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