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Cervical Spine Motion,some questions about Cervical Spine injury 2009ASA

Cervical Spine Motion,some questions about Cervical Spine injury 2009ASA. Anatomy of CS: divided into two parts Upper portion(the skull base ,C1&C2) Subaxial (C2-C7).

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Cervical Spine Motion,some questions about Cervical Spine injury 2009ASA

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  1. Cervical Spine Motion,some questions about Cervical Spine injury2009ASA

  2. Anatomy of CS: divided into two parts Upper portion(the skull base ,C1&C2) Subaxial (C2-C7)

  3. C1(the Atlas):C1 is a ring ,with large superior and inferior articular surfaces,it has no vertebral body and no spinous process

  4. C2(the Axis):It has a large superior articular surfaces,its most unusual feature is odontoid process

  5. AADI The anterior atlanto-dental interval(AADI) and the posterior atlanto-dental interval(PADI). PADI

  6. Motion:themotion is not distributed uniformly.O-C1 joints/ligaments are “tight”and allow little motion.This rigidity may explain the fact that Cspine fractures occur most frequently at the ring of C1.At C2-C3 and below,motion is more uniformly distributed;maximal motion occurs at C4-C5-C6,more ligamentous injury at these levels.

  7. Movement withIntubation:The primary force applied by the laryngoscopist is upward lift,this force can be as high as 50-70N.The more difficult the exposure ,the greater the force applied.This results in most extension of the occiput-on-C1,combined with flexion at C7-T1. extension flexion

  8. Questions and Answers 1.Is there a difference in movement with straight and curved blades? Yes,but not much,use whicherer blade you are best with.

  9. 2.What about newer airway devices such as the Glidescope? The existing date do not support this.

  10. 3.Is a fiberoptic intubation really “better”? In a word,yes.Several studies have shown nearly zero Cspine motion-but all bets are off when things don`t go smoothly.Also,FOB is not always feasible,particularly in emergency situations.

  11. 4.Dose every patient with Cspine pathology require a”special”intubation? No,many injuries do not create instability or alter motion-spinous process fracture.Find out as much as you can about the specific details of the abnormality and assess the airway.Caution:watch out for ligamentous injuries.

  12. 5.What is meant by instability? “Excessive” motion of any vertebrae.One diagnostic clue is an increase in the AADI to more than 4-5mm as the patient flexes the neck.This is important because lifting the head(sniffing position)can result in anterior movement of C1 on C2 and a decrease in the space available to the cord,(odontoid fractures).

  13. 6.What is the most common injury seen following trauma? Ligamentous injuries are much more common at C5 and C6,although fracure are most often seen at C1 and C2.Serious Cspine injuries are present in 2% of all blunt trauma patients-but are 4 to 5 times more common in patients with closed head injuries.

  14. 7.How is the Cspine “Cleared”? The first step is a clinical decision about the injury: 1)Neck pain 2)Loss of consciousness at the scene of injury 3)Any neurologic abnormality or symptoms 4)Intoxication 5)Distracting severe pain If “rules in”,do lateral and an open mouth view X film.If can go straight to CT,of course MRI is the best.

  15. 8.Is there a prefered intubation method in patients with injury or who have not been cleared? The answer is an unambiguous “NO”.In the best of cases,a FOB is associated with the least motion,but may not be feasible in the presence of airway trauma,in intoxicated/combative patients.Mask ventilation or even inserting an LMA can move an unstable segment.The best rule is to use the method with which you are most comfortable.

  16. 9.Isn`t “Manual In-line Stabilize”a standard of care? Yes,and you should do it!It can reduce upper Cspine extension and lower Cspine flexion,but the evidence that it stabilizes the spine is weak.Do not do axial traction!!

  17. 10.Is cricoid pressure dangerous? Probably not,as long as excessive pressure is avoided.

  18. 11.How would you recommend that I manage the airway in a trauma patient with an unstable neck? First,ask yourself if the patient is appropriate for an awake fiberoptic intubation. If the answer is “no”,then try your best to evaluate the airway and determine if a DL(or Glidescopy)is likely to be “easy”.If “yes”,do with MILS. The worst thing you can do is fail at a DL and then keep trying:multiple attempts,multiple laryngoscopists are a prescription for a major injury.If you can`t do a DL,move quickly to a surgical airway.If you`ve induced anesthesia and can`t intubate,insert an LMA ,or cricothyroidotomy.

  19. Thanks!!!

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