dodge
TRANSCRIPT
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Larry D. Dodge, MD
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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.
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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.
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Asymptomatic Trauma Patient
Cervical x-rays not required in patients without tenderness and are alert.
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Trauma Patients with Neck Pain
2 to 6% incidence of significant spine injuries.
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Do Not Remove Collar Until
Absence of tenderness
Absence of pain
Normal mental status
complete radiographic evaluation
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Most Common Missed Diagnosis
Occipitoathlantoaxial region or cervicothoracic junction
Plain x-ray will miss 15 to 17% of injuries
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CAT scan has 99% predictive value
MRI better for soft tissue, may be oversensitive
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Flexion and Extension Radiographs
Safe in awake alert patients
Exclude significant instability
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Obtunded Patient EvaluationControversial
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.
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Fractures of the Cervical Spine
Most do not require surgery
Ligamentous injuries less predictable, and more require surgery
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Types of OrthrosisHalo- 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.
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Occipitocervical Dissocation
Most are lethal
Neurologic injuries vary from complete to cranial nerve injuries
Diagnosis can be difficult
Occipitocervical fusion is required
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Atlas FracturesAxial load
Stability requires healing of transverse ligament – MRI
Halo- reasonable treatment
C1-C2 fusion if transverse ligament disrupted
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Axis Fractures
Odontoid fractures are most common
Type I – Avulsion Type II – Waist Type III – Vertebral body
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Type Odontoid
Treated with external orthrosis
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Type Odontoid
Controversial treatment
Elderly do not tolerate halo – consider C1- C2 fusion
Fusion needed if reduction not achieved or maintained
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Type Odontoid
High healing rate with halo vest
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Traumatic Spondylolisthesis of Axis
MVA- hyperextension, compression and rebound flexion
Most treated in halo
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Subaxial Compression Fractures
Failure of anterior column
Orthosis for 6 – 12 weeks
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Subaxial Burst Fracture
Fracture into posterior cortex with retropulsion
Spinal cord injury rate is high
Most require surgery – anterior or anterior and posterior
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Facet DislocationsTimely reduction required
Subluxation of 25% suggests unilateral, 50% suggests bilateral
MRI needed to assess for HNP
Failure of closed reduction mandates open reduction
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Cervical Disk Disease
Symptoms can be insidious or acute
Minor injured can aggravate the root (radiculopathy) or spinal cord ( myelopathy)
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PathophysiologyDisk 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
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Cervical Roots exhibit a higher degree of overlap than seen in the thoracolumbar spine, therefore symptom patterns may fail to localize.
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Hyporeflexia
Biceps
Brachioradialis C- 6
Triceps C- 7
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Most Commonly Affected
C-5, C-6, C-7
More motion in these areas
Watershed area of blood supply – roots more susceptible
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Myelopathy
Most commonly presents as clumsiness, ataxia, loss of fine motor skills.
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Cervical Spondylosis
May cause radicular pain from nerve root origin
May cause referred sclerotomal pain ( occiput, interscapular region, or
shoulders)
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Treatment
75% of radiculopathy improve with P.T. , activity modification, medication
Soft disk herniations can resorb
Myelopathy
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Imaging StudiesPlain x-ray – alignment, spondylosis
Flexion – extension for instability
MRI
CAT – defines bone anatomy
Diskography
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Electrodiagnostic Studies
Paresthesias cannot be localized
Imaging does not correlate with clinical picture
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Nonsurgical Care
P.T. – emphasize isometric exercise
Traction with slight flexion
Medication
Epidural steroids
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Surgical Indications
Success for axial pain is 60 %
Success for radiculopathy is 90%
Disk Replacement – evolving technology
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ACDF
Allograft versus autograft
Plate fixation
Accelerates degeneration at adjacent levels
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Posterior Decompression
Foraminotomy for bony foraminal stenosis
Laminectomy – risk of kyphosis
Laminectomy – decompression without adding fusion
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Thank you
We will now move into the exam
part of the lecture.