4Canadian Cervical Spine Rule for Radiographic Examination Sensitivity: 99.4%Specificity: 45.1%Active Rotation because of muscle spasming to protect.Stiell IG, Clement C, et al. The CanadianC-Spine Rule versus the Nexus Low-RiskCriteria in Patients with Trauma.JAMA 2003, 349;26
5Canadian Cervical Spine Rule for Radiographic Examination Stiell et al in 2003 examined patients to determine the characteristics of those who had positive cervical spine fractures versus those who were negative.By following these rules, the number of unnecessary radiographs for the cervical spine was decreased dramatically(full text article)
6ImportanceBy following the Canadian Cervical Spine Rules, A clinician can be reasonably certain that a patient needs a radiograph of the cervical spine.Sensitivity is high, - SnNout- therefore, if following these rules and the tests are negative, and you send the patient for a radiograph, only 1% will have a fracture. 99% will not have a fracture.Specificity is mid range - SpPin - therefore, if the tests are positive, you send the patient for a radiograph, only 45% will have a fracture.
7Fractures of the Cervical Spine Musculoskeletal Practice Pattern G75% of all spine fractures occur in the cervical spine due to the instability of the atlanto-occipital joints
8Jefferson’s Fracture: Burst Fracture of C1.Head holder, so fragments everywhere, very unstable, neck brace or halo.1. MOI: Axial Compression2. Radiograph: odontoid view, greater than 7 mm difference between both lateral massesof the atlas and those of the axis.3. Unstable Fracture
10Hangman’s Fracture:Fracture of the neural arch of the axis, fractures the pedicles of C2 with dislocation of C2 on C31. MOI: Hyperextensiona blow on the forehead forcing the neck into extension is a classic mechanism of injury producing fractures thru the pedicles2. Radiograph: lateral view shows bilateraldisruption through the pedicles of the axis3. Unstable fractureVery unstable
11Hangman’s FracturesCan be common in car accidents.
12Hangman’s FractureNeuro Rehab: where the fragments go determines the nerve damage, could be very sever.
13Dens FracturesType 1: (A ) avulsion of the tip of the dens as a result of apical or alar ligament stressType 2: (B) fracture of the junction of the dens with the body of the axis.Type 3: (C) fracture deep within the body below the dens.Type 4: see belowDens is not stable so lots of neuro issues
14Dens FracturesLeft: Type 2 dens fracture at the junction of the dens with the vertebral body with posterior displacementRight: fracture of the dens with posterior displacement of the atlas causing a small degree of spinal canal compression
15CT scan of odontoidFractures Type 3Notice on this CT scanThe foramen for theVertebral arteryemedicine.medscape.com/article/94234-media
16Dens FractureType 4: sagittal or parasagittal fracture extending from a point lateral to the dens vertically or diagonally to the inferior surface of C2
17Os Odontoideum: Congenital Disorder Failure of the dens to unite with the body of the vertebrae.1. Radiograph: Odontoid view-Tell it is not a dens fracture by the smoothness around parts
18Wedge Fracture: MOI: Hyperflexion and Compression -Like a crunch, divingRadiograph: lateral view, the anterior height of the vertebral body is shorter by 3mm than the posterior borderStable fracture-If it has no neuro s(x), then will not do anything, end with a little kyphosis curve
19Wedge FractureThis fracture is easy to see compared to some. In comparing anterior height to posterior height, you should see a difference.
20Burst Fracture of the Vertebral Body Lower cervical vertebraeMOI: AxialCompression2. Radiograph: lateral view, comminuted vertebral body is flattened centrallyCan be stable or unstable-Described by presence of neuro s(x), impingement of the spinal canal.
21Radiograph: lateral view, comminuted vertebral body is flattened centrally emedicine.medscape.com/article/94234-media
22Clay-Shoveler’s Fracture Avulsion fracture of the Spinous Process1. MOI:a. Hyperflexion-Where the pulley is over-used and detaches-Trapezius, Rhomboids, Para spinals
23Hypomobility of the Cervical Spine 1. Pathology: tightness of the capsule of one of the synovial facet joints2. Radiographic signs: generally none3. Clinical Symptoms: aching, dull, stiff feeling inthe neck *Headaches*Clinical Signs: loss of movement in a capsular pattern for the facet jointsJoint play is decreased at the segmental levelCapsular end feelPattern: Upper Cervical: limited lateral flexion and rotation equally limited %-wise, then extension limited less.-Lower cervical is oppositeLower vs. Upper Cervical.Stiffer on that side on that joint.Lead to facet syndrome if left untreated
24Facet SyndromeJoint DysfunctionPathology: joint capsules are stretched from joint subluxations or distension of the joint with fluid.-Looser the capsule gets, tight Para spinals.Body will protect the area with posture and muscle spasms of the paravetebral muscles which leads to a decrease in spinal mobility and a secondary muscle fatigue.
25Facet SyndromeOccurs early in the degenerative process for the young or middle aged patientLoading patterns change which lead to cartilage degeneration, facet hypertrophy and bony adaptation in the form of sclerosis or spurring (ostephyte formation).Alters joint function which alters disc function
26Radiographic Signs: Oblique view: Hypertrophy of the facet jointOsteophyte formation at the superior and inferior articulating processesc. Decrease in joint space
27Clinical Symptoms of Facet Syndrome Presentation is variable, generally a steady ache with long periods of inactivity.Pain present after activity, not during.Progression of pain gets more sever over timePain will come and go with activity demands and disease progression.Sharp pain with abrupt movements.Catching or locking sensation.Some radiation of pain may occur if nerve root is involved
28Clinical Signs of Facet Syndrome Muscle spasms in the paraspinalsDecrease lordosisDecrease ROM all directions particularly with extension and rotation to one sidePain with extensionNeurological exam is normal initially, may be abnormal eventually with osteophyte formation.
30Impingement Syndrome1. Onset: sudden, often without a memorable trauma 2. Radiographic Signs: generally none 3. Clinical Symptoms: sharp, unilateral pain, stiff neck and c/o loss of movement
31Signs of Impingement Syndrome ROM limited in area’s that close or compress the facet joint on the painful side.Extension and rotation to the side of dysfunction are limitedLateral flexion may be painful, not as limitedCompression increases pain, distraction decreases pain.Muscle guarding during passive and active movement.Can be acute trama or progression
32Osteoarthritis, Degenerative Joint Disease Joint DysfunctionPathology: progressive degeneration as a natural consequence of aging, loss of flexibility or movement occurs as the disease progresses -Look for osteophyte formation, anteriorly first bridging between vertebrae.
33Osteoarthritis: oblique view Osteophyte formation is usually seen as bridging the vertebrae – carefully review the shape of the vertebrae in this viewEncroachment of the neural foramen is also notedemedicine.medscape.com/article/ media
34Cervical Spinal Stenosis: Joint DysfunctionPathology: narrowing of the central spinal canal or the intervetebral foraminaIncrease in bone formation around the nueral foramen.Etiology:Developmental, congenital, or traumatic, age relatedCan be caused by intervetebral disc disease or osteoarthritis
35Symptoms and Signs of Spinal Stenosis Radiating arm pain and numbness in nerve root distributionClumsiness if severe enoughSignsMyotomal weaknessHyperreflexia: will increase foramen space, so will look down, and adjust entire posture to compensate.Clonus-May think that it is a “Disk Herniation”, but way to differentiate is an MRIWhat to think of with radiating pain down the arm?-Cervical impingement-MI-Burner/Stinger-Facet Syndrome-Thoracic Outlet Syndrome-Disk Buldge/Protrusion-Tumor
36Imaging Studies MRI: imaging study of choice CT myelogram can be used but will be invasive so may not be the one of choice
37Disc Herniation Causing Impingement of Specific Spinal Nerve Can occur with or without radiculopathy. Less common in the cervical spine than in the lumbar spine.Individual nerve roots may be impinged or tethered within the foramin.
383. Herniation Sites a. C1-2: no disc b. C2-3: rare c. C3-4: rare d. C4-5:1) clinical symptoms2) signs: MotorSensoryReflexes
39Herniated Disc: MRILook at the spinal cord by C4-5 and C5-6. C4-5 is a larger herniation. This one is impinging on the spinal cord.Consider the clinical symptoms this patient may have.C5-6 slightly smaller and may only be a bulge.
40Disc Herniation MRI: encroachment by the disc on the spinal canal Stenosis of the canal is also occurring giving the spinal cord a strangled appearancePE-HCDisc.htm
41MRI Best able to detect Disk height loss Annular fissures OsteophytosisEnd plate changesHerniationAPTA 2009 CRHazleC5-6 disc herniation extendingPosterior into the canal
42Pathological Findings Winking Owl Sign:Metastatic cancer to the spine can show up initially as a missing pedicleIt gives the impression that the one of the “eyes” is closed.= pedicle
43Whiplash: Musculoskeletal Practice Pattern 4E Definition: cervical strains or acceleration injuries “whiplash”MOI: Sudden Acceleration-Deceleration movement of the head and neckCauses: Falls, car accidents, sports injuriesHead inertia creates a high velocity force or accelerationResults in severe overstretch injuryAge of patient, general health, direction of forces and magnitude of forces determines the extent of injury and the tissues that are involvedSoft tissue structures which can be potentially injured include: disc, spinal ligaments, capsule, muscles, nerves, spinal cord and vertebrae
44Radiographic signs: Changes in cervical curve on x-ray Fanning of interspinous spaces (great space, curve in opposite direction)Increased prevertebral spaceAcute loss of disc heightDisplaced prevertebral fat spaceVacuum cleft signParaspinals go into sever spasms.Vacuum cleft sign on extension view:intravertebral vacuum cleft sign appears on radiographs as a transverse, linear or semilunar radiolucent shadow that is located centrally within or adjacent to the endplate of a collapsed vertebral bodyRepresents gas, probably nitrogen
45Force Amount of force= weight of head plus speed that the head moves. Direction of Force:Where was the car hitSymmetry of impactDouble injury – hit from behind, pushed into another vehiclePosition of person in relation to impact
46C. Onset: may not be for several hours after an accident Symptoms: pain, stiffness, and muscle spasm in the cervical spine, headaches are usually posterior, may have some dysphagia-Spasms are the Hallmark, extreme tenderness to palpation.
47Post Concussion Syndrome SoftTissuePathology: blow to the headOnset: develops after the concussion within a 48 hour period after traumaMay last several weeks or months after injury3. Symptoms: persistent headaches, inability to concentrate, irritability and fatigue
48Medical Tests: CT scan usually negative for any brain injury Specific Conditions related to return to playDependent upon severity of concussion – mild, moderate, or severeNumber of concussions a player has had in a season
49Grade I: Mild Concussion Momentary confusion, no loss of consciousness, symptoms disappear within 15 minutesFirst concussion: return to play if asymptomatic for one weekSecond: return to play in 2 weeks if asymptomatic for 1-2 weeksThird: terminate season, may return to play next season if asymptomatic
50Grade II: Moderate Concussion Brief concussion, no loss of consciousness, symptoms last longer than 15 minutesFirst concussion: return to play if asymptomatic for one weekSecond: minimum of 1 month off play and asymptomatic for 1 week. If not asymptomatic, terminate seasonThird: terminate season, may return next season
51Grade III: Severe Concussion Loss of consciousness – briefly or prolongedFirst concussion: return to play after a minimum of one month off and asymptomatic for one weekSecond: terminate season, may return to play next season if asymptomatic
52Post Dural Puncture Headache Spinal headacheRisk Factors:Anyone who has an epidural or spinal tap procedureSX: severe, dull, non-throbbing pain, usually in fronto-occipital regionSigns: aggravated by upright position, decreased in supine positionMay have nausea, vomiting, visual disturbance and/or auditory disturbanceSelf-limiting usuallyTell them to drink Mt. Dew (Caffine)spinal headache" is usually described as a severe, dull, nonthrobbing pain, usually fronto-occipital, which is aggravated in the upright position and diminished in the supine position. It may or may not be accompanied by nausea, vomiting, visual disturbances and/or auditory disturbances. Patients who experience a postdural puncture headache should not be taken lightlyPDPH is usually a self-limiting process. If left untreated, 75% of them will resolve within the first week and 88% will have resolved by 6 weeks. (2) Most treatments are geared towards lessening the pain and symptoms until the hole in the dura can heal, or at least until it can close to the point where the symptoms are tolerable. So-called "conservative treatment" involves hydration, bedrest and analgesics.
53Other DxRA: particularly in the C spine can lead to spinal cord injuries, death if forced into hyper extension due to fragilely of the joints.Other types of headaches covered in Neuro:MigrainesCluster HeadachesPostural Headaches
54Cervical Spine: Radiology Typical Views Special Views Open Mouth ViewAP viewLateral ViewRight ObliqueLeft ObliqueLateral FlexionLateral Extension
55Evaluation using ABCDS Odontoid or Open Mouth ViewPatient Position: Supine, mouth openBeam: directed downward into the open mouthFilm placed between posterior C-spine and table-For Evaluating stability of upper cervical spine.
56Alignment: Demonstrate odontoid and lateral masses of C1. Draw around the odontoid, and body of C2, draw the lateral masses of C1.Look at the alignment between the lateral masses of C1 and the body of C2, these should match upThere shouldn’t be any overhanging edges laterally, if there is, this may suggest a burst fracture of C1Look at the medial edges of the C1 lateral masses and the body of the dens, these should be symmetrical with the dens centered between them.
57Bone Density and Dimension Odontoid should have NO lucencies in superior portion, base, or vertebral bodyBones should have equal density, consistent with no unexpected lucencies
58Cartilage and Soft Tissue: Cartilage: No intervertebral disk, can evaluate facet joints. These should be parallel and equally spacedSoft Tissue: not applicable in this view
59AP View, Alignment Patient Sitting or Supine Assesses C3-C7 Alignment: Draw a vertical line superior to inferior along the spinous processes to assess segmental rotation – SP are bifidIdentify Pedicles: look for rotationVertebral Bodies: Size, C3-C7Uncinate joints: for osteophyte formation
60Arrow is darker because of the central beam and the cervical lordosis making it further apart.
61Can’t see the cartialge need a lateral view. Dark bottle is Trachea
62Bone Density and Dimension Evaluate each pedicle and vertebral body for a change in density or dimensions. Compare with segments above and below to see if there are any asymmetries in size or position and measure horizontal and vertical dimensions
63Cartilage and Soft Tissue Cartilage: evaluated on lateral view, not assessed in AP viewSoft Tissue: identify bottle shaped tracheaShould be mid line, if not mid line, it may indicate the presence of a tumor, pneumothorax or hemothorax
64Lateral View, Alignment Patient PositionLateral standingSupine cross table viewAlignment:Line 1: anterior borders of vertebral bodiesLine 2: posterior borders of vertebral bodiesLine 3: spinolaminar line: junction of lamina at the spinous processesThese three lines help to assess for several types of pathologies that can be found on this view such as spondylolisthesis or burst fractures
65Alignment cont. Check for the normal lordosis: Flat C spine: indicates muscle spasms from traumaIncreased lordosis:Kyphosis: anterior segmental compression fracture
66ADI: Atlantodens Interval: space MUST not exceed 3 mm ADI: Atlantodens Interval: space MUST not exceed 3 mm. Any greater distance and this must be evaluated by a physician for C1 or C2 instabilities.emedicine.medscape.com/article/93546-media
67Alignment cont.Look at the margins of each vertebrae for possible osteophyte formationEvaluate the facet joints and look for possible osteophyte formation
69Bone Density and Dimensions Evaluate the density of each cervical vertebrae for changes in densityMeasure the vertebral body height anteriorly and posteriorly
70Cartilage and Soft Tissue Assess disk heightSoft Tissue:Prevertebral tissueFanning of cervical vertebrae may demonstrate interspinous ligamentsRetropharyngeal space should measure 7mm or less
71Retropharyngeal space: measure less than 7 mm Space between C2 anterior vertebral body and the posterior pharyngeal wallRetrotracheal space: should measure no more than 22 mm in adults and 14 mm in childrenSpace between C6 anterior vertebral body and the posterior tracheal wall
72Oblique Radiographs Patient Position: Posterioanterior or AnterioposteriorStanding, sitting, or supinePatient rotated 45 dg to one side and demonstrates opposite side neural foraminaPrimarily used to evaluate the intervertebral foramina
73Alignment Evaluate both oblique views and compare side to side Draw each foramen on the oblique radiograph, evaluate for narrowing of the foramen, osteophyte formation, and anterior movement of one vertebrae over the otherCan also look at the pedicles and laminae
76Special ViewsLateral Flexion and Extension Stress Views: observe joint alignment with movement, largely replaced with fluoroscopy as you can watch the movement occurPillar View: view the lateral masses of the cervical vertebrae, patient is turned to one side about 45 dg and extended about 30 dg.
77Special Views cont. Swimmers view: Patient prone on table with arm abducted to 180 dgCross table radiograph with central beam directed to the axisFilm on opposite sideVisualizes C7, T1 and T2 vertebrae
78Cervical Spine: CT Sagittal Slice: Orientate by finding the dens, C1 is just anterior to the tip of the dens, C3-C6 bodies of the vertebrae can be seen on this view.Spinous processes are posterior to the spinal canalSmall circle at the top of the Largest spinous process is the posterior arch of C1Good view to see bone intruding into the spinal canalAnterior arch ofC1
79Trans axial CT: Intervertebral Space Body of VertebraeFacet jointsSpinal canalLaminaBifed Spinous processemedicine.medscape.com/article/ overview
80MRI of the Cervical Spine T2 weighted sagittal MRI of the cervical spineOrientate by finding the dens, anterior arch of C1, posterior arch of C1, cervical vertebaral bodies of C3-C7, T1-T5Spinous processesSpinal Cord, canal – any buckling of the cord? Any encroachment by the vertebral bodies into the canal? Check out C5-6. What do you think?Disk Space: evenly spaced? Disk height is similar?Soft tissue
81Cervical Spine: MRI Body of vertebrae is very dark in this MRI Body of vertebrae is very dark in this MRISpinal Canal/Cord is lighterAs pictures progress, can see more of the spinal nerve appearing and its attachment to the cordMuscle