Cervical Spine Assessment Peter Llewellin SDMH EMC 2015

Epidemiology Incidence of 1-3% of all blunt trauma cases Commonest in MVA, Falls patients (60-90%) Minor trauma only in elderly and spondylytic patients Of all spinal cord injuries, 60% are cervical spine injuries in origin

Anatomy C1 : Ring with lateral masses Occipital articulation above Axial articulation below.

Anatomy C2 vertebrae

Anatomy C1 on C2

Standard C-spine vertebrae Vertebral body Pedicle, Laminae, Facet joints, Spinous processes

Anatomy Cervical alignment

Cervical ligaments

Clinical Features History of blunt trauma - MVA, Fall > 1m, Diving, Sporting accident. Neck pain - almost universally present Limb weakness, paraesthesiae, paralysis (particularly upper limb). Frequently absent despite significant injury. Clinical findings unreliable in multi-trauma, elderly or intoxicated patients.

C-Spine Decision Rules Imaging not always indicated Often immobilised and imaged without need However, miss of cervical injury potentially disastrous Major decision rules – NEXUS Canadian C-Spine Rule (CCSR)

NEXUS Midline neck tenderness Altered level of consciousness Identified 5 features that prevent C-spine clearance Studied 34000 pts Plain Cervical XR Ages 1-101 99.6% sensitive 12.6% specific 99.8% NPV Sensitivity in elderly >65 questioned Sensitivity may be lower in ‘real life’ Midline neck tenderness Altered level of consciousness Focal neurological deficit Intoxication Distracting injury If present , imaging required

Canadian C-Spine Rule 8954 pts Excluded <16yr Plain Cervical XR Note functional aspect of assessment 100% sensitive 42.5% specific In practice, either rule acceptable for low risk cervical assessment Note that elderly require special attention if using NEXUS

Radiology of C-spine Imaging – XR vs CT? Decision rules - plain views CT higher sensitivity Radiation dose? – 0.05mSv vs 3.8mSv High risk vs Low risk patients? CT for difficult XR pt’s

The C-spine Series 3 shot series Lateral AP Open mouth ‘peg’ view

C-spine films 7ABC’S 7 vertebra including C7-T1 interface need to be visible Swimmers view may assist this

Assessing C-spine films Assess Alignment of lateral film - check for the cervical spine lines, ensuring no irregularity.

Assessing C-spine films Assess Bones Assess Cartilages Assess Soft tissues- soft tissue swelling will occur around injuries Maximum measures -pre-dental space < 3mm; C2 < 6mm; C6 < 22mm

Peg view Shot as ‘open mouth’ view Needs pt. co-operation Looks at atlanto-axial joint and dens Dens should be intact; lateral masses of C1 should be symmetrical and aligned with C2

Other Imaging AP view – limited additional information Flexion-Extension views ligamentous injury; no longer recommended (MRI) CT scanning indicated – a) abnormality identified b) imaging sub-optimal.

Types of fracture Approximately 20 fracture patterns identified Often more useful to assess stability rather than pattern

Assessing Stability 3 column theory Instability occurs with damage to middle column and 1 other column. i.e. spinous process fracture stable, burst fracture C6 body unstable.

Disposition ABC of resuscitation take priority over C-spine management All C-spine injuries should be reviewed by spinal surgical team regarding management plan Cord syndromes should be referred to specialist spinal units.

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