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C-spine Trauma
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C-spine Trauma - January 23, 2005 10:55:00 PM
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Alex Brenner PT MPT OCS
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From: Kentucky
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57 year old male retired military tripped over a curb. He had both his hands in his coat pockets so he was unable to break the fall. He complains of neck pain with symptoms radiating into both shoulders. What are the findings?
(All images obtained and used with permission)
[IMG]http://img.photobucket.com/albums/v85/brennerak/c-spinelat.jpg[/IMG]
[IMG]http://img.photobucket.com/albums/v85/brennerak/c-spineap.jpg[/IMG]
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Alex Brenner, PT, MPT, OCS
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Re: C-spine Trauma - January 24, 2005 12:37:00 AM
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Jeep
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With this much arthrosis- obliques are indicated. The probability of stenosis is very high.
And if no "flags" on his history/exam- I'd consider flexion/extension views.(looks like a lot of potential for ligamentous instability) Are these the only two views taken of this gentleman?
There is a lot going on here!!!
What pops out (besides the obvious extensive dengerative changes) is the posterior/inferior margin of C5. I am suspicious of the lamina, but will have to take more time to study it later.
As an aside- This is good example of how osteporosis is not just a womens problem.
We can also ascertain from the above that this is not the first time he has injured his neck.
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Re: C-spine Trauma - January 24, 2005 1:16:00 AM
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Alex Brenner PT MPT OCS
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From: Kentucky
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A Dens view was also obtained. Flexion-extension views were not ordered.
[IMG]http://img.photobucket.com/albums/v85/brennerak/densview.jpg[/IMG]
(all images obtained and used with permission)
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Alex Brenner, PT, MPT, OCS
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Re: C-spine Trauma - January 24, 2005 4:24:00 AM
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chiroortho
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Other than the advanced degenerative changes, I don't see a thing wrong with these films.
The vertilinear opacities behind the neck are not avulsions, they are just calcifications within the lig nuchae. Some say it's due to old injury, the jury's still out on that.
Side note: he has kind of a shallow sella. No clinical significance.
His mom should have told him to brush his teeth more often when he was a kid, that's for sure.
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Greg Priest, DC, DABCO
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Re: C-spine Trauma - January 24, 2005 9:06:00 AM
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FLOrthoPT
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wow, lots of spondylosis degenerative changes here, DDD, with nice spurring anteriorly and post., and prob lots of nerve root impingement and flare up that had been aggravated by sudden extension. Very arthiritic neck aggravated with trauma. Prob will need to be on some sort of steroid for a short time if has true nerve root radic pain. this guy was a train wreck waiting to happen though...the foraminal space for those nerve roots appear almost non existant the more you creep down from C3...maybe if no lig laxity some c-spine traction, some flexion exercises, maybe a collar if pain is real bad and needs to totally avoid any side flexion...This is one of those X rays though were there is so much too look at I may be overlooking something more sever, otherwise a guy with horribly arthritic c-spine fell into an extended motion causing those spurs to come cramping in on the nerve root and viola some nice radic pain and since the space was not accommodating to begin with now that he has inflammation they are contstantly being aggravated with all motions that close the space down i.e. ext, sf, rot...so get this guy a good saunders hometrac unit, and have fun!
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Re: C-spine Trauma - January 24, 2005 10:23:00 AM
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nari
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I don't like the look of OC1C2 at all.
Does the guy remember how he landed when he fell?
Apart from loss of IVD space -which may be resulting in some peripheral symptoms -I would go for the apparent retrolisthesis at the top??
Nari
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Re: C-spine Trauma - January 24, 2005 11:01:00 AM
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pablo w
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The appearance at C1-2 on the lateral view and the open mouth view suggest an undisplaced fracture through the base of the dens. It's hard to be sure though, and it could be that it's been like that all along as sometimes ossification is not complete. It is undisplaced, but until cleared it warrants a collar.
Aside from the obvious scoliosis, spurs and osteophytes, I don't like the look of the AP view. I suspect there may be a fracture at C6-7 and at C4-5 of the uncovertebral processes but it's hard to be sure. In any case, given the appearance of teh films I think it warrants further investigation with CT and an isotope scan.
Pablo
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Re: C-spine Trauma - January 24, 2005 12:16:00 PM
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InOrbit
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Definitely a fx of C2.
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Re: C-spine Trauma - January 24, 2005 1:33:00 PM
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chiroortho
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I disagree, dens looks perfectly normal to me. Besides, with a dens fx I'd expect to see prevertebral soft tissue swelling. It it's fractured I need a new monitor.
There's often a line across the base of the dens that looks like a type II dens fx, but it's due to summation of overlying structures. Sometimes it's the bottom of the incisors, but not in this case.
As I said the dens looks perfectly normal to me. If it's fractured feel free to mock me mercilessly. :)
Going out on a limb like this is fun. Looking at films on a monitor is not the same as looking at them on the viewbox, everybody recognizes that. Don't be afraid to take your best shot.
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Greg Priest, DC, DABCO
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Re: C-spine Trauma - January 24, 2005 2:38:00 PM
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Jeep
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Chiro-
Do you recall A-D interspace measurements?
Too lazy to look it up!
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Re: C-spine Trauma - January 24, 2005 3:59:00 PM
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chiroortho
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Less than 5mm in children, less than 3mm in adults (as measured on the flexion view)
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Greg Priest, DC, DABCO
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Re: C-spine Trauma - January 24, 2005 4:51:00 PM
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OrthoSam
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Looks like he has cervical ribs.Spine seems almost fused down to the level of C3-4, with advanced degenerative changes throughout.
Sam
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Re: C-spine Trauma - January 24, 2005 5:29:00 PM
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Jeep
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I was thinking the same.(per LCN) but the visualization on the APLC is such that counting seven segments is ambiguous.
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Re: C-spine Trauma - January 24, 2005 6:35:00 PM
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UTDC
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IMHO:
1. no cervical rib
2. no odontoid fracture
3. no c5 fracture
4. no uncovertebral fracture(although betting against Pablo is probably not a good idea)
5. no fusion
6. moderately advanced spondylosis and djd as mentioned.
7. With the usual monitor disclaimer....the posterior aspect of the C3 spinous looks rather ragged, suspiciously like a fracture line...
8. The soft tissue opacities may be Lig Nuc. calcification as mentioned, also may be lymph node calcification. It is difficult to see where they are in space as I cannot appreciate them on the APLC.
9. There seems to be a lot of concern over the spondylosis. Remember that this may not at all be a factor in the patient's complaint and may never cause a problem in the future.
The clinical exam would be important here: without neurological findings, obliques would not be indicated...posterior tenderness centrally would help determine the spinous fracture. I would probably want a CT, not so much a bone scan.
Thanks for letting me play,
Jeff
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Re: C-spine Trauma - January 25, 2005 1:14:00 AM
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Jeep
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I disagree as to the obliques- I think they are warranted- due to the advanced DJD and the high probability of IVF encroachment thereof.
I also would lean towards a CT- considering the osteoporsis evidenced,and and it's role in increased fracture risk, combined with the trauma Hx. However, as always, clinical correlation(which we have very little here) is needed.
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Re: C-spine Trauma - January 25, 2005 4:25:00 AM
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chiroortho
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Call me dense, but I don't see the osteoporosis. I'd even question if the films demonstrate osteopenia. Honestly, I think it's normal mineralization.
Easy way to tell when the cervicals end and the thoracics begin on an AP view: the first TP's that are pointing upward are thoracics. Thus, as Jeff aptly notes, no cervical ribs. Those are the normal first ribs.
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Greg Priest, DC, DABCO
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Re: C-spine Trauma - January 25, 2005 4:48:00 AM
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Alex Brenner PT MPT OCS
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From: Kentucky
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Nari,
He has trouble recalling but I think this gentleman did a left shoulder first to face plant-type of landing forcing the neck into extension and right rotation. He had abrasions on the left side of his face.
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Alex Brenner, PT, MPT, OCS
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Re: C-spine Trauma - January 25, 2005 5:23:00 AM
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fapt
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hmm
According to the radiology,
I think this man has degenerated and stenosis cervical spine at C2-3, C4-5, and C7-T1. And also has osteophyte at C6 and C7. I saw some superficial osscified pecises at his C7~T1 area. I don;t know what it is? May be some seperated(fx) spinaous proceses...I guessed.
From the PS view, This patient has scoliosis hx....
That is my opinion..
Cheers, Lin, MSPT, Taiwan
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夏之日，冬之夜，百歲之後，歸于其居。
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Re: C-spine Trauma - January 25, 2005 5:26:00 AM
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chiroortho
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Army, being a gentleman, is pushing us to look more closely at the upper cervical area.
I'm going to continue to say that the dens looks normal to me.
There is something called a 'mach band' that makes it appear that there is a dens fx.
Sorry, I just don't see a fx.
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Greg Priest, DC, DABCO
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Re: C-spine Trauma - January 25, 2005 6:13:00 AM
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Jeep
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Chiro-
Osteoporosis-- evidenced by overall opacity/radiolucency, thin cortical margins( remember pencil line cortex?) -
Somewhere in my totally disorganized computer filing(lack of)system, I have a really good radiaology ed/tutorial site. I'll see if I can find it later.
Regardless, IMO strongly, this guy has classic diffuse Osteoporosis.
I agree- no dens fx visualized on submitted films.
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