CERVICAL SPINE INJURY

Common causes: 1. MVA (esp major or if head injury), 2. sporting 3. diving, 4. falls, 5. assault,

Incidence:
~2% based on sig. spine or cord injuries found in trauma imaging of C-spines. 10-20% HI injury also have a cervical spine injury. ~15% have missed or delayed diagnosis of cervical spine injury, with a risk of permanent neurologic deficit of 29%.

Site: 33% of injuries occur at the level of C2, and 50% occur at the level of C6 or C7.

Pediatric: Most injuries are C1-C2 as relatively heavier head, lax ligaments.
Gender: 4M:1F

Presentation
Cervical spine injury should be suspected if: Dangerous mechanism: MVA, fall, diving accident, axial load to head, sporting tackles Neck pain: Midline tenderness = vertebral vs lateral tenderness = muscle.

 Neurological signs: Paraesthesiae & weakness/paralysis. Spinal cord injury various deficits, injury syndromes
Other trauma: Multi-trauma, significant HI, distracting painful injury Elderly increased fragility.

LOC makes assessment difficult assume an injury

 Injuries to the cervical spine are serious because the crushing, stretching, and rotational shear forces exerted on the cord at the time of trauma can produce severe neurologic deficits

Edema and cord swelling contribute further to the loss of spinal cord function.

Injury Mechanisms
Hyperflexion (most common, 80%) o Fractures: Ant wedge #, flexion teardrop #, clay shovellers #, peg # o Dislocations: ant subluxation, bilateral interfacet dislocation, antlanto-occipital dislocation, ant atlanto-axial dislocation Hyperextension: o Fractures: Hangman's #, extension teardrop #, o Dislocation: ant atlanto-axial dislocation

Injury Mechanisms
Axial compression: Jefferson #, vertebral burst # Distraction Lateral rotation: Unilat interfacet dislocation, rotatory atlanto-axial dislocation

Atlas (C1) injury

1. 2. 3. 4. Neural arch fracture Burst (Jefferson) fracture Atlanto-occipital dislocation Transverse ligament disruption (ant. atlantoaxial dislocation)

Neural arch fracture

Longitudinal # through post. neural arch, usually bilateral caused by hyperextension. Stable.

Jefferson Fracture
Compression fracture of the bony ring of C1, characterized by lateral masses splitting and transverse ligament tear. Best seen on odontoid view

 Signs: Displacement of the lateral masses of vertebrae C1 beyond the margins of the body of vertebra C2.

CT is required to define the extent of fracture

Caused by axial compression

 Uncommon. Disruption of all ligaments between occiput and atlas with subluxation or complete dislocation of the occipitoatlantal facets.

Atlanto-occipital dislocation

 Anterior translation of the skull can stretch brainstem respiratory arrest & death. More common in children due to the larger head. Up to 50% of atlanto-occipital dislocations are initially missed.

Transverse ligament disruption (ant. atlantoaxial dislocation)

Predental space>3mm (child >5mm) as dens moves back compressing spinal cord

Axis (C2) injury

1. Odontoid peg fracture 2. Hangmans fracture (traumatic spondylolisthesis)

Odontoid Fracture
Fracture of the odontoid (dens) of C2 (most common) 3 categories, I-III

Flexion, extension, and rotation may contribute to the fractures Best seen on the lateral view

Type I
Type I Fx through superior portion of dens

Type II Fx through the base of the dens

Type III Fx that extends into the body of C2

Hangmans Fracture (traumatic spondylolisthesis)

Fx through the pars reticularis of C2 secondary to hyperextension; fracture of the pedicles of the axis or second cervical vertebra Best seen on lateral view

 Signs: Prevertebral soft tissue swelling Avulsion of anterior inferior corner of C2 associated with rupture of the anterior longitudinal ligament. Anterior dislocation of the C2 vertebral body. Bilateral C2 pars interarticularis fractures. MOI: extreme hyperextension during a diving accident or motor vehicle collision Hanging or hitting a dashboard

C2-C7 Injury
Anterior wedge compression fracture Teardrop flexion fracture Teardrop extension fracture Burst fracture Unilateral (locked) facet joint dislocation Bilateral (locked) facet joint dislocation Spinous process fracture Whiplash (Cervical Sprain) Hyperflexion Strain Hyperextension Strain

Anterior wedge compression fracture

Hyperflexion # with reduced ht (<3mm) of vertebral body only anteriorly.

Compression fracture resulting from flexion.

Mechanism: hyperflexion and compression

 Signs: Buckled anterior cortex.

Loss of height of anterior vertebral body. Anterosuperior fracture of vertebral body.

Flexion Teardrop Fracture

Posterior ligament disruption and anterior compression fracture of the vertebral body which results from a severe flexion injury. Best seen on lateral view

 Signs: Prevertebral swelling associated with anterior longitudinal ligament tear. Teardrop fragment from anterior vertebral body avulsion fracture. Posterior vertebral body subluxation into the spinal canal. Spinal cord compression from vertebral body displacement. Fracture of the spinous process. Mechanism: hyperflexion and compression (e.g. diving into shallow water)

 Neurologic injury is very common. The result is often the anterior cord syndrome, manifesting as quadriplegia and loss of pain and temperature sensation. The most common level for a teardrop fracture is C5.

Teardrop extension fracture

Hyperextension causes a triangular fragment to be avulsed off the anteroinferior corner of the vertebral body. C2 is most commonly involved. Only rarely assoc with neurological deficit.

Burst Fracture
results from axial compression. Axial compression comminuted fracture fragment surface driven back into spinal canal

CT is required for all patients to evaluate extent of injury.

 Injury to spinal cord, secondary to displacement of posterior fragments, is common.

Facet Joint Dysfunction

Cervical instability MOI - from acute trauma (whiplash) or repetitive motions S&S posterior neck pain in paraspinal region, pain with A and PROM during extension and rotation of the c-spine, clicking or catching; referred pain but no radicular pain

Unilateral Facet Dislocation

Facet joint dislocation and rupture of the apophyseal joint ligaments resulting from rotatory injury of the cervical vertebrae. (vertebra being displaced anteriorly by up to 25% on the lateral film.) Best seen on lateral or oblique views Mechanism: simultaneous flexion and rotation

 Signs: Anterior dislocation of affected vertebral body by less than half of the vertebral body AP diameter. Discordant rotation above and below involved level. Facet within intervertebral foramen on oblique view. Widening of the disk space. "Bow tie" or "bat wing" appearance of the overriding locked facets.

Bilateral Facet Dislocation

Complete anterior dislocation of the vertebral body resulting from extreme hyperflexion injury. It is associated with a very high risk of cord damage. (displaced ant by 50% on lateral view.) Best seen on lateral view

 Mechanism: extreme flexion of head and neck without axial compression.

most severe form of anterior subluxation Neurologic injury is common.

 Signs: Complete anterior dislocation of affected vertebral body by half or more of the vertebral body AP diameter. Disruption of the posterior ligament complex and the anterior longitudinal ligament. "Bow tie" or " bat wing" appearance of the locked facets.

Spinous process fracture

Hyperflexion causes avulsion of the spinous process by the supraspinatous ligament, usually C6 or C7 (Clay shovellers).

 This is caused by flexion as the body rotates relative to the head and neck. Usually undisplaced, stable and seen on lateral film.

Clay Shovelers Fracture

Fracture of a spinous process C6-T1 Best seen on lateral view Mechanism: powerful hyperflexion, usually combined with contraction of paraspinous muscles pulling on spinous processes (e.g. shoveling).

 Signs: Spinous process fracture on lateral view. Ghost sign on AP view (i.e. double spinous process of C6 or C7 resulting from displaced fractured spinous process).

 Sprain injury to a ligament or non-contractile tissue Sudden deceleration of the body, with flexion and extension movements of the cervical spine usually results in sprain or intervertebral disc injury without fracture or dislocation.

Whiplash (Cervical Sprain)

 The commonest radiographic appearance is straightening of the cervical spine due to severe muscle spasm, with the normal curvature reduced or reversed. Usually MVA. May be increased with seat belts. Reduced by proper head rests.

Whiplash injury
Sudden hyperextension and flexion Increasing neck pain for the first 24hours Associated headache, pain radiating to both shoulders and paraesthesia in hands Reduced lateral flexion Anterior longitudinal ligaments are torn causes dysphagia Forward flexion against resistance is painful 90% are asymptomatic after 2years 10% still have pain

Hyperflexion Strain
Anterior subluxation occurs with disruption of posterior longitudinal ligament, interspinous ligament and intervertebral disc. Lat film shows localised kyphotic angulation with increase in height of intervertebral disc posteriorly and associated fanning of the spinous processes.

Hyperextension Strain
The converse of hyperflexion strain; the anterior longitudinal ligament is disrupted as evidenced by widening of the intervertebral disc space anteriorly. The facet joints are disrupted and the interspinous distance is narrowed.

Anterior Subluxation
Disruption of the posterior ligamentous complex resulting from hyperflexion. It may be difficult to diagnose because muscle spasm may result in similar findings on the radiograph. Subluxation may be stable initially, but it associates with 20%-50% delayed instability. Flexion and extension views are helpful in further evaluation. Mechanism: hyperflexion of neck

 Signs: Loss of normal cervical lordosis. Anterior displacement of the vertebral body. Fanning of the interspinous distance.

Brachial Plexus / Neuropraxia

Commonly called burners, stingers, pinched nerves MOI: stretch or compression S/S: burning or stinging neck/arm/hand, muscle weakness, supraclavicular tenderness (Erbs Point), neck painchronic: numbness ,tingling, and weakness lasts longer

 Compression force nerve roots pinched between adjacent vertebrae Increased risk if spinal stenosis (narrowing of intervertebral foramen) exists Distraction force tension or stretch force on nerve roots Most common at C5/C6 levels but may involve any cervical nerve root Erbs point 2-3 cm above clavicle anterior to C6 transverse process, most superficial passage of brachial plexus

Brachial Plexus Injury

Other Pathology
1. 2. 3. 4. Spondylosis Metastatic disease Congenital fusion Hanging

Spondylosis
Refers to OA of the spine. Disc space narrowing and osteophyte formation. The associated osteophytes may impinge on the nerve root foramina. May obscure underlying injury. A common injury mechanism in these patients (often elderly) is a fall directly onto forehead C2 #.

Spinal Stenosis
can be congenital S&S:
can be asymptomatic Neurological pain Increased leg pain with standing that resolves by sitting (increases available space in spinal canal) Can be ipsilateral (foramen) or bilateral (canal)

Metastatic disease
Primary tumours can metastasise to vertebral bodies demonstrating a lucent, moth-eaten, permeative appearance. There is often subsequent collapse.

Congenital fusion
It is not unusual to see a congenital fusion within the cervical spine, usually at C2/C3 with fusion of the vertebral bodies and posterior elements. This is associated with a hypoplastic odontoid peg.

Hanging
3rd most popular method of suicide. More common in young adult males & indigenous pop. Cervical spine injury in only 1% (Hangmans fracture) only if drop>patient height. Death less likely from tracheal obstruction as from venous obstruction suffusion, venous cerebral infarction, carotid sinus reflex bradycardia & CNS asphyxia. May have petechial/sub conj haemorrhages, hyoid #, laryngeal #or thyroid/cricoid cartilages. 75% intact if survive to ED.

Assessment
History: Details of trauma. When neck pain/neuro symptoms developed (usually delayed with whiplash). Prior spinal injuries. AMPLE history. Examination: Palpate for tenderness, swelling, gap or step, muscle spasm. Neuro. (sensation, motor fn, reflexes, rectal tone, perianal sensation), other injuries. Investigation: Decision to image based on NEXUS criteria or Canadian C-spine rule.

CERVICAL SPINE IMAGING

National Emergency X-radiography Use Study (NEXUS) Low Risk Criteria (NLC)
Aim: Criteria for clearing a patient of any or significant C-spine injury without imaging. Included: All who had trauma imaging of Cspine Excluded: Penetrating trauma

 Criteria: No midline posterior tenderness No focal neurological deficit Alert Not intoxicated No distracting painful condition e.g. long bone #, large lac, degloving, crush injury, burns Performance: Sensitivity 99% (any) or 99.6% (sig). Specificity 12.9% (any) or 12.9% (sig) Validated: in elderly (have a higher prevalence of odontoid fx) & children>9 y

Canadian C-Spine Rules

Aim: Rules for detecting C-spine injuries in blunt trauma Included: All who had blunt head or neck trauma, GCS15, stable (BPsys>90mmHg & RR 11-23) Excluded: Penetrating trauma, age<16, pregnant, minor injuries only, GCS<15, >48h since injury, acute paralysis, known spinal disease, return for same injury. Performance: Sensitivity 100%. Specificity 42.5%

Imaging Modalities
Plain radiography typically includes 3 views: anteroposterior, lateral, and odontoid. This imaging modality is falling out of favor because its false-negative rate is higher than that associated with CT Shows skeletal #s, alignment

CT imaging
to evaluate patients for injury. CT allows easy imaging of the cervical spine when clinically indicated. A CT scan is best for detecting bony abnormalities; it can detect 97% of osseous fractures. shows skeletal #s, sublux/disloc injuries, disc spaces, alignment,

MRI
shows ligamentous, disc & cord injuries well, less good view of #s. Controversy over use.

Primary Assessment

 Any person with a head, neck, or back injury or fractures to the upper leg bones or to the pelvis should be suspected of having a potential spinal cord injury until proven otherwise

 Provide immediate immobilization of the spine while performing assessment.

Airway.

Breathing.
Intercostal paralysis with diaphragmatic breathing indicates cervical spinal cord injury.

Primary interventions

1. Immobilize the cervical spine.

The protocol for spinal immobilization is as follows: 1. Maintain the head in neutral in-line position with a cervical collar in place 2. Logroll the patient onto the backboard 3. Secure the torso with spider straps or buckle straps 4. Secure the head to the backboard with foam blocks or towel rolls 5. Secure the legs to the backboard.

2. Open the airway using the jaw-thrust technique without head tilt.
3. If the patient needs to be intubated, it may be done nasally.
Recommendations for managing the airway of a trauma patient are: 1. Rapid-sequence intubation (RSI): When managing an unconscious patient, standard drugs should be used for paralysis and induction

2. Manual in-line stabilization: An assistant firmly holds both sides of the patients head, with the neck in the midline and the head on a firm surface throughout the procedure, to reduce cervical spine movement and minimize potential injury to the spinal cord 3. Orotracheal intubation is preferred in trauma patients requiring intubation 4. Use a tracheal tube introducer such as a Bougie or stylet 5. Have a selection of blades ready: evidence supports the use of a Macintosh blade 6. A laryngeal mask airway (LMA) can be used as a temporary device.

4. If respirations are shallow, assist with a bag-valve mask. 5. Administer high-flow oxygen to minimize potential hypoxic spinal cord damage.

Subsequent assessment

1. Assess the position of the patient when found; this may indicate the type of injury incurred. 2. Hypotension and bradycardia accompanied by warm, dry skin (hypothermia)suggests spinal shock.
3. Neck and back pain/extremity pain or burning sensation to the skin. 4. History of unconsciousness.

5. Total sensory loss and motor paralysis below level of injury. 6. Loss of bowel and bladder control; usually urinary retention and bladder distention.
7. Loss of sweating and vasomotor tone below level of cord lesion.

8. Priapismpersistent erection of penis.

9. Hypothermiadue to the inability to constrict peripheral blood vessels and conserve body heat. 10. Loss of rectal tone.

General interventions

NURSING ALERT

A spinal cord injury can be made worse during the acute phase of injury, resulting in permanent neurologic damage. Proper handling is an immediate priority.

1. Insert an NG tube. 2. Keep the patient warm. 3. Initiate I.V. access. 4. Insert an indwelling urinary catheter to avoid bladder distention. 5.Monitor for hypotension, hypothermia, and bradycardia. 6. Continue with repeated neurologic examinations to determine if there is deterioration of the spinal cord injury.

7. Be prepared to manage seizures. 8. Pharmacologic interventions: high-dose steroids (methylprednisolone). The standard regimen is 30 mg/kg I.V. loading dose over 15 minutes, followed by a 5.4 mg/kg/hour infusion to be initiated 45 minutes later.

Continue the infusion for 23 hours.

Cord-Level Findings
Neurologic deficits correlate with the level of the injury, resulting in weakness or paralysis below the lesion. There are 8 pairs of spinal nerves in the cervical spine. From C1 to C7, the nerve root exits above the level of the vertebra; from C8 and below, the nerve root exits below the level of the vertebra.

Myotome and Dermatome Testing

Nerve Root Level C1-C2 C3 C4 C5 Sensory Testing Motor Testing Reflex Testing Front of face Lateral face and skull Supraclavicular Lateral shoulder/upper arm Neck flexion Lateral flexion Shoulder shrug Shoulder abduction Elbow flexion and wrist extension Elbow extension and wrist flexion Finger flexion and thumb extension N/A N/a N/A Bicipital (musculocutane ous) Brachialradial (musculocutane ous) Triceps (radial) N/A

C6

Lateral lower arm and hand (thumb and index finger) Palmar aspect of hand middle 3 fingers Medial lower arm and hand

C7 C8

T1

Medial elbow and upper arm

Finger abduction

N/A

The presentation of incomplete cord injuries depends on the level and location of the lesion. The anterior column conveys motor function, pain, and temperature, and the posterior column conveys impulses related to fine touch, vibration, and proprioception.

Partial Cord Syndromes

Anterior cord syndrome results from compression of the anterior spinal artery, direct compression of the anterior cord, or compression induced by fragments from burst fractures. Anterior cord syndrome manifests as complete motor paralysis, with loss of pain and temperature perception distal to the lesion. Posterior cord syndrome is very rare; involvement of the posterior column is most often seen in Brown-Se quard syndrome.

Brown-Se quard syndrome

Brown-Se quard syndrome is characterized by paralysis, loss of vibration sensation, and proprioception ipsilaterally, with contralateral loss of pain and temperature sensation. These signs and symptoms result from hemisection of the spinal cord, most often from penetrating trauma or compression from a lateral fracture.

Central cord syndrome

Central cord syndrome, induced by damage to the corticospinal tract, is characterized by weakness in the upper extremities, more so than in the lower extremities. The weakness is more pronounced in the distal portion of the extremities. This injury is usually caused by hyperextension in a person with an underlying condition such as stenosis or spondylosis.