Semin Musculoskelet Radiol 2013; 17(04): 380-388
DOI: 10.1055/s-0033-1356467
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Imaging of Acute Cervical Spine Trauma: When to Obtain Which Modality

Erika J. Ulbrich
1   Department of Radiology, University Hospital Zürich, Zürich, Switzerland
,
John A. Carrino
2   Department of Radiology, Johns Hopkins University Hospital, Baltimore, Maryland
,
Matthias Sturzenegger
3   Department of Neurology, Inselspital, University Hospital, and University of Berne, Berne, Switzerland
,
Mazda Farshad
4   Department of Spine Surgery, Hospital for Special Surgery, New York, New York
› Author Affiliations
Further Information

Publication History

Publication Date:
07 October 2013 (online)

Abstract

The current knowledge and evidence around the merits of different imaging modalities for the evaluation of cervical spine injuries are reviewed. The National Emergency X-Radiography Use Study, Canadian Cervical Spine rule, and American College of Radiology appropriateness criteria are reviewed and summarized. The advantages and disadvantages of available imaging modalities for selected cervical spine injury patterns are also illuminated to simplify the decision making on when to use which modality.

 
  • References

  • 1 Grossman MD, Reilly PM, Gillett T, Gillett D. National survey of the incidence of cervical spine injury and approach to cervical spine clearance in U.S. trauma centers. J Trauma 1999; 47 (4) 684-690
  • 2 Hills MW, Deane SA. Head injury and facial injury: is there an increased risk of cervical spine injury?. J Trauma 1993; 34 (4) 549-553 ; discussion 553–554
  • 3 Blauth MKA, Mair G, Schmid R, Reinhold M, Rieger M. Classification of injuries of the subaxial cervical spine. In: Aebi M, Arlet V, Webb JK, , eds. AO Spine Manual: Principles and Techniques, Clinical Applications. Stuttgart, Germany: Thieme; 2007: 21-38
  • 4 Waninger KN, Swartz EE. Cervical spine injury management in the helmeted athlete. Curr Sports Med Rep 2011; 10 (1) 45-49
  • 5 Clayton JL, Harris MB, Weintraub SL , et al. Risk factors for cervical spine injury. Injury 2012; 43 (4) 431-435
  • 6 Davis JW, Phreaner DL, Hoyt DB, Mackersie RC. The etiology of missed cervical spine injuries. J Trauma 1993; 34 (3) 342-346
  • 7 Gerrelts BD, Petersen EU, Mabry J, Petersen SR. Delayed diagnosis of cervical spine injuries. J Trauma 1991; 31 (12) 1622-1626
  • 8 Reid DC, Henderson R, Saboe L, Miller JD. Etiology and clinical course of missed spine fractures. J Trauma 1987; 27 (9) 980-986
  • 9 Sekhon LH, Fehlings MG. Epidemiology, demographics, and pathophysiology of acute spinal cord injury. Spine (Phila Pa 1976) 2001; 26 (24, Suppl): S2-S12
  • 10 Lieberman IH, Webb JK. Cervical spine injuries in the elderly. J Bone Joint Surg Br 1994; 76 (6) 877-881
  • 11 Lomoschitz FM, Blackmore CC, Mirza SK, Mann FA. Cervical spine injuries in patients 65 years old and older: epidemiologic analysis regarding the effects of age and injury mechanism on distribution, type, and stability of injuries. AJR Am J Roentgenol 2002; 178 (3) 573-577
  • 12 Pope AMTA. Disability in America: Toward a National Agenda for Prevention. Washington, DC: National Academy Press; 1991
  • 13 Bub LD, Blackmore CC, Mann FA, Lomoschitz FM. Cervical spine fractures in patients 65 years and older: a clinical prediction rule for blunt trauma. Radiology 2005; 234 (1) 143-149
  • 14 Viccellio P, Simon H, Pressman BD, Shah MN, Mower WR, Hoffman JR. NEXUS Group. A prospective multicenter study of cervical spine injury in children. Pediatrics 2001; 108 (2) E20
  • 15 Adelgais KM, Grossman DC, Langer SG, Mann FA. Use of helical computed tomography for imaging the pediatric cervical spine. Acad Emerg Med 2004; 11 (3) 228-236
  • 16 Kokoska ER, Keller MS, Rallo MC, Weber TR. Characteristics of pediatric cervical spine injuries. J Pediatr Surg 2001; 36 (1) 100-105
  • 17 Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI. National Emergency X-Radiography Utilization Study Group. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. N Engl J Med 2000; 343 (2) 94-99
  • 18 Hoffman JR, Wolfson AB, Todd K, Mower WR. Selective cervical spine radiography in blunt trauma: methodology of the National Emergency X-Radiography Utilization Study (NEXUS). Ann Emerg Med 1998; 32 (4) 461-469
  • 19 Stiell IG, Wells GA, Vandemheen KL , et al. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA 2001; 286 (15) 1841-1848
  • 20 Stiell IG, Clement CM, McKnight RD , et al. The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J Med 2003; 349 (26) 2510-2518
  • 21 Mower WR, Wolfson AB, Hoffman JR, Todd KH. The Canadian C-spine rule. N Engl J Med 2004; 350 (14) 1467-1469 ; author reply 1467–1469
  • 22 AppCriteria/Diagnostic/SuspectedSpineTrauma.pdf. American College of Radiology Web site. http://www.acr.org/∼/media/ACR/Documents/
  • 23 Sliker CW, Mirvis SE, Shanmuganathan K. Assessing cervical spine stability in obtunded blunt trauma patients: review of medical literature. Radiology 2005; 234 (3) 733-739
  • 24 Platzer P, Jaindl M, Thalhammer G , et al. Clearing the cervical spine in critically injured patients: a comprehensive C-spine protocol to avoid unnecessary delays in diagnosis. Eur Spine J 2006; 15 (12) 1801-1810
  • 25 Woodring JH, Lee C. Limitations of cervical radiography in the evaluation of acute cervical trauma. J Trauma 1993; 34 (1) 32-39
  • 26 Chiu WC, Haan JM, Cushing BM, Kramer ME, Scalea TM. Ligamentous injuries of the cervical spine in unreliable blunt trauma patients: incidence, evaluation, and outcome. J Trauma 2001; 50 (3) 457-463 ; discussion 464
  • 27 Insko EK, Gracias VH, Gupta R, Goettler CE, Gaieski DF, Dalinka MK. Utility of flexion and extension radiographs of the cervical spine in the acute evaluation of blunt trauma. J Trauma 2002; 53 (3) 426-429
  • 28 White III AA, Johnson RM, Panjabi MM, Southwick WO. Biomechanical analysis of clinical stability in the cervical spine. Clin Orthop Relat Res 1975; (109) 85-96
  • 29 Fleming JC, Bao F, Chen Y , et al. Timing and duration of anti-alpha4beta1 integrin treatment after spinal cord injury: effect on therapeutic efficacy. J Neurosurg Spine 2009; 11 (5) 575-587
  • 30 Powers B, Miller MD, Kramer RS, Martinez S, Gehweiler Jr JA. Traumatic anterior atlanto-occipital dislocation. Neurosurgery 1979; 4 (1) 12-17
  • 31 Roche C, Carty H. Spinal trauma in children. Pediatr Radiol 2001; 31 (10) 677-700
  • 32 Harris Jr JH, Carson GC, Wagner LK, Kerr N. Radiologic diagnosis of traumatic occipitovertebral dissociation: 2. Comparison of three methods of detecting occipitovertebral relationships on lateral radiographs of supine subjects. AJR Am J Roentgenol 1994; 162 (4) 887-892
  • 33 Harris Jr JH, Carson GC, Wagner LK. Radiologic diagnosis of traumatic occipitovertebral dissociation: 1. Normal occipitovertebral relationships on lateral radiographs of supine subjects. AJR Am J Roentgenol 1994; 162 (4) 881-886
  • 34 Hogan GJ, Mirvis SE, Shanmuganathan K, Scalea TM. Exclusion of unstable cervical spine injury in obtunded patients with blunt trauma: is MR imaging needed when multi-detector row CT findings are normal?. Radiology 2005; 237 (1) 106-113
  • 35 Blackmore CC, Ramsey SD, Mann FA, Deyo RA. Cervical spine screening with CT in trauma patients: a cost-effectiveness analysis. Radiology 1999; 212 (1) 117-125
  • 36 Daffner RH. Cervical radiography for trauma patients: a time-effective technique?. AJR Am J Roentgenol 2000; 175 (5) 1309-1311
  • 37 Daffner RH. Helical CT of the cervical spine for trauma patients: a time study. AJR Am J Roentgenol 2001; 177 (3) 677-679
  • 38 Blackmore CC, Mann FA, Wilson AJ. Helical CT in the primary trauma evaluation of the cervical spine: an evidence-based approach. Skeletal Radiol 2000; 29 (11) 632-639
  • 39 Brandt MM, Wahl WL, Yeom K, Kazerooni E, Wang SC. Computed tomographic scanning reduces cost and time of complete spine evaluation. J Trauma 2004; 56 (5) 1022-1026 ; discussion 1026–1028
  • 40 Grogan EL, Morris Jr JA, Dittus RS , et al. Cervical spine evaluation in urban trauma centers: lowering institutional costs and complications through helical CT scan. J Am Coll Surg 2005; 200 (2) 160-165
  • 41 Nguyen GK, Clark R. Adequacy of plain radiography in the diagnosis of cervical spine injuries. Emerg Radiol 2005; 11 (3) 158-161
  • 42 Schenarts PJ, Diaz J, Kaiser C, Carrillo Y, Eddy V, Morris Jr JA. Prospective comparison of admission computed tomographic scan and plain films of the upper cervical spine in trauma patients with altered mental status. J Trauma 2001; 51 (4) 663-668 ; discussion 668–669
  • 43 Tins BJ, Cassar-Pullicino VN. Imaging of acute cervical spine injuries: review and outlook. Clin Radiol 2004; 59 (10) 865-880
  • 44 Widder S, Doig C, Burrowes P, Larsen G, Hurlbert RJ, Kortbeek JB. Prospective evaluation of computed tomographic scanning for the spinal clearance of obtunded trauma patients: preliminary results. J Trauma 2004; 56 (6) 1179-1184
  • 45 Munera F, Rivas LA, Nunez Jr DB, Quencer RM. Imaging evaluation of adult spinal injuries: emphasis on multidetector CT in cervical spine trauma. Radiology 2012; 263 (3) 645-660
  • 46 Panczykowski DM, Tomycz ND, Okonkwo DO. Comparative effectiveness of using computed tomography alone to exclude cervical spine injuries in obtunded or intubated patients: meta-analysis of 14,327 patients with blunt trauma. J Neurosurg 2011; 115 (3) 541-549
  • 47 Link TM, Schuierer G, Hufendiek A, Horch C, Peters PE. Substantial head trauma: value of routine CT examination of the cervicocranium. Radiology 1995; 196 (3) 741-745
  • 48 Nuñez Jr DB, Zuluaga A, Fuentes-Bernardo DA, Rivas LA, Becerra JL. Cervical spine trauma: how much more do we learn by routinely using helical CT?. Radiographics 1996; 16 (6) 1307-1318 ; discussion 1318–1321
  • 49 Poonnoose PM, Ravichandran G, McClelland MR. Missed and mismanaged injuries of the spinal cord. J Trauma 2002; 53 (2) 314-320
  • 50 Pfirrmann CW, Binkert CA, Zanetti M, Boos N, Hodler J. MR morphology of alar ligaments and occipitoatlantoaxial joints: study in 50 asymptomatic subjects. Radiology 2001; 218 (1) 133-137
  • 51 Atlas SW, Thulborn KR. MR detection of hyperacute parenchymal hemorrhage of the brain. AJNR Am J Neuroradiol 1998; 19 (8) 1471-1477
  • 52 Bradley Jr WG, Schmidt PG. Effect of methemoglobin formation on the MR appearance of subarachnoid hemorrhage. Radiology 1985; 156 (1) 99-103
  • 53 Hayman LA, McArdle CB, Taber KH , et al. MR imaging of hyperacute intracranial hemorrhage in the cat. AJNR Am J Neuroradiol 1989; 10 (4) 681-686
  • 54 Yucesoy K, Yuksel KZ. SCIWORA in MRI era. Clin Neurol Neurosurg 2008; 110 (5) 429-433
  • 55 Aebi M, Mohler J, Zäch GA, Morscher E. Indication, surgical technique, and results of 100 surgically-treated fractures and fracture-dislocations of the cervical spine. Clin Orthop Relat Res 1986; (203) 244-257
  • 56 Aebi M, Nazarian S. Classification of injuries of the cervical spine [in German]. Orthopade 1987; 16 (1) 27-36
  • 57 Bohlman HH. Acute fractures and dislocations of the cervical spine. An analysis of three hundred hospitalized patients and review of the literature. J Bone Joint Surg Am 1979; 61 (8) 1119-1142
  • 58 Daffner SD, Daffner RH. Computed tomography diagnosis of facet dislocations: the “hamburger bun” and “reverse hamburger bun” signs. J Emerg Med 2002; 23 (4) 387-394
  • 59 Shanmuganathan K, Mirvis SE, Levine AM. Rotational injury of cervical facets: CT analysis of fracture patterns with implications for management and neurologic outcome. AJR Am J Roentgenol 1994; 163 (5) 1165-1169
  • 60 Kim KS, Chen HH, Russell EJ, Rogers LF. Flexion teardrop fracture of the cervical spine: radiographic characteristics. AJR Am J Roentgenol 1989; 152 (2) 319-326
  • 61 Chew FSDD, Rhea JT. Musculoskeletal imaging, trauma, spine. In: Weissledder R, Wittenberg J, Harisinghani MG, , eds. Primer of Diagnostic Imaging. 3rd ed. Philadelphia, PA: Mosby; 2003: 374
  • 62 Levine AM, Edwards CC. The management of traumatic spondylolisthesis of the axis. J Bone Joint Surg Am 1985; 67 (2) 217-226
  • 63 Scher AT. Hyperextension trauma in the elderly: an easily overlooked spinal injury. J Trauma 1983; 23 (12) 1066-1068
  • 64 Cintron E, Gilula LA, Murphy WA, Gehweiler JA. The widened disk space: a sign of cervical hyperextension injury. Radiology 1981; 141 (3) 639-644
  • 65 Taljanovic MS, Hunter TB, Wisneski RJ , et al. Imaging characteristics of diffuse idiopathic skeletal hyperostosis with an emphasis on acute spinal fractures: self-assessment module. AJR Am J Roentgenol 2009; 193 (3, Suppl): S20-S24
  • 66 Anderson LD, D'Alonzo RT. Fractures of the odontoid process of the axis. J Bone Joint Surg Am 1974; 56 (8) 1663-1674
  • 67 Anderson PA, Montesano PX. Morphology and treatment of occipital condyle fractures. Spine (Phila Pa 1976) 1988; 13 (7) 731-736
  • 68 Fisher CG, Sun JC, Dvorak M. Recognition and management of atlanto-occipital dislocation: improving survival from an often fatal condition. Can J Surg 2001; 44 (6) 412-420
  • 69 Fielding JW, Hawkins RJ. Atlanto-axial rotatory fixation. (Fixed rotatory subluxation of the atlanto-axial joint). J Bone Joint Surg Am 1977; 59 (1) 37-44
  • 70 Spitzer WO, Skovron ML, Salmi LR , et al. Scientific monograph of the Quebec Task Force on Whiplash-Associated Disorders: redefining “whiplash” and its management. Spine (Phila Pa 1976) 1995; 20 (8, Suppl): 1S-73S
  • 71 Holm LW, Carroll LJ, Cassidy JD , et al; Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders. The burden and determinants of neck pain in whiplash-associated disorders after traffic collisions: results of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders. Spine (Phila Pa 1976) 2008; 33 (4, Suppl): S52-S59
  • 72 Carroll LJ, Holm LW, Hogg-Johnson S , et al; Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders. Course and prognostic factors for neck pain in whiplash-associated disorders (WAD): results of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders. Spine (Phila Pa 1976) 2008; 33 (4, Suppl): S83-S92
  • 73 Barnsley L, Lord SM, Wallis BJ, Bogduk N. The prevalence of chronic cervical zygapophysial joint pain after whiplash. Spine (Phila Pa 1976) 1995; 20 (1) 20-25 ; discussion 26
  • 74 Pettersson K, Hildingsson C, Toolanen G, Fagerlund M, Björnebrink J. MRI and neurology in acute whiplash trauma. No correlation in prospective examination of 39 cases. Acta Orthop Scand 1994; 65 (5) 525-528
  • 75 Ronnen HR, de Korte PJ, Brink PR, van der Bijl HJ, Tonino AJ, Franke CL. Acute whiplash injury: is there a role for MR imaging?—a prospective study of 100 patients. Radiology 1996; 201 (1) 93-96
  • 76 Radanov BP, Sturzenegger M, Di Stefano G. Long-term outcome after whiplash injury. A 2-year follow-up considering features of injury mechanism and somatic, radiologic, and psychosocial findings. Medicine (Baltimore) 1995; 74 (5) 281-297
  • 77 Siegmund GP, Myers BS, Davis MB, Bohnet HF, Winkelstein BA. Mechanical evidence of cervical facet capsule injury during whiplash: a cadaveric study using combined shear, compression, and extension loading. Spine (Phila Pa 1976) 2001; 26 (19) 2095-2101
  • 78 Ito S, Ivancic PC, Panjabi MM, Cunningham BW. Soft tissue injury threshold during simulated whiplash: a biomechanical investigation. Spine (Phila Pa 1976) 2004; 29 (9) 979-987
  • 79 Anderson SE, Boesch C, Zimmermann H , et al. Are there cervical spine findings at MR imaging that are specific to acute symptomatic whiplash injury? A prospective controlled study with four experienced blinded readers. Radiology 2012; 262 (2) 567-575
  • 80 Ulbrich EJ, Eigenheer S, Boesch C , et al. Alterations of the transverse ligament: an MRI study comparing patients with acute whiplash and matched control subjects. AJR Am J Roentgenol 2011; 197 (4) 961-967
  • 81 Ulbrich EJ, Anderson SE, Busato A , et al. Cervical muscle area measurements in acute whiplash patients and controls. J Magn Reson Imaging 2011; 33 (3) 668-675
  • 82 Ulbrich EJ, Aeberhard R, Wetli S , et al. Cervical muscle area measurements in whiplash patients: acute, 3, and 6 months of follow-up. J Magn Reson Imaging 2012; 36 (6) 1413-1420