Cervical Spine Trauma

Front 1

What is the incidence of spinal cord injuries a year?

Back 1

7000-10,000 injuries a year

Front 2

What percent of all trauma victims suffer from C Spine Injuries?

Back 2

2.60%

Front 3

What percent of all C spine injuries suffer a delay in diagnosis?

Back 3

23%

Front 4

Of all the spinal cord injuries a year, how many involve the cervical spine?

Back 4

5,000

Front 5

What is the demographic of C spine injuries?

Back 5

82% are male, usually between 16-30 years old (there is a 2nd smaller peak over 55 years of age)

Front 6

Lower cervical spine injuries (C3-7) account for what percent of all C spine frx?

Back 6

80%

Front 7

Upper cervical spine (c1-2) account for what percent of all C spine frx?

Back 7

20%

Front 8

What percent of C Spine Injuries suffer neurologic injury?

Back 8

up to 47%

Front 9

What type of frx is the most common of all spine frx?

Back 9

Flexion Type

Front 10

What type of frx accounts for about 46% of all C spine frx?

Back 10

Hyperflexion

Front 11

What percent of spine injuries in children occur in the UPPER cervical spine?

Back 11

60%

Front 12

C Spinal cord injury increases with what 6 demographic facts?

Back 12

1. increased daylight hours 2. increased temps 3. Summer Seasonal Activities 4. Outdoor sports activity 5. June, July, August account for 31.9% 6. Weekends (fri thru sat) account for 53.1%

Front 13

What percent of C spine injuries occur in June, July and August?

Back 13

31.90%

Front 14

What percent of C spine injuries occur during the weekends (fri thru sun.)?

Back 14

53.10%

Front 15

What is responsible for 42-56% of all C spine injuries?

Back 15

MVA

Front 16

What percent of C spine injuries are due to fall from a height?

Back 16

19-30%

Front 17

What percent of C spine injuries are due to gunshots?

Back 17

12-21%

Front 18

What percent of C spine injuries are due to sports-related activities?

Back 18

6-7%

Front 19

SC injuries occur in what percent of pts with spinal fractures?

Back 19

10-20%

Front 20

SC injuries occur in what percent of pts with C vertebral injuries?

Back 20

50%

Front 21

What are four probs with patients who are squirrels?

Back 21

1. difficult to evaluate 2. unreliable historians 3. usually noncompliant 4. often fail to disclose their injuries

Front 22

What is the definition for STABLE?

Back 22

condition of the spine in which, under normal physiologica loading, there is neither abnormal strain nor excessive abnormal motion

Front 23

What is the definition for UNSTABLE?

Back 23

condition in which anatomic elements of the spine are disrupted, causing deformity. The spine can no longer maintain normal alignment, protect the spinal cord, support the body in an upright position, or allow normal motion.

Front 24

What are 5 HYPERflexion injuries?

Back 24

FSCAB--- FLEXION tear drop, Simple wedge compression frx, Clay shovelers fx, Anterior Subluxation, Bilateral facet dislocation

Front 25

___________ results in distraction of the posterior and middle columns and compression of the anterior column.

Back 25

Hyperflexion

Front 26

Hyperflexion + Rotation =

Back 26

UNIlateral facet dislocation

Front 27

What are 6 HYPERextension Injuries?

Back 27

LEFT HA! 1. Laminar Fx 2. Extension Tear Drop Fx 3. Fracture Posterior arch C1 4. Traumatic Spondylolisthesis (HANGMAN's fx) 5. Hyperextension Dislxn 6. Avulsion Fx, anterior arch C1

Front 28

HyperEXTENSION + Lateral Tilt =

Back 28

Pillar Fx, Pedicolaminar Fx

Front 29

What are 2 examples of Vertical Compression (Axial Load)?

Back 29

Jefferson Fx, Burst Fx of lower C spine

Front 30

Axial loading frx occur only in those segments of the spine that can _________________.

Back 30

be voluntarily STRAIGHTENED. Frx occurs at the PRECISE instant the spine is straight.

Front 31

What extends from basi-occiput to the C2 interspace?

Back 31

Cervicocranium

Front 32

What fxs are NOT visible on lateral x-ray b/c of superimposed skeletal parts?

Back 32

Occiptal Condylar and Lateral Mass of C1

Front 33

Give 6 Cervicocranium injuries.

Back 33

1. Occipitoatlantal subluxation 2. Occipital Condylar Fx 3. Lateral mass, C1 fx 4. Jefferson Burst Fx 5. Traumatic Rupture TAL 6. Dens Fx (types I, II, III)

Front 34

________________ result in distraction of the anterior and middle columns and compression of the posterior.

Back 34

Hyperextension.

Front 35

What are the 3 Cervical Spine views?

Back 35

Lateral, AP, and Open Mouth

Front 36

When is a Swimmers View implicated?

Back 36

when you can not see C7-T1 interspace

Front 37

The canal of an Adult should be at least ____________.

Back 37

13-15 mm

Front 38

If you have a pt with a canal less than 9 mm than you should think…..

Back 38

Stenosis

Front 39

Soft Tissue for C2-C4 should be what measurement?

Back 39

less than 7 mm

Front 40

Soft Tissue for C5-C7 should be what measurement?

Back 40

less than 22 (14 mm for children)

Front 41

What is the Rule of Spence?

Back 41

in the open mouth odontoid view, displacement of the lateral masses of C1 on C2 over 6.9 mm implies ruptured TRANSVERSE LIG of the dens

Front 42

What is the purpose of the Transverse lig of the dens?

Back 42

to hold the dens against arch of C1

Front 43

What is used to measure AtlantoOccipital Dissociation?

Back 43

Clivus Base Line (Basilar Line Wackenheim) and Powers Ration

Front 44

How do measure Clivus Base Line (Basilar Line Wackenheim)?

Back 44

straight line drawn down thru the foramen magnum anterior border (Basion) and should hit posterior 1/3 of the dens.

Front 45

What is the Basion?

Back 45

Anterior aspect of the Foramen Magnum

Front 46

what is the Opsithion?

Back 46

Posterior aspect of the Foramen Magnum

Front 47

How do you measure for the Power's Ratio?

Back 47

2 lines 1. from Basion to Spinolaminar line of C1 2. Opisthion to Posterior cortest of C1 anterior arch---------ratio should be 1:1

Front 48

What is the normal Pre-dental space for adults?

Back 48

less than 3 mm

Front 49

What is the normal Pre-dental space for a child?

Back 49

4-5 mm

Front 50

What is the name of the method when you use 2 colums, Anterior and Posterior to determine stability?

Back 50

Mechanical Stability

Front 51

What is in the Anterior column when determining stability?

Back 51

1. Vertebral Body 2. Disks 3. Anter. And Post longitudinal lig.

Front 52

What is in the Posterior Column when determining stability?

Back 52

Pedicles, Laminae, Articulating Facets, Spinous processes, nuchal ligaments and Capsular and lig flavum

Front 53

What is the 3 Column Model Stability?

Back 53

Anterior Column (ALL, ant. Annulus fibrosus, Ant. VB), Middle Column (PLL, Post Annulus, Post VB) and Posterior Column (Posterior Arch, Ligs, Facets)

Front 54

List 8 UNSTABLE injuries.

Back 54

1. Bilateral Facet Dislocation 2. Flex/Ext Tear Drop Fx 3. Hangman's Fx 4. Jefferson Fx 5. Hyperextension Fx/dislxn 6. Cervicocranial Dislxn 7. Den Fx (Type II) 8. Burst Fx

Front 55

Estimated that ______________ pts immobilized at a cost of $75 million/yr in the US.

Back 55

5 million

Front 56

How many C spine xray were taken a year? (before the Nexus study) and how much did this cost?

Back 56

800,000 C-spine xrays a year taken by 25,000 ER physicians at 180 million dollars a year

Front 57

Before the Nexus study came along, how many thyroid cancers were caused by the unnecessary radiation?

Back 57

3,760 Thyroid cancers

Front 58

What were the benefits of the Nexus Study?

Back 58

Saved 100 million a year!!! Plus 474 fewer thyroid cancers

Front 59

What are the 5 Clinical criteria to rule out need for xray?

Back 59

1. No posterior MIDLINE tenderness 2. No focal neuro deficit 3. Normal level of alertness 4. No evidence of intoxication 5. No distracting injury

Front 60

Where do you measure for posterior midline tenderness?

Back 60

from the nuchal ridge to T1

Front 61

How many patients were involved in the Nexus?

Back 61

34, 000 patients and only 818 of them needed the Xray----so ONLY 2.4% had positive xrays

Front 62

What was the Negative Predictive Value of the Nexus Study?

Back 62

99.80%

Front 63

What is the overall rate of missed CSI?

Back 63

less than 1 in 4000

Front 64

The Nexus criteria decreased xray used by _____________%.

Back 64

12.6 % (100,000 exams annually)

Front 65

What are the 5 goals of treatment?

Back 65

Realign, prevent loss of fxn of undamaged part, improve neuro recovery, obtain/maintain spinal stability, obtain early fxnl recovery

Front 66

What are 6 Indications for Surgery?

Back 66

1. Failure to obtain reduction (normal position) 2. failure to maintain reduction 3. pseudoarthrosis 4. purely ligamentous injury 5. Re-subluxation 6. Any patient with jumped facets (Cooper)

Front 67

What is the gold standard for cervical orthotics?

Back 67

Halo Vest (flex/ext 4-10) (Lateral 4-10) (Rotation 1-2.5)

Front 68

What cervical orthotic reduces flexion but is otherwise USELESS?

Back 68

Philadelphia Collar (Flex/Ext 30) ( Lateral 66) (Rotation 45)

Front 69

What is the best way to immobilize UPPER segments C spine (C1-4)?

Back 69

Halo Vest (flex/ext 4-10) (Lateral 4-10) (Rotation 1-2.5)

Front 70

What percent of patients with a Halo fail therapy and will need surgery?

Back 70

10-15%

Front 71

What percent of patients with Lower C spine injury will failure therapy with a Halo Vest?

Back 71

25%

Front 72

_____________ should NEVER be treated with Halo Vests.

Back 72

Ligamentous Injury

Front 73

What is an Anterior Subluxation?

Back 73

Soft Tissue injury and disruption post. Ligamentous comples, post. IV disc. LOWER C spine. Stable b/c ALL is intact

Front 74

What is it called when you have a Compression posterior arch C1 and it causes a fx btwn Occipital CONDYLES and C2 spinous process?

Back 74

Atlas Frx (Post. Neural Arch C1)

Front 75

30-50% of Atlas Frx are associated with what??

Back 75

C2 Dens Fx

Front 76

What is an Oblique/Vertical frx of the spinous process?

Back 76

Clay Shoveller's Frx

Front 77

How does one get a Clay Shoveller's Fx?

Back 77

acute powerful Flexion, C7 most, then C6, then T1

Front 78

How is Clay Shovellers considered to be Stable??

Back 78

PLC is still intact

Front 79

What is it called to have extreme flexion head-neuro injury causing extensive disruption of PLC?

Back 79

Bilateral Facet dislxn

Front 80

With Bilateral Facet Dislocation you have complete disruption of what?

Back 80

PLC, PLL, Annulus Fibrosis

Front 81

What is the KEY TO DIAGNOSIS for Bilateral Facet Dislocation/ LOCKED?

Back 81

Anterior Displacement of 50% of the VB

Front 82

When looking at an xray for Bilateral Facet Dislocation what wil you see?

Back 82

Anterior Displacement of 50% of the VB and fanning of the interspinous proces

Front 83

At what Vertebrae does the Vertebral A enter at?

Back 83

C6

Front 84

What is the most severe and most unstable of injuries?

Back 84

Flexion Tear Drop Fx

Front 85

What would forceful Flexion and Axial Compression cause?

Back 85

Flexion Tear Drop Fx

Front 86

What happens with Flexion Tear Drop Fx?

Back 86

Posterior displacement VB into spinal canal and frx to posterior elements, disruption of lig. Flavum, shear stress ant column, All rupture and avulse tear drop

Front 87

What type of syndrome is commonly seen with Flexion Tear Drop Fx?

Back 87

Anterior Cord Syndrome to Quadriplegia

Front 88

What type of fx is commonly assoc. with diving in a pool?

Back 88

Flexion Tear Drop Fx

Front 89

What is the Classification of Anderson and D'Alonzo used for?

Back 89

to classify Odontoid Fxs

Front 90

What type of injury is an Odontoid Fx?

Back 90

Flexion

Front 91

What Odontoid Fx is considered to be UNSTABLE?

Back 91

Type II

Front 92

Type II Odontoid Fx are unstable with nonunion in what percent of cases?

Back 92

35-85%

Front 93

What percent of all C spine frxs involve the dens?

Back 93

10-15%

Front 94

2/3 of dens fractures are _______________.

Back 94

Type II

Front 95

Who is at risk for NON union from an Odontoid Frx Type II?

Back 95

more than 6 mm displacement, more than 50 yrs old, smokers, angulation

Front 96

What percent of type II frx have a C1 ring frx?

Back 96

16%

Front 97

The Atlantal-Dens interval should be less than ____________.

Back 97

3 mm

Front 98

What ligament is disrupted with Odontoid Fx?

Back 98

Transverse Lig. Of Dens

Front 99

What type of Fx occurs when you have the ALL avulses tear drop from ant inf. Body

Back 99

Extension Tear Drop Frx

Front 100

Extension tear Drop Fx can be assoc. with _____________syndrome.

Back 100

Central Cord Syndrome

Front 101

Where do Extension Tear Drop Frx occur and in who?

Back 101

occur at C2 or C3 and in older patients

Front 102

Hyperextension + Distraction=

Back 102

HANGMANS! Bilateral Frx thru pedicles of axis with ant. Dislocation of body and tearing of Spinal cord

Front 103

Type II and Type III Hangman Frx involve what?

Back 103

Discs

Front 104

What kind of damage is seen with Hangman fx?

Back 104

1. Pars Interarticularis Fx 2. Prevertebral Soft Tissue Swelling 3. Anterior Dislocation of VB

Front 105

What type of frx results in bilateral, symmetrical frxs of the ANT and POST arches of C1 and disruption of Transverse Lig of Dens?

Back 105

Jefferson Fx

Front 106

What is a Burst Frx of C1?

Back 106

Jefferson Fx

Front 107

What is the mechanism of A Jefferson Fx?

Back 107

blow to vertex- axial force transmitted thru condyles into sup. Surface lateral masses of atlas- drives lateral masses outward.

Front 108

With a Jefferson Frx, the total overhang of C1 lateral masses on C2 more than 7 mm in open mouth implies what?

Back 108

disrupted transverse lig

Front 109

What is identical to Jefferson Frx but occurs in LOWER C spine (C2-C7)?

Back 109

Burst Frx

Front 110

What would cause the Nucleus Pulposus to drive thru the frxed vertebral endplate into the VB, and the body thus explodes and results in comminuited fx?

Back 110

Burst Frx

Front 111

Burst Frx causes what to happen?

Back 111

Post fragment displaced into canal

Front 112

What type of C spine injury is usually fatal and is due to all of the major ligaments disrupted?

Back 112

Atlanto-Occipital Dislocation

Front 113

How is SCIWORA possible?

Back 113

Inherent elasticity of juvenile spine

Front 114

What is the age range for SCIWORA?

Back 114

1.5 to 16 years

Front 115

What is the percent of possible repeat injury in less than 10 weeks from primary injury?

Back 115

20% (Girlford Brace)

Front 116

What percent of patients have a delayed onset of neuro abnormalities and may not occur for 4-5 days after injury?

Back 116

30%

Front 117

What Syndrome has complete motor paralysis below lesion, loss of ant. Column sensation due to injury of ANTERIOR spinal Artery?

Back 117

Anterior Cord Syndrome

Front 118

What is a Hyperextension Injury that causes bulging of ligamentum flavum into a narrow canal?

Back 118

Central Cord Syndrome

Front 119

What do you think if a patient walks in with upper extremity weakness?

Back 119

Central Cord Syndrome

Front 120

What age tends to be vulnerable to Central Cord Syndrome?

Back 120

over 50

Front 121

What is the prognosis of Central Cord Syndrome?

Back 121

more than 50% are left with deficits ;(

Front 122

What presents with Ipsi motor loss, ipsi loss touch/propioception, and contra loss of P and T sensation?

Back 122

Brown Sequard Syndrome

Front 123

Missed Spinal Fractures are responsible for ____________ malpractice claims.

Back 123

3%

Front 124

Spinal Cord injuries account for ____________ total dollars paid in claims.

Back 124

more than 9%

Front 125

_____________ % spinal cord injuries occur after the initial traumatic insult.

Back 125

3-25% spinal cord injuries

Front 126

______________ % spinal cord injuries occurred or exaberated following initiation of medical care.

Back 126

10%