![]() The management algorithm however is also dependent upon the integrity of the C2/3 disc, the anterior and the posterior longitudinal ligaments. The Effendi, Levine, and Francis classifications are solely based on static radiographs. MRI is less dangerous than flexion-extension cervical injury. T2 signal hyperintensities and STIR changes within the dens, ligaments, or soft tissue can illustrate a critical component. MRI is also useful for determining the acute nature of the fracture when this is otherwise unknown. This can be coupled with a CT angiogram (see below) for evaluation of the vascular anatomy.Įvaluation with MRI is essential for analyzing the ligamentous construct, disc space, spinal cord, nerve roots, and other soft tissue injuries. Non-contrast CT scan is adequate for evaluating the bony anatomy for fracture. It is important to recognize the importance that complete imaging will require dedicated thin-cut CT reconstructions. CT scan does not directly evaluate the spinal cord, soft tissue, or ligamentous construct. A CT scan is warranted even if plain films are negative and clinical suspicion is high. CT scan is the most important modality for determining fracture etiology and ruling out an injury regarding a C2 fracture. X-rays are an excellent modality for determining alignment during the immediate injury, post-operative period, as well as long-term follow-up.Ĭomputed tomography is the mainstay of radio imaging. Approximately 93% of cervical spine injuries appear with combined, lateral, AP, and odontoid view radiographs. Lateral, anteroposterior (AP), and open-mouth odontoid views are necessary. This is essential in reviewing cervical spine trauma. Care must be taken to ensure proper radiographic imaging creates a picture from the occiput to the C7 through the T1 disc space. Normalized hemoglobin, hematocrit, PT/PTT, INR, and platelet counts will be needed for operative intervention.Įvaluation with X-rays will provide limited but important information. Laboratory tests should be ordered as an adjunct to overall medical status. Anterior subluxation of C2 on C3 greater than 3 mm is a marker for C2 to C3 intervertebral disc disruption. It is important to recognize that this grading system does not apply to the pediatric population. Multiple grading systems for hangman’s fractures exist however, the Levine and Edwards classifications are the most widely used.Īngulation in this system is measured as the angle between the inferior endplate of C2 and C3. The flexion type of injury harbingers the risk of injury to the C2–C3 disc anteriorly and C1–C2 posterior ligament complex (PLC) posteriorly. The flexion subtype of Hangman's fracture results following the bending failure of the pedicle over the fulcrum formed by the superior facet of C3. The extension compression subtype of Hangman's fracture results from pincer-like compression of the C2 pedicle between adjoining articular processes of C1 and C3. Leaf spring hypothesis: C2 pedicle is like the shackle in the assembly and therefore the weak link within the same.
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