Lower Cervical Spine

Injuries
Prepared by dr. Hunar Abdulkhalq
3rd Stage KBMS
Trainee
Supervised by dr. Omar Barawi
21- 4 - 2015

Lower Cervical Spine

Injuries
It means injury to
C3 to C7 levels

3
4
5
6
7

Depending on the mechanism of injury

there will be characteristic injury
: patterns
Posterior Ligament Injury
Wedge compression fracture
Burst and Compression-flexion (tear-drop)
fractures
Fracture-dislocations
Hyperextension injury
Double injuries
Cervical disc herniation
Neurapraxia of the cervical cord
Sprained neck (Whiplash Injury).

Posterior Ligament Injury

Posterior ligament
complex
(Interspinous lig. ,
facet capsule and
supraspinous lig.)
Sudden flexion of
the mid-cervical
spine

Clinical Features
Pain
Localized
tenderness
posteriorly
X-ray :
The upper vertebra
tilts forward on the
one below, opening
up the interspinous
space posteriorly.

Signs Of Instability
1. Angulation of the vertebral body
with its neighbour exceeds 11
degrees.
2. Anterior translation of one vertebral
body upon the other of more than
3.5 mm
3. Facets are fractured or displaced

Management
Stable injuries
Semi-rigid collar/6 wk

Unstable injuries
Posterior fixation+
fusion

Wedge Compression Fracture

Pure flexion injury
Wedge compression
facture of the
vertebral body
Middle and posterior
elements remain
intact
Stable
Treatment /
comfortable collar for
6 12 weeks.

Burst And Compression-Flexion

(tear-drop) Fractures
Axial compression such as in
diving
If the vertebral body is crushed
in neutral position of the neck
the result is a burst fracture.
With combined axial
compression and flexion, an
antero-inferior fragment of the
vertebral body is sheared off,
producing tear-drop on the
lateral x-ray.
In both types of fracture
there is a risk of posterior
displacement of the
vertebral body fragment and
spinal cord injury.

 The x-ray images

should be carefully
examined for evidence
of middle column
damage.
Traction must be
applied immediately
CT or MRI should be
performed to look for
retropulsion of bone
fragments into the
spinal canal.

Treatment
No neurological deficit:
Conservative treatment:
weeks 42
86
weeks

Surgical Treatment

Urgent anterior decompression+ Fixation:

If any deterioration of neurological status
fracture is unstable
MRI shows that there is a threat of cord compression.

Fracture-dislocations
Bilateral facet joint
dislocations :
caused by severe flexion or
flexionrotation injuries.
The inferior articular facets of
one vertebra ride forward over
the superior facets of the
vertebra below.
One or both of the articular
masses may be fractured or
there may be a pure dislocation
jumped facets.
The posterior ligaments are
ruptured and the spine is
unstable; often there is cord
damage.

 The displacement must be reduced as a matter of

urgency.
Skull traction is used, starting with 5 kg and
increasing it step-wise by similar amounts up to
about 30kg; intravenous muscle relaxants.
The entire procedure should be done without
anaesthesia (or under mild sedation only) and
neurological examination should be repeated after
each incremental step.
If neuro - logical symptoms or signs develop, or
increase, further attempts at closed reduction
should be stopped.

 When x-rays show that the dislocation has

been reduced, traction is diminished to about 5
kg and then maintained for 6 weeks.
During this time MRI can be performed to rule
out the presence of an associated disc
disruption.
At the end of that period the patient should still
wear a collar for another 6 weeks; however, it
may be more convenient to immobilize the
neck in a halo-vest for 12 weeks.

 Another alternative is to carry out a

posterior fusion as soon as reduction
has been achieved; the patient is
then allowed up in a cervical brace
which is worn for 68 weeks.
Posterior open reduction and fusion
is also indicated if closed reduction
fails.

Unilateral facet dislocation

Flexionrotation
Only one apophyseal joint is
dislocated.
Associated fracture of the
facet
Lateral x-ray the vertebral
body appears to be partially
displaced (less than one-half
of its width).
the anteroposterior x-ray the
alignment of the spinous
processes is distorted.
Cord damage is unusual.
Injury is stable.

 Management is the same as for

bilateral dislocation.
Immobilize neck in a halo-vest for 68
weeks after reduction.
in about 50 per cent of the patients
surgery may still have to be considered
at the end of this period.
If closed reduction fails, open reduction
and posterior fixation are advisable.

Hyperextension injury
Ranges from hyperextension
strains of soft-tissue structures
(common) to bone and joint
disruptions (rare).
The posterior bone elements are
compressed and may fracture;
the anterior structures fail in
tension, with tearing of the
anterior longitudinal ligament or
an avulsion fracture of the
anterosuperior or anteroinferior
edge of the vertebral body,
opening up of the anterior part of
the disc space, fracture of the
back of the vertebral body and/or
damage to the intervertebral
disc.

 In patients with pre-existing

cervical spondylosis, the
cord can be pinched
between the bony spurs or
disc and the posterior
ligamentum flavum; oedema
and haematomyelia may
cause an acute central cord
syndrome (quadriplegia,
sacral sparing and more
upper limb than lower limb
deficit, a flaccid upper limb
paralysis and spastic lower
limb paralysis).

 These injuries are stable in the neutral

position, in which they should be held
by a collar for 68 weeks.

Healing may lead to spontaneous fusion

between adjacent vertebral bodies.

Double injuries
With high-energy trauma the cervical
spine may be injured at more than
one level.

Cervical disc herniation

Acute post-traumatic disc herniation may cause
severe pain radiating to one or both upper limbs.
neurological symptoms and signs ranging from mild
paraesthesia to weakness, loss of a reflex and
blunted sensation.
The diagnosis is confirmed by MRI or CT-myelography.
Sudden paresis will need immediate surgical
decompression.
With lesser symptoms and signs, one can afford to
wait a few days for improvement; if this does not
occur, then anterior discectomy and interbody fusion
will be needed.

Neurapraxia of the cervical cord

Accidents causing sudden, severe axial loading with the neck
in hyperflexion or hyperextension are occasionally followed
by transient pain, paraesthesia and weakness in the arms or
legs, all in the absence of any x-ray or MRI abnormality.
Symptoms may last for as little as a few minutes or as long
as two or three days.
Ascribed to pinching of the cord by the bony edges of the
mobile spinal canal and/or local compression by infolding of
the posterior longitudinal ligament or the ligamentum
flavum.
Treatment consists of reassurance (after full neurological
investigation) and graded exercises to improve strength in
the neck muscles.

SPRAINED NECK (WHIPLASH

INJURY)
Soft-tissue sprains of the
neck are common after
motor vehicle accidents
Head flips backwards and
then recoils in flexion.
Women are affected more
often than men.
There is no correlation
between the amount of
damage to the vehicle and
the severity of complaints.

Clinical features
Often the victim is unaware of any abnormality immediately
after the collision.
Pain and stiffness of the neck usually appear within the next
1248 hours, or occasionally only several days later.
Pain sometimes radiates to the shoulders or interscapular area
and may be accompanied by other, more ill-defined, symptoms
such as headache, dizziness, blurring of vision, paraesthesia in
the arms, temporomandibular discomfort and tinnitus.
Neck muscles are tender and movements often restricted; the
occasional patient may present with a skew neck.
Other physical signs including neurological defects are
uncommon.
X-ray examination may show straightening out of the normal
cervical lordosis.

 Examination is not indicated except in

patients with convincing neurological
signs.

Differential diagnosis
Diagnosis is by a process of exclusion.
X-rays should be carefully scrutinized to avoid
missing a vertebral fracture or a mid-cervical
subluxation.
The presence of neurological signs such as muscle
weakness and wasting, a depressed reflex or
definite loss of sensibility should suggest an acute
disc lesion and is an indication for MRI.
Seat-belt injuries often accompany neck sprains,
but they can produce pressure or traction injuries
of the suprascapular nerve or the brachial plexus.

Treatment
Simple pain-relieving measures, including
analgesic medication
Graded exercises, beginning with isometric
muscle contractions and postural
adjustments, then going on gradually to
active movements and lastly movements
against resistance.
The range of movement in each direction
is slowly increased without subjecting the
patient to unnecessary pain.

THANK
YOU

Avulsion injury of the spinous

process

Fracture of the C7 spinous process may occur with

severe voluntary contraction of the muscles at the back
of the neck; it is known as the clay-shovellers fracture.

The injury is painful but harmless. No treatment is

required; as soon as symptoms permit, neck exercises
are encouraged.