Cervical spine injuries

Zafar Iqbal
Abbasi Shaheed Hospital
Karachi
Types
 burst fracture of the cervical spine
 rupture of the anterior longitudinal ligament of the spi

 cervical disc prolapse

 cervical dislocation
 cervical subluxation
 clay-shoveller's fracture
 hangman's fracture
 odontoid fracture
 Whiplash injury
burst fracture of the cervical spine
 Burst fractures result from severe axial
compression such as may occur if a heavy
object fell on the head or in diving accidents.
In the most severe cases the vertebral body
literally bursts and bone fragments may be
driven backwards into the spinal canal
causing spinal cord damage.
'Jefferson Fracture'.
 A burst fracture of C1 (atlas) is known as a
'Jefferson Fracture'. About 50% of patients
survive this injury without neurological deficit
because the majority of the mass of the atlas
is in the two lateral masses which displace
sideways away from the spinal canal.
treated with skull traction
 Displaced fractures are treated with skull
traction for six to eight weeks followed by a
plastic collar until interbody fusion is seen on
X-ray.
halo-body cast
 Undisplaced fractures are treated with a halo-
body cast or in less severe cases a cervical
brace.
rupture of the anterior longitudinal
ligament of the spine
 Hyperextension may tear the anterior
longitudinal ligament. There is no fracture but
an extension X-ray film shows a gap between
the two vertebral bodies. This is most
common in the cervical spine.
 Neurological damage is variable. The injury is
stable in flexion and is treated using a
cervical collar for 6 weeks
cervical disc prolapse
 Prolapsed cervical disc may be precipitated
by local strain or injury: often unguarded
flexion and rotation. Usually there is a
predisposing abnormality of the disc with
increased nuclear tension.
 This condition usually occurs immediately
above or below the 6th cervical vertebra
affecting the 6th or 7th cervical nerves.
clinical features
 When a cervical disc prolapses, central
protrusion presents with signs of spinal cord
compression.
 A postero-lateral protrusion presents with
acute neck stiffness within hours or days
following the insult. It is aggravated by
coughing and other straining. Later, there is
pain radiating over the shoulder and
throughout the upper limb. There may be
paraesthesia in the digits.
 On examination, certain neck movements
may be limited by pain but movement in at
least one direction, often lateral flexion, is
free. There may be slight muscle wasting and
sensory impairment in the distribution of the
cervical nerves with the corresponding tendon
reflexes depressed or absent.
 The clinical picture is variable. A history of
injury may not always be obtainable;
symptoms may be confined to either the neck
or to the upper limb; muscle wasting may be
marked or absent.
 There may be further attacks, either sudden
or gradual in onset.
clinical features of cervical
spondylosis
 The neurological symptoms associated with
cervical spondylosis may vary from local neck
pain with muscular bracing and no
neurological deficit at one end of the scale, to
radicular complaints due to root compression
or myelopathy secondary to cord
compression at the other
 typical early spondylotic neck and shoulder and neck
muscle pain is followed by brachalgia, i.e. by referred
or radicular pain going down into the arm and/or
forearm, this suggests a progression from 'simple
spondylosis', to nerve root irritation and compromise,
and/or frank compression
 features of radiculopathy from spondylotic osteophytes
may develop insidiously or acutely
 trauma or acute disc herniation may precipitate the
symptoms
 bilateral symptoms are less common and may span
several segments if more than one cervical level is
involved
 Neck and arm pain, along with weakness, are typical
but one may exist without the other. Other features
include sensory loss, paraesthesia and hyporeflexia
Degenerative features:
 reduced neck mobility
 painful, tender spine
 crepitus on movement
Radicular features:
 pain - sharp, stabbing; exacerbated by coughing; may be
superimposed on a more constant deep ache over the
shoulders down to the lower scapulae and down the arms;
occipital headache
 paraesthesia - numbness / tingling in a root distribution
 root signs:
 dermatosensory loss
 lower motor neurone signs - according to site of lesion
 compression of vertebral artery and oesophagus may give
rise to 'drop attacks' and dysphagia
 Myelopathic features:
 features of cervical spondylotic myelopathy usually develop insidiously
 75% of cases there is progression in either a stepwise (one-third) or gradual (two-thirds) fashion
 an initial phase of deterioration may be followed by a stable period, which may last for years
 patients notice impaired co-ordination of the hands and complain of difficulty with tasks such as
buttoning clothes
 may be weakness and wasting of the hand muscles, and opening and closing of the fist is slowed and
stiff
 arms - lower motor neurone signs at the level of the lesion with upper motor neurone signs below
that level; for example, C5 lesion - wasting and weakness of biceps, reduced biceps jerk (LMN);
increased finger jerks (UMN)
 legs - upper motor neurone signs; sensory signs less prominent
 sphincter - disturbance seldom seen as an early feature
 about 50% develop bladder sphincter symptoms such as urgency, but anal sphincter disturbance is
rare
 in about 80% of cases there may be loss of vibration sensation in the lower extremities
 some patients may have posterior column dysfunction with impaired joint position sense and two-
point discrimination
 Lhermitte's sign – paraesthesia in all extremities induced by flexion or extension of the cervical
spine and caused by cord compression – is seldom found
 acute myelopathy may occur as a result of a fall in an elderly patient with pre-existing spondylosis
and stenosis of the vertebral canal - may or may not have been symptomatic before the fall
 central cord syndrome typically produces weak arms and hands, but spares the peripheral
corticospinal tracts, thus lower limb function is not as severely impaired.
 Typically in this condition there are
exacerbations of more acute discomfort, and
long periods of relative quiescence.
Notes:
 there are eight cervical nerve roots and only seven
cervical vertebrae. Thus, cervical roots exit above their
corresponding vertebrae, and thoracic nerve roots exit
below their corresponding vertebrae
 symptoms stem from compression of the sensorimotor
roots at the intervertebral foramina, and clinical
analysis of their distribution and the neurological
findings may allow the segmental level to be defined.
Approximately 90% of cases occur at the C5/6 and
C6/7 levels, where the mobile cervical spine joins the
immobile thoracic segments
cervical dislocation
 Cervical dislocations are the result of flexion-
rotation injuries between C3 and T1. One or both
of the articular facets of one vertebrae ride
forward over the facets of the vertebrae below.
Often one or both of the facets are fractured but
there may be pure dislocation - 'jumped facets' -
since the facets are relatively horizontal in the
neck. The injury is unstable if the facets are not
locked and is often associated with neurological
damage.
Radiography: marked forward
displacement of one vertebrae on the
other
 less than one half displaced - single or
unilateral facet dislocation.
 half or more displaced - Bilateral facet
dislocation.
facet dislocation (bilateral, cervical
spine)
 In bilateral facet dislocation both facets have
dislocated and/or fractured. On X-ray the
affected vertebral body is displaced by at
least a half its length forwards.
 Initial treatment centres around reduction of
the dislocation. This can be achieved by
heavy skull traction for a few hours. If the
facets are locked this may fail. Manipulation
under relaxation or open reduction from the
back may be required.
Once the dislocation is reduced:
 Traction may be continued for six weeks
followed by a cervical collar for six weeks or...
 A halo body cast may be worn for eight
weeks or...
 A posterior fusion may be performed followed
by a cervical brace for eight weeks.
cervical subluxation
 Cervical subluxation is a flexion injury. There
is no bony damage but the soft tissues are
extensively damaged and the posterior
ligaments torn. The affected vertebra hinges
forward on the one below, opening up the
interspinous space posteriorly then falls back
again.
 Radiologically there may be an increased gap
between the spines of affected vertebra, but
the film often appears normal - flexion
radiology may be required to demonstrate the
instability.
 Treatment is usually a collar for six weeks.
However, if there is persistent instability a
posterior spinal fusion may be required.
clay-shoveller's fracture
 This is an avulsion fracture of the spinous
process of the seventh cervical vertebrae
(vertebra prominens). It is essentially a
muscle injury associated with severe muscle
contraction - as when shovelling clay ! It is
painful but harmless.
Treatment
rest with exercise within the limits of the pain.
hangman's fracture
 This fracture may be produced in two ways;
 Simultaneous extension and distraction of the neck as occurs in
hanging and in motorcyclists caught under the neck by a tree
branch. Treatment involves skull traction for 4 to 6 weeks to
maintain position with the possibility of local fusion (posterior or
anterior).
 Extension of the neck with compression. This pattern of injury
occurs in road traffic accidents where the head hits the roof of
the car (compression) and is then thrown into extension.
Treatment depends on the stability of the injury. Stable injuries
can be treated with a well-fitting collar for 6 weeks. If there is
neurological injury or instability skull traction and or local fusion
are indicated.

 Neurological damage is common in the first case but rare in the

second.
odontoid fracture
 Fractures of the odontoid peg of the axis (C2)
may result from extension of the neck in a
high-velocity accident or a severe fall. They
are difficult to diagnose and should be
suspected from the history in association with
local pain and protective muscle spasm.
 In the majority of cases the diagnosis is
confirmed on AP 'through the mouth' and
lateral x-rays. In some cases tomography
may be necessary. Confusion may arise
because of congenital abnormalities including
non-fusion of the odontoid process. Be
careful not to mistake the vertical cleft
between the incisors or the epiphyses in
children for a fracture.
Odontoid fractures can be
classified as follows:
 type I:
involving the tip of the odontoid peg
 are stable and require only symptomatic treatment with a
collar
 type II:
 involving the junction of the odontoid peg with the body
 are the commonest type
 require reduction and immobilisation with a Halo and body
cast
 if at 12 weeks the fracture is still unstable posterior fusion of
C1 to C2 is advisable
 type III:
 this type of fracture runs deeply into the body of C2
 union fails to occur in about 25% of cases
 management is as for type II fractures
whiplash injury
 Whiplash injury is a combined flexion /
extension soft-tissue injury of the cervical
spine, common in road traffic accidents.
There are two types of injury:
 in a rear end shunt, the head is thrown backwards
and the neck is hyperextended. This tears the
anterior longitudinal ligament resulting in bleeding
between the ligament and the vertebra. There may
be retropharyngeal swelling and dysphagia within
hours of the injury.
 a rapid deceleration injury throws the head forwards
and flexes the cervical spine. The chin limits forward
flexion but the forward movement may be sufficient to
cause longitudinal distraction and neurological
damage. Hyperextension may occur in subsequent
recoil.
Treatments.
 Analgesia and patience are the only
treatments.
clinical features
 The clinical symptoms of whiplash injury may
not develop until 6-12 hours after the injury or
even after a few days. These include:
 loss of movement and tenderness
 headache, dizziness, blurring of vision
 paraesthesia and weakness in the arms and
legs - dependent upon the site of the cord
contusion
 sometimes there is dysphagia
 Lhermitte's symptom
 Symptoms may be impressive and severe,
but investigation often fails to reveal any
abnormality.
management
 Cervical radiology after a whiplash injury is
usually unremarkable.
Analgesia and patience are
required.
 there is now overwhelming evidence that the use of
collars in confirmed whiplash injury (neck sprain)
prolongs the recovery of the patient. Patients should be
advised about neck mobilisation and encouraged to
start as soon as possible
 patients should be educated regarding posture advice
regarding support of the neck whilst sleeping, and
instruction about exercises
 patients with particularly severe symptoms or symptoms
that are not resolving may benefit from physiotherapy
back
 The examination of the back in the secondary
survey should entail a formal logroll with in-
line stabilisation:
 look for bruising
 palpate for a uniform interspinous gap and
alignment of vertebrae
 test saddle area sensation
Examination of Spine
This is defined in terms of:
 inspection
 palpation
 movement and measurement
 neurology of the limbs
 The examination of the neck and cervical
spine is dealt with separately.
Inspection
 Pay attention to the patient's gait as they enter the room.
 Expose the back and legs.
 Look for the following:
 skin pigmentation - e.g. cafe au lait spots; sinuses; scars
and nodes
 deformity and asymmetries - postural or permanent;
direction / plane i.e. kyphosis or scoliosis, degree, size, site
 tilt
 muscle spasm, fasiculation, wasting - specifically calf and
buttock
 legs / arms - wasting, movement, muscle imbalance, size
palpation
 With the patient standing and then perhaps
later, lying supine, palpate the back for the:
 skin temperature
 deformity of the spine - steps or a steady
contour ?
 vertebral tenderness - localised or general ?
 paraspinal spasm and muscle tenderness
 sacro-iliac tenderness in sacroileitis
Elsewhere:
 feel for peripheral pulses
 palpate groin and abdomen for abscesses
 if diagnosis is still uncertain, carry out full
thoracic, abdominal, rectal and vaginal
examination
neurology of the limbs
 Neurological assessment is an essential part
of the examination of the spine.
 The examination should involve a full
assessment of muscle wasting, fasiculation,
tone, power, coordination / proprioception,
sensation and reflexes.
.
 Similarly, if indicated by the history, perianal
reflexes and sphincter tone should be tested
neck examination
 Following trauma, the neck should be
immobilised until a lateral xray is performed.
Examination of the neck is a more specialised
form of the general spinal examination.
inspection
 look
 posture
 deformity
 asymmetry e.g. of scapulae / anterior
Pancoast tumour
 torticollis or sternomastoid 'tumour' in infants
 arms and hands - for wasting, fasciculation
 legs weak, 'Off-legs' cord compression
Palpation
 Palpate for tenderness and masses. Palpate
posteriorly in the midline, laterally,
supraclavicularly - check for cervical rib - and
anteriorly
 Midline tenderness in the cervical spine may
be due to supraspinous damage following
whiplash injuries. Midline tenderness
associated with a defect in the supraspinous
ligament is a serious finding, often resulting
from major trauma. Paraspinal tenderness
radiating into trapezius is found in cases of
cervical spondylosis.
 Crepitation may be evident upon flexion and
extension with cervical spondylosis. One
hand may be ischaemically cold, discoloured
and atrophic secondary to a cervical rib.
movement
 ask the patient to flex and extend head; a spatula
held in the mouth acts as a pointer to enable the
range of movement to be measured by goniometer:
normal range is 130 degrees. The occipito-atlantoid
joint is primarily involved.
 lateral flexion: ask the patient to tilt his head laterally
from a neutral position; normal range is 45 degrees.
Whole of cervical spine involved.
 rotation: ask the patient to look over his shoulder -
normal range is 80 degrees to either side. Rotation is
a function of the atlanto-axial joint.
 palpate the radial pulse and then apply traction to the
arm; cessation of pulsation is suggestive of a cervical
rib
segmental neurology
 When examining the cervical spine it is
essential to examine the segmental
neurology.
 Root lesions may be indicated by weakness
in the upper limbs in a segmental distribution,
with loss of dermatomal sensation and altered
reflexes. If cervical cord compression is
suspected the lower limbs should also be
examined specifically looking for upgoing
planters and hyperreflexia.