WIDI - N30) Neck pain after trauma

N30) Neck pain after trauma

Review the Learning Outcomes, Hx, PE and Labs, and begin the module with your Provisional Diagnosis. Keep hitting "Next" to move through the module.

Learning Outcomes

Articulate your relationship with the consulting diagnostic radiologists in the evaluation of a trauma patient with neck pain.
Review the role of different imaging modalities for evaluating patients with neck pain after trauma.

History

A 19 year old male was an unrestrained driver in a motor vehicle accident vs tree, at moderate speed. He was not ejected and had no loss of consciousness. He complained of neck and left shoulder pain. He refused transport and drove himself to the ED. A cervical collar was placed in the ED. His PMH was unremarkable.

Physical Exam

Oriented x 3. BP 120/60. HR 81. RR 16. Temp 36.6. No cranial nerve abnormality. No traumatic head injury. There is midline tenderness over the upper cervical spine. Tender to palpation over the left shoulder and clavicle. The remainder of the PE is normal.

Labs

WBC 11.3.Hb 15.4. Hct 44.3. Plt 246. BMP (basic metabolic panel) and LFTs are normal. UA normal INR 1.

Provisional Diagnosis

Select the Dx you believe is most appropriate

No traumatic injury evident.

Neck pain likely from muscle sprain or whiplash.

Possible soft tissue and/or bony injury of neck.

Neck injury with referred pain to the left shoulder/clavicle.

In a patient involved in an MVA with neck pain, soft tissue/ligamentous injury as well as the possibility of fractures must be investigated.

Well done. You were correct

Potential Acuity

What is your assessment of the likely acuity for this patient?

Emergent (immediate plan required)

Urgent (plan required within 4 hours)

Routine

Well done. You were correct

There could be an unstable injury to the cervical spine. There is also the possibility of injury to the spinal cord.

First Imaging Study

What is the first imaging study you will order?

C spine radiographs in the collar

C spine radiographs with collar removed to improve technique

C spine MRI

Radiographs are often obtained as the initial study particularly when the patient is still in a collar. If the exam adequately covers the cervical spine and C7-T1 junction and no abnormality is seen, the collar may be removed and further imaging obtained if symptoms persist. Many institutions obtain the CT scan as the initial exam. In this case, the radiographs were obtained first.

Well done. You were correct

Pertinent Imaging Observations

Click on the links below to view images from the study, and assess these key findings as best you can.

XR Cervical Spine AP and Lateral

There is a fracture of the C1 ring. There is slight anterolisthesis of C4 on C5.

Yes

Yes, the lateral view shows a fracture of the C1 ring and slight anterolisthesis at C4-C5.

There is prevertebral soft tissue swelling.

Yes

No, there is no prevertebral soft tissue swelling. This does not preclude injury to the cervical spine.

View Report

Second Imaging Study

What is the next imaging study you will order?

Flexion and extension views of the cervical spine

C spine MRI

C spine CT scan

A CT scan is obtained to detail bony injuries. MRI can miss fractures especially if a fracture is not distracted, but is more sensitive to ligamentous, capsular, spinal cord, or other soft tissue injuries. Flexion and extension views would be contraindicated.

Well done. You were correct

Third Imaging Study

What is the next imaging study you will order?

C spine CT without and with IV contrast

C spine MRI

No other imaging indicated at this time.

The CT scan without contrast already shows significant injuries likely from hyperextension, axial loading, and rotatory mechanisms. It would not be repeated at this time. MRI is needed since it is more sensitive to spinal cord, synovial joint, or other soft tissue especially ligament injuries. CT angiography of the neck may be needed in the future if there is suspicion of vascular injury.

What is your Diagnosis now that you have seen the imaging results?

Fractures of the dens and C1 ring are not significantly distracted and are likely stable. There is a fracture of the right articular pillar of C4. There are C3-C4 and C4-C5 joint injuries.

The combination of a C1 ring fracture and the type-2 dens fracture plus the upper cervical facet joint strain make the upper cervical region likely unstable. There is evidence of rotary injury at C4-C5 related to the right articular pillar fracture at C4.

There is likely an unstable fracture involving the C1 ring and dens. There is ligamentous and uncovertebral injury at C4-C5 with mild anterolisthesis at C4-C5. There is a compression fracture of the right articular pillar of C4.

This case demonstrates how multiple mechanisms are often at play in any significant cervical trauma. In this case the C1 ring fractures and the upper cervical synovial joint effusion are axial-loading injuries, while the articular pillar and oblique dens fractures are likely rotary in nature. The MR helps delineate the extent of the synovial joint injuries.

Current Acuity

Initially, you selected and we suggested acuity.

Has your concern for this patient changed?

Emergent (immediate plan required)

Urgent (plan required within 4 hours)

Routine

Neurosurgery would be consulted immediately (and likely was consulted early, given the initial radiographs).

Socioeconomic Factors: In this case, plain films were done initially. Much more commonly, especially in trauma centers, a CT will be the initial study of choice in a patient with neck pai following an MVA. MRI is typically reserved to further evaluate positive findings on CT scan or other circumstances that suggest a high risk of disc/ ligament/spinal cord injury.

That's the end of the module! Once you've reviewed the video(s), you can click here for another case challenge.

Contributors:
Robbie Slater, MD - Editor
Bayar Batmunh, MS - Coordinator