cervical and thoracic spine injuries

Question 1

1. what is cervical spondylosis?
2. what is the pathology of cervical spondylosis?
3. what are the symptoms of cervical spondylosis?

Answer 1

1. cervical spondylosis is a degenerative osteoarthritis affecting intervertebral joints in cervical spine
2. usually age-related disc degeneration followed by marginal osteophytosis and facet joint osteoarthritis
3. narrowing of intervertebral foramina puts pressure on spinal nerves causing radiculopathy - causes parasthesia, pain + myotomal motor weakness, if there is narrowing of spinal canal there’s pressure on spinal cord causing myelopathy - causes global muscle weakness, gait dysfunction, loss of balance + loss of bowel control

Question 2

1. what is a fracture of the C1 (atlas) vertebrae (Jefferson’s fracture)?
2. what is the mechanism of injury of a C1 vertebrae fracture?
3. what are the symptoms of a C1 vertebrae fracture?

Answer 2

1. fracture of anterior + posterior arches of the C1 vertebrae
2. axial loading e.g. diving into shallow water, hitting head on car roof
3. presents with lots of pain, reduced likelihood of impingement on spinal cord reduces risk of neurological issues, may damage arteries at base of skull causing secondary neurological consequences e.g. ataxia or stroke

Question 3

1. what is a hangman’s fracture?
2. what is the mechanism of injury of a hangman’s fracture?
3. what are the symptoms of a hangman’s fracture?

Answer 3

1. occurs when C2 vertebrae is fractured through the pars interarticularis (the region between the superior and inferior articular processes)
2. hyperextension of the neck
3. fracture expands spinal canal so reduces risk of spinal cord injury + therefore reduced risk of neurological issue

Question 4

1. what is an odontoid process (peg) fracture?
2. what is the mechanism of injury of a odontoid process fracture?
3. what are the symptoms of a odontoid process fracture?

Answer 4

1. fracture of the odontoid process (peg) of the C2 vertebrae
2. hyperextension or flexion of the cervical spine, most commonly seen in elderly patients with osteoporosis
3. neck pain and stiffness that is exacerbated during neck movement

Question 5

1. what is whiplash injury?
2. what is the mechanism of injury of a whiplash injury?
3. what are the symptoms of whiplash injury?

Answer 5

1. forceful hyperextension-hyperflexion injury of the cervical spine
2. patients car being struck from the rear: vehicle accelerates forward, then patients trunk + shoulders follow. Patients head remains static in space but as shoulders move anteriorly to head there is hyperextension of neck. The neck then acts as a lever increasing forward acceleration of head forcing neck into flexion. This hyperextension + hyperflexion cause tearing of cervical muscles + ligaments
3. secondary oedema, haemorrhage, inflammation, pain and stiffness

Question 6

1. what is a cervical intervertebral disc prolapse?
2. what is the mechanism of injury of a cervical intervertebral disc prolapse?
3. what are the symptoms of a cervical intervertebral disc prolapse?

Answer 6

1. a slipped disc results in the compression of nerve roots or spinal cord
2. tear develops in the annulus fibrosus of the disc, and the nucleus pulposus protrudes from the disc, with impingement onto an adjacent nerve root or the spinal cord
3. paracentral prolapse impinges on spinal nerve leading to radiculopathy, canal-filling prolapse may lead to acute spinal cord compression, parasthesia, pain and weakness

Question 6

1. what is cervical myelopathy?
2. what is the mechanism of injury of cervical myelopathy?
3. what are the symptoms of cervical myelopathy?

Answer 6

1. spinal cord dysfunction due to compression of the spinal cord due to narrowing of the spinal canal
2. degenerative stenosis of the spinal canal caused by cervical spondylosis, ligamentum flavum hypertrophy or buckling, facet joint hypertrophy, disc protrusion and osteophyte formation
3. compression of long tracts in spinal cord cause symptoms associated with myelopathy, loss of balance with poor coordination, decreased dexterity, weakness, numbness and in severe cases paralysis. Pain is a symptom in many patients but it is important to remember that it may be absent; the absence of pain often leads to a delay in diagnosis. In older patients, cervical myelopathy often manifests with a rapid deterioration of gait and hand function, patient may demonstrate an exaggerated response to stimulation, as seen in a positive Hoffman’s or Babinski sign

Question 7

what is the Hoffman’s test used for and what does a positive result indicate?

Answer 7

In Hoffman’s test, the doctor holds the patient’s middle finger at the middle phalanx and flicks the finger nail.
If there is no movement in the index finger or thumb after this motion, the patient has a negative Hoffman’s sign (normal). If the index finger and thumb move, the patient has a positive Hoffman’s sign (abnormal).

Question 8

what is the Babinski’s test used for and what does a positive result indicate?

Answer 8

In the Babinski sign, the lateral side of the sole of the foot is stroked with a blunt instrument from the heel towards the toes.
Normally in children over the age of approximately 2-3 years and adults, the response is flexor in that the toes flex downwards towards the sole (plantarflex). In a positive (abnormal) Babinski sign, the hallux dorsiflexes and the toes fan out. This suggests damage to the long tracts of the spinal cord.

Question 9

what is the L’Hermitte’s phenomenon and what does it indicate?

Answer 9

sensation of intermittent electric shocks in limbs exacerbated by neck flexion
associated with cervical myelopathy

Question 10

1. what is thoracic cord compression?
2. what is the mechanism of injury in a thoracic cord compression?
3. what are the symptoms associated with a thoracic cord compression?

Answer 10

1. spinal cord compression in thoracic region
2. compressions due to vertebral fractures, tumours in spinal canal
3. pain at site of lesions, spastic paralysis of all of muscles in legs, paraesthesia in dermatomes distal to site of cord compression

Question 11

1. what is spondylodiscitis (or just discitis)?
2. what is the mechanism of injury of spondylodiscitis?
3. which organisms cause spondylodiscits?
4. what are the symptoms associated with spondylodiscitis?

Answer 11

1. infection of intervertebral disc
2. intervertebral disc is avascular so the organisms initially deposits in the vertebral body via segmental arteries, causes bony ischaemia + infarction, necrosis of bone then allows direct spread of organisms into adjacent disc space, epidural space + adjacent vertebral bodies
3. Staphylococcus aureus (50%), and Gram negative bacilli such as Escherichia coli (up to 30%)
4. Spread of infection into the spinal canal can lead to neurological damage via the following mechanisms:
   * Septic thrombosis leading to ischaemia
   * Compression of neural elements by abscess / inflammatory tissue
   * Direct invasion of neural elements by inflammatory tissue
   * Mechanical collapse of bone leading to instability, particularly in chronic infections

Question 12

how can pathogens reach the bones and tissues of the spine?

Answer 12

• Haematogenous (most common route)
• Direct inoculation during invasive spinal procedures (e.g. lumbar
  puncture, epidural or spinal anaesthesia)
• Spread from adjacent soft tissue infection