SPINAL TEAM

Dr. Soetomo General Hospital/

Medical Faculty-Airlangga University
SURABAYA-INDONESIA
Trauma to the cervical spine is
serious:

40% of
cervical spinal
trauma have
spinal cord
injury.
 Trauma to the cervical spine
can become more
serious because:
5%-10% damaged
could occur in the
post injury
period caused by
patient handling and
delayed treatment
Early recognition of spinal trauma by
diagnostic imaging
followed by appropriate management
protocol
is essential for optimum recovery of
damaged cord.
 Why algorithm?

Delayed or missed diagnosis is usually

attributed to:

Failure to suspect an injury

Inadequate cervical spine radiology
Incorrect interpretation of radiographs
 Algorithm of:

1. Imaging Examination
2. Interpretation the image
 Algorithm of:
What to do?

1. Imaging Examination What to see?

2. Interpretation the image
 Radiological Investigation
3 QUESTIONS:

What happened with the spine?

What happened with the spinal canal?
What happened with the spinal cord?
Imaging Modalities
1. Plain radiographs:
AP + lat.+ Odontoid view =
three-view, dynamic films
2. Tomogram
3. CT scanning
4. MRI
Does all trauma patients with
significant injury mush have
cervical spine radiographs?

NO!
 Trauma Patients Low Risk

High Risk Exclude

Cross table lateral Inadequate

Repeat film or
Adequate + Swimmers view or
+ CT scan (+ Recon)
 Low Risk Patients (adults):
No neck pain or tenderness
No neurologic signs or symptoms
No loss of conciousness
No distracting injury
Normal mental status
Once the decision is made,
proceed with a radiographic
evaluation.

Algorithm
 Trauma Patients Low Risk

High Risk Exclude

Cross table lateral Inadequate

Repeat film or
Adequate + Swimmers view or
+ CT scan (+ Recon)
 Trauma Patients Low Risk

High Risk Exclude

Cross table lateral Inadequate

Repeat film or
Adequate + Swimmers view or
+ CT scan (+ Recon)
Start with plain radiographs
Plain film are more sensitive than
CT in demonstrating:
Posture of the spinal column
Alignment of vertebral bodies
Reduction in height of vertebral bodies
& disc space
Discrete deformation and subluxation
Complex fractures
(if 3D CT is not available)
Cross table lateral view
 Cross-table lateral
view can detect 83%
of all cervical
spine injuries with
a specificity of 97%
 Adequate:
visualization
C2 of
craniocervical
junction
upper part of
C7 T1
T1
 Trauma Patients Low Risk

High Risk Exclude

Cross table lateral Inadequate

Repeat film or
Adequate + Swimmers view or
+ CT scan (+ Recon)
C2

Less favorable
C6 Lat. View
in a muscular
patient
When the lower cervical spine
is not imaged well in the
lateral view..

Swimmers view
The solution is: Swimmers Position
 Trauma Patients Low Risk

High Risk Exclude

Cross table lateral Inadequate

Repeat film or
Adequate + Swimmers view or
+ CT scan (+ Recon)
 Cross table lateral Abnormal
Adequate

Normal

AP+Odontoid view

Normal
 Cross table lateral Abnormal
Adequate
But, what is
normal?
Normal

AP+Odontoid view

Normal
ABCs approach
to radiographic
assestment:

Alignment
Bones
Cartilage
Soft tissue
ABCs approach
to radiographic
assestment:

Alignment
Bones
Cartilage
Soft tissue
Disruption of spinolaminar line
Unilateral facet Bilateral Lock facet
dislocation dislocation
Dynamic: flexion
ABCs approach
to radiographic
assestment:

Alignment
Bones
Cartilage
Soft tissue
ABCs approach
to radiographic
assestment:

Alignment
Bones
Cartilage
Soft tissue
Soft tissue?
 Cross table lateral Abnormal
Adequate

Normal

AP+Odontoid view

Normal
The clue is at the AP view
Open Mouth View
Normal C1-C2
?
Tomogram
 Cross table lateral Abnormal
Adequate

Three Views
Normal

AP+Odontoid view

Normal
 Cross table lateral Abnormal
Adequate

Bone
Normal
Radiographs

AP+Odontoid view

Normal
 Bone Abnormal
radiographs

Normal

? ?
 Bone Abnormal
radiographs

Normal

Neurology? Neurology?
 Bone Abnormal
radiographs

Normal

Neurology? Neurology?

Normal Abnormal Abnormal Normal

 Bone Abnormal
radiographs

Normal

Neurology? Neurology?

Normal Abnormal Abnormal Normal

Exclude
 Bone Abnormal
radiographs

Normal

Neurology? Neurology?

Normal Abnormal Abnormal Normal

Exclude Treatment
 Bone Abnormal
radiographs

Normal

Neurology? Neurology?

Normal Abnormal Abnormal Normal

Exclude Treatment
 Bone Abnormal
radiographs
Normal

Neurology? Neurology?

Normal Abnormal Abnormal Normal

Exclude *
CT scan(+recon)

MRI

Treatment
 Bone Abnormal
radiographs
Normal

Neurology? Neurology?

Normal Abnormal Abnormal Normal

Exclude *
CT scan(+recon)

MRI

Treatment
CT is more sensitive than plain films
in demonstrating:
Fractures of vertebral circumference
Deformity of disc
Spinal canal narrowing
Vertical fractures
Surrounding soft tissue process.
Vertebral circumference fracture
Is there any canal encroachment?
Canal encroachment?

Sagittal reconstruction
Pedicle fracture
Laminal &
sagittal fracture
 Bone Abnormal
radiographs
Normal

Neurology? Neurology?

Normal Abnormal Abnormal Normal

*
Exclude
CT scan(+recon)

MRI

Treatment
 MRI demonstrate:
Cord injury (cord contussion)
Ligamentous injury
Disc injury and herniation
Late squelae on myelum

Especially: if the neurologic findings is

inappropriate with the pathology of the bone
Inapropriate findings between plan radiograph and neurology
 Spinal Team Discussion
Dr Soetomo General Hospital/ -
Medical Faculty-Airlangga University
Thank You