Adjacent Level Ligamentous Injury Associated with Traumatic Cervical Spine Fractures: Indications for Imaging and Implications for Treatment.

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.