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Case 28 - Cervical Spine Flexion Injury

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As we moved from the craniovertebral junction, the CVJ,

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into the atlantoaxial region, which is the C1-C2 region,

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we finally get to the subaxial cervical spine.

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So the axis being the C2 vertebra,

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the atlantis being the C1 vertebra.

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We're now into the C3 through C7

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vertebra of the cervical spine.

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I want to introduce at this point the three column

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injury model that Denis, D-E-N-I-S, has

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the classification which actually originally

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described in the thoracic spine.

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But it does make sense even in the cervical spine.

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And what we have are three different columns.

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The first column represents the anterior longitudinal ligament

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and the anterior half of the vertebrae as the first column.

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The second column represents the posterior vertebra,

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including the posterior longitudinal ligament.

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And then the third column are the posterior ligaments of the

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interspinous ligaments and the ligamentum flavum, and the

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spinal laminar line and these posterior

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portion of the vertebral bodies.

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What the Denis classification says is that if you

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have two out of three of the columns injured,

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it's likely to represent an unstable spine.

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So here we have the same anatomy on the axial scan,

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the first column, the second column,

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posterior vertebra and posterior longitudinal ligament,

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and then the third column with the posterior elements,

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as well as the interspinous ligaments and ligamentum flavum.

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This is also demonstrated here on the diagram to the left.

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Now, if you have a fracture that goes all the way through

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the intervertebral disc from anterior to posterior,

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you're actually incorporating two columns, right?

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So this is the first column,

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but if it crosses into the posterior vertebra segment,

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you'd have two column disease.

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So this is the spinal stability theory,

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at least of the subaxial cervical spine in the Denis

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classification. And we actually think about it in those terms

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for stability or instability.

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I'm going to move in the cervical spine to the

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subaxial spine hyperflexion injuries.

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And here are some of the hyperflexion

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injury fracture types that can occur,

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which include your flexion teardrop injury,

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your bilateral facet dislocation and your clay shovelers

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fracture, which is in the spinous process.

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Here's a couple of examples.

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You notice that with these flexion injuries,

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you often show anterior displacement of one vertebral

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body versus the other, because these do represent not

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just the bony injury, but often there is two column

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injury leading to instability. In this case,

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we have a perched facet.

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This is one tip touching the other tip.

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But as we go off midline,

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we also see that this facet is now anteriorly

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located versus the facet below.

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Normally,

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the top of the superior facet is anterior to the inferior facet.

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This superior facet is posterior to the inferior facet.

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And we also have flexion teardrop fracture of the

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vertebra. So angulation, offset, dislocation, perched facet.

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This is a bilateral process,

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in this case, of a flexion injury type,

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leading to the fractures and the unstable spine.

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Here is the MRI scan of that exact same patient.

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And not only do we see the continued offset,

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but we see the injury to the posterior longitudinal ligament,

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we see the injury to the ligamentum flavum,

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we see the high signal intensity in the interspinous ligaments,

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we see the high signal intensity in the intervertebral disc,

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and we see the injury also to the anterior longitudinal

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ligament. This is three column disease,

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and let's not forget to look at the spinal cord.

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Whereas you can see there has been injury to

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the spinal cord with bright signal intensity.

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So this was a bilateral facet dislocation and a flexion

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teardrop fracture with ligamentous injury to anterior

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longitudinal ligament, posterior longitudinal ligament,

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as well as ligamentum flavum and interspinous ligament.

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Unstable spine. Another example.

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Here you can see the compression deformity

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and the flexion teardrop pattern.

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Little bit of posterior displacement of this vertebral

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body, compromising the spinal canal.

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And this is this triangular fracture,

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which is fairly typical of a flexion teardrop fracture.

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Here is the last of the flexion injury,

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the clay shoveler's fracture. This clay shoveler fracture,

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as you see,

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represents a fracture of the spinous process, that if you can

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imagine the individual taking the shovel and pushing

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it into the clay and then yanking the neck back,

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that's what causes the fracture of that spinous process,

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as they're trying to, you know, pull that clay out of the ground.

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Notice that in this instance,

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you do not have any offset of the anterior margin of the

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vertebral body, the posterior margin of the vertebral body,

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nor the spinal lamina ligament,

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but the spinous process is offset.

Report

Faculty

David M Yousem, MD, MBA

Professor of Radiology, Vice Chairman and Associate Dean

Johns Hopkins University

Tags

Neuroradiology

Head and Neck

Emergency

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