PATHOLOGY AND MEDICAL MANAGEMENT OF THE CERVICAL SPINE PTP 521, Musculoskeletal Diseases and Disorders

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

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

Canadian 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 Canadian C-Spine Rule versus the Nexus Low-Risk Criteria in Patients with Trauma. JAMA 2003, 349;26

Canadian 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 http://content.nejm.org/cgi/content/full/349/26/2510 (full text article)

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.

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

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

Jefferson’s Fractures: Burst!

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 Very unstable

Hangman’s Fractures Can be common in car accidents.

Hangman’s Fracture Neuro Rehab: where the fragments go determines the nerve damage, could be very sever.

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 Dens is not stable so lots of neuro issues

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

CT scan of odontoid Fractures Type 3 Notice on this CT scan The foramen for the Vertebral artery emedicine.medscape.com/article/94234-media

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

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

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

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

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

Radiograph: lateral view, comminuted vertebral body is flattened centrally emedicine.medscape.com/article/94234-media

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

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* 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 Lower vs. Upper Cervical. Stiffer on that side on that joint. Lead to facet syndrome if left untreated

Facet Syndrome Joint Dysfunction 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.

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

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

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

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.

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

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. Can be acute trama or progression

Osteoarthritis, Degenerative Joint Disease Joint Dysfunction 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.

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 emedicine.medscape.com/article/305145-media

Cervical Spinal Stenosis: Joint Dysfunction 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

Symptoms and Signs of Spinal Stenosis 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 What to think of with radiating pain down the arm? -Cervical impingement -MI -Burner/Stinger -Facet Syndrome -Thoracic Outlet Syndrome -Disk Buldge/Protrusion -Tumor

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

Disc 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.

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

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.

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 www.mayfieldclinic.com/ PE-HCDisc.htm

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

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 www.medscape.com/viewarticle/421516_6

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

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. 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 body Represents gas, probably nitrogen

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

C. 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.

Post Concussion Syndrome Soft Tissue Pathology: blow to the head 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

Medical Tests: CT scan usually negative for any brain injury 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

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

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

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

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) 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 lightly PDPH 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.

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

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

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.

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.

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

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

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

Arrow is darker because of the central beam and the cervical lordosis making it further apart.

Can’t see the cartialge need a lateral view. Dark bottle is Trachea

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

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

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

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

ADI: 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

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

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

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

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

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

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

Left Oblique

Right Oblique

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.

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 www.biomedcentral.com/.../2/figure/F1?highres=y

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

Trans axial CT: Intervertebral Space Body of Vertebrae Facet joints Spinal canal Lamina Bifed Spinous process emedicine.medscape.com/article/1264627-overview

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

Cervical Spine: MRI Body of vertebrae is very dark in this MRI www.gehealthcare.com/.../products/cimages.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