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Cervical Spine

Orthopedics

QuestionAnswer
C2: Axis has what features? bifid spinous process & odontoid process
C7: Vertebra prominans has: a large spinous process
Atlas (C1): ring structure with: anterior & posterior arches; lateral masses separate A&P arches
Axis (C2): 1st vertebra with: a heavy body
C2: superior projection of the body = odontoid process (dens); articulates with the C1 anterior arch
What ligaments hold atlas to axis & keep it stable? Alar ligaments
Light touch: Upper Neck: C2
Light touch: Lower Neck: C3
Anterior vert column: vert bodies, disc spaces, A&P longitudinal ligaments, & annulus fibrosis
Posterior vert column: pedicles, facet joints, laminar spinous processes, & posterior ligament complex
If one of the two vert columns is intact, then: the injury is stable
If both columns are disrupted, then: the injury is unstable
2 major regions of C spine: cranio-cervical junction (occiput to C2); lower cervical spine (C3 - C7)
Cranio-cervical jnct (occiput to C2) 50% of motion; atl-occ jnt (Yes); atl-axial jnt (No)
Lower C spine (C3 - C7) 50% of motion divided evenly between segments
Spine Forces: flexion (forward & lateral), extension, axial compression, rotation, & distraction
Anterior Marginal Line line drawn along the anterior vertebral bodies
Posterior Marginal Line line drawn along the posterior vertebral bodies C2 - C7
Spinolaminal Line line drawn along the bases of the spinous processes C1 - C7 (marks the posterior margin of the spinal canal)
Posterior Spinous Line line drawn along the tips of the spinous processes C2 - C7
Radiology: Trauma: order lateral, AP, & odontoid view; all 7 vertebrae must be seen
Radiology: Lateral: 4 smooth lines
Radiology: AP: spinous processes should be in a vertical row
Radiology: Odontoid: open mouth: inspect odontoid, distance between axis & dens should be equal bilateral
Tx Jefferson fx: stable Rigid collar (cervicothoracic) x 3 mo; regular f/u for radiographs
Tx Jefferson fx: unstable Cranial traction; halo x 3 months; > 5mm C1-C2 subluxation = C1-C3 fusion
Odontoid fx types type I (rare): avulsion fx of alar ligament; type II & III
Burst Jefferson fx stability: determined by: transverse ligament
Burst Jefferson fx stability: neuro effects Usually neuro intact (fragments burst away; wide breadth of C1 canal)
Burst Jefferson fx: 1/3 of fx assoc with: an axis fx
Burst Jefferson fx: 50% chance that: some other C spine injury is present
Odontoid fx MOA Hyper-flexion or hyper-extension
Odontoid fx: Blood supply (watershed area): neck
Odontoid fx: assoc with: C1 neural arch fracture or Jefferson fx
Odontoid fx: 25% incidence of: neurologic injury
Odontoid fx: non-displaced fx show: callus at 2-3 weeks
Hangmans Fx = Traumatic Spondylolisthesis of C2 (bilateral C2 pedicle fx)
Hangmans Fx MOA hyperextension & sudden violent distraction; hyperextension & axial loading; or flexion & compression (usu combination of forces)
Hangmans Fx: Types 4 types (I, II, IIA, III = worst)
Hangmans Fx: Immobilization: rigid cervical orthosis or halo vest system
Hangmans Fx: Traction: used generally for reductions (Gardner-Wells tongs or halo vest system)
C spine injury prevalence in football 10-15% of football players
Sp cord injury overall incidence 4/100,000 per year
Most recent sport SCI: football, trampoline (gymnastic), diving
Highest % head injuries football; then ice hockey
Acute Cervical Sprain = Injury to restraining ligaments of cervical spine
Acute C- Sprain grade I (mild): ligaments damaged but not lengthened
Acute C- Sprain grade II (mod): some laxity but not total disrupt
Acute C- Sprain grade III (severe): ligament completely disrupt
Acute C- Sprain can occur alone or with: C-strain (mx), fx/ dislocation, instability
Isolated C-sprain: S/S localized pain, decreased ROM, no neurologic deficits
Acute C- Sprain: if no fx/ sublux on films, then get: flex/ext (assess for instability)
Acute C- Sprain: if sig mx spasm, then: repeat flex/ext films after spasms subside (protect neck)
Acute C- Sprain: if poss subluxation: pt should wear hard collar & flex/ext films repeated in 2-4 wks
Acute C- Sprain: if instability present, may need: 6-12 wks immobilization in rigid orthosis and/or surgery
Acute C- Sprain: if xray w/u neg: RTP only when painless full ROM & normal neck strength
Cervical Stenosis = narrowing of sagittal diameter of cervical canal
C-stenosis often asymptomatic until: acute hyperflexion/ extension or axial loading of C-spine produces neuro signs
C-stenosis: segments most commonly involved C5 and C6 segments
Cervical Stenosis Types Congenital; Developmental; Acquired
C-stenosis: Congenital = short pedicles, funnel shape of cervical canal
C-stenosis: Developmental = bone size due to stress in weight training
C-stenosis: Acquired = spondylosis, spurs, disc bulge or space narrowing
Paresthesia with transient quadriplegia incidence: 1.3/10,000
Fx & Dislocation: Injury MOA axial load w/ slight neck flexion (spearing)
Downed Player: initial x-rays s/b obtained: on spine board with helmet on
Cervical Spondylosis = Chronic disc degeneration (arthritis)
Cervical Spondylosis: Represents: nerve root compression
Cervical Spondylosis S/S: neck pain, radicular pain radiating from neck to upper extremity
Cervical Spondylosis Rx: supportive, facet injections, operative decompression
Brachial Plexus Neuropraxia include: Burners, stingers, hot shots (football, wrestlers, hockey)
Brachial Plexus = C5, C6, C7, C8, T1
Brachial Plexus Neuropraxia: Blow to head: lateral flexion to contra side of shoulder being depressed results in traction on nerves
Brachial Plexus Neuropraxia S/S Sudden burning pain, numbness in lateral arm, thumb, & index finger, lasts 1-2 min
Brachial Plexus Neuropraxia: if S/S persist/ repeated: MRI is indicated
Brachial Plexus Neuropraxia RX: ROM, strengthening, protection
Atlas: superior surface of lateral masses articulates with: the occipital condyles forming the occipito-atlantal joints
Atlas: inf surface of lateral masses articulate with: the superior articular facets of C2 forming the C1 - C2 apophyseal joints
R/O C Spine Fx Pt not c/o neck pain; no neck tenderness on palp; no hx LOC; no mental status changes fr trauma, etc; no S/S referable to neck inj (paralysis, sensory changes); no other distracting inj
C Spine injuries Occ- atl Dislocn; Occ Condyle Fx; Atlas fx (C1); Odontoid fx; Atl-Axl (C1-C2) instability; C2 Lateral Mass fx; traumatic Spondylolisthesis of C2 (Hangmans fx)
Burst Jefferson fx MOA Axial blow to head, force transmitted thru occ condyles; forces C1 lateral masses outward
Burst Jefferson fx Radiology: C1 lat masses not line up vertly w/ C2 sup articular facets; distance btw dens & C1 lat masses is asymmetric
Odontoid fx: tx Reduce fx & hold in halo immobilization (3 months); C1-C2 fusion if severely displaced or non-union; Few advocate acute ORIF dens
Hangmans Fx: alignment: vert body of C2 is normally aligned w/ C1 & dens; post elements of C2 are normally aligned w/ C3
Hangmans Fx: Stability: unstable; neuro deficit is surprisingly rare unless C2 - C3 subluxation is severe
Hangmans Fx: Tx will usually stabilize with halo fixation; anterior fusion may be needed due to delayed instability
Hangmans Fx: Operative Tx: occipitocervical fusion; atl-axial fusion; transarticular screw fixation; ant. screw fixation of dens; internal fixation w/ posterior plating of occiput to C2
Evaluation of cervical instability (White & Punjabi ) Vert malalignment; >3.5mm translational displacement; 1.7 mm or greater disk widening
C-Cord Neurapraxia & Transient Quadriplegia: S&M recovery usu occurs in: 10-15 minutes (up to 24-36h in some)
C-Cord Neurapraxia & Transient Quadriplegia may involve: both legs, both arms, or ipsilateral arm & leg
C-Cord Neurapraxia & Transient Quadriplegia Initial evaluation: routine c-spine films & poss CT scan (flex/ext films if routine films normal); consider MRI
Fx & Dislocation: forces transmitted: directly to spinal structures; energy first absorbed by discs with compressive deformation; continued energy: angular deformation & buckling w/ failure of discs, lig structures & bony elements
On Field Eval (Downed Player) 1: Assess ABCs; 2: initial neuro; 3: turning the athlete; 4: immobilization; 5: evacuation
Downed Player: turning athlete Doc at head grasp player shoulders & cradle head w/ forearms (if use hands alone, avoid flexing neck). Avoid cervical traction
Downed Player: immobilization Leave helmet & shoulder pads on; fasten torso to spine board w/ straps; sandbags/ blankets on either side of head and taped with helmet to board
Downed Player: immobilization: C-collar = NOT an alternative to proper head immobilization on the board & may compromise the airway
C Spine injuries: Tx Philadelphia collar immobilization (stable); Halo immobilization (stable); Occipito-cervical fusion (unstable)
Trapezial strain: localized pain posterior C-Spine; Pain reproducible with palpation of trapezius; Wry neck or torticollis; Rx: Supportive
Stingers & Burners = transient shooting/ burning pain or paresthesia in one arm related to neck or shoulder trauma
Stingers & Burners: due to: stretch injury on brachial plexus or compression on nerve root (neural foramen)
Stingers & Burners: If S/S longer than 15 min: consider w/u (if compression type injuries, image for foraminal stenosis or herniated disk)
Most common Spinous Process fx found in: C-spine (Clay Shovelers fx)
Football player with burning pain, numbness, tingling from shoulder to hand which resolves Brachial plexus neurapraxia, “stinger,” caused by stretching of brachial plexus
cervical impingement: common sites & MOA C5-C7 most common; often d/t DDD or HNP; surg if persistent neuro sxs
Axial blow to the head with force transmitted through the occipital condyles; Forces the lateral masses of C1 outward Jefferson fracture
bilateral C2 pedicle fractures (usually due to combo of forces; eg, hyperextension and sudden violent distraction) Hangman's fracture
C1: Atlas has no: spinous process
C spine inj prevalence in football 10-15% of football players
Paresthesia with transient quadriplegia incidence: 1.3/10,000
On Field Eval (Downed Player) 1: Assess ABCs; 2: initial neuro; 3: turning the athlete; 4: immobilization; 5: evacuation
Downed Player: immobilization: C-collar is NOT: an alternative to proper head immobilization on the board & may compromise the airway
C Spine injuries: Tx Philadelphia collar immobilization (stable); Halo immobilization (stable); Occipito-cervical fusion (unstable)
Dec. cervical ROM, pain below elbow = Cervical disc disease
Created by: Abarnard