Gatot Soebroto Presidential Army Hospital, Jakarta

2024

IMAGING OF SPINE TRAUMA

Mayor CKM dr. Leksmana Arry Chandra, Sp. Rad. (K)MSK
Department of Radiology
Gatot Soebroto Presidential Army Hospital
 OVERVIEW
• Introduction
• Biomechanics of spine injury
• Imaging of spine trauma in sport injury
• Cases
• Take home message
 Introduction
• Most commonly occur in :
Collision sports (rugby, American football, ice
hockey, skiing, snowboarding, and equestrian
sports)
Motorized sports
→ can lead to devastating consequences for the athlete
• The cervical spine is most commonly involved
 Biomechanic
Neck flexion with axial loading (most common)

Banerjee et al. The American Journal of Sports Medicine Vol. 32, No. 4, 2004
Biomechanic...
• Compression and tensile force
→ Flexion tear-drop fracture

Compressive failure of the

anterior column.
Tensile forces cause disruption
of the posterior spinal ligaments.
Biomechanic...
• Flexion distraction &
axial rotation injury
→ interfacetal dislocation

Unilateral or bilateral
Biomechanic...
• Burst / vertical compression
→ causes a progressive
rise in intradiskal pressure,
fails of the adjacent endplate

the vertebral body

essentially explodes,
displacing bone fragments in
all directions
Imaging of spine trauma in sport injury
 ANATOMY
Cervical Thoracal-lumbal

https://www.pinterest.com
The radiological investigation of the cervical spine
→ three major issues should be addressed :
• Instability should be suspected when there is lack of alignment of the
vertebral bodies or facet joints

• Impingement → encroachment of the spinal cord (through narrowing

of the spinal canal) or the nerve roots (through narrowing of the
intervertebral foramina).

• Impairment → can be due to structural causes (e.g. disc herniation,

fracture-luxation, ligament injury)
Cervical Stability

Anterior vertebral Spinolaminar line

body line
Posterior spinous
Posterior line
vertebral body
line
Disk spaces The interspinous or
symmetric, no interlaminar distances
widening or demonstrate little
narrowing variation
anteriorly or
posteriorly
NORMAL INTERSPINOUS DISTANCE FACET DISLOCATION
Normal spacing of the
facet joints: parallel to
each other, uniform facet
joint interval.
Impingement

Cervical stenosis is indicated

when the canal diameter
measures less than 13-14 mm
or the Pavlov ratio is below
0.8
 Imaging Modality
Plain radiographs CT MRI
• Remain useful in • Preferred technique • Method of choice for
mild cervical spine in more severe assessing spinal cord,
trauma trauma (fracture- ligaments, muscles
and soft tissues
• Underestimate dislocation)
fractures, especially • Fat-suppressed
near the cervico- • Provides limited soft sequences
thoracic junction tissue contrast • Useful in the
• Flexion-extension diagnosis of nerve
views are useful to root and brachial
show instability plexus avulsion
CASES ILLUSTRATION
Case : Hyperflexion injury of C7 in a 23-year-old rugby player

T2
T1

Simple anterior wedge fr

 WEDGE COMPRESSION FRACTURE
• Compression fracture of the STABLE
anterosuperior endplate
• Mechanism : Hyperflexion + axial
loading
• Stable if :
- Fractures do not extend beyond
the endplate UNSTABLE
- < 25% loss of vertebral body
height
- No signs of injury to the PLC
Case: A 10-year boy with a diving accident

Overhanging marging
Bilateral lateral displacement of the
articular masses of C1

https://www.hawaii.edu/medicine/pediatrics/pemxray/v5c04.html
Increase ADI
JEFFERSON’S
FRACTURE
 JEFFERSON’S FRACTURE
• = Burst fracture of C1
• Mechanism :
Axial loading along the axis of
the cervical spine.
• Normally is not associated
with neurological deficit.
• If there is a retropulsed
fragment → spinal cord injury
 Jefferson’s fracture
Abnormal atlanto-dental distance

Overhang

Normal:
No overhang of
lateral mass C1
 Case : Acute cervical disc herniation from a football game

• A disc herniation extending

into the left lateral recess and
into the intervertebral
foramen.
• Impingement on the left nerve
root

CECT
Case: Catastrophic diving accident in a 23-year old man

• Cord
contusion

• Partial
transsection
of the spinal
cord
Case: gymnastic sport injury

• Distracted hyperflexion
injury
• Anterior subluxation at
C6–C7.
• Marked anterior
displacement of C6 →
indicates disruption of
all ligamentous
structures and
interfacetal dislocation.
 FACET DISLOCATION
• Mechanism: simultaneous hyperflexion
and axial rotation

• The superior facet on one side slides over

the inferior facet and becomes locked

• Resulted in anterior subluxation of the

upper vertebral body

• Unilateral & bilateral

Klein GR, Vaccaro AR: Cervical spine trauma: upper and lower. In Vaccaro AR, Betz RR, Zeidman
SM, editors: Principles and practice of spine surgery, Philadelphia, 2003, Mosby, p 456.)
UNILATERAL FACET DISLOCATION

LOCKED
FACET →
BOWTIE
UNILATERAL FACET DISLOCATION

https://www.researchgate.net
BILATERAL FACET DISLOCATION

https://www.researchgate.net/
Case : Rugby player who was
injured after tackling
FLEXION TEAR DROP FRACTURE
Compression of body of C4 with tear-
drop fracture fragment

Mild retropulsion of C4

Widening of interspinous distance

 FLEXION TEARDROP FRACTURE
• Mechanism : Flexion and
compression
• Teardrop fragment of the
anteroinferior aspect of vertebral
body
• Retropulsion of the larger posterior
part
• Widening of facet joints and
interspinous distances
• Unstable : fracture + complete
disruption of ligaments and anterior
cord syndrome
Bucholz RW, Heckman JD, Court-Brown C, et al., eds. Rockwood and Green’s
Fractures in Adults, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2006
 Burners or Stingers Injury
• The most common cervical injury in players of contact sports
• Is a transient loss of function (weakness) with burning pain,
numbness or tingling irradiating down one arm following a collision
• Stretching or distraction injury to the upper cords of the brachial
plexus due to forced depression of the ipsilateral shoulder, with
movement of the head to the side opposite the painful arm.
→ causes tethering of the cervical nerves
Case: 29-year-old man, injured in a cross-country motorcycle racing accident

• Left brachial plexus

nerve root avulsion
• Formation of a
pseudomeningocele
filled with
cerebrospinal fluid

Parizel et al. 2007. Imaging of

Orthopedic Sports Injuries
pp.377-389
 Injury of thoracolumbal spine in sports
• Not as often as cervical injury
• May related to motor vehicle or watersport injury
Case : Speedboat sport accident

Anterior
wedge
fracture

Allami et al. Injury Extra (2005) 36, 511—516

 Case : speedboat sport accident

Compression
fracture

Retropulsion

Canal
stenoses

Biomed J Sci & Tech Res 12(2)-2018

Case : A 23 year-old female professional
soccer player with thoracolumbar injury

Gotfryd et al. Einstein (Sao Paulo). 2016;

14(1): 67–70.
 TAKE HOME MESSAGE
• Spine trauma related to sport injury can be an a catastrophic trauma
in an athlete’s life.
• Effective on-field and emergency department management of these
injuries requires a concerted effort from the athletic team care
providers.
• An improved knowledge and understanding of biomechanic and
imaging findings related to spinal trauma caused by sport injury can
lead to improved prevention and emergent treatment strategies
THANK YOU