Chance Fractures in the Pediatric Population Are Often Misdiagnosed.

BACKGROUND: Flexion injuries of the spine range from mild compression fractures to severe flexion-distraction injuries, that is, Chance fractures. Chance fractures are often unstable and Arkader and colleagues demonstrated improved outcomes when Chance fractures are treated operatively compared with those managed nonoperatively. METHODS: A retrospective review was conducted of all patients treated over a 5-year period (2008 to 2013) for a flexion injury, either a Chance or a compression fracture, of the thoracolumbar spine at our tertiary pediatric level I trauma center. Patients were excluded if they had prior spine surgery or had a pathologic fracture. RESULTS: Of the 26 patients who met the inclusion criteria, 27% (7/26 patients) had a Chance fracture and 73% (19/26) had compression fracture(s). The mean age of the 7 patients with Chance fractures was 14.6 years (range, 13 to 16 y). In total, 71% (5/7) of the patients with Chance fractures were initially misdiagnosed: (3 as compression fractures, 1 as a burst fracture, 1 as muscular pain) and 80% (4/5) of these misdiagnoses were made by a neurosurgeon or orthopaedic surgeon. Average delay to correct diagnosis was 95 days (range, 2 to 311 d), with 57% (4/7) of the patients having ≥1 month delay. These 4 patients with a Chance fracture and ≥1 month delay in correct diagnosis presented to our clinic electively with chronic back pain. None of the patients with Chance fractures had a neurological injury. Six patients with posterior ligamentous disruption were treated with surgical instrumentation and fusion. All Chance fractures occurred between the levels of T12 and L3. CONCLUSIONS: The majority of pediatric Chance fractures in this series were initially misdiagnosed (71%; 5/7) or mistreated (14%; 1/7) by neurosurgeons or orthopaedic surgeons. Mean time to the correct diagnosis was 3 months for the Chance fractures in this series. LEVEL OF EVIDENCE: Level IV.

CT for thoracic and lumbar spine fractures: Can CT findings accurately predict posterior ligament complex injury?

PURPOSE: This study aims to determine whether secondary CT findings can predict posterior ligament complex (PLC) injury in patients with acute thoracic (T) or lumbar (L) spine fractures. METHODS: This is a retrospective study of 105 patients with acute thoracic and lumbar spine fractures on CT, with MRI as the reference standard for PLC injury. Three readers graded CT for facet joint alignment (FJA), widening (FJW), pedicle or lamina fracture (PLF), spinous fracture (SPF), interspinous widening (ISW), vertebral translation (VBT), and posterior endplate fracture (PEF). Univariate and multivariate logistic regression analyses were performed separately for each reader to test for associations between CT and PLC injury, and diagnostic performance of CT was calculated. RESULTS: Fifty-three of 105 patients had PLC injury by MRI. Statistically significant predictors of PLC injury were VBT, PLF, ISW, and SPF. Using these four CT findings, odds of PLC injury ranged from 3.8 to 5.6 for one positive finding, but increased to 13.6-25.1 for two or more. At least one positive CT finding was found to yield average sensitivity of 82% and specificity 59%, while two or more yielded sensitivity 46% and specificity 88%. CONCLUSION: While no individual CT finding is sufficiently accurate to diagnose or exclude PLC injury, greater the number of positive CT findings (VBT, PLF, ISW, and SPF), the higher the odds of PLC injury. The presence of a single abnormal CT finding may warrant confirmatory MRI for PLC injury, while two or more CT findings may have adequate specificity to avoid need for MRI prior to surgical intervention. These slides can be retrieved under Electronic Supplementary Material.

Does the novel lateral trauma position cause more motion in an unstable cervical spine injury than the logroll maneuver?

OBJECTIVE: Prehospital personnel who lack advanced airway management training must rely on basic techniques when transporting unconscious trauma patients. The supine position is associated with a loss of airway patency when compared to lateral recumbent positions. Thus, an inherent conflict exists between securing an open airway using the recovery position and maintaining spinal immobilization in the supine position. The lateral trauma position is a novel technique that aims to combine airway management with spinal precautions. The objective of this study was to compare the spinal motion allowed by the novel lateral trauma position and the well-established log-roll maneuver. METHODS: Using a full-body cadaver model with an induced globally unstable cervical spine (C5-C6) lesion, we investigated the mean range of motion (ROM) produced at the site of the injury in six dimensions by performing the two maneuvers using an electromagnetic tracking device. RESULTS: Compared to the log-roll maneuver, the lateral trauma position caused similar mean ROM in five of the six dimensions. Only medial/lateral linear motion was significantly greater in the lateral trauma position (1.4mm (95% confidence interval [CI] 0.4, 2.4mm)). CONCLUSIONS: In this cadaver study, the novel lateral trauma position and the well-established log-roll maneuver resulted in comparable amounts of motion in an unstable cervical spine injury model. We suggest that the lateral trauma position may be considered for unconscious non-intubated trauma patients.

The radiologic assessment of posterior ligamentous complex injury in patients with thoracolumbar fracture.

PURPOSES: To discuss whether radiologic parameters are closely related to posterior ligamentous complex (PLC) injury identified by magnetic resonance imaging (MRI). METHODS: One hundred and five thoracolumbar fracture (T11-L2) patients were retrospectively analyzed in the study. The patients were divided into different groups by the status of the PLC on MRI: intact, incompletely ruptured and ruptured. The radiographic parameters included the anterior edge-inferior endplate angle (AEIEA), the anterior edge displacement (AED), the Cobb angle (CA), the region angle (RA), the sagittal index (SI), local kyphosis (LK), the anterior/posterior vertebral height ratio (A/P ratio), the anterior vertebral height ratio (AVH ratio), and bony fragment in front of the fractured vertebra (BFOFV). T test, Pearson's Chi-square and multivariate logistic regression were calculated for the variables. RESULTS: Supraspinous ligament (SSL) rupture versus intact was not only associated with the occurrence of AEIEA <70°, LK >25° and BFOFV, but also with increased AED (9.89 ± 3.12 mm and 9.34 ± 3.36 mm, P = 0.034), RA (9.52 ± 3.93° versus 7.91 ± 3.99°, P = 0.042), and LK (23.98 ± 5.88° versus 15.55 ± 5.28°, P = 0.021). The indications for interspinous ligament (ISL) injury included AEIEA <75°, AEIEA <70° (P = 0.004 and P < 0.001, respectively), increased AED (P = 0.010), LK >25° (P = 0.024), AVH (P < 0.001), and BFOFV (P < 0.001). Multivariate logistic regression analysis revealed that AEIEA <70° and BFOFV were high risk factors for SSL rupture [standard partial regression coefficients (betas) were 0.439 and 0.408, P = 0.003 and 0.001, respectively] and ISL rupture (betas were 0.548 and 0.494, P = 0.028 and 0.001, respectively). Increased AED and LK >25° were also related to either ISL rupture (P = 0.035 and 0.001, respectively) or SSL rupture (P = 0.014 and 0.008, respectively). CONCLUSION: Our data may prove useful in a preliminary assessment of the PLC integrity based on plain radiographic imaging. We show that radiologic indications, such as AEIEA <70°, BFOFV, LK >25°, and increased AED, are correlated with ISL or SSL rupture, while RA, CA, SI, A/P ratio, and AVH ratio are not.

Another diagnostic tool in thoracolumbar posterior ligament complex injury: interspinous distance ratio.

PURPOSE: The increased interspinous distance ratio (ISDR) at the fracture site in plain X-ray is useful as an indicator of injury of the posterior ligament complex in thoracolumbar fractures. METHODS: 154 patients of thoracolumbar junctional fracture (T12, L1, L2) were subjects for this study. The sensitivity, specificity, accuracy of MRI was measured by comparing the surgery findings for the two analysis groups: one in which indeterminate cases were included in the intact group and another in which the indeterminate cases were included in the ruptured group. Sensitivity, specificity, accuracy of ISDR (measured in lateral decubitus X-ray) were measured after dividing patients into 3 groups (110, 120, 130 % increased). RESULTS: MRI's sensitivity, specificity and accuracy were 70.8, 100, and 80.5 %, respectively, when the indeterminate was assumed to have intact PLC. After assuming the indeterminate to have ruptured PLC, sensitivity, specificity and accuracy were 99.1, 52.4, and 85.7 %, respectively. In 53 cases with indeterminate MRI reading, sensitivity, specificity and accuracy were 81.2, 76.2, and 79.2 % %, respectively. CONCLUSION: In this study, in cases where it was difficult to make a diagnosis of the injury in the posterior ligament complex, based on the interspinous distance ratio (ISDR) of 120 % measured in plain X-ray in a lateral decubitus position, the sensitivity was 81.3 %, the specificity was 76.2 %, and the accuracy was 79.2 %. Therefore, measuring the ISDR will be helpful in determining whether surgical treatment is required in patients with thoracolumbar injury.

Addition of lateral bending range of motion measurement to standard sagittal measurement to improve diagnosis sensitivity of ligamentous injury in the human lower cervical spine.

PURPOSE: This study examined the cervical spine range of motion (ROM) resulting from whiplash-type hyperextension and hyperflexion type ligamentous injuries, and sought to improve the accuracy of specific diagnosis of these injuries. METHODS: The study was accomplished by measurement of ROM throughout axial rotation, lateral bending, and flexion and extension, using a validated finite element model of the cervical spine that was modified to simulate hyperextension and/or hyperflexion injuries. RESULTS: It was found that the kinematic difference between hyperextension and hyperflexion injuries was minimal throughout the combined flexion and extension ROM measurement that is commonly used for clinical diagnosis of cervical ligamentous injury. However, the two injuries demonstrated substantially different ROM under axial rotation and lateral bending. CONCLUSIONS: It is recommended that other bending axes beyond flexion and extension are incorporated into clinical diagnosis of cervical ligamentous injury.

Prediction of posterior ligamentous complex injury in thoracolumbar fractures using non-MRI imaging techniques.

PURPOSE: We aimed to formulate a radiological index based on plain radiographs and computer tomography (CT) to reliably detect posterior ligamentous complex (PLC) injury without need for MRI. METHODS: Sixty out of 148 consecutive thoracolumbar fractures with doubtful PLC were assessed with MRI, CT and radiographs. PLC injury was assessed with the following radiological parameters: superior-inferior end plate angle (SIEA), vertebral body height (BH), local kyphosis (LK), inter-spinous distance (ISD) and inter-pedicular distance (IPD) and correlated with MRI findings of PLC injury. Statistical analysis was performed to identify the predictive values for the parameters to identify PLC damage. RESULTS: MRI identified PLC injury in 25/60 cases. The ISD and LK were found to be significant predictors of PLC injury. On radiographs the mean LK with PLC damage was 25.86° compared to 21.02° with an intact PLC (p = 0.006). The ISD difference was 6.70 mm in cases with PLC damage compared to 2.86 mm with an intact PLC (p = 0.011). In CT images, the mean LK with PLC damage was 22.96° compared to 18.44° with an intact PLC ( p = 0.019). The ISD difference was 3.10 mm with PLC damage compared to 1.62 mm without PLC damage (p = 0.005). CONCLUSIONS: On plain radiographs the presence of LK greater than 20 °(CI 64-95) and ISD difference greater than 2 mm (CI 70-97) can predict PLC injury. These guidelines may be utilised in the emergency room especially when the associated cost, availability and time delay in performing MRI are a concern.

Correlations between posterior longitudinal injury and parameters of vertebral body damage.

BACKGROUND: The posterior longitudinal ligament (PLL) is an important structure of spinal stability. The loss of vertebral body height, local kyphosis (LK), and canal compromise may lead to spinal instability. This study determined the correlations between injury of the PLL and the loss of vertebrae height, kyphosis, and canal compromise. MATERIALS AND METHODS: A retrospective review of a thoracolumbar burst fracture database was conducted from January 2009 to December 2011. Patients were divided into an intact group and a disrupted group according to the status of the PLL. The loss of vertebral height, mid-sagittal canal diameter, and LK was measured. The anterior, middle, and posterior vertebral compression ratios (AVBCR, MVBCR, and PVBCR) and mid-sagittal diameter compression ratio (MSDCR) were calculated. RESULTS: Forty-seven patients were included in the study, including 25 patients in the intact group and 22 patients in the disrupted group. There were significant differences in the AVBCR (t = -3.048, P = 0.004), MVBCR (t = -2.301, P = 0.048), PVBCR (t = -2.116, P = 0.040), and MSDCR (t = -4.095, P = 0.000) but no difference in the LK (t = 0.408, P = 0.686) between the two groups. There was a positive correlation between the injury of the PLL and the MSDCR (r = 0.428, P < 0.01), AVBCR (r = 0.372, P < 0.01), and PVBCR (r = 0.271, P < 0.05). There was no correlation between the injury of the PLL and the LK and MVBCR. CONCLUSIONS: The MVBCR and LK are not predictive of a PLL injury. The MSDCR, AVBCR, and PVBCR were associated with a PLL injury.

Sensitivity and specificity of ultrasound in spinal trauma in 29 consecutive patients.

PURPOSE: Indication for surgery in spine trauma patients depends on the extent of destruction of the spine. Computer-assisted tomography scan (CAT scan) is not suitable to diagnose type B-injuries. Aim of the study was to investigate whether ultrasound is able to detect destruction of the posterior ligament complex (PLC). METHODS: Twenty-nine patients were included. The results of ultrasound were compared with magnetic resonance imaging (MRI), CAT scan, X-ray, intraoperative findings. Statistical analysis was carried out by an independent observer. RESULTS: In 27 cases both ultrasound and MRI had the same result. In two cases, ultrasound failed to detect ligamentous injury. The sensitivity of ultrasound was 0.82 (CI 0.48-0.98), its specificity: 1. MRI and Ultrasound findings had a strong positive correlation (phi = 0.85, Cohen's kappa: 0.85, with 95 % confidence interval 0.65-1) and a high significance (Fischer's exact test: p < 0.0001). CONCLUSION: Ultrasound may indicate rupture or integrity of PLC in cases where MRI is missing.

Efficacy of MRI for assessment of spinal trauma: correlation with intraoperative findings.

STUDY DESIGN: Observational diagnostic study on consecutive patients. OBJECTIVE: To assess the efficacy of magnetic resonance imaging (MRI) for detecting spinal soft tissue injury after acute trauma using intraoperative findings as a reference standard. SUMMARY OF BACKGROUND DATA: Recognizing injuries to spinal soft tissue structures is critical for proper decision making and management for blunt trauma victims. Although MRI is considered the gold standard for imaging of soft tissues, its ability to identify specific components of soft tissue damage in acute spine trauma patients is poorly documented and controversial. METHODS: Intraoperative findings were recorded for 21 acute spinal trauma patients (study group) and 14 nontraumatic spinal surgery patients (control group). Preoperative MRI's were evaluated randomly and blindly by 2 neuroradiologists. MRI and intraoperative findings were compared. By using the intraoperative findings as the reference standard, sensitivity, specificity, positive and negative predictive values of MRI in detecting spinal soft tissue injury were determined. RESULTS: MRI was 100% sensitive and specific in detecting injury to the anterior longitudinal ligament. MRI was moderately sensitive (80%) but highly specific (100%) for injury to the posterior longitudinal ligament. In contrast, MRI was highly sensitive but less specific in detecting injury to paraspinal muscles (100%, 77%), intervertebral disk (100%, 71%), and interspinous ligament (100%, 64%). MRI was moderately sensitive and specific in detecting ligamentum flavum injury (80% and 86.7%) but poorly sensitive for facet capsule injury (62.5%). CONCLUSIONS: MRI demonstrated high sensitivity for spinal soft tissue injuries. However, MRI showed a definite trend to overestimate interspinous ligament, intervertebral disk, and paraspinal muscle injuries. On the basis of these results, we would consider MRI to be a useful tool for spine clearance after trauma. Conversely, caution should be applied when using MRI for operative decision making due to its less predictable specificity.

Traumatic myelopathy: current concepts in imaging.

Traumatic myelopathy is a frequent complication after spinal trauma. The prognosis is often very poor, and the condition has important socioeconomic consequences. Knowledge of the epidemiology and imaging features is mandatory to ensure correct diagnosis and timely intervention. Imaging studies play an increasing role in the diagnosis and follow-up of this condition. Computed tomography remains the first-line investigation whenever spinal cord injury is suspected. It may indicate the presence of spinal cord lesions by visualizing vertebral lesions, but it cannot assess the spinal cord itself. Magnetic resonance imaging (MRI) can depict possible spinal cord edema, hemorrhage, or transection, and it is essential in diagnosing and predicting the outcome of spinal cord injury. Follow-up should also be performed with MRI to evaluate long-term intramedullary changes. Diffusion-weighted imaging and diffusion tensor imaging are promising new techniques that allow very early detection of spinal cord injury by measuring the diffusion within the spinal cord, thereby providing information on white matter integrity. However, technical limitations of these new techniques prompt further investigation to improve specificity.

Failure properties and damage of cervical spine ligaments, experiments and modeling.

Cervical spine ligaments have an important role in providing spinal cord stability and restricting excessive movements. Therefore, it is of great importance to study the mechanical properties and model the response of these ligaments. The aim of this study is to characterize the aging effects on the failure properties and model the damage of three cervical spine ligaments: the anterior and the posterior longitudinal ligament and the ligamentum flavum. A total of 46 samples of human cadaveric ligaments removed within 24-48 h after death have been tested. Uniaxial tension tests along the fiber direction were performed in physiological conditions. The results showed that aging decreased the failure properties of all three ligaments (failure load, failure elongation). Furthermore, the reported nonlinear response of cervical ligaments has been modeled with a combination of the previously reported hyperelastic and damage model. The model predicted a nonlinear response and damage region. The model fittings are in agreement with the experimental data and the quality of agreement is represented with the values of the coefficient of determination close to 1.

Severe sprains of the sub-axial cervical spine in adolescents: a diagnostic and therapeutic challenge: a report of three cases.

BACKGROUND: Sub-axial cervical spine(C spine) distraction flexion injuries, known as cervical sprains, have been divided into either "benign" or "severe" sprains depending on the integrity of the posterior longitudinal ligament (PLL) of the spinal column. It is a very uncommon injury and rarely reported in the literature. Most of the reports in the literature discuss this injury in the adult age group and so the adolescent age group was also considered to follow the same model of progression of mechanical instability depending on the degree and extent of structures injured, including the PLL as a cutoff factor between a "stable" and an "unstable" injury. PATIENTS AND METHODS: We report three cases of adolescents with severe cervical sprains at the C2-C3 level and argue the integrity of PLL as a determinant factor in the sagittal stability of the C spine in this age group.

Clinical applicability of magnetic resonance imaging in acute spinal cord trauma.

PURPOSE: To assess the clinical application of magnetic resonance imaging (MRI) in patients with acute spinal cord trauma (SCT) according to the type, extension, and severity of injury and the clinical-radiological correlation. METHODS: Diagnostic imaging [computed tomography (CT) and MRI] tests of 98 patients with acute SCT were analyzed to assess their clinical diagnostic value. The following radiological findings of SCT were investigated: vertebral compression fractures, bursts and dislocations, posterior element fractures, C1 and C2 lesions, vertebral listhesis, bone swelling, spinal canal compression, disk herniation, extradural hematoma, spinal cord contusions, spinal cord swelling, and posterior ligamentous complex (PLC) injuries. RESULTS: The radiological findings were better visualized using MRI, except for the posterior elements (p = 0.001), which were better identified with CT. A total of 271 lesions were diagnosed as follows: 217 using MRI, 154 using CT, and 100 (36.9 %) using both MRI and CT. MRI detected 117 more lesions than CT. CONCLUSION: MRI was significantly superior to CT in the diagnosis of bone swelling, PLC injury, disk herniation, spinal canal compression, spinal cord contusion and swelling present in SCT. MRI detected a larger number of lesions than CT and is highly useful for the diagnosis of soft tissue and intrathecal injuries.

Usefulness of MRI detection of cervical spine and brain injuries in the evaluation of abusive head trauma.

BACKGROUND: In the evaluation of children younger than 3 years with intracranial hemorrhage it can be difficult to determine whether the cause of hemorrhage was traumatic, and if so, whether abusive head trauma (AHT) is a possibility. Cervical spine MRI is not a routine part of the nationally recommended imaging workup for children with suspected abusive head trauma. There is increasing evidence that spinal injuries are found at autopsy or MRI in abused children. However the prevalence of cervical spine injuries in children evaluated for abusive head trauma is unknown. We sought to determine both the incidence and the spectrum of cervical spine and brain injuries in children being evaluated for possible abusive head trauma. We also examined the relationship between cervical and brain MRI findings and selected study outcome categories. MATERIALS AND METHODS: This study is a 3-year retrospective review of children evaluated for abusive head trauma. Inclusion criteria were: children with head trauma seen at our institution between 2008 and 2010, age younger than 36 months, availability of diagnostic-quality brain and cervical spine MRI, and child abuse team involvement because abusive head trauma was a possibility. A child abuse pediatrician and pediatric radiologists, all with board certification, were involved in data collection, image interpretation and data analysis. Statistical analysis was performed using Stata v12.1. RESULTS: The study included 74 children (43 boys, 31 girls) with a mean age of 164 days (range, 20-679 days). Study outcomes were categorized as: n = 26 children with accidental head trauma, n = 38 with abusive head trauma (n = 18 presumptive AHT, n = 20 suspicious for AHT), and n = 10 with undefined head trauma. We found cervical spine injuries in 27/74 (36%) children. Most cervical spine injuries were ligamentous injuries. One child had intrathecal spinal blood and two had spinal cord edema; all three of these children had ligamentous injury. MRI signs of cervical injury did not show a statistically significant relationship with a study outcome of abusive head trauma or help discriminate between accidental and abusive head trauma. Of the 30 children with supratentorial brain injury, 16 (53%) had a bilateral hypoxic-ischemic pattern. There was a statistically significant relationship between bilateral hypoxic-ischemic brain injury pattern and abusive head trauma (P < 0.05). In addition, the majority (81%) of children with bilateral hypoxic-ischemic brain injuries had cervical injuries. CONCLUSION: Although detection of cervical spine injuries by MRI does not discriminate between accidental and abusive head trauma, it can help to distinguish a traumatic from non-traumatic intracranial subdural hemorrhage. Cervical MRI should be considered in children with acute intracranial bleeds and otherwise non-contributory history, physical examination and ophthalmological findings. There is a statistically significant relationship between diffuse hypoxic-ischemic brain injury patterns and abusive head trauma. The high incidence of cervical injuries in children with hypoxic-ischemic injuries suggests a causal relationship. Overall, increased utilization of brain and spine MRI in children being evaluated for abusive head trauma can be helpful.

Spinal cord avulsion in the pediatric population: case study and review.

Spinal cord injury without radiographic abnormality (SCIWORA) is a rare phenomenon, but with advances in imaging and improvements in magnetic resonance imaging more cases are being identified. Even more uncommon is the finding of spinal cord avulsion as a type of SCIWORA with only single case reports in the literature. We present the case reports of 2 patients both experiencing spinal cord avulsion as a type of SCIWORA, secondary to improper lap-belt restraint during a motor vehicle accident.

An elderly woman with increasing dyspnoea after a fall.

An otherwise healthy 92-year-old woman was admitted to our department with shortness of breath and dysphagia 10 h after a fall in her bathroom. Medical checkup at another institution had not uncovered the causation of the complaints. Clinical and radiological examinations at our department then revealed an expanding retropharyngeal and prevertebral haematoma. Because of increasing dyspnoea, a lateral cervical approach was used to remove the haematoma and to achieve haemostasis. The authors could demonstrate that the source of bleeding was a minor injury of the anterior longitudinal ligament. Retropharyngeal haematoma is a potentially life-threatening condition because it can rapidly progress to airway obstruction. Large retropharyngeal haematoma after minor blunt head and neck trauma is not a well-recognised condition. This case, however, illustrates that precarious retropharyngeal haematoma can occur after low-energy trauma even without anticoagulation therapy. A high index of suspicion for this airway collapse is advisable in older patients.

[Ultrasound examination of the posterior ligament complex in thoracolumbar spinal fractures]. / Ultraschall zur beurteilung des posterioren ligamentkomplexes bei thorakolumbalen wirbelsäulenfrakturen.

BACKGROUND: thoracolumbar distraction injuries (AO classification type B) with damage to the posterior ligament complex (PLC) represent an indication for surgery but the use of X-ray and CT imaging often does not identify injuries of the PLC. The aim of this study was to evaluate the accuracy of ultrasound imaging in the assessment of the PLC status in thoracolumbar fractures of the spine. MATERIAL AND METHODS: in a prospective study the findings of the preoperative ultrasound examination were compared to the intraoperative findings. RESULTS: over a period of 2 years a total of 24 patients with 27 thoracolumbar fractures (18 type A, 9 type B) were examined. In 22 cases ultrasound examination was possible and correct ultrasound findings were made in 20 cases (91%). The sensitivity was 83.3%, specificity 93.8%, positive predictive value 83.3% and negative predictive value 93.8%. CONCLUSION: the use of ultrasound examination in thoracolumbar fractures is a suitable diagnostic tool for injuries of the posterior ligament complex in addition to radiological imaging.

A 92-year-old man with retropharyngeal hematoma caused by an injury of the anterior longitudinal ligament.

Traumatic retropharyngeal hematoma is a rare condition and may be lethal in some cases. In patients with this condition, the absence of a vertebral fracture or a major vascular injury is extremely rare. We present the case of a 92-year-old man who hit his forehead by slipping on the floor in his house. He had no symptoms at the time; however, he experienced throat pain and dyspnea at 6 hours after the injury. On arrival, he complained of severe dyspnea; therefore, an emergency endotracheal intubation was performed. A lateral neck roentgenogram after intubation showed dilatation of the retropharyngeal and retrotracheal space and no evidence of a cervical vertebral fracture. Cervical computed tomography (CT) with contrast medium revealed a massive hematoma extending from the retropharyngeal to the superior mediastinal space but no evidence of contrast medium extravasation or a vertebral fracture. However, sagittal magnetic resonance imaging (MRI) revealed an anterior longitudinal ligament (C4-5 levels) injury. We determined that the cause of the hematoma was an anterior longitudinal ligament injury and a minor vascular injury around the injured ligament. Therefore, we recommend that patients with retropharyngeal hematoma undergo sagittal cervical MRI when roentgenography and CT reveal no evidence of injury.