Spinal Trauma and Acute Pathology Flashcards
- Which one of the following statements
regarding pre-hospital spinaL immobilization is LEAST accurate?
a. Pre-hospital spine immobilization should be routinely used in the setting of penetrating trauma
b. Time spent on a spinal board is associated with pressure ulcer development in the next 8 days
c. The probability of a noncontiguous spinal injury in the setting of a known injury is approximately 20%
d. Firm application of a cervical collar may be associated with an ICP rise of 2-5 mmHg
e. Pre-hospital selective spine immobilization protocols can be up to 99% sensitive in identifying trauma patients with cervical injuries requiring immobilization
e. Pre-hospital selective spine immobilization protocols can be up to 99% sensitive in identifying trauma patients with cervical injuries requiring immobilization
Penetrating trauma (stab and gunshot) rarely
causes spinal instability even when specifically
injuring the spine and those who are placed in
spinal immobilization at scene are twice as likely
to die as those who are not (due to proper application of spinal immobilization delaying patient
resuscitation) hence routine use is not recommended. Pre-hospital spinal immobilization is
advised when there is: (i) spinal pain or tenderness, including any neck pain with a history of
trauma, (ii) significant multiple system trauma,
(iii) severe head or facial trauma, (iv) numbness
or weakness in any extremity after trauma, (v)
loss of consciousness caused by trauma, (vi)
mental status is altered (including drugs, alcohol,
trauma) and no history is available, or the
patient is found in a setting of possible trauma
(e.g. lying at the bottom of stairs or in the
street); or the patient experienced near drowning with a history or probability of diving, (vii)
any significant injury distracting the patient
from reporting spinal pain/symptoms. These
criteria are 99% sensitive in identifying trauma
patients with cervical injuries requiring immobilization, but extra vigilance is required in old (>67 years) and very young patients. As such,
immobilization of trauma patients who are
awake, alert, and are not intoxicated, who are
without neck pain or tenderness, who do not
have an abnormal motor or sensory examination
and who do not have any significant associated
injury that might detract from their general evaluation is not recommended. The probability of a noncontiguous spinal injury in the setting of a
known injury is approximately 20%, necessitating the need for complete spinal immobilization.
Limiting untoward spinal motion during transportation of patients with cervical spine injuries is considered essential to preserve neurological function and to limit further injury from spinal instability. Cervical SCIs have a high incidence of airway compromise and pulmonary dysfunction; therefore, respiratory support measures should be available during transport. Immobilization is associated with modest morbidity such as rises in ICP due to cervical collar placement, risk of pressure sores in the next 8 days (proportional to length of time on rigid spinal
board; also if not turned in the first 2 h), risk
of aspiration and impaired respiratory function,
and must take into account pre-existing spinal
deformity (e.g. ankylosing spondylitis, occipital
recess in children)—favoring removal as soon
as safe to do so.
Which one of the following statements regarding clinical assessment of SCI using the American Spinal Injury Association Scale is most accurate?
a. ASIA E is where no sensory or motor
function is preserved below the level of
injury or in the sacral segments S4-S5
b. ASIA D is where sensory but not motor
function is preserved below the neurological level and includes the sacral segments S4-S5
c. ASIA C describes preserved motor function below the neurological level, and more than half of key muscles below the neurological level have a muscle
grade <3
d. ASIA B describes preserved motor function below the neurological level, and
at least half of key muscles below the
neurological level have a muscle grade >3
e. ASIA A describes normal sensory and
motor function
c. ASIA C describes preserved motor function below the neurological level, and more than half of key muscles below the neurological level have a muscle
grade <3
Which one of the following statements regarding clearing the cervical spine in suspected spinal injury is most accurate?
a. NEXUS low-risk criteria includes absence of a flexion-distraction mechanism of injury
b. In awake, symptomatic patients threeview radiographs are the initial imaging study for cervical spine injury
c. In obtunded or comatose patients a highquality CT scan of the entire spinal axis is recommended
d. Canadian C-spine rules require assessment of the range of movement of the cervical spine to justify not imaging the cervical spine
e. STIR MRI is used to confirm spinal
instability
c. In obtunded or comatose patients a highquality CT scan of the entire spinal axis is recommended
In awake trauma patients in the emergency
department, cervical spine imaging is recommended unless they meet all of the NEXUS
low-risk criteria: absent posterior midline cervical
tenderness, no evidence of intoxication, a normal
level of alertness and consciousness, absence of
any focal neurological deficit, absence of any distracting injuries (painful enough to distract the
patient from another, particularly cervical, injury
e.g. long-bone fracture; a visceral injury; a significant laceration, degloving or crush, large burns).
Alternatively, the Canadian C-spine rules can be
applied to stable trauma patients with a GCS
15/15 to determine the need for imaging based
on the presence/absence of high risk factors
necessitating radiography (age >65, significant
mechanism, paresthesias in extremities), presence
or absence of low-risk factors allowing safe assessment of cervical ROM (simple rear-end collision, sitting up in ED, delayed onset of neck pain, absence of midline cervical tenderness) and
American Spinal Injury Association
Impairment Scale ASIA A No sensory or motor function is preserved below the level of injury or in
the sacral segments S4-S5 ASIA B Sensory but not motor function is preserved below the neurological level and includes the sacral segments S4-S5
ASIA C Preserved motor function below the
neurological level, and more than half
of key muscles below the neurological
level have a muscle grade <3
ASIA D Preserved motor function below the
neurological level, and at least half of
key muscles below the neurological
level have a muscle grade 3
ASIA E Normal sensory and motor function
(if safe to do so) the ability to rotate neck actively
45° to right and left. Imaging would need to be
performed if (i) high risk factors are present,
(ii) low-risk factors are absent, or (iii) if low-risk
factors present but the physician is unable to
complete the range of motion assessment.
Although not 100% sensitive, clinicians can easily
apply the NEXUS criteria or Canadian C-spine
rules to deciding whether to request further cervical spine imaging for an awake and asymptomatic patient. In awake, symptomatic patients (neck pain and/or neurology) CT of the cervical spine should be the initial imaging study. Traditional three-view radiographs (anteroposterior, lateral
and open-mouth odontoid view) should be
obtained only if it is not possible to obtain a
high-quality CT scan, but should be supplemented with CT as soon as it becomes available if
there is high suspicion of injury or poor visualization on plain X-ray. If the CT scan is normal and the patient continues to have neck pain then several options exist: (i) continue cervical immobilization until asymptomatic, (ii) discontinue
cervical immobilization after normal MRI
(<48 h post-injury) and/or adequate dynamic
flexion/extension radiographs, or (iii) discontinue
immobilization at the discretion of the treating
physician. MRI including short T1 inversion
recovery (STIR) fat suppressed sequences to
identify damaged ligaments that indirectly suggests potential laxity in the joints and vertebrae
(i.e. potential instability), which could cause a
subluxation and narrow the spinal canal. True
cervical spinal instability can only be directly confirmed with cervical flexion-extension lateral
radiographs. These films must be performed
under controlled conditions to ensure that the
patient does not move his/her neck past the point
of worsening pain or symptoms, and the lateral
views must include the C7-T1 disc space to
ensure the entire cervical spine can be imaged.
If CT, MRI and dynamic flexion/extension views
are normal in a symptomatic patient (i.e. most
likely muscle spasm or soft tissue trauma) one
can either remove the collar or continue immobilization until the patient is reviewed in a few weeks, at which point the collar can be remove
without further imaging if the patient has a stable
and normal neurological examination or repeat
dynamic X-rays if still symptomatic. In obtunded
or comatose patients a high-quality CT scan of
the entire spinal axis is recommended initially (as
there is a risk of noncontiguous injury that would
otherwise remain occult). If the CT scan is normal,
MR imaging within 48 h may identify subtle signs
of cervical spine injury. If the MR scan is normal or
performed after 48 h, the clinician must determine
whether to continue cervical collar immobilization
on an individual patient basis.
An 18-year-old male is brought into the emergency room after diving into a shallowpool. He is awake and alert, has intact cranial nerves (CNs), and is able to move his shoulders, but has a flaccid quadriplegia and a sensory level at C5. Which one of the following
statements regarding medical management of SCI is most accurate?
a. Methylprednisolone should be administered if the injury was within 3 h of arrivalto the emergency department (30 mg/kgbolus followed by a 5.4-mg/kg/h infusion for 24 h)
b. Class II studies have shown therapeutic efficacy of methylprednisolone in improving
motor function in acute spinal cord injury
c. Class I studies have shown significant
harmful side effects associated with methylprednisolone in spinal cord injury
d. Maintenance of mean arterial pressure from 85 to 90 mmHg in the first 7 days may improve spinal cord perfusion and outcome after SCI
e. Cardiovascular instability is unlikely to
develop if the patient is initially stable
on admission
d. Maintenance of mean arterial pressure from 85 to 90 mmHg in the first 7 days may improve spinal cord perfusion and outcome after SCI*
Administration of methylprednisolone for the
treatment of acute spinal cord injury is no longer
recommended based on evidence, although variation in practice persists due to medicolegal and
other contentions. There is no Class I or Class
II medical evidence supporting clinical benefit
in the treatment of acute SCI (e.g. NASCIS I
and III), but Class I, II, and III evidence does exist
suggesting that high-dose steroids are associated
with harmful side effects including death, GI
hemorrhage, pneumonia, steroid-induced myopathy and wound infection. A variety of Class III
medical evidence (e.g. NASCIS II) has been published supporting the neuroprotective effect of
methylprednisolone in SCI but generally, these
studies suffer from 1 of 2 significant limitations:
limited sample size derived retrospectively from
much larger study populations and/or incomplete
data reporting in which omitted data are likely to
have negated the proposed beneficial effect.
Additionally, the claimed beneficial effects have
been inconsistent (e.g. sensory only, motor only,
or other type of neurological recovery) and not
necessarily clinically/functionally meaningful.
For example, although NASCIS III was a randomised double-blind trial (without a placebo arm)
assessing effect of starting steroids within 8 hours
of SCI the only positive results came from an
arbitrary post-hoc analysis (i.e. decision to split
into <3 h and 3-8 h groups, which showed a
5-point motor improvement at 1 year in the latter
group with a p¼0.053) which cannot be classed as
level I evidence. In light of both significant methodological errors and inconsistent neurologicaloutcomes, the beneficial effects of MP can as easily be ascribed to random chance as to any true therapeutic effect. In head injured patients, the CRASH trial showed the administration of steroids led to a worse outcome and they should not be used in this context either. Where methylprednisolone is still given the accepted dose is a 30-mg/kg bolus followed by a 5.4-mg/kg/h infusion for either 24 h (if started <3 h post-injury) or 48 h (3-8 h post-injury). In general, ICU/HDU management of patients with an acute cervical spinal cord injury should include cardiac, hemodynamic, and respiratory monitoring to detect cardiovascular dysfunction and respiratory insufficiency. Hypotension, hypoxemia, pulmonary
dysfunction, and cardiovascular instability, are
frequent despite initial stable cardiac and pulmonary function. Life-threatening cardiovascular instability and respiratory insufficiency may be transient and episodic and may be recurrent in the first 7-10 days after injury. Prompt treatment of these events in patients with acute SCI reduces cardiac- and respiratory-related morbidity and mortality. Hypotension may be due to hypovolemia, direct severe spinal cord trauma
itself, or a combination of the two and contributes
to secondary injury after acute SCI by further
reducing spinal cord blood flow and perfusion.
Correction of hypotension in spinal cord injury
(systolic blood pressure >90 mmHg) and volume
expansion have improved ASIA scores in patients
with acute SCI compared with historical controls.
Maintenance of mean arterial blood pressure
between 85 and 90 mmHg for the first 7 days is
safe and may improve spinal cord perfusion and
ultimately neurological outcome
A 21-year-old male is involved in an RTA. Examination shows that he is able to move over half of muscles but not against gravity (ASIA C) and CT trauma protocol shows a C4 burst fracture, 25% loss of vertebral body height, 70% encroachment of the spinal canal
due to retropulsion. MRI shows evidence of injury to the posterior ligamentous complex and cervical cord compression. Which one of the following statements regarding the STASCIS trial is most accurate?
a. The results are not applicable to traumatic cervical spinal cord injury
b. Those with ASIA A injuries at presentation were excluded
c. Early decompression ( <24 h ) was associated with significantly more patients witha > 2 grade improvement in ASIA impairment scale at 6-month follow-up
d. Early decompression (<24 h) was associated with significantly more patients with a only 1 grade improvement in ASIA impairment scale at 6-month follow-up
e. Odds of a 2 grade improvement in ASIA impairment scale at 6-month follow-up were fourfold higher in the early decompression (<24 h) versus late decompression (>24 h) group
c. Early decompression ( <24 h ) was associated with significantly more patients witha > 2 grade improvement in ASIA impairment scale at 6-month follow-up
There are currently no standards regarding the
role, timing, and method of vertebral decompression in acute spinal cord injury. Options include
closed reduction using traction and open surgical
procedures. Goals for surgical intervention in
TSCI include stabilization of the spine (preceded
by closed or open reduction of dislocations if
required) and decompression of neural elements.
Neurologically intact patients are treated nonoperatively unless there is instability of the vertebral column. Indications for cervical spine
surgery include significant cord compression with
neurologic deficits, especially those that are progressive, that are not amenable or do not respond
to closed reduction, or an unstable vertebral fracture or dislocation. Most penetrating injuries
require surgical exploration to ensure that there
are no foreign bodies imbedded in the tissue,
and also to clean the wound to prevent infection.
More contemporary studies suggest that medical
complication rates are actually lower in patients
who undergo early surgery, which allows for earlier mobilization and reduced length of intensive
care unit and hospital stay. The nonrandomized,
Surgical Timing in Acute Spinal Cord Injury
Study (STASCIS), compared 6-month outcomes
in those with acute cervical SCI (ASIA A-D) who
received surgery within 24 h after injury (n¼131)
to those whose surgery was performed later
(n¼91). It found that 19.8% of patients undergoing early surgery showed a 2 grade improvement in ASIA impairment scale compared to
8.8% in the late decompression group. After
adjusting for glucocorticoid treatment and injury
severity, there was a 2.8-fold higher odds of 2
grade improvement in ASIA impairment scale
with early surgery (but no difference between
groups of patients with only 1 AIS grade improvement). Mortality and complications were similar
in both patient groups. The role of early surgery
with a complete TSCI (ASIA grade A) is debatable and although surgery to stabilize the spine
is performed it is not immediate. Most clinicians
consider deteriorating neurologic function after
incomplete TSCI to be an indication to perform
surgery as early as possible if there are no contraindications (e.g. hemorrhagic shock, blood dyscrasias) hence shorter time intervals (within 6-
12 h) are preferred. Criticisms of the study
include problems related to baseline differences
in epidemiological characteristics of the groups
under study (patient age, injury morphological
subtype, steroid administration, and neurological
status at admission), biases related to treatment
peculiarities (patient allocation by different physicians’ discretion and variations in surgical technique), and further concerns regarding data
analysis (loss of follow-up, specific criteria for
outcomes evaluation—such as AIS >2, and
unclearly reported findings).
Which one of the following statements regarding spinal cord perfusion pressure (SCPP) and intradural spinal pressure (ISP) in spinal cord injury patients is most accurate?
a. Inotropes cause an increase in ISP and MAP but with a net increase in SCPP
b. Mannitol administration causes a reduction in ISP and increases MAP
c. Reduction in PaCO2 reduces ISP
d. Sevoflurane increases ISP
e. Laminectomy plus expansion duraplasty
provided a higher ISP and SCPP
a. Inotropes cause an increase in ISP and MAP but with a net increase in SCPP
Intraspinal pressure (ISP) and spinal cord perfusion pressure (SCPP) at the site of injury in severe
TSCI (ASIA grade A-C) has been monitored via
laminectomy and insertion of a pressure transducer between the swollen spinal cord and the dura for up to 1 week. After severe TSCI, ISP is
high (typically 20-40 mmHg) and SCPP low (typically 40-60 mmHg). Interestingly, although mannitol administration, reduction in PaCO2,
and increase in sevoflurane dose are known to
have a major effect on intracranial pressure, they
had little effect on ISP after TSCI. Increasing
the dose of inotropes caused an increase in ISP
and MAP but with a net increase in SCPP. By
intervening to increase SCPP, we could improve
outcome in some patients as assessed using motor
evoked potentials and a limb motor score. In addition to bone, dura is a major cause of spinal cord compression after TSCI and may explain why
studies of bony decompression without dural
opening have not convincingly shown a beneficial
effect on outcome. Spinal decompression combined with dural decompression (expansion duroplasty) safely and effectively improves ISP, SCPP and spinal cord pressure reactivity after TSCI.
Compared with the laminectomy group, the laminectomy plus duroplasty group had greater
increase in intradural space at the injury site and
more effective decompression of the injured cord.
In the laminectomy+duroplasty group, ISP was
lower, SCPP higher, and sPRx lower, (i.e.
improved vascular pressure reactivity), compared
with the laminectomy group. Laminectomy + duroplasty caused cerebrospinal fluid leak that settled with lumbar drain in one patient and pseudomeningocele that resolved completely in five patients. Change in ASIA grade (ASIA grade at
follow-up minus ASIA grade at presentation),
walking ability, bladder function, and bowel function were better in the laminectomy+duroplasty
versus the laminectomy group, though not significant (p<0.05) and assessed at significantly different time points post-injury (10 months vs.
25 months post-injury, respectively).
A 75-year-old man falls sustaining a hyperextension injury to his neck. On examination, he has 3/5 strength in his deltoids, elbow and wrist flexors and extensors bilaterally in the upper limbs. In the lower limbs, he has 4/5 strength in his hip flexors, knee flexors, extensors, ankle dorsiflexors and plantarflexors bilaterally. Sensation is intact throughout the limbs and saddle area. T2 weighted axial MRI is shown. Which one of the following is most likely?
a. Complete spinal cord injury
b. Central cord syndrome
c. Anterior cord syndrome
d. Posterior cord syndrome
e. Brown-Sequard syndrome
b. Central cord syndrome
Acute traumatic central cord syndrome is an
incomplete spinal cord injury in which the upper
extremities are weaker, (at least 10 points in ASIA
Motor Score) than the lower extremities with variable involvement of the sensory system and
a variable effect on bladder function. Regardless
of the mechanism, nearly 70% of patients suffering from incomplete spinal cord injuries will have
central cord syndrome. Despite this, it is the
mechanism and associated degree of instability,
biomechanical failure, urgency of spinal cord
decompression, and the need for internal fixation
of a potentially unstable cervical spine which will
influence management hence early CT and MRI
are recommended. Approximately 10% of
patients with ATCCS have MRI evidence of signal change within the spinal cord with no other
radiographic abnormality. It is recommended
that these patients be managed medically cardiac,
hemodynamic, and respiratory monitoring, and
maintenance of mean arterial blood pressure at
85-90 mmHg for the first week after injury to
improve spinal cord perfusion. Roughly 20% of
patients present with an acute disc herniation as
the cause of ATCCS. Surgical intervention is
recommended for this group. Nearly 30% of
patients with ATCCS have cervical spine skeletal
injuries in the form of fracture subluxation injuries. In this group of patients, early re-alignment
of the spinal column (closed or open) with spinal
cord decompression is recommended. The last
group of patients (approximately 40%) have spinal stenosis without evidence of bony or ligamentous injury and management remains
controversial due to the variable degree of spontaneous recovery of neurological function.
Patients with central cord syndrome usually
regain bowel and bladder function and their ability to ambulate. Return of upper extremity function is less reliable, and patients are often left with
deficits in their upper extremity, worse distally,
characterized by “clumsy” hands.
A patient develops Wallenberg syndrome 4 days after C5-C6 fracture dislocation: Which one of the following statements
regarding further management is most accurate?
a. CT head, CT angiogram and start anticoagulation
b. Diffusion weighted MRI
c. Clinical observation
d. CT head and anticoagulation
e. CT head and commence antiplatelet
a. CT head, CT angiogram and start anticoagulation
The incidence of vertebral artery injury may be as
high as 11% after nonpenetrating cervical spinal
trauma in patients meeting specific clinical and
physical exam criteria. The modified Denver
Screening Criteria for BCVI are the most commonly used: lateralizing neurologic deficit (not
explained by CT head), infarct on CT head scan, cervical hematoma (nonexpanding), massive epistaxis, anisocoria/Homer’s syndrome, GCS
<8 without significant CT findings, cervical spine
fracture, basal skull fracture, severe facial fracture
(LeForte II or III only), seatbelt sign above clavicle, and presence of cervical bruit or thrill. Gold
standard of imaging is catheter angiography but
there is Class I evidence supporting CTA as a
highly accurate alternative to catheter angiography for screening for VAI in blunt injury trauma
patients, with a very high negative predictive
value. It appears that the majority of patients
with VAI are asymptomatic, and those who with
symptomatic VAI have neurological deficit attributable to the initial blunt traumatic injury; no
definitive longitudinal study has defined the
future stroke risk of either of these groups, with
or without anticoagulation/antiplatelets. While
no conclusive medical evidence supports treatment for VAI, most clinicians support treatment for patients with symptomatic VAI with either anticoagulation or antiplatelet therapy individualized based on the patient’s vertebral artery injuries, associated traumatic injuries, and the relative risk of bleeding associated with that form of therapy. Because of an increased relative risk of hemorrhagic complications from anticoagulation therapy for VAI, without clear superior efficacy, anticoagulation therapy is not considered ideal treatment in multiple trauma patients with either symptomatic or asymptomatic VAI. Antiplatelet therapy (aspirin the most studied) appears to be a safe and comparable option for symptomatic patients with VAI after blunt trauma. For asymptomatic patients with documented VAI, no treatment is comparable to antiplatelet therapy but the potential to reduce future stroke risk favors the use of aspirin if there are no contraindications.
Which one of the following statements regarding VTE prophylaxis in SCI is most accurate?
a. Prophylactic IVC filter insertion is appropriate in those with complete SCI
b. Low molecular weight heparin should be discontinued after 3 months postinjury in those without other risk factors for VTE
c. Oral anticoagulation is the new standard of care for VTE prophylaxis in SCI in the first 28 days post-injury
d. Patients tolerating mechanical DVT prophylaxis do not require anticoagulation
e. SCI patients with retained lower limb
function have similar DVT rate to those
with complete injury
b. Low molecular weight heparin should be discontinued after 3 months postinjury in those without other risk factors for VTE
Thromboembolic disease is a common occurrence in patients who have sustained a cervical spinal cord injury and is associated with significant
morbidity. Class I medical evidence exists demonstrating the efficacy of several means of prophylaxis for the prevention of thromboembolic
events. Therefore, patients with SCI should be
treated with a regimen aimed at VTE prophylaxis.
Although low-dose heparin therapy has been
reported to be effective as prophylaxis for thromboembolism in several Class III studies,
other Class I, Class II, and Class III medical evidence indicates that better alternatives than lowdose heparin therapy exist. These alternatives
include the use of low molecular weight heparin,
adjusted dose heparin, or anticoagulation in conjunction with rotating beds, pneumatic compression devices or electrical stimulation. Oral
anticoagulation alone does not appear to be as
effective as these other measures used for prophylaxis. There appears to be a DVT prophylaxis benefit to early anticoagulation in acute spinal cord
injury patients. Class II medical evidence supports
beginning mechanical and chemical prophylaxis
upon admission after SCI and holding chemical
prophylaxis 1 day prior to and 1 day following surgical intervention. The incidence of thromboembolic events appears to decrease over time and the
prolonged use of anticoagulant therapy is associated with a definite incidence of bleeding complications. There are multiple reports of the
beneficial effects of the prophylaxis therapy for
6-12 weeks following spinal cord injury. Class II
medical evidence indicates that the majority of
thromboembolic events occur in the first
3 months following acute SCI and very few
occur thereafter. For these reasons, it is recommended that prophylactic therapy be discontinued after 3 months unless the patient is at high risk for a future VTE event (previous thromboembolic events, obesity, advanced age). It is reasonable to discontinue therapy earlier in
patients with retained lower extremity motor
function after spinal cord injury, as the incidence
of thromboembolic events in these patients is substantially lower than among those patients with
motor complete injuries. Although the guidelines
author group concluded that caval filters appeared
to be efficacious for the prevention of PE in SCI
patients in the 2002 guideline on this topic, more
recent medical evidence suggests that prophylactic filters may be more morbid than initially
believed. Caval filters still have a role for SCI
patients who have suffered thromboembolic
events despite anticoagulation, and for SCI
patients with contraindications to anticoagulation
and/or the use of pneumatic compression devices.
Regarding Punjabi and white stability criteria, which one of the following weightings is inaccurate?
a. Anterior elements destroyed or unable to function (2 points)
b. Posterior elements destroyed or unable to function (2 points)
c. Relative sagittal plane translation
>3.5 mm (or >20% AP vertebral width)
on X-ray (2 points)
d. Relative sagittal plane rotation >11° on
X-ray (2 points)
e. Cord or root damage (2 points)
e. Cord or root damage (2 points)
In 1990,White and Punjabi described a formula for
evaluating fracture stability in the subaxial cervical
spine based on cadaveric studies utilizing radiographs. Under normal physiological conditions, cervical spine movements are smooth, effortless,
pain-free, and do not produce neurological symptoms. One should consider the fact that White and Panjabi’s stability checklist was based on radiographs (not CT/MRI) and that some suggested
maneuvers, such as stretch testing or dynamic studies, may not be compatible with the present standards of cervical spine clearance in patients with traumatic brain or cervical spine injuries. The
checklist has never been validated nor its reliability
measured but it remains in use. A total of 5 points or more suggests spinal instability: anterior elements destroyed or unable to function [2 points], posterior elements destroyed or unable to function [2 points] relative sagittal plane translation >3.5 mm (or >20% AP vertebral width) on X-ray [2 points], relative sagittalplane rotation>11°onX-ray [2points],
positive stretch test [2 points], cord damage
[2 points], root damage [1 point], developmentally
narrow spinal canal (sagittal <13 mm or Pavlov’s
ratio <0.8) [1 point], abnormal disc narrowing
[1 point], dangerous loading anticipated [1 point].
An 18-year-old male was admitted following a fall from a height of 20 m. His American Spinal Injury Association (ASIA) motor score was 43/100 and ASIA Impairment Scale (AIS) A. Cervical spine CT showed a C7/T1 flexion-distraction injury. MRI indicated complete disruption of discoligamentous complex with persistent spinal cord compression. Which one of the following is the most
likely SLIC score?
a. 7
b. 8
c. 9
d. 10
e. 11
c. 9
The Subaxial cervical spine Injury Classification
(SLIC) and severity scale (0-10) is recommended
as a classification system for spinal cord injury.
This system includes morphology of the anatomical injury, including the discoligamentous
complex and neurological condition of the
patient. The total score in this case was 9. The
patient was treated with circumferential (anterior
cervical discectomy and fusion and posterior
spinal fusion) fusion of the cervical spine. Morphology in this case is eligible for a score of
4 (translation/rotation), DLC a score of 2 (complete disruption), and neurology a score of 2 for
complete spinal cord injury (+1 for persistent).
The Cervical Spine Injury Severity Score
(CSISS) is limited to clinical trials rather than
daily practice.
Which one of the following statements regarding closed reduction of cervical fracture-dislocations is LEAST accurate?
a. MRI is essential before attempted closed reduction of cervical fracture-dislocations
b. MRI results should be available before
open reduction of fractures as a significant disc herniation may favor an anterior cervical approach
c. Closed reduction of cervical fracturedislocations is safe in awake patients
d. Risk of transient injury with closed reduction is 2-4%
e. Risk of permanent neurological injury
from closed reduction is 1%
a. MRI is essential before attempted closed reduction of cervical fracture-dislocations
Closed reduction of cervical fracture-dislocations
may obviate surgery and promote neurologic
improvement in some cases. Early reports raised
a concern that closed reduction in the setting of
associated disc disruption and/or herniation has
the potential to exacerbate neurologic injury but
studies have shown this not to be true in practice.
In the clinical scenario of traumatic cervical spine
fractures and cervical facet dislocation injuries,
narrowing of the spinal canal caused by displacement of fracture fragments or subluxation of one vertebra over another frequently produces spinal cord compression and injury, necessitating urgent reduction of the dislocation which may improve neurologic outcome. Closed reduction of fracture/dislocation injuries of the cervical spine by traction-reduction appears to be safe and effective
in awake patients. Approximately 80% of patients
will have their cervical fracture dislocation injuries
reduced with this technique. The overall permanent neurological complication rate of closed reduction is approximately 1%. The associated risk of a transient injury with closed reduction appears to be 2-4%. Closed traction-reduction appears to be safer than MUA. Pre-reduction MRI has not been shown to improve the safety or efficacy of closed traction-reduction of patients with acute cervical fracture dislocation injuries, hence may unnecessarily delay spinal column realignment for decompression of the spinal cord. The ideal timing of closed reduction of cervical spinal fracture dislocation injuries is unknown, but many investigators favor reduction as rapidly as possible after injury to maximize the potential for neurological recovery. Patients who fail attempted closed reduction of cervical fracture injuries have a higher incidence of anatomic obstacles to reduction, including facet fractures and disc herniations.
Patients who fail closed reduction should undergo
more detailed radiographic study/MRI before
attempts at open reduction. The presence of a significant disc herniation in this setting is a relative indication for an anterior decompression procedure, either in lieu of or preceding a posterior procedure. Patients with cervical fracture dislocation injuries who cannot be examined because of head injury or intoxication cannot be assessed for neurological deterioration during attempted closed reduction. For this reason, an MRI before attempted reduction (open or closed) is recommended as a treatment option on the basis of Class III medical evidence.
Which one of the following is a reasonable guide for weight increments used in cervical traction with Gardener Wells tongs?
a. 1 lb per level
b. 5 lb per level
c. 10 lb per level
d. 15 lb per level
e. 20 lb per level
b. 5 lb per level
This technique involves use of longitudinal
traction using skull tongs or a halo headpiece.
An initial weight of 5-15 pounds is applied;
this is increased in 5 lb increments, taking lateral
X-rays after each increment is applied. The more
rostral the dislocation, the less weight is used, usually about three to five pounds per vertebral level.
While weights up to 70 pounds are sometimes
used, we suggest that after 35 pounds is applied,
patients be observed for at least an hour with
repeat cervical spine X-rays before the weight is
cautiously increased further. Administration of a
muscle relaxant or analgesic, such as diazepam or
meperidine, may help facilitate reduction. Position, correct bed type, angle of traction,
X-ray check 15 min post adding weight. Repeat
CT cervical spine 6-8 weeks.
Which one of the following statements regarding management of occipital condyle fractures is LEAST accurate?
a. Occipito-cervical fusion is generally recommended in the context of bilateral fractures with overt instability
b. Halo immobilization is not commonly used in the management of unilateral OC fractures
c. Cervical collars are the mainstay of treatment
d. Cervical collars are contraindicated in the presence of cranial nerve palsy after unilateral fracture
e. MRI is recommended to assess the integrity of the craniocervical ligaments
d. Cervical collars are contraindicated in the presence of cranial nerve palsy after unilateral fracture
OCF is an uncommon injury (1-3% frequency of
OCF in patients sustaining blunt craniocervical
trauma) and requires CT imaging to establish the
diagnosis. Patients sustaining high-energy blunt
craniocervical trauma, particularly in the setting
of loss of consciousness, impaired consciousness,
occipito-cervical pain or motion impairment, and
lower cranial nerve deficits, should undergo CT
imaging of the craniocervical junction. Magnetic
resonance imaging (MRI) is recommended to
assess the integrity of the craniocervical ligaments.
OCFs have been classified by Anderson and Montesano into three types: Type I (comminuted),
Type II (extension of a linear basilar skull fracture),
and Type III (avulsion of a fragment). Untreated
patients with OCF can develop lower cranial nerve
deficits that usually recover or improve with nonrigid external immobilization (cervical collar).
Nonsurgical treatment with external cervical
immobilization is sufficient to promote bony
union/healing and recovery or cranial nerve deficit
improvement in nearly all types of OCF. Bilateral
OCF injuries should prompt consideration for
more rigid external immobilization in a halo vest
device. Surgical treatment (occipito-cervical
instrumented fusion) may be indicated in patients
with OCF who have overt instability, neural compression from displaced fracture fragments, or who have associated occipito-atlantal or atlanto-axial injuries (e.g. Atlanto-occipital dissociation).
A 16-year-old is brought into the emergency department intubated and ventilated after a high speed MVA. Which one of the following statements regarding the injury shown is LEAST accurate?
a. Associated with a Power’s ratio < 0.8
b. Associated with BAI or BDI >12 mm
c. Associated with increased condyle-C1 interval in children
d. Associated with a high mortality
e. Associated with high speed motor vehicle accidents
a. Associated with a Power’s ratio < 0.8
Atlanto-occipital dislocation (dissociation)
accounts for <1% of all acute cervical spine injuries. It is usually seen in high-speed motor vehicle
accidents and results from hyperextension and
distraction of the cervical spine. Atlanto-occipital
dislocation is more commonly seen in children
because the pediatric occipital condyles are small,
are almost horizontal, and lack inherent stability.
Atlanto-occipital dislocation is often immediately
fatal because of associated injury to the brainstem
and there is a high incidence of neurologic deficits
in survivors. Patients who survive AOD injuries often have neurological impairment including
lower cranial nerve deficits, unilateral or bilateral
weakness, or quadriplegia. Nearly 20% of patients
with acute traumatic AOD will have a normal neurological examination on presentation. The lack
of localizing findings and/or global neurological
deficits from severe brain injury may impede/hinder the diagnosis of AOD in patients with normalappearing initial cervical radiographs. A high index of suspicion must be maintained in order to diagnose AOD. Prevertebral soft tissue swelling on a lateral cervical radiograph should prompt CT imaging to rule out AOD. Commonly used radiological parameters suggesting AOD include: craniocervical subarachnoid hemorrhage, Powers ratio (basion-posterior atlas arch distance divided by the opisthion-anterior atlas arch distance) >1,
basion axial interval or basion dental interval
>12 mm (Harris rule of 12), Condyle-C1 interval
(highest diagnostic sensitivity in pediatric AOD).
AOD is classified into Type I (anterior), Type II
(longitudinal), and Type III (posterior) dislocations. All patients with AOD should be treated
with craniocervical fixation and fusion. Without
treatment, nearly all patients developed neurological worsening, many of whom never fully recover.
Treatment of AOD with traction is associated
with 10% risk of neurological deterioration and
external immobilization has a high failure rate.
A 21-year-old male complains of 1 year duration of neck pain. He denies any recent trauma. He has noticed intermittent episodes of gait imbalance and difficulty with buttoning his shirt over the past 3 months. Physical exam shows normal strength in all four
extremities and hyper-reflexic patellar tendons. Neutral and flexion radiographs are awaited. Which one of the following is the most appropriate treatment?
a. Physiotherapy
b. Conservative management with avoidance of contact sport
c. Soft collar during sports
d. Posterior C1-C2 fusion
e. Anterior C1-C2 fusion
d. Posterior C1-C2 fusion
Os odontoideum is an ossicle with smooth circumferential cortical margins representing the
odontoid process that has no osseous continuity
with the body of C2. The origin of os odontoideum remains debated in the literature with
evidence for both acquired and congenital causes.
There are 3 groups of patients with os odontoideum: those with occipito-cervical pain alone,
those with myelopathy, and those with intracranial symptoms or signs from vertebrobasilar
ischemia. Patients with os odontoideum and myelopathy have been subcategorized further into
those with transient myelopathy (commonly after
trauma), those with static myelopathy, and those
with progressive myelopathy. It is usually found
on imaging for other causes, and plain cervical
spine radiographs are sufficient to obtain a diagnosis but will necessitate dynamic flexion/ extension views (plain film and dynamic CT). It
may be orthotopic (moves with the anterior arch
of C1 on flexion/extension) or dystopic (functionally fused to the basion, potentially subluxing
anterior to the arch of C1). Plain dynamic radiographs in flexion and extension have been used to
depict the degree of abnormal motion between
C1 and C2 and narrowest canal diameter. Most
often, there is anterior instability, with the os
odontoideum translating forward in relation to
the body of C2. However, at times, one will see
either no discernible instability or “posterior
instability” with the os odontoideum moving posteriorly into the spinal canal during neck extension. The degree of C1-C2 instability identified on cervical X-rays does not correlate with the presence of myelopathy. A sagittal diameter of
the spinal canal at the C1-C2 level of 13 mm does
correlate with myelopathy detected on clinical
examination. MRI can depict spinal cord compression and signal changes within the cord that correlate with the presence of myelopathy. Management is surveillance or surgery based on
degree of instability, neurological deficits or risk
of future spinal cord injury. Patients who have no
neurological deficit and no instability at C1-C2
on flexion and extension studies can be managed
without operative intervention. However, many
favor operative stabilization and fusion of C1-
C2 instability associated with os odontoideum
because of the increased likelihood of future spinal cord injury following minor trauma (if not
already present). Posterior C1-C2 internal fixation with arthrodesis in the treatment of os odontoideum provides effective stabilization of the
atlantoaxial joint in the majority of patients. Neural compression in association with os odontoideum has been treated with a reduction of
deformity, dorsal decompression of irreducible
deformity, and ventral decompression of irreducible deformity, each in conjunction with C1-C2 or occipito-cervical fusion with internal fixation.
Each of these combined approaches has provided
satisfactory results. Odontoid screw fixation has
no role in the treatment of this disorder.
A 76-year-old falls but does not lose consciousness, but does complain of neck pain. He is neurologically intact. CTs are shown and sum of displacement of C1 lateral masses on C2 is 9 mm.
Which one of the following would be
appropriate management in this case?
a. Conservative management
b. Cervical collar
c. Halo immobilization for 12 weeks
d. C1-C2 instrumented fusion
e. Minerva vest
d. C1-C2 instrumented fusion
Fractures of C1 are usually classified by the
Landell’s and Von Petegham classification.
A central issue in the management of atlas fractures has been the importance placed on the
integrity of the transverse atlantal ligament. Criteria proposed to determine transverse atlantal ligament injury with associated C1-C2 instability
include the sum of the displacement of the lateral
masses of C1 on C2 of 6-9 mm on a plain openmouth X-ray (or 8.1 mm, the rule of Spence corrected for magnification), a predental space of
>5 mm in adults, and evidence of transverse atlantal ligament disruption or avulsion on MRI
41 A. A value less than 0.80 is considered a risk factor for neurological injury after minor trauma.
Craniocervical measurements:
a. Atlantodens interval (ADI)
b. Basion axial interval (BAI)
c. Basion dens interval (BDI)
d. C1-Condyle interval (CCI)
e. Chamberlain
f. McGregor
g. McRae
h. Pavlov (torg) ratio
i. Power’s ratio
j. Ranawat
k. Space available for the cord (SAC)
l. Wackenheim’s line
h. Pavlov (torg) ratio
41 B. A value less than 14 mm is considered a risk
factor for neurological injury in patients
with rheumatoid arthritis.
Craniocervical measurements:
a. Atlantodens interval (ADI)
b. Basion axial interval (BAI)
c. Basion dens interval (BDI)
d. C1-Condyle interval (CCI)
e. Chamberlain
f. McGregor
g. McRae
h. Pavlov (torg) ratio
i. Power’s ratio
j. Ranawat
k. Space available for the cord (SAC)
l. Wackenheim’s line
k. Space available for the cord (SAC)
41 C. A line drawn from the center of the C2 pedicle to the C1 arch.
Craniocervical measurements:
a. Atlantodens interval (ADI)
b. Basion axial interval (BAI)
c. Basion dens interval (BDI)
d. C1-Condyle interval (CCI)
e. Chamberlain
f. McGregor
g. McRae
h. Pavlov (torg) ratio
i. Power’s ratio
j. Ranawat
k. Space available for the cord (SAC)
l. Wackenheim’s line
j. Ranawat
