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.