Presentation on theme: "Evaluation and Treatment of the Cervical Spine"— Presentation transcript:
1Evaluation and Treatment of the Cervical Spine Larry D. Dodge, MD
2Clinical Evaluation Proper Immobilization Assume a spine injury with head or neck trauma3 to 25% of spinal cord injuries occur after initial traumatic episode.
3Ankylosing Spondylitis or DISH Increased risk of fracture even with minor traumaFrequent through ossified disk spaceObtain a CAT scanVery unstable – spinal cord injuries.
4Asymptomatic Trauma Patient Cervical x-rays not required in patients without tenderness and are alert.
5Trauma Patients with Neck Pain 2 to 6% incidence of significant spine injuries.
6Do Not Remove Collar Until Absence of tendernessAbsence of painNormal mental statuscomplete radiographic evaluation
7Most Common Missed Diagnosis Occipitoathlantoaxial region or cervicothoracic junctionPlain x-ray will miss 15 to 17% of injuries
8CAT scan has 99% predictive value MRI better for soft tissue, may be oversensitive
9Flexion and Extension Radiographs Safe in awake alert patientsExclude significant instability
10Obtunded Patient Evaluation ControversialMRI- limited usefulness, lack of correlation between MRI and significant injuryPassive flexion – extension x-ray – possible iatrogenic injuryCombination of CAT and plain x-ray probably standard.
11Fractures of the Cervical Spine Most do not require surgeryLigamentous injuries less predictable, and more require surgery
12Types of Orthrosis Halo- the best, especially at upper cervical Soft collars – little immobilizationSemi rigid- ( Miami J, Philadelphia, Aspen) – still allow motion8-12 weeks of immobilization required with follow-up flexion and extension x-ray.
13Occipitocervical Dissocation Most are lethalNeurologic injuries vary from complete to cranial nerve injuriesDiagnosis can be difficultOccipitocervical fusion is required
14Atlas Fractures Axial load Stability requires healing of transverse ligament – MRIHalo- reasonable treatmentC1-C2 fusion if transverse ligament disrupted
15Axis Fractures Odontoid fractures are most common Type I – Avulsion Type II – WaistType III – Vertebral body
17Type Odontoid Elderly do not tolerate halo – consider C1- C2 fusion Controversial treatmentElderly do not tolerate halo – consider C1- C2 fusionFusion needed if reduction not achieved or maintained
18Type OdontoidHigh healing rate with halo vest
19Traumatic Spondylolisthesis of Axis MVA- hyperextension, compression and rebound flexionMost treated in halo
20Subaxial Compression Fractures Failure of anterior columnOrthosis for 6 – 12 weeks
21Subaxial Burst Fracture Fracture into posterior cortex with retropulsionSpinal cord injury rate is highMost require surgery – anterior or anterior and posterior
22Facet Dislocations Timely reduction required Subluxation of 25% suggests unilateral, 50% suggests bilateralMRI needed to assess for HNPFailure of closed reduction mandates open reduction
23Cervical Disk Disease Symptoms can be insidious or acute Minor injured can aggravate the root (radiculopathy) or spinal cord ( myelopathy)
24PathophysiologyDisk loses water and proteoglycan content changes – less able to support loadDecreased disk height leads to loss of lordosisOsteocartilaginous overgrowth occurs in response to increased load – stenosis develops
25Cervical Roots exhibit a higher degree of overlap than seen in the thoracolumbar spine, therefore symptom patterns may fail to localize.