Download CM 5- Cervical Spine Trauma Spinal Injuries 11,000 New injuries

CM 5- Cervical Spine Trauma
•
•
•
•
•
•
•
Spinal Injuries
11,000 New injuries per year
Initial mortality 50%-due to high spinal cord injury
Blunt trauma causes 90% of injuries
Spinal fractures result in spinal cord injury in 10-20% of patients.
81% are males
55% occur in ages 16-30
Vertebral body anteriorly-main weight bearing column
Held together by anterior and posterior longitudinal ligaments
Spinal cord ends at L1
MOI
• MVA- most common(38.5%)
• Assaults(24.5%)-mostly GSW
• Falls(21.8%)
• Accidents(15%)
Spinal Injuries by Region
• Cervical spine most common site(61%)
• Thoracolumbar junction(19%)
• Thoracic spine(16%)
• Lumbosacral spine(4%)
Immobilization
• Always remember ABC’s
• Immediate immobilization prevents secondary injury
• “LOG ROLL”
Person maintains head and neck in neutral position while at least 2 people roll the patient
• Backboard, collar and sand bags
Cervical Spine Injuries
MOI Injury C1 and C2
VERTICAL COMPRESSION
• Jefferson burst fracture of atlas: C1 (atlas fractures)- direct blow to top of head
Lateral masses displaced- burst fracture
HYPEREXTENSION
•
Avulsion fracture of anterior arch of atlas
•
Fracture of posterior arch of atlas
•
Hangman’s fracture
POORLY UNDERSTOOD MECHANISMS
•
Occipitoatlantal dissociation
•
Occipital condylar fractures
•
Dens fractures
C2 (Axis) fractures
• Odontoid fracture-major force, look for other cervical fractures
• Type I – avulsion of tip
• Type II – junction of odontoid and body(most common)
• Type III – through superior portion of C2 at the base of the dens.
CM 5- Cervical Spine Trauma
Hangman’s fracture- unstable
• Seen in judicial hangings(not suicide), MVA’s and diving accidents (hyperextension)
Ligament Injury
• Occipitoatlantal dissociation: skull may be displaced anteriorly or posteriorly or distracted from the cervical
spine
• Frequently results in death
Transverse Ligament Disruption
• Located anteriorly on the inside of the ring of C1 and runs along the posterior surface of the dens
• Maintains stability of first and second vertebrae
• Older patients
• Direct blow to the occiput
• Lateral x-ray predental space 3mm or less
Lower C spine (C3-C7)
• Anatomy-needed to understand mechanism of injuries
• Consists of 3 columns:
• Anterior column resists compression(flexion) with vertebral body and intervertebral disk and resists
distraction(extension) with the anterior longitudinal ligament and the anterior annulus fibrosis
• Middle column: resists compression through the posterior vertebral body and resists distraction by the
posterior longitudinal ligament and the posterior annulus fibrosis
• Posterior column: resists compression through the facet joints and lateral masses and resists distraction through
the facet joints capsules and intraspinous ligaments
Unstable fractures
• Teardrop fracture-anterior 20% of vertebral body damaged
• Loss of 25% or greater of vertebral body height
• Hyper-flexion- anterior subluxation-failure of posterior ligamentous structures
MOI
FLEXION:
• Anterior subluxation-posterior ligament failure
• Bilateral interfacetal dislocation
• Simple wedge fracture
• Clay-shoveler’s fracture
• Flexion teardrop fracture
FLEXION-ROTATION
•
Unilateral interfacetal fracture
PILAR FRACTURE
•
Pedicolaminar fracture
VERTICAL COMPRESSION
•
Burst fracture
CM 5- Cervical Spine Trauma
•
•
•
•
HYPEREXTENSION
Hyperextension dislocation
Extension teardrop fracture
Laminar fracture
LATERAL FLEXION
Uncinate process fracture
Clay Shoveler’s Fracture
• Avulsion of the spinous process of the lower cervical vertebrae(C7)-stable
Simple Wedge fracture
• Compression between to vertebrae
Flexion Teardrop Fracture
• Extreme flexion-unstable
Vertical Compression Injuries
• Direct axial load
• Burst fracture
• Spinal cord may be injured be fragments
• unstable
Clay
Wedge
Flexion Teardrop
Vertical Compression
Clinical Evaluation
• Patients with suspected injury always should arrive BB and collar PTA
• Patients that present to the hospital after trauma with complaint of neck pain should have a c-collar placed
immediately
Physical Exam
• Inspection
• Palpation
• Neurological exam-motor and sensory evaluation
Clinical Clearance
• No distracting injury
• No alcohol or drugs
• No neurological deficits
• No palpable midline tenderness
• No pain on movement
CM 5- Cervical Spine Trauma
Plain Cervical Spine Xrays
• Lateral view(70-80% of injuries)
• AP view
• Odontoid view
• Must include C7(20% of fractures)
• STS can be the only x-ray finding in a fracture or ligamentous injury
• Sensitivity of 89.4%
• MRI best for soft tissue and spinal cord injury
Flexion-Extension Views
• Ligamentous injury may occur without a fracture
• Performed only in an awake and cooperative patient and should be halted when they cause pain
• Consider MRI
CT and MRI
• CT used in patients that are altered or in suspected injury not evident on plan films
• MRI used for suspected spinal cord injury
Basic Treatment
• Most patients that arrive to the ED may be removed from the BB using the log roll
• Discuss all cervical injuries with the neurosurgeon
• Stable fractures usually placed in Aspen collar and sent home
• Unstable fractures remain in collar and admitted to neurosurgery
Summary Points
• Plain x-rays must be obtained if any pain/tenderness, neurologic dysfunction or unable to evaluate
clinically(AMS, ETOH, distracting injury)
• If abnormality on plain films or highly suspicious for injury and negative x-ray, obtain CT
• MRI indicated if any neurological dysfunction
• Suspect cervical fractures in any patient with trauma, pain, tenderness, neurological deficit, altered mental
status or presence of other injury
• Treatment priorities – ABC’s, while maintaining spinal immobilization