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Case 30 - Unstable Fracture, Two Column Injury

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Looking at this sagittal reconstructions

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of the axial CT scans,

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we see the alignment on the anterior border

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of the vertebral body, looks pretty good.

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On the posterior border of the vertebral body, looks pretty good.

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At the spinolaminar line,

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there is a slight offset posteriorly. That

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in and of itself might not disturb you.

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But when you look and see that there is a widening of the

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distance between the spinous process and posterior element

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of the C5 vertebra with the C6 vertebra,

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that will catch your eye and suggest that you

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better be careful about this particular level.

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As we go off midline,

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we notice that the superior facet of the C6 vertebra is

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posterior to the inferior facet of the

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C5 vertebra on that side.

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Now, notice that there is no malalignment at the vertebral

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body level. When we come off to the contralateral side,

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we see that there is a perched facet on the opposite side.

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This vertebral body also looks a little bit strange.

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It looks like there may be fracture through that.

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So let's go to the axial scans. On the thin section axial scans,

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as we scroll through this and come

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down to that involved level,

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you can see the fracture of the facet

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and the regularity of the facet.

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And you also notice that the fracture line goes across the

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pedicle of the C6 vertebra bilaterally with involvement

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that extends to the transverse process, as well.

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So this is an unstable fracture.

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It involves two columns,

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and we should look at the MRI scan

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to look for ligamentous injury.

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So I'm going to pull up the MRI scan on the same

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patient and look at the sagittal

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STIR image.

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On this sagittal STIR image, you have that same widening

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between the spinous process of C5 and C6.

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You have the interspinous ligament injury,

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we have discontinuity in the spinolaminar line

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of the ligamentum flavum, injured as well.

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And one thing that I have haven't emphasized too much thus

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far is the presence of bone edema.

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On the sagittal STIR image,

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when you see high signal intensity in sort

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of a planar fashion on the sagittal scan,

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more likely than not, that represents bone edema.

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That may be a manifestation of an endplate

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fracture. In this case, indeed,

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you see that there is some bright signal intensity at the

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same level as this higher signal intensity in

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the superior endplate of 2, 3, 4, 5, 6, 7, T1.

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And that was a subtle fracture of the T1 vertebra.

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So now we have the first column injury.

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We have the third column injury.

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The posterior longitudinal ligament actually was intact.

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But the two columns of injury suggest

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that this is an unstable fracture.

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Once again,

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because this fracture extended to the transverse process.

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We want to look carefully at the foramen transverserium and

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the signal intensity of the vertebral arteries, to make

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sure that it is not dissected or occluded.

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And these arteries here look pretty good.

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There doesn't seem to be an injury at the appropriate level.

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We're going to look at the T1-weighted scan and look for any

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epidural hematoma. A little bit of bright signal intensity here.

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I'm not sure where that's a little bit of hemorrhage

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versus an area of hematoma. In order to

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look for that, what we do is we look at the STIRE image,

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because if it is fat, the STIR image will suppress it.

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And in point of fact, it is not suppressing.

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This is this area right here,

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this bright signal and bright signal, which corresponds

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to this area where it's bright signal and bright signal.

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So it's not suppressing like fat should.

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Indeed, there is a small epidural hematoma posteriorly at the

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level just above the fracture and just below the fracture.

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Here's that C5-C6 level where the injury has occurred.

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Inferiorly, little bit of blood products.

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Nope, it suppresses.

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And therefore this is just epidural fat back here that is

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showing the dark signal intensity of

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fat suppression on the STIR image.

4:47

So I hope this helps you with understanding how we use the

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various pulse sequences in order

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to assess for ligamentous injury,

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thrombosis of the vertebral arteries and/or epidural hematoma.

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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