Case: Facet Fracture with Vertebral Artery Occlusion
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I want to use this case to demonstrate the potential
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injury to the vascular structures with a cervical
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spine fracture. So looking at the sagittal scan,
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we see that the C4 vertebra is slightly posterior
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displaced compared to the C5 vertebra.
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And we also see a small area of fracture along the inferior
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emplate with this fragment more posteriorly and
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inferiorly separating from the vertebral body.
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Not only that,
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but you also see this discontinuity in the inferior
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facet at the C4 level and the widening of the space here
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between the facets and the fracture
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line extending towards the pedicle
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of the vertebral body. On the contralateral side,
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again, not as widened,
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but there is that increased space between the facets.
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This shows the narrowing of the spinal canal.
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So there is some spinal stenosis associated
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with the level of the injury.
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When we look at this case on the axial scan,
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one thing that is impressive is the soft tissue that is
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seen causing incredible amount of spinal stenosis.
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This soft tissue is actually a herniated disc.
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So remember that you can have fractures
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that are causing the patient to have pain,
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but you may also have an acutely herniated disc which
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is compressing nerve roots or the spinal cord,
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causing the injury to the patient and/or their pain.
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So this is marked spinal stenosis.
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If we had to measure the AP diameter
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here of the spinal canal,
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you'd note that we're only dealing with a
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3 mm length for the AP diameter.
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So spinal stenosis at the level of the fracture
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dislocation that is seen here.
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Not only that,
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but if we look at this raw data from the CTA
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and follow the left vertebral artery,
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we see that coming up at that level of the...
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just above the fracture,
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we're missing the vertebral artery on the left side.
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But not only that,
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the right vertebral artery is also missing.
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Here it is in the foramen transversarium.
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Now, it's gone.
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And here we have the tight stenosis
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at the level of the fracture.
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We're still missing the vertebral arteries
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bilaterally. And as we come up,
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you start to see them again as they are reconstituted
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from collateral vessels. So important findings.
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Number one,
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the potential of associated disc herniation with traumatic
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injury to the cervical spine as a source of the neck pain.
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Number two, severe spinal stenosis likely to cause the
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patient to have cord injury, secondary to the
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displacement of the fracture fragments.
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Number three, the absence of normal flow on the CTA of
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the vertebral arteries at the level of the spinal stenosis
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and the fracture dislocation. And the presence of the
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widening of the spaces between the facet joints.
David M Yousem, MD, MBA
Professor of Radiology, Vice Chairman and Associate Dean
Johns Hopkins University
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