Cervical spine injuries in suicidal hanging without a long-drop—patterns and possible underlying mechanisms of injury: an autopsy study

Objectives

The incidence of cervical spine injuries in suicidal hangings with a short-drop has been reported to be extremely low or non-existent. The aim of this study was to determine the frequency and pattern of cervical spine injuries in suicidal hanging.

Methods

A retrospective autopsy study was performed and short-drop suicidal hanging cases with documented cervical spine injuries were identified. This group was further analyzed with regard to the gender and age of the deceased, the position of the ligature knot, the presence of hyoid–laryngeal fractures, and the level of cervical spine injury.

Results

Cervical spine injuries were present in 25 of the 766 cases, with an average age of 71.9 ± 10.7 years (range 39–88 years). In 16 of these 25 cases, the ligature knot was in the anterior position. The most common pattern of cervical spine injury included partial or complete disruption of the anterior longitudinal ligament and widening of the lower cervical spine disk spaces, associated with absence of hyoid–laryngeal fractures.

Conclusions

Cervical spine injuries are not commonly found in short-drop suicidal hanging, occurring in only 3.3 % of all observed cases. Cervical spine injury may be occurring in 80 % of subjects aged 66.5 years and above. The most common pattern of cervical spine injury included anterior longitudinal ligament disruption of the lower cervical spine, disk space widening, and no vertebral body displacement. These injuries were mainly associated with an anterior knot position, and may be a consequence of loop pressure to the posterior neck and cervical spine hyperextension.     

经皮穿刺颈椎间盘切除术对山羊颈椎稳定性影响的实验研究

目的 探讨经皮穿刺颈椎间盘切除（ＰＣＤ）对颈椎稳定性的影响。方法 成年山羊１０只,经皮髓核切除：Ｃ３￣４７只,Ｃ４￣５３只。术前及术后均作颈椎矢、冠、轴位ＭＲＩ及摄正侧位Ｘ线片,并分别测量手术椎间盘的高度及其相邻椎体的成角及位移情况。对以上术前与术后的测量数据,运用统计学检验方法进行ｔ检验。结果 ＰＣＤ术后,７例（７０％）手术部位椎间隙明显变窄;５例（５０％）出现骨质增生,４例（４０％）椎间盘膨出     

Are cervical spine radiograph examinations useful in patients with low clinical suspicion of cervical spine fracture? An experience with 254 cases

Trauma patients with low clinical suspicion of cervical spine fracture are often examined with a plain X-ray cervical spine series rather than with cervical spine computed tomography (CT). The authors have been concerned by the absence of fractures in the group of patients examined with plain X-ray. The objective of this investigation was to determine the usefulness of plain X-ray examinations in suspected cases of cervical spine fracture compared to CT. A retrospective review was performed of all trauma patients undergoing imaging for suspected cervical spine fracture in our Emergency Department over a one-year period (January 1, 2007 to December 31, 2007). During the study period, 254 cervical spine plain X-ray and 3,080 cervical spine CT examinations were performed. Of the 254 plain X-ray examinations, 237 were interpreted as negative for fracture, 11 were suboptimal examinations, and six were interpreted as possible fractures (later ruled out by further imaging). Of the 3,080 CT examinations, 2,884 were interpreted as negative for fracture and 196 as positive. The overall positivity rates for acute cervical spine fracture were 0.0% in plain X-ray and 6.4% in CT examinations. These data confirm the authors’ concern that plain X-ray imaging for patients with low clinical suspicion for cervical spine trauma in our hospital may have too low a yield to justify its use. However, the 6.4% positivity rate in the group of patients selected for CT examination justifies its use in this group.     

颈椎前路手术中相关神经损伤并发症的常见原因及治疗

目的 回顾颈椎前路手术中相关神经损伤的常见原因及治疗方法.方法 2008年1月-2009年12月手术治疗859例颈椎病、颈椎后纵韧带骨化症及颈椎外伤行颈椎前路手术患者,对术后出现脊髓损伤症状加重及相关神经损伤的7例患者的临床资料进行回顾性分析.结果 859例患者中共5例发生脊髓损伤,发生率为0.58%;1例发生喉返神经损伤,发生率为0.12%;1例发生喉上神经损伤,发生率为0.12%.术后血肿发生脊髓损伤4例,经过清除血肿、甲基强的松龙等药物、高压氧及时治疗,均逐渐恢复至正常;术后发生脊髓损伤症状加重1例,经气管切开、呼吸机支持治疗及激素、高压氧治疗后脊髓损伤症状逐渐恢复至原有水平.术后发生喉返神经、喉上神经损伤患者2例经过激素、脱水等药物保守治疗,术后3个月内均恢复至正常.结论 颈椎病、颈椎后纵韧带骨化症及颈椎外伤患者行颈椎前路手术中均可能发生脊髓损伤及相关神经损伤,如能注意预防和及时治疗,预后较好.

Abstract：

Objective To review the relevant causes for and treatment of nerve injuries in the anterior cervical surgery. Methods From January 2008 to December 2009,859 cages of cervical spondylosis,ossification of cervical posterior longitudinal ligament and cervical spine trauma were treated by anterior cervical surgery.This study retrospectively analyzed the clinical data of seven cases who were with worsened symptoms of spinal cord injury and related nerve injury. Results Of 859 cases,five cases(0.58%)were with spinal cord injury,one(0.12%)with recurrent laryngeal nerve injury and one (0.12%)with laryngeal nerve injury.Hematoma occurred in four cases after surgery caused spinal cord injury and all the four patients recovered to normal after removal of the hematoma and timely treatment with mythylprednisolone and hyperbaric oxygen.Cervical spine trauma was worsened in one patient after the anterior cervical surgery.The patient restored to its original level of spinal cord gradually through some measures such as tracheotomy,ventilator support,hormone therapy and hyperbaric oxygen treatment.Laryngeal nerve injuries in two cases recovered to normal after conservative treatment with hormone,dehydration and other drugs within three months after surgery. Conclusions Anterior cervical surgery of cervical spondylosis,ossification of cervical posterior longitudinal ligament and cervical spine trauma are likely to induce the related nerve damage.The good prognosis can be obtained under timely prevention and treatment.     

空军招飞体检颈椎X线检查异常情况分析及建议

目的 异常中,曲度反向占颈椎异常的30.6%,合并其他异常占43.3%.序列异常占20.5%,发育异常占34.7%,骨质增生占6.8%. 结论 颈椎异常常引发颈肩不适、头痛、眩晕和晕厥等诸多临床症状,对飞行人员健康造成危害,甚至危及飞行安全.在招飞体检时,颈椎异常除单纯颈椎曲度直外,其他颈椎曲度反向、序列异常、骨质增生、寰椎沟环、颈椎融合、颈肋及颅底凹陷均应确定为不合格.     

CT of the spine: are plain spine radiographs necessary?

This study was designed to determine whether plain radiographs added any information of clinical significance to the information provided by CT (computed tomography) and its standard digital radiographs in 100 patients presenting for CT of the lumbar spine and 46 patients presenting for cervical spine CT. In only three (3%) of the lumbar studies and two (4.3%) of the cervical studies did the plain radiographs add diagnostic information. The added diagnostic information did not affect patient management in all cases with indications other than trauma. Good quality oblique cervical spine digital radiographs were obtained in 10 cases simply by moving the tube and detectors to the 45 degrees and 135 degrees azimuths. The evidence from this study suggests that when a CT examination of lumbar or cervical spines is planned on a high resolution CT scanner for indications other than trauma, a conventional plain radiographic examination can be omitted in the first instance.     

无脊髓损伤的颈椎骨折脱位临床研究

目的探讨无脊髓损伤的颈椎骨折脱位的发病机制及手术治疗方法。方法 32例无脊髓损伤的颈椎骨折或骨折脱位,其中新鲜损伤26例,陈旧性损伤6例。其中28例手术治疗,4例非手术治疗。结果术后全部病例均获随访观察,26例完全恢复,6例残留手指麻木和局部不适。植骨在3个月内牢固融合。颈椎椎间高度、生理曲度维持良好,无断钉及断板等并发症。结论对于无脊髓损伤的颈椎骨折脱位发病机制特殊,手术治疗可使不稳的颈椎获得即刻的稳定性,有效地防止脊髓的继发性损伤。     

颈前路钢板联合钛网或椎间融合器在颈椎前路减压融合中的应用

目的探讨颈前路钢板联合钛网或椎间融合器(cage)内固定在治疗颈椎创伤、脊髓型颈椎病等疾病中的作用和疗效。方法回顾分析2008年6月~2015年6月采用颈前路钢板内固定联合钛网植骨或椎间融合器(cage)植骨治疗的47例患者的临床资料,其中颈椎骨折28例,脊髓型颈椎病17例,颈椎滑脱9例,后纵韧带骨化2例。男性28例,女性19例;年龄22~69岁,平均50.2岁。结果本组47例均获随访,随访时间10~24个月,平均18个月;植骨均已融合,无内固定物松动,颈椎生理曲度存在,无椎间高度的丢失。患者神经功能均有不同程度恢复,JOA评分术前为7.6(3.3~10.9)分,术后6个月为10.8(7.5~14.9)分,改善率为(57.8±9.7)%;术后12个月为11.2(7.9~15.4)分,改善率为(59.8±9.5)%;术后6、12个月与术前比较差异有统计学意义(P0.01),术后6个月与12个月比较差异无统计学意义(P0.05)。影像学检查38例(80.1%)植骨患者植骨融合情况,结果显示无内固定物松动,颈椎生理曲度存在,无椎间高度的丢失。术后6个月47例全部植骨融合。结论颈前路钢板内固定联合钛网植骨或椎间融合器(cage)植骨,术后可即刻获得稳定,无需行石膏外固定,明显提高了植骨融合率。手术操作简单,并发症少,具有显著的优越性。     

Whiplash injuries of the cervical spine and Swiss insurance against accidents (author's transl)]

The indemnity for the consequences of a whiplash injury on the cervical spine by the Swiss Insurance against Accidents is discussed. The number of these cases can be only roughly extimated. We can calculate yearly with about 600 distortions of the cervical spine resulting from motoring accidents. The definition of the whiplash injury is defined on the base of recent German literature. The supposed mechanical assumptions for a lesion of the cervical spine are based mainly on the works of Erdmann (Frandfurt). The relations between the lesion of the cervical spine an the rebound injuries of the skull are discussed. The significance of the preexistent degenerative alterations of the cervical spine in the whiplash injury and the problem of the psychogenic superposition are presented by means of 46 observed cases.     

益脑推拿法对椎动脉型颈椎病患者颈椎生理曲度的影响

目的:观察益脑推拿法对椎动脉型颈椎病患者颈椎生理曲度的影响。方法:160例患者随机分为益脑推拿组(80例)和常规推拿组(80例),采用Borden氏法测量颈椎生理曲度,疗程结束后对两组患者颈椎生理曲度值的变化进行对照分析。结果:治疗后益脑推拿组、常规推拿组的颈椎生理曲度值分别为4.30±1.23 mm、3.55±1.82 mm,两组差别有显著性意义(t′=3.0309,P<0.05)。结论:改善或重建颈椎生理曲度可能是益脑推拿法治疗椎动脉型颈椎病的作用机制之一。     

A rarely recognized metastatic localization. Secondary involvement of the occipito-cervical joint

280 patients presenting osteophilic tumors were evaluated by conventional tomography of the cervical spine. Metastasis were found in 120 cases among which 70% had no symptoms. Axis was first concerned and sometimes lesions could not be detected on plain radiographs. Authors insist on the need of a systematic cervical spine tomographic study in patients with osteophilic tumors.     

颈椎过屈性损伤的MRI诊断

目的分析不同程度颈椎过屈性损伤的影像表现，评价ＭＲＩ表现的意义。方法３１例颈椎过屈性损伤，平均年龄３２岁，外伤史明确。全部病例在伤后不同时间行ＭＲＩ扫描，ＭＲＩ扫描前常规摄颈椎平片，部分行ＣＴ扫描。结果３１例中１７例伤及Ｃ４～６椎体，占５５％，同时累及２个椎体４例，占１３％。影像表现为棘突骨折、椎体前脱位、椎体宽界面压缩骨折、双侧关节突关节脱位、屈曲泪滴样骨折５种类型。ＭＲＩ同时显示２４例后部复合韧带撕裂，３例后纵韧带和５例前纵韧带撕裂，１６例椎间盘受压或碎裂变形，２３例颈髓受压、形态信号异常，其中３例横断。结论ＭＲＩ能反映不同程度不同方向的屈曲外力引起的颈椎和脊髓不同程度的病理变化，ＭＲＩ对脊髓、间盘、韧带等软组织损伤的评价，是判断不同程度颈椎过屈性损伤椎体稳定性及预后的依据。ＭＲＩ可反映颈椎过屈性损伤全部损伤机制及其病理基础     

Fracture detection in the cervical spine with multidetector CT: 1-mm versus 3-mm axial images

BACKGROUND AND PURPOSE: Multidetector CT imaging of the cervical spine performed with submillimeter collimation allows for the production of excellent quality multiplanar reformations and reconstructed axial images at any chosen section thickness. Currently there is no consensus on what images need to be reviewed for accurate diagnosis of cervical spine fractures. Our study assesses whether 1-mm axial images provide any diagnostic advantage over 3-mm images in detection of cervical spine fractures when read in conjunction with multiplanar reformations.MATERIALS AND METHODS: The dataset consisted 50 cases of CT of the cervical spine and included 25 consecutive cases of cervical spine fractures and 25 matched normal CTs. Axial images were reconstructed at 1- and 3-mm thicknesses, and the sagittal and coronal reformations between 2- and 3-mm thicknesses. Four radiologists reviewed all 50 of the cases twice, once at 1 mm and once at 3 mm. Reads were separated by 3 months.RESULTS: There were 39 fractures in total, consisting of 29 clinically significant and 10 insignificant fractures. Thirty-three fractures were missed in 400 reads. Twenty-one misses were at 3 mm (sensitivity, 86%), and 12 misses at 1 mm (sensitivity, 92%; P = .228). Ten of 33 misses were of clinically significant fractures, 6 misses at 1 mm and 4 at 3 mm (P = .52). Twenty-three of 33 misses were of clinically insignificant fractures, 6 at 1 mm and 17 at 3 mm (P = .006).CONCLUSION: For detection of clinically important fractures, there is no significant difference between 1- and 3-mm axial images when read in conjunction with multiplanar reformations.

Multidetector CT imaging of the cervical spine performed with submillimeter collimation allows for the production of excellent quality multiplanar reformations and reconstructed axial images at any chosen section thickness. The large image dataset and the ability to reconstruct a vast number of images leads to issues with data storage and time needed to review the examination. Currently there is no consensus on what images need to be reviewed for accurate diagnosis of cervical spine fractures. The standard in our institution is to read 1-mm axial images with sagittal and coronal reformations. The purpose of our study was to assess whether 1-mm axial images provide any diagnostic advantage over 3-mm images in the detection of cervical spine fractures when read in conjunction with multiplanar reformations, thereby providing objective data in the formulation of guidelines for the assessment of cervical spine CTs.     

Cervical spine injury in the very elderly

Background: Elderly patients are known to be at increased risk of cervical spine injuries. This propensity for injury becomes more important as the population of mobile elderly individuals increases. The present study seeks to examine the incidence and spectrum of spine injury among patients aged 80 years or greater, and to examine the efficacy of a decision rule for obtaining cervical spine radiography in this extreme age group. The decision rule would determine whether imaging could be avoided in patients who have none of the following: (1) posterior midline cervical spine tenderness; (2) focal neurological deficit; (3) abnormal level of alertness; (4) evidence of intoxication; or (5) clinically apparent distracting painful injury. Methods: All blunt trauma victims presenting to participating emergency departments underwent clinical evaluation prior to radiographic imaging. The elements of the decision rule were assessed and documented in each patient prior to radiographic imaging. The presence or absence of cervical spine injury was subsequently based on the final interpretation of all radiographic studies supplemented by a review of neurosurgical and risk management logs from each participating hospital. Data on all patients aged 80 years or greater were sequestered from the main database for separate analysis. Results: The study enrolled 34,069 individuals, including 818 patients (2.4 %) with cervical spine injuries. This population contained 1,070 patients (3.1 % of all cases) aged 80 or greater, 50 of whom (4.7 %) sustained cervical spine injuries. Injuries to the craniocervical junction (particularly C2 and the odontoid) accounted for 47.3 % of the injuries in the elderly, but only 28.6 % of injuries in younger patients. Older fracture victims were also likely to have more injuries (2.54 injuries/patient) than their younger counter parts (1.78 injuries/patient). The decision rule correctly identified all very elderly cervical spine injury victims [sensitivity 100.0 %; confidence interval (CI) 92.9–100.0 %], and designated 132 patients as “low-risk,” yielding a negative predictive value of 100.0 % (CI 97.3–100.0 %). Conclusions: The very elderly are at increased risked of cervical spine injury, particularly injury to the craniocervical junction. They also tend to have more extensive injuries than younger patients. Despite the increased risk of injury, the decision rule performed well in the very elderly, and allowed correct identification of all cervical spine injury victims.     

Evaluation of acute cervical spine imaging based on ACR Appropriateness Criteria?

The objectives of this study were to determine the rate of acute blunt cervical spine injury at an academic urban level 1 trauma center and to evaluate the utilization of cervical spine imaging based on the established American College of Radiology (ACR) Appropriateness Criteria?. We retrospectively reviewed all radiography and CT imaging of the cervical spine performed over a year period in adult patients presenting with acute blunt cervical spine trauma. Exclusion criteria were children ≤17 years, non-acute trauma of ≥72 h, and penetrating trauma. Any fracture, dislocation, or ligamentous instability demonstrated by diagnostic imaging and requiring stabilization or specialized follow-up was defined as clinically significant cervical spine injury. A total of 1,325 cervical spine studies were reviewed in 1,245 patients; 32.7% (433/1,325) were cervical spine radiographs and 67.3% (892/1,325) were CT examinations. Approximately 1.5% (19/1,245) of the patients demonstrated clinically significant acute cervical spine injury. There were 6.4% (80/1,245) patients who received both cervical spine radiographs and CT as imaging evaluation. Based on the ACR Appropriateness Criteria?, all of the cervical spine radiographs performed (433) were determined to be “inappropriate” imaging in the setting of acute cervical spine injury.     

CT在颈椎损伤中的诊断价值

目的：探讨CT扫描在颈椎损伤中的诊断价值。方法：回顾性分析32例颈椎损伤的CT与平片检查资料。结果：骨折28例（其中6例伴脱位）,单纯脱位4例,合并伤10例。结论：CT对颈椎损伤的检出率明显高于平片,能清晰显示其损伤的细节,并对判断失稳及椎管狭窄的程度均有重要价值。     

Flexion teardrop fracture of the cervical spine: radiographic characteristics

Teardrop fracture of the cervical spine is a confusing and loosely used term, often referring to any fracture with a triangular fragment in the involved body. The flexion teardrop fracture is a specific entity that should not be confused with other types of injury with a teardrop fragment. In a radiographic analysis of 45 patients with flexion teardrop fracture, the most characteristic feature was posterior displacement of the upper column of the divided cervical spine, observed in 78% of the cases. Other radiographic characteristics included backward displacement of the posterior fragment of the involved body, widening of the interlaminar and interspinous spaces, widening of the facet joint with backward displacement of the inferior facet, and kyphotic deformity of the cervical spine at the level of injury. The injury was frequently associated with sagittal-body and laminar fractures and occurred predominantly at the C5 level.     

Clearing the cervical spine in victims of blunt trauma

Cervical spine injuries occur in 2.3% to 6.4% of victims of blunt trauma. The difficulty of identifying the minority of patients with cervical spine injuries continues to challenge those who triage and treat the acutely injured. We retrospectively reviewed our practice for cervical spine clearance, which consists of three-view plain radiographs supplemented by focused further studies, such as computed or plain film tomography and flexion/extension views, as needed. Fifty-four patients with cervical spine injuries were identified during a 39-month period, which represented approximately 1% of the patients evaluated. Eighty cervical spine injuries were found, of which nine were missed. Review of the six patients in whom the nine cervical spine injuries were missed demonstrated error in the interpretation of radiographic studies in five patients, only two of whom were felt to have technically adequate films in hindsight. We conclude that a protocol based on three-view plain film radiographs supplemented by focused additional studies will allow the visualization of virtually all cervical spine injuries and that the main cause of missed injuries is errors of interpretation.     

Exclusion of unstable cervical spine injury in obtunded patients with blunt trauma: is MR imaging needed when multi-detector row CT findings are normal?

PURPOSE: To retrospectively determine what information, if any, magnetic resonance (MR) imaging of the cervical spine in obtunded and/or "unreliable" patients with blunt trauma adds to multi-detector row computed tomography (CT) of the entire cervical spine (including routine multiplanar sagittal and coronal reformations) when the CT findings are normal. MATERIALS AND METHODS: The study was HIPAA compliant and institutional review board approved. Informed consent was not required. From April 2001 to November 2003, 1400 trauma patients underwent MR imaging of the cervical spine to evaluate potential cervical spine injuries. Multi-detector row CT of the cervical spine was performed with a four- or 16-detector row scanner. MR imaging of the cervical spine was performed with transverse gradient-echo, sagittal intermediate-weighted, sagittal short inversion time inversion-recovery, and sagittal T1- and T2-weighted fast spin-echo sequences. Many MR examinations were performed to exclude soft-tissue injuries in the cervical spine of obtunded patients with blunt trauma in whom cervical spine injury could not be excluded with physical examination. Complete cervical spine MR studies were obtained to evaluate soft-tissue injuries in 366 obtunded patients with blunt trauma (281 male and 85 female patients; age range, 13-92 years; mean age, 42.1 years). The patients had previously undergone total cervical spine multi-detector row CT with normal findings. The results obtained with these two modalities were compared. RESULTS: MR images were negative for acute injury in 354 of the 366 patients and negative for cervical spine ligamentous injury in 362. Seven of the 366 patients had cervical cord contusions, four patients had ligamentous injuries, three patients had intervertebral disk edema, and one patient had a cord contusion, a ligamentous injury, and an intervertebral disk injury. Four patients had ligamentous injuries; however, all of these patients had ligament injuries limited to only one of the three columns of cervical spine ligament support. Multi-detector row CT had negative predictive values of 98.9% (362 of 366 patients) for ligament injury and 100% (366 of 366 patients) for unstable cervical spine injury. CONCLUSION: A normal multi-detector row CT scan of the total cervical spine in obtunded and/or "unreliable" patients with blunt trauma enabled the authors to exclude unstable injuries on the basis of findings at follow-up cervical spine MR imaging.