Zhu Ce, Yang Hui-Liang, Im Gi Hye, Liu Li-Min, Zhou Chun-Guang, Song Yue-Ming
Department of Orthopedic Surgery and Orthopedics Research Institute, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China.
Department of Emergency Medicine, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI 02903, United States.
World J Clin Cases. 2021 Nov 26;9(33):10369-10373. doi: 10.12998/wjcc.v9.i33.10369.
Missed or delayed diagnosis of cervical spine instability after acute trauma can have catastrophic consequences for the patient, resulting in severe neurological impairment. Currently, however, there is no consensus on the optimal strategy for diagnosing occult cervical spine instability. Thus, we present a case of occult cervical spine instability and provide a clinical algorithm to aid physicians in diagnosing occult instability of the cervical spine.
A 57-year-old man presented with cervical spine pain and inability to stand following a serious fall from a height of 2 m. No obvious vertebral fracture or dislocation was found at the time on standard lateral X-ray, computed tomography, and magnetic resonance imaging (MRI). Subsequently, the initial surgical plan was unilateral open-door laminoplasty (C3-7) with alternative levels of centerpiece mini-plate fixation (C3, 5, and 7). However, the intraoperative C-arm fluoroscopic X-rays revealed significantly increased intervertebral space at C5-6, indicating instability at this level that was previously unrecognized on preoperative imaging. We finally performed lateral mass fixation and fusion at the C5-6 level. Looking back at the preoperative images, we found that the preoperative T2 MRI showed non-obvious high signal intensity at the C5-6 intervertebral disc and posterior interspinous ligament.
MRI of cervical spine trauma patients should be carefully reviewed to detect disco-ligamentous injury, which will lead to further cervical spine instability. In patients with highly suspected cervical spine instability indicated on MRI, lateral X-ray under traction or after anesthesia and muscle relaxation needs to be performed to avoid missed diagnoses of occult cervical instability.
急性创伤后颈椎不稳的漏诊或延误诊断可能给患者带来灾难性后果，导致严重的神经功能障碍。然而，目前对于隐匿性颈椎不稳的最佳诊断策略尚无共识。因此，我们报告一例隐匿性颈椎不稳病例，并提供一种临床算法以帮助医生诊断颈椎隐匿性不稳。
一名57岁男性因从2米高处严重坠落而出现颈椎疼痛且无法站立。当时在标准的侧位X线、计算机断层扫描和磁共振成像（MRI）检查中未发现明显的椎体骨折或脱位。随后，最初的手术方案是单侧开门式椎板成形术（C3 - 7），并在C3、5和7节段采用替代的中心块微型钢板固定。然而，术中C形臂荧光透视X线显示C5 - 6节段椎间隙明显增宽，表明该节段存在术前影像学未发现的不稳。我们最终在C5 - 6节段进行了侧块固定和融合。回顾术前图像，我们发现术前T2加权MRI显示C5 - 6椎间盘和棘突间韧带处有不明显的高信号。
应仔细复查颈椎创伤患者的MRI，以发现椎间盘 - 韧带损伤，这可能导致进一步的颈椎不稳。对于MRI显示高度怀疑颈椎不稳的患者，需要在牵引下或麻醉及肌肉松弛后进行侧位X线检查，以避免漏诊隐匿性颈椎不稳。
