DOI: 10.1148/rg.255045162
Spectrum of Imaging Findings in Hyperextension Injuries of the Neck1
Sameet K. Rao, MD,
Christopher Wasyliw, MD and
Diego B. Nunez, Jr, MD, MPH
1 From the Department of Radiology, Hospital of Saint Raphael, Yale School of Medicine, New Haven, Conn. Recipient of a Certificate of Merit award for an education exhibit at the 2003 RSNA Annual Meeting. Received August 18, 2004; revision requested October 18 and received December 10; accepted January 27, 2005. All authors have no financial relationships to disclose.
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Figure 1a. Anterior arch fracture. (a) Lateral radiograph shows cortical irregularity at the inferior aspect of C1 (arrow) with associated prevertebral soft-tissue swelling (arrowheads). (b) Sagittal reformatted image from CT data shows a transverse avulsion fracture of the inferior pole of C1 (arrow).
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Figure 1b. Anterior arch fracture. (a) Lateral radiograph shows cortical irregularity at the inferior aspect of C1 (arrow) with associated prevertebral soft-tissue swelling (arrowheads). (b) Sagittal reformatted image from CT data shows a transverse avulsion fracture of the inferior pole of C1 (arrow).
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Figure 2. Posterior arch fracture. Three-dimensional volume-rendered (VR) image shows a nondisplaced fracture through the posterior arch of C1 (small arrow). An associated type 2 dens fracture with posterior displacement is also seen (large arrow).
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Figure 3a. Type 2 dens fracture. Sagittal (a) and coronal (b) reformatted images from CT data show a nondisplaced type 2 dens fracture (arrows).
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Figure 3b. Type 2 dens fracture. Sagittal (a) and coronal (b) reformatted images from CT data show a nondisplaced type 2 dens fracture (arrows).
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Figure 4a. Type 3 dens fracture. (a) Lateral radiograph shows a displaced type 3 dens fracture (large arrow) with disruption of the ring of C2 (small arrow). (b, c) Lateral radiograph (b) and coronal reformatted image from CT data (c) obtained in a different patient who had sustained traumatic injury show normal radiographic findings (b) and a nondisplaced type 3 dens fracture (arrows in c).
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Figure 4b. Type 3 dens fracture. (a) Lateral radiograph shows a displaced type 3 dens fracture (large arrow) with disruption of the ring of C2 (small arrow). (b, c) Lateral radiograph (b) and coronal reformatted image from CT data (c) obtained in a different patient who had sustained traumatic injury show normal radiographic findings (b) and a nondisplaced type 3 dens fracture (arrows in c).
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Figure 4c. Type 3 dens fracture. (a) Lateral radiograph shows a displaced type 3 dens fracture (large arrow) with disruption of the ring of C2 (small arrow). (b, c) Lateral radiograph (b) and coronal reformatted image from CT data (c) obtained in a different patient who had sustained traumatic injury show normal radiographic findings (b) and a nondisplaced type 3 dens fracture (arrows in c).
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Figure 5. Drawing illustrates the vertical fracture line through the pars interarticularis of C2 in traumatic spondylolisthesis (arrow).
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Figure 6. Traumatic spondylolisthesis. Lateral radiograph shows a fracture through the pars interarticularis of C2 (arrows).
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Figure 7. Traumatic spondylolisthesis. Axial CT scan through C2 shows bilateral, coronally oriented fracture lines extending through the pars interarticularis (arrows).
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Figure 8. Traumatic spondylolisthesis. Axial CT scan shows an oblique fracture through the posterior C2 body (long arrow), a finding that is consistent with atypical traumatic spondylolisthesis. Note the extension of the fracture to the right transverse process (short arrow).
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Figure 9. Hyperextension teardrop fracture in a patient with underlying degenerative changes. Lateral radiograph shows a displaced triangular fracture fragment off the anteroinferior aspect of C2 (arrow).
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Figure 10. Drawing illustrates hyperextension dislocation. Note the fracture fragment resulting from avulsion by Sharpey fibers (arrow) as well as the disruption of ligamentous structures.
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Figure 11. Hyperextension teardrop fracture. Lateral radiograph shows avulsion of the inferior endplate of C6 (arrowhead). The fact that the transverse dimension of the fracture fragment is greater than its vertical dimension increases the degree of suspicion for hyperextension dislocation.
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Figure 12a. Hyperextension dislocation. (a) Sagittal fat-saturated proton-density–weighted MR image shows disruption of the ALL at C5 (large arrow) with stripping of the PLL from the subjacent vertebral bodies (small arrow). (b) Sagittal proton-density–weighted MR image obtained in a different patient shows similar but less pronounced findings at the C3 through C4 level. Widening of the anterior disk space and posterior narrowing provide evidence of a hyperextension injury.
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Figure 12b. Hyperextension dislocation. (a) Sagittal fat-saturated proton-density–weighted MR image shows disruption of the ALL at C5 (large arrow) with stripping of the PLL from the subjacent vertebral bodies (small arrow). (b) Sagittal proton-density–weighted MR image obtained in a different patient shows similar but less pronounced findings at the C3 through C4 level. Widening of the anterior disk space and posterior narrowing provide evidence of a hyperextension injury.
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Figure 13a. Isolated injury to the cervical spinal cord from hyperextension dislocation. (a) Sagittal proton-density–weighted MR image shows high-signal-intensity edema in the spinal cord at the C7 through T1 level (arrow). (b) Sagittal gradient-echo MR image shows corresponding hemorrhage (arrow). No fractures or ligamentous injury was identified at CT or MR imaging.
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Figure 13b. Isolated injury to the cervical spinal cord from hyperextension dislocation. (a) Sagittal proton-density–weighted MR image shows high-signal-intensity edema in the spinal cord at the C7 through T1 level (arrow). (b) Sagittal gradient-echo MR image shows corresponding hemorrhage (arrow). No fractures or ligamentous injury was identified at CT or MR imaging.
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Figure 14. Laminar fracture. Axial CT scan shows an isolated fracture of the right lamina (arrow).
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Figure 15a. Articular pillar fracture. (a) Axial CT scan through C6 shows a fracture through the left articular pillar (arrow). (b, c) Coronal reformatted (b) and sagittal 3D (c) images optimally show the vertical orientation of the fracture (arrow).
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Figure 15b. Articular pillar fracture. (a) Axial CT scan through C6 shows a fracture through the left articular pillar (arrow). (b, c) Coronal reformatted (b) and sagittal 3D (c) images optimally show the vertical orientation of the fracture (arrow).
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Figure 15c. Articular pillar fracture. (a) Axial CT scan through C6 shows a fracture through the left articular pillar (arrow). (b, c) Coronal reformatted (b) and sagittal 3D (c) images optimally show the vertical orientation of the fracture (arrow).
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Figure 16a. Articular pillar fracture. (a) Anteroposterior radiograph shows a fracture line (arrow) through the left articular pillar (*) with rotation of the fragment, producing the "bow tie" appearance. (b) Axial CT scan shows fracture and rotation of the left articular pillar (short arrows) as well as fracture of the ipsilateral lamina (long arrow).
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Figure 16b. Articular pillar fracture. (a) Anteroposterior radiograph shows a fracture line (arrow) through the left articular pillar (*) with rotation of the fragment, producing the "bow tie" appearance. (b) Axial CT scan shows fracture and rotation of the left articular pillar (short arrows) as well as fracture of the ipsilateral lamina (long arrow).
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Figure 17a. Hyperextension injury in a patient with underlying spinal stenosis at the C5 through C6 level. The injury was caused by a fall forward onto the face. (a) Sagittal T2-weighted MR image shows spinal cord edema (short arrow). Edema within the intervertebral disk (arrowhead) and prevertebral soft-tissue edema (long arrow) are also seen. (b) Proton-density–weighted MR image shows tearing of the ALL (arrow).
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Figure 17b. Hyperextension injury in a patient with underlying spinal stenosis at the C5 through C6 level. The injury was caused by a fall forward onto the face. (a) Sagittal T2-weighted MR image shows spinal cord edema (short arrow). Edema within the intervertebral disk (arrowhead) and prevertebral soft-tissue edema (long arrow) are also seen. (b) Proton-density–weighted MR image shows tearing of the ALL (arrow).
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Figure 18a. Type 2 dens fracture in an elderly patient with underlying degenerative changes and osteopenia. Sagittal reformatted (a) and 3D VR (b) images show a posteriorly displaced type 2 dens fracture (arrow).
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Figure 18b. Type 2 dens fracture in an elderly patient with underlying degenerative changes and osteopenia. Sagittal reformatted (a) and 3D VR (b) images show a posteriorly displaced type 2 dens fracture (arrow).
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Figure 19a. Cervical spine fracture in a patient with ankylosing spondylitis. (a) Sagittal reformatted image shows a fracture through the intervertebral disk at the C7-T1 level (large arrow) with anterior displacement. Comminuted fracture of the posterior body of C7 is also seen (small arrow). (b) Sagittal reformatted image shows the fracture line extending posteriorly through the fused facet joint (arrow).
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Figure 19b. Cervical spine fracture in a patient with ankylosing spondylitis. (a) Sagittal reformatted image shows a fracture through the intervertebral disk at the C7-T1 level (large arrow) with anterior displacement. Comminuted fracture of the posterior body of C7 is also seen (small arrow). (b) Sagittal reformatted image shows the fracture line extending posteriorly through the fused facet joint (arrow).
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Figure 20a. Traumatic injury to the vertebral artery. (a) Unenhanced CT scan shows hyperattenuation in the left vertebral artery (arrow), a finding consistent with acute thrombus. (b, c) Three-dimensional image from CT angiographic data (b) and gadolinium-enhanced maximum-intensity-projection MR image (c) show occlusion of the entire left vertebral artery (arrowhead in c).
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Figure 20b. Traumatic injury to the vertebral artery. (a) Unenhanced CT scan shows hyperattenuation in the left vertebral artery (arrow), a finding consistent with acute thrombus. (b, c) Three-dimensional image from CT angiographic data (b) and gadolinium-enhanced maximum-intensity-projection MR image (c) show occlusion of the entire left vertebral artery (arrowhead in c).
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Figure 20c. Traumatic injury to the vertebral artery. (a) Unenhanced CT scan shows hyperattenuation in the left vertebral artery (arrow), a finding consistent with acute thrombus. (b, c) Three-dimensional image from CT angiographic data (b) and gadolinium-enhanced maximum-intensity-projection MR image (c) show occlusion of the entire left vertebral artery (arrowhead in c).
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Figure 21a. Traumatic injury to the carotid artery from hyperextension of the neck. (a) Contrast-enhanced CT scan shows narrowing of the lumen of the right internal carotid artery (ICA) (small arrow) with surrounding hematoma (large arrow). (b) Fat-saturated T1-weighted MR image shows narrowing of the ICA flow void (small arrow) with surrounding hyperintense intramural hematoma (large arrow). (c) Three-dimensional time-of-flight MR image shows narrowing of the cervical portion of the right ICA (arrows).
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Figure 21b. Traumatic injury to the carotid artery from hyperextension of the neck. (a) Contrast-enhanced CT scan shows narrowing of the lumen of the right internal carotid artery (ICA) (small arrow) with surrounding hematoma (large arrow). (b) Fat-saturated T1-weighted MR image shows narrowing of the ICA flow void (small arrow) with surrounding hyperintense intramural hematoma (large arrow). (c) Three-dimensional time-of-flight MR image shows narrowing of the cervical portion of the right ICA (arrows).
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Figure 21c. Traumatic injury to the carotid artery from hyperextension of the neck. (a) Contrast-enhanced CT scan shows narrowing of the lumen of the right internal carotid artery (ICA) (small arrow) with surrounding hematoma (large arrow). (b) Fat-saturated T1-weighted MR image shows narrowing of the ICA flow void (small arrow) with surrounding hyperintense intramural hematoma (large arrow). (c) Three-dimensional time-of-flight MR image shows narrowing of the cervical portion of the right ICA (arrows).
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Figure 22a. Intracranial injury. (a) Axial CT scan shows atypical traumatic spondylolisthesis of C2 (arrow). (b) Unenhanced CT scan shows associated hemorrhagic contusion (arrow).
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Figure 22b. Intracranial injury. (a) Axial CT scan shows atypical traumatic spondylolisthesis of C2 (arrow). (b) Unenhanced CT scan shows associated hemorrhagic contusion (arrow).
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Figure 23a. Spinal and craniofacial injuries sustained in a motor vehicle accident. The patient had not been wearing a seat beat. (a) Sagittal reformatted image from CT data shows a posteriorly displaced type 2 dens fracture (arrow). (b, c) Axial CT scans of the head show associated frontal soft-tissue hematoma (arrow in b) and a depressed nasal bone fracture (arrow in c) caused by the forehead and face striking the dashboard, with resultant hyperextension of the cervical spine.
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Figure 23b. Spinal and craniofacial injuries sustained in a motor vehicle accident. The patient had not been wearing a seat beat. (a) Sagittal reformatted image from CT data shows a posteriorly displaced type 2 dens fracture (arrow). (b, c) Axial CT scans of the head show associated frontal soft-tissue hematoma (arrow in b) and a depressed nasal bone fracture (arrow in c) caused by the forehead and face striking the dashboard, with resultant hyperextension of the cervical spine.
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Figure 23c. Spinal and craniofacial injuries sustained in a motor vehicle accident. The patient had not been wearing a seat beat. (a) Sagittal reformatted image from CT data shows a posteriorly displaced type 2 dens fracture (arrow). (b, c) Axial CT scans of the head show associated frontal soft-tissue hematoma (arrow in b) and a depressed nasal bone fracture (arrow in c) caused by the forehead and face striking the dashboard, with resultant hyperextension of the cervical spine.
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Figure 24a. Injury from direct blunt trauma to the anterior portion of the neck sustained in a motor vehicle accident. (a) Lateral radiograph shows anterior widening (large arrow) and posterior narrowing (small arrow) of the C6–7 disk space, with diffuse prevertebral hematoma. (b) Axial contrast-enhanced CT scan shows associated disruption of the right lobe of the thyroid gland (arrow).
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Figure 24b. Injury from direct blunt trauma to the anterior portion of the neck sustained in a motor vehicle accident. (a) Lateral radiograph shows anterior widening (large arrow) and posterior narrowing (small arrow) of the C6–7 disk space, with diffuse prevertebral hematoma. (b) Axial contrast-enhanced CT scan shows associated disruption of the right lobe of the thyroid gland (arrow).
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Copyright © 2005 by the Radiological Society of North America.
