Dr. Alex Jimenez, El Paso's Chiropractor
I hope you have enjoyed our blog posts on various health, nutritional and injury related topics. Please don't hesitate in calling us or myself if you have questions when the need to seek care arises. Call the office or myself. Office 915-850-0900 - Cell 915-540-8444 Great Regards. Dr. J

Spinal Trauma Imaging Approach to Diagnosis Part I

Imaging Diagnosis Management:

  • Cervical spinal trauma & radiographic variants simulating disease
  • Cervical spine
  • Arthritis
  • Neoplasms
  • Infection
  • Post-Surgical cervical spine
spinal trauma el paso tx.
  • Cranio-cervical and upper cervical stability is dependent on transverse, superior and inferior bands of the C1-C2 ligament, alar ligaments, along with a few other ligaments
spinal trauma el paso tx.
spinal trauma el paso tx.

Cervical Trauma

  • The C/S is vulnerable to injury. Why?
  • Stability has been sacrificed for greater mobility
  • Cervical vertebrae are small and interrupted by multiple foraminae
  • The head is disproportionately heavy and acts as an abnormal lever especially when forces act against a rigid torso
  • Additionally, C/S is prone to degeneration which makes it more vulnerable to trauma
  • In young children, ligaments are more luxed vs. disproportionately large head size
  • In children, the fulcrum of movement is at C2/3 thus making injuries more common in the upper C/S and craniocervical junction. In children, S.C.I.W.O.R.A. may occur when no evidence of fracture present
  • In adults, the fulcrum of movement is at C5/6 thus making lower C/S more vulnerable to trauma especially during extremes of flexion
  • Cervical Trauma categorized according to mechanisms of injury (Harris & Mirvis classification)

Hyperflexion Injury: Stable vs. Unstable

  • Flexion teardrop Fx (most severe fracture, unstable)
  • Bilateral facet dislocation (severe injury w/o fracture, unstable)
  • Anterior subluxation (potentially unstable) can be very subtle injury
  • Clay Shoveller Fx (lower C/S SP avulsion, stable)
  • Simple wedge compression (most benign Fx, stable)
  • Hyperflexion-rotation with unilateral facet dislocation
  • Obtain a thorough history
  • Perform physical exam including a neurological exam
  • Consider NEXUS criteria (National Emergency X-radiography Utilization Study)

Imaging Techniques:

  • Begins with x-radiography especially in cases with no significant neurological compromise
  • Clear neutral lateral view first
  • If x-radiography is unrewarding but high probability of severe trauma and neurological deficit present, CT scanning w/o contrast is required
  • Consider CT scanning in patients with pre-existing changes: advance spondylosis, DISH, AS, RA, post-surgical spine, congenital abnormalities (Klippel-Feil syndrome, etc.)

Vertical compression:

  • Jefferson aka burst Atlas Fx (unstable especially if the Transverse ligament is torn, cord paralysis in 20-30% only)
  • Why? Due to fragments dissociation and canal widening
  • Burst Fx of the Thoracic or Lumbar spine (unstable, cord paralysis may occur)
spinal trauma el paso tx.

How to Assess Spinal Radiographs in Trauma Cases:

  • Construct 5-lines on the lateral view
  • Note if facets are well-aligned and symmetrical
  • Ensure symmetry of the disc height
  • Note any widening or fanning of the inter-spinous distance
  • Carefully examine prevertebral soft tissues
  • Evaluate atlanto-dental interval (ADI)
spinal trauma el paso tx.
  • In cases of trauma, evaluate and clear neutral lateral first
  • Do not perform flexed and extended views in acute cases before x-rays or CT scanning exclude significant instability
  • Pay extra attention to prevertebral soft tissues
  • If thicker than normal limits, consider severe post-traumatic bleed
  • Subtle asymmetry and widening of posterior disc height and facets with inter-spinous fanning may be a key feature of significant tearing of posterior ligaments
spinal trauma el paso tx.

Hyperflexion Injuries (M/C Mechanism)

  • More frequent in sub-axial C/S C-3-C7)
  • Unstable injuries:
  • Flexion teardrop fracture (M/C C5 & C6) v. unstable
  • Key rad features:
  • Large “teardrop” triangular anterior body fragment
  • Fanning of the SPs, posterior disc and facet widening indicating tearing of major spinal ligaments and instability
  • A posterior shift of the vertebral body fracture suggests direct anterior cord/vessels compression
  • Bulging prevertebral soft tissue >20-mm at C6-7
  • 80% of cases may be paralyzed on the spot or develop significant paralysis soon after
spinal trauma el paso tx.

Acute Neck Trauma. What are the vital radiographic features? What is the diagnosis?

spinal trauma el paso tx.
  • CT scanning w/o contrasts with sagittal reconstruction. Note C7 Flexion teardrop Fx.
  • CT may help with further delineation and preoperative planning
  • May follow with MR imaging and evaluation of the neurological injury
spinal trauma el paso tx.
  • Fluid sensitive (T2) sagittal MRI slice of Flexion teardrop fracture at C4 and possibly C5
  • Note high signal intensity lesion in the cord and surrounding ligaments indicating cord edema and ischemia
  • Management: neurosurgical with spinal fusion
  • Complications:
  • Quadriplegia/paraplegia
  • Respiratory complications
  • Disability, changes in the quality of life
  • Decreased life expectancy
spinal trauma el paso tx.
  • Bilateral facet dislocation (unstable)
  • Mechanism: Flexion-distraction injury
  • Key radiography: anteriorly displaced body 50% or more
  • Facets override and locked (can be perched left image)
  • Major tearing of ligaments
  • Chances of severe cord compression and paralysis
  • Patients with ligaments laxity and degenerative changes are at higher risk
  • Initial x-radiography is the first step
spinal trauma el paso tx.

CT scanning w/o Contrast is Crucial:

spinal trauma el paso tx.
  • Further delineation of this injury
  • Facet fractures, pedicle fracture
  • Management planning

Sagittal fluid sensitive MRI of bilateral C5 facet dislocation, large ischemic cord injury and posterior soft tissue injuries

spinal trauma el paso tx.
  • Management:
  • X-radiography, then CT scanning then immediate closed reduction (esp. if the patient is conscious)
  • Followed in some more complicated cases by MRI and then surgical care
  • If the patient is awake and neurologically stable, CT and closed reduction are adequate
  • Complicated cases and failed closed reduction may require surgical stabilization
  • Complications: spinal cord injury and paralysis
  • Delayed ligamentous laxity and instability
spinal trauma el paso tx.
  • Unilateral facet dislocation (flexion-rotation injury) less severe than bilateral dislocation
  • Most commonly missed unstable cervical injury on x-radiography
  • Key rad features: body anteriorly translated 25% facets appear misaligned and blurred, SPs rotated on frontal views
  • Clinically may be presented as one-sided radiculopathy esp. C6 or C7
  • CT scanning is required to evaluate further facet/pedicle fractures
  • Pre-reduction evaluation and care planning
  • Management: closed reduction esp. in a conscious patient
  • Complications: acute disc herniation/retropulsion, ligamentous laxity, neurological injury

Spinal Trauma Imaging Approach

Resources:

Dr. Alexander Jimenez ♛
Advanced Chiropractic & Wellness Authority ⚕ Healthcare Educator • Injury, Sciatica Specialist • 915-850-0900 📞
We Welcome You 👊🏻. Purpose & Passions: I am a Doctor of Chiropractic specializing in progressive, cutting-edge therapies and functional rehabilitation procedures focused on clinical physiology, total health, practical strength training, and complete conditioning. We focus on restoring normal body functions after neck, back, spinal and soft tissue injuries. We use Specialized Chiropractic Protocols, Wellness Programs, Functional & Integrative Nutrition, Agility & Mobility Fitness Training and Cross-Fit Rehabilitation Systems for all ages. As an extension to effective rehabilitation, we too offer our patients, disabled veterans, athletes, young and elder a diverse portfolio of strength equipment, high-performance exercises and advanced agility treatment options. We have teamed up with the cities premier doctors, therapist and trainers to provide high-level competitive athletes the possibilities to push themselves to their highest abilities within our facilities. We’ve been blessed to use our methods with thousands of El Pasoans over the last three decades allowing us to restore our patients’ health and fitness while implementing researched non-surgical methods and functional wellness programs. Our programs are natural and use the body’s ability to achieve specific measured goals, rather than introducing harmful chemicals, controversial hormone replacement, un-wanted surgeries, or addictive drugs. We want you to live a functional life that is fulfilled with more energy, a positive attitude, better sleep, and less pain. Our goal is to ultimately empower our patients to maintain the healthiest way of living. With a bit of work, we can achieve optimal health together, no matter the age or disability. Join us in improving your health for you and your family. It’s all about: LIVING, LOVING & MATTERING! 🍎 Welcome & God Bless EL PASO LOCATIONS Central: 6440 Gateway East, Ste B Phone: 915-850-0900 East Side: 11860 Vista Del Sol, Ste 128 Phone: 915-412-6677