Unión cráneo-cervical - anatomía normal y correlación con imágenes / Cranio Cervical Junction - Anatomy and Imaging Correlation

La solicitud de estudios de imagen en pacientes con trauma cervical es muy frecuente en la práctica diaria. Esa patología es causa relativamente frecuente de discapacidad en pacientes jóvenes junto con el trauma encéfalo craneano. En un porcentaje no despreciable de los casos, las lesiones traumáticas comprometen la unión cráneo- cervical y en esos pacientes, la morbi-mortalidad es más significativa. La transición entre el cráneo y el raquis se basa en un conjunto de estructuras óseas relacionadas por articulaciones muy móviles y estabilizadas por un grupo de ligamentos y músculos que le brindan al mismo tiempo gran solidez. Para una correcta interpretación de los estudios de imagen de uso corriente en la clínica, es fundamental un sólido conocimiento anatómico de la unión cráneo-cervical y sus componentes. Es el objetivo de esta revisión, sistematizar la anatomía de la unión cráneo-cervical con especial énfasis en sus ligamentos, analizar la fisiología de sus movimientos y el concepto de estabilidad para luego realizar una correlación con tomografía computada multi-detector y resonancia magnética.

The request of imaging techniques in patients with cervical spine trauma is very common in clinical practice. Cervical trauma is a relatively common cause of disability in young patients. In a significant percentage of cases traumatic injuries compromise the cranio-cervical junction with more important morbidity and mortality in this group of patients. The transition between the skull and the spine is based on a set of bony structures, high mobility joints, and stabilization mechanism formed by a group of ligaments and muscles. A solid anatomical knowledge of the cranio-cervical junction and its components is essential for a correct interpretation of current high resolution imaging studies. The goal of this review is highlight the anatomy of the cranio-cervical junction with special emphasis on the ligaments, analyze the biomechanics of their movements and the concept of stability. At last but not leastwe will establish a correlation with multidetector computed tomography and high-resolutionmagnetic resonance imaging.

A importância dos exames neurológico e radiográfico no diagnóstico de lesões cervicais em equino: relato de caso / Fundamentals of neurological and radiographic examination on diagnosis of cervical lesions of a horse: case report

As lesões vertebrais cervicais são relativamente comuns nos equinos. No entanto, são poucas as descrições a respeito desse tema na literatura. Acredita-se que esse fato se deva, em parte, às limitações relacionadas ao diagnóstico. Em virtude de um traumatismo cervical, o animal pode apresentar sinais clínicos de paresia e paraplegia até tetraparesia ou tetraplegia, que podem culminar em estado comatoso e, eventualmente, em morte. Esses sinais clínicos podem ser detectados no exame físico, porém, quando associado à imaginologia (avaliação radiográfica), permite a obtenção de diagnóstico mais preciso da lesão. Consequentemente, um prognóstico mais adequado pode ser estabelecido para o paciente. Em face do exposto, apresenta-se o caso de uma égua Mangalarga, de quatro anos de idade, com sinais de tetraplegia pós-trauma, aumento de tônus muscular e paralisia espástica, com hiperreflexia, nos quatros membros. Por meio dos exames neurológicos realizados na paciente, em associação com as imagens radiográficas convencionais e contrastadas, foi possível estabelecer o diagnóstico do quadro. O animal apresentava lesões envolvendo as duas primeiras vértebras cervicais, atlas (C1) e áxis (C2), e a quinta e a sexta vértebra (C5-C6), destacando fratura de C1, deslocamento do dente de C2 e subluxação entre C5 e C6, com compressão ventrodorsal da medula espinhal. Confirmadas as suspeitas neurológicas e mediante prognóstico desfavorável, o animal foi submetido à eutanásia, com consentimento do proprietário. As lesões observadas nas imagens radiográficas foram confrontadas e confirmadas na necropsia.(AU)

Cervical vertebral lesions are relatively common in equine patients, but its diagnosis seems challenging for the clinician. Clinical signs most commonly associated with this clinical feature are paresis, paraplegia, tetraparesis, tetraplegia, which may lead the patient to a comatose state, and even death. Fortunately, these clinical signs can be perceived during physical examination. All of which, alongside imaging techniques, may allow a precise diagnose of the location of lesions and prediction of a prognosis for the patient. We present a case report of a Mangalarga mare, with four years of age, presenting signs of post-traumatic tetraplegia with spastic paralysis with increased muscular tonus and hyperreflexia in all four limbs. A thorough neurological examination of the patient associated with conventional and contrast medium radiographic imaging of the cervical region identified lesions at the atlas (C1) and axis (C2, and fifth (C5) and sixth (C6) cervical vertebrae. Fracture of the atlas vertebrae, dislocation of the axis' dens as well as subluxation of C5-C6 causing ventrodorsal medullary compression of the spinal cord were diagnosed radiographically. Due to the extent of the lesions the animal was euthanatized with the owner's consent. All lesions identified radiographically were posteriorly confirmed during post-mortem examination.(AU)

Evaluation of the use of tomography in penetrating neck trauma / Avaliação da utilização da tomografia computadorizada no trauma cervical penetrante

ABSTRACTObjective:the study has the intention of evaluate the accuracy of computed tomography for the diagnosis of cervical lesions on penetrating neck trauma and also identify the most frequent mechanisms of trauma. Most injured structures, determine the age range and the most prevalent sex.Methods: observational descriptive retrospective study executed by the systematic retrospective review of medical records of all patients victims of penetrating neck trauma that went through surgery and CT scans, admitted into Hospital do Trabalhador, between January 2009 and December 2013.Results:the final sample was of 30 patients, 96.7% of the male sex, the median age was of 28 years old. Most patients suffered injuries by gun (56.7%) and 33,3% suffered stab wounds. The most stricken area of the neck was Zone II (77.8%) and the left side (55.2%). Regarding the structures injured, the CT showed 6.7% lesions on airways but the surgery showed 40% of damaged, with a value of p=0.002. As to damages of the esophagus and pharynx the CT detected 10% of lesions, while surgery found 30% of lesions, therefore with a significant value of p=0.013. As for the analysis the CT showed reliable. As for the analysis of vascular damage, the CT showed to be, in most cases, reliable to the findings during the surgical act.Conclusion:besides the great use of CT for the diagnosis of penetrating neck injuries we can say that this is an exam with low accuracy for the diagnosis of lesions of aerodigestive tract, therefore it is important a clinical correlation for a good diagnosis.as for the vascular lesions and of other structures, the CT had high sensibility and specificity, thus a good exam to be used in overall.

RESUMOObjetivo:avaliar a acurácia da tomografia computadorizada no diagnóstico de lesões do trauma cervical penetrante.Métodos:estudo retrospectivo descritivo observacional realizado através da revisão de prontuários de todos os pacientes vítimas de trauma cervical penetrante que foram operados e submetidos à tomografia computadorizada no pré-operatório.Resultados:a amostra final compreendeu 30 pacientes, sendo 96,7% do sexo masculino e a mediana de idade foi 28 anos. A maioria dos pacientes sofreu ferimento por arma de fogo (FAF) em 56,7% dos casos e 33,3% foram ferimentos por arma branca (FAB). A zona do pescoço mais acometido foi a zona II (77,8%) e no lado esquerdo (55,2%). Em relação às estruturas lesadas, a tomografia computadorizada (TC) mostrou 6,7% de lesões em vias aéreas e durante a operação encontrou-se 40% de alterações (p=0,002). A tomografia computadorizada detectou 10% de leões do esôfago e faringe, durante a operação encontrou-se 30% de lesões (p=0,013). Já, para análise de danos vasculares, a TC se mostrou, na maioria dos casos, fidedigna aos achados durante o procedimento operatório.Conclusão:apesar do grande uso da tomografia computadorizada no diagnóstico de lesões cervicais penetrantes, pode-se afirmar que este é um exame com baixa acurácia no diagnóstico de lesões de trato aerodigestivo, sendo importante uma correlação clínica para um bom diagnóstico. Já para lesões vasculares e de outras estruturas, a TC apresentou alto grau de sensibilidade e especificidade, sendo assim um bom exame a ser utilizado nesses casos.

The Relationship between Spinal Stenosis and Neurological Outcome in Traumatic Cervical Spine Injury: An Analysis using Pavlov's Ratio, Spinal Cord Area, and Spinal Canal Area

BACKGROUND: This study examined the relationship between four radiological parameters (Pavlov's ratio, sagittal diameter, spinal cord area, and spinal canal area) in patients with a traumatic cervical spine injury, as well as the correlation between these parameters and the neurological outcome. METHODS: A total of 212 cervical spinal levels in 53 patients with a distractive-extension injury were examined. The following four parameters were measured: Pavlov's ratio on the plain lateral radiographs, the sagittal diameter, the spinal cord area, and the spinal canal area on the MRI scans. The Pearson correlation coefficients between the parameters at each level and between the levels of each parameter were evaluated. The correlation between the radiological parameters and the spinal cord injury status classified into four categories, A (complete), B (incomplete), C (radiculopathy), and D (normal) was assessed. RESULTS: The mean Pavlov's ratio, sagittal diameter, spinal cord area and spinal canal area was 0.84, 12.9 mm, 82.8 mm2 and 236.8 mm2, respectively. An examination of the correlation between the radiological spinal stenosis and clinical spinal cord injury revealed an increase in the values of the four radiological parameters from cohorts A to D. Pavlov's ratio was the only parameter showing statistically significant correlation with the clinical status (p = 0.006). CONCLUSIONS: There was a correlation between the underlying spinal stenosis and the development of neurological impairment after a traumatic cervical spine injury. In addition, it is believed that Pavlov's ratio can be used to help determine and predict the neurological outcome.

Lesiones traumáticas del raquis cervical superior / Traumatic injuries of the upper cervical rachis

Se efectúa un análisis acerca de las lesiones del raquis cervical superior. Se estudiaron 30 pacientes atendidos en el Servicio de Neurocirugía del Hospital Universitario "General Calixto García", que constituyen el universo de casos que acudió con este tipo de lesión, en el período comprendido entre septiembre de 1996 y septiembre de 1999. Se describen características sociodemográficas, clínicas e imagenológicas de los pacientes. El síntoma dominante por excelencia fue el dolor occipito-cervical, y en la mayoría de los enfermos quedó intacto el funcionamiento neurológico. Se discuten los resultados y se ofrecen recomendaciones con vistas a contribuir a una utilización más eficiente de los recursos imagenológicos en el diagnóstico y tratamiento de estas afecciones(AU)

An analysis is made about the injuries of the upper cervical rachis. The 30 patients with this type of injury that received attention at the Neurosurgery Service of "General Calixto García" Teaching Hospital from September, 1996, to September, 1999, were included in the study. Sociodemographic, clinical and imgaing features of the patients are described. The predominant symptom was occipitocervical pain and in most of the patients the neurological functioning was intact. The results were discussed and recommendations were made to contribute to a more efficient use of the imaging resources in the diagnosis and treatment of these affections(AU)