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.