B8-9. Cervical Trauma Flashcards
What are the most frequent cervical injuries in athletes?
- acute sprains and strains
- contusions
Pain (sometimes burning and stiffness are often the main complaints with what cervical injury?
Acute cervical strain
A jammed-neck sensation and localized (sometimes sharp) pain are often the pain complaints with what cervical injury?
Acute cervical sprain
What is the symptom progression of a cervical sprain/strain?
- Immediate pain at the time of injury that subsides after a few minutes
- pain, swelling and tenderness with restricted motion that peaks several hours later or following day
- referred pain into occipital area
What finding is more common with traumatic sprains/strains, Torticollis or decreased ROM?
Decreased ROM
What should be done is there is evidence of ligamentous instability in the cervical spine following injury?
Rigid collar
When should flexion-extension x-rays be taken of the spine following a cervical sprain/strain injury if ligamentous injuries are suspected?
May need to wait up to 2-3 weeks for muscle spams and splinting to resolve. During the acute phase, the splinting and spasms can cause a temporary loss of cervical lordosis
What are the three common mechanisms of macro trauma to the cervical spine?
- flexion/extension injury
- compressive injury to top of head
- lateral flexion injury
What are the exam findings for a cervical sprain?
- observation is unremarkable with some swelling and bruising
- AROM is painful
- neck muscle test are painless (except in set phase)
- PROM is painful before end range
- tender palpation over supraspinous ligament
Horizontal movement of one vertebral body on the next should not exceed ____.
3.5 mm
What is the upper limit of normal C1-C2 translation in an adult?
2.5 mm
What is the upper limit of normal C1-C2 translation in a child?
4.5 mm
What are the exam findings for a cervical strain?
- observation is unremarkable with some swelling and bruising
- AROM is painful in motions that require muscle to contract
- neck muscle tests are painful and weak
- PROM painful only at end range when muscle is stretched
- tender palpation over muscle
What are the treatment goals for sprain/strain injuries to the cervical spine?
- control pain and inflammation in acute phase (cryogenic or electrotherapy, hot/cold)
- support and prevent further injury (activity restriction, k-tape, etc.)
- prevent adhesions and atrophy and erosion of motor control pathway (CMT, isometrics, home ROM)
- restore proper muscle balance (PIR, CRAC)
What are the late effects of sprain?
Periarticular fibrosis
What are the late effects of strain?
Myofibrosis, possibly trigger point
What is the most common cause of serious spinal injury?
Cervical acceleration-deceleration syndrome
Over 10% of population has residuals from CAD
Approximately 80% of MVAs occur at less than what speed?
25 mph
IN a rear end collision, at 60 msec, what happens to the cervical spine?
The S curve, where there is a bending moment in extension of the lower cervicals and bending moment in flexion of the upper cervicals
C0-C2 often develop restrictions
C4-C6 often become hypermobile
Why do head rests not prevent the S-curve?
Head contact with the head piece occurs at 70-100 msec while the S curve occurs at 60 msec
Following the S-curve, what happens to the cervical spine?
Hyperextension
How can a head rest help decrease injury?
If properly aligned with the EOP, it can decreased the amount of hyper extension
What anterior neck structure are at risk in cervical extension injuries?
- strains SCM
- strains anterior and middle scalenes
- strains longus colli and capitus
- sprains ALL
- tear anterior disc fibers
- traction injuries to vertebral artery and sympathetic plexus
What posterior neck structure are at risk in cervical extension injuries?
- fascia
- alar ligaments
Upper cervical injury can result in injured nociceptors and mechanoreceptors which can cause:
- balance disorders
- dizziness
- cognitive disorders (mild TBI)
How can whiplash cause TMJ?
Dropping of mandible during hyperextension can strain the anterior capsule of the TMJ
How can a whiplash injury cause injury dysphagia?
The tensile load with hyperextension may tear smooth muscle of the esophagus causing dysphagia although this is not the main cause of dysphagia in whiplash cases. Most are psychological
If the sympathetic chain is injured through traction in a whiplash injury, what can result?
Horner’s syndrome
What kind of instability results from weak, injured or inhibited deep neck flexors?
Functional instability
Sprains of the ALL can lead to what kind of instability in the cervical spine?
Structural instability
Tearing of what structures were the most common hyperextension injuries in cadavers?
Disc
ALL
What are the two typical lesions that occur to the disc in a hyperextension injury?
Avulsion
Anterior annular fiber tears
NOTE: posterior disc herniations are rare in the cervical spine
Where in the cervical spine are disc injuries most common?
Middle and lower cervicals
What kind of injury can happen to the facets during a hyperextension injury?
- shear forces can put tensile load on facet capsule which is rich in nociceptors
- middle and lower cervical facets can compress posteriorly causing meniscus to become impinged
What percentage of chronic pain in late whiplash comes from the facet joints?
60%
How can nerve root trauma happen with a hyperextension injury?
The NR can be traumatized in the IVF during hyperextension
Following the S curve and hyperextension phase of a cervical whiplash injury, what is the next phase?
Cervical flexion
During a front end collision, the head is forcibly flexed forward, followed by a degree of recall resulting in hyperextension. This is called a deceleration injury. What part of the cervical spine undergoes deceleration first?
C0-C1, then C6
What ligamentous structures can be sprained during a deceleration injury?
- alar ligament
- PLL
- nuchal
- supraspinous ligament
- interspinous ligament
- facet capsule
What muscles can be sprained during a deceleration injury?
posterior thoraco-cervical muscles
- semispinalis
- splenius capitis
- rectus capitis
- suboccipitals
- trapezius
- levator scapula
Other than sprains and strains, what other injuries can happen to the cervical spin in a deceleration injury from a head on collision?
- chip fractures to anterior vertebral bodies
- orthopedic subluxations and dislocations
- traction injuries to NR or cord
- traction injury to greater occipital nerve
A broad side collision/lateral flexion injury will cause ______ stress on the concave side and _____ stress on the convex side
Compressive
Tensile
What are the long term effects of whiplash that can become chronic whiplash?
- facet syndrome (40-68% of cases)
- joint dysfunction
- instability
- myofascial pain syndrome
- post traumatic HAs
- CNS and PNS dysfunction
- altered cervical biomechanics
What are the two most common facets that result in persistent facet syndrome in chronic whiplash?
C5-6
C2-3
What position can be assumed to help minimize injury from a collision?
- head and back against the seat
- straight arm the steering wheel
- put foot on brake
- look straight ahead and slightly up
- scrunch your shoulders up to brace
What absorbs damage better, muscle or ligaments?
Muscles are more injury resistant and heal with high resiliency
What 4 parts of a history are needed to determine the mechanism of injury following an MVA?
- magnitude and direction of forces
- position and attitude of the body
- force dampeners and augmenters
- detailed list of symptoms and when they occurred including LOC
How does head position affect prognosis in a MVA?
Rotated or laterally flexed head at time of impact is a primary feature related to symptom persistence
If the head is rotated to the right during impact of an MVA, what facets will experience more load?
Right
If the head is rotated to the right during impact of an MVA, what SCM will more likely tear?
Left
Is a seat belt a dampener or augmenter?
Both.
Dampener for body and augmenter for head and neck
What are examples of force dampeners in an MVA?
- airbag
- damage to seat
- state of preparedness
What is an example of an augmenter in an MVA?
Brakes applied
Augmenter but prevents double impact
What are some possible head and neck symptoms that may be present follow an MVA?
- dizziness
- headache
- vision changes
- TMJ
- dysphagia
- neck pain
What are some possible higher brain center symptoms that may be present after a MVA?
- cognitive: trouble processing, concentrating, remembering
- affective: irritability, fatigue, sadness, anxiety
- sleep: trouble sleeping or too much
What three conditions Of the cervical spine can present with Horner’s syndrome?
- Pancoast tumor
- internal carotid artery dissection
- CAD/WAD
What percentage of patients with concussions lose consciousness?
10%
What are the indications from the history that a patient should have radiographs after an MVA?
- 65 +
- dangerous mechanism of injury
- presence of paresthesia in extremities
- painful, distracting injury elsewhere in the body
- altered level of alertness
- evidence of intoxication
- patients with known vertebral disease
What is Rust’s sign?
Patient holds head up in distraction and this suggests fracture or structural instability
Patients > 65 years, dangerous mechanism of injury, or paresthesia must undergo cervical spine radiography PRIOR to undergoing what other physical exam?
active range of motion testing
What are the indications from the physical exam that a patient should have radiographs after an MVA?
- unable to actively rotate neck 45 degree to left and right
- midline cervical spine tenderness
- focal neurologic deficit
Post-traumatic headache can occur in up to ____% of patients in the first
three months post head trauma.
80
The symptoms of post traumatic headache fall into three groups:
- physical (headache, dizziness, double/blurred vision, nausea, light and sound sensitivity)
- emotional (irritable, frustrated, depressed or restless)
- cognitive (forgetful, poor concentration, taking longer to think)
What radiographic studies are included in the Davis series?
AP, APOM, lateral, 2 obliques, flexion/extension
What are the 4 possible fractures and dislocations that can occur to C1-C2 from CAD?
- anterior displacement associated with cruciate and capsular tearing, rupture or fracture of the dens
- posterior displacement associated with C1 anterior arch or odontoid fracture
- Jefferson fracture from axial compression of C1
- Hangman’s fracture of posterior elements such as pedicles associated with disruption of ALL and anterior annulus
What are the possible fractures and dislocations that can occur in C2-C7 following a CAD?
- unilateral dislocation from throng rotational/lateral flexion injury
- bilateral dislocation from hyperflexion injury
- compression fractures of vertebral body or articular pillars
- chip fracture in the anterior superior vertebral body from compression in hyperflexion
- avulsion fracture in the anterior inferior vertebral body from hyperextension
- clay shoveler’s fracture of the SPs
Instability leading to joint laxity and excessive motion is what kind of instability?
Structural
Instability from damaged mechanoreceptors leading to altered motor control is what kind of instability?
Functional instability
What is the tetrad of clinical instability from CAD based on AP and lateral radiographs?
- widening of the interspinous space
- subluxation of facet joints
- compression fractures of subjacent vertebrae
- loss of cervical lordosis
What are the signs of instability from CAD based on flexion and extension views?`
- listhesis >3.5mm
- forward displacement >11 degrees
- C1-C2 translation >2.5mm
What is the management for structural instability?
Stabilize with rigid collar and possibly surgery
During the acute phase of a CAD injury, what are the treatment goals? What is the operation end point for the acute phase?`
- reduce pain, inflammation and spasm
- decrease anxiety
This phase ends when there is no pain at rest
What specific treatments can be given for CAD patients during the acute phase?
- CMT
- light massage or PIR
- cryotherapy
- NSAIDs
- orthoses such as a soft collar
- home ROM and isometric exercises
During the sub acute repair phase of a CAD injury, what are the treatment goals? What is the operation end point for the acute phase?`
- control pain
- promote flexible healing
- improve circulation
- restore function
- minimize effects of fibrosis
- minimize atrophy
This phase ends when patient can perform unstressed ADLs
During the repair rehab phase of a CAD injury, what are the treatment goals? What is the operation end point for the acute phase?`
- decrease adhesions
- restore normal movement patterns
- restore strength, endurance and motor control
- increase physical work capacity
this phase ends when patient can perform normal activities under some constraints
During the remodeling rehab phase of a CAD injury, what are the treatment goals? What is the operation end point for the acute phase?`
- return to full lifestyle
- prevent future injury
- change psychosocial factors affecting or altered by injury
This phase ends when full recover to pre injury status has been achieved
What were the finding of the Britain orthopedic surgeon study of patients who received cervical spine soft tissue injuries in MVAs?
70% of patient still had symptoms 15 years after injury indicating that soft tissue injuries are more often than not permanent
