PTP 521 , MUSCULOSKELETAL DISEASES AND DISORDERS

PATHOLOGY AND MEDICAL MANAGEMENT OF THE CERVICAL

SPINE

Symbols

this is for your information only, it won’t be used for the exam

important to know for exam

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Cervical Spine Pathology

Trauma

Fractures Spinal StenosisRheumatoid Arthritis

Arthritic Conditions

DJD/Osteoarthritis

Other

DegenerativeDisk Disease

Disk Bulge, Herniation

C2-C7Radiculopathy

Joint

ImpingementSyndrome

Facet Syndrome

Bone Disk

Post ConcussionSyndrome

Whiplash

Soft Tissue

Headaches

Other

Hypomobility

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Stiell IG, Clement C, et al. The Canadian C-Spine Rule versus the Nexus Low-Risk Criteria in Patients with Trauma.

JAMA 2003, 349;26

Sensitivity: 99.4%

Specificity: 45.1%

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Canadian CervicalSpine Rule for RadiographicExamination

Canadian Cervical Spine Rule for Radiographic Examination

Stiell et al in 2003 examined patients to determine the characteristics of those who had positive cervical spine fractures versus those who were negative.

By following these rules, the number of unnecessary radiographs for the cervical spine was decreased dramatically

http://content.nejm.org/cgi/content/full/349/26/2510

(full text article)

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Importance

By following the Canadian Cervical Spine Rules, A clinician can be reasonably certain that a patient needs a radiograph of the cervical spine.

Sensitivity is high, - SnNout- therefore, if following these rules and the tests are negative, and you send the patient for a radiograph, only 1% will have a fracture. 99% will not have a fracture.

Specificity is mid range - SpPin - therefore, if the tests are positive, you send the patient for a radiograph, only 45% will have a fracture.

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Fractures of the Cervical Spine

Musculoskeletal Practice Pattern G

75% of all spine fractures occur in the cervical spine due to the instability of the atlanto-occipital joints

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Jefferson’s Fracture:Burst Fracture of C1.

Head holder, so fragments everywhere, very unstable, neck brace or halo.

1. MOI: Axial Compression

2. Radiograph: odontoid view, greater than 7 mm difference between both lateral masses

of the atlas and those of the axis.

3. Unstable Fracture

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Jefferson’s Fractures: Burst!

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Hangman’s Fracture:

Fracture of the neural arch of the axis, fractures the pedicles of C2 with dislocation of C2 on C3

1. MOI: Hyperextension a blow on the forehead forcing the neck into extension is

a classic mechanism of injury producing fractures thru the pedicles

2. Radiograph: lateral view shows bilateral disruption through the pedicles of the axis

3. Unstable fracture

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Hangman’s Fractures11

Hangman’s Fracture12

Dens Fractures

Type 1: (A ) avulsion of the tip of the dens as a result of apical or alar ligament stress

Type 2: (B) fracture of the junction of the dens with the body of the axis.

Type 3: (C) fracture deep within the body below the dens.

Type 4: see below

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Dens Fractures

Left: Type 2 dens fracture at the junction of the dens with the vertebral body with posterior displacement

Right: fracture of the dens with posterior displacement of the atlas causing a small degree of spinal canal compression 14

CT scan of odontoid Fractures Type 3

Notice on this CT scan The foramen for the Vertebral artery

emedicine.medscape.com/article/94234-media

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Dens Fracture

Type 4: sagittal or parasagittal fracture extending from a point lateral to the dens vertically or diagonally to the inferior surface of C2

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Os Odontoideum:

Congenital Disorder

Failure of the dens to unite with the body of the vertebrae. 1. Radiograph: Odontoid view

-Tell it is not a dens fracture by the smoothness around parts

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Wedge Fracture:

1. MOI: Hyperflexion and Compression

1. -Like a crunch, diving

2. Radiograph: lateral view, the anterior height of the vertebral body is shorter by 3mm than the posterior border

3. Stable fracture2. -If it has no neuro s(x),

then will not do anything, end with a little kyphosis curve

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Wedge Fracture

This fracture is easy to see compared to some. In comparing anterior height to posterior height, you should see a difference.

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Burst Fracture of the Vertebral Body

Lower cervical vertebrae

1. MOI: Axial Compression2. Radiograph: lateral

view, comminuted vertebral body is flattened centrally

3. Can be stable or unstable

3. -Described by presence of neuro s(x), impingement of the spinal canal.

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Radiograph: lateral view, comminuted vertebral body is flattened centrally

emedicine.medscape.com/article/94234-media21

Clay-Shoveler’s Fracture

Avulsion fracture of the Spinous Process 1. MOI: a. Hyperflexion

-Where the pulley is over-used and detaches-Trapezius, Rhomboids, Para spinals

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Hypomobility of the Cervical Spine

1. Pathology: tightness of the capsule of one of the synovial facet joints

2. Radiographic signs: generally none3. Clinical Symptoms: aching, dull, stiff

feeling in the neck *Headaches*4. Clinical Signs: loss of movement in a

capsular pattern for the facet joints Joint play is decreased at the segmental level Capsular end feel Pattern: Upper Cervical: limited lateral flexion

and rotation equally limited %-wise, then extension limited less.

-Lower cervical is opposite

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Facet Syndrome

Pathology: joint capsules are stretched from joint subluxations or distension of the joint with fluid.-Looser the capsule gets, tight Para spinals.

Body will protect the area with posture and muscle spasms of the paravetebral muscles which leads to a decrease in spinal mobility and a secondary muscle fatigue.

Joint Dysfunction

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Facet Syndrome

Occurs early in the degenerative process for the young or middle aged patient

Loading patterns change which lead to cartilage degeneration, facet hypertrophy and bony adaptation in the form of sclerosis or spurring (ostephyte formation).

Alters joint function which alters disc function

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Radiographic Signs: Oblique view:

a. Hypertrophy of the facet joint

b. Osteophyte formation at the superior and inferior articulating processes

c. Decrease in joint space

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Clinical Symptoms of Facet Syndrome

Presentation is variable, generally a steady ache with long periods of inactivity.

Pain present after activity, not during. Progression of pain gets more sever over time Pain will come and go with activity demands and

disease progression.Sharp pain with abrupt movements. Catching or locking sensation. Some radiation of pain may occur if nerve

root is involved

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Clinical Signs of Facet Syndrome

Muscle spasms in the paraspinals Decrease lordosis Decrease ROM all directions particularly with

extension and rotation to one side Pain with extension Neurological exam is normal initially, may be

abnormal eventually with osteophyte formation.

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Impingement Syndrome

1. Onset: sudden, often without a memorable trauma

2. Radiographic Signs: generally none

3. Clinical Symptoms: sharp, unilateral pain, stiff neck and c/o loss of movement

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Signs of Impingement Syndrome

ROM limited in area’s that close or compress the facet joint on the painful side.

Extension and rotation to the side of dysfunction are limited

Lateral flexion may be painful, not as limited

Compression increases pain, distraction decreases pain.

Muscle guarding during passive and active movement.

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Osteoarthritis, Degenerative Joint Disease

Pathology: progressive degeneration as a naturalconsequence of aging, loss offlexibility or movement occurs as the disease progresses

-Look for osteophyte formation, anteriorly first bridging between vertebrae.

Joint Dysfunction

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Osteoarthritis: oblique view

Osteophyte formation is usually seen as bridging the vertebrae – carefully review the shape of the vertebrae in this view

Encroachment of the neural foramen is also noted emedicine.medscape.com/article/

305145-media

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Cervical Spinal Stenosis:

Pathology: narrowing of the central spinal canal or the intervetebral foramina Increase in bone formation around the nueral

foramen.

Etiology: Developmental, congenital, or traumatic, age related Can be caused by intervetebral disc disease or

osteoarthritis

Joint Dysfunction

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Symptoms and Signs of Spinal Stenosis

Symptoms: Radiating arm pain and numbness in nerve root

distribution Clumsiness if severe enough

Signs Myotomal weakness Hyperreflexia: will increase foramen space, so will

look down, and adjust entire posture to compensate. Clonus

-May think that it is a “Disk Herniation”, but way to differentiate is an MRI

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Imaging Studies

MRI: imaging study of choice

CT myelogram can be used but will be invasive so may not be the one of choice

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Disc Herniation Causing Impingement of Specific Spinal Nerve

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Can occur with or without radiculopathy. Less common in the cervical spine than in the lumbar spine.

Individual nerve roots may be impinged or tethered within the foramin.

3. Herniation Sites38

a. C1-2: no discb. C2-3: rarec. C3-4: rared. C4-5:

1) clinical symptoms2) signs: Motor

Sensory Reflexes

Herniated Disc: MRI

Look at the spinal cord by C4-5 and C5-6. C4-5 is a larger herniation. This one is impinging on the spinal cord. Consider the clinical

symptoms this patient may have.

C5-6 slightly smaller and may only be a bulge.

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Disc Herniation

MRI: encroachment by the disc on the spinal canal

Stenosis of the canal is also occurring giving the spinal cord a strangled appearance

www.mayfieldclinic.com/PE-HCDisc.htm

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MRI

Best able to detect Disk height loss Annular fissures Osteophytosis End plate changes Herniation

APTA 2009 CRHazle

C5-6 disc herniation extending Posterior into the canal

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Pathological Findings

Winking Owl Sign: Metastatic cancer to

the spine can show up initially as a missing pedicle

It gives the impression that the one of the “eyes” is closed.

= pedicle www.medscape.com/viewarticle/421516_6

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Whiplash: Musculoskeletal Practice Pattern 4E

Definition: cervical strains or acceleration injuries “whiplash”

MOI: Sudden Acceleration-Deceleration movement of the head and neck

Causes: Falls, car accidents, sports injuriesHead inertia creates a high velocity force or accelerationResults in severe overstretch injuryAge of patient, general health, direction of forces and

magnitude of forces determines the extent of injury and the tissues that are involved

Soft tissue structures which can be potentially injured include: disc, spinal ligaments, capsule, muscles, nerves, spinal cord and vertebrae

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Radiographic signs:

Changes in cervical curve on x-ray

Fanning of interspinous spaces (great space, curve in opposite direction)

Increased prevertebral space

Acute loss of disc height

Displaced prevertebral fat space

Vacuum cleft signParaspinals go into

sever spasms.

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Force

Amount of force= weight of head plus speed that the head moves.

Direction of Force: Where was the car hit Symmetry of impact Double injury – hit from behind, pushed into another

vehicle Position of person in relation to impact

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C. Onset: may not be for several hours after an accident

D. Symptoms: pain, stiffness, and muscle spasm in the cervical spine, headaches are usually posterior, may have some dysphagia

-Spasms are the Hallmark, extreme tenderness to palpation.

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Post Concussion Syndrome

1. Pathology: blow to the head 2. Onset: develops after the concussion

within a 48 hour period after trauma May last several weeks or months after injury

3. Symptoms: persistent headaches, inability to concentrate, irritability and fatigue

SoftTissue

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4. Medical Tests: CT scan usually negative for any brain injury

5. Specific Conditions related to return to play• Dependent upon severity of concussion – mild,

moderate, or severe• Number of concussions a player has had in a

season

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Grade I: Mild Concussion

• Momentary confusion, no loss of consciousness, symptoms disappear within 15 minutes

• First concussion: return to play if asymptomatic for one week

• Second: return to play in 2 weeks if asymptomatic for 1-2 weeks

• Third: terminate season, may return to play next season if asymptomatic

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Grade II: Moderate Concussion

Brief concussion, no loss of consciousness, symptoms last longer than 15 minutes First concussion: return to play if asymptomatic for

one week Second: minimum of 1 month off play and

asymptomatic for 1 week. If not asymptomatic, terminate season

Third: terminate season, may return next season

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Grade III: Severe Concussion

Loss of consciousness – briefly or prolonged First concussion: return to play after a minimum of

one month off and asymptomatic for one week

Second: terminate season, may return to play next season if asymptomatic

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Post Dural Puncture Headache

Spinal headacheRisk Factors:

Anyone who has an epidural or spinal tap procedure

SX: severe, dull, non-throbbing pain, usually in fronto-occipital region

Signs: aggravated by upright position, decreased in supine position

May have nausea, vomiting, visual disturbance and/or auditory disturbance

Self-limiting usuallyTell them to drink Mt. Dew (Caffine)

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Other Dx

RA: particularly in the C spine can lead to spinal cord injuries, death if forced into hyper extension due to fragilely of the joints.

Other types of headaches covered in Neuro: Migraines Cluster Headaches Postural Headaches

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Cervical Spine: RadiologyTypical Views Special Views

Open Mouth ViewAP viewLateral ViewRight ObliqueLeft Oblique

Lateral FlexionLateral Extension

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Evaluation using ABCDS

Odontoid or Open Mouth View Patient Position:

Supine, mouth open Beam: directed

downward into the open mouth

Film placed between posterior C-spine and table

-For Evaluating stability of upper cervical spine.

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Alignment:

Demonstrate odontoid and lateral masses of C1.

Draw around the odontoid, and body of C2, draw the lateral masses of C1.

Look at the alignment between the lateral masses of C1 and the body of C2, these should match up

There shouldn’t be any overhanging edges laterally, if there is, this may suggest a burst fracture of C1

Look at the medial edges of the C1 lateral masses and the body of the dens, these should be symmetrical with the dens centered between them.

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Bone Density and Dimension

Odontoid should have NO lucencies in superior portion, base, or vertebral body

Bones should have equal density, consistent with no unexpected lucencies

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Cartilage and Soft Tissue:

Cartilage: No intervertebral disk, can evaluate facet joints. These should be parallel and equally spaced

Soft Tissue: not applicable in this view

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AP View, Alignment

Patient Sitting or Supine

Assesses C3-C7

Alignment: Draw a vertical line superior to inferior along the

spinous processes to assess segmental rotation – SP are bifid

Identify Pedicles: look for rotation Vertebral Bodies: Size, C3-C7 Uncinate joints: for osteophyte formation

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Bone Density and Dimension

Evaluate each pedicle and vertebral body for a change in density or dimensions. Compare with segments above and below to see if there are any asymmetries in size or position and measure horizontal and vertical dimensions

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Cartilage and Soft Tissue

Cartilage: evaluated on lateral view, not assessed in AP view

Soft Tissue: identify bottle shaped trachea Should be mid line, if not mid line, it may indicate the

presence of a tumor, pneumothorax or hemothorax

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Lateral View, Alignment

Patient Position Lateral standing Supine cross table view

Alignment: Line 1: anterior borders of vertebral bodies Line 2: posterior borders of vertebral bodies Line 3: spinolaminar line: junction of lamina at the

spinous processes These three lines help to assess for several types of

pathologies that can be found on this view such as spondylolisthesis or burst fractures

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Alignment cont.

Check for the normal lordosis: Flat C spine: indicates muscle spasms from trauma Increased lordosis: Kyphosis: anterior segmental compression fracture

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ADI: Atlantodens Interval: space MUST not exceed 3 mm. Any greater distance and this must be evaluated by a physician for C1 or C2 instabilities.

emedicine.medscape.com/article/93546-media

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Alignment cont.

Look at the margins of each vertebrae for possible osteophyte formation

Evaluate the facet joints and look for possible osteophyte formation

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Bone Density and Dimensions

Evaluate the density of each cervical vertebrae for changes in density

Measure the vertebral body height anteriorly and posteriorly

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Cartilage and Soft Tissue

Cartilage: Assess disk height

Soft Tissue: Prevertebral tissue Fanning of cervical

vertebrae may demonstrate interspinous ligaments

Retropharyngeal space should measure 7mm or less

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Retropharyngeal space: measure less than 7 mm

Space between C2 anterior vertebral body and the posterior pharyngeal wall

Retrotracheal space: should measure no more than 22 mm in adults and 14 mm in children

Space between C6 anterior vertebral body and the posterior tracheal wall

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Oblique Radiographs

Patient Position: Posterioanterior or

Anterioposterior Standing, sitting, or

supine Patient rotated 45 dg

to one side and demonstrates opposite side neural foramina

Primarily used to evaluate the intervertebral foramina

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Alignment

Evaluate both oblique views and compare side to side

Draw each foramen on the oblique radiograph, evaluate for narrowing of the foramen, osteophyte formation, and anterior movement of one vertebrae over the other

Can also look at the pedicles and laminae

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Left Oblique74

Right Oblique75

Special Views

Lateral Flexion and Extension Stress Views: observe joint alignment with movement, largely replaced with fluoroscopy as you can watch the movement occur

Pillar View: view the lateral masses of the cervical vertebrae, patient is turned to one side about 45 dg and extended about 30 dg.

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Special Views cont.

Swimmers view: Patient prone on table

with arm abducted to 180 dg

Cross table radiograph with central beam directed to the axis

Film on opposite side Visualizes C7, T1 and

T2 vertebrae

www.biomedcentral.com/.../2/figure/F1?highres=y

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Cervical Spine: CT

Sagittal Slice:

Orientate by finding the dens, C1 is just anterior to the tip of the dens, C3-C6 bodies of the vertebrae can be seen on this view.

Spinous processes are posterior to the spinal canal

Small circle at the top of the Largest spinous process is the posterior arch of C1

Good view to see bone intruding into the spinal canal

Anterior arch ofC1

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Trans axial CT: Intervertebral Space

Body of Vertebrae

Facet joints

Spinal canal

Lamina

Bifed Spinous process

emedicine.medscape.com/article/1264627-overview

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MRI of the Cervical Spine

T2 weighted sagittal MRI of the cervical spine

Orientate by finding the dens, anterior arch of C1, posterior arch of C1, cervical vertebaral bodies of C3-C7, T1-T5

Spinous processes

Spinal Cord, canal – any buckling of the cord? Any encroachment by the vertebral bodies into the canal? Check out C5-6. What do you think?

Disk Space: evenly spaced? Disk height is similar?

Soft tissue

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www.gehealthcare.com/.../products/cimages.html

Body of vertebrae is very dark in this MRI

Spinal Canal/Cord is lighter

As pictures progress, can see more of the spinal nerve appearing and its attachment to the cord

Muscle

Cervical Spine: MRI81