiorbonyfragment.Thisfragmentisatrueavulsion,incontrasttotheflexionteardropfractureinwhichthefragmentisproducedbycompressionoftheanteriorvertebralaspectduetohyperflexion.50.JeffersonFractureC-1BestseenonodontoidviewUnstablefractureFractureduetoAXIALLOADINGfrequentlyassociatedwithdivingintoshallowwater(axialblowtothevertexofthehead)impactagainsttheroofofavehiclefallfromplaygroundequipmentsFractureiscausedbya compressive downward forcethatistransmittedevenlythroughtheoccipitalcondylestothesuperiorarticularsurfacesofthelateralmassesofC1.Thisprocessdisplacesthemasseslaterallyandcausesfracturesoftheanteriorandposteriorarches,alongwithpossibledisruptionofthetransverseligament.51.SIGNS ON XRAY:DisplacementofthelateralmassesofvertebraeC1beyondthemarginsofthebodyofvertebraC2.2mmbilateralisalwaysabnormalC6T1Bestseenonlateral viewPowerful Hyperflexion injury(shoveling)Stable fracture Common in motorvehicleaccidentssuddenmusclecontractiondirectblowstothespine66.67.Apviewshowghostsignwith2spinousprocesses?68.Case15yogirlHitbycarwhileridingbikeVSAatsceneVitalsrecoveredbyEMSRose et al,Am J Surg 2003;185(4)69.Atlanto-OccipitalDislocation2.5xmorecommoninchildrenthanadultsDuetosmalloccipitalcondylesandhorizontalatlanto-occipitaljointsSuspect if distance between occipital condyles and C1 is 5mm at any pointUsually have+soft tissue swelling70.OccipitoAtlantalDissociation(OAD)Commonly FatalPresent 6-20%of post mortem studiesAlker et al,1978Bucholz&Burkhead,1979Adams et al,199250%missed injury rate1/3 Neurological WorseningDavis et al,199371.OccipitoAtlantalDissociation(OAD)Symptoms/FindingsWallenberg SyndromeLower Cranial nerve deficitsHorners syndromeCerebellar ataxiaCruciate paralysisContralateral loss of pain and temperature72.Radiographic LinesBC/OA1 considered abnormalLimited UsefulnessPositive only in Anterior Translational injuriesFalse Negative with pure distractionPowersetal,Neurosurg,1979Powers Ratio73.QUESTIONS74.REFERRENCESTextBookofRadiologyandimaging(DAVIDSUTTON)PrimerofDiagnosticImagingRadiologyReviewManual(Dahnert)75.Thank You!76.