Cervical Spine Trauma 06 - Clinical Case Summary
Cervical Spine Trauma 06 - Clinical Case Summary
Cervical Spine Trauma 06 - Clinical Case Summary
SummaryHistory
5 yo male fell out of car and was run over at low speed
Exams Performed
Cervical spine CT; Cervical spine MR
Prior available imaging reports
Plain film cervical radiograph not available
Cervical CT
1. Right temporal bone and central skull base compressive fractures are evident with separation of the sphenoid-clival synchondrosis.
2. There is a right occipital sutural diastasis without extension to the occipital condyle.
3. Displaced bone fragment is present in the mid cavernous course of the extradural ICA canal. CTA demonstrates a right ICA occlusion in this region. There is radid filling of the adjacent cavernous and inferior jugular veins consistent with a post traumatic AV fistula.
4. Extravasation of gas is evident in the parapharyngeal spaces, the parapharyngeal veins, the right condylar-C1 joint space, intradural suprasellar cisternal gas, and within the epdural space adjacent to the right jugular plate.
5. Although there is gas within the right condylar-C1 joint space, there are no other fractures nor soft tissue injuries.
6. There is very irregular ossification of the dens. It is difficult to confirm whether this is abnormal or not on CT; MR is suggested for further evaluation.
7. There is evidence of right carotid injury with both vascular occlusion and evidence of a post traumatic CC fistula which actually fills from retrograde carotid circulation.
Cervical spine MR
1. The dens status is considered normal for a patient of this age.
2. MR confirms the slow flow state in the right high cervical ICA, but the intrapetrous and trigeminal ICA segments are not included in the field of interest.
3. MR confirms minimal post traumatic joint effusions in the atlanto-axial joint and the condylar-C1 synovial joints, but there is no significant cervical spine injury.
Cervical CT
1. Right temporal bone and central skull base compressive fractures are evident with separation of the sphenoid-clival synchondrosis.
2. There is a right occipital sutural diastasis without extension to the occipital condyle.
3. Displaced bone fragment is present in the mid cavernous course of the extradural ICA canal. CTA demonstrates a right ICA occlusion in this region. There is radid filling of the adjacent cavernous and inferior jugular veins consistent with a post traumatic AV fistula.
4. Extravasation of gas is evident in the parapharyngeal spaces, the parapharyngeal veins, the right condylar-C1 joint space, intradural suprasellar cisternal gas, and within the epdural space adjacent to the right jugular plate.
5. Although there is gas within the right condylar-C1 joint space, there are no other fractures nor soft tissue injuries.
6. There is very irregular ossification of the dens. It is difficult to confirm whether this is abnormal or not on CT; MR is suggested for further evaluation.
7. There is evidence of right carotid injury with both vascular occlusion and evidence of a post traumatic CC fistula which actually fills from retrograde carotid circulation.
Cervical spine MR
1. The dens status is considered normal for a patient of this age.
2. MR confirms the slow flow state in the right high cervical ICA, but the intrapetrous and trigeminal ICA segments are not included in the field of interest.
3. MR confirms minimal post traumatic joint effusions in the atlanto-axial joint and the condylar-C1 synovial joints, but there is no significant cervical spine injury.
Lessons to be Learned
1. Evaluation of the dens on CT in children can be problematic, because of incomplete ossification leaving the dens with a very confusing appearance. The dens has three ossification centers: there is an apical and two side-to-side ossification centers. In children the normal centers of ossification can be very irregular simulating traumatic injury on CT. The two side to side ossifications can simulate a vertical dens fracture and the apical ossification can simulate a Type-1 dens fracture. MR is helpful in distinquishing traumatic injury by the presence of bone edema from normal development with no edema.
2. Significant injuries to the temporal bone(s) and central skull base have a high probability of upper cervical injuries, as well. Some are serious and some are not. Carotid or vertebral artery injuries include occlusion, dissection, and AV fistulae; all are present in this case.
3. CT can detect injuries to the synovial joints when there are facet fractures and when the joint space is widened and/or the facet surfaces are malaligned or offset. However, MR can actually detect more subtle strain injuries be evidence of joint effusions before the joint space is widened.
2. Significant injuries to the temporal bone(s) and central skull base have a high probability of upper cervical injuries, as well. Some are serious and some are not. Carotid or vertebral artery injuries include occlusion, dissection, and AV fistulae; all are present in this case.
3. CT can detect injuries to the synovial joints when there are facet fractures and when the joint space is widened and/or the facet surfaces are malaligned or offset. However, MR can actually detect more subtle strain injuries be evidence of joint effusions before the joint space is widened.