Cervical Strains & Sprains (Whiplash Injury)
? Essentials of Diagnosis
• Pain is the chief complaint
• Local tenderness; decreased range of motion; headaches, typically
occipital; blurred or double vision
• Dysphagia, hoarseness, jaw pain, difficulty with balance, vertigo
• Strain refers to muscle injuries; sprain, to ligamentous and capsular
injuries
• Roentgenographic evaluation is indicated
? Differential Diagnosis
• Fractures
• Subluxations and dislocations
• Herniated disk
• Degenerative disk disease
• Rheumatoid arthritis
• Ankylosing spondylitis
• Infection
? Treatment
• Initial rest, bed rest if necessary, and soft collar immobilization
are indicated, along with use of anti-inflammatory medications
• Encourage early mobilization with progressive range of motion
and weaning from external supports
• Frequent reassurance is often necessary because symptoms may
be long lasting
• About 42% of patients have persistent symptoms beyond 1 y,
with approximately one third having persistent symptoms beyond
2 y; most patients who improve do so within the first 2 mo
• Factors associated with a poor prognosis include the presence of
occipital headaches, interscapular pain, reversal of cervical lordosis,
and involvement in litigation or workers’ compensation
claims; women have a worse prognosis than men
? Pearl
Cervical spine stability must first be verified before the diagnosis of
cervical sprain can be made. Examine appropriate C-spine series,
including flexion and extension views.
Atlas Fracture (C1 Vertebra)
? Essentials of Diagnosis
• Caused by trauma
• Vertebral artery injuries may cause basilar insufficiency: vertigo,
blurred vision, and nystagmus
• May be associated with injury to cranial nerves VI–XII and neurapraxia
of the suboccipital and greater occipital nerves
• Patients present with neck pain or a feeling of “instability”
• Mechanism: axial compression with elements of hyperextension
and asymmetric loading of condyles
• Jefferson fracture is a 4-part fracture of the atlas; most injuries are
2-part and 3-part
? Differential Diagnosis
• Ligamentous injury: transverse ligament rupture, alar ligament
rupture
• Odontoid fracture
• Hangman’s fracture
• Atlanto-occipital dissociation
? Treatment
• Halo traction or immobilization initially
• Stable fractures may be treated with rigid cervical orthoses; less
stable fractures require prolonged halo vest treatment
• C1–C2 or occiput to C2 fusion may be necessary for grossly
unstable acute fractures or for chronic instability
? Pearl
Atlas fractures are rarely associated with neurologic injury but >50%
are associated with other cervical spine fractures, especially odontoid.
Hangman’s Fracture
? Essentials of Diagnosis
• This is not an odontoid fracture; it is a fracture of the ring of C2
producing traumatic spondylolisthesis of C2
• There is a 30% incidence of concomitant cervical spine fractures
• Mechanism is hyperextension and axial load
• Pain, instability, or both are present
• Patient may have neurologic compromise
• May be associated with cranial nerve, vertebral artery, or craniofacial
injuries
• Disruption of the C2–C3 disk causes marked instability
? Differential Diagnosis
• Intervertebral disk disruption
• Ligamentous injury
• Odontoid fracture
• Atlas fracture
? Treatment
• Nondisplaced fractures may be treated in a rigid cervical orthosis
for 6 wk
• Unstable injuries require halo traction or immobilization for at
least 6 wk
• Severe disruption may require open treatment with fusion if reduction
cannot be maintained
? Pearl
Hangman’s fracture is one of the few injuries of the cervical spine that
can be exacerbated by traction.
Fractures of the Lower Cervical Spine
? Essentials of Diagnosis
• History of trauma to the neck or head
• Pain (especially with range of motion)
• Localized tenderness
• Careful neurologic exam is important, including sphincter tone and
Babinski reflex; findings in anterior cord and central cord lesions
may be subtle
• Diagnosis usually is confirmed with radiographic evaluation
• CT or MRI may be necessary, if occult
• Because noncontiguous injury of the spine occurs in ~12% of
cases, evaluation of the thoracic and lumbar spine is important
? Differential Diagnosis
• Ligamentous injury (whiplash)
• Facet joint injury
• Arthritis or stenosis
• Disk herniation
• Infection (tuberculosis)
• Referred pain (cardiac, etc)
• Metastases and neoplasms
? Treatment
• Hard collar; spine precautions
• Surgery for unstable fracture-dislocations to stabilize the spine,
prevent progression of neurologic damage, and enable earlier
rehabilitation
? Pearl
Maintain a high index of suspicion for fracture after a neck injury in
patients with ankylosing spondylitis.
Complete Spinal Cord Injury
? Essentials of Diagnosis
• Total absence of sensation and voluntary motor function caudal
to the level of spinal cord injury in the absence of spinal shock
• Formal diagnosis is established after the period of spinal shock,
which typically lasts 24 h
• Total absence of motor and sensory function below the injury
level; the patient is often hyperreflexic
• No evidence of sacral sparing; presence of the bulbocavernosus
reflex
• Root escape (when some root level function is regained at the
level of injury) should not be confused with the return of cord
function
• Careful neurologic exam is necessary to rule out anterior cord or
central cord syndromes or other incomplete lesion
? Differential Diagnosis
• Spinal shock
• Incomplete lesion
? Treatment
• Acute management: keep systolic blood pressure >90 mm Hg;
restrict fluids for 48 h; keep patient at 100% O2 saturations
• If treating within 8 h of injury, give methylprednisolone, 30 mg/kg
over 15 min; then, 45 min after bolus, give 5.4 mg/kg/h for 23 h
• Prevent contractures by splinting immediately, especially elbow
and wrist in the upper extremity
• Aggressive pulmonary hygiene is required
• Refer for physical and occupational therapy, and psychological
counseling
? Pearl
Watch for autonomic dysreflexia (even in acute spinal cord injury) from
pain, fecal impaction, and abdominal distention, with blood pressure
increasing 35–95% of baseline.
Odontoid Fractures
Most common fracture of Axis (nearly 2/3 of all C2 Fxs)
10 – 20 % of all cervical fractures
Etiology:
Bimodal distribution Young - high energy, multi-trauma
Elderly - low energy, isolated injury (most common C-spine Fx elderly)
Type I 2 %
Type II 50-75 %
Type III 15-25 %
Treatment
Type 1
• C-Collar
• beware unrecognized AOD
Type 3
C-Collar
SOMI brace
Halo Vest
10-15% nonunion rate
Type 2
C-Collar
SOMI brace
Halo Vest
Odontoid Screw
C1-2 posterior fusion
Risk factors of Nonunion ( 10-70%)
1.Initial displacement > 6mm
2.Age > 60 yr old
3.Delay Diagnosis > 3 wk
Angulation > 10°
Posterior displacement
المادة المعروضة اعلاه هي مدخل الى المحاضرة المرفوعة بواسطة استاذ(ة) المادة . وقد تبدو لك غير متكاملة . حيث يضع استاذ المادة في بعض الاحيان فقط الجزء الاول من المحاضرة من اجل الاطلاع على ما ستقوم بتحميله لاحقا . في نظام التعليم الالكتروني نوفر هذه الخدمة لكي نبقيك على اطلاع حول محتوى الملف الذي ستقوم بتحميله .