2.03 Trauma and Orthopaedics - The Spine

Question 1

What is the function of the cervical spine?

Answer 1

To support the head and provide mobility.

Question 2

What are the most frequently fractured cervical vertebrae?

Answer 2

1. C2 (~30%)
2. C7 (~20%)

Question 3

Which classification system is most commonly used to describe fractures of the cervical spine?

Answer 3

AO classification

For upper cervical fractures (involving the C1 or C2 vertebrae), the AO system divides them into:

Region(s) involved:
Type 1 = occipital condyle and craniocervical junction
Type 2 = C1 ring and C1/2 joint
Type 3 = C2 and C2/3 joint

Injury type:
Type A = bony injury only
Type B = tension band injuries
Type C = translation injuries.

For subaxial fractures, the AO system divides them into:

Injury type:
Type A = compression injuries
Type B = distraction injuries
Type C = translation injuries
Type F = facet joint injury

Question 4

Outline the typical aetiology of cervical spine fractures in:

a) younger patients

b) older patients

Answer 4

a) usually the result of high-energy trauma

b) usually the result of low impact injuries, particularly if underlying osteoporosis is present

Question 5

How does a cervical spine fracture present? Give the possible complications of cervical spine fractures…

Answer 5

• neck pain
• varying degrees of neurological involvement, depending on level of spinal cord involvement
• posterior circulation stroke (due to injury to vertebral artery)

Question 6

What is a traumatic spinal cord injury?

Answer 6

A traumatic injury leading to damage of the spinal cord, resulting in temporary or permanent change to neurological function, including paralysis.

TSCI can be classified as complete or incomplete:
- a complete injury is damage occurring across the whole spinal cord width, leading to complete loss of sensation and paralysis below the level of injury
- an incomplete injury is the injury spread across part of the spinal cord, only partially affecting sensation or movement below the level of injury

Question 7

What are the differentials for a patient presenting with cervical neck pain?

Answer 7

• cervical fracture
• cervical spondylosis
• cervical dislocation
• whiplash injury

Question 8

Describe the Jefferson fracture.

Answer 8

A fracture of the C1 vertebrae, typically caused by axial loading of the cervical spine resulting in the occipital condyles being driven into the lateral masses of C1.

They are often associated with head injuries, are usually unstable and account for ~33% of all C1 fractures.

Question 9

Describe the Hangman’s fracture.

Answer 9

A fracture of the pars interarticularis of C2 bilaterally, associated with subluxation of the C2 vertebra on C3. They are typically caused by cervical hyperextension and distraction.

Some Hangman’s fractures are unstable.

Question 10

Describe the Odontoid peg fracture.

Answer 10

A fracture of the odontoid peg of C2, common in older patients following low-impact injuries.

The condition is associated with TSCI and fatality, especially with significant displacement of the odontoid; those who survive can have no neurology.

Question 11

What are the Canadian C-spine rules?

Answer 11

Used to stratify the risk of cervical spine injury following trauma in patients who are alert and stable, therefore aiding in deciding any imaging modalities required.

Question 12

Outline the Canadian C-spine rules.

Answer 12

Patients who have a high-risk factor require immediate radiological imaging:
- age ≥65 years
- dangerous mechanism of injiry
- paraesthesia in extremeties

Patients who have a low-risk factor do not require radiological imaging prior to assessment:
- simple rear-end motor vehicle collision
- waiting in a sitting position
- ambulatory patients
- delayed onset neck pain
- absence of midline C-spine tenderness

An assessment of range of motion can then be caried out, if imaging is deemed not required.

Question 13

What investigations are used when cervical spine injury is suspected?

Answer 13

NICE guidelines suggest:
- CT scan in adults, if suggested by Canadian C-spine rules
- MRI in children, if suggested by Canadian C-spine rules

Question 14

How are suspected cervical fractures managed?

Answer 14

Manage as per ATLS guidelines, including 3-point C-spine immobilisation, until any potential injuries have been excluded.

Question 15

How are

a) stable cervical fractures

b) unstable cervical fractures

managed?

Answer 15

Non-operative management can be appropriate for stable injuries:
- rigid collars for immobilisation of the cervical spine during extrication and initial assessment
- halo vests used when more rigid support is needed

Traction devices can be used for definitive treatment when operative treatment is high risk of fraction reduction is required.

Unstable fractures are treated operatively by fusing across the injuries segment of the spine to the uninjured segments above and below.

Question 16

What is degenerative disc disease?

Answer 16

The natural deterioration of the intervertebral disc structure, which that they become progressively weaker and begin to collapse.

Question 17

What are the factors that precipitate damage to intervertebral discs in degenerative disc disease?

Answer 17

Degenerative disc disease is often related to aging:
- progressive dehydration of nucleus pulposus
- daily activities causing tears in the annulus fibrosis
- injuries or pathologies resulting in instability (e.g. spinal fractures, surgery or osteoporosis)

Question 18

What is the pathophysiology of degenerative disc disease?

Answer 18

1. Dysfunction: outer annular tears and separation of the endplate, cartilage destruction, and facet synovial reaction.
2. Instability: disc resorption and loss of disc space height, along with facet capsular laxity, can lead to subluxation and sponylolisthesis
3. Restabilisation: degenerative changes lead to osteophyte formation and canal stenosis

Question 19

What are the clinical features of degenerative disc disease?

Answer 19

Early stage disease symptoms are often localised and the clinical examination may be unremarkable.

Potential signs include local spinal tenderness or contracted paraspinal muscles, hypomobility, or painful extension of the back or neck.

When disc degeneration causes instability, the pain may become more severe and include radicular leg pain or paraesthesia. Pain may be reproduced by passively raising the extended leg (Lasegue’s sign).

Further disease progression may demonstrate signs of worsening muscle tenderness, stiffness, reduced movement, and scoliosis.

Question 20

What are the differentials for degenerative disc disease?

Answer 20

• cauda equina syndrome
• infection
• malignancy

Question 21

Give the red flag signs for back pain.

Answer 21

• new onset incontinence (urinary or faecal)
• saddle anaesthesia
• immunosuppression / chronic steroid use
• IV drug abuse
• unexplained fever
• significant trauma
• osteoporosis
• new onset after 50yo
• history of malignancy

Question 22

What investigations are indicated in patients with back pain?

Answer 22

NICE guidelines suggest imaging should only be used in cases of suspected degenerative disease if:
- red flags present
- radiculopathy with pain ≥6/52
- evidence of spinal cord compression
- imaging would alter management

MRI is gold standard investigation.

Question 23

What is the management of degenerative disc disease?

Answer 23

Adequate pain relief in first instance
- simple analgesics used first line
- neuropathic analgesics as adjuncts if required

Encourage mobility within patient’s limits, with physiotherapy for strengthening exercises.

If pain continues beyond 3 months, refer to pain clinic.

No evidence to support surgical intervention unless CES is suspected (surgical decompression of spinal canal within 48/24 symptom onset).

Question 24

What is radiculopathy?

Answer 24

A conduction block in the axons of a spinal nerve or its roots, with impact on motor axons causing weakness and on sensory axons causing paraesthesia / anaesthesia.

Question 25

What is the difference between radiculopathy and radicular pain?

Answer 25

Radicular pain is pain deriving from damage or irritation of the spinal nerve tissue particularly in the dorsal root ganglion.

Radiculopathy is a state of neurological loss, and may or may not be associated with radicular pain.

Question 26

Outline the aetiology of radiculopathy.

Answer 26

Most commonly a result of nerve compression, which can be caused by:
- intervertebral disc prolapse
- degenerative diseases of the spine
- fracture
- malignancy
- infection (e.g. Pott’s disease)

Question 27

What are the red flag features of CES?

Answer 27

• faecal incontinence
• urinary retention (painless, with secondary overflow incontinence)
• saddle anaesthesia

Question 28

What are the red flag features of spinal infection?

Answer 28

• immunosuppression
• IV drug abuse
• unexplained fever

Question 29

What are the red flag features of spinal fracture?

Answer 29

• chronic steroid use
• significant trauma
• osteoporosis or metabolic bone disease

Question 30

What are the red flag features of spinal malignancy?

Answer 30

• new onset radiculopathy after 50yo.
• history of malignancy

Question 31

What are the differentials for radiculopathy?

Answer 31

• referred pain
• iliotibial band syndrome
• meralgia paraesthetica
• piriformis syndrome

Question 32

How is radiculopathy managed?

Answer 32

Definitive long-term management depends on the underlying cause.

Symptomatic management includes:
- analgesia (incl. neuropathic pain medications)
- amitriptyline, pregabalin or benzodiazapenes
- physiotherapy

Question 33

What is the most commonly fractures region of the spine?

Answer 33

Fracture at the thoracolumbar junction (T11-L2)

Question 34

Describe the three columns, which are important to consider when assessing the stability of a spinal fracture.

Answer 34

Anterior column: anterior longitudinal ligament and the anterior half of the vertebral body and disc.

Middle column: posterior half of the vertebral body and disc, and posterior longitudinal ligament.

Posterior column: comprised of posterior elements (posterior ligamentous complex) and intervening vertebral arches.

Question 35

What is a burst spinal fracture?

Answer 35

When there is substantial compressive force acting through the anterior and middle column of the vertebrae, bone is retropulsed into the spinal canal. This can cause TSCI.

Question 36

What is a chance spinal fracture?

Answer 36

When the spine is excessively flexed (e.g. head on RTA when affected person is wearing only a lap belt) all three spinal columns fracture. They are unstable and need surgical intervention to stabilise.

Question 37

What are the clinical features of a thoracolumbar fracture?

Answer 37

Result of high-energy trauma in younger patients; result of low-energy trauma in older patients with underlying osteoporosis.

Patients most commonly present with back pain, and there may be varying degrees of neurological involvement (including TSCI).

Question 38

What investigations should be completed if a thoracolumbar fracture is suspected?

Answer 38

• plain film radiograph
• CT scan if radiograph is abnormal or if Canadian C-spine rules indicate
• if a new spinal column fracture is confirmed, image the rest of the spinal column

Question 39

How is thoracolumbar fracture initially managed?

Answer 39

Managed as per ATLS guidance, including appropriate immobilisation to prevent further damage.

Question 40

How is thoracolumbar fracture definitively managed?

Answer 40

Calculate Thoraco-Lumbar Injury Classification and Severity (TLICS) score to quantify the likelihood of instability.

If stable # (TLICS<3) treat conservatively:
- extension bracing
- lumbar corsets
- adequate analgesia and physiotherapy

If unstable # (TLICS) treat surgically:
- decompression
- instrumented spinal fusion