The Cervical Spine

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The Cervical Spine
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The Problem

• 12,000 new spinal cord injuries every year
• Estimated that between 3 and 25 of patients
  with cervical spine injuries suffer extension of
  those injuries from delays in diagnosis or
  unwarranted manipulation in the emergency
  department

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The Solution

• A systematic approach that identifies spinal
  injuries/instability in a timely fashion
• Appropriate care of the spine until such
  injury/instability is ruled out

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Basis for mechanical stability of the cervical
spine

• Anterior column
• Middle column
• Posterior column

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ANTERIOR COLUMN

• Vertebral body and disc resist compression
• Anterior longitudinal ligament and annulus
  fibrosus resist distraction forces

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MIDDLE COLUMN

• Posterior vertebral body wall resists compression
• Posterior longitudinal ligament and posterior
  annulus fibrosus resists distraction
• Middle column is critical to maintaining
  stability and failure indicates serious injury

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POSTERIOR COLUMN

• Facet joints and lateral masses resist
  compression
• Facet capsules, interspinous ligaments, and
  supraspinous ligaments resist distraction

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Bony Anatomy
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Anatomy of the Occiput cervical junction

• Tectorial membrane is continuation of the PLL and
  provides stability of the occipitoatlantal
  articulation

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• Transverse atlantal ligament holds the dens
  against the anterior arch of the atlas and allows
  rotation

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Evaluation of C-spine

• History
• Physical exam
• Bony fractures demonstrated on X-ray or CT
• Ligamentous injury inferred from x-rays by the
  presence of abnormal angulation, translations ,
  separations, or soft tissue swelling

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History

• Mechanism of injury
• Neck pain
• Weakness
• Numbness or tingling
• Moving all extremities at the scene
• Loss of consciousness

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Mechanism of injury
Odds Radio for c-spine injury
Exact Mechanism Axial load, flexion, extension
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Mental Status

• Identify factors that will blunt the physical
  exam and prohibit clinically clearing the
  patients c-spine
• Alcohol or Drugs on board
• Closed head injury
• Distracting injury
• Unconscious
• Intubated

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Physical exam - observation

• Moving all extremities
• trauma to head, neck, or shoulders
• breathing pattern--watch for intercostals

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Physical Examination

• Log Roll
• Inspection Abrasions / Contusions
• Palpation Occiput to Sacrum
• Focal Tenderness
• Gaposis - Posterior Injury

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Neurologic Examination

• Cranial Nerves
• Motor Testing
• Sensory
• Pinprick
• Position / Vibratory
• Light Touch

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Neuro exam

• Spontaneous respiration implies motor function to
  C4

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Neuro exam
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Neuro exam
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Reflexes

• DTRs
• Superficial
• Pathologic
• Priaprism

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Neuro exam

• Pathologic reflexes
• Indicate an upper motor neuron lesion
• Babinski sign
• Oppenheims sign
• Hoffmans sign

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Incomplete vs complete injury

• Sacral sparing is indicative of an incomplete
  injury
• perianal sensation
• rectal motor function
• great toe flexor activity

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Frankel Score

• A Complete Motor / Sensory
• B Complete Motor / Incomplete Sensory
• C Incomplete Motor lt 3 / Incomplete Sensory
• D Incomplete Motor gt 3 / Incomplete Sensory
• E Normal

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Spinal shock

• After a severe spinal cord injury a state of
  complete spinal areflexia can develop
• over in 24-48 hours
• Bulbocavernosis reflex signifies the end of
  spinal shock

• Metabolic, rather than structural derangement
  (?ATP) that
• results in spinal cord dysfunction.

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Treatment of Spinal Cord Injury

• Most spinal cord deficit is attributed to
  contusion and/or compression rather than complete
  transection
• Microvasculature disruption is thought to
  propagate ischemia, edema, and cell membrance
  instability
• Treatment Methylprednisolone- bolus 30mg/kg
  followed by 5.4 mg/kg/hr x23 hours. Patients
  treated within 8 hours respond best
• Steroids suppress breakdown of cell membrances by
  inhibiting lipid peroxidation and hydrolysis

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X-rays or not

• In the alert patient without a distracting
  injury, with a history not suspicious for neck
  injury, completely negative neuro exam, and no
  symptoms you may clear the spine without x-rays
• If there is any doubt get x-rays

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Radiologic exam

• Trauma c-spine series
• AP
• lateral
• open mouth odontoid

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Lateral

• 85 of injuries found on this view
• Adequate films
• must see occiput to T-1
• need to be able to see soft tissue shadows
• Swimmers view or CT if unable to see to T1

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Lateral

• Specific things to look for
• anatomic lines
• translation greater than 3.5 mm
• angulation 11 greater than contiguous segments
• soft tissue swelling
• Facet joints
• Atlantodens interval (ADI) greater than 3-5mm
  indicates rupture of the transverse ligament
• Anterior Occipitoatlantal Dislocation (Powers
  Ratio)

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Lateral

• anatomic lines

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Lateral

• translation greater than 3.5 mm

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Abnormal Angulation

• angulation 11 greater than contiguous segments

• Disruption of the PLL
• Subluxation of C3 on C4

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Soft tissue swelling
C1 - 10 mm C2 -6mm C6 - 22mm
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Facet Dislocation

• unilateral

• Pure Dislocation Halo vs. Fusion

• Facet Fracture with Subluxation
• Posterior Fusion
• Plate or Oblique Wire

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Facet Dislocation

• bilateral

• 50 Subluxation
• Fracture 70 - 80
• Disc Herniation 10-40
• May Compress Cord Post Reduction

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Facet Dislocation Mechanism
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Anterior Occipitoatlantal Dislocation
Powers ratio
BC/OA If greater than 1 then anterior
occipitoatlantal dislocation exists
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Odontoid view

• Shows C1 burst fractures
• C1-2 alignment
• Dens fractures

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C1 Ring Fracture Classification

• Posterior Arch 28
• Jefferson Burst Fx
• Anterior Arch Blow Out
• Lateral Mass Fx
• Transverse Process Fx

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Jefferson Fracture

• Axial loading
• Open Mouth View
• Lateral Mass Spreading
• gt 6.9 mm Transverse Lig Avulsion
• CT 3 - 4 Part Fx

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Atlantodens interval (ADI)

• 3 mm in adults and 5mm in children
• Rupture of the transverse ligament

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C1 Burst Fracture Treatment

• Stable (Intact Transverse Ligament)
• Rx - Halo 10 - 12 wks

• Unstable
• Traction Reduction
• Halo 12 - 16 wks
• Late Instability - C1 - 2 Fusion

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Odontoid Fracture Classification
Anderson/Alonzo

• Type 1 Tip Avulsion
• Type 2 Waist
• Type 3 Body

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Odontoid Fracture

• Type 2

• Unstable
• Easily Missed
• 10 Spinal Cord Injury
• Poor Prognosis
• Assoc Fx 20 - 30
• C1 Arch

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Odontoid fracture

• Type 3

• Good prognosis
• Reduction
• Brace vs fixation

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AP

• Spinous processes should line up and have equal
  gaps
• sagital plane fractures
• lateral mass fractures
• facet fractures

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Complete the exam

• If films negative remove collar and complete exam
• palpation- one person supports the head with
  axial traction while the other palpates from
  occiput to T1
• tenderness
• swelling
• stepoff
• cannot rely on clinical exam if decreased mental
  status or distracting injury
• If symptomatic replace collar
• If negative then proceed to ROM

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Range of Motion

• Active ROM only
• flexion
• extension
• lateral bending
• rotation
• Should be full and pain free
• If Exam completely negative and films negative at
  this point may remove collar
• Write an order that C-spine is clear

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Flexion Extension films

• If done acutely muscle spasm or guarding may hide
  a ligamentous injury
• If unable to perform ROM but the rest of exam is
  negative, replace collar and have patient return
  in 10-14 days for flexion and extension views
• If flexion extension views are negative and the
  physical exam negative may discontinue c-collar

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Atlantoaxial Subluxation

• X-rays show increase of the atlantodens interval
  (gt than 3mm) on lateral projection

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Occipitoatlantal dislocation
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C1 fracture
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Odontoid fx
Type 2
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Hangmans Fracture of C2
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Unilateral Facet Dislocation
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Bilateral facet dislocation of C5-C6
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Flexion Tear drop fracture
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Clay Shovelers fx
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Anterior Wedge fx
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Burst fx
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ER
TWO WEEKS
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Mechanism of Injury
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Stability
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Obtunded patient with normal films

• Leave the collar on
• Dynamic Flouroscopy
• MRI