0:01

Looking at this sagittal reconstructions

0:03

of the axial CT scans,

0:05

we see the alignment on the anterior border

0:08

of the vertebral body, looks pretty good.

0:10

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

0:14

At the spinolaminar line,

0:16

there is a slight offset posteriorly. That

0:18

in and of itself might not disturb you.

0:21

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

0:24

distance between the spinous process and posterior element

0:28

of the C5 vertebra with the C6 vertebra,

0:31

that will catch your eye and suggest that you

0:34

better be careful about this particular level.

0:38

As we go off midline,

0:40

we notice that the superior facet of the C6 vertebra is

0:46

posterior to the inferior facet of the

0:48

C5 vertebra on that side.

0:51

Now, notice that there is no malalignment at the vertebral

0:55

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

1:00

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

1:04

This vertebral body also looks a little bit strange.

1:07

It looks like there may be fracture through that.

1:10

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

1:15

as we scroll through this and come

1:18

down to that involved level,

1:20

you can see the fracture of the facet

1:23

and the regularity of the facet.

1:26

And you also notice that the fracture line goes across the

1:30

pedicle of the C6 vertebra bilaterally with involvement

1:36

that extends to the transverse process, as well.

1:40

So this is an unstable fracture.

1:43

It involves two columns,

1:47

and we should look at the MRI scan

1:50

to look for ligamentous injury.

1:53

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

1:56

patient and look at the sagittal

2:00

STIR image.

2:01

On this sagittal STIR image, you have that same widening

2:06

between the spinous process of C5 and C6.

2:10

You have the interspinous ligament injury,

2:14

we have discontinuity in the spinolaminar line

2:19

of the ligamentum flavum, injured as well.

2:22

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

2:26

far is the presence of bone edema.

2:30

On the sagittal STIR image,

2:32

when you see high signal intensity in sort

2:35

of a planar fashion on the sagittal scan,

2:41

more likely than not, that represents bone edema.

2:44

That may be a manifestation of an endplate

2:47

fracture. In this case, indeed,

2:50

you see that there is some bright signal intensity at the

2:52

same level as this higher signal intensity in

2:55

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

3:00

And that was a subtle fracture of the T1 vertebra.

3:05

So now we have the first column injury.

3:09

We have the third column injury.

3:12

The posterior longitudinal ligament actually was intact.

3:16

But the two columns of injury suggest

3:19

that this is an unstable fracture.

3:22

Once again,

3:23

because this fracture extended to the transverse process.

3:27

We want to look carefully at the foramen transverserium and

3:32

the signal intensity of the vertebral arteries, to make

3:35

sure that it is not dissected or occluded.

3:38

And these arteries here look pretty good.

3:42

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

3:47

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

3:50

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

3:54

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

3:56

versus an area of hematoma. In order to

4:00

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

4:02

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

4:07

And in point of fact, it is not suppressing.

4:10

This is this area right here,

4:12

this bright signal and bright signal, which corresponds

4:15

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

4:18

So it's not suppressing like fat should.

4:20

Indeed, there is a small epidural hematoma posteriorly at the

4:25

level just above the fracture and just below the fracture.

4:29

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

4:33

Inferiorly, little bit of blood products.

4:37

Nope, it suppresses.

4:38

And therefore this is just epidural fat back here that is

4:42

showing the dark signal intensity of

4:45

fat suppression on the STIR image.

4:47

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

4:51

various pulse sequences in order

4:53

to assess for ligamentous injury,

4:56

thrombosis of the vertebral arteries and/or epidural hematoma.