Spine Trauma Imaging

Initial Assessment - 🚦 Spine Alert Rules

Decision tools for selective C-spine imaging, minimizing radiation.

• NEXUS (National Emergency X-Radiography Utilization Study) Criteria: Clears C-spine if all 5 criteria negative:
  • No posterior midline cervical tenderness
  • No intoxication
  • Alertness normal (GCS 15)
  • No focal neurological deficit
  • No painful distracting injury
• Canadian C-Spine Rule (CCR): For alert (GCS 15), stable trauma patients. More complex but higher accuracy.

![Canadian C-Spine Rule clinical decision pathway](https://ylbwdadhbcjolwylidja.supabase.co/storage/v1/object/public/notes/L1/Radiology_Emergency_Radiology_Spine_Trauma_Imaging/8ef83bbe-86e5-4f21-987c-474fd102469e.png)

⭐ CCR demonstrates higher sensitivity and specificity than NEXUS for clinically significant C-spine injuries.

Imaging Modalities - 📸 Pixel Power Play

• X-ray (Plain Radiographs):
  • Initial screening in low-risk patients (e.g., fulfilling NEXUS criteria for C-spine clearance if imaging still pursued) or resource-limited settings.
  • Standard views: AP, lateral; odontoid for C-spine.
  • Assesses alignment, gross fractures. Limited for subtle injuries & soft tissues.
• CT (Computed Tomography):
  • Primary modality for suspected spine trauma, especially unstable injuries.
  • Superior for bony detail, complex fractures, pre-operative planning.
  • Multiplanar Reconstructions (MPR) essential.

  ⭐ CT is the investigation of choice for definitive evaluation of osseous spinal trauma.

• MRI (Magnetic Resonance Imaging):
  • Best for neurological deficits, suspected spinal cord injury (SCI), ligamentous injury, epidural hematoma.
  • Use if CT negative but symptoms persist or to assess soft tissue extent.

Cervical Spine Injuries - 💔 Neck Wrecks

• C1 (Atlas):
  • Jefferson Fracture: Burst # of C1 ring. Rule of Spence: Lateral mass displacement >7mm on open-mouth X-ray suggests transverse ligament injury.
  • 
• C2 (Axis):
  • Odontoid (Dens) Fractures:
    • Type I: Tip avulsion (stable).
    • Type II: Base of dens (unstable, common).
    • Type III: Extends into C2 body (unstable, good prognosis).
  • Hangman's Fracture: Bilateral C2 pars/pedicle # from hyperextension (unstable).
• Lower Cervical (C3-C7) Injuries:
  • Flexion Teardrop Fracture: Anteroinferior vertebral body fragment; highly unstable (ligamentous disruption).
  • Clay-Shoveler's Fracture: Spinous process avulsion (C7>C6); stable.
• Stability Assessment:
  • Denis 3-column theory; ≥2 columns disrupted = unstable.

⭐ Type II Odontoid fracture is the most common type and carries a high risk of non-union, making it unstable.

Thoracolumbar Trauma - 💥 Back Breakers

• Denis Columns: Stability: 3-column model.
  • Anterior, Middle, Posterior.
  • ≥2 columns failed = Unstable.
• Key Fracture Types:
  • Compression: Anterior column fails (wedge). Often stable.
  • Burst: Anterior + Middle fail; retropulsion common; neuro risk.
  • Chance: Flexion-distraction (📌 seatbelt); horizontal #, 3 columns; PLC often disrupted.
  • Fracture-Dislocation: Grossly unstable; 3 columns disrupted, displaced.
• Imaging: X-ray (initial); CT (bone detail); MRI (cord/ligaments/PLC).
• TLICS Score: Guides management (Morphology, Neuro, PLC).
  • Score >4 → surgery.

⭐ TLICS: PLC disruption scores 3 points, strongly favoring surgery due to critical instability.

Special Considerations - 🤔 Tricky Spines

• Pediatric Spine: SCIWORA (Spinal Cord Injury Without Radiographic Abnormality) - MRI crucial. Pseudosubluxation (C2-C3 common).
• Osteoporotic Fractures: Insufficiency fractures; may be occult on X-ray. Consider CT/MRI.
• Ankylosing Spondylitis: ↑Risk of unstable "chalkstick" fractures even with minor trauma.
• Cord Syndromes: Clinical patterns (Central, Brown-Séquard, Anterior, Posterior) guide diagnosis.

  ⭐ Central Cord Syndrome: Most common incomplete lesion; upper limbs affected more than lower; often in elderly with hyperextension injury.

• Degenerative Spine: Pre-existing changes can complicate assessment; differentiate acute vs. chronic findings.

High‑Yield Points - ⚡ Biggest Takeaways

• CT is gold standard for suspected cervical spine trauma.
• MRI is superior for ligamentous injuries, spinal cord assessment, and epidural hematoma.
• NEXUS criteria and Canadian C-Spine Rule guide imaging in alert, stable trauma patients.
• Odontoid fractures: Type II is most common and unstable.
• Recognize unstable patterns: Jefferson fracture (C1 burst), Hangman's fracture (C2 bilateral pedicles).
• Chance fracture indicates a flexion-distraction mechanism, often with seatbelt use.