Best Superspeciality Clinics

Address: Survey No -196
Flat No:101
Kadhiri's Apurupa Urban
Beside Chirec Internationl School
Botanical Garden Rd,Kondapur,500084.

Email: bestclinic27@gmail.com

Mobile No: 9704999588


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Cervical Spine

Cervical Traumatic Facture

Introduction

  • All trauma patients have a cervical spine injury until proven otherwise
  • Cervical spine clearance defined as confirming the absence of cervical spine injury
      • important to clear cervical spine and remove collar in an efficient manner
        • delayed clearance associated with increased complication rate
    • cervical clearance can be performed with
        • physical exam
        • radiographically
  • Missed cervical spine injuries
      • may lead to permanent disability
      • careful clinical and radiographic evaluation is paramount
        • high rate of missed cervical spine injuries due to
          • inadequate imaging of affected level
          • loss of consciousness
          • multisystem trauma
    • cervical spine injury necessitates careful examination of entire spine
    • noncontiguous spinal column injuries reported in 10-15% of patients

History

  • Details of accident
      • energy of accident
        • higher level of concern when there is a history of high energy trauma as indicated by
          • MVA at > 35 MPH
          • fall from > 10 feet
          • closed head injuries
          • neurologic deficits referable to cervical spine
          • pelvis and extremity fractures
    • mechanism of accident
        • e.g., elderly person falls and hits forehead (hyperextension injury)
        • e.g., patient rear-ended at high speed (hyperextension injury)
    • condition of patient at scene of accident
        • general condition
        • degree of consciousness
        • presence or absence of neurologic deficits
  • Identify associated conditions and comorbidities
      • ankylosing spondylitis (AS) 
      • diffuse idiopathic skeletal hyperostosis (DISH)
      • previous cervical spine fusion (congenital or acquired)
        •  connective tissue disorders leading to ligamentous laxity

 Physical Exam

  • Useful for detecting major injuries
  • Primary survey
      • airway
      • breathing
      • circulation
      • visual and manual inspection of entire spine should be performed
        • manual inline traction should be applied whenever cervical immobilization is removed for securing airway
        • seat belt sign (abdominal ecchymosis) should raise suspicion for flexion distraction injuries of thoracolumbar spine
  • Secondary survey
      • cervical spine exam
        • remove immobilization collar
        • examine face and scalp for evidence of direct trauma
        • inspect for angular or rotational deformities in the holding position of the patient”s head
          • rotational deformity may indicate a unilateral facet dislocation
        • palpate posterior cervical spine looking for tenderness along the midline or paraspinal tissues
          • absence of posterior midline tenderness in the awake, alert patient predicts low probability of significant cervical injury
        • log roll patient to inspect and palpate entire spinal axis
        • perform careful neurologic exam

 

Clinical Cervical Clearance

  • Removal of cervical collar WITHOUT radiographic studies allowed if
      • patient is awake, alert, and not intoxicated AND
      • has no neck pain, tenderness, or neurologic deficits AND
      • has no distracting injuries

 

Radiographic Cervical Clearance

  • Indications for obtaining radiographic clearance
      • intoxicated patients OR
      • patients with altered mental status OR
      • neck pain or tenderness present OR
      • distracting injury present
  • Mandatory radiographic clearance with either
      • cervical spine radiographic series
        • must include top of T1 vertebra 
        • includes
          • AP 
          • lateral 
          • open-mouth odontoid view 
        • inadequate radiographs are the most common reason for missed injury to the cervical spine
        • assess alignment by looking at the four parallel lines on the lateral radiograph 
        • look for subtle abnormalities such as
          • soft-tissue swelling
          • hypolordosis
          • disk-space narrowing or widening
          • widening of the interspinous distances 
      • CT to bottom of first thoracic vertebra 
        • replacing conventional radiographs as initial imaging in most trauma centers
        • pros
          • more sensitive in detecting injury than plain radiographs
          • some studies show faster to obtain than plain radiographs
        • cons
          • increased radiation exposure
    • Supplementary radiographic studies include
      • flexion-extension radiographs 
        • pros
          • effective at ruling-out instability
        • cons
          • can only be performed in awake and alert patient
      • MRI
        • pros
          • highly sensitive for detection of soft tissue injuries
            • disc herniations
            • posterior ligament injuries 
            • spinal cord changes
        • cons
          • high rate of false positives
          • only effective if done within 48 hours of injury
          • can be difficult to obtain in obtunded or intoxicated patients
      • MR and CT angiography
        • pros
          • effective for evaluating vertebral artery 

Treatment

  • Nonoperative
      • cervical collar
        • indications
          • initiated at scene of injury until directed examination performed
      • early active range of motion
        • indications
          • "whiplash-like" symptoms and
          • cleared from a serious cervical injury by exam or imaging  

Complications

  • Delayed clearance associated with increased complication rate including
      • increased risk of aspiration
      • inhibition of respiratory function
      • decubitus ulcers in occipital and submandibular areas
      • possible increase in intracranial pressure