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One of our patients (1 st ) showing cervical instability. CT scan (A) and T2 fat suppression sagittal MR image (B) at the time of initial injury present a C5 spinous process fracture and high signal intensity around fracture site which suggest suspicious posterior ligament complex injury. Dynamic flexion and extension views (C, D) on 9 weeks later following the injury show subluxation on C5-6. The patient was underwent posterior fusion on C5-6 with lateral mass screw system and inter-spinous wiring (E, F).
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Prompt and accurate diagnosis of cervical spine injury is important to prevent the catastrophic results that can be caused by undetected lesions. Delayed or missed diagnosis of cervical spine injury occurs with an incidence of 5 to 20% according to previous studies. In this study, we report four cases of cervical instability without initial radiolo...
Contexts in source publication
Context 1
... first case was a 57-year-old woman presenting with mul- tiple trauma caused by a rollover motor vehicle accident. She complained of left shoulder and neck pain, and was diagnosed with multiple fractures in the upper and lower extremities. A spinous process fracture was identified on C5 without invol- ving lamina under routine X-ray (Fig. 1C and D, including antero-posterior, lateral, and open mouth views) and CT scan (Fig. 1A). The patient was found to have suspicious posterior ligament complex injuries including inter-and supra-spinous ligaments and ligamentum flavum on T2 fat suppression sagi- ttal MR imaging (Fig. 1B). We decided to prescribe for the patient a conservative treatment, because of a low possibility of insta- bility with the above radiological examination under the Sub- axial Cervical Injury Classification (SLIC) 11) . She complained of intermittent neck pain and discomfort during follow-up periods at the outpatient department. Subluxation of the facet joint on C5-6 was identified by dynamic flexion and extension radiographies after 9 weeks. The anterior longitudinal liga- ment (ALL) and intervertebral disc presented intact, and only a posterior column injury was observed. She underwent poste- rior fusion on C5-6 with a lateral mass screw system and inter- spinous wiring ( Fig. 1E and ...
Context 2
... first case was a 57-year-old woman presenting with mul- tiple trauma caused by a rollover motor vehicle accident. She complained of left shoulder and neck pain, and was diagnosed with multiple fractures in the upper and lower extremities. A spinous process fracture was identified on C5 without invol- ving lamina under routine X-ray (Fig. 1C and D, including antero-posterior, lateral, and open mouth views) and CT scan (Fig. 1A). The patient was found to have suspicious posterior ligament complex injuries including inter-and supra-spinous ligaments and ligamentum flavum on T2 fat suppression sagi- ttal MR imaging (Fig. 1B). We decided to prescribe for the patient a conservative treatment, because of a low possibility of insta- bility with the above radiological examination under the Sub- axial Cervical Injury Classification (SLIC) 11) . She complained of intermittent neck pain and discomfort during follow-up periods at the outpatient department. Subluxation of the facet joint on C5-6 was identified by dynamic flexion and extension radiographies after 9 weeks. The anterior longitudinal liga- ment (ALL) and intervertebral disc presented intact, and only a posterior column injury was observed. She underwent poste- rior fusion on C5-6 with a lateral mass screw system and inter- spinous wiring ( Fig. 1E and ...
Context 3
... first case was a 57-year-old woman presenting with mul- tiple trauma caused by a rollover motor vehicle accident. She complained of left shoulder and neck pain, and was diagnosed with multiple fractures in the upper and lower extremities. A spinous process fracture was identified on C5 without invol- ving lamina under routine X-ray (Fig. 1C and D, including antero-posterior, lateral, and open mouth views) and CT scan (Fig. 1A). The patient was found to have suspicious posterior ligament complex injuries including inter-and supra-spinous ligaments and ligamentum flavum on T2 fat suppression sagi- ttal MR imaging (Fig. 1B). We decided to prescribe for the patient a conservative treatment, because of a low possibility of insta- bility with the above radiological examination under the Sub- axial Cervical Injury Classification (SLIC) 11) . She complained of intermittent neck pain and discomfort during follow-up periods at the outpatient department. Subluxation of the facet joint on C5-6 was identified by dynamic flexion and extension radiographies after 9 weeks. The anterior longitudinal liga- ment (ALL) and intervertebral disc presented intact, and only a posterior column injury was observed. She underwent poste- rior fusion on C5-6 with a lateral mass screw system and inter- spinous wiring ( Fig. 1E and ...
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Citations
... Cervical spine instability occurs in the instability stage of the degeneration, which is predominantly observed in individuals aged between 35 and 70 years [8]. However, trauma, inflammatory arthritis, congenital collagenous compromise, and surgery involving the neck region can also cause cervical spine instability [9][10][11]. ...
Neck pain, dizziness, difficulty supporting the head for an extended period, and impaired movement are all symptoms of cervical spine instability, which may produce cervical spondylolisthesis in patients who have more severe symptoms. To avoid problems and consequences, early detection of cervical spine instability is required. A previous study created a Thai-language version of a cervical spine instability screening tool, named the CSI-TH, and evaluated its content validity. However, other characteristics of the CSI-TH still needed to be evaluated. The objective of the current study was to assess the rater reliability and convergent validity of the CSI-TH. A total of 160 participants with nonspecific chronic neck pain were included in the study. The Neck Disability Index Thai version (NDI-TH), the Visual Analog Scale Thai version (VAS-TH), and the Modified STarT Back Screening Tool Thai version (mSBST-TH) were used to evaluate the convergent validity of the CSI-TH. To determine inter- and intra-rater reliabilities, novice and experienced physical therapists were involved. The results showed that rater reliabilities were excellent: the intra-rater reliability was 0.992 (95% CI = 0.989 ± 0.994), and the inter-rater reliability was 0.987 (95% CI = 0.983 ± 0.991). The convergent validities of the VAS-TH, NDI-TH, and mSBST-TH when compared with the CSI-TH were 0.5446, 0.5545, and 0.5136, respectively (p < 0.01). The CSI-TH was developed for use by physical therapists and is reliable. It can be used by physical therapists, whether they are experienced or novices, and has an acceptable correlation to other neck-related questionnaires. The CSI-TH is concise, suitable for clinical use, and lower-priced when compared to the gold standard in diagnosis for patients with cervical spine instability.
... • Lateral cervical spine projections are predominantly used for biomechanical analysis and segmental stability of the cervical spine thus is essential for some contraindications to cSMT. (105)(106)(107)(108)(109)(110)(111) • Flexion and extension evaluations of the cervical spine are performed in the sagittal plane to assess segmental motion and stability. (105)(106)(107)(108)(109)(110)(111) Thus, these were included in the study. ...
... (105)(106)(107)(108)(109)(110)(111) • Flexion and extension evaluations of the cervical spine are performed in the sagittal plane to assess segmental motion and stability. (105)(106)(107)(108)(109)(110)(111) Thus, these were included in the study. ...
Introduction: Neck pain is a common health complaint in the UK and the second most common complaint seen by chiropractors worldwide. Spinal manipulative therapy (SMT) is an effective treatment intervention for patients with neck pain. The risks of SMT of the cervical spine (cSMT) are well documented in the literature; however, investigations into patient risk factors are lacking. Debate exists within the profession regarding the appropriate use of x-rays for spinal complaints with screening for contraindications to cSMT seen by some as inappropriate. This retrospective review of records and service evaluation examines how frequently lateral cervical spine x-rays alter treatment options in 1 chiropractic practice.
Methods: Data from 626 patient records were retrospectively reviewed from a private chiropractic clinic in the UK. Of the 626 new patients, 293 (47%) had x-rays of their cervical spine before commencing treatment. Patient x-rays and x-ray reports were reviewed for contraindications to cSMT.
Results: Of the 293 cervical spine x-rays, 177 (60%) revealed contraindications to cSMT over the 4 years of data collection. Thus, 28% of the 626 new patients who attended the clinic during that time period had their treatment option altered due to findings of contraindications on lateral cervical spine x-rays. Data analysis found that of those x-rays with contraindications, 46% had more than 1 contraindication present in the same patient. Extrapolating these data to the entire new patient population who attended the clinic, 15% of patients per annum had their treatment options altered as a direct result of x-rays findings.
Conclusion: The study found that 60% of cervical spine x-rays revealed contraindications to cSMT over the entire study period. Approximately 30% of lateral cervical spine x-rays revealed contraindications to cSMT, subsequently altering the treatment options of patients. This study adds supporting evidence to the validity of x-rays in chiropractic clinical practice in reducing risks of adverse events from cSMT and increasing patient safety.
... If these two regions are not properly seen on plain X-rays or if a patient complains of neck pain with normal plain Xrays, the CT scan becomes necessary for the exclusion of cervical/cervicothoracic spine injury, according to Platzer et al. [3]. When there is a high level of uncertainty related to bony structures or ligamentous injuries in the static X-rays, dynamic flexion and extension should be avoided until the extent of the lesion is determined by CT scan or MRI [3,4]. ...
... It seems to be the more logical attitude in spite of a lack of consensus. 4 Case Reports in Orthopedics ...
Neglected unreduced cervical dislocation is very uncommon. In our case (a lady who stayed asymptomatic for 13 months before development of cervicobrachialgia), the anterior reduction/arthrodesis was easy, and we did not find any benefit from an additional posterior procedure thanks to a congenital block between C7 and T1 vertebral bodies. This point is nevertheless a matter of debate. After a review of the literature, we did not find any consensus about the ideal scheme and sequence to reduce and stabilize this delayed type of cervical trauma. We emphasize the need of dynamic radiographies to exclude unstable injuries but also a prereduction MRI (especially in unexaminable patients) to detect any dangerous disc fragment. If there is no visible change in the radiological status while attempting to reduce the dislocation by external maneuvers, there is little chance to reduce it successfully only by a single approach. Therefore, in irreducible delayed dislocations, it seems safer to prepare the reduction/fusion stage (either anterior/posterior, depending on the habits and skills of the surgeon) by a first stage carrying out a release of the fibrous tissues on the opposite side (either posterior to release the facet joints or anterior to release the intervertebral disc), followed by the reduction/fusion stage itself and then by a third stage to lock the level. Like many authors, we recommend an anterior approach first in case of an extruded disc visible on the MRI, and therefore, we show a preference for the anterior-posterior-anterior sequence in irreducible delayed cervical dislocations.
... Missing cervical spine injuries are known. [32] In 30% of patients with discoligamentous injuries, initial imaging shows no evidence of injury, which is evident on subsequent imaging. [33] Patients with PLC injures in isolation on MRI may not need surgical management. ...
This section of the symposium deals with different clinical situations related to the management of traumatic cervical spine cord injury (SCI) and its complications. These cases give an overview of the clinical dilemmas that test our decision-making abilities in dealing with patients with cervical SCI and its associated complications. The patients were managed in various centers across India with different infrastructures and facilities. They are managed by different experts in the field of spine surgery. This should help the reader in providing a wider perspective in the management of vertebral lesions of traumatic cervical SCI. This section also helps in understanding the newer advances in dealing with the dreaded complication of invasive long-Term ventilation in a patient with cervical SCI. The spine clinic ends with comments by the authors on key takeaway points from each case scenario, and some literature supported recommendations for the management of traumatic cervical SCI.
... For patients who require concomitant trauma surgery, lateral X-ray can be obtained after anesthesia and muscle relaxation prior to surgery to assess the stability of the cervical spine. Some physicians may recommend getting flexion/extension lateral X-rays, which unlike static lateral X-rays, may detect instability of the cervical spine from a subtle disc or ligamentous injury [10,11]. However, the use of flexion/extension X-rays after acute cervical spine trauma is debated since this movement of the neck may aggravate the injury [12]. ...
Background:
Missed or delayed diagnosis of cervical spine instability after acute trauma can have catastrophic consequences for the patient, resulting in severe neurological impairment. Currently, however, there is no consensus on the optimal strategy for diagnosing occult cervical spine instability. Thus, we present a case of occult cervical spine instability and provide a clinical algorithm to aid physicians in diagnosing occult instability of the cervical spine.
Case summary:
A 57-year-old man presented with cervical spine pain and inability to stand following a serious fall from a height of 2 m. No obvious vertebral fracture or dislocation was found at the time on standard lateral X-ray, computed tomography, and magnetic resonance imaging (MRI). Subsequently, the initial surgical plan was unilateral open-door laminoplasty (C3-7) with alternative levels of centerpiece mini-plate fixation (C3, 5, and 7). However, the intraoperative C-arm fluoroscopic X-rays revealed significantly increased intervertebral space at C5-6, indicating instability at this level that was previously unrecognized on preoperative imaging. We finally performed lateral mass fixation and fusion at the C5-6 level. Looking back at the preoperative images, we found that the preoperative T2 MRI showed non-obvious high signal intensity at the C5-6 intervertebral disc and posterior interspinous ligament.
Conclusion:
MRI of cervical spine trauma patients should be carefully reviewed to detect disco-ligamentous injury, which will lead to further cervical spine instability. In patients with highly suspected cervical spine instability indicated on MRI, lateral X-ray under traction or after anesthesia and muscle relaxation needs to be performed to avoid missed diagnoses of occult cervical instability.
... Cervical spine instability prevents the spine from maintaining its normal pattern of displacement under physiological loads [1]. It is often caused by trauma (such as car accident or a high impact on the neck) when the traumatic flexion-extension movements exerted on the spine may lead to ligamentous disruption with subsequent atlantoaxial instability, also known as upper cervical instability [3]. It is also related to pathologies, such as rheumatoid arthritis [4], or to congenital deviation, such as down syndrome [5]. ...
Comparison of derivative operators via quantitative performance analysis is rarely addressed in medical imaging. Indeed, the main application of such operators is the extraction of edges and, since there is no unequivocal definition of edges, the common trend is to identify the best performing operator based on a qualitative match between the extracted edges and the fickle human perception of object boundaries. This study presents an objective comparison of four first-order derivative operators through quantitative analysis of results yielded in a specific task, i.e. a spine kinematics application. Such application is based on a template matching method, which estimates common kinematic parameters of intervertebral segments from an X-ray fluoroscopy sequence of spine motion, by operating on the image derivatives of each frame. Therefore, differences in image derivatives, computed via different derivative operators, may lead to differences in estimated parameters of intervertebral kinematics. The comparison presented in this study focused on the trajectory of the instantaneous center of rotation (ICR) of an intervertebral segment, as it is particularly sensitive even to very small differences in displacements and velocities. Therefore, a quantitative analysis of the discrepancies between the ICR trajectories, obtained with each of the four considered derivative operators, was carried out by defining quantitative measures. The results showed detectable differences in the obtained ICR trajectories, thus highlighting the need for quantitative analysis of derivative operator performances in applications aimed at providing quantitative results. However, the significance level of such differences for clinical applications should be further assessed, but, currently, it is not possible, as there is no consensus and sufficient data on kinematic parameters features associated with specific spinal pathologies.
... In initial and follow-up studies, dynamic flexion and extension radiography has been used to exclude the possibility of cervical instability in cervical trauma patients without instability in static MRI or CT. For example, Yeo et al. 7 reported that four patients whose initial static CT and MRI showed no instability were diagnosed with cervical instability by dynamic radiographs several days to weeks after injury and then received surgical treatment. Anekstein et al. 8 used dynamic CT to evaluate instability due to occult ligamentous injury of the cervical spine in comatose trauma patients. ...
Objective
To evaluate the feasibility and safety of cervical kinematic MRI (KMRI) in patients with cervical spinal cord injury without fracture and dislocation (CSCIWFD).
Methods
This was a single‐institution case‐only study. Patients with CSCIWFD were enrolled in our institution from February 2015 to July 2019. Cervical radiography and CT were performed first to exclude cervical tumors, and major fracture or dislocation. Then neutral static and kinematic (flexion and extension) MRI was performed for patients who met the inclusion criteria under the supervision of a spinal surgeon. Any adverse events during the KMRI examination were recorded. Patients received surgical or conservative treatment based on the imaging results and patients’ own wishes. The American Spinal Injury Association impairment scale (AIS) grade and the Japanese Orthopedic Association (JOA) score were evaluated on admission, before KMRI examination, and after KMRI examination. For the surgical patients, AIS grade and JOA score were evaluated again 1 week after the operation. The JOA scores were compared among different time points using the paired t‐test.
Results
A total of 16 patients (12 men and 4 women, mean age: 51.1 [30–73] years) with CSCIWFD were included in the present study. Clinical symptoms included facial trauma, neck pain, paraplegia, paresthesia, hyperalgesia, sensory loss or weakness below the injury level, and dyskinesia. On admission, AIS grades were B for 2 cases, C for 5, and D for 9. A total of 14 patients underwent neutral, flexion, and extension cervical MRI examination; 2 patients underwent neutral and flexion examination because they could not maintain the position for a prolonged duration. No patient experienced deterioration of neurological function after the examinations. The AIS grades and JOA scores evaluated post‐examination were similar to those evaluated pre‐examination (P > 0.05) and significantly higher than those on admission (P < 0.05). A total of 12 patients received surgical treatment, 11 of whom underwent anterior cervical discectomy and interbody fusion and 1 underwent posterior C3/4 fusion with lateral mass screws. The remaining 4 patients were offered conservative therapy. None of the patients experienced any complications during the perioperative period. The AIS grade did not change in most surgical patients, except that 1 patient changed from grade C to D 1 week after the operation. The JOA score 1 week after surgery was significantly higher than those on admission and around examination for the surgical patients (P < 0.05).
Conclusion
Cervical KMRI is a safe and useful technique for diagnosis of CSCIWFD, which is superior to static cervical MRI for therapeutic decision‐making in patients with CSCIWFD.
... The incidence of delayed or missed diagnosis of spinal trauma has decreased in recent years, with developments in radiological diagnostic examination tools including computed tomography (CT) and magnetic resonance imaging (MRI). [2] Nevertheless, incomplete radiological studies and misinterpretation sometimes result in delayed or missed diagnosis. We recently experienced a patient in whom C3 vertebra anterior subluxation was diagnosed 10 days after craniotomy for the treatment of an epidural hematoma. ...
... However, delayed instability and dislocation have been reported in cases, in which an obvious bone wound was not confirmed. [2,[4][5][6][7] We have herein described the first reported case of delayed cervical subluxation diagnosed after surgery for traumatic ICH. The initial head CT of this patient demonstrated scalp swelling in the right temporooccipital region [ Figure 1a, arrow]. ...
... When the occipital side of the head has been impacted as in our patient, distractive flexion cervical injuries should be considered even if the cervical CT findings are normal because such patients may develop posterior ligament complex injuries and consequently delayed subluxation. [2,3] For acutely injured patients with a normal level of consciousness, we typically perform evaluation of bony structures by a three-view radiographic study as recommended by the American College of Surgeons Committee on Trauma guidelines. [8] Even in case radiographic findings are normal, soft cervical collar is used if patient complained of neck pain or midline tenderness and further examination including MRI or flexion and extension radiographs is considered. ...
A case of delayed occurrence of C3 vertebra anterior subluxation diagnosed 10 days after surgery for epidural hematoma is herein described. A 56-year-old man underwent surgery for right epidural hematoma. No spinal fracture was identified on the cervical–spinal computed tomography (CT) on arrival. The patient developed neck pain after the craniotomy, and cervical magnetic resonance imaging 5 days postoperatively revealed a disruption of the C3–C4 posterior ligament complex. The patient was conservatively treated with immobilization. Cervical CT 10 days postoperatively revealed C3 vertebra anterior subluxation. Posterior fixation surgery was performed 21 days after admission, and the postoperative course was uneventful. This case suggests that awareness of delayed occurrence of cervical dislocation after traumatic intracranial hemorrhage should be increased among neurosurgeons.
... This may have been due to progression of the injury, inaccurate assessment of radiological findings or diagnostic error etc. Spinal injury was also a commonly missed injury found in the current study that may result in significant mortality and morbidity. Many studies have stated that spinal injuries are often missed and mismanaged which may be catastrophic in terms of outcome [14,15] . In the study. ...
Introduction. Motor vehicle accidents are one of the leading causes of death in the world. The autopsy serves as a quality indicator for missed injuries in clinical management. Objectives. To identify and describe missed injuries in motor vehicle fatalities by comparing clinical records and autopsy findings in Central Durban during the year 2012. Methods. The study was a retrospective descriptive analysis of missed injuries determined at autopsy at an Durban-based mortuary. 181 cases were accepted into the study. Copies of the hospital notes and summaries were studied which were obtained from the case files in the archives of the Forensic Medicine and Pathology Department in Inkosi Albert Luthuli Central Hospital. The data collected was captured and analysed using the Statistical Package for Social Sciences (SPSS version 21). Results. Missed injuries were detected at autopsy in 41% of cases. The regions with missed injuries in decreasing order were the thorax (56.6%), head and neck (47%), the abdomen (31.6%), pelvis (15.8%), face (3.9%) and limbs (2.6%). Cases with the most missed injuries were generally pedestrians and had a low Glascow Coma Scale score. In-hospital investigations were done adequately in most cases but injuries were still missed. The period of survival of case subjects with missed injuries were reduced compared to the subjects without missed injuries. Conclusion. The study confirmed that injuries contributory to the cause of death are missed clinically. The regions with the most commonly missed injuries were the head and chest. © 2018 Surgical Society of Northern Greece. All Rights Reserved.
