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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