Evaluation and Treatment of the Cervical Spine

1
Evaluation and Treatment of the Cervical Spine

• Larry D. Dodge, MD

2
Clinical Evaluation

• Proper Immobilization
• Assume a spine injury with head or neck trauma
• 3 to 25 of spinal cord injuries occur after
  initial traumatic episode.

3
Ankylosing Spondylitis or DISH

• Increased risk of fracture even with minor
  trauma
• Frequent through ossified disk space
• Obtain a CAT scan
• Very unstable spinal cord injuries.

4
Asymptomatic Trauma Patient

• Cervical x-rays not required in patients without
  tenderness and are alert.

5
Trauma Patients with Neck Pain

• 2 to 6 incidence of significant spine injuries.

6
Do Not Remove Collar Until

• Absence of tenderness
• Absence of pain
• Normal mental status
• complete radiographic evaluation

7
Most Common Missed Diagnosis

• Occipitoathlantoaxial region or cervicothoracic
  junction
• Plain x-ray will miss 15 to 17 of injuries

8

• CAT scan has 99 predictive value
• MRI better for soft tissue, may be oversensitive

9
Flexion and Extension Radiographs

• Safe in awake alert patients
• Exclude significant instability

10
Obtunded Patient Evaluation

• Controversial
• MRI- limited usefulness, lack of correlation
  between MRI and significant injury
• Passive flexion extension x-ray possible
  iatrogenic injury
• Combination of CAT and plain x-ray probably
  standard.

11
Fractures of the Cervical Spine

• Most do not require surgery
• Ligamentous injuries less predictable, and more
  require surgery

12
Types of Orthrosis

• Halo- the best, especially at upper cervical
• Soft collars little immobilization
• Semi rigid- ( Miami J, Philadelphia, Aspen)
  still allow motion
• 8-12 weeks of immobilization required with
  follow-up flexion and extension x-ray.

13
Occipitocervical Dissocation

• Most are lethal
• Neurologic injuries vary from complete to cranial
  nerve injuries
• Diagnosis can be difficult
• Occipitocervical fusion is required

14
Atlas Fractures

• Axial load
• Stability requires healing of transverse ligament
  MRI
• Halo- reasonable treatment
• C1-C2 fusion if transverse ligament disrupted

15
Axis Fractures

• Odontoid fractures are most common
• Type I Avulsion
• Type II Waist
• Type III Vertebral body

16
Type ? Odontoid

• Treated with external orthrosis

17
Type ?? Odontoid

• Controversial treatment
• Elderly do not tolerate halo consider C1- C2
  fusion
• Fusion needed if reduction not achieved or
  maintained

18
Type ??? Odontoid

• High healing rate with halo vest

19
Traumatic Spondylolisthesis of
Axis

• MVA- hyperextension, compression and rebound
  flexion
• Most treated in halo

20
Subaxial Compression Fractures

• Failure of anterior column
• Orthosis for 6 12 weeks

21
Subaxial Burst Fracture

• Fracture into posterior cortex with retropulsion
• Spinal cord injury rate is high
• Most require surgery anterior or anterior and
  posterior

22
Facet Dislocations

• Timely reduction required
• Subluxation of 25 suggests unilateral, 50
  suggests bilateral
• MRI needed to assess for HNP
• Failure of closed reduction mandates open
  reduction

23
Cervical Disk Disease

• Symptoms can be insidious or acute
• Minor injured can aggravate the root
  (radiculopathy) or spinal cord ( myelopathy)

24
Pathophysiology

• Disk loses water and proteoglycan content changes
  less able to support load
• Decreased disk height leads to loss of lordosis
• Osteocartilaginous overgrowth occurs in response
  to increased load stenosis develops

25

• Cervical Roots exhibit a higher degree of
  overlap than seen in the thoracolumbar spine,
  therefore symptom patterns may fail to localize.

26
Hyporeflexia

• Biceps
• Brachioradialis C- 6
• Triceps C- 7

27
Most Commonly Affected

• C-5, C-6, C-7
• More motion in these areas
• Watershed area of blood supply roots more
  susceptible

28
Myelopathy

• Most commonly presents as clumsiness, ataxia,
  loss of fine motor skills.

29
Cervical Spondylosis

• May cause radicular pain from nerve root origin
• May cause referred sclerotomal pain
• ( occiput, interscapular region, or shoulders)

30
Treatment

• 75 of radiculopathy improve with P.T. , activity
  modification, medication
• Soft disk herniations can resorb
• Myelopathy

31
Imaging Studies

• Plain x-ray alignment, spondylosis
• Flexion extension for instability
• MRI
• CAT defines bone anatomy
• Diskography

32
Electrodiagnostic Studies

• Paresthesias cannot be localized
• Imaging does not correlate with clinical picture

33
Nonsurgical Care

• P.T. emphasize isometric exercise
• Traction with slight flexion
• Medication
• Epidural steroids

34
Surgical Indications

• Success for axial pain is 60
• Success for radiculopathy is 90
• Disk Replacement evolving technology

35
ACDF

• Allograft versus autograft
• Plate fixation
• Accelerates degeneration at adjacent levels

36
Posterior Decompression

• Foraminotomy for bony foraminal stenosis
• Laminectomy risk of kyphosis
• Laminectomy decompression without adding fusion

37
Thank you

• We will now move into the exam
• part of the lecture.