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Traumatic disco-ligamentous injury of the cervical spine with vertebral artery dissection

Case contributed by Rajalakshmi Ramesh
Diagnosis certain

Presentation

Intoxicated driver involved in a high-speed motor vehicle accident.

Patient Data

Age: 55 years
Gender: Male
  • exaggerated cervical lordosis at C4/C5 secondary to anterolisthesis of the C5 vertebral body
  • associated widening of the anterior intervertebral disc space at C4/C5
  • widening of the right facet joint at C4/C5
  • right transverse process fracture of C4 without the involvement of the transverse foramen
  • bilateral C5 transverse process fractures with extension into the transverse foramen
  • fracture of the left anterior scalene tubercle of the right C6 transverse foramen.
  • significant prevertebral hematoma indicating a ligament injury
  • anterior epidural hematoma extending from the intervertebral disc space at C4/C5 along the posterior aspect of the C5 vertebral body

Non- opacification of the left vertebral artery is seen in the region of the C4/5 injury with irregular opacification of the more distal V2, V3 and 4 (intradural) segments consistent with dissection.

Complete disruption of the C4/5 and anterior and posterior longitudinal ligaments. This is associated with extensive thickening of the prevertebral soft tissues. A small epidural hematoma extends from the C4/5 level, down to C6, without evidence of cord compression. Widening of the C4/5 facet joints with associated interspinous ligament damage, not only at this level but also at the level above and below. A flow void in the left vertebral artery is not visible, instead a high signal is seen along its length (including V4) consistent with dissection and thrombosis.

Case Discussion

Multiples cervical injuries are demonstrated by this case, including disco-ligamentous injury at C4/5 with a widening of the associated facet joints (consistent with an unstable three-column injury) and left vertebral artery dissection/occlusion. These findings are consistent with a severe hyper-flexion mechanism of injury to the cervical spine.

Case courtesy of Associate Professor Pramit Phal

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