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

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

3. 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

4. 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

5. 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
(full text article)

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.

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

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

9. Jefferson’s Fractures: Burst!

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
Very unstable

11. Hangman’s Fractures
Can be common in car accidents.

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

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
Dens is not stable so lots of neuro issues

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

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

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

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

18. 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

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

20. 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.

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

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

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*
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

24. 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.

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

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

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

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.

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

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.
Can be acute trama or progression

32. 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.

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
emedicine.medscape.com/article/ media

34. 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

35. 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

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

37. 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.

38. 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

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.

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

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

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

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

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.
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

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

46. 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.

47. 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

48. 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

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

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

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

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)
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.

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

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

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.

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.

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

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

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

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

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

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

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

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

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

66. 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

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

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

70. 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

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

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

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

74. Left Oblique

75. Right Oblique

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.

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

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

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

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

81. Cervical Spine: MRI Body of vertebrae is very dark in this MRI
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