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Cervical Spine Injuries: Zafar Iqbal Abbasi Shaheed Hospital Karachi
Cervical Spine Injuries: Zafar Iqbal Abbasi Shaheed Hospital Karachi
Zafar Iqbal
Abbasi Shaheed Hospital
Karachi
Types
burst fracture of the cervical spine
rupture of the anterior longitudinal ligament of
the spine
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.