Larry D.

Dodge, MD

Clinical Evaluation
Proper Immobilization

Assume a spine injury with head or neck

trauma
3 to 25% of spinal cord injuries occur after

initial traumatic episode.

Ankylosing Spondylitis or DISH

Increased risk of fracture even with minor
trauma
Frequent through ossified disk space
Obtain a CAT scan Very unstable spinal cord injuries.

Asymptomatic Trauma Patient

Cervical x-rays not required in patients

without tenderness and are alert.

Trauma Patients with Neck Pain

2 to 6% incidence of significant spine

injuries.

Do Not Remove Collar Until

Absence of tenderness

Absence of pain
Normal mental status complete radiographic evaluation

Most Common Missed Diagnosis

Occipitoathlantoaxial region or

cervicothoracic junction
Plain x-ray will miss 15 to 17% of injuries

 CAT scan has 99% predictive value

MRI better for soft tissue, may be

oversensitive

Flexion and Extension Radiographs

Safe in awake alert patients

Exclude significant instability

Obtunded Patient Evaluation

Controversial MRI- limited usefulness, lack of correlation

between MRI and significant injury

Passive flexion extension x-ray possible

iatrogenic injury
Combination of CAT and plain x-ray

probably standard.

Fractures of the Cervical Spine

Most do not require surgery Ligamentous injuries less predictable,

and more require surgery

Types of Orthrosis
Halo- the best, especially at upper cervical
Soft collars little immobilization Semi rigid- ( Miami J, Philadelphia, Aspen)

still allow motion

8-12 weeks of immobilization required with

follow-up flexion and extension x-ray.

Occipitocervical Dissocation

Most are lethal

Neurologic injuries vary from complete to

cranial nerve injuries

Diagnosis can be difficult Occipitocervical fusion is required

Atlas Fractures
Axial load
Stability requires healing of transverse

ligament MRI
Halo- reasonable treatment C1-C2 fusion if transverse ligament disrupted

Axis Fractures
Odontoid fractures are most common

Type I Avulsion

Type II Waist Type III Vertebral body

Type Odontoid

Treated with external orthrosis

Type Odontoid

Controversial treatment

Elderly do not tolerate halo consider C1-

C2 fusion
Fusion needed if reduction not achieved or

maintained

Type Odontoid
High healing rate with halo vest

Traumatic Spondylolisthesis of Axis

MVA- hyperextension, compression and

rebound flexion
Most treated in halo

Subaxial Compression Fractures

Failure of anterior column

Orthosis for 6 12 weeks

Subaxial Burst Fracture

Fracture into posterior cortex with

retropulsion
Spinal cord injury rate is high Most require surgery anterior or anterior

and posterior

Facet Dislocations
Timely reduction required
Subluxation of 25% suggests unilateral, 50%

suggests bilateral
MRI needed to assess for HNP Failure of closed reduction mandates open

reduction

Cervical Disk Disease

Symptoms can be insidious or acute

Minor injured can aggravate the root

(radiculopathy) or spinal cord ( myelopathy)

Pathophysiology
Disk loses water and proteoglycan content

changes less able to support load

Decreased disk height leads to loss of

lordosis
Osteocartilaginous overgrowth occurs in

response to increased load stenosis develops

Cervical Roots exhibit a higher degree of overlap than seen in the thoracolumbar spine, therefore symptom patterns may fail to localize.

Hyporeflexia
Biceps

Brachioradialis C- 6
Triceps C- 7

Most Commonly Affected

C-5, C-6, C-7

More motion in these areas

Watershed area of blood supply roots

more susceptible

Myelopathy
Most commonly presents as clumsiness, ataxia, loss of fine motor skills.

Cervical Spondylosis
May cause radicular pain from nerve root

origin
May cause referred sclerotomal pain

( occiput, interscapular region, or shoulders)

Treatment
75% of radiculopathy improve with P.T. ,

activity modification, medication

Soft disk herniations can resorb Myelopathy

Imaging Studies
Plain x-ray alignment, spondylosis
Flexion extension for instability MRI CAT defines bone anatomy Diskography

Electrodiagnostic Studies
Paresthesias cannot be localized

Imaging does not correlate with clinical

picture

Nonsurgical Care
P.T. emphasize isometric exercise

Traction with slight flexion

Medication Epidural steroids

Surgical Indications
Success for axial pain is 60 %

Success for radiculopathy is 90%

Disk Replacement evolving technology

ACDF
Allograft versus autograft

Plate fixation
Accelerates degeneration at adjacent levels

Posterior Decompression
Foraminotomy for bony foraminal stenosis

Laminectomy risk of kyphosis

Laminectomy decompression without

adding fusion

Thank you
We will now move into the exam part of the lecture.