0:00

So the vast majority of you, uh,

0:03

identified the various fractures on this cervical spine case.

0:08

Obviously at, at Hopkins, like with most institutions,

0:11

things start with a CT scan of the cervical spine with patients who have trauma,

0:16

this patient, um, how they fall.

0:22

And, uh,

0:22

what you notice on the sagittal reconstructed image is

0:27

that there is widening of the interspinous space here

0:33

between, uh, 2, 3, 4, 5, 6, and seven.

0:37

And then as we go off midline,

0:42

we can see the plane of the fracture through the superior facet of C

0:47

seven.

0:48

We see that this facet on the left side is

0:53

perched. It's, um, one on top of the other,

0:57

but as we go off to the contralateral side, the right side,

1:03

it's, um, actually jumped.

1:06

So now the superior facet is behind that of the inferior facet

1:11

of C six as opposed to being kind of perched there.

1:16

The, the, it doesn't really make a difference with the terminology here,

1:20

it's just a matter of degree. Um, what you're not seeing,

1:25

which is a little unusual,

1:27

is offset anteriorly in the spinal column.

1:32

Um,

1:32

this is an unstable fracture and it may be that in the collar that the

1:37

patient is in, the patient is, um,

1:41

stable with in the collar, but unstable, uh,

1:45

as soon as you take 'em outta the collar. And so, uh, for this reason,

1:50

um, the patient will remain in the collar and this neurosurgeons will assess the

1:53

patient on the axial scans.

1:57

We're at a little bit of a peculiar, uh, plane here, um,

2:02

for the frac, uh, for, for the angulation.

2:07

But nonetheless, as you go, um, through here,

2:09

you can see the fracture on the left side. This is the lamina of the facet,

2:14

and then into the facet here.

2:17

And on the contralateral side,

2:19

you actually have a portion of the pedicle that's involved, um,

2:25

as well as the, um, the facet.

2:30

And here again,

2:31

it's a little bit of obliquely through the pedicle on the contralateral side as

2:35

well. So, um,

2:41

the Corona, I'm not sure helped us very much

2:50

for, you know, identifying the disease and the fractures.

2:56

So in, in this setting, um, two things usually happen.

3:00

One thing is that we usually recommend an MRID for ligamentous injury, uh,

3:05

to determine whether there is additional injury, uh, to the bones,

3:10

for example, that may not be seen on the, uh, on the CT scan.

3:14

And if the fracture does enter the frame and verium,

3:18

which this one apparently does not, we would also recommend,

3:24

excuse me, we'd recommend the CTA and look for vertebral artery dissection.

3:29

So this patient did go onto,

3:33

go onto an MRI again. So, um,

3:37

most of the time the main focus is on the stir image. As you know,

3:41

the stir has the fat suppress that allows us to see the amount of edema that's

3:45

in these soft tissues, as well as looking at the ligamentum,

3:50

uh, ligamentous injury. So here's our distance between, um,

3:56

C six and C seven,

3:58

and you can see the bright single intensity and the interspinous ligament. And,

4:02

um, what we're also seeing is here in the ligament and flamm,

4:07

you've got some bright signal intensity. It's, it's discontinuous at this,

4:12

uh, C seven level. Um,

4:15

normally we would see this darker line continuously here,

4:18

and here we have a little gap in that dark line indicating that there is

4:23

some abnormality, uh, identified there. Um,

4:30

sometimes what you'll also see is this bright signal intensity in the nplate.

4:35

That's often a stress injury or bone edema associated with a fracture that may

4:39

or may not be evident on the CT scan. The problem is, of course,

4:44

that while patients in this age group, um,

4:47

also have DJD and the DJD Nplate disease may be bright on

4:52

the T two A scan when it's MODIC type one.

4:55

So you look at the T one way image and, you know, look and see whether there's,

4:59

um, similar findings on T one,

5:02

the dark one T one corresponding with the bright on stir,

5:05

which would be the modic type one changes. So sometimes we, we end up hedging,

5:10

you know, I'm not really sure. Um, here you can see,

5:15

you know, some brighter signal intensity. The superior nplate,

5:18

I think this is of T 1, 2, 3, 4, 5, 6, 7 T one. Yeah.

5:22

So with the adjacent injury,

5:24

you'd probably be concerned that there may be additional nplate, uh,

5:28

stress injury. Um, what you're not seeing is, uh,

5:32

cord signal abnormality, which is a good thing in this, in,

5:37

in this case. And on that sagittal,

5:40

you wanna make sure that things haven't moved because there

5:45

is certainly a propensity for moving. Uh, this is the not,

5:50

this is not the non stir T two,

5:52

and maybe this shows in this particular case,

5:57

The, um,

5:58

defect in the ligament and flam right here a little bit more

6:03

clearly than the, um, stir, for example.

6:07

And then you have your facet joint injury over here and here.

6:13

So, uh, pretty routine, uh, case of how we would handle a patient with,

6:18

uh, such a fracture with demonstration of both the, uh,

6:23

fracture on the CT as well as the mr and the result in injury to the ligaments.

6:29

Um, some people make, uh, comments about the supra spinous ligaments,

6:33

which are the ligaments that connect the is processes in this case. They,

6:37

there also seems to be bright signal intensity involving them.

6:40

And then all this is just sort of soft tissue muscular injury on the, uh,

6:44

on the stir. So, um,

6:50

case number one, cervical spine fracture jump facet C seven,

6:55

uh, C 67.

6:57

Any questions about the cervical spine case

7:04

on these T two weighted images, you will, um,

7:07

you should look at the vertebral artery in the wall,

7:09

the vertebral artery to identify whether there's any evidence of dissection.

7:13

We don't do routinely for trauma axial

7:18

T one weighted fat SAT scans,

7:21

which are the best for looking for dissection. Um,

7:27

but that's not part of our cervical spine protocol.

7:30

If they specifically ask for rollout dissection,

7:33

we will add a fats SAT T one to look for bud products in the wall

7:38

of the vessels, be it the carotids or the Burts.

7:42

How do you tell if the spine is unstable? So we're still using the,

7:45

the le level of the, um, the columns,

7:50

um, methodology. Um,

7:52

I think that you had in your lecture with

7:57

Francis, uh, he went through a little bit more sophisticated, uh,

8:01

analysis of how you tell whether a spine is unstable. Uh,

8:05

there's all kinds of systems. Uh, I'm still old school too calm,

8:11

unstable. And, um, in this situation with, um,

8:16

not having the posterior ligament, the, the, uh, the, um,

8:24

with only having the single column involvement by the columns,

8:28

it would be a stable, um, injury.

8:33

But bilateral facet fractures and bilateral pedicle fractures is

8:38

unstable. So in this case,

8:40

the single column involvement I I is not as helpful

8:45

in this, in this specific case.