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Cervical Spine Injuries

Cervical Spine Injuries

Introduction

  • Common cause of disability 
  • Most common causes:–  RTA, Fall, Penetrating trauma, Sports 
  • Highly prone to traumatic injury:
  • Mobile, relatively unprotected, and its high position 
  • 60% of all spinal injuries occur in the cervical spine 
  • Subaxial cervical spine injuries include:
    • 2/3rd of all cervical fractures
    • 75% of all cervical dislocations 
  • One third of injuries occur at the level of C2, and one half of injuries occur at the level of C6 or C7.

Epidemiology

  • Bimodal Peak
  • Adolescents and Young Adults
  • Middle Aged Individuals (55 years)
  • Males accounts for 80% of injuries 

Epidemiology of Cervical Spine Injuries




Epidemiology of Cervical Spine Injuries

Subaxial Cervical Spine Anatomy

  • Subaxial Spine: C3 - C7 segments
  • Denis’ 3 columns- Anterior, middle and Posterior
    • Anterior- ALL, Ant 2/3 rd  body & disc
    • Middle- Post 1/3rd of body & disc, PLL 
    • Posterior- Pedicle, lamina, facet, transverse process,  spinous process, Ligaments-Interspinous, lig.flavum 
  • Posterior column most important for stability 
  • Encasement of the vertebral arteries generally from C1 through C6 via the transverse foramina
  • C7 has a transverse foramen, but the paired vertebral arteries generally do not course through them 
  • Exiting root corresponds to the lower vertebra (C6 root exits the C5-6) foramen 
  • C6 transverse process harbors an anterior tubercle : chassaignac tubercle –> carotid artery
  • Most common injury happen at C6 or C7 level :  
    • exposed to great axial compression and flexion loads due to its location
    • transition from a very mobile cervical to a rigid thoracic spine. 




3 column model of Denis




Allen's Classification Cervical Spine Injuries


Anatomy of Cervical Spine and Cervical Spine Injuries



Anatomy of Cervical Spine and Cervical Spine Injuries

Cervical Spine : Radiological Anatomy




Anatomy of Cervical Spine and Cervical Spine Injuries




Anatomy of Cervical Spine and Cervical Spine Injuries



Types of Cervical Spine Injuries


Mechanism of Injury


Mechanism Cervical Spine Injuries

Cervical Spine Injuries: Clinical Features

  • Neck pain
  • Restriction of neck movements 
  • Neck tenderness 
  • Varying degrees of neurological deficits 
    • Complete cord syndrome
    • Incomplete cord syndrome
    • Central cord syndrome 
    • Brown-Sequard syndrome 
    • Anterior cord syndrome 
    • Combination of the above

Spinal Cord Injury Without Radiographic Abnormality (SCIWORA)

  • Initially described by Pang et al, in 1982
  • Spinal cord dysfunction without the presence of any fracture, dislocation, or ligamentous injury on x-rays or CT scans 
  • 20% to 35% of all paediatric spinal injuries 
  • Due to elastic ligamentous laxity and the immaturity of osseous structures
  • can be an indication for MRI when there is a persisting, objective myelopathy after a traumatic event with normal plain film and CT findings
  • Other related terms used to describe specific situations with advent of new imaging techniques
    • Spinal cord injury without radiographic evidence of trauma (SCIWORET) 
    • SCIWOCTET (spinal cord injury without CT evidence of trauma)
    • spinal cord injury without neuroimaging abnormality (SCIWONA): patients without traumatic signs using radiographs, CT and MRI. 
    • more accepted general term SCIWORA is usually used to describe all variants of clinico-radiological mismatches.







ASIA Impairment Scale




ASIA  Cervical Spine Injuries


Cervical Injury Classifications



Classification Cervical Spine Injuries



Holdsworth Classification Cervical Spine Injuries





Allen Classification Cervical Spine Injuries


AO Subaxial Spine Classification


AO Classification Cervical Spine Injuries






AO Classification Cervical Spine Injuries






Type A AO Classification Cervical Spine Injuries






Type A AO Classification Cervical Spine Injries






Type A AO Classification Cervical Spine Injries







Type A AO Classification Cervical Spine Injries







Type A AO Classification Cervical Spine Injries







Type B AO Classification Cervical Spine Injries




Type B AO Classification Cervical Spine Injries








Type B AO Classification Cervical Spine Injries








Type B AO Classification Cervical Spine Injries







Type C AO Classification Cervical Spine Injries







Type C AO Classification Cervical Spine Injries








Facet AO Classification Cervical Spine Injries





Facet AO Classification Cervical Spine Injries



Facet AO Classification Cervical Spine Injries

SLIC Classification Cervical Spine Injries

SLIC Classification Cervical Spine Injries





Management Cervical Spine Injries


Management

  • All trauma patients are considered to have a cervical spine injury until proven otherwise
  • Cervical spine clearance : confirming the absence of cervical spine injury
  • It is important to clear cervical spine and remove collar in an efficient manner
  • delayed clearance associated with increased complication rate
  • cervical clearance can be performed with
    • physical exam
    • radiographically

NEXUS Low risk criteria


Cervical spine imaging recommended for all pts with trauma

EXCEPT
  • No midline tenderness
  • No intoxication
  • Normal alertness
  • No FND
  • No distracting injuries (eg Upper torso injuries may be sufficiently painful to distract from a reliable cervical spine examination)

*Hoffman JR et al. Ann Emerg Med 1998;32:461-469


Missed cervical spine injuries

  • may lead to permanent disability
  • careful clinical and radiographic evaluation is paramount
  • high rate of missed cervical spine injuries due to 
    • inadequate imaging of affected level
    • loss of consciousness
    • multisystem trauma
  • cervical spine injury necessitates careful examination of entire spine
  • noncontiguous spinal column injuries reported in 10-15% of patients

Clinical Cervical Clearance

Removal of cervical collar WITHOUT radiographic studies allowed if 
  • patient is awake, alert, and not intoxicated
AND
  • has no neck pain, tenderness, or neurologic deficits 
AND
  • has no distracting injuries


Radiographic Cervical Clearance

Management Cervical Spine Injuries



Management Cervical Spine Injuries




Management Cervical Spine Injuries





Management Cervical Spine Injuries




Management Cervical Spine Injuries






Non Operative Management Cervical Spine Injuries



Operative Treatment for Cervical Spine Surgeries


Indications of SUrgery Non Operative Management Cervical Spine Injuries



Indications of Surgery Non Operative Management Cervical Spine Injuries



Indications of SUrgery Non Operative Management Cervical Spine Injuries







Indications of SUrgery Non Operative Management Cervical Spine Injuries






Indications of SUrgery Non Operative Management Cervical Spine Injuries





Indications of SUrgery Non Operative Management Cervical Spine Injuries






Indications of SUrgery Non Operative Management Cervical Spine Injuries





Indications of SUrgery Non Operative Management Cervical Spine Injuries





Indications of SUrgery Non Operative Management Cervical Spine Injuries






Indications of SUrgery Non Operative Management Cervical Spine Injuries





Indications of SUrgery Non Operative Management Cervical Spine Injuries





Indications of SUrgery Non Operative Management Cervical Spine Injuries


References







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