Lect. 4 Cervical Spine
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- C_ (____): supports head, arches from bony ring
-C_(____): Dens; privot point on which head rotates
-C_-C_: share similar osseous features
- -C1 (atlas)
- -C2 (axis)
T or F: ligaments show up on radiographs
F: can be directly assessed on X-rays/indirectly assessed by looking at relationship of joints (i.e. loss of normal articular relationship implies loss of ligament support.)
___ has been found to be more specific than plain radiographs at detecting subtle injuries.
___ recommended if neurological deficit is present. Can demonstrate "position of bony fragment...injury to spinal cord, disk, and soft tissue in same exam.
____ not indicated in patients with significant injury and other imaging is available (fracture, dislocation, instability)
_______ __-Spine Rules:
-applies to patients who are alert and stable
-designed t ohelp clinicians determine if radiographs are necessary for patients who have sustained traumatic injury to head or neck.
-Meant to identify "clinically important cervical spine injry, defined as fracture, dislocation, or ligamentous instability demonstraded by diagnostic imaging.
Canadian C-spine rules
1. Are there high risk factors
-age greater than ____ or
-paresthesias in extremities or
-dangerous mechanism of injury
-fall from >_m or __stairs
-MVA at speeds >__mph or involving rollover/ejection
-motorized recreational acccident
__ or more high risk factors present= radiographs required
- -greater than 65
- -fall from >1m or 5 stairs
- -MVA at speeds >60
- 1 or more high risk factors present=radiographs required
2. Are ther any low risk factors that permit safe AROM?
-Able to assume sitting position in ER or
-ambulatory at any time or
-onset of neck pain not immediate or
-absence of tenderness in C-spine or
-MVA that does not include any of the following
-pushed into oncoming traffic
-hit by bus or large truck
-hit by high speed vehicle
Cannot Assess ROM= _______ required
Cannot assess ROM= radiographs required
3. Can the patient actively rotate the neck __ degrees in both directions?
If yes= no radiographs required
If no= radiographs required
Nexus Low Risk Criteria: developed to identify patients who do not need diagnostic imaging for C-spine. Imaging is required unless patient meets all 5 of the following criteria.
1. No posterior midline _______ tenderness
2. No evidence of ______>
3. Normal level of alertness and ______.
4. No focal _______ deficit.
5. No painful ______ injuries.
- 1. NO posterior midline cervical tenderness
- 2. No evidence of intoxication
- 3. Normal level of alertness and consciousness
- 4. No focal neurological deficits
- 5. No painful distracting injuries
Routine Radiological Eval of C-spine
____ view: 5 lower cervical vert, upper thoracic vert and associated ribs, medial 3rd of clavicles, and trachea.
•______ views –7 cerv vert, intervertebral disk spaces, articular pillars, facet joints, spinous processes, and paravertebral soft tissues.
- 1. A-P view
- 2. lateral view
•A-P ____ ____ – C1 and C2, dens
•A-P or P-A ______ views –IV foramina, uncovertebral joints, facet joints, and pedicles
•Lateral flexion and extension stress views—look for ______ ______.
•_______ Lateral –Reveals C7, T1, T2
- -open mouth- C1 C2 and dens
- -oblique: IV foramina, uncovertebral joints, facet joints, and pedicles
- -latera flexion and extension look for joint instabilities
- -Swimmer's lateral reveals C7, T1, T2
- 1. anterior vertebral line
- 2. Posterior vertebral line
- 3. spino-laminar line
- 4. posterior spinous line
Radiological Signs of Cervical Trauma (3 total)
1. Abnormal _____ ____: widened retropharyngeal or retrotracheal space; displacement of paravertebral fat pad; tracheal or laryngeal displacement *** sugges presence of ___ or ____.
2. Abnormal _____ alignment: loss of parallel outline on lateral view; loss of lordosis; acute kyphotic angulation c widened interspinous space; rotation of vertebral body.
3. Abnormal _____ relationships: widened atlantodental space (damage to _____ ligament); widened interspinous space; widened IV disk space; narrowed IV disk space; loss of facet jt. articulation.
- 1. Abnorma Soft Tissue: suggests presence of hemorrhage or edema
- 2. Abnormal Vertebral alignment
- 3. Abnormal joint relationships: damage to transverse ligament
Upper Cervical Fractures:
C1: ______ fracture: fracture of anterior and posterior arch of C1, results of compression force such as diving head first in shallow water.
C2: _____ fracture: 3 types, classified as stable or unstable
C2: _____ fracture: fracture of pedicles of the axis, can cause dislocatoin of C2 on C3. Hyperextension injury
- C1: Jefferson's Fracture
- C2: Odontoid Fracture
- C2: Hangman's Fracture
Odontoid Fractures :3 types
Type __: upper dens: oblique (8%)
Type__: base of dens; transverse (59%)
Type __: body of axis, facets (33%)
- Type I: upper dens/oblique
- TypeII: base of dens/transverse
- Type III: body of axis/facets
Conditions with Atlanto-Axial Issues: there are 6 (4 are reasonable and the last two are dumb)
- Down syndrome
- Rheumatoid arthritis
- ankylosing spondylitis
- marfan syndrome
- post trauma
- post surgical intervention/failure
_____ ____ ____: common in most people over 60; breakdown of intervertebral disk; imaging shows hallmark sign of decreased disk space, may have Schmorll's nodes, osteophytes at uncovertebral joints and vertebral endplates, and vacuum deformity.
Degenerative Disk Disease (DDD)
______ ______ disease: OA changes to facet joints; imaging hallmarks include decreased joint space, subchondral sclerosis and osteophytes
Degenerative joint disease
______ Encroachment: narrowing of intervertebral foramen as a result of degenerative changes of surrounding structures (DDD and/or DJD); nerve root can become compressed.
______ ______: formation of osteophytes in response to DDD; predominate location of osteophytes at areas with greater segmental mobility (C4-5, C5-6)
________ of C-spine: used for cervical trauma; shows bony injury, degree of displacement, soft tissue and spinal cord injury; most common Sagittal SE T1 and T2
MRI of C-spine
Thoracic Spine: Acute LBP clincial findings
-presence of ___ ___.
-No response to __ weeks of PT intervention.
in the presence of these radiographs are indicated
- -presence of red flags
- -no response to 3 weeks of PT intervention
___: shows all 12 vertebrae, vertebral end plates, pedicles, IV disk spaces.
___: reveals all but upper 2 or 3 vertebrae, vertebral bodies, and IV disk spaces
_____ ____: (position shoulder overhead): may be done to reveal upper thoracic vertebrae.
- -Swimmer's shoulder
______ vertebral body compression fractures: most common spinal injury detected on radiographs; comprise majority of vertebral fractures in thos over 60; pre-existing osteoporosis is a contributing factor; _____ forces causes 90% of this type of fx, and remaining 10% from fall or MVA.
Anterior vert body compression fx's
_______ disease: common in adolescent boys and girls; symptoms of backache and thoracic kyphosis from osteochondrosis; schmorl's nodes are consistent finding.
Lumbar Spine Views:
__: shows all 5 vertebral bodies
___: shows alignment of lumbar vert and IV disk spaces
__ and __ ____: show facet articulations, pedicles, pars (___ __ fx's). These have high levels of gonadal radiation!
- A/P and P/A oblique (scotty dog fx)
Scotty Dog Fx: in an oblique view of a normal lumbar spine, the outline of a scotty dog can be seen.
-the _____ process is the nose
-the ______ is the eye
-the ___ ______ is the neck
- the _____ articular facet is the ear.
- the _____ articualr facet is the front leg.
- -transverse process is the nose
- -pedicle is the eye
- -pars interarticularis is the neck
- -superior articular face is the ear
- -inferior articular facet is the front leg
Degenerative Conditions of Lumbar Spine:
______: formation of osteophytes in response to DDD.
______: defect in pars interarticularis (scotty dog fx)
______: forward displacement of vertebra. Can result from degenerative changes and/or fracture.
_____ ____: central, intervertebral foramen, lateral or sub-articular recesses.
- -spondylosis: formation of osteophytes in response to DDD
- -Spondylysis: defect in pars interarticularis
- -spondylolisthesis: forward displacement of vertebra
- -spinal stenosis
IVT ____ ____: protrusion of disk material through annulus; conventional radiographs poor at showing disk material but will show chronic changes to bone such as jt space changes, spondylosis, osteophytes vaccum sign and Schmorl's nodes.
___ myelography excellent for showing anatomic detail and ____ excellent at showing morphological and physiochemical changes of disk.
- IVT disk herniation
- CT myelography
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