Imaging of cervical spine traumas

doi:10.1016/j.ejrad.2019.05.007

European Journal of Radiology

Volume 117, August 2019, Pages 75-88

https://doi.org/10.1016/j.ejrad.2019.05.007 Get rights and content

Highlights

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This article on investigates the pathophysiological biomechanics involved in the pathogenesis of cervical spine traumas.
•
Classifications for the assessment and management of cervical spine trauma are discussed.
•
The role of Imaging in the evaluation of cervical spine trauma is discussed.

Abstract

Spinal traumas represent a significant proportion of muscle-skeletal injuries worldwide.

Spinal injuries involve a complex structure with components having different traumatic susceptibility and variable healing capabilities.

The interaction of numerous variables at time of trauma creates a great variety of lesions which makes challenging the creation and comparison of homogeneous groups, with difficulties in classifying spinal lesions, in assessing their instability, and in defining the indication and outcome of different treatment strategies.

The evolution of concepts on instability has accompanied that of traumas classification schemes and treatment strategies. The assessment of instability in a spinal injury is actually crucial in front of newer surgical techniques and hardwares.

Despite a long history of attempts to classify spinal traumas, it remains some degree of controversy in describing imaging data and a wide variety of treatment strategies.

Acute cervical spine injuries affect from 1.9% to 4.6% of subjects reporting a blunt trauma, and up to 5.9% of multiple-injured patients.

Most of spinal cord injuries are a consequence of unstable fractures of the cervical spine.

An accurate and early diagnosis is mandatory to prevent neurological damage in unstable fractures.

Classic and newer classifications are primarily based on features identifiable by using conventional imaging and CT scan, which are the most available modalities at most trauma centers.

Even though multidetector-CT remains superior in assessing with high accuracy bone injuries, MRI is the most sensitive modality for detecting soft tissues injuries and spinal cord damage.

Introduction

Spinal traumas represent a significant proportion of muscle-skeletal injuries worldwide.

Acute cervical spine injuries affect from 1.9% to 4.6% of subjects reporting a blunt trauma, and up to 5.9% of multiple-injured patients [1].

Most of spinal cord injuries (SCI) are a consequence of unstable fractures of the cervical spine.

SCI are an important cause of disability among young adults and working subjects, with high burden for both the individuals and society.

Spinal traumas involve a complex structure with components having different traumatic susceptibility and healing capabilities.

The wide variety of lesions hampers the creation and comparison of homogeneous groups with difficulty in classifying spinal fractures, in evaluating instability, and in the assessing the indication and efficacy of different treatments.

Despite of the numerous classifications of spinal injuries proposed for guide therapeutic strategies and for predict outcome, to date there are not universally accepted algorithms as to need and timing of surgery and on the most appropriate intervention techniques. However, an accurate and early diagnosis is mandatory to prevent neurological damage in unstable fractures.

Classic and newer classifications are primarily based on features identifiable by using conventional imaging and CT scan, which are the most available modalities at most trauma centers. However, MRI can aid in the diagnosis of subtle injuries to the disc-ligamentous complex (DLC).

Even though multidetector-CT (MDCT) remains superior in assessing with high accuracy bone injuries, MRI is the most sensitive modality for detecting soft tissues injuries and is the only modality for evaluating spinal cord damage. MRI is the method of choice in examining patients with SCI. Quantitative and qualitative parameters measured on MRI have a significant role in predicting initial severity of neurological status and outcome.

The injury patterns differ for the UCS and LCS. The combination of upper and lower cervical spine injuries in a single patient is inusual.

Missed, incorrect or delayed diagnosis all impact negatively on outcome.

Acute cervical spine injuries affect from 1.9% to 4.6% of subjects reporting a blunt trauma, and up to 5.9% of multiple-injured patients [1].

Cervical spine injuries (CSIs) concentrate at the extremities of the segment, with about one third involving C2 and one half C6 or C7.

In US, CSIs occur in 150.000 people per year, 11.000 of which report spinal cord damage, with an estimated 20% of all death for traffic accidents being due to a severe spinal cord injuries

[2].

CSI victims mainly are young men (aged 16–30; M:F 4:1) owing to high-energy traumas, such as traffic accidents, fall, assaults, and sport activities, in descending order. Only 1–3% of fatal spinal cord injuries occur in people before 15 years. Most of studies report a second peak of incidence in adults over 65 years of age.

Injuries in older people usully result from low-energy trauma, such as falling from standing or even seated height because of osteoporosis and stiffening in ageing spine.

As many as one-third of polytrauma patients have a closed head injury that increases the risk of cervical spine injury by 8.5% [3].

Section snippets

Biomechanics of the cervical spine

The UCS segment (C0-C1-C2) and subaxial cervical spine (SCS) (C3 -C7) have distinct anatomic features and functional programs.

The middle and lower cervical spine segments have similar anatomic and functional characteristics. Inside the subaxial cervical spine every motion segment (MS) formed by two adjacent vertebrae along with disc and ligaments, exhibits the same biomechanical characteristics as the whole spine.

Each MS has six degrees of freedom (three rotations around and three translations

Classification of SCS traumas: a work in progress

The subaxial cervical spine is involved in 65% of cervical fractures and accounts for the majority of spinal cord injuries, but despite the high incidence the classification and management of these lesions remain controversial.

Spinal traumas involve a complex structure with components having different injury susceptibility and healing potentiality.

At moment of injury, the interaction of numerous variables creates a great variety of lesions which hamper the creation and comparison of homogeneous

The morphological damage

The morphological damage refers to the structural integrity and relationships of vertebrae after a blunt trauma on which immediate mechanical instability depends.

There are four main mechanism of spinal injury, including compression, hyperflexion with posterior distraction, hyperextension with anterior distraction, and dislocation/rotation.

Each of main injury mechanisms has an own recognizable or inferable radiologic pattern or “footprint” [22]. However, to the main mechanism it may often

Disc-ligament complex damage

The majority of the cervical spinal cord injuries results from unstable fractures of the spine which can be initially clinically unapparent. Only one third of spinal trauma patients have neurological deficit at presentation. Patients with occult spine fractures or ligamentous lesions can become symptomatic during stay in emergency department [2].

About 89% of cervical spine post-traumatic lesions detected on postmortem imaging involve soft tissues, with or without bone lesions [47]. On clinical

The neurological damage

About 11.000 spinal cord injury occur every year in US, 55% of which involve the cervical spinal cord [2]. Spinal cord injury (SCI) is a disastrous, often definitive and irreversible event which besides worsening the quality of life, also reduces life expectancy approximately to half of that in normal people.

SCI represents also a great burden to individual as well as to the society. In US the lifetime costs of care for an individual averages $2 million, but vary widely according to the age,

Conclusions

CT and MRI play complementary roles as imaging modalities for the evaluation of the traumatic cervical spine, in acute setting. MDCT is the first-line imaging modality being rapid, easily performed, and optimally depicts bone anatomy and fractures.

MRI provides unmatched soft tissue delineation for the assessment of the discs, ligaments, and spinal cord. According to actual spine trauma classification schemes which account for the patient’s neurological status MR is the modality of choice in any

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Conflict of interest

All authors have read the manuscript, they approved this submission and declare that they do not have any conflicts of interest related to this work.

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The feasibility of performing cervical MRI may be limited in trauma patients with severe injuries, implanted pacing devices, or metallic foreign bodies, in addition to the higher cost, slower scanning speed, and limited availability in some regions.13,26 Carefully monitored dynamic plain film evaluation of the atlantoaxial joint following a prolonged period of external immobilization may help mitigate the inability to perform a cervical MRI.27,28 As a static examination in patients braced with a cervical neck collar, cervical CT may underestimate the degree of anterior or lateral subluxation at the atlantoaxial joint due to the injury being partially reduced by external neck support.
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The common goal of any classification scheme by imaging is to identify the presence and degree of spinal instability, in order to promote the best therapy and improve outcome. Radiological assessment of TLS injuries starts with the evaluation of the structural integrity and alignment of the vertebrae, the morphological damage, by radiographs and MDCT [3]. Traditionally, standing or supine anteroposterior and lateral radiographs serve to show the level and type of fractures, offering an overall view of the spine closer to what appears during surgery.
Spine trauma is an ominous event with a high morbidity, frequent mortality, and significant psychological, social, and financial consequences for patients, their relatives and society. On average three out of four spinal fractures involve the thoracolumbar spine and up to one-third are complicated by spinal cord injury. Spinal cord injuries (SCI) are a significant cause of disability in US and in all western countries. Knowledge of the main principles of biomechanics is essential in understanding the patho-morphology of spinal injuries, and the evolution of the various classification systems. Classification systems should be able to create a common language between specialists in order to improve patients’ prognosis, guide treatment and compare treatment outcomes. Imaging has always been crucial in the evaluation of the injury type and accompanied the development of different classification systems. Thoracolumbar spine (TLS) trauma has a wide spectrum ranging from minor isolated fractures to highly unstable fracture-dislocations. Early classification systems were based on the analysis of the pattern of bony injuries on radiographs and CT. Traditionally, conventional radiographs are performed to confirm the clinical suspicion and to depict the level and type of bone injury. However, because of their inherent limitations, radiographs are often more helpful in proving the existence of a suspected bony spinal injury rather than excluding it. Multidetector computed tomography (MDCT) is superior in evaluating bone anatomy and, especially in polytrauma patients, it is the first line imaging modality. Morphological bone damage may be accurately shown and classified on CT. the most recent classifications also incorporate the integrity of soft tissues structures, which is considered equally relevant to spinal stability. Injuries to ligaments and discs can only be suspected on radiographs and conventional CT, although dual-energy CT is offering new insights on collagen mapping of damaged discs. Magnetic resonance imaging (MRI) may directly assess disc and ligamentous injuries, but also subtle osseous injuries, playing a complementary role in defining the whole spinal damage and an eventual instability. MRI is the only valid modality to assess the spinal cord (SC) and is indicated whenever a neurologic injury is suspected. Advanced MRI techniques, such as diffusion weighted imaging (DWI) and tractography, may provide further information regarding the integrity of the white matter which may improve outcome prognostication. Despite challenges in terms of costs, availability, accessibility and specificity, MRI and advanced MRI techniques are increasingly being used in spinal injuries. We present a review on TLS traumas discussing on the development of different classification system used in their evaluation, the role of imaging for their detection and the correlation to the patients’ outcomes and treatment options.
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Dislocation is a serious situation correlated with a high risk of spinal cord injury (Mattucci et al., 2019). Dislocation and subluxation are the most severe stages of flexion-distraction type injuries, which are characterized by rupture of the posterior ligamentous complex and intervertebral disc (IVD) with or without bony fracture (Izzo et al., 2019). Flexion-distraction injuries are common at the cervical spine and are associated with neurological deficits in 61% of cases (Blauth et al., 2007).
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View full text

ReviewImaging of cervical spine traumas

Highlights

Abstract

Introduction

Section snippets

Biomechanics of the cervical spine

Classification of SCS traumas: a work in progress

The morphological damage

Disc-ligament complex damage

The neurological damage

Conclusions

Funding

Conflict of interest

J. Biomech.

Eur. J. Radiol.

Orthop. Clin. North Am.

Spine J.

Semin. Ultrasound CT MR

Spine J.

Neurosurg. Clin. N. Am.

Cervical spine trauma: how much more do we learn by routinely using helical CT?

Radiographics

Sub-axial cervical spine trauma

J. Am. Acad. Orthp. Surg.

Cervical spine imaging in patients with trauma: determination of fracture risk to optimize use

Radiology

Padova: Piccin Ed

Biomechanical analysis of clinical stability in the cervical spine

Clin. Orthop. Relat. Res.

The stabilizing system of the spine. II. Neutral zone and instability hypothesis

J. Spinal Disord.

Injuries to the rigid spine: what the spine surgeon wants to know

Radiographics

Fractures, dislocations, and fracture-dislocations of the spine

J. Bone Joint Surg. Am.

The three column spine and its significance in the classification of acute thoracolumbar spinal injurues

Spine

A mechanistic classification of closed, indirect fractures and dislocations of the lower cervical spine

Spine

The Sub-axial cervical spine injury classification system (SLIC): a novel approach to recognize the importance of morphology, neurology, and integrity of the discoligamentous complex

Spine

Subaxial cervical spine trauma classification: the Subaxial Injury Classification system and case examples

Neurosurg. Focus

Measuring nominal scale agreement among many raters

Psychol. Bull.

A comprehensive classification of thoracic and lumbar injuries

Eur. Spine J.

AOSpine subaxial cervical spine injury classification system

Eur. Spine J.

An independent inter- and intraobserver agreement evaluation of the AO spine subaxial cervical spine injury classification system

Spine

Evaluation of the reliability and validity of the newer AO Spine subaxial cervical injury classification (C-3 to C-7)

J. Neurosurg. Spine

“Fingerprints” of vertebral trauma—a unifying concept based on mechanisms

Skeletal Radiol.

Imaging evaluation of adult spinal injuries: emphasis on multidetector CT in cervical spine trauma

Radiology

Multidetector CT of blunt cervical spine trauma in adults

RadioGraphics

Controversies in clearing the spine

The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma

N. Eng. J. Med.

Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma

N. Eng. J. Med.

Clearance of the asymptomatic cervical spine: a metaanalysis

J. Orthop. Trauma

The Canadian C-spine rule for radiography in alert and stable trauma patients

JAMA

Are five-view plain films of the cervical spine unreliable? A prospective evaluation in blunt trauma patients with altered mental status

J. Trauma

Computed tomography versus plain radiography to screen for cervical spine injury: a meta-analysis

J. Trauma

Clinical examination and its reliability in identifying cervical spine fractures

J. Trauma

Clearing the cervical spine in multiple trauma victims: a time-effective protocol using helical computed tomography

Emerg. Radiol.

Spiral computed tomography for the initial evaluation of spine trauma: a new standard of care?

J. Trauma

Use of computed tomography to predict failure of nonoperative treatment of unilateral facet fractures of the cervical spine

Spine

Review
Imaging of cervical spine traumas