Abusive Pediatric Thoracolumbar Fracture Due to Forced Hyperextension: Case Report, Biomechanical Considerations, and Review of the Literature.

Pediatric thoracolumbar fractures are rare due to the physiological differences which afford greater resilience to the immature spine. Most pediatric thoracolumbar fractures occur as the result of high energy trauma, such as motor vehicle accidents, and modes of reasonable accidental injuries are limited by age and developmental capabilities of the child. These fractures can occur as the result of inflicted blunt force trauma and child abuse, and in most cases, the mechanism of injury to the spine is not known. We report the death of a 29-month-old man due to blunt force trauma to the back and forced hyperextension of the thoracolumbar spine causing fracture of the fourth lumbar (L4) vertebral body. A complete forensic examination revealed a previous healing fracture of the anterior aspect of the L4 vertebral body, with acute disruption of the anterior longitudinal ligament overlying the fracture site, complete fracture of the vertebral body, and fatal retroperitoneal hemorrhage. We present a review of the biomechanical considerations of the pediatric spine, a survey of pediatric spinal fractures, and a review of the literature on pediatric abusive thoracolumbar fractures. In this case, there was never a provided explanation for how the injury occurred; however, understanding the biomechanics of the pediatric spine allowed for the determination of the mechanism, force required to produce this specific pattern of abusive spinal injury, and the manner of death.

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.

Effectiveness of posterior structures in the development of proximal junctional kyphosis following posterior instrumentation: A biomechanical study in a sheep spine model.

INTRODUCTION: Proximal junctional kyphosis - PJK has been defined by a 10 or greater increase in kyphosis at the proximal junction as measured by the Cobb angle from the caudal endplate of the uppermost instrumented vertebrae (UIV) to the cephalad endplate of the vertebrae 1 segments cranial to the UIV. In this biomechanical study, it is aimed to evaluate effects of interspinosus ligament complex distruption and facet joint degeneration on PJK development. MATERIALS AND METHODS: Posterior instrumentation applied between T2 - T7 vertebrae using pedicle screws to randomly selected 21 sheeps, divided into 3 groups. First group selected as control group (CG), of which posterior soft tissue and facet joints are protected. In second group (spinosus group, SG) interspinosus ligament complex which 1 segment cranial to UIV has been transected, and third group (faset group-FG) was applied facet joint excision. 25 N, 50 N, 100 N, 150 N and 200 N forces applied at frequency of 5 Hertz as 100 cycles axial to the samples. Then, 250 N, 275 N and 300 N forces applied static axially. Interspinosus distance, kyphosis angle and discus heights was measured in radiological evaluation. Abnormal PJK was defined by a proximal junctional angle greater than 100 and at least 100 greater than the corresponding preoperative measurement. RESULTS: In CG group, average interspinosus distance was 6,6 ± 1.54 mm and kyphosis angle was 2,2 ± 0.46° before biomechanical testing, and they were measured as 9,4 ± 1.21 mm and 3,3 ±0.44° respectively after forces applied to samples. In SG group, average interspinosus distance was 6,2 ± 1.72 mm and kyphosis angle was 2,7 ± 1.01° before experiment, and they were measured as 20,8 ± 5.66 mm and 15,1 ± 2.34° respectively after forces applied to samples. In FG group, average interspinosus distance was 4,8 ± 1.15 mm and kyphosis angle was -1 ± 4.14° before experiment, and they were measured as 11,1 ±1.96mm and 11 ± 2.87° respectively after forces applied to samples. In comparison to group CG, statistically significant junctional kyphosis was seen on both FG and SG group after statistical analysis. (p < 0.05). PJK was seen statistically significant more on SG group than FG group. (p < 0.05). Not any statistically significant difference was seen on measurement of disk distances among three groups. (p > 0.05) CONCLUSIONS: Protecting interspinosus ligament complex and facet joint unity during posterior surgical treatment for spine deformation is vital to prevent PJK development. Based on our literature review, this is the first biomechanical study that reveals interspinosus ligament complex are more effective on preventing PJK development than facet joints.

C2-C3 spinal fracture subluxation with ligamentous and vascular injury: a case report and review of management.

Introduction: Spinal cord injury is one of the leading causes of paralysis and permanent morbidity. High cervical spine injuries, in particular, have the potential to be fatal and debilitating due to injury to multiple components, including but not limited to, discoligamentous disruption, vascular insult and spinal cord injury. To date, no unifying algorithm exists making it challenging to guide treatment decisions. Case presentation: We present the case of a 29-year-old polytrauma patient with an unstable C2-C3 fracture subluxation secondary to hyperextension and rotation injury with complete ligamentous dissociation and vertebral artery dissection after a high-velocity injury. We review the literature on injury patterns, associated complications and neurological outcomes in subaxial cervical spine injuries. Discussion: Our patient's injuries had several components including fracture subluxation, ligamentous disruption, central cord syndrome, and vascular insult. The lack of a unifying algorithm to guide treatment decisions highlights the variations in pathology and subsequent limitations in generalizability of current literature. Our patient underwent an open anterior C2-C3 reduction and discectomy with fusion and plating and a subsequent C2-C4 posterior instrumented fusion. The patient regained some motor function postoperatively and through rehabilitation. Careful consideration of multiple components is crucial when treating subaxial spine injuries.

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.

Quantitative T2-Mapping and T2⁎-Mapping Evaluation of Changes in Cartilage Matrix after Acute Anterior Cruciate Ligament Rupture and the Correlation between the Results of Both Methods.

OBJECTIVES: To quantitatively assess changes in cartilage matrix after acute anterior cruciate ligament (ACL) rupture using T2- and T2⁎-mapping and analyze the correlation between the results of both methods. METHODS: Twenty-three patients and 23 healthy controls were enrolled and underwent quantitative MRI examination. The knee cartilage was segmented into six compartments, including lateral femur (LF), lateral tibia (LT), medial femur (MF), medial tibia (MT), trochlea (Tr), and patella (Pa). T2 and T2⁎ values were measured in full-thickness as well as superficial and deep layers of each cartilage compartment. Differences of T2 and T2⁎ values between patients and controls were compared using unpaired Student's t-test, and the correlation between their reciprocals was analyzed using Pearson's correlation coefficient. RESULTS: ACL-ruptured patients showed higher T2 and T2⁎ values in full-thickness and superficial layers of medial and lateral tibiofemoral joint. Meanwhile, patients exhibited higher T2⁎ values in deep layers of lateral tibiofemoral joint. The elevated percentages of T2 and T2⁎ value in superficial LT were most significant (20.738%, 17.525%). The reciprocal of T2⁎ value was correlated with that of T2 value (r = 0.886, P < 0.001). CONCLUSION: The early degeneration could occur in various knee cartilage compartments after acute ACL rupture, especially in the superficial layer of LT. T2⁎-mapping might be more sensitive in detecting deep layer of cartilage than T2-mapping.

The Relationship between Superior Disc-Endplate Complex Injury and Correction Loss in Young Adult Patients with Thoracolumbar Stable Burst Fracture.

BACKGROUND: To determine the relationship between superior disc-endplate complex injury and correction loss after surgery in a group of young adult patients with a stable thoracolumbar burst fracture. METHODS: The study group was comprised of young adult patients who had undergone short-segment posterior fixation and bone grafting under the diagnosis of a stable thoracolumbar burst fracture from March 2008 to February 2014. Follow-up was available for more than 1 year. Before surgery, magnetic resonance imaging was performed to determine injury to the anterior longitudinal ligament, posterior longitudinal ligament, and superior and inferior intervertebral discs and endplates. Correction loss was evaluated by the Cobb angle, intervertebral disc height, upper intervertebral disc angle, vertebral wedge angle, and vertebral body height. RESULTS: No significant relation was noted between correction loss and an injury to the anterior longitudinal ligament, posterior longitudinal ligament, inferior intervertebral disc/endplate, and fracture site, whereas an injury to the superior endplate alone and superior disc-endplate complex showed a significant association. Specifically, a superior intervertebral disc-endplate complex injury showed statistically significant relation to postoperative changes in Cobb angle (p = 0.026) and vertebral wedge angle (p = 0.047). CONCLUSIONS: A superior intervertebral disc-endplate complex injury may have an influence on the prognosis after short-segment fixation in young adult patients with a stable thoracolumbar burst fracture.

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.

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.

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.

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.

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.

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.

Delayed presentation of a cervical spine fracture dislocation with posterior ligamentous disruption in a gymnast.

Cervical spine injuries are uncommon but potentially devastating athletic injuries. We report a case of a girl gymnast who presented with a cervical spine fracture dislocation with posterior ligamentous disruption several days after injury. To our knowledge, this type of presentation with such severity of injury in a gymnast has not been reported in the literature. The patient was performing a double front tuck flip and sustained a hyperflexion, axial-loading injury. She experienced mild transient numbness in her bilateral upper and lower extremities lasting for about 5 minutes, after which it resolved. The patient was neurologically intact during her clinic visit, but she endorsed significant midline cervical tenderness. Plain radiographs and computed tomography imaging of the cervical spine revealed a C2-C3 fracture dislocation. She underwent posterior open reduction followed by C2-C3 facet arthrodesis and internal fixation. This case highlights the importance of very careful evaluations of neck injuries and the maintenance of high suspicion for significant underlying pathology.

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.

Fatal child abuse presenting with multiple vertebral and vascular trauma.

This case study involves the unexplained death of a previously healthy 30-month-old child. Reportedly, she was found unresponsive by her foster father following a 2-hour nap. She was transported to the hospital and died in the emergency room of unknown causes. Blood drawn in the ER showed hemoglobin of 4.3 mg/dL. Postmortem skeletal survey, magnetic resonance imaging (MRI) of the brain, and retinal examinations were negative. The medical examiner assumed jurisdiction of the body. The autopsy showed massive retroperitoneal hemorrhage, transections of the abdominal aorta, and inferior vena cava, and complete tears of the anterior longitudinal ligament of the spine at C5/C6 and L1/L2 with diastases of the vertebral bodies at the corresponding intervertebral disk spaces. The case is believed to be extraordinary due to both the extent of injury that does not match the reported history and the mechanism of vertebral and vascular injuries.

Traumatic rupture of the neurocentral synchondrosis of the axis in a child.

The authors report the first case of unilateral traumatic rupture of the C-2 neurocentral synchondrosis. A 26-month-old child was in a vehicular collision that caused his head to be rotated sharply to the left with the neck flexed. He had severe neck pain but was neurologically normal. Computerized tomography scanning showed rupture of the left C-2 neurocentral synchondrosis, a right C-2 pars interarticularis fracture, and anterior angulation of C-2 on C-3. The neck injury was unrecognized until postinjury Day 9 when an MRI study showed a tear of the posterior longitudinal ligament at C2-3 and separation of the C-2 body from the inferior anular epiphysis. A second CT showed widening of the synchondrosis fracture, increased angulation of C-2 on C-3, and distraction of the right C-2 pars fracture. The mechanism of the neurocentral synchondrosis fracture is thought to be hyperflexion-axial loading combined with leftward rotation, which provided the lateral force that overcame the cartilaginous synchondrosis and extruded the lateral mass. The patient underwent open reduction and posterior fusion of C1-3, and was maintained in a halo jacket for 4 months, when CT scans demonstrated solid C1-C3 fusion and ossification of the injured synchondrosis. Unilateral traumatic rupture of the C-2 neurocentral synchondrosis is one component of several injuries involving C-2 sustained before synchondrosis closure. The resulting C2-3 relationship is highly unstable. Reduction and C1-C3 fusion are necessary in patients with significant displacement of the adjacent bony units.