1. Evaluation and Treatment of the Cervical Spine
Larry D. Dodge, MD

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. 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. Asymptomatic Trauma Patient
Cervical x-rays not required in patients without tenderness and are alert.

5. Trauma Patients with Neck Pain
2 to 6% incidence of significant spine injuries.

6. Do Not Remove Collar Until
Absence of tenderness
Absence of pain
Normal mental status
complete radiographic evaluation

7. Most Common Missed Diagnosis
Occipitoathlantoaxial region or cervicothoracic junction
Plain x-ray will miss 15 to 17% of injuries

8. CAT scan has 99% predictive value
MRI better for soft tissue, may be oversensitive

9. Flexion and Extension Radiographs
Safe in awake alert patients
Exclude significant instability

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. Fractures of the Cervical Spine
Most do not require surgery
Ligamentous injuries less predictable, and more require surgery

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. Occipitocervical Dissocation
Most are lethal
Neurologic injuries vary from complete to cranial nerve injuries
Diagnosis can be difficult
Occipitocervical fusion is required

14. Atlas Fractures Axial load
Stability requires healing of transverse ligament – MRI
Halo- reasonable treatment
C1-C2 fusion if transverse ligament disrupted

15. Axis Fractures Odontoid fractures are most common Type I – Avulsion
Type II – Waist
Type III – Vertebral body

16. Type  Odontoid
Treated with external orthrosis

17. Type  Odontoid Elderly do not tolerate halo – consider C1- C2 fusion
Controversial treatment
Elderly do not tolerate halo – consider C1- C2 fusion
Fusion needed if reduction not achieved or maintained

18. Type  Odontoid
High healing rate with halo vest

19. Traumatic Spondylolisthesis of Axis
MVA- hyperextension, compression and rebound flexion
Most treated in halo

20. Subaxial Compression Fractures
Failure of anterior column
Orthosis for 6 – 12 weeks

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. 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. Cervical Disk Disease Symptoms can be insidious or acute
Minor injured can aggravate the root (radiculopathy) or spinal cord ( myelopathy)

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. Cervical Roots exhibit a higher degree of overlap than seen in the thoracolumbar spine, therefore symptom patterns may fail to localize.

26. Hyporeflexia
Biceps
Brachioradialis C- 6
Triceps C- 7

27. Most Commonly Affected
C-5, C-6, C-7
More motion in these areas
Watershed area of blood supply – roots more susceptible

28. Myelopathy
Most commonly presents as clumsiness, ataxia, loss of fine motor skills.

29. Cervical Spondylosis May cause radicular pain from nerve root origin
May cause referred sclerotomal pain
( occiput, interscapular region, or shoulders)

30. Treatment
75% of radiculopathy improve with P.T. , activity modification, medication
Soft disk herniations can resorb
Myelopathy

31. Imaging Studies Plain x-ray – alignment, spondylosis
Flexion – extension for instability
MRI
CAT – defines bone anatomy
Diskography

32. Electrodiagnostic Studies
Paresthesias cannot be localized
Imaging does not correlate with clinical picture

33. Nonsurgical Care P.T. – emphasize isometric exercise
Traction with slight flexion
Medication
Epidural steroids

34. Surgical Indications Success for axial pain is 60 %
Success for radiculopathy is 90%
Disk Replacement – evolving technology

35. ACDF Allograft versus autograft Plate fixation
Accelerates degeneration at adjacent levels

36. Posterior Decompression
Foraminotomy for bony foraminal stenosis
Laminectomy – risk of kyphosis
Laminectomy – decompression without adding fusion

37. Thank you
We will now move into the exam part of the lecture.