PATHOLOGY AND MEDICAL MANAGEMENT OF THE CERVICAL SPINE

1. PATHOLOGY AND MEDICAL MANAGEMENT OF THE CERVICAL SPINE PTP 521, Musculoskeletal Diseases and Disorders

2. Symbols this is for your information only, it won’t be used for the exam important to know for exam

3. Cervical Spine Pathology Bone Joint Soft Tissue Disk Arthritic Conditions Trauma Degenerative Disk Disease Whiplash Spinal Stenosis Fractures Rheumatoid Arthritis Disk Bulge, Herniation Post Concussion Syndrome DJD/Osteoarthritis C2-C7 Radiculopathy Headaches Other Other Hypomobility Facet Syndrome Impingement Syndrome

4. Canadian CervicalSpine Rule for RadiographicExamination Sensitivity: 99.4% Specificity: 45.1% Stiell IG, Clement C, et al. The Canadian C-Spine Rule versus the Nexus Low-Risk Criteria in Patients with Trauma. JAMA 2003, 349;26

5. Canadian Cervical Spine Rule for Radiographic Examination • Stiell et al in 2003 examined patients to determine the characteristics of those who had positive cervical spine fractures versus those who were negative. • By following these rules, the number of unnecessary radiographs for the cervical spine was decreased dramatically • http://content.nejm.org/cgi/content/full/349/26/2510 • (full text article)

6. Importance • By following the Canadian Cervical Spine Rules, A clinician can be reasonably certain that a patient needs a radiograph of the cervical spine. • Sensitivity is high, - SnNout- therefore, if following these rules and the tests are negative, and you send the patient for a radiograph, only 1% will have a fracture. 99% will not have a fracture. • Specificity is mid range - SpPin - therefore, if the tests are positive, you send the patient for a radiograph, only 45% will have a fracture.

7. Fractures of the Cervical Spine • Musculoskeletal Practice Pattern G • 75% of all spine fractures occur in the cervical spine due to the instability of the atlanto-occipital joints

8. Jefferson’s Fracture: • Burst Fracture of C1. • Head holder, so fragments everywhere, very unstable, neck brace or halo. 1. MOI: Axial Compression 2. Radiograph: odontoid view, greater than 7 mm difference between both lateral masses of the atlas and those of the axis. 3. Unstable Fracture

9. Jefferson’s Fractures: Burst!

10. Hangman’s Fracture: • Fracture of the neural arch of the axis, fractures the pedicles of C2 with dislocation of C2 on C3 1. MOI: Hyperextension • a blow on the forehead forcing the neck into extension is a classic mechanism of injury producing fractures thru the pedicles 2. Radiograph: lateral view shows bilateral disruption through the pedicles of the axis 3. Unstable fracture

11. Hangman’s Fractures

12. Hangman’s Fracture

13. Dens Fractures Type 1: (A ) avulsion of the tip of the dens as a result of apical or alar ligament stress Type 2: (B) fracture of the junction of the dens with the body of the axis. Type 3: (C) fracture deep within the body below the dens. Type 4: see below

14. Dens Fractures • Left: Type 2 dens fracture at the junction of the dens with the vertebral body with posterior displacement • Right: fracture of the dens with posterior displacement of the atlas causing a small degree of spinal canal compression

15. CT scan of odontoid Fractures Type 3 Notice on this CT scan The foramen for the Vertebral artery emedicine.medscape.com/article/94234-media

16. Dens Fracture Type 4: sagittal or parasagittal fracture extending from a point lateral to the dens vertically or diagonally to the inferior surface of C2

17. Os Odontoideum: • Congenital Disorder • Failure of the dens to unite with the body of the vertebrae. 1. Radiograph: Odontoid view -Tell it is not a dens fracture by the smoothness around parts

18. Wedge Fracture: • MOI: Hyperflexion and Compression • -Like a crunch, diving • Radiograph: lateral view, the anterior height of the vertebral body is shorter by 3mm than the posterior border • Stable fracture • -If it has no neuro s(x), then will not do anything, end with a little kyphosis curve

19. Wedge Fracture • This fracture is easy to see compared to some. In comparing anterior height to posterior height, you should see a difference.

20. Burst Fracture of the Vertebral Body • Lower cervical vertebrae • MOI: Axial Compression 2. Radiograph: lateral view, comminuted vertebral body is flattened centrally • Can be stable or unstable • -Described by presence of neuro s(x), impingement of the spinal canal.

21. Radiograph: lateral view, comminuted vertebral body is flattened centrally emedicine.medscape.com/article/94234-media

22. Clay-Shoveler’s Fracture • Avulsion fracture of the Spinous Process 1. MOI: a. Hyperflexion -Where the pulley is over-used and detaches -Trapezius, Rhomboids, Para spinals

23. Hypomobility of the Cervical Spine 1. Pathology: tightness of the capsule of one of the synovial facet joints 2. Radiographic signs: generally none 3. Clinical Symptoms: aching, dull, stiff feeling in the neck *Headaches* • Clinical Signs: loss of movement in a capsular pattern for the facet joints • Joint play is decreased at the segmental level • Capsular end feel • Pattern: Upper Cervical: limited lateral flexion and rotation equally limited %-wise, then extension limited less. • -Lower cervical is opposite

24. Facet Syndrome Joint Dysfunction Pathology: joint capsules are stretched from joint subluxations or distension of the joint with fluid. -Looser the capsule gets, tight Para spinals. • Body will protect the area with posture and muscle spasms of the paravetebral muscles which leads to a decrease in spinal mobility and a secondary muscle fatigue.

25. Facet Syndrome • Occurs early in the degenerative process for the young or middle aged patient • Loading patterns change which lead to cartilage degeneration, facet hypertrophy and bony adaptation in the form of sclerosis or spurring (ostephyte formation). • Alters joint function which alters disc function

26. Radiographic Signs: Oblique view: • Hypertrophy of the facet joint • Osteophyte formation at the superior and inferior articulating processes c. Decrease in joint space

27. Clinical Symptoms of Facet Syndrome • Presentation is variable, generally a steady ache with long periods of inactivity. • Pain present after activity, not during. • Progression of pain gets more sever over time • Pain will come and go with activity demands and disease progression. • Sharp pain with abrupt movements. • Catching or locking sensation. • Some radiation of pain may occur if nerve root is involved

28. Clinical Signs of Facet Syndrome • Muscle spasms in the paraspinals • Decrease lordosis • Decrease ROM all directions particularly with extension and rotation to one side • Pain with extension • Neurological exam is normal initially, may be abnormal eventually with osteophyte formation.

30. Impingement Syndrome 1. Onset: sudden, often without a memorable trauma 2. Radiographic Signs: generally none 3. Clinical Symptoms: sharp, unilateral pain, stiff neck and c/o loss of movement

31. Signs of Impingement Syndrome • ROM limited in area’s that close or compress the facet joint on the painful side. • Extension and rotation to the side of dysfunction are limited • Lateral flexion may be painful, not as limited • Compression increases pain, distraction decreases pain. • Muscle guarding during passive and active movement.

32. Osteoarthritis, Degenerative Joint Disease Joint Dysfunction Pathology: progressive degeneration as a natural consequence of aging, loss of flexibility or movement occurs as the disease progresses -Look for osteophyte formation, anteriorly first bridging between vertebrae.

33. Osteoarthritis: oblique view • Osteophyte formation is usually seen as bridging the vertebrae – carefully review the shape of the vertebrae in this view • Encroachment of the neural foramen is also noted emedicine.medscape.com/article/305145-media

34. Cervical Spinal Stenosis: Joint Dysfunction • Pathology: narrowing of the central spinal canal or the intervetebralforamina • Increase in bone formation around the nueral foramen. • Etiology: • Developmental, congenital, or traumatic, age related • Can be caused by intervetebral disc disease or osteoarthritis

35. Symptoms and Signs of Spinal Stenosis • Symptoms: • Radiating arm pain and numbness in nerve root distribution • Clumsiness if severe enough • Signs • Myotomal weakness • Hyperreflexia: will increase foramen space, so will look down, and adjust entire posture to compensate. • Clonus -May think that it is a “Disk Herniation”, but way to differentiate is an MRI

36. Imaging Studies • MRI: imaging study of choice • CT myelogram can be used but will be invasive so may not be the one of choice

37. Disc Herniation Causing Impingement of Specific Spinal Nerve • Can occur with or without radiculopathy. Less common in the cervical spine than in the lumbar spine. • Individual nerve roots may be impinged or tethered within the foramin.

38. 3. Herniation Sites a. C1-2: no disc b. C2-3: rare c. C3-4: rare d. C4-5: 1) clinical symptoms 2) signs: Motor Sensory Reflexes

39. Herniated Disc: MRI • Look at the spinal cord by C4-5 and C5-6. C4-5 is a larger herniation. This one is impinging on the spinal cord. • Consider the clinical symptoms this patient may have. • C5-6 slightly smaller and may only be a bulge.

40. Disc Herniation • MRI: encroachment by the disc on the spinal canal • Stenosis of the canal is also occurring giving the spinal cord a strangled appearance www.mayfieldclinic.com/ PE-HCDisc.htm

41. MRI • Best able to detect • Disk height loss • Annular fissures • Osteophytosis • End plate changes • Herniation • APTA 2009 CRHazle C5-6 disc herniation extending Posterior into the canal

42. Pathological Findings • Winking Owl Sign: • Metastatic cancer to the spine can show up initially as a missing pedicle • It gives the impression that the one of the “eyes” is closed. = pedicle www.medscape.com/viewarticle/421516_6

43. Whiplash: Musculoskeletal Practice Pattern 4E Definition: cervical strains or acceleration injuries “whiplash” MOI: Sudden Acceleration-Deceleration movement of the head and neck Causes: Falls, car accidents, sports injuries Head inertia creates a high velocity force or acceleration Results in severe overstretch injury Age of patient, general health, direction of forces and magnitude of forces determines the extent of injury and the tissues that are involved Soft tissue structures which can be potentially injured include: disc, spinal ligaments, capsule, muscles, nerves, spinal cord and vertebrae

44. Radiographic signs: • Changes in cervical curve on x-ray • Fanning of interspinousspaces (great space, curve in opposite direction) • Increased prevertebral space • Acute loss of disc height • Displaced prevertebral fat space • Vacuum cleft sign • Paraspinals go into sever spasms.

45. Force • Amount of force= weight of head plus speed that the head moves. • Direction of Force: • Where was the car hit • Symmetry of impact • Double injury – hit from behind, pushed into another vehicle • Position of person in relation to impact

46. C. Onset: may not be for several hours after an accident • Symptoms: pain, stiffness, and muscle spasm in the cervical spine, headaches are usually posterior, may have some dysphagia -Spasms are the Hallmark, extreme tenderness to palpation.

47. Post Concussion Syndrome Soft Tissue • Pathology: blow to the head • Onset: develops after the concussion within a 48 hour period after trauma • May last several weeks or months after injury 3. Symptoms: persistent headaches, inability to concentrate, irritability and fatigue

48. Medical Tests: CT scan usually negative for any brain injury • Specific Conditions related to return to play • Dependent upon severity of concussion – mild, moderate, or severe • Number of concussions a player has had in a season

49. Grade I: Mild Concussion • Momentary confusion, no loss of consciousness, symptoms disappear within 15 minutes • First concussion: return to play if asymptomatic for one week • Second: return to play in 2 weeks if asymptomatic for 1-2 weeks • Third: terminate season, may return to play next season if asymptomatic

50. Grade II: Moderate Concussion • Brief concussion, no loss of consciousness, symptoms last longer than 15 minutes • First concussion: return to play if asymptomatic for one week • Second: minimum of 1 month off play and asymptomatic for 1 week. If not asymptomatic, terminate season • Third: terminate season, may return next season