Larry D. Dodge, MD
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.
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.
Asymptomatic Trauma Patient
Cervical x-rays not required in patients without tenderness and are alert.
Trauma Patients with Neck Pain
2 to 6% incidence of significant spine injuries.
Do Not Remove Collar Until
Absence of tenderness
Absence of pain
Normal mental status
complete radiographic evaluation
Most Common Missed Diagnosis
Occipitoathlantoaxial region or cervicothoracic junction
Plain x-ray will miss 15 to 17% of injuries
CAT scan has 99% predictive value
MRI better for soft tissue, may be oversensitive
Flexion and Extension Radiographs
Safe in awake alert patients
Exclude significant instability
Obtunded Patient EvaluationControversial
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.
Fractures of the Cervical Spine
Most do not require surgery
Ligamentous injuries less predictable, and more require surgery
Types of OrthrosisHalo- 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.
Occipitocervical Dissocation
Most are lethal
Neurologic injuries vary from complete to cranial nerve injuries
Diagnosis can be difficult
Occipitocervical fusion is required
Atlas FracturesAxial load
Stability requires healing of transverse ligament – MRI
Halo- reasonable treatment
C1-C2 fusion if transverse ligament disrupted
Axis Fractures
Odontoid fractures are most common
Type I – Avulsion Type II – Waist Type III – Vertebral body
Type Odontoid
Treated with external orthrosis
Type Odontoid
Controversial treatment
Elderly do not tolerate halo – consider C1- C2 fusion
Fusion needed if reduction not achieved or maintained
Type Odontoid
High healing rate with halo vest
Traumatic Spondylolisthesis of Axis
MVA- hyperextension, compression and rebound flexion
Most treated in halo
Subaxial Compression Fractures
Failure of anterior column
Orthosis for 6 – 12 weeks
Subaxial Burst Fracture
Fracture into posterior cortex with retropulsion
Spinal cord injury rate is high
Most require surgery – anterior or anterior and posterior
Facet DislocationsTimely reduction required
Subluxation of 25% suggests unilateral, 50% suggests bilateral
MRI needed to assess for HNP
Failure of closed reduction mandates open reduction
Cervical Disk Disease
Symptoms can be insidious or acute
Minor injured can aggravate the root (radiculopathy) or spinal cord ( myelopathy)
PathophysiologyDisk 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
Cervical Roots exhibit a higher degree of overlap than seen in the thoracolumbar spine, therefore symptom patterns may fail to localize.
Hyporeflexia
Biceps
Brachioradialis C- 6
Triceps C- 7
Most Commonly Affected
C-5, C-6, C-7
More motion in these areas
Watershed area of blood supply – roots more susceptible
Myelopathy
Most commonly presents as clumsiness, ataxia, loss of fine motor skills.
Cervical Spondylosis
May cause radicular pain from nerve root origin
May cause referred sclerotomal pain ( occiput, interscapular region, or
shoulders)
Treatment
75% of radiculopathy improve with P.T. , activity modification, medication
Soft disk herniations can resorb
Myelopathy
Imaging StudiesPlain x-ray – alignment, spondylosis
Flexion – extension for instability
MRI
CAT – defines bone anatomy
Diskography
Electrodiagnostic Studies
Paresthesias cannot be localized
Imaging does not correlate with clinical picture
Nonsurgical Care
P.T. – emphasize isometric exercise
Traction with slight flexion
Medication
Epidural steroids
Surgical Indications
Success for axial pain is 60 %
Success for radiculopathy is 90%
Disk Replacement – evolving technology
ACDF
Allograft versus autograft
Plate fixation
Accelerates degeneration at adjacent levels
Posterior Decompression
Foraminotomy for bony foraminal stenosis
Laminectomy – risk of kyphosis
Laminectomy – decompression without adding fusion
Thank you
We will now move into the exam
part of the lecture.