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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_6009_Библиотеки_им_академика_М_И_Перельмана.pdf
Burst C2 Fracture
KEY FACTS
TERMINOLOGY
Trauma
• Comminuted fracture through C2 vertebral body
• Displacement of fragments in AP direction
IMAGING
• AP displacement of fracture fragments
• Fat C2 sign
• Often see associated hangman's fracture, unstable injury
• Displaced fracture fragments may encroach on spinal canal
• CTA or MRA for screening vertebral artery injury
○ Especially if fracture extends to foramen transversarium
TOP DIFFERENTIAL DIAGNOSES
• Flexion teardrop fracture of C2
• Other nonodontoid, non-hangman's C2 body fracture
• Pathologic fracture
PATHOLOGY
• High-energy mechanisms cause most C2 fractures
(Left) Axial NECT shows a
comminuted C2 body fracture
with fragmentation of the
right lateral mass . There is
slight posterior displacement
of fragments ſt flattening the
thecal sac. C2 burst injuries
may occur as a result of
isolated or combined
hyperflexion or
hyperextension forces. (Right)
Coronal CT illustrates a highly
comminuted C2 burst fracture
ſt. The fracture extends into
the superior articular facets
with widening of the C1-2
facet joint on the left st.
• Fujimara (1996) classification of C2 body fractures (nonhangman's, nonodontoid C2 fractures)
○ Avulsion fracture
○ Transverse fracture
○ Burst fracture
○ Sagittal fracture
CLINICAL ISSUES
• High-energy, high-velocity trauma
• May have concomitant head injury
• Often managed with conservative/nonoperative treatment
• Surgical management for inability to reduce fragments,
associated hangman's fracture, malalignment of
atlantoaxial articulation
DIAGNOSTIC CHECKLIST
• C2 burst fractures can involve body, pedicle, lateral mass,
and transverse foramina
170
(Left) Axial bone CT
demonstrates a comminuted
burst fracture of C2 st
involving the left transverse
foramen ſt. Primary
hyperflexion mechanism
predominantly disrupts the
anterior margin, while primary
hyperextension is suggested if
the posterior margin is
disrupted. Combined
hyperextension-hyperflexion
injuries may result in the
interruption of both margins.
(Right) Axial CTA exhibits
occlusion of the left vertebral
artery ſt due to C2 burst
fracture st involving the left
transverse foramen.
Hangman's C2 Fracture
KEY FACTS
Trauma
TERMINOLOGY
• Traumatic spondylolisthesis of axis
• Bilateral C2 pars interarticularis fractures
IMAGING
• Fracture through pars interarticularis of C2
○ Fracture may extend into C2 vertebral body
○ Anterior displacement of C2 body relative to C3
○ C1 arch and skull ride forward with C2 vertebral body
○ Posterior elements and spinolaminar line of C2 and C3
remain aligned
○ Flexion exaggerates C2-C3 subluxation
○ Involvement of vertebral artery foramen would be
concerning for vertebral artery injury
○ Additional fracture levels seen in 33% of cases, C1 most
common
• Imaging: Thin-section (1-mm) helical CT with sagittal and
coronal reformations
○ Any anterior subluxation of C2 vs. C3 on lateral x-ray
warrants CT
PATHOLOGY
• Hyperextension with axial loading or forced hyperflexion
with axial loading
• Effendi classification
○ Type I: Hairline fracture, nondisplaced; no disruption of
C2-C3 disc
○ Type II: Fracture with ≥ 3-mm anterior translation of C2
on C3, abnormal C2-C3 disc
○ Type IIA: Minimal C2-C3 displacement but severe
angulation associated with flexion distraction
○ Type III (rare): Displaced anterior fracture fragment with
dislocated or subluxed facet joints
CLINICAL ISSUES
• Type I: Stable lesion, no permanent deficits
• Types II, III: Higher rates of sequelae, disability
(Left) Lateral radiograph
shows fractures of bilateral C2
pars interarticularis with
distraction and
anterolisthesis of C2 on C3.
The C2-C3 spinolaminar line
ſt is preserved with
interruption at C2 . (Right)
Axial NECT shows posteriorly
displaced fractures of bilateral
C2 pars interarticularis ſt in
this adolescent with
hyperextension injury.
(Left) Sagittal bone CT shows
anterolisthesis of C2 on C3
with a bone fragment from
the inferior posterior C2 body
extending into the canal and
compressing the cord ſt.
(Right) Sagittal T2W MR
shows disruption of the
posterior longitudinal and
interspinous ligaments
with C2-C3 anterolisthesis.
Prevertebral soft tissue edema
is noted ſt and there is a
ventral epidural hematoma st
and bone fragment causing
canal stenosis and cord
compression.
171
Apophyseal Ring Fracture
KEY FACTS
TERMINOLOGY
Trauma
• Fracture or avulsion of vertebral ring apophysis following
injury in immature skeleton
IMAGING
• Concentric bone fragment displaced from vertebral
endplate margin in skeletally immature patient
• Inferior or superior endplate may be involved
○ Limbus vertebra usually superior
• Fractured apophyseal fragment usually midline
TOP DIFFERENTIAL DIAGNOSES
• Flexion teardrop fracture of anterior endplate corner
• Schmorl node
• Calcified disc fragment; posterior osteophyte
• Disc herniation
(Left) Sagittal graphic
demonstrates an acute lumbar
apophyseal ring fracture ſt
involving the posterior inferior
vertebral body corner with
displacement and associated
hemorrhage. There is
compression of the adjacent
thecal sac. (Right) Sagittal
nonenhanced T1W MR shows
a focal area of fat signal
within the posterior disc
margin ſt, which is the old
ring apophyseal avulsion. Note
the endplate irregularity
involving L5 .
PATHOLOGY
• Limbus vertebra: Herniation of nucleus pulposus between
ring apophysis and vertebral body
• Posterior apophyseal fracture: 2 mechanisms described
○ Same as limbus vertebra
○ Herniating nucleus spares Sharpey fibers, avulses ring
apophysis
CLINICAL ISSUES
• Back pain in acute (adolescent) cases
• Adolescent athlete with acute low back pain
• Majority of patients report engagement in sporting
activities
DIAGNOSTIC CHECKLIST
• MR more sensitive than radiographs or CT in young children
since ring apophysis not ossified
• T2WI FS/STIR MR essential to assess for associated
ligamentous injury
172
(Left) Sagittal T1WI MR in this
case of posterior ring
apophysis fracture
demonstrates herniation of
the L5-S1 disc ſt and fracture
with displacement of the L5
ring apophysis st. Note
marrow edema and endplate
irregularity. (Right) Axial T2WI
MR shows posterior
displacement of the fractured
apophysis ſt, narrowing the
central spinal canal and both
lateral recesses.
Cervical Hyperflexion Injury
KEY FACTS
Trauma
TERMINOLOGY
• Injury from cervical hyperflexion with compression or
hyperflexion with distraction/shearing
IMAGING
• Hyperflexion with compression
○ Forced flexion of cervical spine with axial loading vector
slightly anterior to vertebral column
○ Primary injury to anterior and (later) middle columns
• Hyperflexion with distraction
○ Forced flexion of cervical spine with rostrally oriented
force vector nearly perpendicular to trunk
○ Primary failure of posterior and (later) middle columns
○ Focal kyphosis, ↑ space between spinous processes;
distracted, perched, or jumped facets
• Mid or lower cervical spine more common
• Best imaging modality
○ Thin-slice (≤ 1-mm) helical CT with sagittal and coronal
reformations
○ MR (especially STIR and GRE) to evaluate soft tissue
structures, spinal cord
TOP DIFFERENTIAL DIAGNOSES
• Burst fracture
• Flexion-rotation injury
• Whiplash fracture
PATHOLOGY
• Spinal instability
• Spinal cord injury, radiculopathy
• Associated with closed head injury, polytrauma
CLINICAL ISSUES
• Immobilization, axial traction, surgical fusion
• Surgical decompression for spinal cord injury
• Methylprednisolone for treatment of acute spinal cord
injurynot recommended
(Left) Sagittal graphic shows
flexion injury at C4-C5 with
subluxation, disc disruption,
disc herniation ſt,
ligamentous disruption ,
cord compression, and
epidural hemorrhage st.
(Right) Sagittal T2WI MR
shows severe flexion injury
with subluxation of C5 on C6,
flexion deformity and severe
cord compression ſt, and cord
edema. Note the posterior
ligamentous injury .
(Left) CT angiogram shows the
typical CT and MR appearance
of severe hyperflexion injury
with vertebral C5-C6
subluxation with C6 corner
fracture ſt and severe
widening of the spinous
processes, reflecting
interspinous ligament
disruption . (Right) Axial
CECT in a flexion injury with
jumped facets shows inferior
facets of the C6 ſt anterior to
superior facets of C7
(known as naked facets sign or
hamburger sign).
173
Cervical Hyperextension Injury
KEY FACTS
TERMINOLOGY
Trauma
• Injury from cervical hyperextension with compression or
hyperextension with distraction/shearing
IMAGING
• Hyperextension injury with axial compression
○ Unilateral or bilateral fracture of posterior elements
○ Traumatic anterolisthesis with more severe injury;
ligamentous disruption ± superior endplate impaction
fracture of subjacent vertebral body
• Hyperextension injury with distraction or shear
○ May have minimal radiographic findings even with
significant injury
○ Anterior longitudinal ligament (ALL) rupture, widening of
anterior disc space
○ Minimally displaced fracture of anterior margin of
inferior vertebral body (extension teardrop) without
retrolisthesis
• Best imaging modality
(Left) Lateral radiograph
shows mild prevertebral soft
tissue swelling ſt. Mild
changes of preexisting cervical
spondylosis are also noted.
(Right) Sagittal STIR MR in the
same patient shows
prevertebral edema ſt and
disruption of the ALL . A
nonphysiologic hyperintense
signal within the C6-C7 disc
space reflects disruption of
the discovertebral unit by
hyperextension-distraction
injury at this level. Posterior
soft tissue edema is also
present st.
○ Thin-slice helical CT with sagittal and coronal
reformations
○ MR (especially STIR) to evaluate ligaments, cord
– STIR MR
□ Disruption of ALL, widened and ↑ signal in disc
space anteriorly
□ Marrow edema if bone contusion, fracture
□ ↑ signal in cord, if cord injury present
TOP DIFFERENTIAL DIAGNOSES
• Flexion teardrop fracture
• Clay shoveler fracture
• Whiplash injury
PATHOLOGY
• Spinal cord injury
○ Especially central cord syndrome
○ Potential for injury increased with congenital spinal
stenosis
174
(Left) Axial NECT shows mildly
displaced fractures of bilateral
C7 articular pillars ſt due to a
hyperextension-compression
type of injury. (Right) Sagittal
STIR MR in this patient with a
normal cervical spine CT
shows an abnormal increased
signal from the disrupted ALL
ſt at the C4-C5 level and disc.
Note the prevertebral edema
.
Cervical Burst Fracture
KEY FACTS
Trauma
TERMINOLOGY
• Comminuted fracture of cervical vertebral body due to axial
loading
• Vertical compression fracture
IMAGING
• Loss of vertebral body height
• Vertically oriented fracture planes
○ Extending to endplates and posterior cortex
• Centrifugal displacement of fragments
○ Compromise of spinal canal
○ Cord injury on MR
• Typically mid or lower cervical spine
• Prevertebral soft tissue swelling
TOP DIFFERENTIAL DIAGNOSES
• Flexion teardrop fracture
• Hyperextension teardrop fracture
• Benign compression fracture
• Pathologic compression fracture
PATHOLOGY
• Axial loading with neck in neutral position
• Centrifugal displacement of comminuted fracture
fragments
• Displacement into spinal canal → cord injury
○ Spinal cord injury common
• Spinal cord injury common with retropulsion
CLINICAL ISSUES
• Variable neurologic symptoms, from no deficit to
tetraparesis
• Treatment
○ May be able to be managed conservatively
– Traction, immobilization
○ Unstable injury may need surgical stabilization
– ± surgical decompression of canal if cord injury
present
(Left) Axial bone CT shows a
vertebral body fragment ſt
displaced into the spinal canal.
Fracture of the right pedicle
is also seen. This is the
classic CT appearance of burst
fracture, which causes loss of
vertebral body height and
posterior displacement of
bone fragment into the spinal
canal. (Right) Axial NECT
shows a burst fracture in the
sagittal fracture plane st.
There is widening of the
interpedicular width and
multiple fractures of the
neural arch .
(Left) Sagittal STIR MR shows
a C7 burst fracture with
posterior displacement of a
fracture fragment ſt into the
spinal canal, contacting the
spinal cord. There are no
signal changes in the cord. A
small amount of ventral
epidural hemorrhage st is
seen. Edema of the dorsal soft
tissue is also present .
(Right) Sagittal T2* GRE MR
shows extensive edema and
low-signal hemorrhage ſt
within the cervical cord in this
patient with a C5 burst
fracture . There is moderate
retropulsion of the posterior
aspect of the C5 body.
175
Traumatic Disc Herniation
KEY FACTS
TERMINOLOGY
Trauma
• Traumatic disruption of annularis fibrosis with associated
displacement of nucleus pulposus
IMAGING
• Location: Cervical > thoracic > > lumbar
• Radiographs insensitive for disc pathology
○ Cause of spinal cord injury without radiographic
abnormality
• Associated with spinal fracture, facet subluxation
• MR is modality of choice to evaluate intervertebral discs,
soft tissue contents of spinal canal
○ Disc material effacing anterior CSF ± cord or nerve root
compression
○ ± cord edema if cord compressed
TOP DIFFERENTIAL DIAGNOSES
• Nontraumatic intervertebral disc herniation
• Epidural abscess, phlegmon
(Left) Sagittal T2WI MR shows
hyperflexion-compression
injury with focal kyphosis of
C6-C7, disruption of the
posterior longitudinal
ligament ſt, narrowing of the
anterior disc space, and a
posterior disc protrusion
causing canal stenosis. There
is splaying of the spinous
processes and a small amount
of dorsal epidural hematoma
st. (Right) Sagittal T2WI MR
shows a flexion teardrop
fracture of C2 st, increased
kyphosis at C2-C3, and a
traumatic disc protrusion ſt
effacing the thecal sac at C2C3.
• Epidural tumor
CLINICAL ISSUES
• Anterior cord syndrome highly associated with traumatic
disc herniation
• Cauda equina syndrome with lumbar herniation: Pain,
incontinence 2° to compression of lumbosacral spinal nerve
roots
• 5-54% incidence of herniation with cervical spine trauma
• Cord compression from herniation is reported complication
of reduction of cervical facet dislocation without
discectomy
DIAGNOSTIC CHECKLIST
• Consider MR prior to reduction of facet dislocation
• MR to exclude anterior cord compression from herniated
disc or hematoma prior to aggressive attempts at closed
reduction
176
(Left) Sagittal T1WI MR shows
C5-C6 flexion injury with
subluxation, prevertebral
hemorrhage ſt, and disc
extrusion touching ventral
cord . (Right) Sagittal STIR
MR in this trauma patient
shows a large disc extrusion at
C6-C7 ſt that compresses the
cord. There is disruption of the
anterior longitudinal ligament
and endplate marrow
edema st from axial loading.
Note the extensive dorsal soft
tissue edema .
Thoracic and Lumbar Burst Fracture
KEY FACTS
Trauma
TERMINOLOGY
• Vertebral body fracture due to axial load, involving anterior
& middle, ± posterior columns
○ Anterior: Anterior longitudinal ligament, anterior 1/2
vertebral body, & anterior anulus fibrosis
○ Middle: Posterior longitudinal ligament, posterior 1/2
vertebral body, & posterior anulus fibrosis
○ Posterior: Neural arch, facet ligaments, ligamentum
flavum, inter- & supraspinous ligaments
IMAGING
• Thoracolumbar junction with loss of vertebral height
• Fracture involves posterior vertebral body cortex
○ ± retropulsion of posterior cortex
○ ± vertically oriented posterior element fractures
• Cord contusion best seen on T2WI MR
TOP DIFFERENTIAL DIAGNOSES
• Compression fracture
• Chance fracture
• Pathologic fracture due to tumor
• Fracture-dislocation
PATHOLOGY
• Associated with other spine fractures, pelvic/lower
extremity fractures
CLINICAL ISSUES
• Surgical indications include neural compression and
kyphosis
DIAGNOSTIC CHECKLIST
• Orientation of posterior element fractures distinguish
between Chance and burst fractures
○ Burst: Vertically oriented posterior element fractures
reflect axial load force
○ Chance: Horizontally oriented posterior element
fractures reflect distraction force
(Left) Axial bone CT shows a
sagittal fracture line ſt
through the vertebral body.
The axial load force has
continued through the right
lamina st. The posterior
vertebral body cortex is
displaced posteriorly .
(Right) Sagittal bone CT in the
same patient shows a sclerotic
line ſt reflecting trabecular
impaction. There is also a
coronal fracture line st
extending to the inferior
vertebral body cortex.
(Left) Sagittal T1WI MR in the
same patient shows the body
deformity st and epidural
hematoma . However, the
fracture line ſt is difficult to
see because of the
surrounding red marrow.
(Right) Sagittal T2WI MR in
the same patient better shows
the low signal intensity
fracture line ſt outlined by
marrow hematoma. The tip of
the conus is displaced
posteriorly.
177
Fracture Dislocation
KEY FACTS
TERMINOLOGY
Trauma
• Transversely applied force vector, resulting in shearing
injury ± flexion &/or rotation
IMAGING
• Traumatic spondylolisthesis with fracture(s) of posterior
elements &/or vertebral body
○ Vertebral column discontinuity/listhesis at level of injury,
involving 3 columns
○ Complete disruption of disc or horizontal fracture
through vertebral body with displacement &/or rotation
○ Soft tissue edema associated with ligamentous
disruption
• Spinal cord injury common
TOP DIFFERENTIAL DIAGNOSES
• Chance fracture
○ Distracted, horizontal fracture through pedicles, no
listhesis
(Left) Sagittal CT
reconstruction shows a
widened T10-T11 disc space
ſt with mild traumatic
anterolisthesis. The inferior
T10 facet is fractured st and
perched. There is a
fragmented fracture of the
anterior T11 vertebral body
. (Right) Sagittal T2WI MR
in the same patient shows
abnormal signal and widening
of the T10-T11 disc space st
and fracture of the T10
spinous process and lamina
ſt. Traumatic anterolisthesis
causes spinal canal stenosis
and spinal cord contusion .
• Burst fracture
○ Comminuted fracture of vertebral body extending to
posterior cortex
PATHOLOGY
• Force vector perpendicular to vertebral column, ± rotation
&/or flexion
• Shear injury, failure of all 3 columns
• High-energy mechanisms
CLINICAL ISSUES
• Severely injured trauma patient
• Lower extremity paralysis, sensory deficit
• Spinal shock with hypotension
DIAGNOSTIC CHECKLIST
• Fracture-dislocation injuries have high rate of paraplegia,
instability
178
(Left) Sagittal reconstructed
bone CT shows anterior
fracture-dislocation of T10T11 with comminuted
fracture of the T11 vertebral
body. There is severe canal
stenosis due to 75% anterior
translation and bone fragment
st displaced into the spinal
canal. Mild compression
fractures are noted at T5 and
T7 ſt. (Right) Axial NECT
(bone window) in the same
patient shows the margin of
T10 anteriorly displaced
relative to T11 ſt. Thickening
of the paravertebral soft
tissues is due to hematoma.
Chance Fracture
KEY FACTS
Trauma
TERMINOLOGY
• Flexion-distraction injury, seat belt fracture
• Compression injury of anterior column with distraction of
middle and posterior columns
IMAGING
• Usually occurs at T11-L3, occasionally midthoracic
• Wedging of anterior vertebral body
• Focal kyphosis ±fracture
• Bony or ligamentous injury to posterior column
○ Transversely oriented posterior element fracture &/or
– Separation of facet joints
– Increased interspinous distance
– Ligament disruption on MR
• No subluxation of vertebral body
TOP DIFFERENTIAL DIAGNOSES
• Shear injury
• Distraction injury
• Burst fracture
• Traumatic compression fracture
• Pathologic vertebral fracture
PATHOLOGY
• Anterior compression, posterior distraction around fulcrum
• 15-80% have significant abdominal injuries (bowel and
mesentery most common)
CLINICAL ISSUES
• Traumatic back pain ± neurologic injury
DIAGNOSTIC CHECKLIST
• MR evidence of hematoma between spinous processes is
not sufficient to diagnose ligament disruption
○ Hematoma may occur due to compression force
○ Look for discontinuity of ligament on MR
• Chance fracture may have retropulsion of posterior
vertebral body cortex mimicking burst fracture
(Left) Sagittal NECT in a child
shows the typical horizontal
pedicle fracture of the Chance
morphology ſt. There is
distraction of the posterior
elements with a compressive
component anteriorly. (Right)
Lateral radiograph shows a
different variant in the
osteoligamentous pattern.
Wide separation of the spinous
processes st indicates rupture
of supraspinous and
interspinous ligaments. A
fracture ſt extends through
the pedicle and superior
articular facet into the
vertebral body.
(Left) Sagittal T2WI MR in the
same patient shows rupture of
the interspinous st and
supraspinous ligaments.
The anterior longitudinal
ligament and posterior
longitudinal ligament appear
intact. (Right) Sagittal T2WI
MR in the same patient shows
a vertebral body fracture ſt
and facet joint disruption .
The combination of fracture
and ligamentous injury is
variable in Chance injury but
all types show evidence of
anterior compression and
posterior distraction without
an anterior to posterior vector
force.
179