颈椎损伤影像学评估

Zachary J. Kastenberg, HMSIII Gillian Lieberman, MD November 12, 2006 Radiological Evaluation of the Traumatic Cervical Spine Injury Zachary J. Kastenberg, Harvard Medical School Year III Gillian Lieberman, MD 2 Zachary J. Kastenberg, HMSIII Gillian Lieberman, MD November 12, 2006 C-Spine Trauma: Imaging Algorithm Traumatic injury NO IMAGING * -No Midline Neck Pain -Not Intoxicated -Normal Alertness -No Focal Neuro Findings -No Major Distracting Injuries RADIOGRAPHS -Neck Pain, Swelling -Neurologic Signs/Sx -Intoxication -Altered Mental Status -Loss of Conciousness CT -No Fracture on Radiograph despite Sx -Suspicious Radiograph MRI -Evidence of Vertebral Canal Encroachment -Evidence of Ligament Damage -Neurological Sx CT Myelogram -MR Contraindicated LARGE MEDICAL CENTERS *NEXUS CRITERIA FOR C-SPINE RADIOGRAPHY: 99% sensitive, 12.9% specific MRA Conventional Angio CTA CNS Pathology Vascular Pathology 3 Zachary J. Kastenberg, HMSIII Gillian Lieberman, MD November 12, 2006 Standard C-Spine Radiographs BIDMC PACSBIDMC PACS AP Lateral Odontoid BIDMC PACS 4 Zachary J. Kastenberg, HMSIII Gillian Lieberman, MD November 12, 2006 Standard Radiographs: Lateral Anatomy BIDMC PACS http://www.emory.edu/ANATOMY/AnatomyManual/back.html Normal C-Spine LateralCervical Vertebra Body Articular Proc. Spinous Proc. 5 Zachary J. Kastenberg, HMSIII Gillian Lieberman, MD November 12, 2006 Standard Radiographs: Odontoid Anatomy BIDMC PACS http://www.emory.edu/ANATOMY/AnatomyManual/back.html http://www.emory.edu/ANATOMY/AnatomyManual/back.html C1: Atlas C2: Axis Normal Odontoid View C1 C2 6 Zachary J. Kastenberg, HMSIII Gillian Lieberman, MD November 12, 2006 Patient History and Physical Patient: -48 year old male HPI: -Pt fell approximately 10 ft from ladder -Landed on the right side of his head -Right arm numbness (minutes) -Persistent neck/skull base pain. PMH/FmHx/SoHx: Unremarkable Physical Exam: -Vitals: WNL -General: Uncomfortable -HEENT: Tenderness on the posterior aspect of the head and neck -Lungs: CTA -Cardiac: RRR S1/S2 -Abdomen: Soft, NTND, BS+ -Extremities: No C/C/E -Back: No Point tenderness -Neuro: Alert and Oriented x3, No focal findings, Sensorium intact 7 Zachary J. Kastenberg, HMSIII Gillian Lieberman, MD November 12, 2006 Imaging Algorithm: C-Spine Trauma Traumatic injury NO IMAGING * -No Midline Neck Pain -Not Intoxicated -Normal Alertness -No Focal Neuro Findings -No Major Distracting Injuries RADIOGRAPHS -Neck Pain, Swelling -Neurologic Signs/Sx -Intoxication -Altered Mental Status -Loss of Conciousness CT -No Fracture on Radiograph despite Sx -Suspicious Radiograph MRI -Evidence of Vertebral Canal Encroachment -Evidence of Ligament Damage -Neurological Sx LARGE MEDICAL CENTERS *NEXUS CRITERIA: 99% sensitive, 12.9% specific MRA -Encroachment of Foramen Transversarium Conventional Angio CTA CNS Pathology Vascular Pathology 8 Zachary J. Kastenberg, HMSIII Gillian Lieberman, MD November 12, 2006 Normal Atlanto-dens interval No Gross Atlanto-Occipital Disslocation CT Scout Lateral View Pt’s Lateral Scout Radiograph 9 Zachary J. Kastenberg, HMSIII Gillian Lieberman, MD November 12, 2006 Pt’s Lateral Scout Radiograph Loss of Cervical Lordosis No Obvious Dens Fracture PACS Images Courtesy of Dr. Teich CT Scout Lateral View 10 Zachary J. Kastenberg, HMSIII Gillian Lieberman, MD November 12, 2006 1. Basion-dens interval <12mm 2. Anterior Atlanto-dens interval <2mm 3. Prevertebral soft tissue <6mm at C2 4. Osteoarthritic Changes C5-C6 -Decreased disc vertical disc space -Subchondral osteosclerosis -Osteophyte formation -Subchondral cyst 1. Lateral Atlanto-dens interval <2mm difference side-to-side 2. Fracture to the Right Anterior Mass/Transverse Process of C2 3. Osteoarthritic changes C5-C6 BIDMC PACS BIDMC PACS PT’s Reconstructed CT Images PACS Images Courtesy of Dr. Teich Midline Sag. Coronal 1. 3. 4. 2. 1. 3. 2. 11 Zachary J. Kastenberg, HMSIII Gillian Lieberman, MD November 12, 2006 A B C D A B C D BIDMC PACS Pt’s CT Axial Views: Multiple Fractures PACS Images Courtesy of Dr. Teich Midline Sag. 11BIDMC PACS BIDMC PACS BIDMC PACS BIDMC PACS 12 Zachary J. Kastenberg, HMSIII Gillian Lieberman, MD November 12, 2006 Radiographic Findings: Summary 1. Comminuted displaced fracture of the right lateral mass of C2 with encroachment upon the right foramen transversarium. 2. Minor lateral displacement of dens is non-specific and may be normal, but l ligamentous damage can not be ruled out. 3. Comminuted fracture through the right lamina and pedicle of C6 with extension inferiorly through the transverse process of C7 (Transient Sx). No encroachment of CNS or vascular structures suspected. 13 Zachary J. Kastenberg, HMSIII Gillian Lieberman, MD November 12, 2006 Radiographic Findings: Summary 1. Comminuted displaced fracture of the right lateral mass of C2 with encroachment upon the right foramen transversarium. 2. Minor lateral displacement of dens is non-specific and may be normal, but ligamentous damage can not be ruled out. 3. Comminuted fracture through the right lamina and pedicle of C6 with extension inferiorly through the transverse process of C7 (Transient Sx). No encroachment of CNS or vascular structures suspected. These findings are concerning for vertebral artery injury given the encroachment of the displaced fracture fragment upon the foramen transversarium. 14 Zachary J. Kastenberg, HMSIII Gillian Lieberman, MD November 12, 2006 Imaging Algorithm: C-Spine Trauma Traumatic injury NO IMAGING * -No Midline Neck Pain -Not Intoxicated -Normal Alertness -No Focal Neuro Findings -No Major Distracting Injuries RADIOGRAPHS -Neck Pain, Swelling -Neurologic Signs/Sx -Intoxication -Altered Mental Status -Loss of Conciousness CT -No Fracture on Radiograph despite Sx -Suspicious Radiograph MRI -Evidence of Vertebral Canal Encroachment -Evidence of Ligament Damage -Neurological Sx CT Myelogram -MR Contraindicated LARGE MEDICAL CENTERS MRA Conventional Angio CTA CNS Pathology Vascular Pathology 15 Zachary J. Kastenberg, HMSIII Gillian Lieberman, MD November 12, 2006 Choosing an Angiographic Modality What is the most likely Pathology? 1. Traumatic Dissection 2. Psuedoaneurysm 3. Arteriovenous Fistula First Ask… Then Ask… Which imaging modality best illustrates this pathology? 16 Zachary J. Kastenberg, HMSIII Gillian Lieberman, MD November 12, 2006 Comparison Pt #1: Traumatic Dissection Aneurysmal Dilatation Of the Left Vertebral Artery Increased Caliber lumen with an Intimal Flap within the Left Vertebral Artery 17 Zachary J. Kastenberg, HMSIII Gillian Lieberman, MD November 12, 2006 Comparison Pt #2: Pseudoaneurysm Saccular dilatation Of the Left vertebral artery Bullet lodged in Cervical region Near aneurysm 18 Zachary J. Kastenberg, HMSIII Gillian Lieberman, MD November 12, 2006 Comparison Pt #3: Arteriovenous Fistula Right vertebral artery Showing communication With vertebral venous plexus Increased contrast within the Vertebral venous plexus 19 Zachary J. Kastenberg, HMSIII Gillian Lieberman, MD November 12, 2006 Angiographic Modalities Imaging Contrast Time Conv. Angio -Highest sensitivity for Lumen Pathology -Poor wall/extravascular visualization Iodinated 1-2 hrs MRA -Highest sensitivity for extravascular and vessel wall -Dissections, Aneurysms, patency/stenosis Gadolinium 1 hr CTA -Inferior sensitivity-Readily available Iodinated <30 min There is continued controversy over which is the “Best” Study. Institutional Capabilities combine with the stability of the Pt at the time of imaging typically determine which modality is used. 20 Zachary J. Kastenberg, HMSIII Gillian Lieberman, MD November 12, 2006 BIDMC PACS Pt’s Vertebral Artery Pathology: MRA V1 V4 V3 V2 C2 1. Normal Left Vertebral 2. Hypoplastic Right Vertebral 3. Signal Loss Throughout V3 4. Resumption of Low Caliber Right Vertebral in V4 5. Normal Signal Throughout Circle of Willis (not shown) PACS Images Courtesy of Dr. Teich Vertebral Artery MIP 1 2 3 4 Findings are suggestive of traumatic occlusion of a congenitally hypo- plastic right vertebral artery 21 Zachary J. Kastenberg, HMSIII Gillian Lieberman, MD November 12, 2006 BIDMC PACSBIDMC PACS BIDMC PACS Normal L Vertebral Flow VoidNormal L Vertebral Absent R Vertebral Increased T1 Signal Compressed R Foramen Transversarium Vertebral Artery Pathology: Multimodality PACS Images Courtesy of Dr. Teich Axial CT MR Time of Flight MR T1 Fat Suppression Findings suggestive of occlusion of right vertebral artery at the level of C2 fracture. T1 Fat suppression images suggestive of possible hematoma formation at this level. 22 Zachary J. Kastenberg, HMSIII Gillian Lieberman, MD November 12, 2006 Case Summary CT: 1. Multiple fractures to superior and inferior cervical spine with damage to the right foramen transversarium of C2. 2. No spinal cord impingement or nerve root damage 3. Possible Atlanto-Axial ligment instability MRA: 1. Congenital hypoplasia of the right vertebral artery 2. Occlusion of right vertebral artery throughout V3 with adequate Circle of Willis collateral circulation 3. Possible hematoma at the level of C2 with no signs of dissection or aneurysm of the right vertebral artery at that level. Plan: Home in neck brace for 3-4 weeks, return for reassessment of vascular and vertebral anatomy. 48 year old male s/p fall with persistent neck discomfort due to multiple stable fractures of the cervical spine. Asymptomatic occlusion of the right vertebral artery is of no immediate concern in the absence of dissection or aneurysm, but due to the evolving nature of such lesions continued monitoring will be necessary. 23 Zachary J. Kastenberg, HMSIII Gillian Lieberman, MD November 12, 2006 Acknowledgements Douglas Teich, MD Atif Zaheer, MD Gillian Lieberman, MD Pamela Lepkowski Larry Barbaras 24 Zachary J. Kastenberg, HMSIII Gillian Lieberman, MD November 12, 2006 References Web Sources Articles 1. Luke L. Yao MD et. al. , http://www.med-ed.virginia.edu/courses/rad/cspine/index.html 2. Author Unknown, http://www.emory.edu/ANATOMY/AnatomyManual/back.html 1. Hoffman, JR, Mower, WR, Wolfson, AB, et al. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt truama. National Emergency X-Radiography Utilization Study Group. N Engl J Med 2000; 343:94.. 2. Berquist, TH. Imaging of adult cervical spine trauma. Radiographics; 8:4. 3. Deliganis, AV, Baxter, AB, Hanson, MB, et al. Radiologic spectrum of craniocervical distraction injuries. Radiographics; 20:S237. 4. Nunez, DB, Zuluaga, A, Fuentes-Bernardo, DA, et al. Cervical Spine Trauma: How much do we learn by routinely using helical CT? Radiographics; 16:6. 5. Amirjamshidi, A, Abbassioun, K, Rahmat, H. Traumatic aneurysms and arteriovenous fistulas of the extracranial vessels in war injuries. Surgical Neurology; 53:p136-45. 6. Shin, JH, Suh, DC, Choi, CG, Lee, HK. Vertebral Artery Dissection: Spectrum of Imaging findings with emphasis on angiography and correlation with clinical presentation. Radiographics; 20:6. 7. Nunez, DB, Torres-Leon, M, Munera, F. Vascular Injuries of the Neck and Thoracic Inlet: Helical CT-Angiographic Correlation. Radiographics; 24:4. Radiological Evaluation of the Traumatic �Cervical Spine Injury Slide Number 2 Slide Number 3 Slide Number 4 Slide Number 5 Slide Number 6 Slide Number 7 Slide Number 8 Slide Number 9 Slide Number 10 Slide Number 11 Slide Number 12 Slide Number 13 Slide Number 14 Slide Number 15 Slide Number 16 Slide Number 17 Slide Number 18 Slide Number 19 Slide Number 20 Slide Number 21 Slide Number 22 Slide Number 23 Slide Number 24