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Trauma of the spine Cheat Sheet (DRAFT) by

Imaging , presentation etc

This is a draft cheat sheet. It is a work in progress and is not finished yet.

Cx f#

- More common at C1-2 & C5-6
- Flexion most common

Instabilty

Defini­tion: Gross ligame­ntous damage with or without or potential for neurol­ogical insult­/co­mpr­omise

Hyperf­lexion injuries

Odontoid f# - mostly unstable
Wedge f# - Stable
Teardrop f# - severe and unstable
Bilateral locked facets - unstable
Spinous process f# - stable

Hypere­xte­nsion injuries

- Hangmans f# - unstable
- Ext teardrop - can be stable­/un­stable
- Neural arch f# of C1 - stable

Flexion Rotation

- Unilateral Locked Facets - stable

Vertical Compre­ssion

- Jefferson f# (commi­nuted f# of ring of C1) - unstable
- Burst f# (IVD driven into VB below) - stable

F# of the Atlas/C1

- Posterior Arch - Most common, hypere­xte­nsion, most have other associated Cx F# and artery injury
- Jefferson f# - F# through anterior and posterior ring , lateral masses displaced laterally on APOM
If lateral mass displaced >8mm consider transverse ligament rupture
CT gold standard
Rupture of Transverse Ligament: Uncommon as an isolated incident - ADI (Down syndrome, RA)

Jefferson f#

L - APOM X-ray
R - CT of C1

F# of Axis/C2

Den's F# - Common
Type 1: Avulsion of the tip
Type 2: F# at the base of the dens - most common
Type 3: F# deep within C2 body
Teardrop F#: Avulsion of anteri­or-­inf­erior corner of C2 due to hypere­xte­nsion
- Hangman's f# - Bilateral pedicle f# - some have another f# , usually at C1
Associated with artery injury + anterior transl­ation of C2 on C3
Caused by hypere­xte­nsion of the neck - rapid decela­ration

Den's F#

L - Type 2 Den's f# (not through lateral masses)
R - Anterior transl­ation of C2 on C3

Extension Teardrop F#

Hangman's f#

Compre­ssion f#

Wedge: Hyperf­lexion - stable
Flexion Tear Drop: Severely unstable
Burst: Vertical - poster­iorly displaced fragments can cause cord damage (CT/MRI)

Osteop­orosis Compre­ssion F#

- Axial loads + flexion
- Osteoc­lasts overtake osteob­lasts - diminishes bone density
- Classfication:
 Type I: Postme­nop­ausal - women aged 51-65 oestrogen deficiency
Type II: Senile - both sexes after age 75 (women more affected)

Wedge

- Compre­ssion of vertebral body between adjacent bodes during flexion
- Vertical height is decreased anteriorly
- Posterior height maintained
- Usually at T10-L2 (if osteop­orotic)

Flexion Teardrop

- Flexion + Axial compre­ssion
- Risk of spinal cord injury (MRI/CT)
- May be soft tissue swelling pre-ve­rtebral area
- Posterior displa­cement and diastasis of the interf­acetal joints = disruption of longit­udinal + posterior ligaments, IVD,

Burst F#

Burst F# on X-ray (L) and CT (R)
- Posterior fragments can impinge upon spinal cord/n­eural canal

Clay Shovel­ler's f#

- Avulsion of SP of C6,C7,T1 - Stable
- Rotation of the upper trunk when Cx is fixed

Disloc­ations

Atlant­o-O­cci­pital - Rare, usually fatal
Atlant­o-axial - Anterior if transverse ligament ruptured
Facet Disloc­ation: Unilat­era­l/b­ila­teral

Facet Disloc­ation

- Bilate­rally usually associated with some degree of neurol­ogical deficit
- Unilateral - flexion + rotation (opposite to the direction of rotation, SP points to the side of disloc­ation)
- Lateral projection - bow tie/bu­tterfly appearance (ringed in red) - anterior displa­cement of dislocated VB a distance >one half sagittal diameter of a cx vb.
- Presents as painful tortic­ollis with trauma

Signs of soft tissue injury

- Wide Retrop­har­yngeal space (>7mm)
- Wide Retrot­racheal Soft Tissue (>1­4-22mm)
- Tracheal Deviation
- Soft Tissue Emphysema

Tx Spine

Common f# areas: T11-T12
If T4-T8, suspect convul­sions

Tx compre­ssion F# (new)

New due to the preserved posterior VB height
- Anterior step defect present
-Line of conden­sation

- Old would have
- Wedge deformity (not as sticky outy)
-Intact cortex
- Normal trabec­ulation
On MRI
New f# will present increased signal on T2 and decreased signal on T1

F# disloc­ation

Chance

Lap belt f#
Usually associated with severe organ damage

Osteop­orosis

- Biconcave VB = codfish vertebra
- Thinning of cortices present
- DEXA screen (1-2.5 = osteop­enia, >2,5 = osteop­orosis)
- Tx spine pain can be red flag - other pathology (neoplasm, haeman­gioma, aneurymal bone cyst, multiple myeloma, sarcoma, mets) RULE OUT AGGRESSIVE CAUSES FIRST!

TVP F#

- Caused by avulsion - hypere­xte­nsion and lateral flexion
- 2nd common f# in lx
- Most common in L2 and L3

Pathol­ogical Compre­ssion F#

- Decreased body height of the whole VB
- Consider Osteop­orosis, Lytic metastasis or multiple myeloma
- Mets from prostate, kidney, breasts, lungs or skin (usually below T5)
- Look for signs of pathology - interp­edi­cular widening, posterior VB involv­ement (pancake) - may need advanced imaging to conform as hard to tell

Risk Factors for osteo compr f#

- Osteop­orosis (common in women and increases over time)
- Verteb­rop­las­ty/­kyp­hop­lasty
- Family Hx
- Low body weight
- Recent weight loss
- Smoking
- Sedentary Lifest­yle­/oc­cup­ation
- Poor diet
- Inadequate Calciu­m/v­itamin D intake
- Excessive alcoho­l/c­affeine intake
- Scoliosis
- Epidural steroid injections

Presen­tation for osteo com f#

- Fall on buttoc­k/pain with arising from seated position, bending forward, coughi­ng/­sne­ezing
- Can be asympt­omatic
- Aching­/st­abbing back pain
- Can radiate to ribs, hip, groin or buttocks
- Decond­iti­oning, insomnia, depres­sion, breathing diffic­ulties from kyphosis
- Severe cases - spinal cord compre­ssion, transient ileus, urinary retention, paralysis
- On obs, increased tx kyphos­is/loss of lx lordosis
- Patient feels as though they have lost height
- Fingertips extend to lower thigh when standing
- +ve Supine sign, +ve closed fist percussion
- Tenderness over site
- Limited ROM
- REFER IMMEDI­ATELY IF CAUDA EQUINA S&S ARE THERE

DDx

- Mets
- Osteom­yelitis
- Pott disease (spinal TB)
- Hyperp­ara­thy­roidism
- Paget's disease
- Spondy­losis
- Spondy­lolysis
- Spondy­lol­ithesis
- Mechanical LBP
- Disc Lesion
- Viscer­oso­matic referral - GI/GU/­car­dio­pul­monary systems

Management of os com f#

- Education about avoiding pain and mainta­ining mobility
- Bracing/lx corset
- Streng­thening of spinal extensors
- Aerobic condit­ioning
- Propri­oce­pti­ve/­balance training
- 800-1000IU of vitamin D
- 1000-1200 of calcium
- Sunlight exposure 6-7 mins (summer) and 15-29 minutes in the winter per day
- SMT contra­ind­icated
- Surgical interv­ention if con care fails (3-4 weeks)
Criteria for earlier surgery:
Progre­ssive increase in f# angle (>10 degrees)
Persis­tent, progre­ssive or debili­tating pain
- Medica­tions: Bispho­sph­onates (Fosamax, Didronal, Boniva, Actonel, Skelid, Aredia, Reclast, Zometa , Raloxifene (Evista), Denosumab {Prolia), hormones Calcitonin (Fortical or Miacalcin and Teripa­ratide (Forteo)