Spinal Disorders: Fundamentals of Diagnosis and Treatment Part 85 potx

Standard Radiographs
Radiographs remain
the imaging modality
of first choice
Radiography has been the standard initial “screening” examination used to eval-
uate alert and stable patients with suspected cervical spine trauma. At least three
views are recommended for alert and stable trauma patients [105]:
anteroposterior view
cross-table lateral view
open-mouth dens view
The lateral view should
extend from the occiput
to T1
The series of conventional radiographs has shown to be accurate in detecting cer-
vical spine injuries in 84% of cases [187]. The lateral view should extend from the
occiput to T1. The lower cervical spine is often obscured by the shadow of the
shoulders elevated by muscle spasm or in patients with a “short neck.” It may be
necessary to gently pull down the arms to visualize the entire T1 vertebra.
In trauma patients for whom the standard three view series fails to demon-
strate the cervicothoracic junction, swimmer’s views (one arm abducted 180°,
the other arm extended posteriorly) and supine oblique views were compared.
The authors concluded that both views show the alignment of the vertebral bod-
ies with equal frequency. However, supine oblique films are safer, expose patients
to less radiation, and are more often successful in demonstrating the posterior
elements (e.g., riding facet) [110].
Oakley introduced a simple system (r adiological ABC) for analyzing plain
films [164]:
A1: appropriateness: correct indication and right patient
A2: adequacy: extent (occiput to T1, penetration, rotation/projection)
A3: alignment: anterior aspect of vertebral bodies, posterior aspect of verte-
bral bodies, posterior pillar line, spinolaminar line; craniocervical and

other lines and relationships
B: bones
C: connective tissues: pre-vertebral soft tissue, pre-dental space, interverte-
bral disc spaces, interspinous gaps
Davis et al. [61] described 32117 acute trauma patients. Cervical spine injuries
were missed in 34 symptomatic patients: 23 patients either did not have radio-
graphs or had inadequate radiographs that did not include the region of injury,
8 patients had adequate X-ray studies that were misread by the treating physi-
cian, 1 patient had a missed injury that was undetectable on technically adequate
films, even after retrospective review, and in the remaining 2 patients, the error
was not described. These results confirm that it is not uncommon to miss cervical
spine injuries even with adequate plain radiographic assessment of the occiput
through T1.
The most common causes of missed cervical spine injury are:
not obtaining radiographs
making judgments on technically suboptimal films
Do not miss injuries
at the cervicocranial
and cervicothoracic junctions
The latter cause most commonly occurs at the cervical-occipital and cervical-
thoracic junction levels [61, 87, 163].
Functional Views
Active flexion/extension is a safe and helpful test in conscious, cooperative
patients to screen for ligamentous instability [164]. Cervical instability occurred
in 8% of alert, trauma patients in a Missouri Level I Trauma Center study, nearly
half of whom had a normal three film series [130]. The addition of flexion/exten-
838 Section Fractures
sion views to a three film series increases sensitivity (99%) and specificity (93%)
withahighpositive(89%)andnegative(99%)predictivevalue,withfalsenega-
tives largely due to muscle spasm [130]. However, flexion/extension radiography

is often unable to exclude instability until the spasm has resolved.
Passive flexion/extension
views in unconscious
or sedated patients
must not be done
Passive flexion/extension views or fluoroscopy in unconscious or sedated
patients are technically inadequate in up to a third of cases and may even cause
devastating neurological deficits. Their value therefore remains controversial
[164]. Fortunately, the incidence of isolated ligamentous injury is low. In a retro-
spective review of 14577 blunt trauma victims in a tertiary referral center in Bal-
timore [48], 614 (4.2%) of patients had cervical spine injuries, of whom only 87
(0.6%) had isolated ligamentous injuries. There were 2605 patients in the series
with a GCS of less than 15 and only 14 (0.5%) had isolated ligamentous injuries.
Interestingly, 13 were identified on the initial lateral radiograph and the other
was diagnosed on CT. In these cases of isolated ligamentous injury, flexion/exten-
sion views were not needed to reveal instability. In a series of 14755 trauma cases
in Los Angeles, 292 patients had cervical spinal injuries [64]. Of these, 250
(85.6%) had fractures, 10% had subluxations (presumably with ligamentous dis-
ruption) and 3.8% (11 patients) had isolated cord injury without fracture or
obvious ligamentous damage.
Criteria for Trauma and Instability
Clark et al. [50] suggested 12 helpful signs in diagnosing cervical spine trauma
(
Table 4):
Table 4. Radiographic signs of cervical spine trauma
Soft tissues
retropharyngeal space >7 mm in adults or children
retrotracheal space > 14 mm in adults or > 22 mm in children
displaced prevertebral fat stripe
tracheal and laryngeal deviation

Vertebral alignment
loss of lordosis
acute kyphotic angulation
torticollis
widened intraspinous space
axial rotation of vertebra
Abnormal joints
atlantodentalinterval>4mminadultsor>5mminchildren
narrowed or widened disc space
wide apophyseal joints
According to Clark et al. [50]
For the upper cerv ical spine, White and Panjabi [206] suggested criteria indica-
tive of instability based on conventional radiography (
Table 5, Fig. 5a, b ).
Table 5. Criteria for C0-C1-C2 instability
>8° axial rotation C0 –C1 to one side
>1mm
translation of basion to dens top (normal 4 –5 mm) on flexion/extension (Fig. 5a)
>7mm bilateral overhang C1 – C2 (see Fig. 5b)
>45°
axial rotation (C1 – C2) to one side
>4mm
C1–C2 translation measurement (see Fig. 5a)
<13mm
posterior body C2 – posterior ring C1 (see Fig. 5a)
avulsion fracture of transverse ligament
According to White and Panjabi [206], modified
Cervical Spine Injuries Chapter 30 839
abc
Figure 5. Instability of the upper cervical spine

According to White and Panjabi [206]. a Assessment of C0 – 1-2 stabilities on lateral radiographs. An increase of more
than 1 mm in the distance between the basion (clivus) and the top of the dens on flexion/extension view (normal
4–5 mm) is indicative of an atlanto-occipital instability (only if transverse ligament is intact).
b Assessment of the stability
of the atlas on an open-mouth (ap) view of the dens.
c Assessment of the C0–1 stability. A ratio of BC to AO of greater
than 1 is indicative of an atlanto-occipital dislocation. This is only valid in the absence of atlas fracture [206].
ab
Figure 6. Instability of the lower cervical spine
a Sagittal plane displacement or translation greater than 3.5 mm on either static or functional views should be consid-
ered potentially unstable according to White and Panjabi [206].
b Angulation between two vertebrae which is greater
than 11° than that at either adjacent interspaces is interpreted as evidence of instability by White and Panjabi [206].
Kricun [120] suggested a criterion (Fig. 5c) to detect atlanto-occipital dislocation.
For the lower cervical spine, White and Panjabi [206] have suggested criteria
indicative of instability based on conventional radiographs (
Fig. 6a, b).
Computed Tomography
CT is the first choice
for unconscious
or polytraumatized patients
While standard radiographs remain the imaging study of first choice in alert and
stable patients after cervical spine injuries, most large trauma centers now per-
form multislice CT scans for the assessment of polytraumatized or unconscious
840 Section Fractures
patients [164]. The reasons why CT has surpassed radiography include the ease
of performance, speed of study, and, most importantly, the greater ability of CT
to detect fractures other than radiography [60]. The craniocervical scans should
be of a maximum 2 mm thickness, because dens fractures can even be invisible
on 1-mm slices with reconstructions [164].

Computed tomography scans are sensitive for detecting characteristic frac-
ture patterns not seen on plain films. One such pattern is the midsagittal fracture
through the posterior vertebral wall and lamina. These injuries are very fre-
quently associated with neurological deficits. CT is the modality of choice for
diagnosing rotatory instability at the atlantoaxial joints [67, 68]. Failure of C1 to
reposition on a left-and-right rotation CT scan indicates a fixed deformity. CT
alsoshowsifthedensseparatesfromtheanteriorarchofC1withincreasedrota-
tion. Griffen et al. [92] evaluated the role of standard radiographs and CT of the
cervical spine in the exclusion of cervical spine injury for adult blunt trauma
patients. For 1199 of patients at risk for cervical spine injury, both X-rays and CT
were performed to evaluate and compare cervical spine injuries. In 116 patients,
a cervical spine injury (fracture or subluxation) was detected. The injury was
CT can replace radiographyidentified on both plain films and CT scans in 75 patients but on CT only in 41
patients. Importantly, all the injuries that were missed by plain films required
treatment.
Magnetic Resonance Imaging
Magnetic resonance imaging is the imaging study of choice to exclude discoliga-
mentous injuries, if lateral cervical radiographs and CT are negative [164]. MRI
is the modality of choice for evaluation of patients with neurological signs or
symptoms to assess soft tissue injury of the cord, disc and ligaments.
MRI is additional to CT
for specific diagnostic
assessments
According to Richards [164], MRI exhibits several significant advantages in
the assessment of cervical trauma and allows the following to be diagnosed:
discoligamentous lesions
vertebral artery injuries
neural encroachment and spinal cord contusion
traumatic meningoceles or CSF leaks
non-contiguous vertebral fractures

injury sequelae (e.g., myelomalacia, cysts, syrinx)
Particularly, STIR sequences [164] are very helpful in visualizing posterior soft
tissue injuries and thereby helping to diagnose unstable Type B or Type C frac-
tures. On the other hand, MRI of asymptomatic individuals has shown that
Morphological abnormali-
ties are frequent at the
craniocervical junctions
and are not per se evidence
forsequelaeoftheinjury
asymmetry of alar ligaments, alterations of craniocervical and atlantoaxial
joints, and joint effusions are common in asymptomatic individuals. The clinical
relevance of these MR findings is therefore limited in the identification of the
source of neck pain in traumatized patients [154]. Furthermore, there is wide
variation of segmental motion in the upper cervical spine. Differences in right-
to-left rotation are frequently encountered in an asymptomatic population.
These measurements are unsuitable for indirect diagnosis of soft tissue lesions
after whiplash injury and should not be used as a basis for treatment guidelines
[153].
MRI is unsuitable for unstable polytrauma patients, because of the difficulties
in monitoring ventilated patients, in spite of the expensive specialized equip-
ment. In addition, the MRI scanner is often remote from the emergency depart-
ment, and necessitates further hazardous transfers and delays.
Cervical Spine Injuries Chapter 30 841
Neurophysiology
Neurophysiologic studies
are of prognostic value
for recovery after SCI
It has been shown that clinical and electrophysiological examinations (see Chap-
ter
12 ) are of prognostic value for functional recovery in both ischemic and

traumatic SCI [111]. Motor evoked potential (MEP) recordings are of additional
value to the clinical examination in uncooperative or incomprehensive patients.
The combination of clinical examination and MEP recordings allows differentia-
tion between the recovery of motor function (hand function, ambulatory capac-
ity) and that of impulse transmission of descending motor tracts [58]. Further-
more, the initial clinical and electrophysiological examinations are of value in
assessment of the degree to which the patient will recover somatic nervous con-
trol of bladder function [59].
Vascular Assessment
The association of cerebrovascular insufficiency and cervical fracture was first
described by Suechting and French in a patient with Wallenberg’s syndrome
occurring 4 days after a C5/C6 fracture dislocation injury [189]. The incidence of
The incidence of vertebral
artery insufficiency ranges
up to 45% in patients
with cervical fractures
vertebral artery insufficiency (VAI) is reported in up to 46% of patients with cer-
vical fractures. Fractures through the foramen transversarium (44% [208]), facet
fracture-dislocations (45% [208]), or vertebral subluxation (80% [208, 211])
have the highest incidence of post-traumatic VAI. Most patients with VAI are
asymptomatic. Among the diagnostic modalities for identifying VAI, angiogra-
phy, MRI, and duplex sonography seem to be of similar value, although none of
these modalities has been compared in a clinical context of cervical injuries. Biffl
et al. [29] reported that patients not treated initially with intravenous heparin
anticoagulation despite an asymptomatic VAI reported strokes more frequently.
However, because the risk of significant complications related to anticoagulation
is approximately 14% in these studies, there is insufficient evidence to recom-
mend anticoagulation in asymptomatic patients.
Synopsis of Assessment Recommendations
The Neck Pain Task Force issued recommendations for the clinical management

of patients with neck pain presenting to the emergency room after motor vehicle
collisions, falls and other mishaps involving blunt trauma to the neck [93]. The
task force proposed that the initial clinical assessment should classify patients
into four broad categories or grades rather than establishing a specific structural
diagnosis [93] (
Table 6).
In Grade I neck pain, complaints of neck pain may be associated with stiffness
or tenderness but no significant neurological complaints. There are no symp-
toms or signs to seriously suggest major structural pathology, such as vertebral
Table 6. Grading of blunt neck injuries
Grade I neck pain with no signs of serious pathology and no or little interference
with daily activities
Grade II
neck pain with no signs of serious pathology, but interference with daily
activities
Grade III
neck pain with neurological signs of nerve compression
Grade IV
neck pain with signs of major structural pathology
According to the Neck Pain Task Force [93]
842 Section Fractures
Figure 7. Assessment recommendations
The assessment and management of blunt neck trauma in the emergency room as proposed by the Neck Pain Task
Force [93], reproduced with permission from Lippincott, Williams & Wilkins). High and low risk factors are defined
according to the Canadian C-Spine Rule (see
Fig. 4) [186].
fracture, dislocation, and injury to the spinal cord or nerves. In Grade II neck
pain, complaints of neck pain are associated with interference in daily activities,
but no signs or symptoms to seriously suggest major structural pathology or sig-
nificant nerve root compression. Interference with daily activities can be ascer-

tained by self-report questionnaires. In Grade III neck pain, complaints of neck
pain are associated with significant neurological signs such as decreased deep
tendon reflexes, weakness, and/or sensory deficits. These clinical signs suggest
malfunction of spinal nerves or the spinal cord. The mere presence of pain or
numbness in the upper limb without definitive neurological findings and consis-
tent imaging studies does not warrant a Grade III neck pain designation. Grade IV
includes complaints of neck pain and/or its associated disorders where the exam-
ining clinician detects signs or symptoms suggestive of major structural pathol-
ogy. Each “grade” of neckpain requires different investigations and management.
Cervical Spine Injuries Chapter 30 843
For patients presenting to the emergency room after a blunt trauma, a distinct
algorithm [93] is suggested (
Fig. 7)anddiagnostic work-up is recommended by
the Neck Pain Task Force [93]:
Patients with suspected blunt trauma to the neck presenting to the emer-
gency room with decreased level of consciousness, intoxication, and/or
major distracting injuries should be considered high risk for cervical spine
fracture or dislocation [105]. A CT scan of the cervical spine should be con-
sidered if available.
Alert (Glasgow Coma Scale of 15) and stable patients should be screened
according to the NEXUS criteria or the Canadian C-Spine Rule [105, 186].
Patients screened as low risk with the above criteria (i.e., Grade I and Grade
II) do not require radiological investigation and should receive reassurance
and supportive care.
Patients who do not meet the low-risk criteria (NEXUS, C-Spine Rule) [105,
186] should receive a plain (three-views) radiograph or a CT of the cervical
spine (C0–T1). If suspicion remains about cervical spine fracture or disloca-
tionafterplainradiography,thisgroupshouldreceiveaCTscan.
In the absence of radicular pain or neurological signs, and where radio-
graphs and/or a CT scan rule out spinal fracture or dislocation, patients

should be classified as Grade I or Grade II (as appropriate).
Patients with radiographs or CT scan compatible with spinal fracture or
dislocation and those with radicular findings (decreased deep tendon
reflexes, weakness and/or sensory deficits) should be referred to a spinal
surgery specialist for evaluation.
Flexion/extension radiographs, five-view radiographs, and MRI of the
cervical spine do not add meaningful clinical information to the emergency
management of blunt trauma to the neck in the absence of fracture, disloca-
tion, or radicular signs [148].
General Treatment Principles
The general objectives of the treatment of cervical injuries are (Table 7):
Table 7. General objectives of treatment
restoration of spinal alignment preservation or improvement of neurological function
restoration of spinal stability avoidance of collateral damage
restoration of spinal function resolution of pain
The treatment should provide a biological and biomechanical sound environ-
ment that allows uneventful bone and soft-tissue healing and finally results in a
stable, fully functional and pain-free spinal column. These goals should be
accomplished with a minimal risk of morbidity.
Whiplash-Associated Disorders
Treatment recommendation cannot be solidly based on scientific evidence
from the literature because of the poor methodological quality and inhomoge-
neity of the studies [199]. However, it appears that rest and immobilization
using collars are not recommended for the treatment of whiplash, while active
interventions, such as advice to “maintain normal activities,” might be effective
in acute whiplash patients [177, 198]. In chronic WAD, a combination of cogni-
844 Section Fractures
In WAD, reassurance about
the absence of a structural
lesion and the recommen-

dation to maintain normal
activities are most
important for recovery
tive behavioral therapy with physical therapy intervention and coordination
exercise therapy appear to be effective [177]. Recent research has demonstrated
that both coping behaviors and depressive symptomatology play a significant
role in the recovery of patients with WAD and need to be addressed at an early
stage [41, 42].
The Bone and Joint Decade Task Force recommends certain management
strategies which can help, at least in the short term. In the early stages of Grade
IorIIneckpain(noradiculopathyorstructuralpathology)afteramotorvehicle
collision, the Neck Pain Task Force recommends the following clinical approach
[93]:
reassurance about the absence of serious pathology
education that the development of spinal instability, neurological injury or
serious ongoing disability is very unlikely
promotion of timely return to normal activities of living
if needed, exercise training and/or mobilization to provide short-term relief
Cervical sprains and strains of the cervical spine after non-motor vehicle
accidents are quite common [201] and similar treatment recommendations
apply.
Non-operative Treatment Modalities
Cervical orthoses limit movement of the cervical spine by buttressing structures
at both ends of the neck, such as the chin and the thorax. However, applied pres-
sure over time can lead to complications such as:
pressure sores and skin ulcers
weakening and atrophy of neck muscles
contractures of soft tissues
decrease in pulmonary function
chronic pain syndrome

Collars
Soft collars (Fig. 8a, b) have a limited effect on controlling neck motion, restrict-
ing flexion/extension about 20–25%, lateral bending 8%, and one-directional
rotation 17% [155]. A soft collar is at best useful for the acute (short-term) treat-
ment of minor cervical muscle strains and sprains. However, soft collars are no
better than the recommendation of “return to normal activities” particularly not
in WADs [148]. The Philadelphia collar (
Fig. 8c, d) has been shown to control
neck motion, especially in the flexion/extension plane, much better than the soft
collar. Restriction in flexion/extension is 71%, lateral bending 34%, and axial
rotation 56%. Disadvantages of the Philadelphia collar are the lack of control for
flexion/extension control in the upper cervical region and lateral bending and
axial rotation [155]. Further, the Philadelphia collar was shown to elicit increased
occipital pressure, which may result in scalp ulcers, particularly in comatose
patients.
Minerva Brace/Cast
A Minerva cervical brace is a cervicothoracal orthosis with mandibular, occipi-
tal, and forehead contact points. Radiological evaluation showed the Minerva
cervical brace to limit flexion/extension in 79%, lateral bending in 51%, and
axial rotation in 88% of cases [178]. This brace provides adequate immobiliza-
tion between C1 and C7, with less rigid immobilization of the occipital-C1 junc-
Cervical Spine Injuries Chapter 30 845
abcd
ef
Figure 8. Orthosis and casts
a, b Soft collar, c, d Philadelphia collar, e, f Minerva cast.
tion. The addition of the forehead strap and occipital flare assists in immobiliz-
ing C1–C2 [178]. However, we prefer a customized Minerva cast made of a Sc ot ch
cast, which can be individually molded and provides a reliable fixation which the
patient cannot simply take off (

Fig. 8e, f ).
Traction
The Gardner-Wells tongs (
Fig. 9a
) can be applied using local anesthesia. The
pin application sites should be a finger breadth above the pinna of the auricle
of the ear in line with, or slightly posterior to, the external auditory canal (
Fig.
9d, e
). The exact anteroposterior position can be chosen to help apply traction
with the neck in some flexion (posterior site)orextension(anterior site). The
device should be tightened until 1 mm of the spring-loaded stylet protrudes
(
Fig. 9b, c
), which corresponds to an average of 13.5 kg of compressive force.
Of note, the pin only penetrates the external skull lamina. The average force
necessary to penetrate the inner table with cadaveric specimens with the tong
pin was 73 kg [126], indicating a large safety margin. If the device is planned
to remain for an extended time period, the marker should be tightened once
again 24–48 h after application. A nut located over each pin should be tight-
ened down to the tong to secure the pins in position, minimizing the risk of
break-out.
Rule out AOD or discoliga-
mentous disruption before
applying traction
Although most cervical injuries can be stabilized with traction, it is manda-
tory to rule out an atlanto-occipital dislocation or complete discoligamentous
injuries before applying traction because of the inherent risk of rapid neurologi-
cal deterioration, which can be irreversible.
846 Section Fractures

abc
de
Figure 9. Traction
Gardner-Wells tongs. a Anteroposterior view; b view of spring-loaded stylet (unloaded); c view of spring-loaded stylet
(loaded);
d, e correct positioning of the skull pins.
The initial weight should not exceed 5–7 kg (depending on body weight) and
increases incrementally (30–60 min) only after control imaging. Recommenda-
tions for the maximum weight cannot be based on the literature. However,
weights up to 60 kg have been reported [53], but we do not recommend to go to
that limit.
Halo
Thehalovestisthefirst
conservative choice for
unstable lesions
Since its introduction by Nickel [145, 146], the halo skeletal fixator has proved to
be the most rigid and effective method of cervical spine immobilization [116]. It
was originally developed to immobilize the unstable cervical spine for surgical
arthrodesis in patients with poliomyelitis. Longitudinal traction with a cranial
halo affords control and positioning in cervical flexion, extension, tilt, and rota-
tion as well as longitudinal distraction forces. The optimal position for anterior
halo pin placement is 1 cm superior to the orbital rim (eyebrow), above the lateral
two-thirds of the orbit, and below the greatest circumference of the skull. This
area can be considered as a relatively “safe zone”(
Fig. 10a, b). Ring or crown size
is determined by selection of a ring that provides 1–2 cm clearance around every
Cervical Spine Injuries Chapter 30 847