頸椎骨折-英文課件【圖好+精】.

1、 Cervical AnatomyBiomechanically SpecializedSupport of “l(fā)arge” Cranial massLarge range of motionFlexion/extensionAxial rotationUnique osteological characteristicsC1 - AtlasNo body2 articular pillarsFlat articular surfaceVertebral artery foramen2 archesAnteriorPosteriorVertebral artery grooveFunction

2、 The AtlasTransition zone between head and c-spineImportant anatomical pointsSuperior articular processes allow flex/extInferior articular processes are important for rotationNotch for vertebral artery is a common fracture siteC2 AnatomyDensEmbriological C1 bodyBase poorly vascularizedOsteoporoticFl

3、at C1-2 jointsVertebral artery foramenaInferomedial to superolateralAnatomy The AxisImportant transition point for forces within the c-spineImportant anatomical pointsSuperior and inferior articular processes are “offset” in the AP direction- due to different functions at each articulationPars inter

4、articularis- due to this transition is a frequent fracture siteOdontoid process- the “pivot” for rotationAnatomy The LigamentsAllow for the wide ROM of upper C-spine while maintaining stabilityClassified according to location with respect to vertebral canalInternal:Tectorial membraneCruciate ligamen

5、t including transverse ligamentAlar and apical ligamentsExternalAnterior and posterior atlanto-occipital membranesAnterior and posterior atlanto-axial membranesArticular capsules and ligamentum nuchaeAtlantoAxial AnatomyAtlantoAxial AnatomyTectorial MembraneAtlantoAxial AnatomyAtlantoAxial Anatomyoc

6、ciputC1C2Tranverse LigamentC1-C2 jointAlar LigamentAtlantoAxial AnatomyAtlantoAxial AnatomyTransverseLigamentFacet forOccipitalCondyleAtlantoAxial AnatomyAtlantoAxial AnatomyVertebral ArteryAPPROACH TO C-SPINE INJURIES Following trauma or complaint of neck painObtain lateralAP, and odontoid viewsThe

7、 lateral view is only adequate if T1 can be visualizedIf there is any doubt of fracture or prevertebral swelling , obtain oblique views and consider CTAll patients with sign/symptoms of cord injury require MRICervical ViewsAPOdontoidObliquesSwimmers ViewLATERAL VIEW 1. Anterior vertebral line (anter

8、ior margin of vertebral bodies) 2. Posterior vertebral line (posterior margin of vertebral bodies) 3.Articular pillar (where superior and inferior articular processes of cervical vertebrae have fused on either or both sides)4. Spinolaminar line (posterior margin of spinal canal) 5. Posterior spinous

9、 line (tips of the spinous processes) C1-C2Predental space(distance between posterior aspect of anterior arch of C1 and anterior aspect of odontoid process )should be 3mm In adult and less 5mm in childrenOr lessring sign of C2C3-C7Anterior spinal, posterior spinal and spinolaminar lines: should be s

10、mooth lines Disc Spaces should be approximately same anterior narrowing = flexion injury. Widening = extension injuryFacet joints should be parallelInterspinous distance should decrease from C3 to C7Transverse process of C7 points downward and T1 UPWARDS INTERVERTEBRAL DISC SPACES Prevertebral Soft

11、TissueNasopharyngeal space (C1) - 10 mm (adult)Retropharyngeal spaceC 2-C4 ( between posterior pharyngeal wall and anterior border of vertebrae). Retro tracheal space C5-7 (space between posterior tracheal wall and anterior inferior body C6 ) c3-4 5mm from vertebral body is normalC4-7 20mm from vert

12、ebral body is normal5mm 22mm 10mmAP ViewThe height of the cervical vertebral bodies should be approximately equal The height of each joint space should be roughly equal at all levels.Spinous process should be in midline and in good alignment. Odontoid ViewAn adequate film should include the entire o

13、dontoid and the lateral borders of C1-C2. Occipital condyles should line up with the lateral masses and superior articular facet of C1.The distance from the dens to the lateral masses of C1 should be equal bilaterally. The tips of lateral mass of C1 should line up with the lateral margins of the sup

14、erior articular facet of C2. The odontoid should have uninterrupted cortical margins blending with the body of C2. Classification of Fractures of c-spine HYPERFLEXION INJURIES Flexion teardrop fracture Hyper flexion Strain Wedge Compression fracture Bilateral facet LockUnilateral facet dislocationCl

15、ay-shovelers fractureHyper extention injuries Hangman fracture Extention teardrop fracture laminar fracture Pillar fracture Posterior arch of c1 fracture FRACTURE DUE TO AXIAL LOADING Jefferson fracture Burst fracture OTHER INJURIES Odontoid fracture Rotational InjuriesHyperflexionDistraction create

16、s tensile forces in posterior columnCan result in compression of body (anterior column)Most commonly results from MVC and fallsCompressionResult from axial loadingCommonly from diving, football, MVAInjury pattern depends on initial head positionMay create burst, wedge or compression fxsHyperextensio

17、nImpaction of posterior arches and facet compression causing many types of fxslaminaspinous processespediclesWith distraction get disruption of ALLEvaluate carefully for stabilityLOOK FOR CENTRAL CORD SYNDROMETypes of InjuriesFlexion Teardrop Fracture C5-6fracture is the result of a combinationof fl

18、exion and compression ,most commonly at C5-6The teardrop fragment comes from the anteroinferior aspect of the vertebral body. The larger posterior part of the vertebral body is displaced backward into the spinal canal.Best seen on lateral viewIt is an completely unstable fracture associated with com

19、plete disruption of ligaments and anterior cord syndrome and quadriplegia 70% of patients have neurologic deficit. common in MOTOR VECHICLE ACCIDENT Signs: Prevertebral swelling associated with anterior longitudinal ligament tear.Teardrop fragment from anterior vertebral body avulsion fracture.Poste

20、rior vertebral body subluxation into the spinal canal.Spinal cord compression from vertebral body displacement.Fracture of the spinous process. Fracture of the body of c5 with a small fragment anteriorlyFracture of the spinous process of C4Acute angulation at the level of C5C6 with displacement of C

21、5 in posterior directionWedge fracture Compression fracture resulting from flexion.Flexion compression injury Best seen on lateral viewStableCommon in Elderly patients with osteoporosis or osteogenesis imperfectaWedge shape vertebraAntersuperior body fractureHangmans Fracture C-2Fx through the pars

22、interarticularis of C2 secondary to hyperextensionBest seen on lateral viewHyperextention injury Stable fracture ? The most common scenario would be frontal motor vehicle(hitting dash board)Hanging falls, diving injuriescontact sports.Neurological involvement is rare Classification of Hangman s frac

23、tures Type I (65%)hair-line fractureC2-3 disc normalType II (28%)displaced C2disrupted C2-3 discligamentous rupture with instabilityC3 anterosuperior compression fractureType III (7%)displaced C2C2-3 Bilateral interfacet dislocationSevere instabilityTYPE 1 HANGMAN FRACTURE TYPE 1 HANGMAN FRACTURE Th

24、ere is a hair-line fracture and there is no displacement.C23 NORMAL HANGMAN FRACTURE TYPE 3 Anterior dislocation of the C2 vertebral bodyBILATRAL C2 pars interarticularis fractures. Prevertebral soft tissue swelling The CT-images confirm the fracture-lines of the hangmans fracture.They run through t

25、he pars interarticularis resulting in a traumatic spondylolysis.In this case there was no neurologic deficit, because the spinal canal is widened at the level of the fracture.Extention tear drop fracture AVULSION FRACTURE of anterio inferior content of the axis resulting from hyperextentionThis inju

26、ry is stable in flexion but highly unstable in mon in diving accidents It also may be associated with the central cord syndrome .The CT confirms the displaced anteroinferior bony fragment. This fragment is a true avulsion, in contrast to the flexion teardrop fracture in which the fragment is produce

27、d by compression of the anterior vertebral aspect due to hyperflexion.Jefferson Fracture C-1 Best seen on odontoid view Unstable fracture Fracture due to AXIAL LOADING frequently associated with diving into shallow water(axial blow to the vertex of the head ) impact against the roof of a vehicle fal

28、l from playground equipments Fracture is caused by a compressive downward force that is transmitted evenly through the occipital condyles to the superior articular surfaces of the lateral masses of C1. This process displaces the masses laterally and causes fractures of the anterior and posterior arc

29、hes, along with possible disruption of the transverse ligament.SIGNS ON XRAY: Displacement of the lateral masses of vertebrae C1 beyond the margins of the body of vertebra C2.2mm bilateral is always abnormalC6T1Best seen on lateral viewPowerful Hyperflexion injury(shoveling)Stable fracture Common in motor vehicle accidentssudden muscle contractiondirect blows to the spine Ap view show ghost sign with 2 spinous processes ?Case 15 yo girlHit by car while riding bikeVSA at sceneVitals recovered by EMSRose et al, Am J Surg 2003;185(4