title: Adjacent Level Ligamentous Injury Associated with Traumatic Cervical Spine Fractures: Indications for Imaging and Implications for Treatment.
abstract: BACKGROUND
  Magnetic resonance imaging (MRI) is a vital tool for detection of soft tissue injury (STI) after cervical spine injury (CSI). However, high cost, prolonged imaging time, and limited use in hemodynamically unstable patients necessitates that the utility of MRI in all patients with CSI be scrutinized.
  
  
  METHODS
  A retrospective review was performed of all patients treated for a CSI at a Level I trauma center between 2005 and 2010. Patient demographics, fracture characteristics, and associated STIs were collected. STIs were classified further into same level ligamentous injury, adjacent level ligamentous injury (ALLI), cord contusion, and traumatic herniated disc. ALLI was defined as anterior or posterior longitudinal ligament, ligamentum flavum, or supraspinous or interspinous ligamentous injury.
  
  
  RESULTS
  MRI was performed in 240 of 787 patients. Evidence of STI was identified in 54.6%. ALLI was the most common STI (80 of 240 patients); these injuries were subdivided into above, below, or both above and below the concurrent fracture level. Patients with ALLI were significantly more likely to have injured C3 (P < 0.01) and C5 (P < 0.03) levels, association with widened disc space (P = 0.03), and multiple CSIs (P = 0.008). The whole ALLI was included in the fixation strategy in 100% of patients with ALLI only above the concurrent fracture level and 87% of patients with ALLI only below the concurrent fracture level.
  
  
  CONCLUSIONS
  MRI detected an associated STI in about 55% of patients who underwent imaging. Injuries involving multiple fractured cervical levels, fractures at C3 and C5, and widened disc space should raise the treating physician's level of suspicion for ALLI. Our data show that treatment directed by MRI findings in select cases has substantial value.
authors.affiliation: Department of Neurological Surgery, Case Western Reserve University School of Medicine and MetroHealth Spine Center, Cleveland, Ohio, USA; Department of Neurological Surgery, Mansoura University School of Medicine, Mansoura, Egypt.
authors.forename: Basem I
authors.initials: BI
authors.lastname: Awad
authors.affiliation: University Hospitals Case Medical Center, Cleveland, Ohio, USA.
authors.forename: Margaret A
authors.initials: MA
authors.lastname: Carmody
authors.affiliation: Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, USA.
authors.forename: Daniel
authors.initials: D
authors.lastname: Lubelski
authors.affiliation: Ain Shams School of Medicine, Cairo, Egypt.
authors.forename: Mohamed
authors.initials: M
authors.lastname: El Hawi
authors.affiliation: Division of Trauma, Critical Care, Burns, and Acute Care Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA.
authors.forename: Jeffrey A
authors.initials: JA
authors.lastname: Claridge
authors.affiliation: Division of Trauma, Critical Care, Burns, and Acute Care Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA.
authors.forename: John J
authors.initials: JJ
authors.lastname: Como
authors.affiliation: Neurological Institute, Center for Spine Health, Cleveland Clinic, Cleveland, Ohio, USA.
authors.forename: Thomas E
authors.initials: TE
authors.lastname: Mroz
authors.affiliation: Department of Orthopedic Surgery, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.
authors.forename: Timothy A
authors.initials: TA
authors.lastname: Moore
authors.affiliation: Department of Neurological Surgery, Case Western Reserve University School of Medicine and MetroHealth Spine Center, Cleveland, Ohio, USA. Electronic address: msteinmetz@metrohealth.org.
authors.forename: Michael P
authors.initials: MP
authors.lastname: Steinmetz
mesh_terms: D000058:Accidental Falls; D000063:Accidents, Traffic; D000328:Adult; D000368:Aged; D002574:Cervical Vertebrae / Q000293:injuries*; D005260:Female; D015600:Glasgow Coma Scale; D006801:Humans; D015601:Injury Severity Score; D008023:Ligaments, Articular / Q000293:injuries* / Q000473:pathology; D008279:Magnetic Resonance Imaging / Q000592:standards; D008297:Male; D008875:Middle Aged; D009820:Ohio; D012189:Retrospective Studies; D016103:Spinal Fractures / Q000150:complications* / Q000175:diagnosis* / Q000473:pathology / Q000628:therapy; D013124:Spinal Injuries / Q000150:complications* / Q000175:diagnosis* / Q000473:pathology / Q000628:therapy
keywords: Adjacent level ligamentous injury; Cervical spine trauma; Conservative treatment; Surgical management