Disección arterial cérvico-cefálica post trauma en pediatría / Cervicocephalic arterial dissection post trauma in children

Introducción: la disección arterial cérvico-cefálica (DACC) es una causa importante de accidente cerebrovascular (ACV) en pediatría. Dentro de los factores de riesgo más relevantes están los traumas cervicales y cefálicos, presentes en el 50% de los casos. El pronóstico es variable y depende de la magnitud de oclusión de la arteria afectada. Es importante la detección precoz de esta patología, que muchas veces se presenta con pocos síntomas en pediatría, lo que genera retraso en el diagnóstico y tratamiento. Objetivo:presentar la evidencia disponible sobre DACC incluyendo DACC post trauma para familiarizar a los médicos generales y especialistas sobre la sospecha diagnóstica, diagnóstico enfocado en neuroimágenes y posibles manejos de esta patología. Métodos: se llevó a cabo una revisión bibliográfica de la literatura científica sobre esta condición. Dentro de los criterios de selección de los estudios se consideró la fecha de publicación, el diseño y la relevancia.Conclusiones: la DACC post trauma es una causa frecuente de ACV en pediatría. Se puede presentar con escasa sintomatología, por lo que es importante mantener una alta sospecha en contexto de trauma cervical o cefálico, implementando un diagnóstico y tratamiento precoces para mejorar el pronóstico de los pacientes.

Introduction:Craniocervical arterial dissection (CCAD) is a major cause of arterial ischemic stroke (AIS) in children. The most important risk factors are cervical and cephalic traumas, present in 50% of all cases.The prognosis changes depending on the magnitude of the artery affected. Early detection of this pathology is important. It many times presents itself with few symptoms, which generates a de-lay in its diagnosis and treatment. Objective: To present the evidence available on CCAD, including CCAD post-trauma,to familiarize general physicians and specialists with this diagnosis, neuroimages required, and possible treatments.Methods: Extensive revision of bibliographic scientific literature about this condition. The criteria selection to include studies in this review were the date of publication, the design of the study, and their relevance.Conclusions: the CCAD post-trauma is asignificant cause of AIS in children. It can present itself with mild symptomatology, which is why it is relevant to suspect it in the context of cervical or cephalic trauma, aiming for an early diagnosis and treatment to improve the outcome of patients.

Unión cráneo-cervical - anatomía normal y correlación con imágenes / Cranio Cervical Junction - Anatomy and Imaging Correlation

La solicitud de estudios de imagen en pacientes con trauma cervical es muy frecuente en la práctica diaria. Esa patología es causa relativamente frecuente de discapacidad en pacientes jóvenes junto con el trauma encéfalo craneano. En un porcentaje no despreciable de los casos, las lesiones traumáticas comprometen la unión cráneo- cervical y en esos pacientes, la morbi-mortalidad es más significativa. La transición entre el cráneo y el raquis se basa en un conjunto de estructuras óseas relacionadas por articulaciones muy móviles y estabilizadas por un grupo de ligamentos y músculos que le brindan al mismo tiempo gran solidez. Para una correcta interpretación de los estudios de imagen de uso corriente en la clínica, es fundamental un sólido conocimiento anatómico de la unión cráneo-cervical y sus componentes. Es el objetivo de esta revisión, sistematizar la anatomía de la unión cráneo-cervical con especial énfasis en sus ligamentos, analizar la fisiología de sus movimientos y el concepto de estabilidad para luego realizar una correlación con tomografía computada multi-detector y resonancia magnética.

The request of imaging techniques in patients with cervical spine trauma is very common in clinical practice. Cervical trauma is a relatively common cause of disability in young patients. In a significant percentage of cases traumatic injuries compromise the cranio-cervical junction with more important morbidity and mortality in this group of patients. The transition between the skull and the spine is based on a set of bony structures, high mobility joints, and stabilization mechanism formed by a group of ligaments and muscles. A solid anatomical knowledge of the cranio-cervical junction and its components is essential for a correct interpretation of current high resolution imaging studies. The goal of this review is highlight the anatomy of the cranio-cervical junction with special emphasis on the ligaments, analyze the biomechanics of their movements and the concept of stability. At last but not leastwe will establish a correlation with multidetector computed tomography and high-resolutionmagnetic resonance imaging.

Comparison of effectiveness of intubation by way of "Gum Elastic Bougie" and "Intubating Laryngeal Mask Airway" in endotracheal intubation of patients with simulated cervical trauma / Comparação da eficácia de intubação por meio de guia introdutor Bougie de tubo endotraqueal e máscara laríngea em intubação traqueal de pacientes com trauma cervical simulado

Abstract Purpose: In this study, we evaluated the effectiveness of intubations by way of "Gum Elastic Bougie" and "Intubating Laryngeal Mask Airway" in endotracheal intubation of patients with simulated cervical trauma. Method: 134 patients were included in the study. All patients were placed cervical collar for a simulated cervical trauma. Patients were allocated randomly into three groups: Group NI (n = 45) intubation with Macintosh laryngoscopy, Group GEB (n = 45) intubation with Gum Elastic Bougie, and Group ILMA (n = 44) intubation with Intubating Laryngeal Mask Airway. The number of intubation attempts, success of intubation, duration of complete visualization of the larynx, duration of intubation, user's performance score, hemodynamic changes and the observed complications were recorded. Results: Success of intubation in the first attempt was highest in Group GEB while it was lowest in Group ILMA. Regarding the intubation success, rates of successful intubation were 95.6%, 84.4% and 65.9% in Groups GEB, NI, and ILMA, respectively. Durations of visualization of larynx and intubation were shorter in Groups NI and GEB than in Group ILMA. This difference was statistically significant (p < 0.05) while there was no significant difference between Groups NI and GEB. The number of patients with "good" intubation performance was significantly higher in Group GEB while the number of patients with "poor" intubation performance was significantly higher in Group ILMA (p < 0.05). Conclusions: We conclude that GEB, which is cheap and easily accessible, should be an advantageous choice in cervical trauma patients for both the easeness of intubation and patient morbidity and mortality.

Resumo Objetivo: Neste estudo avaliamos a eficácia de intubações por meio de guia introdutor Bougie e máscara laríngea em intubação endotraqueal de pacientes com trauma cervical simulado. Método: Foram incluídos no estudo 134 pacientes. Colar cervical foi colocado em todos os pacientes para um trauma cervical simulado. Os pacientes foram alocados aleatoriamente em três grupos: Grupo NI (n = 45) foi submetido à intubação com laringoscópio Macintosh; Grupo ITE (n = 45) foi submetido à intubação com guia introdutor de tubo endotraqueal e Grupo ML (n = 44) foi submetido à intubação com máscara laríngea. Número de tentativas de intubação, sucesso de intubação, tempo de visualização completa da laringe, tempo de intubação, escore de desempenho do usuário, alterações hemodinâmicas e complicações observadas foram registrados. Resultados: O sucesso da intubação na primeira tentativa foi maior no Grupo ITE e menor no grupo ML. Ainda em relação ao sucesso da intubação, as taxas de sucesso foram 95,6%, 84,4% e 65,9% nos grupos ITE, NI e ML, respectivamente. Os tempos de visualização da laringe e de intubação foram menores nos grupos NI e ITE do que no Grupo ML. Essa diferença foi estatisticamente significativa (p < 0,05), enquanto não houve diferença significativa entre os Grupos NI e ITE. O número de pacientes com bom desempenho na intubação foi significativamente maior no grupo ITE, enquanto o número de pacientes com mau desempenho na intubação foi significativamente maior no grupo ML (p < 0,05). Conclusões: Concluímos que o ITE, que é barato e facilmente acessível, deve ser uma opção vantajosa em pacientes com trauma cervical, tanto pela facilidade de intubação quanto devido à taxa de morbidade e mortalidade dos pacientes.

Evaluation of alar ligament injury with MR proton-weighted imaging / 中华放射学杂志

Objective To investigate the imaging features of alar ligament and its extent, and provide the basis forclinical treatment.Methods 3.0 T superconducting MRI was used to scan the alar ligament with high resolution PDWI sequence (Proton density weighted imaging, PDWI)in 109 patients of emergency admissions due to head and neck trauma. Based on imaging features, ligamentous injury was classified into three degrees(Ⅰ to Ⅲ degrees).Patients with Ⅰ degree ligamentous injury were treated conservatively, andⅡtoⅢdegree injury patients were treated with surgery, then follow-up was performed with MRI for the recovery of ligaments and clinical evaluation for symptoms (6 months follow-up period). Results High-resolution PDWI showed 78 patients with no ligament injury.On follow-up, patients recovered well (atlantoaxial joint motor function and clinical symptoms). Thirty one patients had alar ligament injury in varying degrees, of which 18 patients had grade Ⅰ injury, nine patients had degree Ⅱinjury, and four patients had degreeⅢinjury .All gradeⅠinjury patients received conservative treatment. Follow-up of patients showed good recovery, MR revealed the lesions shrank in varying degrees or disappear. Six gradeⅡinjury patients had surgical treatment, and three received conservative treatment. On follow-up, seven patients had a good recovery, two patients underwent surgical treatment within 3 months after injury and recovered well.Three gradeⅢpatients treated by surgery, and all with good recovery postoperative, and a patient died of respiratory failure. Conclusions High resolution PDWI is an effective tool to evaluate the extent of the alar ligament injury. Grade Ⅰ ligamentous injury patients treated conservatively can achieve good results, GradeⅡandⅢligamentous injury patients should receive surgical treatment early.

Delayed Vertebral Artery Dissection after Posterior Cervical Fusion with Traumatic Cervical Instability: A Case Report

Vascular injury presented immediately after the penetration, but delayed onset of vascular symptom caused by an embolism or vessel dissection after cervical fusion or traumatic event is extremely rare. We present a case of a 56-year-old woman who underwent an operation for cervical fusion for type II Odontoid process fracture. She presented symptoms of seizure with hemiparesis in 6 days after the operation. Multifocal acute infarction due to an embolism from the left VA (V3 segment) dissection was observed without a definite screw breach the transverse foramen. We hereby reported the instructive case report of delayed onset of vertebral artery dissection after posterior cervical fusion with type II odontoid process fracture patient. When a cervical operation performed in the cervical trauma patient, even if no apparent VA injury occurs before and during the operation, the surgeon must take caution not to risk cerebral infarction because of the delayed VA dissection.

Delayed Brain Infarction due to Bilateral Vertebral Artery Occlusion Which Occurred 5 Days after Cervical Trauma

Vertebral artery (VA) injuries usually accompany cervical trauma. Although these injuries are commonly asymptomatic, some result in vertebrobasilar infarction. The symptoms of VA occlusion have been reported to usually manifest within 24 hours after trauma. The symptoms of bilateral VA occlusions seem to be more severe and seem to occur with shorter latencies than those of unilateral occlusions. A 48-year-old man had a C3-4 fracture-dislocation with spinal cord compression that resulted from a traffic accident. After surgery, his initial quadriparesis gradually improved. However, he complained of sudden headache and dizziness on the 5th postoperative day. His motor weakness was abruptly aggravated. Radiologic evaluation revealed an infarction in the occipital lobe and cerebellum. Cerebral angiography revealed complete bilateral VA occlusion. We administered anticoagulation therapy. After 6 months, his weakness had only partially improved. This case demonstrates that delayed infarction due to bilateral VA occlusion can occur at latencies as long as 5 days. Thus, we recommend that patients with cervical traumas that may be accompanied by bilateral VA occlusion should be closely observed for longer than 5 days.

Interobserver and Intraobserver Reliability of Sub-Axial Injury Classification and Severity Scale between Radiologist, Resident and Spine Surgeon

OBJECTIVE: The sub-axial injury classification (SLIC) and severity scale was developed to decide whether to operate the cervical injured patient or not, but the reliability of SLIC and severity scale among the different physicians was not well known. Therefore, we evaluated the reliability of SLIC among a spine surgeon, a resident of neurosurgery and a neuro-radiologist. METHODS: In retrograde review in single hospital from 2002 to 2009 years, 75 cases of sub-axial spine injured patients underwent operation. Each case was blindly reviewed for the SLIC and severity scale by 3 different observers by two times with 4 weeks interval with randomly allocated. The compared axis was the injury morphology score, the disco-ligamentous complex score, the neurological status score and total SLIC score; the neurological status score was derived from the review of medical record. The kappa value was used for the statistical analysis. RESULTS: Interobserver agreement of SLIC and severity scale was substantial agreement in the score of injury morphology [intraclass correlation (ICC)=0.603] and total SLIC and severity sacle (ICC value=0.775), but was fair agreement in the disco-ligamentous complex score (ICC value=0.304). Intraobserver agreements were almost perfect agreement in whole scales with ICC of 0.974 in a spine surgeon, 0.948 in a resident of neurosurgery, and 0.963 in a neuro-radiologist. CONCLUSION: The SLIC and severity scale is comprehensive and easily applicable tool in spine injured patient. Moreover, it is very useful tool to communicate among spine surgeons, residents of neurosurgery and neuro-radiologists with sufficient reproducibility.

Accuracy and Safety in Pedicle Screw Placement in the Thoracic and Lumbar Spines : Comparison Study between Conventional C-Arm Fluoroscopy and Navigation Coupled with O-Arm(R) Guided Methods

OBJECTIVE: The authors performed a retrospective study to assess the accuracy and clinical benefits of a navigation coupled with O-arm(R) system guided method in the thoracic and lumbar spines by comparing with a C-arm fluoroscopy-guided method. METHODS: Under the navigation guidance, 106 pedicle screws inserted from T7 to S1 in 24 patients, and using the fluoroscopy guidance, 204 pedicle screws from T5 to S1 in 45 patients. The position of screws within the pedicle was classified into four groups, from grade 0 (no violation cortex) to 3 (more than 4 mm violation). The location of violated pedicle cortex was also assessed. Intra-operative parameters including time required for preparation of screwing procedure, times for screwing and the number of X-ray shot were assessed in each group. RESULTS: Grade 0 was observed in 186 (91.2%) screws of the fluoroscopy-guided group, and 99 (93.4%) of the navigation-guided group. Mean time required for inserting a screw was 3.8 minutes in the fluoroscopy-guided group, and 4.5 minutes in the navigation-guided group. Mean time required for preparation of screw placement was 4 minutes in the fluoroscopy-guided group, and 19 minutes in the navigation-guided group. The fluoroscopy-guided group required mean 8.9 times of X-ray shot for each screw placement. CONCLUSION: The screw placement under the navigation-guidance coupled with O-arm(R) system appears to be more accurate and safer than that under the fluoroscopy guidance, although the preparation and screwing time for the navigation-guided surgery is longer than that for the fluoroscopy-guided surgery.

Máscara laríngea proseal, una alternativa en el trauma cervical quirúrgico / ProSeal laryngeal mask, an alternative in the surgical cervical trauma

Introducción: la intubación endotraqueal es el método que más se indica para permeabilizar la vía aérea en el paciente con traumatismo raquimedular que requiere ventilación mecánica. Objetivo: comparar los resultados del uso de la máscara laríngea proseal vs. tubo endotraqueal, en pacientes con lesión cervical traumática con cirugía de columna cervical electiva. Métodos: se realizó un estudio analítico de casos y controles, en un período de 5 años. Se obtuvo una muestra de 158 pacientes con lesión cervical que acudieron al centro de trauma con criterios de fijación de columna cervical y corrección quirúrgica electiva. Se crearon 2 grupos mediante un muestreo aleatorio: un grupo estudio (máscara laríngea proseal), y un grupo control (tubo orotraqueal). El procesamiento de los datos incluyó el cálculo de medidas de resumen para variables cualitativas, y para el contraste de hipótesis de homogeneidad entre los grupos de estudio se empleó el chi cuadrado, con un nivel de significación p< 0,05. Resultados: predominaron pacientes entre 20 y 30 años de edad, del sexo masculino. Con el uso de la máscara laríngea se logró permeabilizar la vía aérea en más del 90 por ciento de los casos durante el primer intento; con la colocación del tubo endotraqueal solo se logró en el 70 por ciento de los pacientes. Los tiempos requeridos para establecer una ventilación adecuada fueron menores en los que se utilizó la máscara laríngea, que en los que se utilizó el tubo endotraqueal, con diferencias significativas desde el punto de vista estadístico, y mínimas complicaciones tras el uso de la máscara laríngea proseal. Conclusiones: se demostró que la máscara laríngea proseal resultó más efectiva para el tratamiento de la vía aérea en pacientes con trauma cervica(AU)

Introduction: the endotracheal intubation is the more used method for airways permeability in the patient presenting with rachimedullary requiring mechanical ventilation. Objective: to compare the use of the ProSeal laryngeal mask versus endotracheal tube in patients presenting with traumatic cervical injury with elective cervical spine surgery. Methods: a case/control and analytical study was conducted over 5 years. The sample included 158 patients presenting with cervical injury who came to our trauma center with criteria of cervical spine fixation and elective surgical correction. Two groups were created by randomized sampling: a study group (ProSeal laryngeal mask) and a control group (orotracheal tube). Data processing included the estimation of summary measures for qualitative variables and for the contrast of homogeneity hypothesis among the study groups authors used the Chi² test with a significance level of p< 0,05. Results: there was predominance of patients aged 20 and 30 and of male sex. With the use of laryngeal mask it was achieved the permeation of airway in more than 90 percent of cases during the first attempt; with the placement of endotracheal tube only it was achieved in the 70 percent of patients. Times required to establish appropriate ventilation were less in those where we used laryngeal mask than in those with endotracheal tube with significant differences from the statistical point of view and less complications after the use of the above mentioned mask. Conclusions: it was demonstrated that theis type of mask was more effective for airway treatment in patients presenting with cervical trauma(AU)

Optimal Use of the Halo-Vest Orthosis for Upper Cervical Spine Injuries

PURPOSE: Upper cervical fractures can heal with conservative treatments such as halo-vest immobilization (HVI) and Minerva jackets without surgery. The most rigid of these, HVI, remains the most frequently used treatment in many centers despite its relatively high frequency of orthosis-related complications. We conducted this study to investigate the clinical outcome, effectiveness, patient satisfaction, and associated complications of HVI. MATERIALS AND METHODS: From April 1997 to December 2008, we treated 23 patients for upper cervical spinal injuries with HVI. For analysis, we divided high cervical fractures into four groups, including C1 fracture, C2 dens fracture, C2 hangman's fracture, and C1-2 associated fracture. We evaluated the clinical outcome, complications, and patient satisfaction through chart reviews and a telephone questionnaire. RESULTS: The healing rate for upper cervical fracture using HVI was 60.9%. In most cases, bony healing occurred within 16 weeks. Older patients required longer fusion time. We observed a 39.1% failure rate, and 60.9% of patients experienced complications. The most common complications were frequent pin loosening (34.8%; 8/23) and pin site infection (17.4%; 4/23). The HVI treatment failed in 66.7% of patients with pin site problems. The patient approval rate was 31.6%. CONCLUSION: The HVI produced frequent complications and low patient satisfaction. Bony fusion succeeded in 60.9% of patients. Pin site complications showed a tendency to influence the outcome of HVI, and would be promptly addressed to prevent treatment failure if they develop. The decision to use HVI requires an explanation to the patient of potential complications and constant vigilance to prevent such complications and unsatisfactory outcomes.

Traumatic Cervical Cord Transection without Facet Dislocations-A Proposal of Combined Hyperflexion-Hyperextension Mechanism: A Case Report

A patient is presented with a cervical spinal cord transection which occurred after a motor vehicle accident in which the air bag deployed and the seat belt was not in use. The patient had complete quadriplegia below the C5 level and his imaging study showed cervical cord transection at the level of the C5/6 disc space with C5, C6 vertebral bodies and laminar fractures. He underwent a C5 laminectomy and a C4-7 posterior fusion with lateral mass screw fixation. Previous reports have described central cord syndromes occurring in hyperextension injuries, but in adults, acute spinal cord transections have only developed after fracture-dislocations of the spine. A case involving a post-traumatic spinal cord transection without any evidence of radiologic facet dislocations is reported. Also, we propose a combined hyperflexion-hyperextension mechanism to explain this type of injury.

Soft Tissue Damage in Cervical Spine Extension Injury / 대한정형외과학회잡지

PURPOSE: To diagnose the extent of soft tissue damage with MRI, and to evaluate the relationship between soft tissue damage and a spinal cord injury in an extension injury to the lower cervical spine trauma. MATERIALS AND METHODS: Eighty-one patients who treated surgically for an anextension injury to the cervical spine over the past 5 years, were analyzed. All patients had undergone MRI after the injury, and for the specific grading of soft tissue damage, the grades were defined from grades 1 to 5. RESULTS: The spinal cord injury developed with more than grade 3 soft tissue damage associated with a rupture of the posterior longitudinal ligament (p<0.01). The changes in signal intensity of the spinal cord also developed according to the severity of soft tissue damage (p<0.01). There was no relationship between the soft tissue damage and the spinal cord injury in spinal stenosis (p=0.75). CONCLUSION: The extent of soft tissue damage was diagnosed precisely with MRI, and there was an close relationship between the soft tissue damage and spinal cord injury in the distractive- extension injury to the lower cervical spine trauma.

Relationship between Soft Tissue Damages and Spinal Cord Injury in Lower Cervical Spine Trauma / 대한정형외과학회잡지

PURPOSE: To determine the implications of soft tissue damage and to evaluate the correlations between the extent of soft tissue damages and spinal cord injury after a lower cervical spine trauma. MATERIALS AND METHODS: This study analyzed the medical records, plain radiograms, and MRI of the consecutive 89 patients who underwent operative treatment in the lower cervical trauma. The radiological parameters of soft tissue damage including anterior longitudinal ligament (ALL), intervertebral disc (Disc), posterior longitudinal ligament (PLL), ligamentum flavum (LF), interspinous ligament (ISL), supraspinous ligament (SSL), posterior muscle group (PM), cord compression (CC), and cord signal changes (CS) were evaluated using plain radiograms and magnetic resonance imaging. The relationship between the level of cord injury and the type of soft tissue damage, injury type and severity was determined. RESULTS: There was a significant correlation between the extent of cord injury and the injury type. Cord injury frequently occurred as a result of compressive extension (3 of 4 cases), combined injury (4 of 7 cases) and distractive extension (14 of 23 cases). On the other hand, only 11 of the 16 cases with compressive flexion had a cord injury. In the distractive-extension cord injury cases (2 out of 10 cases in stage I, 12 out of 13 cases in stage II) the frequency of cord injury increased with increasing degree of the soft tissue damage. The incidence of cord injury was higher in the distractive-flexion cases (stage I, 0 out of 6 cases, stage II, 8 out of 35 cases, stage III, 3 out of 5 cases), (p=0.082). Multiple logistic analysis revealed a significant correlation between the cord injury and soft tissue damage including parameters such as the injury type, PLL injury, CC and CS. There was more frequent cord injury encountered in patients with more extensive injuries to the posterior neck muscles (p=0.063). CONCLUSION: There was a significant correlation between the injury type and the incidence of cord injury. In distractive extension and distractive flexion, there was more increasing incidence of cord injury with increasing severity of the injury. In addition, there was a high incidence of cord injury associated with not only the injury type but also a PLL and posterior neck muscle injury.

Propriospinal Myoclonus: Clinical and Neurophysiologic Characteristics

BACKGROUND: Propriospinal myoclonus (PSM) is characterized by rhythmic or arrhythmic, flexion or extension movements of the axial body muscles involving many spinal segments linked by long propriospinal pathways. We described the clinical and electrophysiological features of 7 PSM patients. METHODS: Neurophysiologic studies included routine electroencephalography, polymyography, and posterior tibial somatosensory evoked potentials (PTSEP). RESULTS: Myoclonic jerks originated from the rectus abdominis in 3 patients, and pectoralis major, thoracic paraspinalis, sternocleidomastoid, and vastus lateralis in every other case. Polymyography showed rostral and caudal propagations from the originated muscles. The durations of myoclonic jerks were about 100 to 400 ms and their velocities ranged from 3.2 to 6.7 (5.4+/-1.4) m/s. PSM developed after cervical trauma in 2 patients (cases 1, 2), after general anesthesia in case 4, and after infectious or inflammatory myelopathy in case 3. PSM in 3 patients were idiopathic, of which one patient had diabetes mellitus for 10 years with autonomic and somatosensory polyneuropathy. Two patients, who showed PSM after general anesthesia and myelopathy respectively, were cured completely within one month. Though others had not completely recovered, they had a relatively benign course. CONCLUSIONS: In our cases, the generators of myoclonus seemed to be most commonly located in the midthoracic lesion of the spinal cord with up and down propagation of slowly conducting pathways, such as propriospinal fibers. Cervical trauma can lead to the partial release of a spinal pattern generator, which is capable of recruiting muscles through long propriospinal pathways into complex rhythmic activity.

Applications of MSCT in Acute Cervical Trauma Examination / 医疗卫生装备

Objective To analyze the application of MSCT in A.C.T. Methods MSCT and CR examination results of 41 A.C.T cases were compared and analyzed by 3 doctors. Results Compared with plain flim,MSCT markly increased the fracture detection rate. Conclusion MSCT is precise and safe in the diagnosis of A.C.T.