John H. Woodring

Limitations of cervical radiography in the evaluation of acute cervical trauma.

We retrospectively reviewed the medical records and cervical films, computed tomographic (CT) scans, and tomographic studies of 216 consecutive patients with cervical injuries. A trauma series of roentgenograms--a cross-table lateral (CTL), a supine anteroposterior, and an open-mouth odontoid view--was performed in 100%; CT scanning was performed in 100%; and tomography was done in 9% of cases. We determined what percentage of the patients were asymptomatic initially in the emergency department; the total numbers of fractures, subluxations, and dislocations of the cervical spine in these patients; and what percentage of the cervical injuries were not detected with the plain films. Of the 216 patients in the series, 188 (87%) had known signs or symptoms of cervical injury; however, 28 (13%) of the patients were initially asymptomatic with no neurologic deficit. Of these 28, 17 were intoxicated or had mild closed head injuries; however, in 11 (5%) there was no clinical clue to their cervical injury other than a known injury mechanism. Prospectively, 67% of the fractures and 45% of the subluxations and dislocations were not detected by the CTL films, and 32% of the patients, over half of whom had unstable cervical injuries, were falsely identified as having normal spines. Prospectively, the trauma series improved the sensitivity of plain films for detecting cervical injuries but still did not detect 61% of the fractures and 36% of the subluxations and dislocations, and falsely identified 23% of the patients, half of whom had unstable cervical injuries, as having normal cervical spines.(ABSTRACT TRUNCATED AT 250 WORDS)

The role and limitations of computed tomographic scanning in the evaluation of cervical trauma.

We retrospectively reviewed the medical records, plain films, CT scans and complex-motion tomographic studies (TOMOS) of 216 consecutive patients with cervical injuries to determine the uses and limitations of CT in the evaluation of cervical trauma and the indications, if any, for the continued use of TOMOS in evaluating cervical trauma. There were 453 fractures and 104 subluxations or dislocations of the cervical spine in the 216 patients. Plain films detected 58% (262 of 453) of the fractures and 93% (97 of 104) of the subluxations and dislocations; and 94% (202 of 216) of the patients with abnormalities were identified. Computed tomographic scans detected 90% (406 of 453) of the fractures and 54% (56 of 104) of the subluxations and dislocations; 92% (198 of 216) of the patients with abnormalities were identified. Most of the abnormalities missed on the CT scans involved the dens, C-6, and C-7, and were oriented in the axial plane. Although CT scanning was better than plain films in detecting most types of cervical fractures, plain films were better than CT for detecting fractures of the vertebral body, dens, and spinous processes, and significantly better than CT in detecting subluxation and dislocation. When plain films and CT scans were combined they identified 98% (443 of 453) of the fractures and 99% (103 of 104) of the subluxations and dislocations; 100% (216 of 216) of the patients with abnormalities were identified. In the 20 patients who underwent both CT scanning and TOMOS, TOMOS detected more fractures, subluxations, and dislocations than CT scanning. Complex-motion tomographic studies detected atlanto-occipital dislocation and subluxation of the vertebral bodies and fractures of the spinous processes, lateral masses, articular processes, vertebral bodies, and dens better than CT scanning. Although the more routine use of CT scanning in evaluating cervical trauma should increase the detection of cervical abnormalities to near 100%, TOMOS remain the gold standard of diagnosis for atlanto-occipital dislocation, subluxation of the vertebral bodies, and fractures of the lateral masses, articular processes, vertebral bodies, and dens.

Congenital tracheobronchomegaly (Mounier-Kuhn syndrome): a report of 10 cases and review of the literature.

Mounier-Kuhn syndrome is a congenital abnormality of the trachea and main bronchi characterized by atrophy or absence of elastic fibers and thinning of muscle, which allows the trachea and main bronchi to become flaccid and markedly dilated on inspiration with narrowing or collapse on expiration or cough. The abnormal airway dynamics and pooling of secretions in broad outpouchings of redundant musculomembranous tissue between the cartilaginous rings predispose to the development of chronic pulmonary suppuration, bronchiectasis, emphysema, and pulmonary fibrosis. A broad spectrum of clinical abnormalities has been documented in Mounier-Kuhn syndrome, ranging from minimal disease with good preservation of pulmonary function to progressive disease leading to respiratory failure and death. In the appropriate clinical setting, Mounier-Kuhn syndrome is diagnosed in women from chest radiographs when the transverse and sagittal diameters of the trachea exceed 21 mm and 23 mm, respectively, and when the transverse diameters of the right and left main bronchi exceed 19.8 mm and 17.4 mm, respectively. In men it is diagnosed when the transverse and sagittal diameters of the trachea exceed 25 mm and 27 mm, respectively, and when the transverse diameters of the right and left main bronchi exceed 21.1 mm and 18.4 mm, respectively. The diagnosis can be confirmed easily by computed tomography.

THE NORMAL MEDIASTINUM IN BLUNT TRAUMATIC RUPTURE OF THE THORACIC AORTA AND BRACHIOCEPHALIC ARTERIES

In a review of 52 articles, published between 1953 and 1989, 656 patients with blunt traumatic rupture of the thoracic aorta or brachiocephalic arteries were identified. Of these, 608 (92.7%) had an abnormal mediastinum on initial chest radiographs obtained in the emergency department, thus allowing early detection of the vascular injury. Unfortunately, 48 (7.3%) of these patients had a normal mediastinum on their initial chest radiographs. This appears to occur when the traumatic pseudoaneurysm is not accompanied by associated mediastinal hemorrhage or hematoma formation, and the pseudoaneurysm is either small or is situated in such a way that it does not alter the mediastinal contour. The use of accessory clinical and radiographic signs to indicate the need for aortography has been shown to be of very low yield, but would have allowed the early detection of an additional 5.6% of the reported cases. Performing aortography solely on the basis of a history of major decelerating blunt trauma to the thorax remains the only way, in the acute emergency department setting, to detect the 1.7% of patients with aortic or brachiocephalic arterial rupture who have no mediastinal abnormality or accessory clinical or radiographic signs of vascular injury. There is evidence from the literature, however, to suggest that the evaluation of serial chest radiographs obtained at close intervals for the first month following trauma for the development of mediastinal abnormality or large hemothorax is an acceptable alternative to the routine performance of aortography in those blunt chest trauma victims with no clinical or radiographic suspicion of vascular injury.

Transverse process fractures of the cervical vertebrae : are they insignificant ?

Transverse process fractures of the cervical vertebrae have been considered rare and insignificant. In a retrospective study of 216 patients with cervical fractures evaluated by plain films and computed tomography, we found that transverse process fractures were common. Transverse process fractures were present in 24% of patients with cervical fractures and accounted for 13.2% of all cervical fractures. Cervical radiculopathy and brachial plexus palsy were present in 10% of patients with transverse process fractures. In 78% of transverse process fractures, CT scanning showed that the fracture extended into the transverse foramen. Vertebral angiography, performed in eight patients with fractures involving the transverse foramen, showed dissection or occlusion of the vertebral artery in seven (88%) instances. Two of these seven patients had clinical evidence of vertebral-basilar artery stroke. Vertebral angiography should be considered when patients with transverse process fractures extending into the transverse foramen develop signs and symptoms of vertebral-basilar artery insufficiency.

Carotid and vertebral artery injury in survivors of atlanto-occipital dislocation : case reports and literature review

Atlanto-occipital dislocation (AOD) usually results in immediate death from transection of the upper cervical spinal cord near the spinomedullary junction. However, over the last several decades increasing numbers of AOD survivors have been identified. Although many of these patients initially demonstrate profound neurologic deficits, a number who survive have regained most or all neurologic functions, indicating that they did not suffer mechanical disruption of the spinal cord at the time of AOD. In the survivors, a growing body of evidence indicates that many of the initial neurologic deficits are related to vascular injury to the carotid or vertebral arteries and their branches. We recently encountered three AOD survivors with no evidence of mechanical injury to the spinal cord in which angiography demonstrated vascular injury to the internal carotid artery in the form of vasospasm in one case and to the vertebral arteries in the forms of focal stenosis at the site of dural penetration, focal stenosis and distal vasospasm, and focal stenosis with distal intimal flap and dissection in one case each. Autopsy after one of the three died after cardiac arrest demonstrated diffuse infarction of the cerebrum, cerebellum, midbrain, brainstem, and upper cervical spinal cord without evidence of mechanical laceration or transection of the spinal cord. Recovery of neurologic function in two cases following prompt immobilization and angiography suggests that neurologic deficits secondary to vascular injury are potentially reversible.

Radiographic Manifestations of Mediastinal Hemorrhage from Blunt Chest Trauma

The diagnosis of rupture of the thoracic aorta or its major branches depends largely on the recognition of mediastinal hemorrhage from the initial chest radiograph and subsequent thoracic aortography. This review discusses the radiographic manifestations of mediastinal hemorrhage, including widening of the mediastinum; a ratio of mediastinal width to chest width greater than 0.25; abnormalities of aortic contour; opacification of the aortopulmonary window; depression of the left main bronchus; deviation of the trachea to the right; deviation of the nasogastric tube to the right; the apical cap sign; widening of the paraspinal lines; widening of the right paratracheal stripe; and left hemothorax. The relationship of these manifestations to major thoracic arterial injury is examined. Pitfalls in the radiographic evaluation of mediastinal abnormalities are considered, and indications for computed tomography of the thorax and thoracic aortography in the severely injured patient are reviewed.

Determination of Normal Transverse Mediastinal Width and Mediastinal-width to Chest-width (M/C) Ratio in Control Subjects: Implications for Subjects with Aortic or Brachiocephalic Arterial Injury

We measured transverse mediastinal width and mediastinal-width to chest-width (M/C) ratio on supine films of 100 nontraumatized controls. In 95% the transverse mediastinal width was less than 7.5 cm and the M/C ratio was less than 0.38. Thus a transverse width of 7.5 cm or more or an M/C ratio of 0.38 or more can be defined as abnormal with 95% confidence. Application of these values to determine abnormality in 32 patients with proven aortic or brachiocephalic injury showed that the transverse mediastinal width was within normal limits in 41% and M/C ratio was normal in 69%. Utilizing smaller values that would identify all abnormals resulted in false positive rates in the controls of 74% and 87%, respectively. However, one or more of eight specific signs of mediastinal abnormality related to hemorrhage or pseudoaneurysm formation were present in 94% of abnormals compared to only 11% of controls. Because of extreme overlap of transverse mediastinal width and M/C ratio between normals and abnormals, precise measurement of the mediastinum cannot reliably separate the two groups. The subjective assessment of anatomic mediastinal abnormality remains a superior plain film method in determining the need for aortography.

The radiographic distinction of degenerative slippage (spondylolisthesis and retrolisthesis) from traumatic slippage of the cervical spine

In a review of 42 cases of degenerative arthritis of the cervical spine and 22 cases of cervical spine trauma with an observed anterior slippage (spondylolisthesis) or posterior slippage (retrolisthesis) of the vertebral bodies of 2 mm or more, characteristic features were observed which allowed distinction between degenerative and traumatic slippage of the cervical spine. In degenerative slippage the shape of the articular facets and width of the facet joint space may remain normal; however, in most cases the articular facets become “ground-down” with narrowing of the facet joint space and the articular facets themselves becoming thinned or ribbon-like. In traumatic slippage the artucular facets will either be normally shaped or fractured and the facet joint space will be abnormally widened. Plain radiographs will usually allow this distinction to be made; however, in difficult cases polytomography may be required.

Occipital condyle fracture associated with cervical spine injury

Fracture of the occipital condyle is a rare sequela of craniocervical trauma; it has been reported in only 8 patients since 1816. In one-third of the cases, the fracture was associated with dislocation of the atlantooccipital junction, a uniformly fatal injury. We report a case of fracture of the occipital condyle associated with fractures of C6 and C7, a combination of injuries not previously reported to the best of our knowledge.