Evaluation and Treatment of the Cervical Spine

1. Evaluation and Treatment of the Cervical Spine Larry D. Dodge, MD

2. 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.

3. 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.

4. Asymptomatic Trauma Patient • Cervical x-rays not required in patients without tenderness and are alert.

5. Trauma Patients with Neck Pain • 2 to 6% incidence of significant spine injuries.

6. Do Not Remove Collar Until • Absence of tenderness • Absence of pain • Normal mental status • complete radiographic evaluation

7. Most Common Missed Diagnosis • Occipitoathlantoaxial region or cervicothoracic junction • Plain x-ray will miss 15 to 17% of injuries

8. CAT scan has 99% predictive value • MRI better for soft tissue, may be oversensitive

9. Flexion and Extension Radiographs • Safe in awake alert patients • Exclude significant instability

10. 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.

11. Fractures of the Cervical Spine • Most do not require surgery • Ligamentous injuries less predictable, and more require surgery

12. 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.

13. Occipitocervical Dissocation • Most are lethal • Neurologic injuries vary from complete to cranial nerve injuries • Diagnosis can be difficult • Occipitocervical fusion is required

14. Atlas Fractures • Axial load • Stability requires healing of transverse ligament – MRI • Halo- reasonable treatment • C1-C2 fusion if transverse ligament disrupted

15. Axis Fractures • Odontoid fractures are most common • Type I – Avulsion Type II – Waist Type III – Vertebral body

16. Type  Odontoid • Treated with external orthrosis

17. Type  Odontoid • Controversial treatment • Elderly do not tolerate halo – consider C1- C2 fusion • Fusion needed if reduction not achieved or maintained

18. Type  Odontoid • High healing rate with halo vest

19. Traumatic Spondylolisthesis of Axis • MVA- hyperextension, compression and rebound flexion • Most treated in halo

20. Subaxial Compression Fractures • Failure of anterior column • Orthosis for 6 – 12 weeks

21. Subaxial Burst Fracture • Fracture into posterior cortex with retropulsion • Spinal cord injury rate is high • Most require surgery – anterior or anterior and posterior

22. 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

23. Cervical Disk Disease • Symptoms can be insidious or acute • Minor injured can aggravate the root (radiculopathy) or spinal cord ( myelopathy)

24. 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

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

26. Hyporeflexia • Biceps • Brachioradialis C- 6 • Triceps C- 7

27. Most Commonly Affected • C-5, C-6, C-7 • More motion in these areas • Watershed area of blood supply – roots more susceptible

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

29. Cervical Spondylosis • May cause radicular pain from nerve root origin • May cause referred sclerotomal pain ( occiput, interscapular region, or shoulders)

30. Treatment • 75% of radiculopathy improve with P.T. , activity modification, medication • Soft disk herniations can resorb • Myelopathy

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

32. Electrodiagnostic Studies • Paresthesias cannot be localized • Imaging does not correlate with clinical picture

33. Nonsurgical Care • P.T. – emphasize isometric exercise • Traction with slight flexion • Medication • Epidural steroids

34. Surgical Indications • Success for axial pain is 60 % • Success for radiculopathy is 90% • Disk Replacement – evolving technology

35. ACDF • Allograft versus autograft • Plate fixation • Accelerates degeneration at adjacent levels

36. Posterior Decompression • Foraminotomy for bony foraminal stenosis • Laminectomy – risk of kyphosis • Laminectomy – decompression without adding fusion

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