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2 Symbols this is for your information only, it won’t be used for the exam important to know for exam 2

3 Cervical Spine Pathology Trauma Fractures Spinal Stenosis Rheumatoid Arthritis Arthritic Conditions DJD/Osteoarthritis Other Degenerative Disk Disease Disk Bulge, Herniation C2-C7 Radiculopathy Joint Impingement Syndrome Facet Syndrome Bone Disk Post Concussion Syndrome Whiplash Soft Tissue Headaches Other Hypomobility 3

4 Stiell IG, Clement C, et al. The Canadian C-Spine Rule versus the Nexus Low-Risk Criteria in Patients with Trauma. JAMA 2003, 349;26 Sensitivity: 99.4% Specificity: 45.1% 4 Canadian Cervical Spine Rule for Radiographic Examination

5 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 10 10 (full text article) 5

6 Importance By 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. 6

7 Fractures of the Cervical Spine Musculoskeletal Practice Pattern G 75% of all spine fractures occur in the cervical spine due to the instability of the atlanto- occipital joints 7

8 Jefferson’s Fracture: Burst Fracture of C1.  Head holder, so fragments everywhere, very unstable, neck brace or halo. 1. MOI: Axial Compression 2. Radiograph: odontoid view, greater than 7 mm difference between both lateral masses of the atlas and those of the axis. 3. Unstable Fracture 8

9 Jefferson’s Fractures: Burst! 9

10 Hangman’s Fracture: Fracture of the neural arch of the axis, fractures the pedicles of C2 with dislocation of C2 on C3 1. MOI: Hyperextension  a blow on the forehead forcing the neck into extension is a classic mechanism of injury producing fractures thru the pedicles 2. Radiograph: lateral view shows bilateral disruption through the pedicles of the axis 3. Unstable fracture 10

11 Hangman’s Fractures 11

12 Hangman’s Fracture 12

13 Dens Fractures Type 1: (A ) avulsion of the tip of the dens as a result of apical or alar ligament stress Type 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 below 13

14 Dens Fractures Left: Type 2 dens fracture at the junction of the dens with the vertebral body with posterior displacement Right: fracture of the dens with posterior displacement of the atlas causing a small degree of spinal canal compression 14

15 CT scan of odontoid Fractures Type 3 Notice on this CT scan The foramen for the Vertebral artery 15

16 Dens Fracture Type 4: sagittal or parasagittal fracture extending from a point lateral to the dens vertically or diagonally to the inferior surface of C2 16

17 Os 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 17

18 Wedge Fracture: 1. MOI: Hyperflexion and Compression 1. -Like a crunch, diving 2. Radiograph: lateral view, the anterior height of the vertebral body is shorter by 3mm than the posterior border 3. Stable fracture 2. -If it has no neuro s(x), then will not do anything, end with a little kyphosis curve 18

19 Wedge Fracture This fracture is easy to see compared to some. In comparing anterior height to posterior height, you should see a difference. 19

20 Burst Fracture of the Vertebral Body Lower cervical vertebrae 1. MOI: Axial Compression 2. Radiograph: lateral view, comminuted vertebral body is flattened centrally 3. Can be stable or unstable 3. -Described by presence of neuro s(x), impingement of the spinal canal. 20

21 Radiograph: lateral view, comminuted vertebral body is flattened centrally 21

22 Clay-Shoveler’s Fracture Avulsion fracture of the Spinous Process 1. MOI: a. Hyperflexion - Where the pulley is over- used and detaches -Trapezius, Rhomboids, Para spinals 22

23 Hypomobility of the Cervical Spine 1. Pathology: tightness of the capsule of one of the synovial facet joints 2. Radiographic signs: generally none 3. Clinical Symptoms: aching, dull, stiff feeling in the neck *Headaches* 4. Clinical Signs: loss of movement in a capsular pattern for the facet joints  Joint play is decreased at the segmental level  Capsular end feel  Pattern: Upper Cervical: limited lateral flexion and rotation equally limited %-wise, then extension limited less.  -Lower cervical is opposite 23

24 Facet Syndrome Pathology: 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. Joint Dysfunction 24

25 Facet Syndrome Occurs early in the degenerative process for the young or middle aged patient Loading 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 25

26 Radiographic Signs: Oblique view: a. Hypertrophy of the facet joint b. Osteophyte formation at the superior and inferior articulating processes c. Decrease in joint space 26

27 Clinical 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 time  Pain 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 27

28 Clinical Signs of Facet Syndrome Muscle spasms in the paraspinals Decrease lordosis Decrease ROM all directions particularly with extension and rotation to one side Pain with extension Neurological exam is normal initially, may be abnormal eventually with osteophyte formation. 28

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30 Impingement Syndrome 1. 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 30

31 Signs 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 limited Lateral flexion may be painful, not as limited Compression increases pain, distraction decreases pain. Muscle guarding during passive and active movement. 31

32 Osteoarthritis, Degenerative Joint Disease Pathology: 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. Joint Dysfunction 32

33 Osteoarthritis: oblique view Osteophyte formation is usually seen as bridging the vertebrae – carefully review the shape of the vertebrae in this view Encroachment of the neural foramen is also noted 45-media 33

34 Cervical Spinal Stenosis: Pathology: narrowing of the central spinal canal or the intervetebral foramina  Increase in bone formation around the nueral foramen. Etiology:  Developmental, congenital, or traumatic, age related  Can be caused by intervetebral disc disease or osteoarthritis Joint Dysfunction 34

35 Symptoms and Signs of Spinal Stenosis Symptoms:  Radiating arm pain and numbness in nerve root distribution  Clumsiness if severe enough Signs  Myotomal weakness  Hyperreflexia: 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 MRI 35

36 Imaging Studies MRI: imaging study of choice CT myelogram can be used but will be invasive so may not be the one of choice 36

37 Disc Herniation Causing Impingement of Specific Spinal Nerve 37 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.

38 3. Herniation Sites 38 a. C1-2: no disc b. C2-3: rare c. C3-4: rare d. C4-5: 1) clinical symptoms 2) signs: Motor Sensory Reflexes

39 Herniated Disc: MRI Look 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. 39

40 Disc Herniation MRI: encroachment by the disc on the spinal canal Stenosis of the canal is also occurring giving the spinal cord a strangled appearance PE-HCDisc.htm 40

41 MRI Best able to detect  Disk height loss  Annular fissures  Osteophytosis  End plate changes  Herniation  APTA 2009 CRHazle C5-6 disc herniation extending Posterior into the canal 41

42 Pathological Findings Winking Owl Sign:  Metastatic cancer to the spine can show up initially as a missing pedicle  It gives the impression that the one of the “eyes” is closed. = pedicle 42

43 Whiplash: Musculoskeletal Practice Pattern 4E Definition: cervical strains or acceleration injuries “whiplash” MOI: Sudden Acceleration-Deceleration movement of the head and neck Causes: Falls, car accidents, sports injuries Head inertia creates a high velocity force or acceleration Results in severe overstretch injury Age of patient, general health, direction of forces and magnitude of forces determines the extent of injury and the tissues that are involved Soft tissue structures which can be potentially injured include: disc, spinal ligaments, capsule, muscles, nerves, spinal cord and vertebrae 43

44 Radiographic signs: Changes in cervical curve on x-ray Fanning of interspinous spaces (great space, curve in opposite direction) Increased prevertebral space Acute loss of disc height Displaced prevertebral fat space Vacuum cleft sign Paraspinals go into sever spasms. 44

45 Force Amount of force= weight of head plus speed that the head moves. Direction of Force:  Where was the car hit  Symmetry of impact  Double injury – hit from behind, pushed into another vehicle  Position of person in relation to impact 45

46 C. Onset: may not be for several hours after an accident D. 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. 46

47 Post Concussion Syndrome 1. Pathology: blow to the head 2. Onset: develops after the concussion within a 48 hour period after trauma  May last several weeks or months after injury 3. Symptoms: persistent headaches, inability to concentrate, irritability and fatigue Soft Tissue 47

48 4. Medical Tests: CT scan usually negative for any brain injury 5. Specific Conditions related to return to play Dependent upon severity of concussion – mild, moderate, or severe Number of concussions a player has had in a season 48

49 Grade I: Mild Concussion Momentary confusion, no loss of consciousness, symptoms disappear within 15 minutes First concussion: return to play if asymptomatic for one week Second: return to play in 2 weeks if asymptomatic for 1-2 weeks Third: terminate season, may return to play next season if asymptomatic 49

50 Grade II: Moderate Concussion Brief concussion, no loss of consciousness, symptoms last longer than 15 minutes  First concussion: return to play if asymptomatic for one week  Second: minimum of 1 month off play and asymptomatic for 1 week. If not asymptomatic, terminate season  Third: terminate season, may return next season 50

51 Grade III: Severe Concussion Loss of consciousness – briefly or prolonged  First concussion: return to play after a minimum of one month off and asymptomatic for one week  Second: terminate season, may return to play next season if asymptomatic 51

52 Post Dural Puncture Headache Spinal headache Risk Factors:  Anyone who has an epidural or spinal tap procedure SX: severe, dull, non-throbbing pain, usually in fronto-occipital region Signs: aggravated by upright position, decreased in supine position May have nausea, vomiting, visual disturbance and/or auditory disturbance Self-limiting usually Tell them to drink Mt. Dew (Caffine) 52

53 Other Dx RA: 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:  Migraines  Cluster Headaches  Postural Headaches 53

54 Cervical Spine: Radiology Typical ViewsSpecial Views Open Mouth View AP view Lateral View Right Oblique Left Oblique Lateral Flexion Lateral Extension 54

55 Evaluation using ABCDS Odontoid or Open Mouth View  Patient Position: Supine, mouth open  Beam: directed downward into the open mouth  Film placed between posterior C-spine and table  -For Evaluating stability of upper cervical spine. 55

56 Alignment: 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 up There shouldn’t be any overhanging edges laterally, if there is, this may suggest a burst fracture of C1 Look 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. 56

57 Bone Density and Dimension Odontoid should have NO lucencies in superior portion, base, or vertebral body Bones should have equal density, consistent with no unexpected lucencies 57

58 Cartilage and Soft Tissue: Cartilage: No intervertebral disk, can evaluate facet joints. These should be parallel and equally spaced Soft Tissue: not applicable in this view 58

59 AP 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 bifid  Identify Pedicles: look for rotation  Vertebral Bodies: Size, C3-C7  Uncinate joints: for osteophyte formation 59

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62 Bone 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 62

63 Cartilage and Soft Tissue Cartilage: evaluated on lateral view, not assessed in AP view Soft Tissue: identify bottle shaped trachea  Should be mid line, if not mid line, it may indicate the presence of a tumor, pneumothorax or hemothorax 63

64 Lateral View, Alignment Patient Position  Lateral standing  Supine cross table view Alignment:  Line 1: anterior borders of vertebral bodies  Line 2: posterior borders of vertebral bodies  Line 3: spinolaminar line: junction of lamina at the spinous processes  These three lines help to assess for several types of pathologies that can be found on this view such as spondylolisthesis or burst fractures 64

65 Alignment cont. Check for the normal lordosis:  Flat C spine: indicates muscle spasms from trauma  Increased lordosis:  Kyphosis: anterior segmental compression fracture 65

66 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. 66

67 Alignment cont. Look at the margins of each vertebrae for possible osteophyte formation Evaluate the facet joints and look for possible osteophyte formation 67

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69 Bone Density and Dimensions Evaluate the density of each cervical vertebrae for changes in density Measure the vertebral body height anteriorly and posteriorly 69

70 Cartilage and Soft Tissue Cartilage:  Assess disk height Soft Tissue:  Prevertebral tissue  Fanning of cervical vertebrae may demonstrate interspinous ligaments  Retropharyngeal space should measure 7mm or less 70

71 Retropharyngeal space: measure less than 7 mm Space between C2 anterior vertebral body and the posterior pharyngeal wall Retrotracheal space: should measure no more than 22 mm in adults and 14 mm in children Space between C6 anterior vertebral body and the posterior tracheal wall 71

72 Oblique Radiographs Patient Position:  Posterioanterior or Anterioposterior  Standing, sitting, or supine  Patient rotated 45 dg to one side and demonstrates opposite side neural foramina Primarily used to evaluate the intervertebral foramina 72

73 Alignment 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 other Can also look at the pedicles and laminae 73

74 Left Oblique 74

75 Right Oblique 75

76 Special Views Lateral Flexion and Extension Stress Views: observe joint alignment with movement, largely replaced with fluoroscopy as you can watch the movement occur Pillar View: view the lateral masses of the cervical vertebrae, patient is turned to one side about 45 dg and extended about 30 dg. 76

77 Special Views cont. Swimmers view:  Patient prone on table with arm abducted to 180 dg  Cross table radiograph with central beam directed to the axis  Film on opposite side  Visualizes C7, T1 and T2 vertebrae 77

78 Cervical 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 canal Small circle at the top of the Largest spinous process is the posterior arch of C1 Good view to see bone intruding into the spinal canal Anterior arch of C1 78

79 Trans axial CT: Intervertebral Space Body of Vertebrae Facet joints Spinal canal Lamina Bifed Spinous process 79

80 MRI of the Cervical Spine T2 weighted sagittal MRI of the cervical spine Orientate by finding the dens, anterior arch of C1, posterior arch of C1, cervical vertebaral bodies of C3-C7, T1-T5 Spinous processes Spinal 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 80

81 mages.html mages.html Body of vertebrae is very dark in this MRI Spinal Canal/Cord is lighter As pictures progress, can see more of the spinal nerve appearing and its attachment to the cord Muscle Cervical Spine: MRI 81


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