Feasibility analysis of high pitch cervical spine CT in uncooperative patients with acute cervical spine trauma: An initial experience

Cervical computed tomography (CT) often suffers from examination failure in uncooperative patients with acute cervical spinal trauma. Therefore, this study aimed to evaluate the feasibility of using high-pitch cervical CT (HP-CT) in such populations. A total of 95 patients with acute neck/head-neck trauma who underwent HP-CT (n = 29) or standard cervical CT (SD-CT, n = 66) from October 2020 to June 2021 were included in this study. Differences in patient characteristics between the HP-CT group and the SD-CT group were firstly compared. Then, the objective image quality based on the mean score of the signal-to-noise ratio (SNR)/contrast noise ratio (CNR) was evaluated, while double-blind five-point scoring was adopted for the subjective evaluation. Finally, radiation doses in HP-CT and SD-CT were compared. Furthermore, the Student t test and/or Mann–Whitney U test were performed to analyze differences in patient characteristics, image quality, and radiation dose between the two regimes. A total of 17 cases of cervical spine fractures were found in 95 patients, including 6 cases in the HP-CT group and 11 cases in the SD-CT group. The average age of patients who received HP-CT was higher than that of those who received SD-CT, and the scan time using HP-CT was shorter than that SD-CT. The differences were statistically significant (both, P < .05). In addition, there was no significant difference between HP-CT and SD-CT in terms of sex, body mass index, field of view (FOV), and scan length (all P > .05). The SNR/CNR at the middle and upper neck was not significantly different between HP-CT and SD-CT (all P > .05). However, the SNR/CNR at the lower neck in HP-CT was lower than that in SD-CT (all P < .05). There was no significant difference in the subjective scores between HP-CT and SD-CT images in both the soft tissue and bone window (P = .129 and 0.649, respectively). The radiation dose in HP-CT was lower than that in SD-CT (all P < .05). With a scan time reduction of 73%, radiation dose reduction of 10%, and similar image quality, high-pitch cervical CT was of feasibility to evaluate cervical spine injury in uncooperative patients with acute cervical spine trauma.     

Cervical spine lateral radiograph versus whole spine lateral radiograph: A retrospective comparative study to identify a better modality to assess cervical sagittal alignment

This study is aimed to compare whole-spine lateral radiograph (WLR) and cervical lateral radiograph (CLR) in terms of T1 slope visibility and cervical sagittal parameters and to identify the superior imaging modality for assessment of cervical sagittal parameters.We retrospectively reviewed the radiographic data of 60 consecutive adult patients (male-to-female ratio, 38:22; mean age, 55.6 ± 1.3 years) who presented with only neck pain (without radiculopathy or myelopathy). All the patients underwent standing CLR and WLR. The following parameters were measured and analyzed:

• 1.T1 slope visibility,
• 2.T1 slope,
• 3.C7 slope,
• 4.C0–C2 Cobb angle (CAC0–C2),
• 5.C2–C7 Cobb angle (CAC2–C7), and
• 6.cervical sagittal vertical axis (cSVA).

The visibility of the T1 slope was significantly lower with WLR than with CLR (28.3% vs 83.3%, P  = .049). The mean CAC2–C7 on WLR was significantly less lordotic than that on CLR (11.2 ± 9.2° vs 14.3 ± 11.3°; P = .01). The mean cSVA was translated more posteriorly on WLR than on CLR (9.9 ± 18.9 mm vs 15.0 ± 13.4 mm, P = .04). However, no significant differences in T1 slope, C7 slope, and CAC0–C2 were found between CLR and WLR.This study shows that standing CLR could provide better visualization of the upper endplate of T1. Furthermore, WLR taken in hands on clavicle position distorted radiographic measurements such as CAC2-C7 and cSVA. Therefore, CLR performed in the standing position seems to allow more-accurate measurements of cervical sagittal parameters.     

Clinical presentation of patients with acute cervical spine injury

A retrospective review of 67 patients with acute cervical spine fracture and/or dislocation was conducted at two suburban community hospital emergency departments. The mean age was 39, and two-thirds of the patients were male. Motor vehicle accidents and falls accounted for more than 80% of all injuries. On emergency department evaluation, it was found that there was no history of loss of consciousness in 42 patients (63%), no associated cranio-facial injuries in 31 patients (46%), and a normal sensorimotor examination in 59 patients (88%). Thirty-four patients (50%) were evaluated for cervical range of motion, which was found to be normal in one-third of the cases. The absence of mental status changes, cranio-facial injuries, range of motion abnormalities, and focal neurological findings is, therefore, not uncommon in patients who have sustained cervical spine injury.     

术中CT导航和单纯术中CT扫描辅助下颈椎椎弓根螺钉内固定技术的对比研究

目的探讨使用术中CT导航和单纯术中CT扫描辅助下进行下颈椎椎弓根螺钉内固定的临床效果。方法总结诊断为颈椎病、颈椎外伤、颈椎肿瘤而行CT辅助颈椎椎弓根螺钉内固定的65例老年患者的临床资料。根据术中是否采用CT导航将患者分为术中CT导航组和术中非CT导航组。术后进行经椎弓根螺钉水平的CT平扫,观察椎弓根螺钉置入的精确性。对2组椎弓根螺钉置钉的准确率、翻修率、置钉时间和术中CT的扫描数据进行比较。结果术中CT导航组椎弓根螺钉的穿破率和平均置钉时间显著低于非CT导航组（P〈0.05或P〈0.01）。2组病例均未出现明显的神经、血管损伤并发症。在2组中均没有因内置物位置不佳而行二次手术的病例。结论术中CT导航系统辅助进行颈椎椎弓根螺钉内固定是可行的,能够显著提高后路颈椎椎弓根螺钉置钉的精确性,同时医护人员无X射线暴露。     

颈椎手术后出现吞咽困难的相关因素分析

目的 分析颈椎前路及后路手术后出现吞咽困难的相关因素.方法 颈椎手术患者354例,其中行颈椎前路手术172例（AC组）,颈椎后路手术182例（PC组）;术后随访平均28个月,了解患者术后当天及1、3、6、12个月吞咽困难发生情况.采用单因素及二元Logistic回归模型,分析患者临床资料与与吞咽困难发生的关系.结果 两组术后各时点吞咽困难发生率及严重程度比较,P均＞0.05.单因素分析结果显示,两组吞咽困难发生均与年龄、性别、BMI、翻修手术比例、手术时间、出血量无关,P均＞0.05.二元Logistic回归分析结果显示,性别、年龄、BMI、手术方式（AC或PC）、手术节段数目、最高手术节段水平、翻修手术比例、手术时间、出血量等与术后吞咽困难的发生无显著关联,P均＞0.05.结论 颈椎手术后吞咽困难的发生不受患者性别、年龄、BMI、手术时间、出血量、手术方式、翻修手术比例、手术节段数目、最高手术节段水平等因素的影响.     

A case report on a child with fracture and dislocation of the upper cervical spine accompanied by spinal cord injury

Rationale:This study describes an 8-year-old boy with a C2 fracture and dislocation with a left C2–C3 articular process interlocking and spinal cord injury who underwent open reduction and internal fixation using the posterior cervical approach and achieved satisfactory results.Patient concerns:An 8-year-old boy underwent an emergency transfer from a previous hospital after a car accident.Diagnoses:Axial fracture and dislocation with spinal cord injury (American Spinal Injury Association grade C), traumatic shock, brain contusion, intracranial hemorrhage, mandibular fracture, pulmonary contusion and hemorrhage, left vertebral artery stenosis, and multiple fractures throughout the body. Radiological examination revealed a fracture of the lower edge of the C2 vertebral body, fourth-degree anterior spondylolisthesis of the C2 vertebral body, interlocking of the left C2–C3 articular processes, widening of the C2–C3 vertebral space, and occlusion of the V1 and 2 segments of the left vertebral artery.Interventions:The boy was immediately intubated and transferred to the pediatric intensive care unit for rescue treatment. However, the reduction was unsuccessful with 2 weeks of cranial traction. Thus, an open reduction was performed under general anesthesia. One month after the surgery, the boy was discharged from the hospital on foot after rehabilitation treatment.Outcomes:The boy was discharged from the hospital 1 month after surgery. At the 8-month follow-up, a radiological examination showed that the corrected C2 vertebral body fracture and dislocation were satisfactorily reduced, and the spinal cord was adequately decompressed. The internal fixation position was also good, and the spinal sequence had recovered well. In summary, except for the muscle strength of the right upper limb, which was slightly worse, the other clinical symptoms were significantly improved.Lessons:In treating cervical fracture and dislocation with unilateral facet lock, the posterior open reduction of pedicle screw and lateral mass screw internal fixation achieved satisfactory results. Consequently, treating complex cervical spine injuries in children requires an accurate diagnosis and careful treatment strategy.     

Anterior cervical transpedicular screw fixation system in subaxial cervical spine: A finite element comparative study

Multilevel cervical corpectomy has raised the concern among surgeons that reconstruction with the anterior cervical screw plate system (ACSPS) alone may fail eventually. As an alternative, the anterior cervical transpedicular screw (ACTPS) has been adopted in clinical practice. We used the finite element analysis to investigate whether ACTPS is a more reasonable choice, in comparison with ACSPS, after a 2-level corpectomy in the subaxial cervical spine. These 2 types of implantation models with the applied 75 N axial pressure and 1 N • m pure moment of the couple were evaluated. Compared with the intact model, the range of motion (ROM) at the operative segments (C4–C7) decreased by 97.5% in flexion-extension, 91.3% in axial rotation, and 99.3% in lateral bending in the ACTPS model, whereas it decreased by 95.1%, 73.4%, 96.9% in the ACSPS model respectively. The ROM at the adjacent segment (C3/4) in the ACTPS model decreased in all motions, while that of the ACSPS model increased in axial rotation and flexion-extension compared with the intact model. Compared to the ACSPS model, whose stress concentrated on the interface between the screws and the titanium plate, the stress of the ACTPS model was well-distributed. There was also a significant difference between the maximum stress value of the 2 models. ACTPS and ACSPS are biomechanically favorable. The stability in reducing ROM of ACTPS may be better and the risk of failure for internal fixator is relatively low compared with ACSPS fixation except for under lateral bending in reconstruction the stability of the subaxial cervical spine after 2-level corpectomy.     

Osteomyelitis of the cervical spine: reversible quadraplegia resulting from Philadelphia collar placement

Pyogenic osteomyelitis of the vertebrae accounts for 4% of all osteomyelitis, and is believed to be increasing in incidence. Pyogenic osteomyelitis of the cervical spine is even more uncommon, accounting for 10% of all spinal pyogenic osteomyelitis. Presented is a case of pyogenic osteomyelitis of the cervical spine in which appropriate methods of immobilization of the cervical spine resulted in a surgically reversible acute deterioration of the patient's neurologic status. While immobilization of the cervical spine remains the initial treatment of choice in most patients with suspected disease of the cervical spine, it is not without potential complications.     

An unusual presentation of bilateral facet dislocation of the cervical spine

We report the case of a patient who presented complaining of neck pain after a fall. Initial physical examination was remarkable for an occipital scalp contusion and tenderness to palpation in the mid-cervical spine. Neurological examination demonstrated an absence of response to pinprick below approximately the T4 level. Upper extremities had equal withdrawal to pain and lower extremities were without movement. Initial cervical, thoracic, and lumbar spine films were normal. An emergency myelogram demonstrated a complete extradural block at the C6 level. Cross-table lateral cervical spine films revealed a C5-C6 bilateral facet dislocation. The patient subsequently underwent closed reduction with in-line-traction. He had a prolonged hospital course and was eventually transferred for rehabilitation, with some improvement in neurologic status.     

无创通气在颈椎损伤并呼吸衰竭救治中的评估

目的评估无创通气在颈椎损伤并发呼吸衰竭救治中的作用。方法19例颈椎损伤致高位截瘫并呼吸衰竭的住院患者,比较无创通气前后血气变化,及治疗结果。结果病人应用无创通气后1h和24h的血气均明显改善,但19例患者中有12例在第2～5天符合治疗标准而行气管插管或气管切开人工支持通气,另2例分别在第9、10天行气管切开。只有2例患者成功脱离无创通气,3例因脓毒症、MODF死亡。无创通气并发症包括鼻部压伤和胃胀气。结论无创通气在颈椎损伤并呼吸衰竭救治中并不是最佳选择,及早实施气管插管或气管切开术可避免一些严重并发症的发生。     

Use of plain radiography to screen for cervical spine injuries.

STUDY OBJECTIVE: Standard radiographic screening may fail to reveal any evidence of injury in some patients with spinal injury. The purposes of this investigation were to document the efficacy of standard radiographic views and to categorize the frequencies and types of injuries missed on plain radiographic screening of the cervical spine. METHODS: All patients with blunt trauma selected for radiographic cervical spine imaging at 21 participating institutions underwent a standard 3-view series (cross-table lateral, anteroposterior, and odontoid views), as well as any other imaging deemed necessary by their physicians. Injuries detected with screening radiography were then compared with final injury status for each patient, as determined by review of all radiographic studies. RESULTS: The study enrolled 34,069 patients with blunt trauma, including 818 patients (2.40% of all patients; 95% confidence interval [CI] 2.40% to 2.40%) having a total of 1,496 distinct cervical spine injuries. Plain radiographs revealed 932 injuries in 498 patients (1.46% of all patients; 95% CI 1.46% to 1.46%) but missed 564 injuries in 320 patients (0.94% of all patients; 95% CI 0.94% to 0.94%). The majority of missed injuries (436 injuries in 237 patients [representing 0.80% of all patients]; 95% CI 0.80% to 0.80%) occurred in cases in which plain radiographs were interpreted as abnormal (but not diagnostic of injury) or inadequate. However, 23 patients (0.07% of all patients; 95% CI 0.05% to 0.09%) had 35 injuries (including 3 potentially unstable injuries) that were not visualized on adequate plain film imaging. These patients represent 2.81% (95% CI 1.89% to 3.63%) of all injured patients with blunt trauma undergoing radiographic evaluation. CONCLUSION: Standard 3-view imaging provides reliable screening for most patients with blunt trauma. However, on rare occasions, such imaging may fail to detect significant unstable injuries. In addition, it is difficult to obtain adequate plain radiographic imaging in a substantial minority of patients.     

Neurologic complications following immobilization of cervical spine fracture in a patient with ankylosing spondylitis

Axial traction is widely recommended for stabilization of cervical spine fractures. This procedure may be inappropriate and even dangerous in patients with long-standing ankylosing spondylitis (AS). We present the case of an 80-year-old woman with AS who fell at home and suffered an unstable large C5-C6 fracture/dislocation associated with left-sided weakness and decreased sensation. Medical treatment included placing her neck in a neutral position, despite her preference for neck flexion. This procedure increased her pain and paresthesias; the complications decreased, but did not entirely resolve, when the patient resumed a semi-flexed position. This patient's neurologic sequelae may have been exacerbated by attempts to stabilize her neck in a neutral position. Standard stabilization recommendations should be appropriately altered in some patients with cervical spine AS.     

Clinical feasibility of MR-generated synthetic CT images of the cervical spine: Diagnostic performance for detection of OPLL and comparison of CT number

We aimed to determine the incremental value of magnetic resonance generated synthetic computed tomography (MRCT), evaluate cervical ossification of the posterior longitudinal ligament (OPLL), and compare the computed tomography (CT) numbers between MRCT and conventional CT.Twenty-two patients who underwent magnetic resonance imaging (MRI) with MRCT protocols and CT were enrolled. MRCT images were generated from 3D-T2-weighted imaging, 3D-pointwise-encoding time reduction with radial acquisition, 3D-T1-Dixon, and 3D-time-of-flight sequences. Two radiologists independently evaluated the presence of OPLL at each cervical spine level during sessions 1 (MRI alone) and 2 (MRI + MRCT). CT was the reference standard for the presence of OPLL. One reader measured the mean CT number of the vertebral body and spinous process at each cervical spine level in the MRCT and CT images.Sensitivity for the detection of OPLL was markedly higher in session 2 (MRI + MRCT) than in session 1 (MRI alone), as measured by both readers (47% vs. 90%, reader 1; 63% vs. 93%, reader 2). The mean CT number of MRCT and CT showed a moderate to strong positive correlation (ρ = .42–.72, P < .001).The combined use of MRCT and MRI showed improved sensitivity for the evaluation of cervical OPLL. The mean CT number of MRCT and CT showed a positive correlation.     

Treatment of upper cervical spine involvement in rheumatoid arthritis patients

The cervical spine, especially the upper cervical spine, is a common focus of destruction by rheumatoid arthritis (RA). Because of its potentially debilitating and life-threatening sequelae, cervical spine involvement remains a priority in the diagnosis and treatment of RA. Many studies show that early surgical intervention gives a more satisfactory outcome. Surgery aims to establish spinal stability and to prevent neurological deterioration and injury to the spinal cord, leading to improved neurological function. The recent sophisticated screw-rod-plate technique allows one to obtain a solid fixation of the upper cervical spine with a high possibility of bone union even in RA patients. Although surgery of the occipitoatlantoaxial region is a challenge with many possibilities of serious complications, recent advances in the surgical technique, complete understanding of the anatomy, and precise preoperative evaluation have decreased complication rates. Early consultation with a specialized spine surgeon is mandatory once cervical involvement is suspected in an RA patient because once the patient becomes myelopathic, the rate of long-term mortality increases and the chance of neurological recovery decreases.