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Copy of CERVICAL SPINE TRAUMA

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Jade Jucar

on 11 February 2014

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Transcript of Copy of CERVICAL SPINE TRAUMA

CERVICAL FRACTURE
BACKGROUND
Incidence of 15-40 new cases per million ppl annually.
Est. 6,000 deaths and 5,000 new cases of quadriplegia in the U.s each yr.

Relatively low incidence but high mortality and disability.

Imp to recognize injury and protect spine.

Etiology:
ANATOMY
7 Cervical Vertebrae

Spinal Cord

Intervertebral Discs

Supporting Ligaments

Neurovascular Structures

AXIAL VERTEBRAE
Functionally and anatomically unique.
Form complex articulations that allow for rotary motion
C1 (Atlas)
C2 (Axis)
Consists of an anterior vertebral body with superior projection called the Dens.

Dens (Odontoid process): Extension of the vertebral body into atlas ring.

Stabilized by the transverse ligament during rotation.

** Allows 50% of lateral rotation of the head.





SUB-AXIAL VERTEBRAE
C3-C7 vertebrae are fundamentally the same.

Increase in size toward lower end of vertebral column.

C7 most prominent spinous process

**Contributes to mobility of C-spine, but comparatively less mobile than axial C-spine.

INTERVERTEBRAL DISC
Supportive structures located btw vertebral bodies.

Annulus fibrosus: cartilaginous ring of tissue that surrounds the nucleus pulposus

Nucleus pulposus: soft gelatinous center

**Provide support, elasticity and cushioning to spine
**Account for 25% the spines height
LIGAMENTS
Complex network of ligaments that further stabilize the C-spine & maintain alignment

Anterior Longitudinal ligament (ALL)
Connects anterior aspect of vertebral bodies.
Resists hyperextension

Posterior Longitudinal ligament (PLL)
Connects posterior aspect of vertebral bodies.
Limits hyperflexion.

Ligamentum flavum (LF)
Connects vertebrae laminae
Forms posterior surface of spinal canal

Transverse ligament (TL)
Stabilizes C1/C2 during rotart mvmts
Ring like structure with A/P arches separated by lateral masses that articulate with the skull.

No vertebral body

Transverse ligament crucial in maintaining stability of C1/C2

** Supports the head
** Allows 50% of neck flexion & extension
NERVOUS SYSTEM
Complex network of spinal nerves that interconnect with Sympathetic Nervous System.

Nerve roots exit ABOVE corresponding vertebrae.

Foramina is largest at C2-C3, progressively decrease down to C6-C7
BLOOD SUPPLY
Consists of single Anterior and 2 Posterior vessels originating from vertebral arteries.

Run parallel to cervical spine through transverse foramen.

Supplemented by segmental medullary arteries.
PATHOPHYSIOLOGY
Injury occurs when forces applied overwhelms anatomic support structures.

Fatal injuries most common at cranio-cervical junction or atlanto-axial joint.

C1-C4 nerves control imp autonomic functions inc breathing. Injury often results in tetra/quadriplegia

**Imperative ED physician is able to recognize and stabilize cervical spine when injury suspected...
SPINE STABILITY
Ability of the spine to limit displacement of spinal cord under applied physiologic loads, preventing spinal cord injury.

Unfortunately not always clear to ED physician

C-spine injuries are unique and stability is dependent on multiple factors.

** Therefore all but the most minor C-spine fx must be treated as unstable injuries until proven otherwise.
IMAGING
Missed cervical spine injury can have devastating consequences.

ED physician should be able to decide if imaging is necessary.
Cervical spine injury should always be assumed until proven otherwise.

Immobilization helps prevent further injury and destabilization of C Spine.

MANAGEMENT
MECHANISM OF INJURY:
Flexion

Extension

Vertical compression

Rotation

Combination of all the above
Radiographs: AP, Lateral, Odontoid, *Swimmers
**Adequate film should include all 7 vertebrae and C7-T1 Junction

CT: Best imaging modality for detecting osseous abnormalities.
**Preferred imaging of choice at most centers.

MRI: Indicated when ligament or spinal cord injury is suspected.
However it's not practical to image the spine in EVERY trauma pt.

Guidelines have been developed to assist a physician's judgement in deciding whom to image...

NATIONAL EMERGENCY X-RADIOLOGY UTILIZATION STUDY (NEXUS)
LOW RISK CRITERIA
No posterior midline cervical spine tenderness
No evidence of intoxication
Alert mental status
No focal neurologic deficits
No painful distracting injuries

CANADIAN C-SPINE RULE (CCR)
GCS 15

High risk factors mandate radiology: Age>65, paresthesias in extremities, Dangerous mechanism (fall >3ft, >5 steps, axial load to head, MVC >62mph, ejection from vehicle)

Low risk factors allow ROM assessment: Absence of cervical spine tenderness, Simple rear end MVC, sitting position in ED, ambulatory at any time, delayed onset of neck pain

Actively rotate neck 45 degrees both left and right allows clearance of C-spine
**Sensitivity 99.6% and specificity 12.9%
**Sensitivity 100% & specificity 42.5%

MNEMONIC:
A- Alert mental status
B- Bony midline spine tenderness
C- CNS deficits
D- Distracting Injury
E- Etoh or drug intoxication
CCR SUMMARY
CCR is the NLC
Age >65
Mechanism of injury
Ranging neck 45 degrees L and R.

Allowing improved sensitivity and specificity for injury.

BUTTOM LINE
Any sig injury or concern for C-spine injury in a pt >65 yo IMAGE!!!

Otherwise use NEXUS.

If NEXUS is negative & there are no high risk criteria, remove collar and assess ability to range neck 45 degrees in either direction.
range neck 45 degrees
IMAGE!!!
NEXUS.
PRE-HOSPITAL SETTING
EMS provider follow standardized immobilization protocols.

On ED arrival, various immobilization modalities will usually be present.
Rigid backboard
Cervical Collar
Spider straps
Head blocks
Occipital padding

All serve to secure pt to back board, minimize mvmt and maintain neutral position of the spinal column.
ED evaluation of trauma pt with potential spinal cord injury does not differ substantially from any other trauma pt.

As always, ABCs are monitored first.

Special consideration for Immediate airway control.
Higher C-spine injuries associated with Respiratory or airway compromise

Injury above clavicle or sig. head injury with GCS <9 are at high risk of C-spine injury.
AIRWAY CONTROL
Use Manual Inline Stabilization (MILI) to minimize head mvmts during interventions. **Req. assistance
After mngmt of airway, attention to hemodynamic support and BP mngmt is essential

Hypotension is assoc. with worse outcomes and contributes to secondary injury due to reduced perfusion of the spinal cord

**Hypotension should NEVER be attributed to neurogenic shock until hemorrhage, cardiac injury and other trauma related causes have been managed or ruled out.
HYPOTENSION
If possible, neurological assessment should be performed before pt is intubated/sedated.

Detailed history:
LOC, Urine/Fecal incontinence, priapism

Physical Exam:
Delineate level of cord injury, midline tenderness, motor function, Sensory, DTR, Rectal tone.

**Cervical spine: arm abduction, elbow flexion/extension, finger abduction, hand grasp.
NEUROLOGIC EXAM
STEROIDS
Controversial in tx of acute spinal injury with abnormal neurological exam.

**Dont give Steroids without consultation with Neurosurgery or Orthopedic spine surgery.
National Acute Spinal Cord Injury Study (NACIS) evaluated efficacy of methylprednisolone in blunt spine trauma.
Positive outcomes dependent on dosage and time of administration.

American Associated of Neurological Surgeons:
"There is insufficient evidence to support its use."

Optional use recommended with awareness that evidence is more consistent with harmful side effects, than it's clinical benefit.
MYOFASCIAL PAIN
Limited guidelines for treating cervical strain without assoc. fx or neurological deficit.

Most common modality:
Rest, Ice, Analgesics, Muscle relaxant.

Evidence suggests:
Gentle ROM exercises & Ibuprofen.

+Spasms/NSAID CCI: cyclobenzaprine 5mg TID substituted with pcp f/u.

PT if necessary.
DISPOSITION
Early consultation with orthopedic spine or neurosurgery is critical to optimal mngmnt of c-spine injuries,

Early interventions provide the best pt outcomes

ICU care consultation and admission is indicated for unstable cervical spine fx or injury.
COMPLEX FRACTURES
XRAY - ODONTOID VIEW
CT - AXIAL VIEW
C1 JEFFERSON FRACTURE
Compressive downward force displacing C1 lateral masses laterally resulting in anterior/posterior arch fractures (Type I)

Instability may occur when associated with rupture of transverse ligament (Type II)

Mechanisms: Dive into shallow water, impact against roof of vehicle
C1 JEFFERSON FRACTURE
C2
C1
C1
A.D.I
Odontoid view diagnostic.

Displacement of lateral masses >7mm, rupture of transverse ligament is likely.

Atlanto-Dental Interval (A.D.I) >3mm indicative of ligament damage, >7mm indicative of rupture.
1.
2.
XRAY - LATARAL
OCCIPITO-ATLANTAL DISLOCATION (OAD)
Severe ligamentous injury to joint btw skull and cervical spine resulting in displacement of skull from C-spine.
-Anteriorly (Type I, most common)
-Longitudinally (Type II)
-Posteriorly (Type III)

Extremely unstable, high mortality rate. Often results in instantaneous death, severe neuro deficit.

Occur in 31% of fetal MVAs

More common in children, due to relatively larger skull size.



OCCIPITO-ATLANTAL DISLOCATION (OAD)
Prevertebral soft tissue swelling
Misalignment btw base of occiput and C1.

Subluxations may be subtle and may be overlooked. Catastrophic to pt.

Anatomic landmarks allow systematic approach to assessing cranio-cervical relationship.

POWERS RATIO
Landmarks btw margins of foramen magnum and anterior/posterior arches of C1

If ratio >1, anterior dislocation is likely.
B
O
A
C
BC

AC

=
1
HARRIS MEASUREMENTS
RULES of 12s

Distance btw basion and tip of Dens OR posterior axial line should not exceed 12mm

WACKENHEIM'S CLIVUS LINE
Line along posterior clivus should intersect or be tangentional to odontoid.
WIDENING OF ATLANTO-OCCIPITAL JOINT
Space btw condyles and atlas surface should be <5mm
Occurs as a result of traumatic impact causing hemorrhage, edema, & inflammatory changes

Neurologic deficits that occur may either be temporary or permanent.
SPINAL SHOCK VS NEUROGENIC SHOCK
SPINAL SHOCK:
Temp loss/depression of reflexes & sensorimotor fnctn below level of injury.

Physiologic response to trauma, lasting hours to days.
NEUROGENIC SHOCK:
Hemodynamic instability due to peripheral sympathetic denervation.

Hypotension, Bradycardia, Hypothermia.

**Dx should be one of exclusion!
SPINAL TRACTS
CORTICO-SPINAL TRACT:
Descending motor pathway

Damage: Ipsilat muscle weakness, spasticity, inc DTR
SPINOTHALAMIC TRACT:
Transmits pain & Temp sensation

Damage: Contralat loss of pain & Temp sensation below level of injury.
POSTERIOR COLUMN:
Transmits vibration & Proprioception

Damage: Ipsilat loss of vibration & position sense.

ONE DOES NOT SIMPLY
UNDERSTAND NEUROLOGY
ANTERIOR CORD SYNDROME
Injury to cortico-spinal & spinothalamic pathways.

Complete paralysis below lesion with loss of pain and temp sensation

Flexion injuries, thrombosis of anterior spinal artery.

Prognosis POOR
CENTRAL CORD SYNDROME
Injury to cortico-spinal & spinothalamic pathways.

Dec strength with variable loss of pain and temp.

Upper extremities > Lower extremities

Bladder dysfunction

Older pts with preexisting cervical spondylosis

Prognosis GOOD
BROWN SEQUARD SYNDROME
Hemisection of spinal cord

Ipsilat loss of motor fnctn, proprioceptive and vibratory sense.

Contralat loss of pain & temp

Disk protrusions, hematomas, tumors

Prognosis BEST
SCIWORA
Spinal cord injury on MRI without findings on Xray or CT

More common in pediatric population.

Generally considered stable.
3.
CT - Coronal
CT - Sagittal
ODONTOID FRACTURE
Fractures involving the C2 odontoid process/dens

Significant external trauma (MVCs, elderly falls)

15% of all C-spine fractures

Neurologic injury present in 20% of cases

Type II, III considered unstable.
TYPE 1
Avulsion fx at tip of odontoid process.

Uncommon

Stable

**Can be associated with occipital-atlanto dislocation
TYPE II
Fx at base of odontoid where it joins vertebral body.

Most common of C2 fx.

High prevalence of non-union (>50 yo, displacement >5mm)
TYPE III
Fx extending into body of C2

Very unstable
4.
CT - Sagittal
CT - Coronal
BURST FRACTURE
Downward force, driving discs into vertebral body producing comminuted, vertical fx.

Fragments may retropulse into spinal canal injuring cord.

Unstable
BURST FRACTURE
Wedged anterior portion of vertebral body.

Retropulsion inferred if posterior vertebral body convex toward spinal canal.
FLEXION FRACTURES
1.

XRAY - LATERAL
FLEXION TEARDROP FRACTURE
Fx of the anterior-inferior vertebral body.

Anteriorly displaced fragment sometimes resembles a tear drop.

Disruption of posterior ligaments results in retropulsion into spine.

70% of pts have neurological findings.

Highly unstable .


FLEXION TEARDROP FRACTURE
Avulsion fx of anterior vertebral body.

Prevertebral swelling assoc with ALL tear.

Vertebral body subluxation into spinal canal causing compression.

Occasionally, spinous process fx present.

2.
XRAY - LATERAL
SPINOUS PROCESS AVULSION FX (CLAY SHOVELERS'S FX)
CLAY SHOVELER'S FX
Avulsion fx through base of spinous process.

Intense hyperflexion combined with paraspinous muscle contraction pulling on spinous process.

Mechanisms include shoveling, direct blow to spinous process, occiput trauma.

Mechanically stable fx
Spinous process fx

Commonly occurs at C7

**Imperitive C7-T1 junction visualized.
3.
4.
XRAY - LATERAL
WEDGE FRACTURE
Compression fx as a result of hyperflexion.

Frequently involves only superior endplate.

Mechanically stable.
WEDGE FRACTURE
Buckled anterior cortex

Increased bone density

Diminished anterior vertebral body height
XRAY - LATERAL
UNILATERAL FACET DISLOCATION
Unilateral disruption of an interfacet joint due to anterior subluxation of the vertebral body.

Result of hyperflexion/Rotational forces that cause disruption of the posterior ligaments.

Vertebral artery injuries are common.

Mechanically stable.
UNILATERAL FACET DISLOCATION
Anterior dislocation of vertebral body <50% of AP diameter of vertebral body.

Interspinous widening

Rotation of involved vertebrae, with spinous process pointing towards side of dislocation.


BILATERAL FACET DISLOCATION
Bilateral dislocation of interfacet joints secondary to sig. anterior displacement of affected vertebral body.

Result of severe anterior subluxation and complete ligamentous disruption.

Very unstable
BILATERAL FACET DISLOCATION
Anterior dislocation of vertebral body >50% of AP diameter of vertebral body.

Disruption of anterior and posterior ligaments

Disc retropulsion common
17% of c-spine fx complicated by vertebral artery dissections/vasospasms.

High risk Fx include subluxations, transverse process fx & C1-C3 fx.

Angiography useful in these cases.

Unilateral injuries might be asymptomatic.

Clinical feature: vertigo, facial paresthesia, visual defects
VERTEBRAL ARTERY INJURY
EXTENSION FRACTURES
1.
XRAY - LATERAL
C-2 HANGMAN'S FRACTURE
Traumatic fx through both pedicles of C-2

Displaces vertebral body anteriorly, and posterior element posteriorly.

Mechanism of Injury: Hyperextension will fracture the pars interarticularis w/ secondary flexion injuring the disk and posterior ligament.

Low risk for spinal cord injury due to wide canal.

Mechanically unstable.
C-2 HANGMAN'S FRACTURE
Anterior dislocation of C2 vertebral body.

Bilateral Fx of C2 pedicles.

Disruption of ALL & SL line
Usually occur due to motor vehicle accidents.
ANTERIOR LONGITUDINAL LINE
SPINO-LAMINAR LINE
2.
XRAY- LATERAL
EXTENSION TEARDROP FRACTURE
Avulsion fx of inferior endplate secondary to forced hyperxtension.

True avulsion unlike flexion tear drop, which is due to compressive force.

Maybe normal radiophraphyically due to reduction of dislocationi by C-Collar.

Stable in flexion, unstable in extension


SPINAL CORD INJURIES
COMMON TYPES OF CERVICAL FRACTURE:

Jefferson Fracture
Hangman's Fracture
Odontoid Fracture
(Broken Neck)
Full transcript