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  1. 1. Larry D. Dodge, MD
  2. 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. 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. 4. Asymptomatic Trauma Patient  Cervical x-rays not required in patients without tenderness and are alert.
  5. 5. Trauma Patients with Neck Pain  2 to 6% incidence of significant spine injuries.
  6. 6. Do Not Remove Collar Until  Absence of tenderness  Absence of pain  Normal mental status  complete radiographic evaluation
  7. 7. Most Common Missed Diagnosis Occipitoathlantoaxial region or cervicothoracic junction  Plain x-ray will miss 15 to 17% of injuries
  8. 8.  CAT scan has 99% predictive value  MRI better for soft tissue, may be oversensitive
  9. 9. Flexion and Extension Radiographs  Safe in awake alert patients Exclude significant instability
  10. 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. 11. Fractures of the Cervical Spine Most do not require surgery Ligamentous injuries less predictable, and more require surgery
  12. 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. 13. Occipitocervical Dissocation  Most are lethal Neurologic injuries vary from complete to cranial nerve injuries Diagnosis can be difficult Occipitocervical fusion is required
  14. 14. Atlas Fractures Axial load Stability requires healing of transverse ligament – MRI Halo- reasonable treatment C1-C2 fusion if transverse ligament disrupted
  15. 15. Axis Fractures Odontoid fractures are most common  Type I – Avulsion Type II – Waist Type III – Vertebral body
  16. 16. Type Ι Odontoid  Treated with external orthrosis
  17. 17. Type ΙΙ Odontoid  Controversial treatment Elderly do not tolerate halo – consider C1- C2 fusion Fusion needed if reduction not achieved or maintained
  18. 18. Type ΙΙΙ Odontoid High healing rate with halo vest
  19. 19. Traumatic Spondylolisthesis of Axis MVA- hyperextension, compression and rebound flexion Most treated in halo
  20. 20. Subaxial Compression Fractures Failure of anterior column Orthosis for 6 – 12 weeks
  21. 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. 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. 23. Cervical Disk Disease Symptoms can be insidious or acute Minor injured can aggravate the root (radiculopathy) or spinal cord ( myelopathy)
  24. 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. 25. Cervical Roots exhibit a higher degree of overlap than seen in the thoracolumbar spine, therefore symptom patterns may fail to localize.
  26. 26. Hyporeflexia Biceps Brachioradialis C- 6 Triceps C- 7
  27. 27. Most Commonly Affected C-5, C-6, C-7 More motion in these areas Watershed area of blood supply – roots more susceptible
  28. 28. Myelopathy Most commonly presents as clumsiness, ataxia, loss of fine motor skills.
  29. 29. Cervical Spondylosis May cause radicular pain from nerve root origin May cause referred sclerotomal pain ( occiput, interscapular region, or shoulders)
  30. 30. Treatment 75% of radiculopathy improve with P.T. , activity modification, medication Soft disk herniations can resorb Myelopathy
  31. 31. Imaging Studies Plain x-ray – alignment, spondylosis Flexion – extension for instability MRI CAT – defines bone anatomy Diskography
  32. 32. Electrodiagnostic Studies Paresthesias cannot be localized Imaging does not correlate with clinical picture
  33. 33. Nonsurgical Care P.T. – emphasize isometric exercise Traction with slight flexion Medication Epidural steroids
  34. 34. Surgical Indications Success for axial pain is 60 % Success for radiculopathy is 90% Disk Replacement – evolving technology
  35. 35. ACDF Allograft versus autograft Plate fixation Accelerates degeneration at adjacent levels
  36. 36. Posterior Decompression Foraminotomy for bony foraminal stenosis Laminectomy – risk of kyphosis Laminectomy – decompression without adding fusion
  37. 37. Thank you We will now move into the exam part of the lecture.
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