cervical spine injury | c spine | clearing the cervical spine
DESCRIPTION
Dr. Donald Corenman (http://neckandback.com 970.479.5895) is a spine surgeon and spinal cord expert practicing at the Steadman Clinic in Vail, CO. He created this Power Point presentation on cervical spine injury and the evaluation of the cervical spine with an injury. The cervical spine (C spine) represents the neck area of the upper spine. This presentation--clearing the cervical spine--offers an in-depth look at cervical spine injury of the neck (C spine) including fractures, cervical nonskeletal injuries, and also offers a 3-view radiograph approach into the exam. Dr. Corenman is a spine expert and treats nonskeletal injuries such as ligamentous instability, sciwora and central cord injury. He is an expert in myelopathy, sciatica, degenerative disc disease, scoliosis and slipped disc.TRANSCRIPT
CLEARING THE CERVICAL SPINE
CLEARING THE CERVICAL SPINE
THE 2002 ORTHOPAEDICS AND SPINE LECTURE SERIES
THE 2002 ORTHOPAEDICS AND SPINE LECTURE SERIES
LECTURE OUTLINELECTURE OUTLINE• “CLINICAL CLEARANCE” - THE LATEST
• MANAGEMENT GUIDELINES
• ETIOLOGY OF MISSED CERVICAL SPINE INJURY
• THE QUESTIONS AND CONTROVERSIES - IS THERE A CONSENSUS?
• “CLINICAL CLEARANCE” - THE LATEST
• MANAGEMENT GUIDELINES
• ETIOLOGY OF MISSED CERVICAL SPINE INJURY
• THE QUESTIONS AND CONTROVERSIES - IS THERE A CONSENSUS?
LECTURE OUTLINELECTURE OUTLINE• THE 3-VIEW RADIOGRAPH - A REVIEW OF THE
APPROACH
• CERVICAL FRACTURES -
• NONSKELETAL INJURIES
• THE PEDIATRIC C-SPINE -- THE ANATOMIC DIFFERENCES
• CONCLUSION/PEARLS
• THE 3-VIEW RADIOGRAPH - A REVIEW OF THE APPROACH
• CERVICAL FRACTURES -
• NONSKELETAL INJURIES
• THE PEDIATRIC C-SPINE -- THE ANATOMIC DIFFERENCES
• CONCLUSION/PEARLS
WHAT IS IT?WHAT IS IT?
“CLINICAL CLEARANCE” - THE LATEST
“CLINICAL CLEARANCE” - THE LATEST
ALERT, AWAKE, NO AMS
NO NECK PAIN
NO DISTRACTING INJURY
NO NEURO DEFICITS
NO MIDLINE C-SPINE TENDERNESS
ALERT, AWAKE, NO AMS
NO NECK PAIN
NO DISTRACTING INJURY
NO NEURO DEFICITS
NO MIDLINE C-SPINE TENDERNESS
THE NEXUS STUDY, NEJM 7/00THE NEXUS STUDY, NEJM 7/00
• PROSPECTIVE OBSERVATIONAL STUDY - 34,000 PATIENTS
• IDENTIFIED ALL BUT 8 OF 818 CSI
• 99% SENSITIVE, NEGATIVE PREDICTIVE
VALUE 99.8%• APPLICATION OF THIS DECISION INSTRUMENT
WOULD HAVE DECREASED OVERALL
ORDERING OF XRAYS BY 12.6% == 100,000 C-SPINE RADIOGRAPHS IN THE U.S. PER YEAR
• PROSPECTIVE OBSERVATIONAL STUDY - 34,000 PATIENTS
• IDENTIFIED ALL BUT 8 OF 818 CSI
• 99% SENSITIVE, NEGATIVE PREDICTIVE
VALUE 99.8%• APPLICATION OF THIS DECISION INSTRUMENT
WOULD HAVE DECREASED OVERALL
ORDERING OF XRAYS BY 12.6% == 100,000 C-SPINE RADIOGRAPHS IN THE U.S. PER YEAR
MANAGEMENT GUIDELINES - WHY?
MANAGEMENT GUIDELINES - WHY?
• CSI: 2-4% OF ALL TRAUMA PATIENTS
• CSI: MOST COMMONLY MISSED SEVERE INJURY
• RAMIFICATIONS OF MISSED OR DELAYED DIAGNOSIS = NEURO INJURY OF PROGRESSON OF INCOMPLETE ONE AS WELL AS MEDICOLEGAL
• CSI: 2-4% OF ALL TRAUMA PATIENTS
• CSI: MOST COMMONLY MISSED SEVERE INJURY
• RAMIFICATIONS OF MISSED OR DELAYED DIAGNOSIS = NEURO INJURY OF PROGRESSON OF INCOMPLETE ONE AS WELL AS MEDICOLEGAL
MANAGEMENT GUIDELINES - WHY?
MANAGEMENT GUIDELINES - WHY?
CLINICAL PRACTICE GUIDELINES
ARE USED TO:
“REDUCE INAPPROPRIATE CARE, CONTROL GEOGRAPHIC VARIATIONS IN PRACTICE PATTERNS, AND MAKE MORE EFFECTIVE USE OF HEALTH
CARE RESOURCES”
CLINICAL PRACTICE GUIDELINES
ARE USED TO:
“REDUCE INAPPROPRIATE CARE, CONTROL GEOGRAPHIC VARIATIONS IN PRACTICE PATTERNS, AND MAKE MORE EFFECTIVE USE OF HEALTH
CARE RESOURCES”
Classification of Scientific Evidence and Formulation of Recommendations
Classification of Scientific Evidence and Formulation of Recommendations
QUESTIONS & CONTROVERSIESQUESTIONS & CONTROVERSIES
WHO NEEDS XRAYS?
WHAT VIEWS?
XRAYS NEGATIVE BUT NECK PAIN PERSISTS
ROLE OF FLEX/EXT, CT, MRI
WHO NEEDS XRAYS?
WHAT VIEWS?
XRAYS NEGATIVE BUT NECK PAIN PERSISTS
ROLE OF FLEX/EXT, CT, MRI
“DISTRACTING INJURY”??
OBTUNDED PATIENT -- WHAT TO DO?
“DISTRACTING INJURY”??
OBTUNDED PATIENT -- WHAT TO DO?
DISTRACTING INJURY?DISTRACTING INJURY?
IS THERE A CONSENSUS?IS THERE A CONSENSUS?
ACRACR
ATLSATLS EASTEAST
VVMCVVMC
VVMC MANAGEMENT GUIDELINESVVMC MANAGEMENT GUIDELINES
Awake & Alert Awake &
Alert
Altered
Mental Status
with
Neurological
deficit
No neuro
deficit
Possible C-Spine Injury Possible C-Spine Injury
Immobilize
3 or 5 View C-Spine X – rays
Immobilize
3 or 5 View C-Spine X – rays
AbnormalAbnormal
Consult Spine/Ortho Service
Continue hard collar
Cervical spine CT
and/or MRI Traction /Alignment per
Spine/Ortho. Service
NormalNormal
Awake & Alert No neuro deficit
Significant Neck
Pain
CT Cervical Spine
PositiveNegative
Consult
Spine/Ortho
Service
C-spine
Cleared
C-spine Cleared
Flexion
Extension Films
No neck pain or
tenderness with
full range of
motion
PositiveNegative
Consult
Spine/Ortho
Service
Normal C-Spine X-
rays
Consult Spine/Ortho
Service Continue hard collar
CT or MRI C-Spine
Awake & Alert With neurological deficit
Normal C-Spine X-
rays
Continue hard collar
If patient becomes awake and
cooperative proceed with Awake & Alert
GuidelinesIf patient remains uncooperative obtain
cervical spine CT scan
PositiveNegative
Consult Spine
Ortho
C-spine Cleared
when Awake &
Alert
Normal C-Spine X-
raysAltered Mental Status
HOW IS A C-SPINE INJURY MISSED???
HOW IS A C-SPINE INJURY MISSED???
INADEQUATE CERVICAL SPINE SERIES
MISINTERPRETATION OF STANDARD XRAY FILMS
LACK OF APPROPRIATE INDEX OF SUSPICION
INADEQUATE CERVICAL SPINE SERIES
MISINTERPRETATION OF STANDARD XRAY FILMS
LACK OF APPROPRIATE INDEX OF SUSPICION
• 32,000 PTS, 740 CSI - 34 PTS (4.6%) MISSED OR DELAYED
• “MISSED” = IF PT DISCHARGED AND DX MADE IN F/U
• “DELAY” = IF SPINAL PRECAUTIONS REMOVED, YET CSI DISCOVERED PRIOR TO DISCHARGE
• 32,000 PTS, 740 CSI - 34 PTS (4.6%) MISSED OR DELAYED
• “MISSED” = IF PT DISCHARGED AND DX MADE IN F/U
• “DELAY” = IF SPINAL PRECAUTIONS REMOVED, YET CSI DISCOVERED PRIOR TO DISCHARGE
“THE ETIOLOGY OF MISSED OR DELAYED DIAGNOSIS”
- J. OF TRUAMA, 1993
“THE ETIOLOGY OF MISSED OR DELAYED DIAGNOSIS”
- J. OF TRUAMA, 1993
“THE ETIOLOGY OF MISSED OR DELAYED DIAGNOSIS”
- J. OF TRUAMA, 1993
“THE ETIOLOGY OF MISSED OR DELAYED DIAGNOSIS”
- J. OF TRUAMA, 1993
“THE ETIOLOGY OF MISSED OR DELAYED DIAGNOSIS”
- J. OF TRUAMA, 1993
“THE ETIOLOGY OF MISSED OR DELAYED DIAGNOSIS”
- J. OF TRUAMA, 1993
“THE ETIOLOGY OF MISSED OR DELAYED DIAGNOSIS”
- J. OF TRUAMA, 1993
“THE ETIOLOGY OF MISSED OR DELAYED DIAGNOSIS”
- J. OF TRUAMA, 1993
“THE ETIOLOGY OF MISSED OR DELAYED DIAGNOSIS”
- J. OF TRUAMA, 1993
“THE ETIOLOGY OF MISSED OR DELAYED DIAGNOSIS”
- J. OF TRUAMA, 1993
CONCLUSION: 94% OF THE ERRORS LEADING TO A MISSED/DELAYED DX OF CSI WERE FUNDAMENTAL –
1. FAILURE TO OBTAIN CLINICALLY ADEQUATE 3-VIEW
2. MISINTERPRETATION OF XRAYS
CONCLUSION: 94% OF THE ERRORS LEADING TO A MISSED/DELAYED DX OF CSI WERE FUNDAMENTAL –
1. FAILURE TO OBTAIN CLINICALLY ADEQUATE 3-VIEW
2. MISINTERPRETATION OF XRAYS
3-VIEW RADIOGRAPH: AP, LATERAL, ODONTOID
3-VIEW RADIOGRAPH: AP, LATERAL, ODONTOID• COMBINATION OF AP AND ODONTOID
WITH LATERAL INCREASES SENSITIVITY FROM 85% TO 92%
• 3-VIEW PLUS CT WITH SAGITTAL RECONSTRUCTION THROUGH SUSPICIOUS AREAS == FALSE NEGATIVE OF .1% IF TECHNICALLY ADEQUATE AND PROPERLY INTERPRETED
• COMBINATION OF AP AND ODONTOID WITH LATERAL INCREASES SENSITIVITY FROM 85% TO 92%
• 3-VIEW PLUS CT WITH SAGITTAL RECONSTRUCTION THROUGH SUSPICIOUS AREAS == FALSE NEGATIVE OF .1% IF TECHNICALLY ADEQUATE AND PROPERLY INTERPRETED
THE X-TABLE LATERALTHE X-TABLE LATERALTHE UNDISPUTED
MAINSTAY OF THE CERVICAL SPINE SERIES
85% SENSITIVITY
NEGATIVE PREDICTIVE VALUE: .97 -- BUT NOT SUFFICIENT TO BE ONLY SCREENING STUDY
THE UNDISPUTED MAINSTAY OF THE CERVICAL SPINE SERIES
85% SENSITIVITY
NEGATIVE PREDICTIVE VALUE: .97 -- BUT NOT SUFFICIENT TO BE ONLY SCREENING STUDY
THE X-TABLE LATERALTHE X-TABLE LATERAL
TO BE ADEQUATE:OCCIPUT
ALL 7 VERTEBRAE
SUP. ENDPLATE OF T1
TO BE ADEQUATE:OCCIPUT
ALL 7 VERTEBRAE
SUP. ENDPLATE OF T1
ABC’S OF THE LATERAL XRAY
ABC’S OF THE LATERAL XRAY
A: ALIGNMENT
B: BONY
C: CARTILAGE
S: SOFT TISSUE
A: ALIGNMENT
B: BONY
C: CARTILAGE
S: SOFT TISSUE
LATERAL C-SPINE: LATERAL C-SPINE:
A-ALIGNMENTA-ALIGNMENT
ANTERIOR SPINAL LINEANTERIOR SPINAL LINE
POSTERIOR SPINAL LINE
POSTERIOR SPINAL LINE
SPINOLAMINAR LINESPINOLAMINAR LINE
LATERAL C-SPINE: CLIVUS LINE
LATERAL C-SPINE: CLIVUS LINE
• AKA “BASILAR LINE OF WACKENHEIM”
• MEANS OF VERIFYING ATLANTO-OCCIPITAL RELATIONSHIP
• SHOULD INTERSECT POST. 1/3 OF DENS OR LIE TANGENT TO POST. CORTEX
• BASION-DENTAL INTERVAL > 1.2 CM = ATLANTO-OCCIPITAL DISSOCIATION
• AKA “BASILAR LINE OF WACKENHEIM”
• MEANS OF VERIFYING ATLANTO-OCCIPITAL RELATIONSHIP
• SHOULD INTERSECT POST. 1/3 OF DENS OR LIE TANGENT TO POST. CORTEX
• BASION-DENTAL INTERVAL > 1.2 CM = ATLANTO-OCCIPITAL DISSOCIATION
#13, P. 6 FIG 2
LATERAL C-SPINE: B-BONYLATERAL C-SPINE: B-BONY• ASSESS FOR:
• VERTEBRAL BODY CONTOUR AND AXIAL HEIGHT
• LATERAL BONY MASS -PEDICLES, FACETS, LAMINA, TP
• SPINOUS PROCESS
• ASSESS FOR:• VERTEBRAL BODY
CONTOUR AND AXIAL HEIGHT
• LATERAL BONY MASS -PEDICLES, FACETS, LAMINA, TP
• SPINOUS PROCESS
#28 FIG 2-36 -
ASSESS FOR:
INTERVERTEBRAL DISC
FACET JOINTS
ASSESS FOR:
INTERVERTEBRAL DISC
FACET JOINTS
LATERAL C-SPINE: C-CARTILAGE
LATERAL C-SPINE: C-CARTILAGE
LATERAL C-SPINE: S-SOFT TISSUE
LATERAL C-SPINE: S-SOFT TISSUE
ASSESS FOR:PREVERTEBRAL
SPACE
PREVERTEBRAL FAT STRIPE
SPACE BETWEEN SPINOUS PROCESSES
ASSESS FOR:PREVERTEBRAL
SPACE
PREVERTEBRAL FAT STRIPE
SPACE BETWEEN SPINOUS PROCESSES
FLEXION TEARDROP FRACTURE
FLEXION TEARDROP FRACTURE
POSTERIOR SPINAL LINE
PREVERTEBRAL SWELLING
SPINOUS PROCESS WIDENING
POSTERIOR SPINAL LINE
PREVERTEBRAL SWELLING
SPINOUS PROCESS WIDENING
AP XRAYAP XRAY• ASSESS FOR:
– ALIGNMENT– SYMMETRY OF
PEDICLES– CONTOUR OF BODIES– HEIGHT OF DISC
SPACES– CENTRAL POSITION
OF SPINOUS PROCESSES
• ASSESS FOR: – ALIGNMENT– SYMMETRY OF
PEDICLES– CONTOUR OF BODIES– HEIGHT OF DISC
SPACES– CENTRAL POSITION
OF SPINOUS PROCESSES
AP XRAYAP XRAY
FACET JOINTS ORIENTED AT 45 DEGREE ANGLE FROM CORONAL PLANE -- THUS NOT SEEN ON AP
IF FACET IS CLEARLY IDENTIFIED ON AP, ARTICULAR PILLAR OR PEDICLE FX WITH ROTATION IS LIKELY
FACET JOINTS ORIENTED AT 45 DEGREE ANGLE FROM CORONAL PLANE -- THUS NOT SEEN ON AP
IF FACET IS CLEARLY IDENTIFIED ON AP, ARTICULAR PILLAR OR PEDICLE FX WITH ROTATION IS LIKELY
AP XRAY - OTHER FINDINGSAP XRAY - OTHER FINDINGS• AIR COLUMN
• TRANSVERSE PROCESSES
• DISPLACED SPINOUS PROCESS FRACTURE MAY GIVE APPEARANCE OF “DOUBLE SPINOUS PROCESS”
• ABRUPT SIDE-TO-SIDE DISPLACEMENT OF SP CAN INDICATE UNILATERAL FACET SUBLUXATION/DISLOCATION
• AIR COLUMN
• TRANSVERSE PROCESSES
• DISPLACED SPINOUS PROCESS FRACTURE MAY GIVE APPEARANCE OF “DOUBLE SPINOUS PROCESS”
• ABRUPT SIDE-TO-SIDE DISPLACEMENT OF SP CAN INDICATE UNILATERAL FACET SUBLUXATION/DISLOCATION
ODONTOID FILMODONTOID FILM
• ATLAS, ODONTOID, SUPERIOR FACETS OF AXIS
• ATLAS-AXIS RELATIONSHIP == JEFFERSON FX, C1-2 ROTATORY SUBLUXATION, ODONTOID FRACTURES
• ATLAS, ODONTOID, SUPERIOR FACETS OF AXIS
• ATLAS-AXIS RELATIONSHIP == JEFFERSON FX, C1-2 ROTATORY SUBLUXATION, ODONTOID FRACTURES
WHAT IS IT?WHAT IS IT?
WHAT IS IT?WHAT IS IT?
WHAT IS IT?WHAT IS IT?
NONSKELETAL INJURIES - MUST CONSIDER IN “CLEARANCE”
NONSKELETAL INJURIES - MUST CONSIDER IN “CLEARANCE”
• LIGAMENTOUS INSTABILITY
• SCIWORA
• CENTRAL CORD INJURY
• LIGAMENTOUS INSTABILITY
• SCIWORA
• CENTRAL CORD INJURY
Panjabi and White: Dx of Clinical Instability in the Lower Cervical SpinePanjabi and White: Dx of Clinical
Instability in the Lower Cervical Spine
• Anterior elements Destroyed or Unable to Function 2• Posterior Elements Destroyed of Unable to Function 2• Relative Sagittal Plane Translation > 3.5mm 2• Relative Sagittal Plane Rotation > 11deg 2• Positive Stretch Test 2• Medullary (Cord) Damage 2• Root Damage 1• Abnormal Disc Narrowing 1• Dangerous Loading Anticipated 1
TOTAL OF 5 OR MORE = UNSTABLE
• Anterior elements Destroyed or Unable to Function 2• Posterior Elements Destroyed of Unable to Function 2• Relative Sagittal Plane Translation > 3.5mm 2• Relative Sagittal Plane Rotation > 11deg 2• Positive Stretch Test 2• Medullary (Cord) Damage 2• Root Damage 1• Abnormal Disc Narrowing 1• Dangerous Loading Anticipated 1
TOTAL OF 5 OR MORE = UNSTABLE
SCIWORA: spinal cord injury without radiographic abnormality
SCIWORA: spinal cord injury without radiographic abnormality
• DEFINED BY PANG AND WILBERGER, 1982:
“Objective Signs Of Myelopathy As A Result Of Trauma With No Evidence Of Fracture Or Ligamentous
Instability On Plain Xray And Tomography”
• FINDING OF FRACTURE, SUBLUXATION, OR ABNORMAL INTERSEGMENTAL MOTION AT LEVEL OF NEUROLOGICAL INJURY EXCLUDES SCIWORA AS A DIAGNOSIS
• DEFINED BY PANG AND WILBERGER, 1982:
“Objective Signs Of Myelopathy As A Result Of Trauma With No Evidence Of Fracture Or Ligamentous
Instability On Plain Xray And Tomography”
• FINDING OF FRACTURE, SUBLUXATION, OR ABNORMAL INTERSEGMENTAL MOTION AT LEVEL OF NEUROLOGICAL INJURY EXCLUDES SCIWORA AS A DIAGNOSIS
SCIWORASCIWORA• EXPERIMENTALLY,
OSTEOCARTILAGINOUS STRUCTURES IN SPINAL COLUMN CAN STRETCH 2 INCHES WITHOUT DISRUPTION -- SPINAL CORD RUPTURES AFTER 1/4 INCH
• ANATOMICALLY, CERVICAL SPINAL CORD IS RELATIVELY TETHERED - SPINAL NERVES, DURAL ATTACHMENT TO FORAMEN MAGNUM, AND BRACHIAL PLEXUS
• EXPERIMENTALLY, OSTEOCARTILAGINOUS STRUCTURES IN SPINAL COLUMN CAN STRETCH 2 INCHES WITHOUT DISRUPTION -- SPINAL CORD RUPTURES AFTER 1/4 INCH
• ANATOMICALLY, CERVICAL SPINAL CORD IS RELATIVELY TETHERED - SPINAL NERVES, DURAL ATTACHMENT TO FORAMEN MAGNUM, AND BRACHIAL PLEXUS
SCIWORA: LATENT PERIODSCIWORA: LATENT PERIOD
• PANG AND WILBERGER: 13 OF 24 CHILDREN WITH SCIWORA WITH LATENT PERIOD OF 30 MIN TO 4 DAYS (MEAN 1.2 DAYS) BEFORE ONSET OF OBJECTIVE SENSORIMOTOR DEFICITS
• ALL 13 HAD TRANSIENT SUBJECTIVE COMPLAINTS AT TIME OF INITIAL TRAUMA THAT CLEARED WITHIN 1 HOUR
• OTHER STUDIES: 22%, 23%, AND 27% INCIDENCE OF SAME
• PANG AND WILBERGER: 13 OF 24 CHILDREN WITH SCIWORA WITH LATENT PERIOD OF 30 MIN TO 4 DAYS (MEAN 1.2 DAYS) BEFORE ONSET OF OBJECTIVE SENSORIMOTOR DEFICITS
• ALL 13 HAD TRANSIENT SUBJECTIVE COMPLAINTS AT TIME OF INITIAL TRAUMA THAT CLEARED WITHIN 1 HOUR
• OTHER STUDIES: 22%, 23%, AND 27% INCIDENCE OF SAME
SCIWORASCIWORA
• PRESENTING NEURO EXAM CORRELATES TO OUTCOME
• MRI FINDINGS (OR LACK OF) MAY BE MORE PREDICTIVE OF OUTCOME
• NO CHILD HAS BEEN DOCUMENTED TO DEVELOP SPINAL INSTABILITY AFTER DX OF SCIWORA
• PRESENTING NEURO EXAM CORRELATES TO OUTCOME
• MRI FINDINGS (OR LACK OF) MAY BE MORE PREDICTIVE OF OUTCOME
• NO CHILD HAS BEEN DOCUMENTED TO DEVELOP SPINAL INSTABILITY AFTER DX OF SCIWORA
SCIWORA - TREATMENTSCIWORA - TREATMENT
• NO CONSENSUS:
BUT HARD COLLAR IMMOBILIZATION FOR 12 WEEKS AND AVOIDANCE OF FLEX/EXT ACTIVITIES FOR ANOTHER 12 WEEKS HAS NOT BEEN ASSOCIATED WITH RECURRENT INJURY
• NO CONSENSUS:
BUT HARD COLLAR IMMOBILIZATION FOR 12 WEEKS AND AVOIDANCE OF FLEX/EXT ACTIVITIES FOR ANOTHER 12 WEEKS HAS NOT BEEN ASSOCIATED WITH RECURRENT INJURY
MYELOPATHYMYELOPATHYMYELOPATHYMYELOPATHY• PATHOPHYSIOLOGY --
CORRELATIVE ANATOMY
• THE SPINAL CANAL: • WHAT IS THE SHAPE?• PREPATHOLOGY FOR
MYELOPATHY TO EXIST
• HOW DOES THE DEGENERATIVE CASCADE CAUSE STENOSIS?
• PATHOPHYSIOLOGY -- CORRELATIVE ANATOMY
• THE SPINAL CANAL: • WHAT IS THE SHAPE?• PREPATHOLOGY FOR
MYELOPATHY TO EXIST
• HOW DOES THE DEGENERATIVE CASCADE CAUSE STENOSIS?
MYELOPATHY -- SPINAL MYELOPATHY -- SPINAL CANAL MEASURMENTSCANAL MEASURMENTSMYELOPATHY -- SPINAL MYELOPATHY -- SPINAL CANAL MEASURMENTSCANAL MEASURMENTS
• CRITICAL DIAMETER = 13 MM• VEIDLINGER
PAPER
• TORG RATIO
• KINETIC ASPECTS OF COMPRESSION
• CRITICAL DIAMETER = 13 MM• VEIDLINGER
PAPER
• TORG RATIO
• KINETIC ASPECTS OF COMPRESSION
MYELOPATHY: PhysicalMYELOPATHY: PhysicalMYELOPATHY: PhysicalMYELOPATHY: Physical
• “LONG TRACT SIGNS”• DTRS• BABINSKI AND CLONUS• INVERTED RADIAL REFLEX• HOFFMAN’S
• L’HERMITTES SIGN
• “LONG TRACT SIGNS”• DTRS• BABINSKI AND CLONUS• INVERTED RADIAL REFLEX• HOFFMAN’S
• L’HERMITTES SIGN
PEDIATRICS: A BRIEF OVERVIEW OF THE ANATOMIC
DIFFERENCES
PEDIATRICS: A BRIEF OVERVIEW OF THE ANATOMIC
DIFFERENCES
• CSI IS RARE IN CHILDREN: 1% OF ALL PEDS FRACTURES AND 2% OF ALL SPINE FRACTURES
• BY AGE 8-10, NO ANATOMICAL OR BIOMECHANICAL DIFFERENCES
• PEDS < 10 Y.O. ARE FUNDAMENTALLY DIFFERENT DUE TO ANATOMICAL VARIATIONS OF THE DEVELOPING SPINE, AND TO A LESSER EXTENT, THE DIFFERENCES IN MECHANISMS OF INJURY
• CSI IS RARE IN CHILDREN: 1% OF ALL PEDS FRACTURES AND 2% OF ALL SPINE FRACTURES
• BY AGE 8-10, NO ANATOMICAL OR BIOMECHANICAL DIFFERENCES
• PEDS < 10 Y.O. ARE FUNDAMENTALLY DIFFERENT DUE TO ANATOMICAL VARIATIONS OF THE DEVELOPING SPINE, AND TO A LESSER EXTENT, THE DIFFERENCES IN MECHANISMS OF INJURY
PEDS ANATOMY AND BIOMECHANICS
PEDS ANATOMY AND BIOMECHANICS
INHERENTLY MORE MOBILE:
GENERALIZED LAXITY OF INTERSPINOUS LIGAMENTS AND JOINT CAPSULES
THICK CARTILAGINOUS ENDPLATES
INCOMPLETE VERTEBRAL OSSIFICATION (WEDGE-SHAPED VERTEBRAL BODIES)
SHALLOW ANGLED FACET JOINTS, ESPECIALLY B/W OCCIPUT AND C4
HEAD DISPROPORTIONATELY LARGE
INHERENTLY MORE MOBILE:
GENERALIZED LAXITY OF INTERSPINOUS LIGAMENTS AND JOINT CAPSULES
THICK CARTILAGINOUS ENDPLATES
INCOMPLETE VERTEBRAL OSSIFICATION (WEDGE-SHAPED VERTEBRAL BODIES)
SHALLOW ANGLED FACET JOINTS, ESPECIALLY B/W OCCIPUT AND C4
HEAD DISPROPORTIONATELY LARGE
INITIAL PEDIATRIC EVALUATION
INITIAL PEDIATRIC EVALUATION• CLINICAL
EVALUATION HAMPERED
• MECHANISMS OF INJURY = RISK FACTORS
• MOST RELIABLE SIGNS OF CSI IN PEDS ARE NECK PAIN, GUARDING, TORTICOLLIS
• CLINICAL EVALUATION HAMPERED
• MECHANISMS OF INJURY = RISK FACTORS
• MOST RELIABLE SIGNS OF CSI IN PEDS ARE NECK PAIN, GUARDING, TORTICOLLIS
PEDIATRIC ANATOMIC VARIANTS - NOT TRAUMATIC
INJURY
PEDIATRIC ANATOMIC VARIANTS - NOT TRAUMATIC
INJURY
• PSEUDOSUBLUXATION
• PERSISTENT SYNCHONDROSES
• ANTERIOR ANGULATION OF DENS
• FOCAL KYPHOSIS OF MID-CERVICAL SPINE
• DIFFERENT SOFT TISSUE MEASUREMENTS
• PSEUDOSUBLUXATION
• PERSISTENT SYNCHONDROSES
• ANTERIOR ANGULATION OF DENS
• FOCAL KYPHOSIS OF MID-CERVICAL SPINE
• DIFFERENT SOFT TISSUE MEASUREMENTS
PSEUDOSUBLUXATIONPSEUDOSUBLUXATION
PEDIATRIC C-SPINE CLEARANCE
PEDIATRIC C-SPINE CLEARANCE
CLINICAL CLEARANCE IF:
– AWAKE, ALERT, COOPERATIVE
– NO SIGNS OF CERVICAL INJURY
– MECHANISM NOT CONSISTENT WITH CERVICAL TRAUMA
CLINICAL CLEARANCE IF:
– AWAKE, ALERT, COOPERATIVE
– NO SIGNS OF CERVICAL INJURY
– MECHANISM NOT CONSISTENT WITH CERVICAL TRAUMA
PEDIATRIC C-SPINE CLEARANCE: OBTUNDED
PEDIATRIC C-SPINE CLEARANCE: OBTUNDED
5 VIEW PLUS CT OF THE AXIAL REGION FROM OCCIPUT TO C2PREPONDERANCE OF INJURIES OCCUR
FROM OCCIPUT TO C2 IN KIDS < 8 Y.O.
TECHNICALLY DIFFICULT REGION TO IMAGE WITH PLAIN RADIOGRAPHS
MRI = STUDY OF CHOICE TO EVALUATE CORD AND SOFT TISSUE STRUCTURES
5 VIEW PLUS CT OF THE AXIAL REGION FROM OCCIPUT TO C2PREPONDERANCE OF INJURIES OCCUR
FROM OCCIPUT TO C2 IN KIDS < 8 Y.O.
TECHNICALLY DIFFICULT REGION TO IMAGE WITH PLAIN RADIOGRAPHS
MRI = STUDY OF CHOICE TO EVALUATE CORD AND SOFT TISSUE STRUCTURES
CONCLUSIONS/PEARLSCONCLUSIONS/PEARLS
1-5% OF CSI ARE MISSED - MAINTAIN APPROPRIATE LEVEL OF SUSPICION
IF SEEING A PATIENT WITH CONTINUED NECK PAIN AFTER BEING “CLEARED” -- KNOW THE
BASIC MANAGEMENT GUIDELINES FOR CLEARING THE C-SPINE
1-5% OF CSI ARE MISSED - MAINTAIN APPROPRIATE LEVEL OF SUSPICION
IF SEEING A PATIENT WITH CONTINUED NECK PAIN AFTER BEING “CLEARED” -- KNOW THE
BASIC MANAGEMENT GUIDELINES FOR CLEARING THE C-SPINE
CONCLUSIONS/PEARLSCONCLUSIONS/PEARLS
MISSED/DELAYED CSI OCCURS DUE TO LACK OF AN APPROPRIATE
INDEX OF SUSPICION, INADEQUATE PLAIN FILMS, AND MISREAD
STUDIES
MISSED/DELAYED CSI OCCURS DUE TO LACK OF AN APPROPRIATE
INDEX OF SUSPICION, INADEQUATE PLAIN FILMS, AND MISREAD
STUDIES
CONCLUSIONS/PEARLSCONCLUSIONS/PEARLS
IF HAVE HIGH ENOUGH INDEX OF SUSPICION TO GET XRAYS, THEN DO
NOT ACCEPT INADEQUATE ONES
IF HAVE HIGH ENOUGH INDEX OF SUSPICION TO GET XRAYS, THEN DO
NOT ACCEPT INADEQUATE ONES
CONCLUSIONS/PEARLSCONCLUSIONS/PEARLS
IN “CLEARING” THE C-SPINE, DO NOT FORGET NONSKELETAL INJURIES:
LIGAMENTOUS INSTABILITY, CERVICAL STENOSIS, AND SCIOWRA
IN “CLEARING” THE C-SPINE, DO NOT FORGET NONSKELETAL INJURIES:
LIGAMENTOUS INSTABILITY, CERVICAL STENOSIS, AND SCIOWRA
CONCLUSIONS/PEARLSCONCLUSIONS/PEARLS
KNOW YOUR PEDIATRIC ANATOMICAL VARIATIONS
KNOW YOUR PEDIATRIC ANATOMICAL VARIATIONS
CONCLUSIONS/PEARLSCONCLUSIONS/PEARLS
DON’T BE IN A HURRY TO CLEAR THE CERVICAL SPINE - CAN ALWAYS
LEAVE IN A HARD COLLAR
DON’T BE IN A HURRY TO CLEAR THE CERVICAL SPINE - CAN ALWAYS
LEAVE IN A HARD COLLAR
Thank You!Thank You!