Spine - Spinal Cord Injuries Flashcards
CASE 1: Terminology of Spinal Cord Injuries HISTORY: A 19-year-old male noted neck pain and immediate weakness in all limbs after making a tackle while playing football. He was taken to the local emergency room. EXAMINATION: On examination there was no evidence of trauma except tenderness of the mid-cervical region. He was profoundiy weak (i.e. unable to overcome gravity) in his lower extremities but he was able to move his toes, ankles, knees And hips bilaterally. The patient had no movements of the upper extremities below the biceps muscle levels (C6) bilaterally and had absent deep tendon reflexes in all extremities. The patient had a sensory level at C6 bilaterally which was complete below this level in the arms and upper torso with partial sparing of pinprick and joint position sensation in the lower torso, legs and sacral region. The patient’s anal tone was reduced. X-RAY: Cervical spine x-rays showed a fracture-dislocation at C5-5. HOSPITAL COURSE: In the emergency room, the patient’s family inquired about the nature of the injury and the emergency room physician told them the patient was “paralyzed”.
- Terms which might correctly be used to describe the motor aspect of this patient’s spinal injury are (Select one or more)
A. Paralysis
B. Paresis
C. Quadriplegia
D. Quadraparesis
E. Central cord syndrome
(A,B,D,E) Impairment of strength results in weakness, or paresis; and loss of strength, in paralysis. Plegia is used synonymously with paralysis. This patient is paralyzed in his upper extremities and paretic in his lower extremities. Loss of strength in all four limbs is termed quadraplegia, whereas impaired strength involving four limbs is termed quadraparesis. Since the patient has sparing of some motor function in his lower extremities, he is quadraparetic. Central cord syndrome is characterized by more motor impairment of the upper than the lower extremities, bladder dysfunction and varying decrees of sensory loss below the level of the lesion.
CASE 1: Terminology of Spinal Cord Injuries HISTORY: A 19-year-old male noted neck pain and immediate weakness in all limbs after making a tackle while playing football. He was taken to the local emergency room. EXAMINATION: On examination there was no evidence of trauma except tenderness of the mid-cervical region. He was profoundiy weak ( i . e . unable to overcome gravity) in his lower extremities but he was able to move his toes, ankles, knees And hips bilaterally. The patient had no movements of the upper extremities below the biceps muscle levels (C6) bilaterally and had absent deep tendon reflexes in all extremities. The patient had a sensory level at C6 bilaterally which was complete below this level in the arms and upper torso with partial sparing of pinprick and joint position sensation in the lower torso, legs and sacral region. The patient’s anal tone was reduced. X-RAY: Cervical spine x-rays showed a fracture-dislocation at C5-5. HOSPITAL COURSE: In the emergency room, the patient’s family inquired about the nature of the injury and the emergency room physician told them the patient was “paralyzed”.
- The patient has a “complete” spinal injury. (True or False)
FALSE
In cases of spinal cord trauma any preservation of volitional motor, sensory or autonomic function below the level of the lesion indicates an “incomplete” injury. Reflex activities alone are preserved below the level of the lesion in “complete” spinal injuries. This patient had sparing of sensation below the level of the lesion and therefore, had an “incomplete” spinal injury.
- The following terms are often used to describe other.spinal injuries. Indicate whether each of the definitions is either true or false.
A. Hemiparesis is defined as weakness involving upper and lower limbs on one side of the body
B. Hemiplegia is defined as paralysis involving upper and lower limbs on one side of the body
C. Hemiplegia alternans is defined as fluctuating weakness of upper and lower limbs on one side of the body
D. Monoparesis is defined as weakness of only one limb
E. Monoplegia is defined as paralysis of only one limb
F. Triplegia is defined as paralysis of three limbs
G. Tetraplegia is defined as paralysis of four limbs
H. Diplegia is defined as paralysis of an upper and lower extremity
I. Brown-Sequard syndrome involves unilateral spinal injury with ipsilateral pinprick and temperature loss and loss of contralateral motor and joint position sense
J. Anterior spinal artery syndrome is defined as paralysis with hypesthesia and hypalgesia below the level of the lesion combined with preservation of joint position, vibratory and touch sensation
A. TRUE
B. TRUE
C. TRUE
D. TRUE
E. TRUE
F. TRUE
G. TRUE
H. FALSE
I. FALSE
J. TRUE
Hemiplegia alternans affects one limb on one side of the body and another limb on.the opposite side (i.e. the right upper and left lower extremities). Diplegia isparalysisof like parts on the two sides of the body (i.e. both upper extremities). The Brown-Sequard syndrome, due to hemisection of the spinal cord, is characterized by ipsiiateral paralysis, ipsilateral joint position loss and contralateral pain and temperature loss below the level of the lesion
CASE 2: Spinal Cord Injury in a 22-Year-Old Man After a HISTORY: A 22-year-old male was seen in the emergency room one hour after a motor vehicle accident. He complained of severe neck pain, numbness of his arms and legs and inability to move his legs. EXAMINATION: Physical examination revealed a complete flaccid paralysis below the C5 level and anesthesia below C5. Paralysis of rectal and bladder sphincters was also present. A clinical diagnosis of cervical spinal cord injury was made. X-RAY: A lateral cervical spine x-ray showed a fracture-dislocation at the C5-6 level.
- Males make up a significantly greater proportion of the population who sustain cervical spinal cord injuries than females. (True or False)
TRUE
A retrospective study of 356 patients with major cervical spinal cord injuries which occurred between 1963 and 1972, was carried out in southern California. In this study, males were injured five times more frequently than women.
CASE 2: Spinal Cord Injury in a 22-Year-Old Man After a HISTORY: A 22-year-old male was seen in the emergency room one hour after a motor vehicle accident. He complained of severe neck pain, numbness of his arms and legs and inability to move his legs. EXAMINATION: Physical examination revealed a complete flaccid paralysis below the C5 level and anesthesia below C5. Paralysis of rectal and bladder sphincters was also present. A clinical diagnosis of cervical spinal cord injury was made. X-RAY: A lateral cervical spine x-ray showed a fracture-dislocation at the C5-6 level.
- The incidence of significant spinal cord injuries per million population per year is about (Select only one)
A. less than 10
B. 10-20
C. 30-40
D. more than 50
(B)
Statistics on the incidence of spinal cord injuries are rare. A few estimates from Switzerland, Australia and the United States are available. Based on European statistics, a figure of 10-20 new spinal cord injuries per million population per year is reasonable. Kraus estimated a much higher figure of 53. 4 per million based on statistics from northern California. The methods used in the studies vary and probably account for the differences in results. The European figures are based mainly on admission to specialized spinal cord injury centers in relatively small countries with well organized national health care systems. The United States figures included all types of injury, including deaths on hospital arrival and minor injuries without significant sequelae. The U.S. incidence indeed may be higher than European countries or it may represent broader definition and more careful search for such injuries. Only further experience will define the true incidence of spinal cord injury. Kraus estimated that, based on his figures, 7.000 new spinal cord injuries occur per year in surviving patients in the United States.
CASE 2: Spinal Cord Injury in a 22-Year-Old Man After a HISTORY: A 22-year-old male was seen in the emergency room one hour after a motor vehicle accident. He complained of severe neck pain, numbness of his arms and legs and inability to move his legs. EXAMINATION: Physical examination revealed a complete flaccid paralysis below the C5 level and anesthesia below C5. Paralysis of rectal and bladder sphincters was also present. A clinical diagnosis of cervical spinal cord injury was made. X-RAY: A lateral cervical spine x-ray showed a fracture-dislocation at the C5-6 level.
- The most common location of spinal cord injury is (Select only one)
A. cervical
B. thoracic
C. lumbar
D. sacral
(A)
Gjone estimated that 53% of spinal cord injuries occur in the cervical region. About 25% occur in the thoracic area, about 12% in the lumbar area and about 9% involve the sacrum and cauda equina region.
CASE 2: Spinal Cord Injury in a 22-Year-Old Man After a HISTORY: A 22-year-old male was seen in the emergency room one hour after a motor vehicle accident. He complained of severe neck pain, numbness of his arms and legs and inability to move his legs. EXAMINATION: Physical examination revealed a complete flaccid paralysis below the C5 level and anesthesia below C5. Paralysis of rectal and bladder sphincters was also present. A clinical diagnosis of cervical spinal cord injury was made. X-RAY: A lateral cervical spine x-ray showed a fracture-dislocation at the C5-6 level.
- The most common age range for occurrence of spinal cord injury is (Select only one)
A. below 20
B. 20-30 years
C. 30-40 years
D. 40-50 years
E. over 50 years
(B)
Unquestionably, spinal cord injury is a disease primarily of young adults. The peak incidence in males 20-30 years is twice that for males 40-50 years old. 10 Spinal cord injury is rare in children under 10. Similar age differences are noted in females and males although the female ratio is about hail that for males in all ages.
CASE 2: Spinal Cord Injury in a 22-Year-Old Man After a HISTORY: A 22-year-old male was seen in the emergency room one hour after a motor vehicle accident. He complained of severe neck pain, numbness of his arms and legs and inability to move his legs. EXAMINATION: Physical examination revealed a complete flaccid paralysis below the C5 level and anesthesia below C5. Paralysis of rectal and bladder sphincters was also present. A clinical diagnosis of cervical spinal cord injury was made. X-RAY: A lateral cervical spine x-ray showed a fracture-dislocation at the C5-6 level.
- Which of the following is true concerning cervical spinal cord injuries? (Select only one)
A. Fifty percent occur in patients ages 16-25 years
B. Automobile accidents account for 501% of cases
C. The most common site of fracture-dislocation is at C5-3
D. All of the above
(D)
All three are true. Heiden found that one half of 356 patients with cervical spinal cord injury were between the ages of 16 and 25. The same authors noted that 50% of cervical spinal cord injuries resulted from automobile accidents. A significant number of injuries were related to athletic events and of these 88% were due to water sports such as diving, surfing and water skiing.
CASE 2: Spinal Cord Injury in a 22-Year-Old Man After a HISTORY: A 22-year-old male was seen in the emergency room one hour after a motor vehicle accident. He complained of severe neck pain, numbness of his arms and legs and inability to move his legs. EXAMINATION: Physical examination revealed a complete flaccid paralysis below the C5 level and anesthesia below C5. Paralysis of rectal and bladder sphincters was also present. A clinical diagnosis of cervical spinal cord injury was made. X-RAY: A lateral cervical spine x-ray showed a fracture-dislocation at the C5-6 level.
- Which of the following is true concerning the immediate treatment of complete transverse injury to the cervical spinal cord? (Select only one)
A. Immediate decompressive laminectomy is indicated
B. Immediate anterior cervical exploration and fusion is indicated
C. The incidence of recovery following complete transverse injury to the cervical spinal cord is very low and is not favorably affected by immediate operative therapy
D. None of the above
(C)
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CASE 3: Mortality, Survival and Spinal Cord Injury HISTORY: A patient (X) years old suffered a (complete/incomplete) spinal cord injury at (Y) level. The patient was successfully resuscitated from all associated injuries and had no fatal complications for the first month following injury.
- As a member of a large unselected group of patients with spinal injuries, what is the likelihood that the patient will survive for 10 years? (Select only one)
A. Less than 25%
B. Less than 50%
C. 50%
D. Greater than 50%
E. Greater than 75%
(D)
On the average, more than 50% of a random group of patients with traumatic spinal cord lesions will be alive 10 years after the injury. Fifty-two percent of quadriplegics and 70. 3% of paraplegics will survive at least this length of time.
CASE 3: Mortality, Survival and Spinal Cord Injury HISTORY: A patient (X) years old suffered a (complete/incomplete) spinal cord injury at (Y) level. The patient was successfully resuscitated from all associated injuries and had no fatal complications for the first month following injury.
- if the patient survives longer than three months, his overall chance of surviving 10 years (Select only one)
A. does not change significantly from question I
B. changes to 50% or less
C. changes to 50%
D. changes to 50% or more
E. changes to 75% or more
(E)
There is an early high mortality rate regardless of the patient’s age and the extent and level of the spinal lesion at the time of injury. However, for those patients that survive the first three months after injury, overall 10 year survival is 80% or greater. 4 In fact, for those who survive beyond the first three months, long term survival approximates closely the expected survival of the general population.
CASE 3: Mortality, Survival and Spinal Cord Injury HISTORY: A patient (X) years old suffered a (complete/incomplete) spinal cord injury at (Y) level. The patient was successfully resuscitated from all associated injuries and had no fatal complications for the first month following injury.
- The patient’s age (X) is 20 years at the time of injury. His likelihood of 10 years, survival is approximately twice that of a patient who at the time of injury (Select only one)
A. is 25-35 years old
B. is 35-45 years old
C. is 45 years old or older
D. age is a variable that does not significantly influence long term survival
(C)
Age is an important determining variable influencing survival for spinal cord injury. 1, 5 i n a group of paraplegics, 10 year survival for 15-24 year old was 86% whereas survival decreased to 41% for 45-59 year old.
CASE 3: Mortality, Survival and Spinal Cord Injury HISTORY: A patient (X) years old suffered a (complete/incomplete) spinal cord injury at (Y) level. The patient was successfully resuscitated from all associated injuries and had no fatal complications for the first month following injury.
- The patients neural lesion is complete as opposed to incomplete. This is a detrimental factor with regard to his likelihood of long term survival. (True or False)
TRUE
For patients with lesions at the same level, those with incomplete lesions fare significantly better than those with complete lesions. For instance, in the cervical region overall, 10 year survival is 69% and 40% for incomplete and complete lesions, respectively.
CASE 3: Mortality, Survival and Spinal Cord Injury HISTORY: A patient (X) years old suffered a (complete/incomplete) spinal cord injury at (Y) level. The patient was successfully resuscitated from all associated injuries and had no fatal complications for the first month following injury.
- The level of the patient’s lesion (Y) is C4. The patient’s chance of 3 month survival is approximately half that of a patient with a lesion at (Select only one)
A. C6
B. T6
C. T12
D. L2 or lower
E. survival in spinally injured patients is not significantly affected by the level of the lesion
(C)
Forty-three percent of patients with C1 - 5 lesions survived the first three months after injury, whereas approximately 85% of patients with T2-11 lesions survived at least this length of time. Approximately 70-75% of patients with intermediate level lesions survived three months or more and patients with lesions below thoracic levels have even better survival rates. The level of a spinal lesion is an important variable determining survival following spinal injury.
CASE 3: Mortality, Survival and Spinal Cord Injury HISTORY: A patient (X) years old suffered a (complete/incomplete) spinal cord injury at (Y) level. The patient was successfully resuscitated from all associated injuries and had no fatal complications for the first month following injury.
- Having survived for the first month., the patient is most likely to die of what cause? (Select only one)
A. Renal failure
B. Cardiovascular disease
C. Pneumonia
D. Decubitus ulcers
E. Suicide
(A)
Although all the listed causes of death except B, cardiovascular, are seen with a higher incidence in the spinally injured group than in the general population, renal failure remains the most common fatal complication of spinally injured patients.
CASE 4: Neck Pain in a 37-Year-Old Man Following Cerebral Concussion HISTORY: A 37-year-old man was a passenger in an automobile involved in an accident. He was thrown clear of the automobile and rendered unconscious. A paramedic at the accident scene requests your advice, via two-way radio, concerning transportation of the patient. The paramedic reports that the patient was unconscious about 10 minutes but is now awake and complains of pain in the neck, left forearm and right leg. EXAMINATION: Neurological examination by the paramedic is normal. QUESTIONS
- Concerning transportation to the hospital, you would advise (Select only one)
A. asking the patient to walk to the ambulance impossible
B. log rolling the patient onto a broad piece of plywood or firmly supported stretcher and sandbagging the head and neck
C. lifting the patient under the knees and armpits and transferring him to a stretcher
D. advising the patient to travel by private automobile to the hospital to avoid the expense of ambulance fees
(B)
All patients who complain of spine pain following trauma should be considered as having significant injury to the spinal column until proven otherwise. As such, transportation should be carried out with extreme caution. Under no circumstances should a patient who complains of spine pain following trauma be allowed to move about and ambulate prior to thorough examination. Log rolling of the patient onto a firm surface such as a broad piece of plywood, a wooden door or an appropriately supported spinal stretcher should be utilized for transportation of such patients. During transportation, the head and neck should be sandbagged or otherwise appropriately prevented from moving. Longitudinal traction applied by hand to the patient’s head may be of assistance during patient movement, but solidly securing the head and trunk to a firm surface is recommended. Under no circumstances should a patient with potential cervical spine injury be moved by lifting the patient under the knees and armpits. Such movements result in marked flexion and stress upon the entire spine and the possibility exists of converting a simple fracture or minor fracture-dislocation into a major dislocation with spinal cord injury. Patients with suspected spinal cord trauma should travel by stretcher with supervision by appropriately trained emergency personnel. Problems with hypotension, vomiting and respiratory difficulty may ensue in such patients and means for handling such emergencies should be available. If vomiting should occur during transportation, prevention of aspiration and respiratory distress takes precedence over maintaining body positioning. In such instances, it may be necessary to log roll a patient onto his side with proper vertebral support in order to drain or suction vomitus from the oral pharynx and mouth.
CASE 4: Neck Pain in a 37-Year-Old Man Following Cerebral Concussion HISTORY: A 37-year-old man was a passenger in an automobile involved in an accident. He was thrown clear of the automobile and rendered unconscious. A paramedic at the accident scene requests your advice, via two-way radio, concerning transportation of the patient. The paramedic reports that the patient was unconscious about 10 minutes but is now awake and complains of pain in the neck, left forearm and right leg. EXAMINATION: Neurological examination by the paramedic is normal. QUESTIONS
- Examination of the patient in the emergency room reveals restricted movements of the head and neck in all directions. Neurological examination is normal. Portable AP and lateral x-rays of the cervical spine are normal. Concerning portable x-rays for evaluation of cervical spine trauma, which of the following are true? (Select one or more)
A. Are reliable in excluding cervical spine injury if negative
B. Are useful in screening acutely injured patients for major injuries
C. Must extend from C1 to at least C7
D. Should be followed by a full series of cervical spine x-rays as soon as the patient’s condition permits
(B,C,D)
Portable cervical spine x-rays taken in the evaluation of potential spinal trauma should be considered as screening procedure. Reliance on such portable screening x-rays to evaluate cervical spine trauma will result in a significant number of missed spinal fractures. It is important that screening x-rays of the cervical spine extend from the atlanto-occipital junction to at least CV 3,7 AP and lateral x-rays are important. It is essential to follow screening cervical spine portable x-rays with a complete set of cervical spine x-rays including an anterior-posterior, lateral, open mouth and oblique views from the right and left sides. If such an examination fails to reveal pathology but the patient continues to complain of symptoms or if bothersome signs continue to be present, a variety of additional techniques may be required to adequately evaluate the cervical spine. These might include special views, particularly in the cervical dorsal junction region, traction on the arms to depress the shoulders, swimmer news or tomography. With proper supervision, flexion or extension views or cinefluoroscopy may be of help in identifying dislocations which are primarily due to ligamentous trauma an therefore not revealed on static film.
CASE 4: Neck Pain in a 37-Year-Old Man Following Cerebral Concussion HISTORY: A 37-year-old man was a passenger in an automobile involved in an accident. He was thrown clear of the automobile and rendered unconscious. A paramedic at the accident scene requests your advice, via two-way radio, concerning transportation of the patient. The paramedic reports that the patient was unconscious about 10 minutes but is now awake and complains of pain in the neck, left forearm and right leg. EXAMINATION: Neurological examination by the paramedic is normal. QUESTIONS
- Which of the following are true concerning the evaluation of potential cervical spine trauma in patients with head injury (Select only one)
A. All patients with significant head trauma should be evaluated radiologic ally for possible associated cervical spine trauma
B. Clinical examination is sufficient to exclude significant cervical spine trauma
C. In the absence of complaints, evaluation for cervical spine trauma is unrewarding
D. Significant cervical spine trauma is associated only with major head injuries with prolonged unconsciousness
(A)
The coexistence of significant head trauma with injuries of the cervical spine is well documented in the literatur. Shrago reported that 53% of a series of 50 patient with injuries of the upper cervical spine had evidence of concurrent head trauma. In patients with concomitant head injury and cervical spine injury, the incidence of injury is greatest in the upper cervical spine, particularly in the atlanto-occipital and C1 regions. In Shrago’s series, 56% had injuries involving the upper cervical spine and 34% had injuries at C5 and below. Only 10% had injuries involving the midcervical spine (C3, 4). The wide range of motion at the atlanto-axial and atlanto-occipital joints predisposes to certain traumatic forces. While failure to identify cervical spine trauma in association with head trauma may not always result in immediate spinal cord injury, the potential for delayed injury exists. The occurrence of delayed myelopathy following non-union of unsuspected atlanto-axial dislocations was described by Bachs, et al. Although clinical examination has been correctly stressed in the evaluation of cervical spine trauma, there is no substitute for an adequate radiological examination of the cervical spine to exclude significant spinal trauma. Complaints referrable to the cervical spine may be minimal, or patients may be unconscious or confused following head injury and unable to describe symptoms referrable to the cervical spine. It is essential that in any patient unconscious from head trauma, adequate x-rays of the cervical spine be obtained before manipulations of the head and neck take place. Although the index of suspicion may be high for cervical spine fractures in association with major head injuries, significant cervical spine trauma may also occur with-minor head injuries. Shrago described patients having only minor lacerations and contusions of the scalp or brief periods of unconsciousness with significant associated cervical spine trauma including fracture-dislocation. Thus, a high index of suspicion should be maintained in any patient with head trauma, even though minor, for the possibility of cervical spine injury.
CASE 4: Neck Pain in a 37-Year-Old Man Following Cerebral Concussion HISTORY: A 37-year-old man was a passenger in an automobile involved in an accident. He was thrown clear of the automobile and rendered unconscious. A paramedic at the accident scene requests your advice, via two-way radio, concerning transportation of the patient. The paramedic reports that thepatient was unconscious about 10 minutes but is now awake and complains of pain in the neck, left forearm and right leg. EXAMINATION: Neurological examination by the paramedic is normal. QUESTIONS
The patient in question was admitted to the hospital for observation. On the day following admission while sitting up, he complained of progressive numbness and weakness of the iower extremities which progressed to paraplegia over an hour. Examination revealed flaccid paraplegia except for slight toe movement and loss of all sensation below T3. Sphincter paralysis was also noted.
- Which of the following would be suspected as a potential cause of deterioration? (Select only one)
A. Spinal epidural hematoma
B. Spinal subdural hematoma
C. Acute disc herniation at C7-T1
D. Missed fracture-dislocation C7 –T1
E. All the above
(E)
All of the lesions described could be responsible for delayed progressive myelopathy following spine trauma. Rinaldi, et al described a patient with apparently normal cervical spine films who progressed to paraplegia 24 hours following injury. Repeat x-rays indicated that the patient had a fracture-dislocation at the C7-T1 interspace with locked facets. This fracture was not revealed on the original spine x-rays since they extended as low as C7 but did not include the C7-T1 junction. This case illustrates the need for careful radiological evaluation in patients with potential cervical spine trauma. Intraspinal hematomas, both epidural and subdural, may also be responsible for delayed spinal cord injury following spinal trauma and such hematomas are not necessarily associated with bony injury. Thus, radiologic examination of the spine may be truly normal and subsequent deterioration may occur through the formation of an intraspinal hematoma. Such situations are rare but should be kept in mind when delayed deterioration occurs. Acute traumatic ruptured discs with spinal cord compression also may occur following spinal trauma. Such intervertebral disc herniations may be responsible for spinal cord injury and neurological deterioration either in the immediate post injury period or on a delayed basis, weeks, months or even years following the injury. Patients who deteriorate following an initial injury require immediate vigorous radiologic evaluation including plain x-rays, at times tomography and very frequently myelography, for thorough evaluation of the underlying pathology. Recovery of function may be possible if neurologic deterioration is recognized and treated promptly. In the case illustrated by Rinaldi, et al. nearly complete neurological recovery ensued, although the patient was almost completely paraplegic with total sensory loss and sphincter paralysis prior to operation.
CASE 5: Spinal Shock Following Cervical Spinal Cord Injury HISTORY: A previously healthy 34-year-old woman was admitted to the emergency room following a motorcycle accident. She was alert and complained of neck pain. EXAMINATION: General physical examination was normal. Neurological examination revealed anesthesia, flaccid quadripiegia, areflexia and flaccid sphincter paralysis below C5. Blood pressure was 80/50, pulse 60, T 90.6 ° F . EKG showed sinus bradycardia. QUESTIONS
- The hypotension seen in this patient is most likely due to which one of the following? (Select only one)
A. Hypovolemic shock
B. Cardiogenic shock
C. Sympathectomy effect
D. Gram-negative septicemia
(C)
Although hypovolemic shock from associated injuries is possible, it is unlikely with a bradycardia of 60. Associated injuries should be sought bat volume replacement is unnecessary in the absence of evidence of hemorrhage. Cardiogenic shock is unlikely with a normal EKG. The possibility of cardiac contusion should be considered but is unlikely with the normal EKG. Transverse spinal cord lesions above C8, T1 produce a complete sympathectomy. This results in moderate hypotension and bradycardia. In the absence of associated injuries, this most likely accounts for hypotension and bradycardia noted in this patient. Although treatment is usually unnecessary, if desired the blood pressure may be elevated with vasopressors. Gram-negative sepsis may produce hypotension in patients with chronic spinal cord injury. This usually occurs secondary to urinary tract infection and secondary gram-negative septicemia. It is unlikely with acute spinal cord injury in a previously healthy individual.
CASE 5: Spinal Shock Following Cervical Spinal Cord Injury HISTORY: A previously healthy 34-year-old woman was admitted to the emergency room following a motorcycle accident. She was alert and complained of neck pain. EXAMINATION: General physical examination was normal. Neurological examination revealed anesthesia, flaccid quadripiegia, areflexia and flaccid sphincter paralysis below C5. Blood pressure was 80/50, pulse 60, T 90.6 ° F . EKG showed sinus bradycardia. QUESTIONS
- The hypothermia seen in this patient is most likely due to which one of the following? (Select only one)
A. Secondary to hypotension
B. Sympathectomy effect
C. Prolonged exposure to a low environmental temperature
D. Hypothalamic injury
(B)
Sympathectomy produced by cervical spinai cord injury leads to dilatation of skin blood vessels and anhydrosis. As a result, the normal mechanisms utilized to regulate body temperature are impaired. The patients show poikilothermia or a tendency for body temperature to seek the environmental temperature. Thus, under most ambient outdoor conditions, hypothermia occurs, as in this patient. Prolonged exposure to very low environmental temperatures may lead to hypothermia in normal individuals. There is no evidence that this patient was exposed to such conditions. Mild hypothermia may be associated with hypovolemic shock and marked hypotension. The hypotension seen in this patient is mild and is due to sympathectomy. Erratic fluctuations in body temperature may be seen with hypothalamic injury. This is usuaiiy seen with severe intracranial pathology such as head injury with coma, brain tumor, or intracranial hemorrhage. This patient was mentally alert with no evidence of intracranial pathology.
CASE 5: Spinal Shock Following Cervical Spinal Cord Injury HISTORY: A previously healthy 34-year-old woman was admitted to the emergency room following a motorcycle accident. She was alert and complained of neck pain. EXAMINATION: General physical examination was normal. Neurological examination revealed anesthesia, flaccid quadripiegia, areflexia and flaccid sphincter paralysis below C5. Blood pressure was 80/50, pulse 60, T 90.6 ° F . EKG showed sinus bradycardia. QUESTIONS
- The flaccid quadriplegia seen in this patient is due to which of the following? (Select only one)
A. Spinal shock
B. An upper motor neuron injury
C. A lower motor neuron injury
D. A combination of upper and lower motor neuron injury
E. None of the above
(A)
Spinal shock is defined as a total loss of spinal cord function below the level of an acute spinal cord lesion. It is seen not only with spinal cord injury but also with other acute spinal cord lesions such as infarction, hemorrhage, and infection. It accounts for the quadriplegia in this patient. Although upper motor neuron injury is present in this patient, it does not account for flaccid paralysis. Upper motor neuron lesions are associated with spastic paralysis and hyperreflexia. These clinical signs are masked by spinal shock. Lower motor neuron injury produces flaccid paralysis. In this patient, some of the lower motor neurons to the arms may have been injured. No injury has occurred to the lower motor neurons to the legs. The flaccid paralysis is due to spinal shock.
CASE 5: Spinal Shock Following Cervical Spinal Cord Injury HISTORY: A previously healthy 34-year-old woman was admitted to the emergency room following a motorcycle accident. She was alert and complained of neck pain. EXAMINATION: General physical examination was normal. Neurological examination revealed anesthesia, flaccid quadripiegia, areflexia and flaccid sphincter paralysis below C5. Blood pressure was 80/50, pulse 60, T 90.6 ° F . EKG showed sinus bradycardia. QUESTIONS
- Which of the following are true concerning spinal shock? (Select one or more)
A. Lasts for 4-6 weeks in humans
B. Refers to complete lack of spinal cord function below the level of an acute injury
C. Exact physiological mechanism unknown
D. None of the above
(A,B,C)
Spinal shock in humans usually lasts 4-6 weeks and subsides gradually. As it subsides the expected results of the upper motor neuron lesion in-the cervical spinal cord, namely spastic paralysis and hyperreflexia in the legs, gradually become apparent. The persistence or early return of very caudal reflexes such as the bulbocavernosus should not be taken as evidence that spinal shock has subsided. Increasing muscle tone and return of reflexes herald the end of the period of spinal shock.
CASE 5: Spinal Shock Following Cervical Spinal Cord Injury HISTORY: A previously healthy 34-year-old woman was admitted to the emergency room following a motorcycle accident. She was alert and complained of neck pain. EXAMINATION: General physical examination was normal. Neurological examination revealed anesthesia, flaccid quadripiegia, areflexia and flaccid sphincter paralysis below C5. Blood pressure was 80/50, pulse 60, T 90.6 ° F . EKG showed sinus bradycardia. QUESTIONS
- Which of the following have been proposed as mechanisms for the occurrence of spinal shock? (Select one or more)
A. Interruption of descending facilitation to spinal reflexes
B. Persistent inhibition below the level of injury
C. Axonal degeneration of inter neurons
D. Hyperpolarization of motor neurons
E. None of the above
(A,B,C,D)
McCough suggested three mechanisms involved in the production of spinal shock. The first is loss of reticulospinal and vestibulospinal. Fulton also implicated interruption of descending corticospinal pathways as a mechanism in spinal shock. Interruption of descending facilitatory influences probably represents the commonest theory for the mechanism of spinal shock. As a result of spinal transection there is reduced activity of gamma motor neurons, and increase in presynaptic inhibition locally. Thus, the alpha motor neurons are inhibited, the muscle is flaccid and the afferent input from stretching the muscle tendon is unable to excite the alpha motor neurons, with resulting areflexia. McCough also suggested that persisting inhibitory influences from below the level of injury could also affect spinal reflexes. Inhibitory influences in the lumbar spinal cord have been shown to depress reflexes in the thoracic and cervical regions in decerebrate rigidity and this effect can be abolished by retransection of the spinal cord in the thoracic region. McCough also suggested that degeneration of interneuronal axons might play a role in spinal shock. Barnes found hyperpolarization of the motor neuronal membrane resting potential in spinal shock and felt this was the major physiological derangement responsible for areflexia and. flaccidity.
CASE 5: Spinal Shock Following Cervical Spinal Cord Injury HISTORY: A previously healthy 34-year-old woman was admitted to the emergency room following a motorcycle accident. She was alert and complained of neck pain. EXAMINATION: General physical examination was normal. Neurological examination revealed anesthesia, flaccid quadripiegia, areflexia and flaccid sphincter paralysis below C5. Blood pressure was 80/50, pulse 60, T 90.6 ° F . EKG showed sinus bradycardia. QUESTIONS
- Which of the following clinical phenomena may also be seen with spina! shock due to cervical spinal cord injury? (Select one or more)
A. Nasal obstruction
B. Intestinal paralysis
C. Flaccid urinary bladder
D. None of the above
(A,B,C)
Loss of sympathetic control due to cervical spinal cord injury leads to loss of vasoconstriction of vessels in the head and face. Vasodilatation in the supine and particularly in the prone position leads to nasal mucosal congestion and swelling causing nasal obstruction with difficulty breathing and swallowing. Paralysis of intestinal peristalsis ileus occurs with spinal shock. This may be associated with intestinal and gastric distention. Bowel sounds are hypoactive or absent. Abdominal distention may add to respiratory insufficiency and lead to death in patients with compromised respiratory function following cervical spinal cord injury, Thus, nasogastric drainage and intravenous fluids with no oral intake may be required for several days until peristalsis resumes. Since the intestinal muscle has intrinsic contractile ability, recovery of peristalsis occurs much more quickly than the reflexes related to skeletal muscle. Flaccid paralysis of bladder function also occurs acutely. As spinal shock subsides, bladder muscle tone increases and a spastic neurogenic bladder develops.
CASE 6: Jefferson Fracture HISTORY: A 62-year-old male was involved in an automobile accident as a passenger. He was momentarily unconscious and was amnesic for the event. When questioned in the emergency room he complained of neck pain and numbness and weakness of all limbs. EXAMINATION: The patient was bright and alert but amnesic for the events of the accident, there was a bruise on his forehead, but otherwise, examination of his cranium and cranial nerves was normal. His neck was tender to palpation at the base of the skull. While there was sensory and motor deficit in all limbs, it was considerably and symmetrically worse in his upper extremities. Deep tendon reflexes were diminished throughout. X-RAY: Cervical spine x-rays showed a Jefferson fracture with out evidence of bony abnormality of other cervical elements (Figure 6. 1). QUESTIONS
- Lateral x-ray views of the cervical spine may show which of the following changes with a Jefferson fracture? (Select one or more)
A. A fracture of the posterior arch of the atlas
B. Displaced fragments of the anterior arch of the atlas
C. Soft tissue swelling in the prevertebral space
D. An increase in the distance between the anterior aspect of the dens and the posterior aspect of the anterior arch of the atlas
E. None of the above
(A,B,C,D)
Although all of the lateral cervical x-ray findings mentioned may be seen with Jefferson fracture, routine lateral views do not always reveal the full extent of injuries of the atlas. if the posterior arch is fractured on one side only, a slightly oblique lateral projection may show the fracture to better advantage.
CASE 6: Jefferson Fracture HISTORY: A 62-year-old male was involved in an automobile accident as a passenger. He was momentarily unconscious and was amnesic for the event. When questioned in the emergency room he complained of neck pain and numbness and weakness of all limbs. EXAMINATION: The patient was bright and alert but amnesic for the events of the accident, there was a bruise on his forehead, but otherwise, examination of his cranium and cranial nerves was normal. His neck was tender to palpation at the base of the skull. While there was sensory and motor deficit in all limbs, it was considerably and symmetrically worse in his upper extremities. Deep tendon reflexes were diminished throughout. X-RAY: Cervical spine x-rays showed a Jefferson fracture with out evidence of bony abnormality of other cervical elements (Figure 6. 1). QUESTIONS
- Open mouth anterior-posterior x-ray views of the cervical spine are likely to show which of the following changes associated with a Jefferson fracture? (Select one or more)
A. A fracture of the anterior arch of the atlas
B. A fracture of the posterior arch of the atlas
C. Outward displacement of the lateral masses of the atlas
D. A fracture of the lateral mass or transverse process of the atlas
E. None of the above
(A,C)
A lateral displacement of both lateral masses of the atlas with respect to the lateral borders of the body of the axis is highly suggestive of Jefferson fracture. A fracture through the anterior arch of the atlas can occasionally be seen, but fractures of the posterior arch are visually located just behind the lateral masses and are hidden by the lateral masses on AP views. Fractures of the lateral masses or transverse process of the atlas are extremely uncommon (see discussion for question 3) but do occasionally occur. As with the lateral view, the open mouth AP x-ray may not reveal injuries of the atlas.
CASE 6: Jefferson Fracture HISTORY: A 62-year-old male was involved in an automobile accident as a passenger. He was momentarily unconscious and was amnesic for the event. When questioned in the emergency room he complained of neck pain and numbness and weakness of all limbs. EXAMINATION: The patient was bright and alert but amnesic for the events of the accident, there was a bruise on his forehead, but otherwise, examination of his cranium and cranial nerves was normal. His neck was tender to palpation at the base of the skull. While there was sensory and motor deficit in all limbs, it was considerably and symmetrically worse in his upper extremities. Deep tendon reflexes were diminished throughout. X-RAY: Cervical spine x-rays showed a Jefferson fracture with out evidence of bony abnormality of other cervical elements (Figure 6. 1). QUESTIONS
- The likely mechanism of bony injury in a Jefferson fracture may include which of the following? (Select one or more)
A. Direct force applied to the atlas
B. Force applied to the skull and transmitted through the occipital condyles to the lateral masses of the atlas
C. Force applied to the lower spine and transmitted through the spinal axis to the lateral masses of the atlas
D. Hyperextension of the skull exerting a levering action on the posterior arch of the atlas
E. None of the above
(B,C,D)
Jefferson’s original account of the mechanisms of atlas fractures is still considered accurate. Direct trauma to the atlas is extremely rare, because of the well protected position of the atlas beneath the overhanging output and thick muscular barrier. Indirect forces are usually responsible for atlas fractures, the most common being the mechanism of transmitted forced either from above via the skull, often a blow to the vertex, or from below via the spine, often a fall on the buttocks. The atlas is subjected to forces from above and below which are divergent (Figure 6.2) and the net consequence is a lateral spread of the atlas and one or more fractures at weak points of the atlas ring (Figures 6.3 and 6.4). Fracture of the atlas can also occur indirectly by hyperextension of the head, crushing or cracking the posterior arch between the occiput and the axis. Fractures through the posterior arch commonly occur at the weakest point, namely the anteriorly placed grooves for the vertebral artery and suboccipital nerve. The lateral masses and transverse processes are not usually subject to these indirect forces, although occasionally if a patient’s head is tilted or turned at the time of injury forces may be more directly applied to these structures causing a crush injury of the lateral mass. *pict* *pict* *pict*
CASE 6: Jefferson Fracture HISTORY: A 62-year-old male was involved in an automobile accident as a passenger. He was momentarily unconscious and was amnesic for the event. When questioned in the emergency room he complained of neck pain and numbness and weakness of all limbs. EXAMINATION: The patient was bright and alert but amnesic for the events of the accident, there was a bruise on his forehead, but otherwise, examination of his cranium and cranial nerves was normal. His neck was tender to palpation at the base of the skull. While there was sensory and motor deficit in all limbs, it was considerably and symmetrically worse in his upper extremities. Deep tendon reflexes were diminished throughout. X-RAY: Cervical spine x-rays showed a Jefferson fracture with out evidence of bony abnormality of other cervical elements (Figure 6. 1). QUESTIONS
- Jefferson fractures (Select one or more)
A. represent a small percentage of the total fractures of the cervical spine
B. more than half the time are associated with other fractures of the upper cervical spine
C. more than half the time are associated with spinal cord injury
D. are associated with approximately 10% mortality
E. none of the above
(A,D)
Atlas fractures comprise only 2 to 3 o of fractures of the cervical spine. Fractures at lower cervical levels are much more common. Approximately 30% of fractures of the atlas are associated with fractures at other cervical levels, most notably at C2. The space within the ring of the atlas is approximately 1/3 odontoid, 1/3 spinal cord and 1/3 CSF and soft tissues and, therefore, spinal injury is thought to be uncommon, with isolated Jefferson fractures. In Jefferson’s original reports 19 of 46 patients with fractures of the atlas had spinal injury, but in most of these there was bony injury at other cervical levels. Hinchey and Bickel reviewed 112 fractures of the atlas with a mortality of 10%. However, in this report, as in Jefferson’s, more than half of the patients manifested cervical fractures at other levels. Fractures at multiple levels increase the hazard of morbidity and mortality. In addition, some patients with Jefferson fractures probably sustain immediately fatal injuries and are not included in statistics.
CASE 6: Jefferson Fracture HISTORY: A 62-year-old male was involved in an automobile accident as a passenger. He was momentarily unconscious and was amnesic for the event. When questioned in the emergency room he complained of neck pain and numbness and weakness of all limbs. EXAMINATION: The patient was bright and alert but amnesic for the events of the accident, there was a bruise on his forehead, but otherwise, examination of his cranium and cranial nerves was normal. His neck was tender to palpation at the base of the skull. While there was sensory and motor deficit in all limbs, it was considerably and symmetrically worse in his upper extremities. Deep tendon reflexes were diminished throughout. X-RAY: Cervical spine x-rays showed a Jefferson fracture with out evidence of bony abnormality of other cervical elements (Figure 6. 1). QUESTIONS
- The mechanism of neural injury in this patient might be explained on which of the following bases? (Select one or more)
A. “Cruciate paralysis’
B. Hemiplegia cruciata (crossed hemiplegia)
C. Central cord syndrome
D. Anterior spinal artery syndrome
E. None of the above
(A,C)
“Cruciate paralysis” was described by Bell and ascribed weakness of the arms greater than the legs to acute lower medullary compression. In this region the pyramidal decussation of motor fibers to the arms are more cephalad and more superficial than fibers to the legs and, therefore, in some cases, more vulnerable to upper cervical fractures. “Hemiplegia cruciata” also represents a lesion in the pyramidal decussation but results in ipsilateral paresis of the arm and contralateral paresis of the leg. Disproportionately more motor impairment in the upper than the lower extremities is the hallmark of the central spinal cord syndromic. The anterior spinal artery syndrome is characterized by complete paralysis below the level of the lesion with sparing of dorsal column sensation.
CASE 6: Jefferson Fracture HISTORY: A 62-year-old male was involved in an automobile accident as a passenger. He was momentarily unconscious and was amnesic for the event. When questioned in the emergency room he complained of neck pain and numbness and weakness of all limbs. EXAMINATION: The patient was bright and alert but amnesic for the events of the accident, there was a bruise on his forehead, but otherwise, examination of his cranium and cranial nerves was normal. His neck was tender to palpation at the base of the skull. While there was sensory and motor deficit in all limbs, it was considerably and symmetrically worse in his upper extremities. Deep tendon reflexes were diminished throughout. X-RAY: Cervical spine x-rays showed a Jefferson fracture with out evidence of bony abnormality of other cervical elements (Figure 6. 1). QUESTIONS
- Further details of the patient’s bony injury were seen on tomograms. There were fractures through the anterior and posterior arch of the atlas. There was wide lateral offset of both lateral processes of the atlas. There was no fracture of the odontoid and the relationship between the odontoid and the anterior arch of the atlas was normal (i.e. less than 2. 5 mm). An acceptable plan of therapeutic management for this patient’s Jefferson fracture might include (Select one or more)
A. this is a stable fracture and no treatment is indicated
B. this is a potentially unstable fracture and the patient should be treated with a soft collar
C . this is a potentially unstable fracture and the patient should be treated with skull traction or a halo frame
D. this is an unstable fracture and early operative fusion is indicated
E. none of the above
(C)
While there is no absolute uniformity of opinion regarding management for patients with Jefferson fractures, most authors agree that nondisplaced fractures can be treated with simple neck support (i.e. cervical collar). Atlantoaxial instability is probable following Jefferson fractures if the transverse ligament is ruptured. If lateral displacement of the lateral masses is greater than 6.9 mm or if the distance from the back of the anterior arch of the atlas to the front of the odontoid is greater than 2. 5 mm, the transverse ligament is probably torn and instability is likely. Because of the hazard of further neural injury in potentially unstable Jefferson fractures, cervical traction utilizing either skull calipers or the halo brace, is recommended. If instability remains after a suitable period of immobilization, operative fusion is recommended.
CASE 7: Odontoid Fracture HISTORY: A 62-year-old male fell down a flight of stairs. He was a known alcoholic and was apparently intoxicated at the time of his fall. He struck his head during the fall and was noted by an observer to be unconscious immediately. On arriving in the emergency a few moments later, he was awake but somewhat confused and disoriented. Within twenty minutes, he was oriented but amnesic for the events of the fall. He complained of neck pain. EXAMINATION: The only visible evidence of injury was a bruise on the left parietal eminence of his skull. Vital signs were stable and general physical examination was normal. Aside from his mental status, his neurological examination was normal. His neck was splinted with sandbags and he was sent for x-rays. X-RAY: Skull - normal. Cervical spine - the Lateral view showed a fracture of the odontoid process at its base with a 10 mm posterior subluxation of the dens on the body of C2 (Figure 7. 1). More detailed AP views and tomograms did not significantly add to the plain lateral x-ray findings. QUESTIONS
- Unlike this patient, most patients with odontoid fractures die suddenly as a direct result of the cervical spinal cord injury. (True or False)
FALSE
Accurate mortality figures are not known because a number of patients with odontoid fracture presumably expire acutely and are not included in statistics. A high cervical spinal cord lesion due to odontoid fracture would result in respiratory arrest with rapid demise. However, reported mortality figures for odontoid fractures have ranged from 50% to less than 10%
CASE 7: Odontoid Fracture HISTORY: A 62-year-old male fell down a flight of stairs. He was a known alcoholic and was apparently intoxicated at the time of his fall. He struck his head during the fall and was noted by an observer to be unconscious immediately. On arriving in the emergency a few moments later, he was awake but somewhat confused and disoriented. Within twenty minutes, he was oriented but amnesic for the events of the fall. He complained of neck pain. EXAMINATION: The only visible evidence of injury was a bruise on the left parietal eminence of his skull. Vital signs were stable and general physical examination was normal. Aside from his mental status, his neurological examination was normal. His neck was splinted with sandbags and he was sent for x-rays. X-RAY: Skull - normal. Cervical spine - the Lateral view showed a fracture of the odontoid process at its base with a 10 mm posterior subluxation of the dens on the body of C2 (Figure 7. 1). More detailed AP views and tomograms did not significantly add to the plain lateral x-ray findings. QUESTIONS
- This patient demonstrates the difficulty in diagnosing odontoid fractures by history and physical examination alone. (True or False)
TRUE
Neck pain is the most common symptom associated with odontoid fracture. Paravertebral tenderness, muscle spasm and limitation of neck movement are commonly associated signs if pain is present. However, these findings are not pathognomonic of odontoid fracture. Almost invariably the diagnosis of fractured odontoid is made radiographically.
CASE 7: Odontoid Fracture HISTORY: A 62-year-old male fell down a flight of stairs. He was a known alcoholic and was apparently intoxicated at the time of his fall. He struck his head during the fall and was noted by an observer to be unconscious immediately. On arriving in the emergency a few moments later, he was awake but somewhat confused and disoriented. Within twenty minutes, he was oriented but amnesic for the events of the fall. He complained of neck pain. EXAMINATION: The only visible evidence of injury was a bruise on the left parietal eminence of his skull. Vital signs were stable and general physical examination was normal. Aside from his mental status, his neurological examination was normal. His neck was splinted with sandbags and he was sent for x-rays. X-RAY: Skull - normal. Cervical spine - the Lateral view showed a fracture of the odontoid process at its base with a 10 mm posterior subluxation of the dens on the body of C2 (Figure 7. 1). More detailed AP views and tomograms did not significantly add to the plain lateral x-ray findings. QUESTIONS
- As with this patient, fracture-dislocations of the odontoid in survivors are usually not associated with neurological signs of spinal cord injury. (True or False)
TRUE
In Schatzker’s, et al. review only 9% of patients showed evidence of spinal cord injury. Apuzzo, et al. indicated a slightly higher percentage: 18% of their patients had evidence of myelopathy. The sagittal diameter of the normal adult spinal canal ranges from 16 to 33 mm at the odontoid level. Spinal compression is not usually clinically detectable until this measurement is radiographically less than 14 mm. There is, therefore, for most patients with odontoid fracture, ample room in the spinal canal to accept encroachment associated with fracture dislocations without producing clinical evidence of spinal cord dysfunction.
CASE 7: Odontoid Fracture HISTORY: A 62-year-old male fell down a flight of stairs. He was a known alcoholic and was apparently intoxicated at the time of his fall. He struck his head during the fall and was noted by an observer to be unconscious immediately. On arriving in the emergency a few moments later, he was awake but somewhat confused and disoriented. Within twenty minutes, he was oriented but amnesic for the events of the fall. He complained of neck pain. EXAMINATION: The only visible evidence of injury was a bruise on the left parietal eminence of his skull. Vital signs were stable and general physical examination was normal. Aside from his mental status, his neurological examination was normal. His neck was splinted with sandbags and he was sent for x-rays. X-RAY: Skull - normal. Cervical spine - the Lateral view showed a fracture of the odontoid process at its base with a 10 mm posterior subluxation of the dens on the body of C2 (Figure 7. 1). More detailed AP views and tomograms did not significantly add to the plain lateral x-ray findings. QUESTIONS
- Posterior dislocation of the fractured odontoid, as with this patient, is more common than anterior dislocation. (True or False)
FALSE
Anterior odontoid dislocations are more common than posterior dislocations by a factor of 2:1 to 10:1.
CASE 7: Odontoid Fracture HISTORY: A 62-year-old male fell down a flight of stairs. He was a known alcoholic and was apparently intoxicated at the time of his fall. He struck his head during the fall and was noted by an observer to be unconscious immediately. On arriving in the emergency a few moments later, he was awake but somewhat confused and disoriented. Within twenty minutes, he was oriented but amnesic for the events of the fall. He complained of neck pain. EXAMINATION: The only visible evidence of injury was a bruise on the left parietal eminence of his skull. Vital signs were stable and general physical examination was normal. Aside from his mental status, his neurological examination was normal. His neck was splinted with sandbags and he was sent for x-rays. X-RAY: Skull - normal. Cervical spine - the Lateral view showed a fracture of the odontoid process at its base with a 10 mm posterior subluxation of the dens on the body of C2 (Figure 7. 1). More detailed AP views and tomograms did not significantly add to the plain lateral x-ray findings. QUESTIONS
- A fracture at the base of the odontoid, a? seen with this patient, is an unusual type of axis fracture. (True or False)
FALSE
Anderson and D’Alonzo described three types of axis fracture. The most common (over 50%) is a fracture at the junction of the odontoid process with the body of the atlas. Less common are fractures through the body of the atlas. Least common are fractures, usually oblique, through the rostral portion of the odontoid process. Each type of fracture may be displaced or nondisplaced.
CASE 7: Odontoid Fracture HISTORY: A 62-year-old male fell down a flight of stairs. He was a known alcoholic and was apparently intoxicated at the time of his fall. He struck his head during the fall and was noted by an observer to be unconscious immediately. On arriving in the emergency a few moments later, he was awake but somewhat confused and disoriented. Within twenty minutes, he was oriented but amnesic for the events of the fall. He complained of neck pain. EXAMINATION: The only visible evidence of injury was a bruise on the left parietal eminence of his skull. Vital signs were stable and general physical examination was normal. Aside from his mental status, his neurological examination was normal. His neck was splinted with sandbags and he was sent for x-rays. X-RAY: Skull - normal. Cervical spine - the Lateral view showed a fracture of the odontoid process at its base with a 10 mm posterior subluxation of the dens on the body of C2 (Figure 7. 1). More detailed AP views and tomograms did not significantly add to the plain lateral x-ray findings. QUESTIONS
- Younger patients with nondisplaced odontoid fractures have a favorable outlook for stable union (healing) with conservative (nonoperative) management. (True or False)
TRUE
Apuzzo, et al. assessed the outcome of conservative management and found nonunion in only 16% of all patients with nondisplaced odontoid fractures, whereas nonunion occurred in 60% of all patients with displaced odontoid fractures. Age also seems to effect the probability for stable fusion of an odontoid fracture with conservative measurement. Seventeen percent versus 53% failed to fuse for patients under 40 years of age versus patients over 40 years of age, respectively. Compromise of blood supply to the fractured and displaced odontoid process may adversciv affect the healing process. The atherosclerotic process may play an analogous role in older patients
CASE 7: Odontoid Fracture HISTORY: A 62-year-old male fell down a flight of stairs. He was a known alcoholic and was apparently intoxicated at the time of his fall. He struck his head during the fall and was noted by an observer to be unconscious immediately. On arriving in the emergency a few moments later, he was awake but somewhat confused and disoriented. Within twenty minutes, he was oriented but amnesic for the events of the fall. He complained of neck pain. EXAMINATION: The only visible evidence of injury was a bruise on the left parietal eminence of his skull. Vital signs were stable and general physical examination was normal. Aside from his mental status, his neurological examination was normal. His neck was splinted with sandbags and he was sent for x-rays. X-RAY: Skull - normal. Cervical spine - the Lateral view showed a fracture of the odontoid process at its base with a 10 mm posterior subluxation of the dens on the body of C2 (Figure 7. 1). More detailed AP views and tomograms did not significantly add to the plain lateral x-ray findings. QUESTIONS
- Fusion (union) with conservative (nonoperative) measures would be expected to take about eight months in the patient described (True or False)
FALSE
Union, if it occurs, usually does so by the tenth week.
CASE 7: Odontoid Fracture HISTORY: A 62-year-old male fell down a flight of stairs. He was a known alcoholic and was apparently intoxicated at the time of his fall. He struck his head during the fall and was noted by an observer to be unconscious immediately. On arriving in the emergency a few moments later, he was awake but somewhat confused and disoriented. Within twenty minutes, he was oriented but amnesic for the events of the fall. He complained of neck pain. EXAMINATION: The only visible evidence of injury was a bruise on the left parietal eminence of his skull. Vital signs were stable and general physical examination was normal. Aside from his mental status, his neurological examination was normal. His neck was splinted with sandbags and he was sent for x-rays. X-RAY: Skull - normal. Cervical spine - the Lateral view showed a fracture of the odontoid process at its base with a 10 mm posterior subluxation of the dens on the body of C2 (Figure 7. 1). More detailed AP views and tomograms did not significantly add to the plain lateral x-ray findings. QUESTIONS
- After three months of conservative (nonoperative) managementnon union of the odontoid might be demonstrated radiographically by the following criteria? (Select one or more)
A. A defect in the odontoid with contiguous sclerosis of both fragments
B. A defect in the odontoid with contiguous resorption of both fragments
C. A defect in the odontoid with loss of cortical contiguity
D. Demonstrable movement of the dens fragments on flexion-extension x-rays
E. None of the above
(A,B,C,D)
These are the four criteria used to radiographically diagnose nonunion of an odentoid fracture
CASE 7: Odontoid Fracture HISTORY: A 62-year-old male fell down a flight of stairs. He was a known alcoholic and was apparently intoxicated at the time of his fall. He struck his head during the fall and was noted by an observer to be unconscious immediately. On arriving in the emergency a few moments later, he was awake but somewhat confused and disoriented. Within twenty minutes, he was oriented but amnesic for the events of the fall. He complained of neck pain. EXAMINATION: The only visible evidence of injury was a bruise on the left parietal eminence of his skull. Vital signs were stable and general physical examination was normal. Aside from his mental status, his neurological examination was normal. His neck was splinted with sandbags and he was sent for x-rays. X-RAY: Skull - normal. Cervical spine - the Lateral view showed a fracture of the odontoid process at its base with a 10 mm posterior subluxation of the dens on the body of C2 (Figure 7. 1). More detailed AP views and tomograms did not significantly add to the plain lateral x-ray findings. QUESTIONS
- As a plan of management for this patient one might consider (Select one or more)
A. conservative nonoperative) management using a soft cervical collar.
B. initial stabilization and reduction with skull traction followed by external bracing of the neck. Radiological assessment for fusion at three months
C. initial stabilization and reduction with skull traction followed in several days by operative fusion
D. immediate operative reduction and fusion
E. none of the above
(B,C)
Stable union in nondisplaced fractures can be expected in greater than 30% of all patients utilizing conservative therapy. However, a cervical splinting device (e.g. braces, Minerva plaster jackets or Halo apparatus) rather than a soft cervical collar is recommended to insure cervical stability. Displaced fractures require initial reduction in all cases. This is usually effected by skull tong traction rather than surgically. There is disagreement as to the most suitable subsequent measure to achieve stable fusion of the reduced displaced fracture. Nonfusion occurs in 30-60% of conservatively treated members of this group. Conservative management, using any one of the splinting devices, followed by radiological assessment, or early operative fusion are both acceptable therapeutic alternatives, for patients with reduced odontoid fractures.
CASE 8: Os Odontoideum HISTORY: A 17-year-old high school football player was brought to the emergency room complaining of weakness and numbness of the arms and legs. He apparently sustained a flexion injury of his neck 45’ minutes earlier while being tackled but this appeared to be of relatively minor forces; He reported immediate complete paralysis below the neck but significant return of movement subsequently. He did not complain of neck pain. EXAMINATION: All vital signs were within normal limits. Motor examination revealed minimal weakness of the arms and legs. Muscle tone was slightly increased but no pathological reflexes were present. Pinprick sensation was normal but there was slight decrease in joint position sensation in the hands and feet. Sphincter function was normal. There was no tenderness to palpation of the cervical spine. QUESTIONS
- Which of the following are part of an appropriate plan of action for this patient? (Select one or more)
A. Passively assess flexion and extension of the cervical spine
B. Immobilize the head and neck
C. Obtain cervical spine x-rays
D. Hospitalize the patient for observation
E. Schedule emergency myelogram
(B,C,D)
Immediate immobilization is mandatory in any case of suspected spine or spinal cord injury. 30 The history of injury while playing football is sufficient to indicate a need for immobilization of the head and neck prior to accurate diagnosis. Passive or active head and neck movements must be absolutely avoided until a radiological diagnosis is made. Plain cervical spine x-rays are the cornerstone of radiological diagnosis. Appropriate action may be dictated by findings on these x-rays alone. If plain x-rays are normal or fail to define pathology accurately, polytomography is necessary. The history of temporary paralysis indicates significant spinal cord malfunction. The rapid and marked improvement indicates that the malfunction may be a functional disturbance of spinal cord conduction rather than anatomical disruption of spinal pathways. In spite of rapid recovery, the persistence of increased muscle tone and mild weakness are evidence of possible persistent anatomical spinal cord injury. As such, hospitalization is indicated to observe for further neurological changes or complications of spinal injury such as spinal hematoma. Because of rapid improvement in neurological function, myelography is not indicated on an acute basis.
CASE 8: Os Odontoideum HISTORY: A 17-year-old high school football player was brought to the emergency room complaining of weakness and numbness of the arms and legs. He apparently sustained a flexion injury of his neck 45’ minutes earlier while being tackled but this appeared to be of relatively minor forces; He reported immediate complete paralysis below the neck but significant return of movement subsequently. He did not complain of neck pain. EXAMINATION: All vital signs were within normal limits. Motor examination revealed minimal weakness of the arms and legs. Muscle tone was slightly increased but no pathological reflexes were present. Pinprick sensation was normal but there was slight decrease in joint position sensation in the hands and feet. Sphincter function was normal. There was no tenderness to palpation of the cervical spine. QUESTIONS
- Anteroposterior and lateral polytomographic x-rays of the cervical spine are illustrated in Figures 8.1 and 8.2. They show (Select one or more)
A. normal anatomy
B. fracture of the odontoid process
C. an old unhealed odontoid fracture
D. a congenital nonunion of the odontoid process
E. atlanto-axial dislocation
(D, E)
Congenital nonunion of the odontoid process or so called “os odontoideum” represents a failure of the odontoid process, embryologically the body of the C1 vertebrae, to unite with the axis (C2). Wollin described criteria for identification of the os odontoideum and its differentiation from odontoid fracture. The radiological appearance in the patient presented is typical of the os odontoideum (Figures 8.1 and 8. 2). There is a wide separation of the “odontoid” from the main mass of C2, the fragment has a smooth rounded surface and is circular in shape. In odontoid fracture (see Case 7), an irregular surface usually marks the site of fracture which most commonly occurs at the odontoid base resulting in a relatively rectangular rather than rounded fragment. In addition to the presence of the os odontoideum, significant atlanto-axial dislocation is present (Figure 8. 1). The atlas and attached cranium are displaced posteriorly in regard to their usual relationship to the axis and the remainder of the spine. The anterior atlanto-axial and occipito-axiai ligaments attach to the odontoid process. When the odontoid is firmly attached to the main mass of the axis, dislocation is prevented. When the odontoid is separated from the axis either congenitally or secondary to fracture, the ligaments are ineffective in preventing atlanto-axial dislocation. Early reports indicated that up to 23% of individuals ages 30-50 had incomplete union of the odontoid process to C2. Yashon, however, feels that the true incidence, based on modern polytomographic studies, is much lower. The pathological, clinical and radiological features of congenital failure of fusion of the odontoid have been reviewed in a number of reports.
CASE 8: Os Odontoideum HISTORY: A 17-year-old high school football player was brought to the emergency room complaining of weakness and numbness of the arms and legs. He apparently sustained a flexion injury of his neck 45’ minutes earlier while being tackled but this appeared to be of relatively minor forces; He reported immediate complete paralysis below the neck but significant return of movement subsequently. He did not complain of neck pain. EXAMINATION: All vital signs were within normal limits. Motor examination revealed minimal weakness of the arms and legs. Muscle tone was slightly increased but no pathological reflexes were present. Pinprick sensation was normal but there was slight decrease in joint position sensation in the hands and feet. Sphincter function was normal. There was no tenderness to palpation of the cervical spine. QUESTIONS
- The transient quadriplegia and subsequent mild sensory and motor abnormalities may be due to (Selectone or more)
A. spinal shock
B. the central spinal cord syndrome
C. temporary spinal cord compression
D. the anterior spinal cord syndrome
E. vascular insufficiency
(C,E)
With posterior atlanto-axial dislocation, the anterior arch of the atlas and odontoid fragment move backward and may compress the spinal cord anteriorly. The spinal cord is thus pinched between the posterior arch of the axis (C2) and the odontoid fragment. Anterior atlanto-axial dislocation may injuries of this type may be fatal. Spinal cord injury at this level may result in complete respiratory paralysis since descending input to both phrenic and intercostal respiratory motor neurons is interrupted. Because of the relatively vide dimensions of the spinal canal at this point, atlanto-axial dislocation may occur with little or no neurological deficit. Persistent facet dislocation is not as common in nonfatal upper cervical spine injuries and, thus, rapid dislocation and reduction may occur with only transient spinal cord compression. In lower cervical spine fractures, facet locking may prevents grossly dislocated spine from spontaneously reducing, thus allowing persistent spinal cord compression. This difference in facet dislocations is likely accounted for by the difference in orientation and overlap of facets in the upper, compared to the lower cervical spine. In the upper cervical spine, especially at the C1 - 2 level, the facets are horizontal with only a slight depression in the C2 superior facet to accommodate the C1 inferior facet. Thus, facet dislocation may occur and reduce spontaneously. In the lower cervical spine, marked facet angulation and overlap occur. Thus, when dislocation occurs, persistent locking of adjacent facets occurs with little chance of spontaneous reduction and significant difficulty in obtaining reduction with traction. Schneider and others emphasize the importance of vascular compression in fracture dislocations in the upper cervical region. These occur most commonly with extension injuries. The vertebral arteries emerge from the foramina transversaria of C2 and turn laterally and superiorly, pass through the foramina of the atlas and run in a groove along the superior aspect of the atlas before penetrating the posterior atiantooccipital membrane and entering the posterior cranial fossa. The arteries are fixed at the point of entry into the posterior fossa and may be stretched, compressed or even ruptured by acute dislocations at the atlanto-axial or atlanto-occipitai junctions. This may result in a few minutes of transient neurological deficit, delayed neurological deficit or even death. Spinal shock implies complete loss of spinal cord function below a particular spinal level and is not present in this patient. The central spinal cord syndrome (see Case 10) is characterized by upper extremity weakness disproportionately severe in relation to lower extremity weakness. This patient presents with a mild diffuse weakness of all extremities. The anterior spinal cord syndrome (see Case 11) is characterized by loss of motor function and preservation of dorsal column function. The mild loss of position sense and vibratory perception in this patient are evidence of dorsal column injury and exclude the anterior spinal cord syndrome.
CASE 8: Os Odontoideum HISTORY: A 17-year-old high school football player was brought to the emergency room complaining of weakness and numbness of the arms and legs. He apparently sustained a flexion injury of his neck 45’ minutes earlier while being tackled but this appeared to be of relatively minor forces; He reported immediate complete paralysis below the neck but significant return of movement subsequently. He did not complain of neck pain. EXAMINATION: All vital signs were within normal limits. Motor examination revealed minimal weakness of the arms and legs. Muscle tone was slightly increased but no pathological reflexes were present. Pinprick sensation was normal but there was slight decrease in joint position sensation in the hands and feet. Sphincter function was normal. There was no tenderness to palpation of the cervical spine. QUESTIONS
- Appropriate immediate treatment for this patient might include (Select one or more)
A. corticosteroids systemically
B. skeletal traction
C. decompressive laminectomy
D. anterior resection of the odontoid process
E. placement of a cervical collar and discharge
(A,B)
The role of corticosteroids in the treatment of spinal cord injury is unproven. Nevertheless, there is sufficient suggestion from laboratory research studies that strong recommendations for its clinical use have been made. The patient presented has persistent evidence of mild spinal cord injury as judged by quadriparesis and dorsal column sensory changes and the utilization of all available forms of therapy seem justified in an attempt to treat this problem. Skeletal traction produces excellent reduction in atlanto-axial dislocation due to os odontoideum. Since impacted fracture fragments are not present and since locked facet dislocations at the atlanto-axial region are rare, there is little mechanical resistance to postural reduction by skeletal traction. This situation, is unstable, however, and reduction cannot be maintained with a cervical collar alone. Repeat mild trauma could result in recurrent dislocation with potential neurological catastrophe including quadriplegia or even death due to respiratory arrest. Decompressive laminectomy plays no significant role in the treatment of atlanto-axial dislocation due to os odontoideum. Any residual compression of the spinal cord by the posterior arch of C1 can be relieved most promptly by skeletal traction and reduction of dislocation. Removal of the odontoid anteriorly is unnecessary. This small fragment plays little if any direct role in spinal cord injury if correct alignment is maintained.
CASE 8: Os Odontoideum HISTORY: A 17-year-old high school football player was brought to the emergency room complaining of weakness and numbness of the arms and legs. He apparently sustained a flexion injury of his neck 45’ minutes earlier while being tackled but this appeared to be of relatively minor forces; He reported immediate complete paralysis below the neck but significant return of movement subsequently. He did not complain of neck pain. EXAMINATION: All vital signs were within normal limits. Motor examination revealed minimal weakness of the arms and legs. Muscle tone was slightly increased but no pathological reflexes were present. Pinprick sensation was normal but there was slight decrease in joint position sensation in the hands and feet. Sphincter function was normal. There was no tenderness to palpation of the cervical spine. QUESTIONS
- Appropriate long term treatment for this patient is (Select only one)
A. prolonged immobilization in a halo brace
B. prolonged immobilization with skeletal traction on a spinal frame
C. no long term treatment is required
D. cervical fusion of C1, C2 and C3
E. cervical fusion of C1, C2, C3 and the occiput
(D)
It is highly unlikely that healing of such, a congenital defect in fusion will occur with prolonged immobilization alone. Such is not the case with odontoid fractures where the fresh fracture and otherwise normal anatomy lend themselves to healing with immobilization. Thus, the distinction between a congenital and a traumatic lesion is important in regard to treatment. Funk has pointed cut that the initial presentation of congenital instability of the spine may be falsely attributed to an athletic accident and misdiagnosed and mistreated. The situation may be somewhat different in infants and young children where prolonged immobilization may be effective in promoting odontoid fusion when final ossification has not occurred. Failure to institute treatment of any kind would subject the patient to persistent risk of spinal cord injury or even death in the event of minor trauma or even with excessive nontraumatic neck flexion. The most appropriate form of long term treatment is fusion of C1, C2 and C3 after reduction has been achieved by skeletal traction. Originally fusion to the occiput was also recommended for greater stability. This is unnecessary in os odontoideum since excellent stability is obtained by fusion of C1, C2 and C3 alone. In addition, fusion to the occiput imposes a severe disability on the patient, namely total restriction of lateral rotation and flexion and extension at the atlanto-occipital and atlanto-axial joints. These joints provide the major contributions to head rotation and contribute significantly also to flexion and extension of the head on the spine. Fusion of C1 to C2 alone omitting C3 may be effective but fusion to C3 assures that a fully stable vertebral segment unaffected in any way by the pathological process is included in the fusion to assure excellent and prolonged stabilization. In addition, the inclusion of C3 in the fusion has little if any additional effect in reducing overall neck mobility,
CASE 8: Os Odontoideum HISTORY: A 17-year-old high school football player was brought to the emergency room complaining of weakness and numbness of the arms and legs. He apparently sustained a flexion injury of his neck 45’ minutes earlier while being tackled but this appeared to be of relatively minor forces; He reported immediate complete paralysis below the neck but significant return of movement subsequently. He did not complain of neck pain. EXAMINATION: All vital signs were within normal limits. Motor examination revealed minimal weakness of the arms and legs. Muscle tone was slightly increased but no pathological reflexes were present. Pinprick sensation was normal but there was slight decrease in joint position sensation in the hands and feet. Sphincter function was normal. There was no tenderness to palpation of the cervical spine. QUESTIONS
- Which of the following pathological processes have been associated with spontaneous atlanto-axial dislocation? (Select one or more)
A. Nasopharyngeal infection
B. Rheumatoid arthritis
C. Spinal tumor
D. Ankylosing spondylitis
E. None of the above
(A,B,C,D)
Bell in 1830 first reported spontaneous atlanto-axial dislocation in a patient with a pharyngeal ulcer. Since then, numerous reports of atlanto-axial dislocation have been presented, mainly in relation to inflammatory conditions either in soft tissues surrounding the upper cervical spine or in relation to inflammatory processes or tumors affecting ligaments, joints and bones primarily. Nasopharyngeal infections, particularly in children, may be associated with neck pain and torticollis. Cervical spine x-rays should be carried out in such instances as atlanto-axial dislocation may be identified. Since excessive mobility is present in the upper cervical spines of children, care must be exercised in interpretation of cervical spine x-rays in children. Flexion and extension views with careful supervision may be helpful in ascertaining whether or not true dislocation is present. The mechanism of atlanto-axial dislocation in such inflammatory conditions is undefined. Ligamentous laxity, joint effusions, hyperemic decalcification with loosening of ligaments and irritative contracture of cervical muscles causing secondary dislocation have all been suggested as mechanisms. In rheumatoid arthritis and ankylosing spondylitis the inflammatory process affects the ligaments and joints directly resulting in laxity and dislocation. Local tumors such as eosinophilic granuloma may produce local bone and ligament destruction and resultant dislocation. Tuberculosis, syphilis, poliomyelitis and Down’s Syndrome have all been reported as etiological factors in spontaneous atlanto-axial dislocation. Fortunately spinal cord injury is uncommon in these cases. Reduction is usually effected easily either by halter traction or skeletal traction. Prolonged immobilization and treatment of the underlying pathological process usually lead to permanent stabilization. In some instances, however, surgical fusion is required.
CASE 9: Halo Immooilization for Odontoid Fracture HISTORY: A 33-year-old male was a passenger in an automobile accident and struck his forehead with momentary loss of consciousness. When he regained consciousness he complained of severe pain in the upper cervical region. He had no loss of sensation nor loss of strength in the limbs. His neck was immobilized with sandbags and he was taken directly to the emergency room. EXAMINATION: The patient was awake and complained of neck pain. There was generalized tenderness in the midline upper cervical region. The examination of his limb sensation, strength and reflexes was normal. X-RAY: Cervical spine radiographs showed a nondisplaced fracture of the odontoid process. HOSPITAL COURSE: The patient was placed in skeletal tong traction utilizing five pounds of weight. Serial x-rays showed no evidence of odontoid displacement. Tomograms confirmed the presence of the fracture. The patient’s neurological condition remained stable. On the fourth day after admissionthe patient was fitted for a halo external fixation apparatus and, after x-rays showed good alignment, ambulation was begun. QUESTIONS
- A rigid cervicothoracic brace immobilizes the cervical spine as effectively as tne haloapparatus. (True or False)
FALSE
Johnson et al. in their study of cervical orthoses demonstrated considerably more mobility with a cervicothoracic brace than with the halo apparatus. The halo apparatus appears superior, in their study, to all other forms of orthoses for external immobilization of the neck.
CASE 9: Halo Immooilization for Odontoid Fracture HISTORY: A 33-year-old male was a passenger in an automobile accident and struck his forehead with momentary loss of consciousness. When he regained consciousness he complained of severe pain in the upper cervical region. He had no loss of sensation nor loss of strength in the limbs. His neck was immobilized with sandbags and he was taken directly to the emergency room. EXAMINATION: The patient was awake and complained of neck pain. There was generalized tenderness in the midline upper cervical region. The examination of his limb sensation, strength and reflexes was normal. X-RAY: Cervical spine radiographs showed a nondisplaced fracture of the odontoid process. HOSPITAL COURSE: The patient was placed in skeletal tong traction utilizing five pounds of weight. Serial x-rays showed no evidence of odontoid displacement. Tomograms confirmed the presence of the fracture. The patient’s neurological condition remained stable. On the fourth day after admissionthe patient was fitted for a halo external fixation apparatus and, after x-rays showed good alignment, ambulation was begun. QUESTIONS
- Some cervical mobility is to be expected with the halo apparatus. (True or False)
TRUE
Johnson, et al. demonstrated 1-4% of normal expected cervical mobility in all directions of movements with the halo apparatus. Koch and Nickel, showed that cervical motion with alterations of posture (i,e. change from lying, to sitting) of patients in the halo apparatus is as great as 42% of expected unrestrained cervical movement.
CASE 9: Halo Immobilization for Odontoid Fracture HISTORY: A 33-year-old male was a passenger in an automobile accident and struck his forehead with momentary loss of consciousness. When he regained consciousness he complained of severe pain in the upper cervical region. He had no loss of sensation nor loss of strength in the limbs. His neck was immobilized with sandbags and he was taken directly to the emergency room. EXAMINATION: The patient was awake and complained of neck pain. There was generalized tenderness in the midline upper cervical region. The examination of his limb sensation, strength and reflexes was normal. X-RAY: Cervical spine radiographs showed a nondisplaced fracture of the odontoid process. HOSPITAL COURSE: The patient was placed in skeletal tong traction utilizing five pounds of weight. Serial x-rays showed no evidence of odontoid displacement. Tomograms confirmed the presence of the fracture. The patient’s neurological condition remained stable. On the fourth day after admissionthe patient was fitted for a halo external fixation apparatus and, after x-rays showed good alignment, ambulation was begun. QUESTIONS
- In applying the halo ring to the patient’s head
A. The ring should be approximately 1/2 inch greater than the circumference of the patient’s head. (True or False)
B. the skull puis should be tightened to a torque of five and one-half pounds. (True or False)
(A) TRUE. See Nickel, et al.
(B) TRUE. See Nickel, et al.
CASE 9: Halo Immobilization for Odontoid Fracture HISTORY: A 33-year-old male was a passenger in an automobile accident and struck his forehead with momentary loss of consciousness. When he regained consciousness he complained of severe pain in the upper cervical region. He had no loss of sensation nor loss of strength in the limbs. His neck was immobilized with sandbags and he was taken directly to the emergency room. EXAMINATION: The patient was awake and complained of neck pain. There was generalized tenderness in the midline upper cervical region. The examination of his limb sensation, strength and reflexes was normal. X-RAY: Cervical spine radiographs showed a nondisplaced fracture of the odontoid process. HOSPITAL COURSE: The patient was placed in skeletal tong traction utilizing five pounds of weight. Serial x-rays showed no evidence of odontoid displacement. Tomograms confirmed the presence of the fracture. The patient’s neurological condition remained stable. On the fourth day after admissionthe patient was fitted for a halo external fixation apparatus and, after x-rays showed good alignment, ambulation was begun. QUESTIONS
- In addition to nondisplaced fractures of the odontoid process, other cervical injuries appropriately treated with the halo apparatus might include (Select one or more)
A. Hangman’s fracture
B. Jefferson fracture
C. complex fracture (fracture and/or subluxation at more than one location)
D. subluxation without bone injurv
E. cervical fractures associated with quadraplegia
(A,B,C,D)
In Cooper’s, et al. report, 85% of all cervical ligamentous and bone injuries healed successfully with immobilization in the halo apparatus. They reported good healing in all 17 patients with Hangman’s fractures, in 2 of 3 patients with odontoid fractures, and in 5 of 11 patients with complex fractures. Satisfactory treatment of Jefferson’s fracture with a halo apparatus was reported by Zimmerman, et. al. Although ligamentous injuries have generally been considered an indication for surgical fusion, Norton and Cooper, et al. reported two patients with purely ligamentous injuries and subluxation who achieved stability following treatment in the halo apparatus. Although there is a report of quadriplegic patients treated with the halo apparatus (Zwerling and Riggins), some authors limit the use of the halo apparatus to neurologically intact patients. Cooper, et al. caution against the hazard of cutaneous ulceration with the halo apparatus in patients with anesthetic skin.
CASE 9: Halo Immooilization for Odontoid Fracture HISTORY: A 33-year-old male was a passenger in an automobile accident and struck his forehead with momentary loss of consciousness. When he regained consciousness he complained of severe pain in the upper cervical region. He had no loss of sensation nor loss of strength in the limbs. His neck was immobilized with sandbags and he was taken directly to the emergency room. EXAMINATION: The patient was awake and complained of neck pain. There was generalized tenderness in the midline upper cervical region. The examination of his limb sensation, strength and reflexes was normal. X-RAY: Cervical spine radiographs showed a nondisplaced fracture of the odontoid process. HOSPITAL COURSE: The patient was placed in skeletal tong traction utilizing five pounds of weight. Serial x-rays showed no evidence of odontoid displacement. Tomograms confirmed the presence of the fracture. The patient’s neurological condition remained stable. On the fourth day after admissionthe patient was fitted for a halo external fixation apparatus and, after x-rays showed good alignment, ambulation was begun. QUESTIONS
- Relative contraindications to the management of cervical fractures using the halo apparatus might include (Select one or more)
A. spinal fracture and dislocation which cannot be reduced with skeletal traction
B. an uncooperative patient
C. a patient with chronic pulmonary disease
D. a patient with thoracic gibbus
E. a patient over the age of 40 years with a displaced odontoid fracture
(A,C,D,E)
Cooper, et al. discusses many of the contraindications to the use of the halo apparatus and concluded that surgery is the indicated form of treatment for patients with irreducible fracture dislocations, that increased respiratory compromise precludes the use of the halo apparatus in patients with chronic pulmonary disease and that there is a serious hazard of skin breakdown overlying a thoracic globus from pressure exerted by the jacket of the hale apparatus. Apuzzo, et al. pointed out the poor likelihood of healing of displaced fractures in patients over the age of 40 and recommended surgical fusion for this group. Finally, Cooper, et al. suggested that because the halo is extremely difficult to remove and manipulate, it offers an advantage for patients who might not be relied upon to cooperate with other forms of conservative management of cervical fractures.
CASE 10: Weakness and Loss of Sensation in the Arms of a 64-Year-Old Man HISTORY: A 64-year-old man was a passenger in a motor vehicle which struck a utility pole. The patient was not wearing a seat belt and his head struck the windshield. On admission to the emergency room he complained of neck pain and weakness in his hands. EXAMINATION: He was awake and alert and exhibited contusions and abrasions of the forehead and nose. Motor examination revealed moderate weakness (graded 4/5} bilaterally of shoulder abduction, elbow flexion and extension, and marked weakness of wrist flexion and extension. Grip and intrinsic muscle function were graded 2/5 in the hands. Sensory examination revealed hypalgesia over the C5-T1 dermatomes bilaterally but light touch sensation, vibratory perception and joint position sense was preserved. Reflexes were barelv obtainable in the arms. Strength, sensation and reflexes were all normal below T1. Sphincter function was preserved. X-RAY: A lateral cervical spine x-ray is shown in Figure 10.1. QUESTIONS
- The cervical spine x-ray reveals which of the following? (Select one or more)
A. A fracture
B. A dislocation
C. Normal cervical spine
D. Cervical spondylosis
E. None of the above
(D)
There is no evidence of fracture or dislocation. Intervertebral disc space narrowing and spur formation particularly evident at C4-5 and C5-6 are compatible with the diagnosis of cervical spondylosis or cervical degenerative arthritis. Spurs resulting from degenerative joint disease narrow the saggital diameter of the spinal canal reducing the space available to accommodate the cervical spinal cord. Such patients are particularly susceptible to spinal cord trauma during hyperextension injuries to the cervical spine. Hyperextension has been shown to result in further narrowing of the spinal canal by posterior impingement of the ligamentum flavum. The contusions and abrasions on the forehead and nose of this patient indicate force applied such as to hyperextend the cervical spine.
CASE 10: Weakness and Loss of Sensation in the Arms of a 64-Year-Old Man HISTORY: A 64-year-old man was a passenger in a motor vehicle which struck a utility pole. The patient was not wearing a seat belt and his head struck the windshield. On admission to the emergency room he complained of neck pain and weakness in his hands. EXAMINATION: He was awake and alert and exhibited contusions and abrasions of the forehead and nose. Motor examination revealed moderate weakness (graded 4/5} bilaterally of shoulder abduction, elbow flexion and extension, and marked weakness of wrist flexion and extension. Grip and intrinsic muscle function were graded 2/5 in the hands. Sensory examination revealed hypalgesia over the C5-T1 dermatomes bilaterally but light touch sensation, vibratory perception and joint position sense was preserved. Reflexes were barelv obtainable in the arms. Strength, sensation and reflexes were all normal below T1. Sphincter function was preserved. X-RAY: A lateral cervical spine x-ray is shown in Figure 10.1. QUESTIONS
- The clinical picture exhibited by this patient is due to (Select only one)
A. central cervical spinal cord injury
B. anterior cervical spinal cord injury
C. multiple cervical nerve root injuries
D. none of the above
(A)
The central cervical spinal cord syndrome was described by Schneider. It is characterized clinically by weakness which is most severe in (or confined to) the upper extremities as compared to the lower extremities. Further, the weakness tends to be most severe distally in the small hand muscles and least severe In the shoulder girdle. Sensory abnormalities are minimal but if present tend to be most severe in the upper extremities and may be of the “dissociated type”, i.e. a disproportionately greater loss of pain and temperature sensation as compared to touch. Sphincter function may or may not be affected. Hyperextensior. injuries are usually considered the main cause of the central spinal cord syndrome; however, this is not always the case. Up to 50% of cases may result from flexion injuries. Schneider originally proposed central hematomyelia secondary to mechanical spinal cord compression from hyperextension as the mechanism for the central spinal cord syndrome. This was felt to be aggravated by premorbid narrowing of the spinal canal by cervical spondylosis. Vascular lesions, however, may produce identical lesions. Current research also suggests that a process of spreading spinal cord necrosis may follow initial spinal cord injury and be responsible for the final lesion. Figure 10. 2 shows the anatomical explanation for the central spinal cord syndrome. The diagram is at the lower cervical (C5,C6,C7) area at which point the spinal cord has its largest diameter, related to motor supply to the upper extremities. Central cord injury (shaded area) results in damage to anterior horn cells (motor neurons) which supply muscles in the arms. Since the anterior roots take a slightly caudally directed course before exiting from the spinal cord, injury to motor neurons at the C5, C6, C7 transverse spinal cord level tends to be manifest mainly in the small hand muscles supplied primarily by the C8 and T1 nerve roots. If the lesion is large enough, injury to the ventrally located reticulospinal tract may result in sphincter dysfunction. Variations in lesion size and exact location may alter the details of clinical presentation in an individual patient. Nevertheless, the general features of the central cervical spinal cord syndrome, i.e. motor weakness and dissociated sensory loss mainly or exclusively in the upper extremities, are reliable. The recognition of this clinical syndrome is important since it relates directly to the question of treatment.
CASE 10: Weakness and Loss of Sensation in the Arms of a 64-Year-Old Man HISTORY: A 64-year-old man was a passenger in a motor vehicle which struck a utility pole. The patient was not wearing a seat belt and his head struck the windshield. On admission to the emergency room he complained of neck pain and weakness in his hands. EXAMINATION: He was awake and alert and exhibited contusions and abrasions of the forehead and nose. Motor examination revealed moderate weakness (graded 4/5} bilaterally of shoulder abduction, elbow flexion and extension, and marked weakness of wrist flexion and extension. Grip and intrinsic muscle function were graded 2/5 in the hands. Sensory examination revealed hypalgesia over the C5-T1 dermatomes bilaterally but light touch sensation, vibratory perception and joint position sense was preserved. Reflexes were barelv obtainable in the arms. Strength, sensation and reflexes were all normal below T1. Sphincter function was preserved. X-RAY: A lateral cervical spine x-ray is shown in Figure 10.1. QUESTIONS
- Which of the following may explain the loss of pinprick sensation but preservation of touch, vibration and position sense in the arms? (Select only one)
A. Dorsal column injury
B. Anterior white commissure injury
C. Spinothalamic tract injury
D. B and C
E. None of the above
(D)
The anterior white commissure crosses from the dorsal region and passes just ventral to the gray matter of the spinal cord to form the contralateral spinothalamic tract (Figure 10.2). As the size of the spinothalamic tract increases from sacral, to lumbar, to thoracic, to cervical regions, new fiber are added to the medial edge of the tract and the previously present fibers are pushed more laterally. Therefore, the spinothalamic tract in the cervical region is somatotopically organized with the sacral area most lateral and the cervical region most medial (see Figure 24.1). Centrally located cervical spinal cord lesions thus tend to produce pain and temperature loss in the upper extremities and sparing the legs. The preservation of touch, vibration and position sense implies that the dorsal columns are functioning fairly normally. *pict*
CASE 10: Weakness and Loss of Sensation in the Arms of a 64-Year-Old Man HISTORY: A 64-year-old man was a passenger in a motor vehicle which struck a utility pole. The patient was not wearing a seat belt and his head struck the windshield. On admission to the emergency room he complained of neck pain and weakness in his hands. EXAMINATION: He was awake and alert and exhibited contusions and abrasions of the forehead and nose. Motor examination revealed moderate weakness (graded 4/5} bilaterally of shoulder abduction, elbow flexion and extension, and marked weakness of wrist flexion and extension. Grip and intrinsic muscle function were graded 2/5 in the hands. Sensory examination revealed hypalgesia over the C5-T1 dermatomes bilaterally but light touch sensation, vibratory perception and joint position sense was preserved. Reflexes were barelv obtainable in the arms. Strength, sensation and reflexes were all normal below T1. Sphincter function was preserved. X-RAY: A lateral cervical spine x-ray is shown in Figure 10.1. QUESTIONS
- The statement in the physical examination that grip and intrinsic muscle function are graded 2/5 in the hands implies that the grip and intrinsic muscles (Select only one)
A. are normal in strength
B. will function against resistance
C. will function with gravity eliminated
D. show no muscle contraction
E. show muscle contraction but ho finger movement
(C)
A fairly standardized grading system has been used to assess muscle function. It is reproduced in slightly modified form here: 0 = no contraction 1 = muscle contraction without joint movement 2 = movement with gravity eliminated 3 = movement against gravity 4 = movement against gravity and resistance 5 = normal strength This method is strongly recommended for assessment and recording of muscle function to allow both quantitation and standardization for comparison. The system lacks some flexibility where most clinical weakness occurs, namely in grade 4, and modifications of 4-, 4 and 4+ have been suggested to indicate movement against slight, moderate and strong resistance respectively.
CASE 10: Weakness and Loss of Sensation in the Arms of a 64-Year-Old Man HISTORY: A 64-year-old man was a passenger in a motor vehicle which struck a utility pole. The patient was not wearing a seat belt and his head struck the windshield. On admission to the emergency room he complained of neck pain and weakness in his hands. EXAMINATION: He was awake and alert and exhibited contusions and abrasions of the forehead and nose. Motor examination revealed moderate weakness (graded 4/5} bilaterally of shoulder abduction, elbow flexion and extension, and marked weakness of wrist flexion and extension. Grip and intrinsic muscle function were graded 2/5 in the hands. Sensory examination revealed hypalgesia over the C5-T1 dermatomes bilaterally but light touch sensation, vibratory perception and joint position sense was preserved. Reflexes were barelv obtainable in the arms. Strength, sensation and reflexes were all normal below T1. Sphincter function was preserved. X-RAY: A lateral cervical spine x-ray is shown in Figure 10.1. QUESTIONS
- Appropriate early treatment for this patient would involve which of the following? (Select only one)
A. Decompressive laminectomy
B. Placement of skull tongs
C. Placement of a halo apparatus
D Anterior cervical fusion
E. None of the above
(E)
The central cervical spinal cord syndrome is best managed conservatively. Skull tongs and the halo apparatus are useful in patients requiring reduction and stabilization of fracture-dislocations. These are not present in the patient under discussion and are not present in most patients with the central cord syndrome, Decompressive laminectomy does not benefit such patients as an early measure. Minimal immobilization perhaps with a cervical collar or brace may help reduce neck pain. Steady progressive improvement in neurological function usually occurs in a predictable fashion. The legs tend to recover motor power first, followed by improved bladder function, improved proximal upper extremity strength follows and finally improvement in fine hand and finger movements may occur. Residual disability due to persistent weakness of intrinsic hand muscles is not uncommon.
CASE 11: Sensory Preservation after Spinal Cord Injury in a 29-Year-Old Man HISTORY: A 29-year-old man was brought to the emergency room after an automobile accident. He had gone off the road on a rainy night while driving his auto mobile and had struck a tree. He was awake and alert and complained of neck pain. EXAMINATION: Examination showed complete voluntary motor paralysis below C6. There was total loss of pain and temperature sensation to the same level. Urinary and rectal sphincter paralysis were present. There was preservation of touch sensation, proprioception and vibration sense throughout the body. QUESTIONS
- This patient represents the clinical syndrome of (Select only one)
A. the Brown-Sequard syndrome
B. cervical spinal cord transection
C multiple cervical nerve root injury
D. anterior cervical spinal cord injury
E. none of the above
(D)
The anterior cervical spinal cord syndrome was first described by Schneider. The syndrome includes subtotal loss of spinal cord function with preservation of so-called “dorsal column function’’, i.e. touch, proprioception and vibration. There is complete loss of motor and sphincter function and loss of pain and temperature sensation below a given level.
CASE 11: Sensory Preservation after Spinal Cord Injury in a 29-Year-Old Man HISTORY: A 29-year-old man was brought to the emergency room after an automobile accident. He had gone off the road on a rainy night while driving his auto mobile and had struck a tree. He was awake and alert and complained of neck pain. EXAMINATION: Examination showed complete voluntary motor paralysis below C6. There was total loss of pain and temperature sensation to the same level. Urinary and rectal sphincter paralysis were present. There was preservation of touch sensation, proprioception and vibration sense throughout the body. QUESTIONS
- The most common mechanism of cervical spine injury producing this clinical syndrome is (Select only one)
A. hyperflexion
B. hyperextension
C. rotation
D. none of the above
(A)
The anterior spinal cord syndrome was felt to be caused primarily by hyperflexion injuries to the cervical spine, with resultant rupture of the posterior longitudinal ligament, tearing of the annulus fibrosis and posterior herniation of the nucleus pulposus of the intervertebral disc. This mechanism leads to compression of the anterior aspect to the cervical spinal cord with sparing of the posterior columns. Subsequently, posterior displacement of fractured bone fragments and incomplete spinal cord necrosis have also been recognized as causes of the anterior cervical spinal cord syndrome. Vertebral and anterior spinal artery injuries have also been suggested as causally related to the anterior spinal cord syndrome.
CASE 11: Sensory Preservation after Spinal Cord Injury in a 29-Year-Old Man HISTORY: A 29-year-old man was brought to the emergency room after an automobile accident. He had gone off the road on a rainy night while driving his auto mobile and had struck a tree. He was awake and alert and complained of neck pain. EXAMINATION: Examination showed complete voluntary motor paralysis below C6. There was total loss of pain and temperature sensation to the same level. Urinary and rectal sphincter paralysis were present. There was preservation of touch sensation, proprioception and vibration sense throughout the body. QUESTIONS
- Appropriate diagnostic studies in this patient might include. (Select one or more)
A. cervical spine x-rays
B. cervical myelogram
C. cerebral computerized tomographic (CT) scan
D. spinal angiogram
E. none of the above
(A,B)
Plain cervical roentgenograms often reveal a “tear-drop” fracture of the involved vertebrae with widening of the disc space posteriorly and narrowing anteriorly. The posterior widening suggests rupture of the posterior longitudinal ligament and underlying annulus fibrosis of the intervertebral disc. Plain x-rays, however, may be unremarkable in the anterior spinal cord syndrome. Cervical myelogram is an important diagnostic study in the anterior spinal cord syndrome since it may reveal a herniated cervical intervertebral disc with anterior compression of the spinal cord as described by Schneider. Most, if not all, patients with the anterior cervical spinal cord syndrome should undergo myelography shortly after injury, when their general condition is stabilized. Cerebral CT scan is not indicated unless there is evidence of significant head injury which was not present in the patient illustrated. Spinal angiography is usually reserved for the diagnosis of spinal cord tumor or vascular lesion, neither of which is suggested in this case. *pict*
CASE 11: Sensory Preservation after Spinal Cord Injury in a 29-Year-Old Man HISTORY: A 29-year-old man was brought to the emergency room after an automobile accident. He had gone off the road on a rainy night while driving his auto mobile and had struck a tree. He was awake and alert and complained of neck pain. EXAMINATION: Examination showed complete voluntary motor paralysis below C6. There was total loss of pain and temperature sensation to the same level. Urinary and rectal sphincter paralysis were present. There was preservation of touch sensation, proprioception and vibration sense throughout the body. QUESTIONS
- Anteroposterior and lateral x-rays of the cervical spine are illustrated in Figures 11. 1 and 11.2. They show (Select one or more)
A. normal findings
B. fracture of body of C6
C. fracture of transverse processes of C6 and C7
D. dislocation
E. none of the above
(B,C)
The lateral view (Figure 11.2) shows reduced height of the C6 vertebral body and a small fracture of the anteroinferior corner of the body of C6 as well. This is the socalled ‘‘tear-drop’’ fracture. Fractures of the transverse processes on the right side are seen in the anteroposterior view (Figure 11.1). No significant dislocation is seen as judged by alignment of the posterior surfaces of the bodies of the cervical vertebrae. The malalignment of the anterior surfaces of the body of C6 in relation to C5 and C7 is due to compression and fracture of the CC body. Facet joints are normally aligned without evidence of dislocation.
CASE 11: Sensory Preservation after Spinal Cord Injury in a 29-Year-Old Man HISTORY: A 29-year-old man was brought to the emergency room after an automobile accident. He had gone off the road on a rainy night while driving his auto mobile and had struck a tree. He was awake and alert and complained of neck pain. EXAMINATION: Examination showed complete voluntary motor paralysis below C6. There was total loss of pain and temperature sensation to the same level. Urinary and rectal sphincter paralysis were present. There was preservation of touch sensation, proprioception and vibration sense throughout the body. QUESTIONS
- Figures 11.3 and 11.4 illustrate lateral views from a myelogram performed using air (11.3) and pantopaque (11. 4). They show (Select only one)
A. normal findings
B. a herniated intervertebral disc
C. an extradural defect at C5-6
D. an extradural hematoma
E. none of the above
(C)
The pantopaque myelogram (Figure 11.4) shows a smooth posterior displacement of the dye column primarily opposite the C5-6 intervertebral disc space. The air myelogram (Figure 11.3) shows obliteration of the column of air ventral to the spinal cord in the region of the C5-6 interspace. The “teardrop” fracture of the antero-inferior corner of the body of C6 is also well seen on the myelographic films. It is impossible to ascertain the pathological process responsible for the deficit front the myelographic findings alone. A herniated intervertebral disc or posteriorly displaced bone fragments are likely etiological agents. Spinal hematoma localized to such a small area is uncommon (see Cases 27 and 28).
CASE 11: Sensory Preservation after Spinal Cord Injury in a 29-Year-Old Man HISTORY: A 29-year-old man was brought to the emergency room after an automobile accident. He had gone off the road on a rainy night while driving his auto mobile and had struck a tree. He was awake and alert and complained of neck pain. EXAMINATION: Examination showed complete voluntary motor paralysis below C6. There was total loss of pain and temperature sensation to the same level. Urinary and rectal sphincter paralysis were present. There was preservation of touch sensation, proprioception and vibration sense throughout the body. QUESTIONS
- Appropriate treatment of this patient might include (Select one or more)
A. initial treatment with skeletal traction tongs
B. decompressive laminectomy
C. anterior cervical disc excision at C5-6
D. anterior cervical fusion
E. none of the above
(A,C,D)
Plain roentgenograms of the spine demonstrate a fracture of C6. Although significant dislocation is not identified, skeletal traction with skull tongs is recommended for maintenance of normal alignment. The likely mechanism of injury in this patient is hyperflexion. In such injuries, the interspinous ligaments and facet joint ligaments maybe stretched or torn. The anterior elements (vertebral body and disc space) are also damaged by the compressive effect of flexion. Thus, the injury may be unstable even though gross dislocation is not apparent on x-ray. The myelogram demonstrated an extradural defect opposite the C5-6 interspace. Schneider recommended operative treatment of such lesions particularly in association with the anterior spinal cord syndrome which the patient described exhibited. This is most easily and safely carried out by an anterior approach. Direct access to the injured disc is provided without disturbance of the injured spinal cord. Disc removal and spinal cord decompression may be carried out safely by this approach. Additionally, a bone graft may be inserted into the intervertebral space following disc excision to promote fusion. Hyperflexion injuries of significant severity often produce disruption of the capsular ligaments of the posterior facet joints of the cervical vertebrae. This injury, in addition to disruption of the disc space and longitudinal ligaments, may result in spinal in stability. Thus, the anterior approach allows both removal of the offending pathology compressing the spinal cord as well as fusion if instability is present. Although it was initially recommended for treatment of such lesions, laminectomy in this situation does not permit direct access to the pathological process which is anteriorly located. Manipulation of the already injured spinal cord to obtain anterior access may further injure the cord. Further, the dissection of cervical musculature and removal of laminae may aggravate pre-existing instability and require extensive posterior fusion or a secondary operation for anterior fusion. Thus, laminectomy is not indicated in this situation.
CASE 12: 43-Year-Old Woman With Neck Injury Following Automobile Accident HISTORY: A 43-year-old woman was admitted to the emergency room complaining of severe neck pain following an automobile accident. The patient did not recall the accident nor the ambulance trip to the hospital. EXAMINATION: Examination showed contusions of the neck anteriorly beneath the mandible. Neurological examination was normal except for amnesia. QUESTIONS
- Figure 12.1 is a lateral cervical spine x-ray taken in the emergency room. It shows (Select only one)
A. normal cervical spine
B. fracture of the pedicles of C2
C. fracture of the odontoid process
D. fracture of the arch of C1
E. none of the above
(B)
Bilateral fractures of the pedicles of C2 are shown. The fracture is more easily appreciated on a coned view of C2 as shown in Figure 12.2. In another patient (Figure 12.3), the fracture is obvious. This lesion has been termed ‘‘Hangman’s fracture” because of its similarity to the lesion which occurs after judicial hanging. Although methods of judicial hanging have varied over the years, most hangings in relatively recent times have employed a submental knot. A knot in such a location combined with a sudden drop of the victim’s body results in symmetrical fractures across the pedicles or lateral masses of the axis and may extend across the posterior part of the body as well. Fracture of the odontoid process does not occur in this pathological process. *pict* *pict*
CASE 12: 43-Year-Old Woman With Neck Injury Following Automobile Accident HISTORY: A 43-year-old woman was admitted to the emergency room complaining of severe neck pain following an automobile accident. The patient did not recall the accident nor the ambulance trip to the hospital. EXAMINATION: Examination showed contusions of the neck anteriorly beneath the mandible. Neurological examination was normal except for amnesia. QUESTIONS
- The mechanism of the spinal injury illustrated is (Select only one)
A. hyperflexion
B. rotation
C. hyperextension
D. none of the above
(C)
A combination of hyperextension and compression leads to pressure on the neural arch of the axis. This leads to bilateral fracture of the pedicles. If a distracting force is present, as in judicial hanging, marked dislocation occurs. In vehicular accidents, the most common mechanism of such injuries, strong distracting forces are absent and minimal or no dislocation occurs. Thus, such lesions may be overlooked on screening radiographs. Figure 12,4 illustrated significant dislocation at C2-3 in a patient with “Hangman’s fracture” following vehicular accident. *pict*
CASE 12: 43-Year-Old Woman With Neck Injury Following Automobile Accident HISTORY: A 43-year-old woman was admitted to the emergency room complaining of severe neck pain following an automobile accident. The patient did not recall the accident nor the ambulance trip to the hospital. EXAMINATION: Examination showed contusions of the neck anteriorly beneath the mandible. Neurological examination was normal except for amnesia. QUESTIONS
- Death in judicial hanging is usually due to (Select only one)
A. brainstem injury
B. strangulation
C. decapitation
D. spinal cord transection
E. none of the above
(D)
In judicial hanging, submental knot placement leads to bilateral fracture of the pedicles of the axis. The weight of the falling body results in distraction of the fracture and transection of the spinal cord at C2-3. Respiratory arrest and subsequently cardiac arrest and death ensue. If an insufficient length of drop is utilized in attempted hanging, cervical fracture-dislocation does not occur but death may ensue on a delayed basis, due to strangulation. This frequently occurs with attempted suicides. If an excessive length drop is utilized, decapitation may result. If a subaural instead of a submental knot is utilized, basal skull fracture with brainstem injury may result. Death in such instances is not assured and the subaural knot is not recommended in judicial hanging.
CASE 12: 43-Year-Old Woman With Neck Injury Following Automobile Accident HISTORY: A 43-year-old woman was admitted to the emergency room complaining of severe neck pain following an automobile accident. The patient did not recall the accident nor the ambulance trip to the hospital. EXAMINATION: Examination showed contusions of the neck anteriorly beneath the mandible. Neurological examination was normal except for amnesia. QUESTIONS
- The normal neurological examination in this patient is (Select only one)
A. to be expected
B. unusual
C. likely to deteriorate acutely
D. none of the above
(A)
In patients who sustain a “Hangman’s fracture” accidentally and in whom survival occurs, significant neurological deficit may occur but is uncommon. In those patients in whom hyperexrension is severe, death often occurs before the institution of resuscitative measures because of acute upper cervical spinal cord injury with respiratory paralysis. Occasional survivors with quadriplegia have been reported but are rare. If the degree of hyperextension is less severe, and particularly if unaccompanied by a distractive force, bilateral fracture of the pedicles of C2 occurs without spinal cord injury. Williams proposed that the mechanisms of judicial versus accidentally induced “Hangman’s fracture” are different. He felt the former always associated with distraction, was fatal, whereas the latter, often unaccompanied by distraction., only rarely resulted in neurological injury. Hyperextension-distraction injuries have been reporter in vehicle accidents in relation to diagonal seat belts applied too loosely. In such cases, the results are similar to judicial hanging, namely producing a fatal injury. Even in those accidental cases of neurological injury associated with “Hangman’s fracture”, the presence of severe associated injuries (e.g. head injury) make correlation of the spinal injury and neurological deficit difficult. The occasional neurological injuries seen with “Hangman’s fracture” tend to recover with time. Progressive deficit is rare but may occur with missed “Hangman’s fracture”.
CASE 12: 43-Year-Old Woman With Neck Injury Following Automobile Accident HISTORY: A 43-year-old woman was admitted to the emergency room complaining of severe neck pain following an automobile accident. The patient did not recall the accident nor the ambulance trip to the hospital. EXAMINATION: Examination showed contusions of the neck anteriorly beneath the mandible. Neurological examination was normal except for amnesia. QUESTIONS
- Appropriate treatment for this patient is (Select one ormore)
A. decompressive laminectomy
B. anterior fusion
C. halo brace
D. high dose corticosteroids
E. none of the above
(C)
“Hangman’s fracture” is a relatively stable injury. Originally, the condition was treated by skeletal traction via skull tongs. Excessive distraction can be produced by this means, however, and judicious addition to the amount of weigh utilized to produce traction and monitoring with lateral cervical spine radiographs is necessarv. More recently, management with the halo apparatus has been recommended. Anterior cervical fusion was occasionally used but this seems to be rarely necessary. Decompressive laminectomy plays no role in the treatment of “Hangman’s fracture” since no lesion is present which could be decompressed. Since most patients are neurologically normal, pharmacological agents such as corticosteroids are also not indicated.
CASE 13: Burning Hands in a 21-Year-Old Football Flayer HISTORY: A 21-year-old college football player was injured while tackling an opponent. He was brought to the emergency room complaining of severe burning pain and numbness in his hands. He denied neck pain. EXAMINATION: There was no external evidence of trauma nor pain on palpation of the cervical spine. Motor examination disclosed mild diffuse weakness of the upper extremities bilaterally.Lower extremity strength was normal. Sensory examination revealed decreased touch and pinprick perception in the hands and fingers bilaterally. Reflexes were absent in the upper extremities but present in the lower extremities. No pathologic reflexes were noted and sphincter function was normal. QUESTIONS
- The “burning hands” described by this patient most likely are (Select only one)
A. doe to abrasions from contact with artificial turf
B. due to bilateral carpal tunnel syndrome from acute wrist extension
C. symptoms of central cervical spinal cord injury
D. of no clinical significance
E. none of the above
(C)
Burning dysesthesias are commonly seen after nerve root injuries which most often are unilateral. Maroon, however, recently described “burning hands” in two football players following cervical spine injury. He postulated that a lesion of the spinothalamic tract, concerned with pain and temperature perception, was responsible for the symptom. The spinothalamic tract, like the pyramidal motor tract, is somatotopically organized so that the fibers to the upper extremities, especially the fingers, are located most medially in the cervical segments of the spinal cord. Significant motor loss was noted in the upper extremities with normal motor function in the legs in the patient described in this case and in Maroon’s patients. This is consistent with central cervical spinal cord injury (see Case 10). Maroon demonstrated, utilizing myelography, widening of the cervical spinal cord from C5-C7 consistent with spinal cord contusion and swelling. The presence of sensory changes, arm weakness and loss of reflexes in the arms makes it unlikely that burning pain in the hands is due to local injury such as skin abrasions or carpal tunnel syndrome, although either of those lesions could produce isolated burning pain in the hands. The presence of neurological deficit also confirms the seriousness of the potential problem and suggests the clinical significance of the complaint of burning pain in the hands. Maroon pointed out the absence of neck pain in his patients, a symptom thought to be present almost universally with spine injury. The presence of burning pain should alert the physician to the possibility of spinal injury even in the absence of neck pain. Being so alerted, appropriate steps for careful diagnostic study and treatment may be carried out.
CASE 13: Burning Hands in a 21-Year-Old Football Flayer HISTORY: A 21-year-old college football player was injured while tackling an opponent. He was brought to the emergency room complaining of severe burning pain and numbness in his hands. He denied neck pain. EXAMINATION: There was no external evidence of trauma nor pain on palpation of the cervical spine. Motor examination disclosed mild diffuse weakness of the upper extremities bilaterally.Lower extremity strength was normal. Sensory examination revealed decreased touch and pinprick perception in the hands and fingers bilaterally. Reflexes were absent in the upper extremities but present in the lower extremities. No pathologic reflexes were noted and sphincter function was normal. QUESTIONS
- Appropriate treatment of this patient might include (Select one or more)
A. cervical spine x-rays
B. immobilization of the neck
C. myelography
D. none of the above
(A,B,C)
The clinical history and examination suggest cervicai spine injury. Plain x-rays of the spine are essential in such a circumstance. One of Maroon’s two patients with burning hand pain demonstrated a fracture-dislocation at C5-6 and the other had normal x-rays. The importance of adequate immobilization of the head and neck in such circumstances cannot be overemphasized. The possibility of converting a mild spinal cord injury into a catastrophe is present unless the importance of immobilization before and during x-ray studies is appreciated. Myelography may be of value dependent on the patient’s clinical condition. Usually patients with central cervical spinal cord injury recover without surgery. In one of Maroon’s, two cases, a myelogram done because of persistent radiculopathy showed a ruptured disc at the C5-6 interspace and surgical treatment was accomplished. In the other, myelography demonstrated only widening of the cervical spinal cord and the patient recovered with nonsurgical treatment.
CASE 13: Burning Hands in a 21-Year-Old Football Flayer HISTORY: A 21-year-old college football player was injured while tackling an opponent. He was brought to the emergency room complaining of severe burning pain and numbness in his hands. He denied neck pain. EXAMINATION: There was no external evidence of trauma nor pain on palpation of the cervical spine. Motor examination disclosed mild diffuse weakness of the upper extremities bilaterally.Lower extremity strength was normal. Sensory examination revealed decreased touch and pinprick perception in the hands and fingers bilaterally. Reflexes were absent in the upper extremities but present in the lower extremities. No pathologic reflexes were noted and sphincter function was normal. QUESTIONS
- Which of the following are true concerning cervical spine injuries in football players? (Select only one)
A. Occur rarely
B. Are usually fatal
C. Are frequently undetected
D. Occur primarily in offensive and defensive linemen
E. None of the above
(C)
Albright examined 179 high school players and college freshman football candidates. He found that 32% of the college players and 8% of the high school players had significant x-ray evidence of cervical spine trauma. This x-ray evidence included compression fractures, abnormal motion, narrowed disc spaces and neural arch fractures. Nearly two-thirds of the college players with ah normal x-rays neither complained of neck pain nor gave a history of neck injury. Only 4 of 42 players with abnormal x-rays had significant findings on physical examination. Thus, the incidence of cervical spine injuries in football players, even of relatively young age, is grossly underestimated. This opinion is strengthened by a survey of coaches conducted by Albright. Of 20.189 players on the responding ‘ teams, coaches reported only 1-2% as having been injured. Albright estimated that only about one of 64 actually injured players in an eight team conference had a reported injury. Thus, the incidence of nonfatal cervical spine injuries is probably much underrated. The risk of death due to cervical spine injury is probably overestimated since the number of nonfatal injuries has been previously unappreciated. The actual incidence of serious cervical spine and spinal cord injuries related to athletic injuries is unknown. Leader attributed 4-5% of all spinal cord injuries resulting in permanent paralysis to athletic injuries. Torg documented one serious spinal cord injury per 44.000 participants in football during 1975. Clark surveyed high school and college football teams during 1973-1975 and identified one permanent spinal cord injury per 28,000 participants. Between 1931 and 1975, 819 deaths were attributed to trauma as a result of playing football, two per 100.000 participants, and 79% of the deaths were due to brain and spinal cord injuries. Torg recently suggested that the incidence of cervical spine and spinal cord injury is increasing and questioned the possible emergence of a significant national health problem. Several studies have indicated that the incidence of injuries is related directly to length of participation and position played. Most injuries occur to the individuals involved in making open field tackles. Thus, defensive backs and linebackers are most often injured. Linemen, involved mainly in blocking and tackling at lower speeds in a crowded area, rarely receive significant cervical spine or spinal cord injuries.
CASE 13: Burning Hands in a 21-Year-Old Football Flayer HISTORY: A 21-year-old college football player was injured while tackling an opponent. He was brought to the emergency room complaining of severe burning pain and numbness in his hands. He denied neck pain. EXAMINATION: There was no external evidence of trauma nor pain on palpation of the cervical spine. Motor examination disclosed mild diffuse weakness of the upper extremities bilaterally.Lower extremity strength was normal. Sensory examination revealed decreased touch and pinprick perception in the hands and fingers bilaterally. Reflexes were absent in the upper extremities but present in the lower extremities. No pathologic reflexes were noted and sphincter function was normal. QUESTIONS
- Cervical spine injuries in football players frequently result in quadriplegia. (True or False)
TRUE
Schneider estimated that over 50% of cervical fracture-dislocations incurred in football players between 1959-1963 resulted in quadriplegia of a complete and permanent nature. Of 12 severe neck injuries in football players studied by Torg in 1975, seven resulted in quadriplegia. Thus, the incidence of quadriplegia in cervical spinal cord injuries is very high.
CASE 13: Burning Hands in a 21-Year-Old Football Flayer HISTORY: A 21-year-old college football player was injured while tackling an opponent. He was brought to the emergency room complaining of severe burning pain and numbness in his hands. He denied neck pain. EXAMINATION: There was no external evidence of trauma nor pain on palpation of the cervical spine. Motor examination disclosed mild diffuse weakness of the upper extremities bilaterally.Lower extremity strength was normal. Sensory examination revealed decreased touch and pinprick perception in the hands and fingers bilaterally. Reflexes were absent in the upper extremities but present in the lower extremities. No pathologic reflexes were noted and sphincter function was normal. QUESTIONS
- Cervical spine injuries in football players usually result from tackling using the crown of the helmet as a battering ram. (True or False)
TRUE
Although a variety of mechanisms have been identified as the cause of cervical spine injuries in football players, the use of the crown of the helmet as a battering ram is most often the etiological mechanism. Torg indicated that in six of eight players with spinal cord injury and quadriplegia the helmet had been used by the injured player as a battering ram while making a tackle. The mechanism of spinal cord injury in such cases is felt to be axial loading of the spine, the force vector being directed along the axial alignment of the cervical spine. This results in disruption of the intervertebral discs and posterior ligamentous structures with dislocation and acute spinal cord trauma.
CASE 13: Burning Hands in a 21-Year-Old Football Flayer HISTORY: A 21-year-old college football player was injured while tackling an opponent. He was brought to the emergency room complaining of severe burning pain and numbness in his hands. He denied neck pain. EXAMINATION: There was no external evidence of trauma nor pain on palpation of the cervical spine. Motor examination disclosed mild diffuse weakness of the upper extremities bilaterally.Lower extremity strength was normal. Sensory examination revealed decreased touch and pinprick perception in the hands and fingers bilaterally. Reflexes were absent in the upper extremities but present in the lower extremities. No pathologic reflexes were noted and sphincter function was normal. QUESTIONS
- Which of the following are true concerning the use of neck manipulation in the treatment of persistent neck pain in football players? (Select one or more)
A. Effective means of pain relief
B Safe if cervical spine x-rays are normal
C. May result in spinal injury
D. May result in vascular occlusion
E. May result in brainstem infarction
(C,D,E)
Manipulation of the neck is commonly used in the treatment of persistent neck pain in athletes as well as the general population. It is generally assumed to be a safe and effective means of obtaining pain relief. Significant risk is present, however, as judged by reports of spinal injury, vascular injury and brainstem infarction. Schneider reviewed the risks of neck manipulation in football players and cautioned against its use. Cervical spine dislocation, occlusion of the vertebrobasilar and anterior spinal arteries, brainstem infarction, and even death may result from cervical spine manipulation. This form of treatment is not recommended for persistent neck pain in either the athlete or nonathlete.
CASE 14: Coma in a 17-Year-Old Who Was Struck by an Automobile HISTORY: A 17-year-old female was brought to the emergency room after having been struck by an automobile. The patient was a pedestrian. When first seen by paramedics at the accident scene, the patient was unconscious without spontaneous respirations and pupils were noted to be fixed and dilated; peripheral pulses were absent. An endotracheal tube was inserted and cardiopulmonary resuscitation was begun. EXAMINATION: Neurological status was unchanged on arrival in the emergencv room, Resuscitative attempts were continued X-RAYS: A lateral cervical spine x-ray is illustrated in Figure 14. 1. QUESTIONS
1 . The cervical spine x-ray shows (Select one or more)
A. a fracture-dislocation
B. soft tissue swelling anterior to the cervical spine
C. probably a fatal injury
D. fracture of the odontoid process
(A,B,C)
The x-ray shows a fracture-dislocation at C3-4 with massive dislocation and displacement. The odontoid process of C2 is intact. Actually, the fracture per se appears small, i.e. a fracture of the tip of the spinous process of C4. The primary injury is a dissolution of ligamentous structures between C3 and C4. There is complete rupture through the intervertebral disc space, complete rupture of the capsular ligaments of the facet joints and rupture of the nuchal ligaments between the spinous processes. There is marked increase in distance between the endotracheal tube and the anterior aspect of the bodies of the cervical vertebrae throughout the cervical area due most likely to a combination of hematoma and soft tissue edema. A transverse injury of the spinal cord with complete transection would almost certainly result from such an injury. In addition, significant injury or even transection of the vertebral arteries may occur from such a lesion with resultant acute massive brainstem infarction. Fracture-dislocations with such massive displacement, located at C4 and above are usually fatal due to respiratory arrest.
CASE 14: Coma in a 17-Year-Old Who Was Struck by an Automobile HISTORY: A 17-year-old female was brought to the emergency room after having been struck by an automobile. The patient was a pedestrian. When first seen by paramedics at the accident scene, the patient was unconscious without spontaneous respirations and pupils were noted to be fixed and dilated; peripheral pulses were absent. An endotracheal tube was inserted and cardiopulmonary resuscitation was begun. EXAMINATION: Neurological status was unchanged on arrival in the emergencv room, Resuscitative attempts were continued X-RAYS: A lateral cervical spine x-ray is illustrated in Figure 14. 1. QUESTIONS
- In fatal cervical spinal cord injuries, the cause of death is most often (Select only one)
A. hypovolemic shock
B. spinal shock
C. primary cardiac arrest
D. respiratory arrest
E. none of the above
(D)
Fatal cervical spinal cord injuries result most often in acute primary respiratory arrest followed by secondary cardiac arrest. Thus, most fatal lesions are located at C4 or above. Even complete lesions below C4 are usually not fatal since diaphragmatic respiration often provides sufficient respiratory exchange to sustain life. Fatality maybe avoided in some cases of acute spinal transection above C4 by prompt institution of artificial respiration. Spinal shock results in only mild hypotension due to sympathectomy. Hypovolemic shock may occur due to thoracic or abdominal injuries and may indeed be fatal; however, it does not relate directly to spinal cord injury. Respiratory arrest results from interruption of connections between the respiratory centers of the brainstem and the phrenic (C3-4) and intercostal (Tl-2) respiratory neurons.
CASE 14: Coma in a 17-Year-Old Who Was Struck by an Automobile HISTORY: A 17-year-old female was brought to the emergency room after having been struck by an automobile. The patient was a pedestrian. When first seen by paramedics at the accident scene, the patient was unconscious without spontaneous respirations and pupils were noted to be fixed and dilated; peripheral pulses were absent. An endotracheal tube was inserted and cardiopulmonary resuscitation was begun. EXAMINATION: Neurological status was unchanged on arrival in the emergencv room, Resuscitative attempts were continued X-RAYS: A lateral cervical spine x-ray is illustrated in Figure 14. 1. QUESTIONS
- How frequently are cervical spinal injuries identified in fatal traffic accidents? (Select only one)
A. 20%
B. 40%
C. 60%
D. 80%
(A)
Alker, et al. studied 146 fatalities of traffic accidents. Both radiological and autopsy studies were employed. Twenty-one percent of their patients demonstrated significant cervical spinal injuries. The incidence of cervical spine trauma in other series of fatal accidents is lower, ranging from 3 to 15%. The later figures are based exclusively on autopsy studies. Since detection of fractures and dislocations of the cervical spine is difficult at autopsy, the figures in the later two studies are probably artificially low. The utilization of x-ray evaluation by Alker, et al. yielded a much higher figure and probably more closely approximates the true incidence.
CASE 14: Coma in a 17-Year-Old Who Was Struck by an Automobile HISTORY: A 17-year-old female was brought to the emergency room after having been struck by an automobile. The patient was a pedestrian. When first seen by paramedics at the accident scene, the patient was unconscious without spontaneous respirations and pupils were noted to be fixed and dilated; peripheral pulses were absent. An endotracheal tube was inserted and cardiopulmonary resuscitation was begun. EXAMINATION: Neurological status was unchanged on arrival in the emergencv room, Resuscitative attempts were continued X-RAYS: A lateral cervical spine x-ray is illustrated in Figure 14. 1. QUESTIONS
- Which of the following are true concerning fatal cervical spine injuries? (Select one or more)
A. Predominantly occur in males
B. Rarely occur in conjunction with serious intracranial injury
C. Predominantly occur in upper cervical region
D. None of the above
(A,C)
The preponderance of male traffic accident victims is astonishing. Ninety percent of fatalities among vehicle drivers were male and 49% of pedestrian fatalities were male. In the series of Alker, et al. 25 of 31 fatal cervical spine injuries occured at C3 or above. These included eight with atlantooccipital injuries, seven with injuries to C1 and ten with injuries to C2. Atlanto-occipital injuries occurred almost exclusively in pedestrians struck anteriorly by motor vehicles with sudden posterior acceleration of the body in relation to the head and resultant acute hyperflexion of the head on the neck. One third of patients in Alker’s series with cervical spine trauma also exhibited serious intracranial injury. In fact, of the total of 146 patients studied by Alker, et al., 42 had demonstrable head injuries ranging from relatively simple linear skull fractures to massive skull damage. Death in the latter resulted from intracranial hematoma, brainstem injury or from massive air embolus. Sixty percent of cases with head injury demonstrated intracranial or intravascular air. Massive air embolization of the right atrium was often associated with intravascular air. Air embolization in these cases was due to injury to dural venous sinuses.
CASE 15: Cervical Trauma in a Rheumatoid Arthritic HISTORY: A 59-year-old female was seen in the emergency room following an automobile accident, complaining of neck pain. She had a 32-year history of rheumatoid arthritis. She denied motor or sensory symptoms and had been able to urinate since the accident. She described mild intermittent upper cervical pain over several months prior to the accident. EXAMINATION: She had many of the stigmata of rheumatoid arthritis, including rheumatoid nodules and ulnar deviation of the fingers. The range of motion of her neck was limited in all directions but there was no tenderness. Her gait was limited by hip involvement by arthritic disease but was not spastic. On neurological examination, her motor and sensory functions were normal. Deep tendon reflexes in all extremities were slightly brisk, but she had no pathological reflexes. X-RAY: The lateral cervical spine in the emergency room suggested forward displacement of C1 on C2. AP and odontoid views showed no evidence of fracture. Lateral flexion and extension views were obtained and showed mobility of C I on C2 in anterior flexion indicating atlanto-axial subluxation (Figure 15. 1) QUESTIONS
- Atlanto-axial subluxation can be quantified in adults by which of the following lateral cervical spine measurements? (Select one or more)
A. Chamberlain’s line
B. The distance between the posterior edge of the odontoid process and the posterior arch of the atlas
C. The distance between the posterior edge of the odontoid process and the edge of the posterior lip of the foramen magnum
D. The distance between the anterior edge of the odontoid process and the anterior arch of the atlas E. None of the above
(B,D)
Chamberlain’s line extends from the hard palate to the posterior lip of the foramen magnum0 and is utilized primarily in the diagnosis of basilar impression. Basilar impression is occasionally seen in association with rheumatoid arthritis. B. In adults, the distance between the posterior edge of the odontoid process and the posterior arch of the atlas is normally no less than 17 mm in males and 15.8 mm in females and this distance is reduced in atlanto-axial subluxation. C. The base of the skull moves with the atlas and, therefore, this distance is also compromised in atlanto-axial subluxation. However, use of this measurement has not been standardized in the radiological literature. D. This distance is normally no greater than 2.5 mm and increases if the atlas slides forward with respect to the dens. If this distance is greater than 2.5 mm, it indicates atlantoaxial subluxation and radiographically is termed “increased atlanto-axial distance”.
CASE 15: Cervical Trauma in a Rheumatoid Arthritic HISTORY: A 59-year-old female was seen in the emergency room following an automobile accident, complaining of neck pain. She had a 32-year history of rheumatoid arthritis. She denied motor or sensory symptoms and had been able to urinate since the accident. She described mild intermittent upper cervical pain over several months prior to the accident. EXAMINATION: She had many of the stigmata of rheumatoid arthritis, including rheumatoid nodules and ulnar deviation of the fingers. The range of motion of her neck was limited in all directions but there was no tenderness. Her gait was limited by hip involvement by arthritic disease but was not spastic. On neurological examination, her motor and sensory functions were normal. Deep tendon reflexes in all extremities were slightly brisk, but she had no pathological reflexes. X-RAY: The lateral cervical spine in the emergency room suggested forward displacement of C1 on C2. AP and odontoid views showed no evidence of fracture. Lateral flexion and extension views were obtained and showed mobility of C I on C2 in anterior flexion indicating atlanto-axial subluxation (Figure 15. 1) QUESTIONS
Examination of the patient’s x-rays demonstrated a distance of 5 mm between the front of the dens and the anterior arch of the atlas and this distance increased by 2 mm with anterior flexion. 2. The etiology of this patient’s atlanto-axial subluxation is most likely (Select one or more)
A. related to trauma
B. related to rheumatoid arthritis and is caused primarily by laxity of the transverse odontoid ligament
C. related to rheumatoid arthritis and is caused primarily by erosion of the odontoid process
D. related to rheumatoid arthritis and is caused primarily by inflammation of the synovial joint between the odon toid and the anterior arch of the atlas
E. none of the above
(B)
Instability at the C1-C2 region associated with trauma is almost always due to fracture of the dens and would not be associated with an increased atlanto-axial distance. Laxity of the transverse ligament (Figure 15.2) initiates atlantoaxial dislocation although other factors contribute to instability at this level. Erosion of the odontoid process is commonly inferred if the atlanto-occipital separation exceeds 8 mm. Arthritic inflammatory changes are seen in the synovial joints of the cervicai spine and may be in the form of erosion or ankylosis. *pict*
CASE 15: Cervical Trauma in a Rheumatoid Arthritic HISTORY: A 59-year-old female was seen in the emergency room following an automobile accident, complaining of neck pain. She had a 32-year history of rheumatoid arthritis. She denied motor or sensory symptoms and had been able to urinate since the accident. She described mild intermittent upper cervical pain over several months prior to the accident. EXAMINATION: She had many of the stigmata of rheumatoid arthritis, including rheumatoid nodules and ulnar deviation of the fingers. The range of motion of her neck was limited in all directions but there was no tenderness. Her gait was limited by hip involvement by arthritic disease but was not spastic. On neurological examination, her motor and sensory functions were normal. Deep tendon reflexes in all extremities were slightly brisk, but she had no pathological reflexes. X-RAY: The lateral cervical spine in the emergency room suggested forward displacement of C1 on C2. AP and odontoid views showed no evidence of fracture. Lateral flexion and extension views were obtained and showed mobility of C I on C2 in anterior flexion indicating atlanto-axial subluxation (Figure 15. 1) QUESTIONS
- Atlanto-occipitai subluxation is also seen with rheumatoid arthritis. (True or False)
FALSE
Atlanto-occipital dislocation is rare and is almost always traumatic in origin.
CASE 15: Cervical Trauma in a Rheumatoid Arthritic HISTORY: A 59-year-old female was seen in the emergency room following an automobile accident, complaining of neck pain. She had a 32-year history of rheumatoid arthritis. She denied motor or sensory symptoms and had been able to urinate since the accident. She described mild intermittent upper cervical pain over several months prior to the accident. EXAMINATION: She had many of the stigmata of rheumatoid arthritis, including rheumatoid nodules and ulnar deviation of the fingers. The range of motion of her neck was limited in all directions but there was no tenderness. Her gait was limited by hip involvement by arthritic disease but was not spastic. On neurological examination, her motor and sensory functions were normal. Deep tendon reflexes in all extremities were slightly brisk, but she had no pathological reflexes. X-RAY: The lateral cervical spine in the emergency room suggested forward displacement of C1 on C2. AP and odontoid views showed no evidence of fracture. Lateral flexion and extension views were obtained and showed mobility of C I on C2 in anterior flexion indicating atlanto-axial subluxation (Figure 15. 1) QUESTIONS
- Subluxations at cervical levels below the C1-C2 level are also seen with rheumatoid arthritis. (True or False)
TRUE
In a series of 130 rheumatoid patients with cervical subluxation, 48% of the subluxations occurred at levels other than the C1-C2 level. Fifty-five percent of patients with subluxation associated with rheumatoid arthritis show multiple level involvement.
CASE 15: Cervical Trauma in a Rheumatoid Arthritic HISTORY: A 59-year-old female was seen in the emergency room following an automobile accident, complaining of neck pain. She had a 32-year history of rheumatoid arthritis. She denied motor or sensory symptoms and had been able to urinate since the accident. She described mild intermittent upper cervical pain over several months prior to the accident. EXAMINATION: She had many of the stigmata of rheumatoid arthritis, including rheumatoid nodules and ulnar deviation of the fingers. The range of motion of her neck was limited in all directions but there was no tenderness. Her gait was limited by hip involvement by arthritic disease but was not spastic. On neurological examination, her motor and sensory functions were normal. Deep tendon reflexes in all extremities were slightly brisk, but she had no pathological reflexes. X-RAY: The lateral cervical spine in the emergency room suggested forward displacement of C1 on C2. AP and odontoid views showed no evidence of fracture. Lateral flexion and extension views were obtained and showed mobility of C I on C2 in anterior flexion indicating atlanto-axial subluxation (Figure 15. 1) QUESTIONS
- The statement which most appropriately describes the consensus of opinion regarding treatment of this patient (Select only one)
A. the patient should be admitted to the hospital and undergo cervical fusion
B. the patient should be given a cervical collar and instructed to wear it the rest of her life
C. no treatment is needed for this patient
D. there is no general consensus of opinion concerning treatment for the patient
E. none of the above
(D)
While most authors do not mention asymptomatic atlanto-axial dislocation in association with rheumatoid arthritis as an indication for surgery, there are advocates of aggressive surgical management. Because of the potential for spinal cord compression if atlantoaxial subluxation progresses, some authors recommend treathing even symptomatic atlanto-axial subluxation with a cervical collar. One hundred thirty patients with cervical subluxations without evidence of spinal cord compression were followed for an average of 7,8 years without surgical treatment and only four patients developed myelopathic signs. Comparing this group of 150 patients to life tables of rheumatoid arthritis patients without cervical subluxation showed no evidence that life was shortened in this group. Finally, comparison of patients from this group who wore collars regularly with those who did not wear cervical collars regularly showed no effect on the progression of the severity of subluxation. Based on the above review, there does not appear to be a consensus among authors as to the appropriate therapeutic management of patients with asymptomatic atlanto-axial subluxation.
CASE 16: Persistent Spinal X-Ray Abnormality Associated with Spinal Cord Injury HISTORY: A 39-year-old man was seen in the emergency room complaining of neck pain following a fall down a flight of fifteen steps. He also complained of tingling paresthesias in the legs and diffuse weakness which were present immediately after the injury. EXAMINATION: .Vital Signs were within normal limits. Respirations were diaphragmatic. Shoulder flexion, extension, abduction and adduction were all performed normally. Elbow flexion was also normal. There was weakness graded 4/5 of wrist extension, elbow extension, grip and intrinsic musculature of both arms and diffuse weakness also graded 4 5 of trunk and lower extremity musculature. Muscle tone was increased in the legs and bilateral extensor plantar signs were present. There was hypalgesia to pinprick extending caudally from the index finger bilaterally. Sensation was preserved is the thumbs and radial aspect of both forearms and ab^ve. There was marked diminution of vibratory and proprioceptive sensation in the same distribution. X-RAYS: A lateral x-ray of the cervical spine illustrated in Figure 15. 1. QUESTIONS
- The clinical picture is that of (Select only one)
A. spinal cord transection at C6-7
B. partial spinal cord injury at C6-7
C. spinal cord transection at C5-6
D. partial spinal cord injury at C5-6
E. partial spinal cord injury at C4-5
(B)
The clinical picture is that of partial spinal cord injury at the C6-7 level. Structures innervated by motor and sensory portions of the C6 spinal segment and above remain functional. Thus, elbow flexion (biceps muscle) and sensory function of the radial aspect of the forearm and hand (C6 dermatome) are preserved. These functions are lost in C5-6 spinal cord injury. Structures innervated by the C7 spinal segment and below exhibit a diffuse, severe but incomplete sensorimotor deficit. Thus, elbow and wrist extension (triceps, extensor digitorum and extensor carpi muscles) are grossly impaired, as is sensation extending from, the index finger (C7 dermatome) distally. In spinal cord injury at the C4-5 level, weakness of shoulder abduction and sensory loss overlying the deltoid muscle (C5 dermatome) would be expected. The incomplete nature of the neurological loss indicates that neither anatomical nor physiological spinal cord transection has occurred. In addition, spinal shock is not present (see Case 5). The increased muscle tone, bilateral Babinski’s sign and hyperactive reflexes, including the triceps and lower extremity tendon reflexes with normal biceps reflex, also are indicative of incomplete spinal cord injury affecting the corticospinal pathways from the C7 segment caudally.
CASE 16: Persistent Spinal X-Ray Abnormality Associated with Spinal Cord Injury HISTORY: A 39-year-old man was seen in the emergency room complaining of neck pain following a fall down a flight of fifteen steps. He also complained of tingling paresthesias in the legs and diffuse weakness which were present immediately after the injury. EXAMINATION: .Vital Signs were within normal limits. Respirations were diaphragmatic. Shoulder flexion, extension, abduction and adduction were all performed normally. Elbow flexion was also normal. There was weakness graded 4/5 of wrist extension, elbow extension, grip and intrinsic musculature of both arms and diffuse weakness also graded 4 5 of trunk and lower extremity musculature. Muscle tone was increased in the legs and bilateral extensor plantar signs were present. There was hypalgesia to pinprick extending caudally from the index finger bilaterally. Sensation was preserved is the thumbs and radial aspect of both forearms and above. There was marked diminution of vibratory and proprioceptive sensation in the same distribution. X-RAYS: A lateral x-ray of the cervical spine illustrated in Figure 15.1. QUESTIONS
- The cervical spine x-ray shows (Select only one)
A. unilateral facet dislocation
B. fracture dislocation
C. bilateral facet dislocation
D. bilateral facet fracture
E. none of the above
(C)
There is marked persistent dislocation at the C6-7 level due to bilateral locked facets (Figure 16.1). No definite fracture is identified. This lesion is due to an acute flexion injury with complete disruption of the capsular ligaments of the facet joints bilaterally. The ligamenta flava, interspinous ligaments, paraspinal muscles and ligamentum nuchae are most likely also disrupted due to excessive stretching. The locked position of the facets prevents spontaneous reduction of the dislocation. Observe the normal relationship of facet joints at other levels, for instance C4-5 and C5-6. In the case of unilateral locked facets, the degree of dislocation seen is usually minimal and identification of the dislocation is difficult on the lateral x-ray due to the overlying shadow of the normal opposite facet. In addition, in the case illustrated the facets are clearly seen and no fracture of the facets is identified.
CASE 16: Persistent Spinal X-Ray Abnormality Associated with Spinal Cord Injury HISTORY: A 39-year-old man was seen in the emergency room complaining of neck pain following a fall down a flight of fifteen steps. He also complained of tingling paresthesias in the legs and diffuse weakness which were present immediately after the injury. EXAMINATION: .Vital Signs were within normal limits. Respirations were diaphragmatic. Shoulder flexion, extension, abduction and adduction were all performed normally. Elbow flexion was also normal. There was weakness graded 4/5 of wrist extension, elbow extension, grip and intrinsic musculature of both arms and diffuse weakness also graded 4 5 of trunk and lower extremity musculature. Muscle tone was increased in the legs and bilateral extensor plantar signs were present. There was hypalgesia to pinprick extending caudally from the index finger bilaterally. Sensation was preserved is the thumbs and radial aspect of both forearms and above. There was marked diminution of vibratory and proprioceptive sensation in the same distribution. X-RAYS: A lateral x-ray of the cervical spine illustrated in Figure 15.1. QUESTIONS
- The most important single mode of immediate treatment for this patient is (Select only one)
A. systemic corticosteroids
B. spinal cord hypothermia
C. decompressive laminectomy
D. surgical reduction
E. eduction and immobilization by skeletal traction
(E)
The value of prompt reduction of cervical spine fractures and dislocations by skeletal fraction cannot be overemphasized. This form of therapy offers the best method of internally decompressing the injured spinal cord and maintaining such decompression once appropriate positioning is achieved. Crutchfield in 1933 originally described tongs applied to the skull to provide effective cervical traction. Since then many other types of tongs, including modification of the original Crutchfield tongs, have been utilized. The authors prefer the Gardner-Wells tongs because they can be inserted very rapidly, require no incision or drilling, maintain constant pressure at the tong points due to spring loading, rarely pull out and withstand the very heavy weights necessary to reduce some difficult dislocations. Traction weights of 25-35 pounds or less will reduce most dislocations. With locked facets, however, much greater weight (up to 50-80 pounds) may be required. We have usually applied steadily increasing weight beginning at 20-30 pounds and increasing in increments of 5-10 pounds every 30-60 minutes to obtain reduction in 4-8 hours. Many others favor this approach and some even suggest slower reduction. Yashon has argued in favor of much more rapid reduction with rapid progression from initial weights of 20-30 pounds up to 70-80 pounds over 1-2 hours. Although everyone favors reduction as early as possible, we have found it difficult from a practical standpoint to achieve this, mainly since repeated cervical spine x-rays arc necessary after each weight addition to evaluate the progress of attempted reduction and to avoid excessive weight, which by distracting the injured spine excessively may result in aggravation of neurological deficit. If the method described above is unsuccessful, open operative reduction may be necessary. In our experience the need for open reduction is rare, particularly if one adopts a patient attitude and allows traction sufficient time to be effective. Although theoretically desirable, rapid closed reduction has not been clearly shown to be superior to slower reduction. The value of decompressive laminectomy in the treatment of acute cervical spinal cord injury is unknown. Many physicians with extensive experience, over many years, in the treatment of spinal cord injury, feel that laminectomy is rarely, if ever, indicated in such lesions. No controlled clinical study of the value of laminectomy has been carried out. Some clinical reports suggest that laminectomy may not only be lacking in efficacy in reducing neurological deficit after spinal cord injury but may actually reduce chances for recovery. Several reviews of this complex subject have been carried out. A number of laboratory studies have examined the value of various forms of surgical treatment of acute spinal cord injury. In most of these, laminectomy alone provides little benefit compared to untreated controls in terms of reduction of neurological deficit. The value of opening the dura in addition to the laminectomy has also been discussed clinically and examined in the laboratory setting. No definite conclusion has been reached but, overall, aural opening appears to add little to laminectomy alone in the treatment of spinal cord injury. Systemic corticosteroids and hypothermia represent recent additions to the armamentarium in the treatment of spinal cord injury. Their value at present is unproven (see complete discussion Case 32).
CASE 16: Persistent Spinal X-Ray Abnormality Associated with Spinal Cord Injury HISTORY: A 39-year-old man was seen in the emergency room complaining of neck pain following a fall down a flight of fifteen steps. He also complained of tingling paresthesias in the legs and diffuse weakness which were present immediately after the injury. EXAMINATION: .Vital Signs were within normal limits. Respirations were diaphragmatic. Shoulder flexion, extension, abduction and adduction were all performed normally. Elbow flexion was also normal. There was weakness graded 4/5 of wrist extension, elbow extension, grip and intrinsic musculature of both arms and diffuse weakness also graded 4 5 of trunk and lower extremity musculature. Muscle tone was increased in the legs and bilateral extensor plantar signs were present. There was hypalgesia to pinprick extending caudally from the index finger bilaterally. Sensation was preserved is the thumbs and radial aspect of both forearms and above. There was marked diminution of vibratory and proprioceptive sensation in the same distribution. X-RAYS: A lateral x-ray of the cervical spine illustrated in Figure 15.1. QUESTIONS
- Which of the following are strong indications for decompressive laminectomy in the treatment of spinal cord injury? (Select one or more)
A. An incomplete spinal cord lesion
B. Progressive neurological deficit
C. Spinal block on Queckenstedt test
D. Spinal block on myelogram
E. Central spinal cord syndrome
(B)
The indications for decompressive laminectomy in the treatment of spinal cord injury have been the subject of heated controversy. Most authors agree that progressive neurological deficit is an indication for surgical decompression. In addition, persistent cerebrospinal fluid leakage after penetrating injury is another indication which is reasonably agreed upon. Beyond this, however, there is a wide spectrum of approach to the utilization of decompressive laminectomy in the treatment of spinal cord injury. Young compared recovery after cervical spine injury in a group of patients treated at the Southwest Regional System for Treatment of Spinal Cord Injury in Phoenix, Arizona to a similar group cared for at the Spinal Cord Unit in Stoke-Mandeville, England. In the Phoenix series, 39% had undergone surgical procedures, whereas in the English series no patients were treated surgically. The operated patients in the Phoenix series showed less average neurological recovery (Ps feeling that immediate immobilization, adequate safe radiological examination and postural reduction of fracture-dislocation formed the cornerstone of the treatment of spinal cord injury. Some reports also describe long term instability following extensive cervical laminectomy. The authors agree basically with this later opinion, favoring laminectomy only in rarely seen, specific types of neurological problems limited primarily to progressive neurological loss after spinal cord injury and persistent cerebrospinal fluid leakage. The value of the demonstration of spinal block by either the Queckenstedt test or myelography is open to considerable controversy as well. In the Queckenstedt test, compression of the jugular veins is carried out in the neck after a lumbar puncture has been performed. The test is usually performed at the bedside with manual neck compression and casual observation of changes in spinal fluid pressure. As such, the results are unreliable. More standardized methods using neck compression by sphygmomanometer and careful recording of pressure changes make results more reliable. Nevertheless, in the presence of a spinal block in the cervical area, the test may be misleading because distended epidural veins beneath the lesion may still produce a normal response. In addition, the indications for the Queckenstedt test and myelography are nearly identical but the latter provides considerably more information. Both air and positive contrast agents have been used for myelography in the study of spinal cord injury. Demonstration of a block to passage of contrast by myelography has been taken by some to be an indication for laminectomy but the wisdom of this reasoning is very doubtful. Most serious spinal cord injuries with hemorrhage, edema and necrosis result in marked spinal cord enlargement often witn myelographic block. There is no evidence that decompressive laminectomy favorably affects the neurological recovery of such patients especially in regard to the results which may be achieved with nonoperative treatment.
CASE 16: Persistent Spinal X-Ray Abnormality Associated with Spinal Cord Injury HISTORY: A 39-year-old man was seen in the emergency room complaining of neck pain following a fall down a flight of fifteen steps. He also complained of tingling paresthesias in the legs and diffuse weakness which were present immediately after the injury. EXAMINATION: .Vital Signs were within normal limits. Respirations were diaphragmatic. Shoulder flexion, extension, abduction and adduction were all performed normally. Elbow flexion was also normal. There was weakness graded 4/5 of wrist extension, elbow extension, grip and intrinsic musculature of both arms and diffuse weakness also graded 4 5 of trunk and lower extremity musculature. Muscle tone was increased in the legs and bilateral extensor plantar signs were present. There was hypalgesia to pinprick extending caudally from the index finger bilaterally. Sensation was preserved is the thumbs and radial aspect of both forearms and above. There was marked diminution of vibratory and proprioceptive sensation in the same distribution. X-RAYS: A lateral x-ray of the cervical spine illustrated in Figure 15.1. QUESTIONS
- Which of the following might reasonably be considered for long terra treatment of this patient? (Select one or more)
A. Halo cast immobilization
B. Anterior cervical fusion
C. Posterior cervical fusion
D. None of the above
(A,B,C)
All three of these options should be considered. Halo cast immobilization provides excellent stabilization of fracture-dislocations once reduction has been achieved. It also allows relatively early mobilization of the patient, an important consideration in avoiding complications of prolonged immobility such as pneumonia, venous thrombosis, pulmonary embolism, etc. In utilizing prolonged immobilization with the halo brace or other methods, the normal healing processes must occur and provide natural stability to the spine. This tends to occur most readily when significant bony fracture occurs. Healing of fractured bone provides solid callus and then solid bone to insure stability in most cases. In the lesion illustrated in this case, however, the primary injury is disruption of the capsular ligaments of the facet joints. Healing of such ligamentous injuries is slow and unreliable probably due to the nature of the tissue involved and its relatively poor vascular supply. Thus, poor healing with early or late instability is more likely with primarily ligamentous as compared to primarily bony injury. Nevertheless, a trial of prolonged immobilization is not unreasonable. Stabilization via surgical fusion utilizing either an anterior or posterior approach might be considered on either an early or late basis in the patient present. The proponents of early fusion feel that such procedures provide a high likelihood of solid reliable stabilization of the spine and the possibility of early mobilization. The proponents of late fusion suggest that many fracture-dislocations will heal without surgical fusion. In fact, Burke found only a 4.2% incidence of failure to achieve stability in 175 patients with spinal injury. In their view, nearly all patients should have a period of 8-12 weeks of immobilization and only those who fail to obtain solid stable healing should be considered for surgical fusion. Our position represents a moderate approach between these extremes. If the character of the injury suggests that stable healing is likely, then immobilization in a halo brace seems appropriate. Such injuries have major elements of direct bony fracture and maintenance of the ligamentous structure of the disc space, the capsular ligaments of the facets or the posterior supporting ligaments and muscle. Injuries which are unlikely to heal with stability should be considered for early fusion. Such injuries represent primarily ligamentous injury and injuries to a combination of the major structures contributing to stability, i.e. intervertebral disc, facet joints and posterior elements. The injury in the patient presented would fall into the latter category since disruption of the disc space and posterior longitudinal ligaments, the capsular ligaments of the facets and the posterior supporting ligaments and muscles have all occurred.
CASE 16: Persistent Spinal X-Ray Abnormality Associated with Spinal Cord Injury HISTORY: A 39-year-old man was seen in the emergency room complaining of neck pain following a fall down a flight of fifteen steps. He also complained of tingling paresthesias in the legs and diffuse weakness which were present immediately after the injury. EXAMINATION: .Vital Signs were within normal limits. Respirations were diaphragmatic. Shoulder flexion, extension, abduction and adduction were all performed normally. Elbow flexion was also normal. There was weakness graded 4/5 of wrist extension, elbow extension, grip and intrinsic musculature of both arms and diffuse weakness also graded 4 5 of trunk and lower extremity musculature. Muscle tone was increased in the legs and bilateral extensor plantar signs were present. There was hypalgesia to pinprick extending caudally from the index finger bilaterally. Sensation was preserved is the thumbs and radial aspect of both forearms and above. There was marked diminution of vibratory and proprioceptive sensation in the same distribution. X-RAYS: A lateral x-ray of the cervical spine illustrated in Figure 15.1. QUESTIONS
- The pathophysiology of this patient’s spinal cord injury is most likely (Select one or more)
A. immediate spinal cord contusion at the time of injury
B. immediate contusion followed by central spinal cord necrosis
C. immediate contusion followed by peripheral spinal cord neurosis
D. steadily progressive spinal cord necrosis without initial contusion
E. anatomical complete transverse section of the spinal cord
(B)
The clinical picture of spinal cord injury suggests immediate direct spinal cord contusion. The deficit in the case illustrated and in most cases, occurs immediately at the time of trauma and progresses little if at all. For many years, it was felt that direct disruption of axons occurred in the spinal cord at the time of trauma and, therefore, attempts to treat the spinal cord injury itself were futile. Some authors currently espouse this theory. Studies of experimental spinal cord injury, however, clearly indicate two patterns of injury. First, a direct effect on spinal conduction with minimal irreversible tissue destruction. This is followed by progressive spinal cord necrosis which begins centrally and spreads toward the periphery of the injury and also spreads rostraliy and caudally within the spinal cord. The direct initial spinal cord concussion and resultant spinal cord malfunction likely mask the progressive spinal cord necrosis clinically. The necrosis is usually progressive ever a few hours post injury. Osterholm first postulated that catecholamines were released at the site of injury and led to vasoconstriction, ischemia and necrosis of spinal cord tissue. Osterholm demonstrated elevated levels of norepinephrine in experimentally injured spinal cord. Osterholm injected norepinephrine into the spinal cord of animals and found changes resembling those seen with experimental spinal cord injury. These changes were prevented by previous treatment with anticatecholamine drugs. Although some confirmation of Osterholm’s results were obtained many subsequent reports failed to observe the elevation in catecholamine levels which Osterholm described. Vise suggested that if catecholamine levels were elevated in injured spinal cord it likely was due to systemic release rather than local release. Whatever the responsible mechanism, it appears that ischemia occurs at the site of spinal cord injury. This idea was challenged by Kobrine who found hyperemia in lateral spinal cord white matter after spinal cord injury. In spite of the fact that ischemia is regularly demonstrated, the relationship between ischemia and spinal cord dysfunction in spinal cord injury is questionable. Thus, ischemic may be demonstrated when spinal cord function as measured by evoked potentials is intact. Further, vasodilators such as papaverine and sodium nitroprusside are ineffective in the treatment of experimental spinal cord injury. In addition to catecholamines, other toxic substances such as dopamine, free radicals, proteolytic enzymes released from lysosomes, potassium, 5-hydroxytrptamine, and histamine have all been suggested as responsible for progressive central spinal cord necrosis. Recent experiments, however, suggest that toxic substances, if released at the site of injury, may not be responsible for progressive spinal cord necrosis. Some have suggested that blood leaking from traumatized vessels and necrotic tissue may exert pressure on surrounding uninjured axons with recondary compression, further injury and perpetuation of central spinal cord necrosis and cavitation. The idea that myelotomy, that is, incision into the spinal cord, to release necrotic debris will reverse or prevent neurological injury after spinal cord injury is an old one. Some more recent experiments have suggested that myelotomy may be effective in reducing neurological deficit in animals after experimental spinal cord injury. Tator suggested that, although dorsal myelotomy appeared ineffective, complete midline myelotomy reduced neurological deficit. Little controlled clinical application of myelotomy has been carried out. A recent case report indicated myelotomy was ineffective in a single patient.
CASE 17: Difficulty Walking One Month After Neck Injury in a 47-Year-Old Policeman HISTORY: A 47-year-old policeman complained of numbness in his arms and legs and difficulty walking. Eight weeks previously he had injured his neck in a fail in which sudden neck flexion had occurred. Cervical spine x-rays at that time showed bilateral facet dislocation at C5-6. No neurological deficit was present at the time of injury. A posterior cervical fusion was carried out because the injury was felt to be unstable. The patient was discharged from the hospital four weeks following injury. At discharge his neurological examination was normal. He complained of mild but persistent neck pain. Four weeks after discharge he complained of more severe persistant aching pain at the base of his neck without radiation. He had noted mild tingling of both arms and legs which had increased progressively in severity for about one week. Also for a week he had noted difficulty in ambulation due to stiffness of his legs. EXAMINATION: General physical examination and vital signs were normal. The posterior cervical wound was well healed. His gait was marked by short steps and difficulty with relaxation of muscles in his legs. There was weakness of the biceps muscles bilaterally. Muscle strength was otherwise normal in all extremities. There was a marked increase in muscle tone in the legs. less so in the arms. Tendon reflexes were diffusely hyper active in both upper and lower extremities except for the biceps tendon reflexes which were absent bilaterally. Bilateral Babinski’s signs were present. Sensory examination revealed scattered hypalgesia to pinprick below C5 with normal vibratory and position sense throughout. X-RAYS: Cervical spine x-rays showed excellent alignment of the cervical spine. QUESTIONS
- The motor examination suggests (Select only one)
A. upper motor neuron lesion
B. lower motor neuron lesion
C. both of the above
D. neither of the above
(C)
Bilateral biceps weakness and absent biceps reflexes are indicative of a lower motor neuron lesion. The increased tone in the lower extremities, hyperactive reflexes and bilateral Babinski’s signs are indicative of an upper motor neuron lesion. The lower motor neuron includes the motor neuron located in the anterior horn of the spinal cord and its axonal extension into the peripheral nerve as far as the terminal endings at the myoneural junction. The upper motor neuron refers to nerve cells of the corticospinal tract. Cell bodies located in the posterior frontal cortex send their axons through the central cerebral white matter, the internal capsule, cerebral peduncles and pyramids to form the corticospinal tract of the spinal cord. These upper motor neurons end with synapses on the lower motor neuron in the ventral gray matter of the spinal cord.
CASE 17: Difficulty Walking One Month After Neck Injury in a 47-Year-Old Policeman HISTORY: A 47-year-old policeman complained of numbness in his arms and legs and difficulty walking. Eight weeks previously he had injured his neck in a fail in which sudden neck flexion had occurred. Cervical spine x-rays at that time showed bilateral facet dislocation at C5-6. No neurological deficit was present at the time of injury. A posterior cervical fusion was carried out because the injury was felt to be unstable. The patient was discharged from the hospital four weeks following injury. At discharge his neurological examination was normal. He complained of mild but persistent neck pain. Four weeks after discharge he complained of more severe persistant aching pain at the base of his neck without radiation. He had noted mild tingling of both arms and legs which had increased progressively in severity for about one week. Also for a week he had noted difficulty in ambulation due to stiffness of his legs. EXAMINATION: General physical examination and vital signs were normal. The posterior cervical wound was well healed. His gait was marked by short steps and difficulty with relaxation of muscles in his legs. There was weakness of the biceps muscles bilaterally. Muscle strength was otherwise normal in all extremities. There was a marked increase in muscle tone in the legs. less so in the arms. Tendon reflexes were diffusely hyper active in both upper and lower extremities except for the biceps tendon reflexes which were absent bilaterally. Bilateral Babinski’s signs were present. Sensory examination revealed scattered hypalgesia to pinprick below C5 with normal vibratory and position sense throughout. X-RAYS: Cervical spine x-rays showed excellent alignment of the cervical spine. QUESTIONS
- The patient’s gait disturbance is due to (Select only one)
A. spasticity
B. loss of position sense
C. weakness
D. lower motor neuron lesion
E. none of the above
(A)
The stiff gait and inability to relax suggest spasticity. The presence of increased muscle tone, hyperactive reflexes and bilateral Babinski’s signs confirm that spasticity is the basis of the patient’s gait disturbance. No specific muscle weakness is present in the legs. This is a frequent finding in gait spasticity, where minimal or no weakness is detectable on specific muscle testing of spastic limbs. Gait disturbances maybe due to loss of position sense but the presence of normal vibratory and position sense on examination exclude this possibility.
CASE 17: Difficulty Walking One Month After Neck Injury in a 47-Year-Old Policeman HISTORY: A 47-year-old policeman complained of numbness in his arms and legs and difficulty walking. Eight weeks previously he had injured his neck in a fail in which sudden neck flexion had occurred. Cervical spine x-rays at that time showed bilateral facet dislocation at C5-6. No neurological deficit was present at the time of injury. A posterior cervical fusion was carried out because the injury was felt to be unstable. The patient was discharged from the hospital four weeks following injury. At discharge his neurological examination was normal. He complained of mild but persistent neck pain. Four weeks after discharge he complained of more severe persistant aching pain at the base of his neck without radiation. He had noted mild tingling of both arms and legs which had increased progressively in severity for about one week. Also for a week he had noted difficulty in ambulation due to stiffness of his legs. EXAMINATION: General physical examination and vital signs were normal. The posterior cervical wound was well healed. His gait was marked by short steps and difficulty with relaxation of muscles in his legs. There was weakness of the biceps muscles bilaterally. Muscle strength was otherwise normal in all extremities. There was a marked increase in muscle tone in the legs. less so in the arms. Tendon reflexes were diffusely hyper active in both upper and lower extremities except for the biceps tendon reflexes which were absent bilaterally. Bilateral Babinski’s signs were present. Sensory examination revealed scattered hypalgesia to pinprick below C5 with normal vibratory and position sense throughout. X-RAYS: Cervical spine x-rays showed excellent alignment of the cervical spine. QUESTIONS
- Which of the following would you suggest for this patient at this time? (Select one or more)
A. A cervical collar
B. Cervical traction at home
C. Physical therapy
D. All of the above
E. None of the above
(E)
The history and physical examination suggest progressive spinal cord dysfunction. The measures suggested would be ineffective and could lead to a dangerous delay in pursuing the etiology of the spinal cord pathology.
CASE 17: Difficulty Walking One Month After Neck Injury in a 47-Year-Old Policeman HISTORY: A 47-year-old policeman complained of numbness in his arms and legs and difficulty walking. Eight weeks previously he had injured his neck in a fail in which sudden neck flexion had occurred. Cervical spine x-rays at that time showed bilateral facet dislocation at C5-6. No neurological deficit was present at the time of injury. A posterior cervical fusion was carried out because the injury was felt to be unstable. The patient was discharged from the hospital four weeks following injury. At discharge his neurological examination was normal. He complained of mild but persistent neck pain. Four weeks after discharge he complained of more severe persistant aching pain at the base of his neck without radiation. He had noted mild tingling of both arms and legs which had increased progressively in severity for about one week. Also for a week he had noted difficulty in ambulation due to stiffness of his legs. EXAMINATION: General physical examination and vital signs were normal. The posterior cervical wound was well healed. His gait was marked by short steps and difficulty with relaxation of muscles in his legs. There was weakness of the biceps muscles bilaterally. Muscle strength was otherwise normal in all extremities. There was a marked increase in muscle tone in the legs. less so in the arms. Tendon reflexes were diffusely hyper active in both upper and lower extremities except for the biceps tendon reflexes which were absent bilaterally. Bilateral Babinski’s signs were present. Sensory examination revealed scattered hypalgesia to pinprick below C5 with normal vibratory and position sense throughout. X-RAYS: Cervical spine x-rays showed excellent alignment of the cervical spine. QUESTIONS
- What is the most likely diagnosis? (Select only one)
A. Chronic cervical sprain
B. Herniated cervical disc
C. Spinal hematoma
D. Spinal core tumor
E. None of the above
(B)
The presence of conclusive signs of cervical cord dysfunction rule out a diagnosis of chronic cervical sprain. In cervical sprain, signs and symptoms are limited to neck pain and muscle spasm and are characterized by normal neurological examination. The findings could be due to spinal hematoma but the long delay since the time of injury make it unlikely (see Cases 27 and 28). Spinal cord tumor is also unlikely, although not impossible, based on the history and neurological examination. In spinal cord tumor, the history is usually slow and steadily progressive. Nevertheless, on occasion, insidious symptoms are not apparent to the patient until an episode of trauma focuses attention on neurological disability. The most likely diagnosis is that of herniated cervical disc. The patient has experienced neck pain without radiation since the time of the injury. This suggests a central disc herniation since radiating pain into the extremities which is characteristic of lateral disc herniation is absent from the patient’s history. The clinical picture suggests that the spinal cord dysfunction begins at the C5-6 level based on the bilateral weakness of the biceps muscles and absence of biceps reflexes. Consequently, a herniated cervical disc at the C5-6 interspace is likely.
CASE 17: Difficulty Walking One Month After Neck Injury in a 47-Year-Old Policeman HISTORY: A 47-year-old policeman complained of numbness in his arms and legs and difficulty walking. Eight weeks previously he had injured his neck in a fail in which sudden neck flexion had occurred. Cervical spine x-rays at that time showed bilateral facet dislocation at C5-6. No neurological deficit was present at the time of injury. A posterior cervical fusion was carried out because the injury was felt to be unstable. The patient was discharged from the hospital four weeks following injury. At discharge his neurological examination was normal. He complained of mild but persistent neck pain. Four weeks after discharge he complained of more severe persistant aching pain at the base of his neck without radiation. He had noted mild tingling of both arms and legs which had increased progressively in severity for about one week. Also for a week he had noted difficulty in ambulation due to stiffness of his legs. EXAMINATION: General physical examination and vital signs were normal. The posterior cervical wound was well healed. His gait was marked by short steps and difficulty with relaxation of muscles in his legs. There was weakness of the biceps muscles bilaterally. Muscle strength was otherwise normal in all extremities. There was a marked increase in muscle tone in the legs. less so in the arms. Tendon reflexes were diffusely hyper active in both upper and lower extremities except for the biceps tendon reflexes which were absent bilaterally. Bilateral Babinski’s signs were present. Sensory examination revealed scattered hypalgesia to pinprick below C5 with normal vibratory and position sense throughout. X-RAYS: Cervical spine x-rays showed excellent alignment of the cervical spine. QUESTIONS
- Which of the following would be the most definitive laboratory study in this patient? (Select only one)
A. Electromyogram
B. Myelogram
C. Flexion-extension x-rays of the cervicai spine
D. Diagnostic nerve block
E. None of toe above
(B)
A cervical myelogram is indicated. This could be carried out by instillation of radio-opaque contrast material into the lumbar subarachnoid space or by instillation of air into the cisterna magna. Flexion-extension views of the cervical spine are probably contraindicated at this point. The patient has had a recent fracture-dislocation and posterior cervical fusion. Sufficient time has not passed to expect solid bony union and flexion-extension movements could result in further spinal cord injury. Electromyography is unlikely to add significant information in this patient. The level of spinal cord dysfunction is apparent from the clinical examination and the history and examination do not suggest either peripheral neuropathy or muscle disease. The electromyogram is particularly useful in the diagnosis of diseases of peripheral nerve, the myoneural junction and muscle. Diagnostic nerve block would be of no value in understanding this patient’s problem.
CASE 17: Difficulty Walking One Month After Neck Injury in a 47-Year-Old Policeman HISTORY: A 47-year-old policeman complained of numbness in his arms and legs and difficulty walking. Eight weeks previously he had injured his neck in a fail in which sudden neck flexion had occurred. Cervical spine x-rays at that time showed bilateral facet dislocation at C5-6. No neurological deficit was present at the time of injury. A posterior cervical fusion was carried out because the injury was felt to be unstable. The patient was discharged from the hospital four weeks following injury. At discharge his neurological examination was normal. He complained of mild but persistent neck pain. Four weeks after discharge he complained of more severe persistant aching pain at the base of his neck without radiation. He had noted mild tingling of both arms and legs which had increased progressively in severity for about one week. Also for a week he had noted difficulty in ambulation due to stiffness of his legs. EXAMINATION: General physical examination and vital signs were normal. The posterior cervical wound was well healed. His gait was marked by short steps and difficulty with relaxation of muscles in his legs. There was weakness of the biceps muscles bilaterally. Muscle strength was otherwise normal in all extremities. There was a marked increase in muscle tone in the legs. less so in the arms. Tendon reflexes were diffusely hyper active in both upper and lower extremities except for the biceps tendon reflexes which were absent bilaterally. Bilateral Babinski’s signs were present. Sensory examination revealed scattered hypalgesia to pinprick below C5 with normal vibratory and position sense throughout. X-RAYS: Cervical spine x-rays showed excellent alignment of the cervical spine. QUESTIONS
- An air myelogram was later performed in this patient (Figure 17. 1). The study shows (Select only one)
A. a diffuse extradural defect
B. an intramedullary defect
C. an intradural extramedullary defect
D. a localized extradural defect
E. none of the above
(D)
The myelogram shows a localized extradural defect opposite the C5-6 interspace.
CASE 17: Difficulty Walking One Month After Neck Injury in a 47-Year-Old Policeman HISTORY: A 47-year-old policeman complained of numbness in his arms and legs and difficulty walking. Eight weeks previously he had injured his neck in a fail in which sudden neck flexion had occurred. Cervical spine x-rays at that time showed bilateral facet dislocation at C5-6. No neurological deficit was present at the time of injury. A posterior cervical fusion was carried out because the injury was felt to be unstable. The patient was discharged from the hospital four weeks following injury. At discharge his neurological examination was normal. He complained of mild but persistent neck pain. Four weeks after discharge he complained of more severe persistant aching pain at the base of his neck without radiation. He had noted mild tingling of both arms and legs which had increased progressively in severity for about one week. Also for a week he had noted difficulty in ambulation due to stiffness of his legs. EXAMINATION: General physical examination and vital signs were normal. The posterior cervical wound was well healed. His gait was marked by short steps and difficulty with relaxation of muscles in his legs. There was weakness of the biceps muscles bilaterally. Muscle strength was otherwise normal in all extremities. There was a marked increase in muscle tone in the legs. less so in the arms. Tendon reflexes were diffusely hyper active in both upper and lower extremities except for the biceps tendon reflexes which were absent bilaterally. Bilateral Babinski’s signs were present. Sensory examination revealed scattered hypalgesia to pinprick below C5 with normal vibratory and position sense throughout. X-RAYS: Cervical spine x-rays showed excellent alignment of the cervical spine. QUESTIONS
- The myelogram is most compatible with (Select only one)
A. metastatic spinal tumor
B. spinal meningioma
C. central cervical disc herniation
D. spinal neurofibroma
E. none of the above
(C)
A localized extradural defect lying directly opposite an intervertebral disc space is most compatible with a cervical disc herniation. Spinal meningioma and spinal neurofibroma are intradural, extramedullary tumors which would not produce the type of myelographic defect seen in this patient. Metastatic spinal tumors produce extradural defects but these are most commonly more extensive and are rarely located opposite the disc space. Spinal metastatic tumors most often begin by a metastatic deposit in bone with secondary extension into the extradural space. Thus, the defect in the case of spinal metastatic tumors most often overlies the vertebral body. In addition, pathologic changes frequently occur In bone in association with metastatic spinal tumors.
CASE 17: Difficulty Walking One Month After Neck Injury in a 47-Year-Old Policeman HISTORY: A 47-year-old policeman complained of numbness in his arms and legs and difficulty walking. Eight weeks previously he had injured his neck in a fail in which sudden neck flexion had occurred. Cervical spine x-rays at that time showed bilateral facet dislocation at C5-6. No neurological deficit was present at the time of injury. A posterior cervical fusion was carried out because the injury was felt to be unstable. The patient was discharged from the hospital four weeks following injury. At discharge his neurological examination was normal. He complained of mild but persistent neck pain. Four weeks after discharge he complained of more severe persistant aching pain at the base of his neck without radiation. He had noted mild tingling of both arms and legs which had increased progressively in severity for about one week. Also for a week he had noted difficulty in ambulation due to stiffness of his legs. EXAMINATION: General physical examination and vital signs were normal. The posterior cervical wound was well healed. His gait was marked by short steps and difficulty with relaxation of muscles in his legs. There was weakness of the biceps muscles bilaterally. Muscle strength was otherwise normal in all extremities. There was a marked increase in muscle tone in the legs. less so in the arms. Tendon reflexes were diffusely hyper active in both upper and lower extremities except for the biceps tendon reflexes which were absent bilaterally. Bilateral Babinski’s signs were present. Sensory examination revealed scattered hypalgesia to pinprick below C5 with normal vibratory and position sense throughout. X-RAYS: Cervical spine x-rays showed excellent alignment of the cervical spine. QUESTIONS
- Which of the following treatments would you suggest (Select only one)
A. Cervical traction
B. Decompressive cervical laminectomy
C. Anterior cervical disc excision
D. Radiation therapy
E. Hone of the above
(C)
Anterior cervical disc excision is most appropriate. This procedure allows removal of the offending herniated nuclear disc fragment without a disturbance of spinal cord position. Opening the posterior longitudinal ligament allows thorough inspection of the extradural space for the presence of extradural herniated disc fragments. Decompressive cervical laminectomy would allow some backward movement of the spinal cord and perhaps reduce the spinal cord compression somewhat. It does not, however, treat the underlying pathology direcuy. Removal of a centrally herniated cervical disc via a decompressive laminectomy is difficult in the cervical regionbecause the presence of the spinal cord makes anterior exploration dangerous. Attempts to explore the anterior extradural space in the cervical region to remove a central herniated disc increase the likelihood of irreversible spinal cord injury. Below the level of L1, an anterior central herniated intervertebral disc may be removed transdurally because the fibers of the cauda equina may be separated allowing anterior exposure safely. Radiation therapy is contraindicated in this situation since the most likely diagnosis is cervical disc herniation which is not treatable by radiotherapy. Even in patients in whom a diagnosis of spinal metastatic tumor is entertained, based on the history and myelographic findings, radiation therapy is not recommended as a definitive treatment unless the patient has a previous tissue diagnosis of malignancy. Cervical traction would not be beneficial in this patient since the myelogram makes it obvious that actual herniation of disc material has occurred into the extradural space. Utilization of cervical traction to provide symptomatic treatment prior to a surgical procedure would be acceptable but is unlikely to provide more than minimal symptomatic relief of neck discomfort.
CASE 18: Neck and Arm Pain and Arm Weakness After Motor Vehicle Accident. HISTORY: A 27-year-old man was seen in the emergency room 45 minutes following an automobile accident. The patient was a passenger in the front seat of a vehicle which struck another vehicle at about 35 miles per hour. The patient was thrown forward and struck his occipital region on the dashboard. His neck was acutely flexed forward and to the right. He was not unconscious but had the immediate onset of pain in the neck and right shoulder. Subsequently, he noted that pain extended into the right hand. He also complained of weakness of the right arm. EXAMINATION: He was awake and alert. There was a 2 cm laceration in the right posterior-parietal region of the scalp. His neck was tender to palpation particularly over the spinous processes of C6 and C7. Motor examination revealed marked weakness of extension of the right elbow and weakness of extension of the. right wrist and fingers. Otherwise, motor function was normal. Tendon reflexes were all 2+ except for the right triceps reflex which was absent. There was a deficit in pinprick sensation along the ulnar aspect of the right forearm including the right middle and ring fingers. Minimal contact with the skin of this region elicited a painful, burning sensation. QUESTIONS
- The anatomical localization of the neurological deficit is most likely the (Select only one)
A. spinal cord at C6-7
B. C6 nerve root
C. C7 nerve root
D. C8 nerve root
E. brachial plexus
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CASE 18: Neck and Arm Pain and Arm Weakness After Motor Vehicle Accident. HISTORY: A 27-year-old man was seen in the emergency room 45 minutes following an automobile accident. The patient was a passenger in the front seat of a vehicle which struck another vehicle at about 35 miles per hour. The patient was thrown forward and struck his occipital region on the dashboard. His neck was acutely flexed forward and to the right. He was not unconscious but had the immediate onset of pain in the neck and right shoulder. Subsequently, he noted that pain extended into the right hand. He also complained of weakness of the right arm. EXAMINATION: He was awake and alert. There was a 2 cm laceration in the right posterior-parietal region of the scalp. His neck was tender to palpation particularly over the spinous processes of C6 and C7. Motor examination revealed marked weakness of extension of the right elbow and weakness of extension of the. right wrist and fingers. Otherwise, motor function was normal. Tendon reflexes were all 2+ except for the right triceps reflex which was absent. There was a deficit in pinprick sensation along the ulnar aspect of the right forearm including the right middle and ring fingers. Minimal contact with the skin of this region elicited a painful, burning sensation. QUESTIONS
- Which of the following are likely pathological mechanisms to explain the neurological deficit? (Select one or more)
A. Spinal cord contusion
B. Acute disc herniation
C. Direct nerve root injury
D. Epidural hematoma
E. Spinal cord infarction
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CASE 18: Neck and Arm Pain and Arm Weakness After Motor Vehicle Accident. HISTORY: A 27-year-old man was seen in the emergency room 45 minutes following an automobile accident. The patient was a passenger in the front seat of a vehicle which struck another vehicle at about 35 miles per hour. The patient was thrown forward and struck his occipital region on the dashboard. His neck was acutely flexed forward and to the right. He was not unconscious but had the immediate onset of pain in the neck and right shoulder. Subsequently, he noted that pain extended into the right hand. He also complained of weakness of the right arm. EXAMINATION: He was awake and alert. There was a 2 cm laceration in the right posterior-parietal region of the scalp. His neck was tender to palpation particularly over the spinous processes of C6 and C7. Motor examination revealed marked weakness of extension of the right elbow and weakness of extension of the. right wrist and fingers. Otherwise, motor function was normal. Tendon reflexes were all 2+ except for the right triceps reflex which was absent. There was a deficit in pinprick sensation along the ulnar aspect of the right forearm including the right middle and ring fingers. Minimal contact with the skin of this region elicited a painful, burning sensation. QUESTIONS
- Cervical spine x-rays from this patient are shown in Figures 18.1 and 18.2. The findings are best described as (Select only one)
A. normal
B. bilateral facet dislocation and locking
C. fracture-dislocation
D. unilateral facet dislocation and locking
E. none of the above
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CASE 18: Neck and Arm Pain and Arm Weakness After Motor Vehicle Accident. HISTORY: A 27-year-old man was seen in the emergency room 45 minutes following an automobile accident. The patient was a passenger in the front seat of a vehicle which struck another vehicle at about 35 miles per hour. The patient was thrown forward and struck his occipital region on the dashboard. His neck was acutely flexed forward and to the right. He was not unconscious but had the immediate onset of pain in the neck and right shoulder. Subsequently, he noted that pain extended into the right hand. He also complained of weakness of the right arm. EXAMINATION: He was awake and alert. There was a 2 cm laceration in the right posterior-parietal region of the scalp. His neck was tender to palpation particularly over the spinous processes of C6 and C7. Motor examination revealed marked weakness of extension of the right elbow and weakness of extension of the. right wrist and fingers. Otherwise, motor function was normal. Tendon reflexes were all 2+ except for the right triceps reflex which was absent. There was a deficit in pinprick sensation along the ulnar aspect of the right forearm including the right middle and ring fingers. Minimal contact with the skin of this region elicited a painful, burning sensation. QUESTIONS
- Which of the following are true concerning unilateral facet dislocation and locking? (Select one or more)
A. Associated only with nerve root injury
B. May be associated with incomplete spinal cord injury
C. May be associated with complete spinal cord injury
D. May occur without neurological deficit
E. None of the above
(B,C,D)
Although nerve roots are the commonest neurological structure injured in unilateral facet dislocations, other structures are also frequently damaged. Braakman and Penning indicated that 10% of their patients with unilateral facet dislocations had neurological evidence of complete spinal cord injury 24% had various forms of incomplete spinal cord lesions and another 24% had no neurological signs. The remaining 42% manifested evidence of one or more nerve root lesions ipsilateral to the side of facet dislocation.
CASE 18: Neck and Arm Pain and Arm Weakness After Motor Vehicle Accident. HISTORY: A 27-year-old man was seen in the emergency room 45 minutes following an automobile accident. The patient was a passenger in the front seat of a vehicle which struck another vehicle at about 35 miles per hour. The patient was thrown forward and struck his occipital region on the dashboard. His neck was acutely flexed forward and to the right. He was not unconscious but had the immediate onset of pain in the neck and right shoulder. Subsequently, he noted that pain extended into the right hand. He also complained of weakness of the right arm. EXAMINATION: He was awake and alert. There was a 2 cm laceration in the right posterior-parietal region of the scalp. His neck was tender to palpation particularly over the spinous processes of C6 and C7. Motor examination revealed marked weakness of extension of the right elbow and weakness of extension of the. right wrist and fingers. Otherwise, motor function was normal. Tendon reflexes were all 2+ except for the right triceps reflex which was absent. There was a deficit in pinprick sensation along the ulnar aspect of the right forearm including the right middle and ring fingers. Minimal contact with the skin of this region elicited a painful, burning sensation. QUESTIONS
- Which of the following might be useful in the further evaluation of this patient? (Select one or more)
A. Spinal puncture
B. Queckenstedt test
C. Polytomography
D. Electromyography
E. Flexion and extension views
(C)
Polytomography may be very useful in accurate diagnosis of unilateral facet dislocations. A polytomographic view from the patient described is illustrated in Figure 18.4. The abnormal position of the C7 superior facet (single crossed arrow) placed posterior to the inferior facet of C6 (plain arrow) is clearly demonstrated. The marked compromise of the C6-7 intervertebral foramen is also evident (double crossed arrow) and results from persistent rotation of C7 in relation to C6. Such foraminal compromise results in nerve root injury. The normal relationship of articular facets and the configuration of the intervertebral foramina are well seen at the C5-6 level. In general, polytomography should be carried out to carefully evaluate spinal fractures, particularly in cases where bony injury does not seem sufficient to explain symptomatology. In cases of unilateral facet dislocation, poly tomography often shows associated facet or transverse process fractures. Flexion and extension views in general are hazardous. Only if bony injury or dislocation have been excluded by appropriate plain x-rays and polytomography should flexion and extension views be carried out. These must be supervised by a qualified physician and should not be left to the radiological technician to carry out since risk of spinal cord injury is present with neck movement. Spinal puncture and the Queckenstedt test are of no use in the evaluation of the patient presented. The character of the spinal fluid and the presence or absence of subarachnoid block on the Queckenstedt maneuver are useless in determining the appropriate course of action in spinal injury. Not all authors, however, agree with this view. Electromyography (EMG) is of little value on an acute basis for the diagnosis of neuromuscular disease. Evidence of denervation takes several weeks to develop and at that time the EMG may be useful in the differential diagnosis of spinal injuries. The EMG is most helpful in providing a prognosis in root injuries but may be of some value in decisions on delayed surgical approach to brachial plexus lesions associated with spinal trauma.
CASE 19: Motor and Sensory Loss in One Arm after Injurv in a 37-Year-Old Man HISTORY: A 37-year-old man. was seen in the emergency room complaining of monoplegia of the left arm. One hour prior to admission, he was a spectator at an automobile race in which a race car lost one of its tires. The tire rolled along the race track, jumped a guard rail and protective fence and struck the patient in the left side of the neck, across the left clavicle and left side of the chest. He was knocked unconscious for 3-4 minutes. On awakening he complained of severe left shoulder pain and paralysis and numbness of the entire left arm. EXAMINATION: Vital signs were stable and the patient was conversant. The tire tread design was tatooed on the skin of the anterior aspect of the left shoulder. The gross appearance of the left arm was normal. There was marked swelling about the left clavicle. Breath sounds were decreased in the left lung field. A left Horner’s syndrome was noted. Neurological examination disclosed flaccid paralysis of the entire left arm including the deltoid muscle. There was total anesthesia of the arm beginning at the skin over the deltoid muscle and sparing only a tiny area along the medial aspect of the upper arm near the axilla. Tendon reflexes were absent in the left arm. The remainder of the neurological examination was normal. Strength reflexes and sensation were normal in the other extremities. Sphincter function was normal. No pathological reflexes were noted. QUESTIONS
- The most likely pathological process to explain the neurological findings is (Select only one)
A. central spinal cord syndrome
B hemisection of the spinal cord
C. avulsion of the roots of the left brachial plexus
D. spinal cord contusion
E. subclavian artery occlusion
(C)
Neurological findings are confined to the left arm and include motor and sensory loss in regions innervated by spinal segments C5-T1. These are the segments which compose the brachial plexus. Flaccid motor paralysis and sensory loss confined to one arm are rare with cervical spinal cord injury alone. Combined injuries to the spinal cord and brachial plexus may present problems in clinical diagnosis due to the coexistence of neurological deficits related to the two lesions. In these circumstances, the brachial plexus injury may be overlooked for some time. In spinal cord injury, such as the central spinal cord syndrome, hemisection of the spinal cord or diffuse spinal cord contusion, neurological findings are usually present in the lower extremities and trunk and may include both upper extremities. Sphincter dysfunction is also common. The presence of swelling about the shoulder, tatooing of the skin about the clavicle and the history of the mechanism of injury all suggest brachial plexus rather than spinal cord injury. Although subclavian artery injury commonly occurs with brachial plexus injury, it does not usually produce complete motor and sensory loss. In addition, absence of pulses in the extremity and pallor, neither of which were present in this patient, suggest subclavian or axillary artery injury. Traumatic aneurysms occurring after arterial injury may cause delayed brachial plexus neuropathy due to direct compression of the plexus.
CASE 19: Motor and Sensory Loss in One Arm after Injurv in a 37-Year-Old Man HISTORY: A 37-year-old man. was seen in the emergency room complaining of monoplegia of the left arm. One hour prior to admission, he was a spectator at an automobile race in which a race car lost one of its tires. The tire rolled along the race track, jumped a guard rail and protective fence and struck the patient in the left side of the neck, across the left clavicle and left side of the chest. He was knocked unconscious for 3-4 minutes. On awakening he complained of severe left shoulder pain and paralysis and numbness of the entire left arm. EXAMINATION: Vital signs were stable and the patient was conversant. The tire tread design was tatooed on the skin of the anterior aspect of the left shoulder. The gross appearance of the left arm was normal. There was marked swelling about the left clavicle. Breath sounds were decreased in the left lung field. A left Horner’s syndrome was noted. Neurological examination disclosed flaccid paralysis of the entire left arm including the deltoid muscle. There was total anesthesia of the arm beginning at the skin over the deltoid muscle and sparing only a tiny area along the medial aspect of the upper arm near the axilla. Tendon reflexes were absent in the left arm. The remainder of the neurological examination was normal. Strength reflexes and sensation were normal in the other extremities. Sphincter function was normal. No pathological reflexes were noted. QUESTIONS
- Horner’s syndrome in this patient is due to injury to (Select only one)
A. spinal cord
B. cervical sympathetic trunk
C. C8 and T1 nerve roots
D. parasympathetic pathways
E. none of the above
(C)
Horner’s syndrome consists of ptosis, meiosis, and anhydrosis of the face and is due to dysfunction of the sympathetic pathways. The sympathetic pathways descend through the cervical spinal cord and synapse with cells in the intermediolateral cell column of the spinal cord at the first thoracic segment. Preganglionic fibers exit from the spinal canal with the C8 and T1 nerve roots and ascend to make synaptic connections in the cervical sympathetic ganglia. Postganglionic fibers then pass to the pupillodilator muscle, the tarsal muscle of the upper eyelid and sweat glands in the face and scalp. The clinical picture in this patient is most compatible with avulsion of the nerve roots of the brachial plexus and thus avulsion of the C8 and T1 nerve roots most likely explains the Horner’s syndrome in this patient. Injuries to the cervical sympathetic trunk may also cause Horner’s syndrome but are frequently related to penetrating neck wounds. Horner’s syndrome may also be due to spinal cord injury above the T1 level and in such cases is most often bilateral. However, in hemispinal cord injuries, the Horner’s syndrome may be unilateral.
CASE 19: Motor and Sensory Loss in One Arm after Injurv in a 37-Year-Old Man HISTORY: A 37-year-old man. was seen in the emergency room complaining of monoplegia of the left arm. One hour prior to admission, he was a spectator at an automobile race in which a race car lost one of its tires. The tire rolled along the race track, jumped a guard rail and protective fence and struck the patient in the left side of the neck, across the left clavicle and left side of the chest. He was knocked unconscious for 3-4 minutes. On awakening he complained of severe left shoulder pain and paralysis and numbness of the entire left arm. EXAMINATION: Vital signs were stable and the patient was conversant. The tire tread design was tatooed on the skin of the anterior aspect of the left shoulder. The gross appearance of the left arm was normal. There was marked swelling about the left clavicle. Breath sounds were decreased in the left lung field. A left Horner’s syndrome was noted. Neurological examination disclosed flaccid paralysis of the entire left arm including the deltoid muscle. There was total anesthesia of the arm beginning at the skin over the deltoid muscle and sparing only a tiny area along the medial aspect of the upper arm near the axilla. Tendon reflexes were absent in the left arm. The remainder of the neurological examination was normal. Strength reflexes and sensation were normal in the other extremities. Sphincter function was normal. No pathological reflexes were noted. QUESTIONS
- Appropriate diagnostic studies should include (Select one or more)
A. chest x-ray
B. x-rays of the left shoulder
C. electromyogram
D. cervical spine x-rays
E. none of the above
(A,B,C,D)
Chest x-ray may reveal several associated and even life threatening injuries such as fracture of the clavicle or upper ribs, pneumothorax, hemothorax or pulmonary injury. Chest x-ray in this patient revealed an elevated left hemidiaphragm suggesting unilateral phrenic nerve paralysis. X-rays of the shoulder provide analysis of associated bony injury to the clavicle, ribs, scapula and humerus. Cervical spine x-rays are also indicated to evaluate possible associated cervicle spine trauma. Avulsion of cervical transverse processes, if identified on cervical spine x-rays, may be of prognostic value since they are nearly pathognomonic of avulsion of the roots of the brachial plexus. The electromvogram (EMG) is most useful several weeks after injury when signs of denervation appear in affected muscles. These include excessive insertionai activity and fibrillation potentials. Sensory evoked potential studies may also be helpful in deciding whether the brachial plexus injury is proximal or distal to the dorsal root ganglia. The latter contain the cell bodies of the sensory neurons, the proximal processes of which cuter the spinal cord and the distal processes of which travel to the extremity. Such a distinction between so-called postganglionic and preganglionic lesions is of great importance. In preganglionic injuries, i.e. those affecting the dorsal roots between the spinal cord and the sensory ganglion cells, recovery is impossible. Postganglionic injuries, on the other hand, may show recovery. EMG examination of the paraspinal muscles may also be useful in distinguishing preganglionic lesions from postganglionic. If denervation of paraspiual muscles is demonstrated, the lesion is preganglionic The posterior primary divisions of the ventral roots which innervate the paraspinal muscles leave the nerves just proximal to the location of the dorsal root ganglia and are only affected by preganglionic lesions. Occasionally the EMG may be useful a few days after injury in distinguishing functional disruption of neural conduction, so called neurapraxia, from an anatomic disruption of the nerve fibers or nerve, called axonotmesis and neurotmesis respectively. In neurapraxia, the evoked muscle response to electrical stimulation of the plexus proximal to the point of injury may be preserved in spite of absent or poor volitional activity. The evoked muscle response is diminished or absent in neurotmesis or axonotmesis.
CASE 19: Motor and Sensory Loss in One Arm after Injurv in a 37-Year-Old Man HISTORY: A 37-year-old man. was seen in the emergency room complaining of monoplegia of the left arm. One hour prior to admission, he was a spectator at an automobile race in which a race car lost one of its tires. The tire rolled along the race track, jumped a guard rail and protective fence and struck the patient in the left side of the neck, across the left clavicle and left side of the chest. He was knocked unconscious for 3-4 minutes. On awakening he complained of severe left shoulder pain and paralysis and numbness of the entire left arm. EXAMINATION: Vital signs were stable and the patient was conversant. The tire tread design was tatooed on the skin of the anterior aspect of the left shoulder. The gross appearance of the left arm was normal. There was marked swelling about the left clavicle. Breath sounds were decreased in the left lung field. A left Horner’s syndrome was noted. Neurological examination disclosed flaccid paralysis of the entire left arm including the deltoid muscle. There was total anesthesia of the arm beginning at the skin over the deltoid muscle and sparing only a tiny area along the medial aspect of the upper arm near the axilla. Tendon reflexes were absent in the left arm. The remainder of the neurological examination was normal. Strength reflexes and sensation were normal in the other extremities. Sphincter function was normal. No pathological reflexes were noted. QUESTIONS
- A myelogram done in this patient is shown in It shows (Select only one)
A. a herniated intervertebral disc
B. benign nerve root cysts
C. is normal
D. an extradural hematoma
E. multiple nerve root avulsions
(E)
Extradural pockets of contrast material are demonstrated on the myelogram at C6-7. C7-T1 and T1-2 (Figure 19.1). These are consistent with avulsion of the C7, C8 and T1 nerve roots. The subarachnoid space usually terminates at the point where dorsal and ventral roots join just proximal to the dorsal root ganglia. With root avulsion the subarachnoid space is breached and contrast material leaks into small pseudomeningoceles. In Figure 19.2, contrast material is retained in the pseudomeningoceles when the patient is placed in the upright position. Such radiological findings correlate with a preganglionic location of the lesion and suggest a hopeless prognosis. The results of myelography must be interpreted with caution, however, in establishing a prognosis in brachial plexus injuries, since false-negative and false-positive results have been reported. A herniated intervertebral disc or extradural hematoma would produce appropriate defects in the contrast column or obstruction to flow of contrast material. In addition, while small benign nerve root cysts may occur normally, primarily in the lumbar region, the size and location of the pseudomeningoceles demonstrated, coupled with the clinical picture, are diagnostic of nerve root avulsions. *pict*
CASE 19: Motor and Sensory Loss in One Arm after Injurv in a 37-Year-Old Man HISTORY: A 37-year-old man. was seen in the emergency room complaining of monoplegia of the left arm. One hour prior to admission, he was a spectator at an automobile race in which a race car lost one of its tires. The tire rolled along the race track, jumped a guard rail and protective fence and struck the patient in the left side of the neck, across the left clavicle and left side of the chest. He was knocked unconscious for 3-4 minutes. On awakening he complained of severe left shoulder pain and paralysis and numbness of the entire left arm. EXAMINATION: Vital signs were stable and the patient was conversant. The tire tread design was tatooed on the skin of the anterior aspect of the left shoulder. The gross appearance of the left arm was normal. There was marked swelling about the left clavicle. Breath sounds were decreased in the left lung field. A left Horner’s syndrome was noted. Neurological examination disclosed flaccid paralysis of the entire left arm including the deltoid muscle. There was total anesthesia of the arm beginning at the skin over the deltoid muscle and sparing only a tiny area along the medial aspect of the upper arm near the axilla. Tendon reflexes were absent in the left arm. The remainder of the neurological examination was normal. Strength reflexes and sensation were normal in the other extremities. Sphincter function was normal. No pathological reflexes were noted. QUESTIONS
- Which of the following are true concerning prognosis in this patient? (Select one or more)
A. Recovery of motor function is likely
B. Recovery of motor function is unlikely
C. Recovery of sensory function is likely
D. Recovery of sensory function is unlikely
E. Intractable pain is likely
(B,D,E)
The patient described has clinical and myelographic evidence of a preganglionic injury of a traction type. The clinical evidence is the presence of Horner’s syndrome and physical examination and x-ray evidence of a paralyzed hemidiaphragrn. The myelographic evidence of a preganglionic lesion is the presence of multiple pseudomeningoceles at the cites of nerve root avulsions. In addition, the patient has a closed brachial plexus injury. Such lesions result from stretching or concussive blows to the plexus and produce widespread destruction along the length of nerves and nerve roots. Even when such closed injuries occur in a postganglionic location the prognosis for recovery is poor. Intractable pain is an unfortunate and frequent accompaniment of brachial plexus injury. Treatment of such pain is difficult and often unsuccessful and frequently results in depression and narcotic addiction. Amputation of the useless extremity in an attempt to relieve such pain is also usually unsuccessful. Surgical treatment may be useful in assisting recovery if upper brachial plexus injuries result from penetrating trauma such as knife or gunshot wounds. In such cases, nerve anastomosis or cable grafting of missing segments of nerve may allow it; innervation of proximal shoulder and upper arm muscles. Even in cases of penetrating wounds, with a more localized type of injury, the prognosis for recovery of function for muscles in the forearm and hand is poor. This is due to the excessively long distance the regenerating nerve must travel from the point of injury to the distally located muscle. Such nerve re-growth occurs at a rate of about 1 mm per day. Thus, even if nerve regrowth occurs, irreversible muscle atrophy and fibrosis occurs before reinnervation is accomplished. It is for this reason that many surgeons are pessimistic about improvements in function due to brachial plexus injury with surgical treatment. Microsurgical suture techniques may improve the ability or regenerating nerves to transverse zones of injury but cannot overcome the problem of distal muscle atrophy and fibrosis.
CASE 20: Persistent Neck Pain and Muscle Spasm after Ice Hockey Injury HISTORY: A 19-year-old male was seen 48 hours following injury in an ice hockey game. He was apparently knocked to the ice by an opponent who fell on top of him. The side of his head struck the ice and his neck was forced acutely into right lateral flexion. Ke noted immediate pain in the right shoulder and right side of the neck. He was seen because of persistent pain in the neck, particularly the right side. The shoulder pain had subsided. EXAMINATION: There was mild muscle spasm on the right side of the neck at rest. Neck motion, however, was full with some aggravation of pain on right lateral neck flexion or rotation. The neurological examination was entirely normal. X-RAYS: An anteroposterior (AP) cervical spine x-ray is illustrated in Figure 20.1. A lateral view appeared normal. QUESTIONS
- The AP lateral cervical spine x-ray shows (Select only one)
A. normal findings
B. fracture-dislocation
C. nondisplaced odontoid fracture
D. asymmetry of the atlanto-axial relationship
E. Jefferson’s fracture
(D)
There is asymmetry in the atlanto-axial relationship which is only appreciated on the anteroposterior view (Figure 20.1). The distance between the lateral margin of odontoid process and the medial edge of the articular mass of the atlas is asymmetric. The term “rotational subluxation^’ or “rotaryfixation” has been applied to this condition in the past with the view that it represents a pathological condition due to trauma. Although there is not currently full agreement, most writers, including the present authors, feel that the condition rarely represents true pathology. Braakman has discussed this subject fully with excellent illustrations. Recently computerized tomographic scanning has been effectively utilized to evaluate such asymmetry. No fractures or significant dislocations are shown on the x-rays illustrated.
CASE 20: Persistent Neck Pain and Muscle Spasm after Ice Hockey Injury HISTORY: A 19-year-old male was seen 48 hours following injury in an ice hockey game. He was apparently knocked to the ice by an opponent who fell on top of him. The side of his head struck the ice and his neck was forced acutely into right lateral flexion. Ke noted immediate pain in the right shoulder and right side of the neck. He was seen because of persistent pain in the neck, particularly the right side. The shoulder pain had subsided. EXAMINATION: There was mild muscle spasm on the right side of the neck at rest. Neck motion, however, was full with some aggravation of pain on right lateral neck flexion or rotation. The neurological examination was entirely normal. X-RAYS: An anteroposterior (AP) cervical spine x-ray is illustrated in Figure 20.1. A lateral view appeared normal. QUESTIONS
- The most likely cause of these x-ray findings is (Select only one)
A. fracture of the atlas
B. fracture of the axis
C. injury to facet joint ligaments
D. muscle spasm
(D) The most frequent cause of unilateral asymmetry of the atlanto-axial relationship on x-ray is rotation of the neck due to head tilt and muscle spasm. Hohl and Baker indicated that lateral atlanto-axial movement was possible only when the atlanto-axial joints are in a position of rotation. Braakman showed that on lateral head flexion the atlas moves laterally while, at the same time, atlanto-axial rotation occurs. Therefore, lateral displacement of the atlas on the axis should not automatically be interpreted as a subluxation. Tomography, when abduction and rotation are present at the atlanto-axial joint, may also be misinterpreted. Particularly with anteroposterior tomograms, both lateral joints are not seen in the same plane. Thus, one side may be sharp and the other poorly defined, leading to diagnosis of pathological conditions such as arthritis. In Jefferson’s fracture of the atlas, there is a bursting separation of the atlas ring (see Case 6). Therefore, the anteroposterior view usually shows bilateral increase in distance between the odontoid and lateral mass of the atlas. In addition, there is lateral displacement of the lateral edge of the articular mass of the atlas on the axis. This is not seen with so-called “rotational subluxation”. Bilateral atlanto-axial separation may also occur in certain congenital circumstances as described by Budin. In fractures of the odontoid, displacement is usually in the anteroposterior plane and best appreciated on the lateral view. In addition, the fracture itself is usually visible on the anteroposterior view and no such lesion is seen in the x-ray illustrated. Considerable emphasis has been placed on ligamentous injury as a cause of “rotational subluxation”. Anatomical studies, however, indicate that asymmetry of the atlanto-axial relationship may occur with simple abduction and rotation of the upper spine in the presence of normal ligaments. It seems clear that most cases of asymmetry of the atlanto-axial relationship are due to positioning of the spine at the time of radiological studies. Computerized tomographic scanning, however, confirms that in some cases true “rotational fixation” may be present.
CASE 20: Persistent Neck Pain and Muscle Spasm after Ice Hockey Injury HISTORY: A 19-year-old male was seen 48 hours following injury in an ice hockey game. He was apparently knocked to the ice by an opponent who fell on top of him. The side of his head struck the ice and his neck was forced acutely into right lateral flexion. Ke noted immediate pain in the right shoulder and right side of the neck. He was seen because of persistent pain in the neck, particularly the right side. The shoulder pain had subsided. EXAMINATION: There was mild muscle spasm on the right side of the neck at rest. Neck motion, however, was full with some aggravation of pain on right lateral neck flexion or rotation. The neurological examination was entirely normal. X-RAYS: An anteroposterior (AP) cervical spine x-ray is illustrated in Figure 20.1. A lateral view appeared normal. QUESTIONS
- Which of the following are true concerning atlanto-axial asymmetry identified radiologically ? (Select one or more)
A. Conclusive proof of cervical trauma
B. Occurs only with ligamentous rupture
C. May be due to congenital odontoid asymmetry
D. May be associated with congenital facial asymmetry
(C,D) Brocher described asymmetrical implantation of the odontoid process into the body of the axis which simulated lateral displacement of the atlas. Facial asymmetry with asymmetrical relationships in the occipitocervical region were also reported by Wackenheim. Ligamentous rupture is not necessary in. order to allow lateral shift of the atlas on the axis. This abduction movement can occur with rotation in the presence of normal ligaments. Brav also reported a patient who could voluntarily cause lateral atlanto-axial displacement. Several authors have indicated that an asymmetrical atlantoaxial relationship need not be taken as proof of significant spinal trauma.
CASE 20: Persistent Neck Pain and Muscle Spasm after Ice Hockey Injury HISTORY: A 19-year-old male was seen 48 hours following injury in an ice hockey game. He was apparently knocked to the ice by an opponent who fell on top of him. The side of his head struck the ice and his neck was forced acutely into right lateral flexion. Ke noted immediate pain in the right shoulder and right side of the neck. He was seen because of persistent pain in the neck, particularly the right side. The shoulder pain had subsided. EXAMINATION: There was mild muscle spasm on the right side of the neck at rest. Neck motion, however, was full with some aggravation of pain on right lateral neck flexion or rotation. The neurological examination was entirely normal. X-RAYS: An anteroposterior (AP) cervical spine x-ray is illustrated in Figure 20.1. A lateral view appeared normal. QUESTIONS
- Which of the following treatments would you recommend for the patient illustrated? (Select only one)
A. Skeletal traction
B. Open reduction
C. Halo brace
D. Cervical collar
E. Spinal fusion
(D) Specific treatment of atlanto-axial asymmetry is not required. Attempts at reduction either manually, by halter or skeletal traction are unnecessary. General treatment of cervical muscle spasm and torticollis by rest or cervical collar, mild physical therapy, analgesics and muscle relaxants, depending on the severity of symptoms, is appropriate. The present authors have had universal success with this treatment. Early in our experience, follow-up cervical spine x-rays were obtained and always showed resolution of the asymmetry. Presently, if symptoms of pain and muscle spasm subside, followup x-rays are not felt to be necessary. The halo brace is not required as these lesions are not unstable. Operative procedures such as open reduction and spinal fusion are completely inappropriate.
CASE 20: Persistent Neck Pain and Muscle Spasm after Ice Hockey Injury HISTORY: A 19-year-old male was seen 48 hours following injury in an ice hockey game. He was apparently knocked to the ice by an opponent who fell on top of him. The side of his head struck the ice and his neck was forced acutely into right lateral flexion. Ke noted immediate pain in the right shoulder and right side of the neck. He was seen because of persistent pain in the neck, particularly the right side. The shoulder pain had subsided. EXAMINATION: There was mild muscle spasm on the right side of the neck at rest. Neck motion, however, was full with some aggravation of pain on right lateral neck flexion or rotation. The neurological examination was entirely normal. X-RAYS: An anteroposterior (AP) cervical spine x-ray is illustrated in Figure 20.1. A lateral view appeared normal. QUESTIONS
- The risk of spinal cord injury in this patient is (Select only one)
A. very high
B. minimal
C. impossible to predict
(B) Spinal cord injury has not been reported with so called “rotatory subluxation” of the atlanto-axial region. It is essential to bear in mind that the important aspect of spinal injury relates to the integrity of neural structures, i.e., the spinal cord and nerve roots. Excessive emphasis on the bony aspects of spinal injury are unjustified unless they are related to the associated neural structures. Naturally, the possibility that untreated bony injury may lead to delayed neurological injury must also be kept in mind. In the condition described in this case, there is no evidence of related neurological injury and there is no evidence of longterm instability or delayed neurological deterioration. Thus, treatment, if any, should be conservative and as noninvasive as possible. Unnecessary attempts at reduction and/or immobilization are ill advised.
CASE 21: Spinal Cord injury in a 4-Year-Old Boy Following Automobile Accident HISTORY: A 4-year-old male was seen in the emergency room thirty minutes following an automobile, accident. The child was riding oh his mother’s lap in the front seat when the slowly moving vehicle struck a stopped truck in front. The child was thrown forward against the dashboard. The exact mechanism of injury was unknown but the forces involved appeared to be minimal. No one else was injured. The child was awake and crying. EXAMINATION: BP 110/70, P 92r R 32. There was tenderness to palpation over the spinous processes of C3 and C4. The child was moving all extremities but not as briskly as expected. Specific motor examination could not be carried out because the child would not cooperate fully. He could stand and walk slowly, he could not run. Tendon reflexes were abnormally weak in both upper and lower extremities. Plantar beware flexor. Sensation to pinprick appeared normal. LABORATORY DATA: Complete blood count and urinalysis is normal. QUESTIONS
- The cervical spine x-ray from this patient is illustrated in Figure 21.1. It shows (Select only one) normal findings for age
A. Normal findings for age
B. subluxation C2-3
C. fracture-dislocation
D. facet dislocation
E. odontoid fracture
(A) There is apparent subluxation at the C2-3 interspace, the problem of excessive movement at the C2-3 interspace in children and the differentiation between physiological movement of pathological subluxation has been discussed by several authors. In our experience, true pathological subluxation at C2-3 is rare in children and most apparent subluxations are due to normal movement at the joint. A lateral program in this patient (Figure 21.2) showed no evidence of bony injury and confirmed normal alignment in the neutral position. Dunlap was one of the first to emphasize the normal appearance of subluxation at C2-3 in children, particularly reduceable on the lateral x-ray view of the cervical spine in the flexion. It was suggested that persistent subluxation C2-3 in the neutral or hyperexteaded position would difference pathological from physiological movement at C2-3 in children. This physiological subluxation may cause difficulty in diagnosis of the Hangman’s fracture at C2-3 as well, since anterior displacement of the body of C2 on C3 may occur with bilateral fracture of the pedicles of C2. The incidence of such phvsiological subluxation in children ages 1-17 years has been estimated at 24%. Cattell indicated that the high mobility of the cervical spine and elasticity of facet joint ligaments coupled with the relatively horizontal position of the C2-3 articular facts in children accounted for this excessive movement. In addition, the C2-3 region was felt to be an important fulcrum of cervical movement and such physiological subluxation was maximum there. The relatively poor development of paraspinal muscles in infants and young children may also contribute an excessive spinal mobility. Our review of cervical spine x-rays in children indicates that smaller degrees of physiological subluxation are often found at C3-4 and even C4-5. Although one or two millimeters of anterior subluxation of C2 and or C3 or C4 is considered abnormal in adults, up to 4 mm may be considered within the range of normal for children up eight years of age.
CASE 21: Spinal Cord injury in a 4-Year-Old Boy Following Automobile Accident HISTORY: A 4-year-old male was seen in the emergency room thirty minutes following an automobile, accident. The child was riding oh his mother’s lap in the front seat when the slowly moving vehicle struck a stopped truck in front. The child was thrown forward against the dashboard. The exact mechanism of injury was unknown but the forces involved appeared to be minimal. No one else was injured. The child was awake and crying. EXAMINATION: BP 110/70, P 92r R 32. There was tenderness to palpation over the spinous processes of C3 and C4. The child was moving all extremities but not as briskly as expected. Specific motor examination could not be carried out because the child would not cooperate fully. He could stand and walk slowly, he could not run. Tendon reflexes were abnormally weak in both upper and lower extremities. Plantar beware flexor. Sensation to pinprick appeared normal. LABORATORY DATA: Complete blood count and urinalysis is normal. QUESTIONS
- Which of the following is the most likely diagnosis in this patient? (Select only one)
A. Normal child, no significant injury
B. Spinal cord contusion
C. Epidural hematoma
D. Acute herniated intervertebral disc
E. Subdural hematoma
(D) The neurological examination is abnormal. There is induced extremity movement and use. In addition, the reflexes are diffusely brisk and muscle tone is increased in the lower extrimities. The child is unabie to run. These findings are strongly suggestive of abnormal motor function. There are no specific sensory abnormalities detectable. The difficulty in carrying test neurological evaluation in young children with spinal injury is discussed by Yashon. Because cooperation for detailed motor and sensory examination is often unobtainable, the examiner must often rely on observation of spontaneous motor activity or reflex responses such as withdrawal or crying in response to noxious stimuli. These signs are easily misinterpreted. For instance, withdrawal of extremities in response to noxious stimuli may represent local spinal reflex activity and may not be perceived by the patient as painful due to spinal cord dysfunction at a higher evel. Even crying in conjunction with motor withdrawal may not reliably indicate stimulus perception, as pain may be initiated above the level of a spinal cord injury by reflex motor withdrawal below the lesion. Nevertheless, in the patient presented, the motor examination supports spinal cord pathology. The absence of extensor plantar responses does not exclude motor system pathology. Epidural or subdural hematoma are unlikely due to the minimal nature of the patient’s symptoms and signs and the apparent lack of progression of neurological deficit often seen with these lesions. An acutely herniated intervertebral disc is an extremely unusual injury in children with spinal trauma and the patient does not manifest the anterior spinal cord injury syndrome which may be seen with acute disc herniation secondary to spinal trauma. Although intraspinal hematoma and intervertebral disc herniation cannot be completely ruled out they are unlikely as the cause of the mild neurological deficit identified in the patient described. Also to be considered n children with spine or spinal cord injuries is child abuse. Most commonly these are seen in children without a history of trauma. Considerable emphasis has been placed on long bone fractures and head injuries in battered children but a significant number also have spinal trauma according to Cullen. Since none of the above pathological conditions seems appropriate a mild spinal cord contusion appears most likely. The neurological deficit related to spinal cord contusion may range from very mild to very severe. A static lesion with neurological deficit as described is most compatible with spinal cord contusion.
CASE 21: Spinal Cord injury in a 4-Year-Old Boy Following Automobile Accident HISTORY: A 4-year-old male was seen in the emergency room thirty minutes following an automobile, accident. The child was riding oh his mother’s lap in the front seat when the slowly moving vehicle struck a stopped truck in front. The child was thrown forward against the dashboard. The exact mechanism of injury was unknown but the forces involved appeared to be minimal. No one else was injured. The child was awake and crying. EXAMINATION: BP 110/70, P 92r R 32. There was tenderness to palpation over the spinous processes of C3 and C4. The child was moving all extremities but not as briskly as expected. Specific motor examination could not be carried out because the child would not cooperate fully. He could stand and walk slowly, he could not run. Tendon reflexes were abnormally weak in both upper and lower extremities. Plantar beware flexor. Sensation to pinprick appeared normal. LABORATORY DATA: Complete blood count and urinalysis is normal. QUESTIONS
- Which of the following are true concerning spinal injuries in children or infants who are passengers in motor vehicles? (Select one or more)
A. Children are safest when held on lap of parent
B. Children arc safer in the rear than in the front seat
C. The incidence of childhood spinal injury could be reduced by a restraining system
D. Infants are safest in a bassinet placed on the seat but otherwise unrestrained
E. Infants are safest in a bassinet placed on the seat and restrained by seat belts
(B,C,E) Spinal injuries are frequently sustained by children who are passengers in motor vehicles. Although the child held en its parent’s lap is psychologically the most secure position from the parent’s point of view. it exposes the infant or child to significant risk of injury in case of collision. On impact, the child may be thrown free in the vehicle to strike solid objects such as the dashboard as in the case illustrated or may be crushed between the parent’s body and the automobile. Spinal injuries resulting from such trauma.occur most commonly in the cervical or upper thoracic areas. Many injuries in children who are passengers in motor vehicle accidents apparently could be prevented by proper restraining systems. Appropriate car seats are available for older children and it appears that the rear seat is safer than the front. For infants, the bassinet is safest when placed in the rear seat its long axis parallel to the long axis of the automobile, utilizing the seat belt around the bassinet legs to secure it solidly to the seat. The child should be placed feet forward and a net should be placed over the bassinet to prevent the child from being thrown out and into contact with the inside of the vehicle in case of collision. The idea that passengers in vehicles are safest without restraints is absolutely false. Fears of injured victims being unable to escape from vehicles and sustaining fatal burns in case of explosion or combusion of fuel are, in the main, unfounded. The safest place is within the vehicle, well restrained with lap and shoulder harness for adults and large children. Appropriate car seats or properly restrained bassinet are safest for children.
CASE 21: Spinal Cord injury in a 4-Year-Old Boy Following Automobile Accident HISTORY: A 4-year-old male was seen in the emergency room thirty minutes following an automobile, accident. The child was riding oh his mother’s lap in the front seat when the slowly moving vehicle struck a stopped truck in front. The child was thrown forward against the dashboard. The exact mechanism of injury was unknown but the forces involved appeared to be minimal. No one else was injured. The child was awake and crying. EXAMINATION: BP 110/70, P 92r R 32. There was tenderness to palpation over the spinous processes of C3 and C4. The child was moving all extremities but not as briskly as expected. Specific motor examination could not be carried out because the child would not cooperate fully. He could stand and walk slowly, he could not run. Tendon reflexes were abnormally weak in both upper and lower extremities. Plantar beware flexor. Sensation to pinprick appeared normal. LABORATORY DATA: Complete blood count and urinalysis is normal. QUESTIONS
- Re-examination of the child upon completion of x-ray studies showed marked weakness of both arms and legs. The child could no longer walk or stand alone and no spontaneous arm movement was noted. There was apparent reduced pinprick perception below the C4 dermatomal level. Bilateral extensor plantar responses were noted. Which of the following might explain this neurological deterioration? (Select one or more)
A. Spinal cord infarction
B. Progressive spinal cord necrosis
C. Epidural hematoma
D. Subdural hematoma
E. None of the above
(A,B,C,D) The neurological examination is now indicative of progressive deterioration. The child is quadriparetic with marked reduction in upper extremity movement and inability to stand. Bilateral Babinski’s signs are now present. In addition, there is a sensory level at C4. These are all suggestive of severe spinal cord dysfunction at the upper cervical level. Any of the lesions listed could be responsible for progressive rapid neurological deterioration. Spinal cord infarction after spinal trauma has recently received attention as the cause of neurological deterioration in children. Ahmann described two children, ages 22 months and four years, who sustained relatively minor spinal trauma with minimal initial neurological deficit. In both patients, severe neurological deterioration leading to quadriplegia, respiratory insufficiency, and death occurred over a several hour period post injury. Autopsy examination in both patients showed extensive ischemic necrosis extending from C3-T1 in one patient and from the medulla to C5 in the other. Lenn reported a similar patient with progressive spinal cord dysfunction after spinal trauma of a relatively mild degree which involved the thoracic spinal cord in a 10-year-old child. Pathological confirmation was not obtained in Lenn’s patient because she continued to survive at the time of this report. Ahmann reviewed the vascular supply of the spinal cord in search of a potential etiology for delayed spinal cord infarction after spinal trauma. Neither of his patients showed spinal artery occlusion at autopsy. In addition, the pattern of infarction did not suggest venous occlusion since no evidence of congestion or hemorrhage was seen. Ahmann suggested anomalies in spinal cord vascular supply and arterial vasoplasm as other possibilities. Lenn suggested that the two regions of spinal cord involved with ischemic infarction, namely cervical and thoracic, were in watershed areas of vascular supply. Ahmann also considered a combination of reduced vascular supply due to the watershed phenomenon as well as selective vulnerability of central spinal cord gray matter is responsible for spinal cord infarction. Both epidural and subdural spinal hematomas may occur following spinal trauma and although uncommon in children, are not excluded when spinal fracture is not identified (see Cases 27 and 28). Progressive spinal cord necrosis usually occurs within four hours of trauma and is usually associated with more severe initial spinal cord injury. Nevertheless, progressive spiral cord necrosis is a possibility
CASE 23: Spinal Cord Injury in a 51-Year-Old Man with a Rigid Neck HISTORY: A 51-year-old man was seen in the emergency room He complained of neck pain following a fall after a misstep at the bottom step of a flight of stairs. EXAMINATION: The neck was rigid and in a kyphotic position, flexion and extension could not be performed. There were no marks of trauma on either the head, neck or shoulders. Neurological examination including strength, sensation, reflexes and sphincter function was normal. QUESTIONS
- A lateral cervical spine x-ray is illustrated in Figure 23.1; It shows (Select one or more)
A. normal cervical spine
B. cervical fracture
C. ankylosing spondylitis
D. ankylosing hyperostosis
E. cervical spondylosis
(B, C) The basic underlving pathology illustrated in Figure is that of ankylosing spondylitis. This disease involves a gradual progressive ankylosis of spinal joints and ultimate fusion of uncovertebral (facet) joints, disc spaces and posterior elements (laminae and spinous processes). It occurs primarily in males, begins caudally in the lumbar area and proceeds rostrally to the cervical region. It has been estimated to have an incidence of 1-2% in the white population in general and up to 20% in individuals who possess the HLA-B27 antigen, it is so-called “Marie-StrumpelTs disease” and eventually results in “bamboo spine”. The spine becomes a rigid inflexible bone, resembling a long bone, extending from the sacrum to the base of the skull. The radiological appearance seen in the x-rays illustrated are typical. The bones are generally osteoporotic and cervical kyphosis, rather than the usual lordosis, is seen. There is bony bridging across disc spaces, facet joints and posterior elements. In addition, a hairline fracture passing through the body of C6 from anterior to posterior;is present. A coned view of the midcervical region (Figure 23.3) shows improved demonstration of the fracture line (arrows). Fracture of the posterior elements at the same level, although poorly seen on these x-rays, must be assumed to be present. In the normal spine, fracture of anterior or posterior elements may occur independently with ligaments absorbing the injury force in nonfractured areas. In the spine of ankylosing spondylitis, no such ligamentous and soft tissue force-absorbing mechanism is present. In order for fracture to occur anteriorly, it must occur posteriorly as well. The difference between the normal and spondylitic spine might be compared to that of a green stick and dried stick of wood respectively. The former may break partially when bent but the latter snaps in two under bending force. In ankylosing hyperostosis bony fusion of the spine may occur but only anteriorly involving the disc spaces. The facet joints and posterior elements are uninvolved. In cervical spondylosis, degenerative changes occur in both disc space and facet joints but ankylosis generally does not occur and, if it does, it is localized to only a few interspaces rather than being generalized.
CASE 25: Thoracic-Spinal Cord Injury. HISTORY: A 48-year-old man was seen two hours following an automobile accident. The patient was thrown out of the vehicle. He complained of inability to move his legs, numbness of his legs and midback pain. EXAMINATION: The patient was awake and alert. BP 110/70, pulse 80, R 20, temperature 98.8°F. There was a flaccid paralysis of the legs except for very slight voluntary dorsiflexion of the left great toe. The umbilicus moved upward as the patient lifted his head off the pillow in the supine position. Reflexes were 2-f and symmetrical in the arms and absent in the legs. There was no response to plantar stimulation. Sensory examination revealed loss of all modalities below the level of the umbilicus. Rectal and bladder sphincters were paralyzed. X-RAYS: X-rays of the thoracic spine showed a fracture of the bodies of T8 and T9 and angulation at T8 (Figures 25.1A and 25.1B). QUESTIONS
- The lesion responsible for the patient’s deficit can best be characterized clinically as (Select only one)
A. the anterior spinal cord syndrome
B . incomplete spinal cord injury
C. spinal cord transection
D. Brown-Sequard syndrome (hemisection of the spinal cord)
E. none of the above
(B) The preservation of dorsiflexion of the left great toe indicates that the spinal cord lesion in this patient is incomplete Aside from this, the clinical picture is one of total loss of function extending candaliy from the level of injury. The anterior spinal cord syndrome (See Case 11 ) is confined almost exclusively to injuries of the cervical spine (and uncommon cases of anterior spinal artery interruption) and is characterized by loss of all motor function below a specific spinal level, loss of pain and temperature sensation, and preservation of joint position sense, vibratory sensation and touch. The loss of all sensory modalities in the patient presented excludes this syndrome. The Brown-Sequard syndrome!, 6 (hemisection of the cord) is characterized by ipsilateral motor loss and contralateral loss of pain and temperature sensation. Ipsilateral loss of proprioception and vibratory, sensation is also seen. The bilateral global loss of sensory and motor function of a symmetrical type exciudes the Brown-Sequard syndrome in the patient described. Thus, the lesion is best described clinically as an incomplete spinal cord injury.
CASE 27: Interscapular Pain and Paraplegia in a 47-Year-Old Man HISTORY: A 47-year-old man was seen complaining of interscapular pain and weakness of his legs of two days’ duration. He was a chronic alcoholic. He gave no specific history of trauma. The pain was moderate in severity and radiated along the ulnar aspect of both upper arms and forearms. It was aggravated by straining and relieved by rest. The weakness of his legs had progressed to the point that the patient was unable to stand or walk. He had been unable to urinate for 24 hours. EXAMINATION: He was an obese male who was awake and cooperative but somewhat tremulous. Respirations were diaphragmatic. There was mild tenderness to percussion over the spinous processes of C7, T1 and T2. A firm, slightly tender liver edge was palpable 6 cm below the right costal margin. The urinary bladder was percussed to the level of the umbilicus. The rest of the general physical examination was unremarkable. Neurological examination revealed flaccid paralysis of the leg. The abdominal muscles were also flaccid. Arm strength was normal. Tendon reflexes were absent in the legs and there was no response to plantar stimulation. Abdominal and cremasteric reflexes were also absent. The rectal sphincter was patulous. Sensation was normal to touch, pinprick, position and vibratior throughout. QUESTIONS
- A myelogram was done (Figures 27. 1 and 27.2). It shows {Select only one)
A. an epidural block
B. a subdural block
C. an intramedullary block
D. none of the above
(A) The myelogram shows an epidural block. Contrast material was instilled rostrally at the C1-2 level and caudally via a lumbar puncture. The caudally instilled contrast (Figure 27.2) shows a smooth deviation of the contrast column from left to right and gradual tapering to the point of obstruction. The rostrally instilled contrast material (Figure 27.1) shows a more abrupt block typical of an epidural lesion. The myelogram also showed that the lesion extended from C7 to T6. In reference to question 2 concerning the differential diagnose the myelographic findings are compatible with possibilities A or C. Either an epidural metastatic tumor or spontaneous spinal epidural hematoma could produce an epidural myelography block extending over many spinal segments. A herniated intervertebral disc could also produce an epidural spinal block but the block should be localized opposite the intervertebral disc space involved and be ventral in. location. A spinal cord contusion, since it results in expansion of the spinal cord substance from within, should procuce the myelographic picture an intramedullary lesion.
CASE 28: Paraplegia Following a Fall in an 11-Month-Old Child HISTORY: An 11-month-old male was seen in the emergency room one hour after having fallen down fifteen stairs while in a baby walker. The child was not unconscious. EXAMINATION: Neurological examination was normal. There were minor contusions of the skin over the posterior surface of the shoulders. HOSPITAL COURSE: The child was discharged home. 4 hours later, he was returned to the emergency room. The patents described irritability and progressive decrease in use of his legs over 30-60 minutes. Repeat neurological examination disclosed an alert but slightly irritable child. Cranial nerve examination was normal. There was analgesia to pinprick to low the T5 level. A flaccid paraplegia was present and tendon reflexes were absent in the lower extremities. Motor and reflexes were normal in the arms. Rectal sphincter tone was diminished. QUESTIONS
- The child was admitted to the hospital and a myelogram was performed (Figure 28.1). It shows a block to the flow of contrast material. The block is typical of (Select only one)
A. an intramedullary lesion
B. a subdural lesion
C. an extradural lesion
D. none of the above
(C) Extradural lesions produce progressive obliteration of the contrast column as the point of obstruction is approached. In this patient, the contrast column is obstructed at a higher level (T2) on the left and at a lower level (about T3) on the right (Figure 28.1) . Widening of the spinal cord shadow, characteristic of an intramedullary lesion (i.e. within the spinal cord) is not seen. Deviation of the spinal cord to one side characteristic of a subdural (intradural extramedullary) lesion is also not seen. Further, the “capping effect” seen in subdural lesions due to direct contact of the contrast column and lesion is also not seen. A lateral view did not show a lesion opposite the intervertebral disc space. Thus, the myelogram is most compatible with an extradural lesion, most likely a hematoma,
CASE 29: Post-traumatic Lumbar Herniated Disc with Cauda Equina Compression HISTORY: Twenty-four hours prior to hospital admission, this 42-year-old previously healthy female Was accidentally knocked over by her dog. She landed directly on her lower sacral region and experienced sudden low back and bilateral posterior thigh pain. The pain persisted and, although she noted no leg weakness, she became concerned because of difficulty emptying her bladder. She had a sensation of fullness in her lower abdomen and was able, in the last hours before admission, to feel her distended bladder. EXAMINATION: On admission, the patient was in obvious discomfort and efforts to move were accompanied by further complaints of pain. There was no point tenderness in her lumbar region although there was an ecchymosis over her lower sacrum. Lumbosacralparaspinal muscle spasm was noted. Straight leg raising signs were positive at 55° bilaterally. The motor examination of her lower extremities was normal. Tendon reflexes at the knees were normal and were slightly depressed at the ankles. On sensory examination, there was a slight diminution of pinprick perception over the saddle area bilaterally. A distended urinary bladder was palpable through the anterior abdominal wall and her anal tone was patulous. The urinary bladder was catheterized and 800 cc of urine was obtained. X-RAY: Plain lumbosacral spine x-rays were normal without evidence of fractures or dislocation. A pantopaoue myelogram demonstrated a complete block at L4-5. The block appeared to be extradural in nature (Figures 29.1A and 29.2B) . HOSPITAL COURSE: The patient was taken directly to the operating room where a large herniated L4-5 disc fragment was removed via an L5 laminectomy. Postoperatively her neurological status was unchanged except that the zone of saddle sensory loss was complete. TWELVE MONTH FOLLOWUP: The patient as neurological status was unchanged, In that she still had saddle anesthesia. She was, however, free of pain and had returned to work. She had voluntary control of voiding but had occasional urinary and fecal incontinence with coughing or straining. QUESTIONS
- Cauda equina compression without spinal cord compression can occur with lesions as high as T12. (True or False)
TRUE The caudal spinal cord usually tapers to an end opposite the L1 vertebral body but the point of termination maybe as high as the middle of the T12 body. Therefore, pure cauda equina compression may occur with lesions as high as T12.
CASE 29: Post-traumatic Lumbar Herniated Disc with Cauda Equina Compression HISTORY: Twenty-four hours prior to hospital admission, this 42-year-old previously healthy female Was accidentally knocked over by her dog. She landed directly on her lower sacral region and experienced sudden low back and bilateral posterior thigh pain. The pain persisted and, although she noted no leg weakness, she became concerned because of difficulty emptying her bladder. She had a sensation of fullness in her lower abdomen and was able, in the last hours before admission, to feel her distended bladder. EXAMINATION: On admission, the patient was in obvious discomfort and efforts to move were accompanied by further complaints of pain. There was no point tenderness in her lumbar region although there was an ecchymosis over her lower sacrum. Lumbosacralparaspinal muscle spasm was noted. Straight leg raising signs were positive at 55° bilaterally. The motor examination of her lower extremities was normal. Tendon reflexes at the knees were normal and were slightly depressed at the ankles. On sensory examination, there was a slight diminution of pinprick perception over the saddle area bilaterally. A distended urinary bladder was palpable through the anterior abdominal wall and her anal tone was patulous. The urinary bladder was catheterized and 800 cc of urine was obtained. X-RAY: Plain lumbosacral spine x-rays were normal without evidence of fractures or dislocation. A pantopaoue myelogram demonstrated a complete block at L4-5. The block appeared to be extradural in nature (Figures 29.1A and 29.2B) . HOSPITAL COURSE: The patient was taken directly to the operating room where a large herniated L4-5 disc fragment was removed via an L5 laminectomy. Postoperatively her neurological status was unchanged except that the zone of saddle sensory loss was complete. TWELVE MONTH FOLLOWUP: The patient as neurological status was unchanged, In that she still had saddle anesthesia. She was, however, free of pain and had returned to work. She had voluntary control of voiding but had occasional urinary and fecal incontinence with coughing or straining. QUESTIONS
- Signs and symptoms of cauda equina compression may elude (select one or more)
A. anal and bladder sphincter disturbance
B. limb muscle weakness
C. sensory deficit
D. pain
E. none of the above
(A,B,C,D) In general, sphincter and bladder dysfunction are considered the common denominator of cauda equina syndromes (CES). Occasionally, patients may have other clear-cut indications of cauda equina compression without evidence of bladder or sphincter disturbance. Limb muscle weakness, pain and sensory deficit may also occur as part of CES. Limb weakness, if present, usually occurs below the knees. Pain may be located in the low back region or may be unilateral or bilateral radiating radicular type pain. Sensory disturbances, if present, usually involve the saddle distribution, but may be unilateral.
CASE 29: Post-traumatic Lumbar Herniated Disc with Cauda Equina Compression HISTORY: Twenty-four hours prior to hospital admission, this 42-year-old previously healthy female Was accidentally knocked over by her dog. She landed directly on her lower sacral region and experienced sudden low back and bilateral posterior thigh pain. The pain persisted and, although she noted no leg weakness, she became concerned because of difficulty emptying her bladder. She had a sensation of fullness in her lower abdomen and was able, in the last hours before admission, to feel her distended bladder. EXAMINATION: On admission, the patient was in obvious discomfort and efforts to move were accompanied by further complaints of pain. There was no point tenderness in her lumbar region although there was an ecchymosis over her lower sacrum. Lumbosacralparaspinal muscle spasm was noted. Straight leg raising signs were positive at 55° bilaterally. The motor examination of her lower extremities was normal. Tendon reflexes at the knees were normal and were slightly depressed at the ankles. On sensory examination, there was a slight diminution of pinprick perception over the saddle area bilaterally. A distended urinary bladder was palpable through the anterior abdominal wall and her anal tone was patulous. The urinary bladder was catheterized and 800 cc of urine was obtained. X-RAY: Plain lumbosacral spine x-rays were normal without evidence of fractures or dislocation. A pantopaoue myelogram demonstrated a complete block at L4-5. The block appeared to be extradural in nature (Figures 29.1A and 29.2B) . HOSPITAL COURSE: The patient was taken directly to the operating room where a large herniated L4-5 disc fragment was removed via an L5 laminectomy. Postoperatively her neurological status was unchanged except that the zone of saddle sensory loss was complete. TWELVE MONTH FOLLOWUP: The patient as neurological status was unchanged, In that she still had saddle anesthesia. She was, however, free of pain and had returned to work. She had voluntary control of voiding but had occasional urinary and fecal incontinence with coughing or straining. QUESTIONS
- Sphincter disturbances may occur with cauda equina compression in the absence of (Select one or more)
A. limb weakness
B. sensory deficit
C. pain
D. deep tendon reflex changes
(A,B,C,D) Limb weakness may be absent with CES associated with bladder and sphincter disturbance. Limb weakness was found in approximately 66% of patients with CES. Sensory deficit is more commonly (80-100%) associated with CES but is not necessarily associated with sphincter or bladder disturbance. Likewise, pain occurs in most cases of CES but may be absent from the onset or disappear during the course of this syndrome. Diminution of deep tendon reflexes in association with CES was unusual at the knee but occurred at the ankle in approximately 60% of patients. Absence of reflex abnormalities in CES associated with sphincter or bladder dysfunction is attributed to midline compression of the more medially placed lower sacral nerve roots, This spares the S1 nerve root which subserves the ankle jerk but compresses the roots from S2 and below which subserve parasympathetic and somatic bladder and sphincter activity.
CASE 29: Post-traumatic Lumbar Herniated Disc with Cauda Equina Compression HISTORY: Twenty-four hours prior to hospital admission, this 42-year-old previously healthy female Was accidentally knocked over by her dog. She landed directly on her lower sacral region and experienced sudden low back and bilateral posterior thigh pain. The pain persisted and, although she noted no leg weakness, she became concerned because of difficulty emptying her bladder. She had a sensation of fullness in her lower abdomen and was able, in the last hours before admission, to feel her distended bladder. EXAMINATION: On admission, the patient was in obvious discomfort and efforts to move were accompanied by further complaints of pain. There was no point tenderness in her lumbar region although there was an ecchymosis over her lower sacrum. Lumbosacralparaspinal muscle spasm was noted. Straight leg raising signs were positive at 55° bilaterally. The motor examination of her lower extremities was normal. Tendon reflexes at the knees were normal and were slightly depressed at the ankles. On sensory examination, there was a slight diminution of pinprick perception over the saddle area bilaterally. A distended urinary bladder was palpable through the anterior abdominal wall and her anal tone was patulous. The urinary bladder was catheterized and 800 cc of urine was obtained. X-RAY: Plain lumbosacral spine x-rays were normal without evidence of fractures or dislocation. A pantopaoue myelogram demonstrated a complete block at L4-5. The block appeared to be extradural in nature (Figures 29.1A and 29.2B) . HOSPITAL COURSE: The patient was taken directly to the operating room where a large herniated L4-5 disc fragment was removed via an L5 laminectomy. Postoperatively her neurological status was unchanged except that the zone of saddle sensory loss was complete. TWELVE MONTH FOLLOWUP: The patient as neurological status was unchanged, In that she still had saddle anesthesia. She was, however, free of pain and had returned to work. She had voluntary control of voiding but had occasional urinary and fecal incontinence with coughing or straining. QUESTIONS
- Cauda equina compression syndromes usually occur in association with herniated lumbar intervertebral discs. (True or False)
FALSE The incidence of CES associated with lumbar disc prolapse varies from 1-15%.
CASE 29: Post-traumatic Lumbar Herniated Disc with Cauda Equina Compression HISTORY: Twenty-four hours prior to hospital admission, this 42-year-old previously healthy female Was accidentally knocked over by her dog. She landed directly on her lower sacral region and experienced sudden low back and bilateral posterior thigh pain. The pain persisted and, although she noted no leg weakness, she became concerned because of difficulty emptying her bladder. She had a sensation of fullness in her lower abdomen and was able, in the last hours before admission, to feel her distended bladder. EXAMINATION: On admission, the patient was in obvious discomfort and efforts to move were accompanied by further complaints of pain. There was no point tenderness in her lumbar region although there was an ecchymosis over her lower sacrum. Lumbosacralparaspinal muscle spasm was noted. Straight leg raising signs were positive at 55° bilaterally. The motor examination of her lower extremities was normal. Tendon reflexes at the knees were normal and were slightly depressed at the ankles. On sensory examination, there was a slight diminution of pinprick perception over the saddle area bilaterally. A distended urinary bladder was palpable through the anterior abdominal wall and her anal tone was patulous. The urinary bladder was catheterized and 800 cc of urine was obtained. X-RAY: Plain lumbosacral spine x-rays were normal without evidence of fractures or dislocation. A pantopaoue myelogram demonstrated a complete block at L4-5. The block appeared to be extradural in nature (Figures 29.1A and 29.2B) . HOSPITAL COURSE: The patient was taken directly to the operating room where a large herniated L4-5 disc fragment was removed via an L5 laminectomy. Postoperatively her neurological status was unchanged except that the zone of saddle sensory loss was complete. TWELVE MONTH FOLLOWUP: The patient as neurological status was unchanged, In that she still had saddle anesthesia. She was, however, free of pain and had returned to work. She had voluntary control of voiding but had occasional urinary and fecal incontinence with coughing or straining. QUESTIONS
- Most cauda equina compression syndromes due to herniated lumbar discs are associated with a history of trauma. (True or False)
FALSE The role of trauma in the onset of CES with lumbar disc herniation varies greatly from report to report but, in general, a history of trauma is not the rule, in studies containing a high proportion of patients with a history of trauma (i.e. 75% of the patients in Shephard’s series), many of the trauma events involve “strain” (e.g. lifting of heavy weights).
CASE 29: Post-traumatic Lumbar Herniated Disc with Cauda Equina Compression HISTORY: Twenty-four hours prior to hospital admission, this 42-year-old previously healthy female Was accidentally knocked over by her dog. She landed directly on her lower sacral region and experienced sudden low back and bilateral posterior thigh pain. The pain persisted and, although she noted no leg weakness, she became concerned because of difficulty emptying her bladder. She had a sensation of fullness in her lower abdomen and was able, in the last hours before admission, to feel her distended bladder. EXAMINATION: On admission, the patient was in obvious discomfort and efforts to move were accompanied by further complaints of pain. There was no point tenderness in her lumbar region although there was an ecchymosis over her lower sacrum. Lumbosacralparaspinal muscle spasm was noted. Straight leg raising signs were positive at 55° bilaterally. The motor examination of her lower extremities was normal. Tendon reflexes at the knees were normal and were slightly depressed at the ankles. On sensory examination, there was a slight diminution of pinprick perception over the saddle area bilaterally. A distended urinary bladder was palpable through the anterior abdominal wall and her anal tone was patulous. The urinary bladder was catheterized and 800 cc of urine was obtained. X-RAY: Plain lumbosacral spine x-rays were normal without evidence of fractures or dislocation. A pantopaoue myelogram demonstrated a complete block at L4-5. The block appeared to be extradural in nature (Figures 29.1A and 29.2B) . HOSPITAL COURSE: The patient was taken directly to the operating room where a large herniated L4-5 disc fragment was removed via an L5 laminectomy. Postoperatively her neurological status was unchanged except that the zone of saddle sensory loss was complete. TWELVE MONTH FOLLOWUP: The patient as neurological status was unchanged, In that she still had saddle anesthesia. She was, however, free of pain and had returned to work. She had voluntary control of voiding but had occasional urinary and fecal incontinence with coughing or straining. QUESTIONS
- The level of the herniated lumbar disc in cases presenting with cauda equina compression can usually be determined by (Select one or more)
A. sensory level
B. reflex changes
C. muscle weakness
D. plain x-ray findings
E. none of the above
(E) CES due to herniated lumbar discs, occur most commonly at the L4-5 and L5-S1 levels followed by the L2-3 and L3-4 levels. It is difficult to make an accurate determination of the level of the compressive lesion based on the sensory, reflex or muscular examination. Plain lumbosacral x-rays in these patients commonly show evidence of nonspecific degenerative changes but rarely have localizing value and may occasionally be normal.
CASE 29: Post-traumatic Lumbar Herniated Disc with Cauda Equina Compression HISTORY: Twenty-four hours prior to hospital admission, this 42-year-old previously healthy female Was accidentally knocked over by her dog. She landed directly on her lower sacral region and experienced sudden low back and bilateral posterior thigh pain. The pain persisted and, although she noted no leg weakness, she became concerned because of difficulty emptying her bladder. She had a sensation of fullness in her lower abdomen and was able, in the last hours before admission, to feel her distended bladder. EXAMINATION: On admission, the patient was in obvious discomfort and efforts to move were accompanied by further complaints of pain. There was no point tenderness in her lumbar region although there was an ecchymosis over her lower sacrum. Lumbosacralparaspinal muscle spasm was noted. Straight leg raising signs were positive at 55° bilaterally. The motor examination of her lower extremities was normal. Tendon reflexes at the knees were normal and were slightly depressed at the ankles. On sensory examination, there was a slight diminution of pinprick perception over the saddle area bilaterally. A distended urinary bladder was palpable through the anterior abdominal wall and her anal tone was patulous. The urinary bladder was catheterized and 800 cc of urine was obtained. X-RAY: Plain lumbosacral spine x-rays were normal without evidence of fractures or dislocation. A pantopaoue myelogram demonstrated a complete block at L4-5. The block appeared to be extradural in nature (Figures 29.1A and 29.2B) . HOSPITAL COURSE: The patient was taken directly to the operating room where a large herniated L4-5 disc fragment was removed via an L5 laminectomy. Postoperatively her neurological status was unchanged except that the zone of saddle sensory loss was complete. TWELVE MONTH FOLLOWUP: The patient as neurological status was unchanged, In that she still had saddle anesthesia. She was, however, free of pain and had returned to work. She had voluntary control of voiding but had occasional urinary and fecal incontinence with coughing or straining. QUESTIONS
- Myelography always demonstrates an extradural defect in cases of herniated lumbar disc. (True or False)
FALSE Complete myelography blocks, which manifest as a sharply cut off or feathered interface at the site of blockage, occur in a high proportion of patients with CES from herniated lumbar disc. Occasionally, myelography in these patients may show extradural defects without a complete block. Even more rarely, myelography may be interpreted as normal. Particularly with pantopaque myelograms, relatively small anteriorly placed lesions may be obscured by the dense contrast material.
CASE 29: Post-traumatic Lumbar Herniated Disc with Cauda Equina Compression HISTORY: Twenty-four hours prior to hospital admission, this 42-year-old previously healthy female Was accidentally knocked over by her dog. She landed directly on her lower sacral region and experienced sudden low back and bilateral posterior thigh pain. The pain persisted and, although she noted no leg weakness, she became concerned because of difficulty emptying her bladder. She had a sensation of fullness in her lower abdomen and was able, in the last hours before admission, to feel her distended bladder. EXAMINATION: On admission, the patient was in obvious discomfort and efforts to move were accompanied by further complaints of pain. There was no point tenderness in her lumbar region although there was an ecchymosis over her lower sacrum. Lumbosacralparaspinal muscle spasm was noted. Straight leg raising signs were positive at 55° bilaterally. The motor examination of her lower extremities was normal. Tendon reflexes at the knees were normal and were slightly depressed at the ankles. On sensory examination, there was a slight diminution of pinprick perception over the saddle area bilaterally. A distended urinary bladder was palpable through the anterior abdominal wall and her anal tone was patulous. The urinary bladder was catheterized and 800 cc of urine was obtained. X-RAY: Plain lumbosacral spine x-rays were normal without evidence of fractures or dislocation. A pantopaoue myelogram demonstrated a complete block at L4-5. The block appeared to be extradural in nature (Figures 29.1A and 29.2B) . HOSPITAL COURSE: The patient was taken directly to the operating room where a large herniated L4-5 disc fragment was removed via an L5 laminectomy. Postoperatively her neurological status was unchanged except that the zone of saddle sensory loss was complete. TWELVE MONTH FOLLOWUP: The patient as neurological status was unchanged, In that she still had saddle anesthesia. She was, however, free of pain and had returned to work. She had voluntary control of voiding but had occasional urinary and fecal incontinence with coughing or straining. QUESTIONS
- Immediate surgery is indicated in all cases of cauda equina compression due to herniated lumbar discs. (True or False)
TRUE Surgical removal of the compressive lesion commonly relieves pain and motor weakness, but is less effective in relieving sensory and sphincter disturbances. Most authors agree that the earlier surgery is performed after the onset of symptoms of CES the better the outlook for preservation of all neuronal functions.
CASE 29: Post-traumatic Lumbar Herniated Disc with Cauda Equina Compression HISTORY: Twenty-four hours prior to hospital admission, this 42-year-old previously healthy female Was accidentally knocked over by her dog. She landed directly on her lower sacral region and experienced sudden low back and bilateral posterior thigh pain. The pain persisted and, although she noted no leg weakness, she became concerned because of difficulty emptying her bladder. She had a sensation of fullness in her lower abdomen and was able, in the last hours before admission, to feel her distended bladder. EXAMINATION: On admission, the patient was in obvious discomfort and efforts to move were accompanied by further complaints of pain. There was no point tenderness in her lumbar region although there was an ecchymosis over her lower sacrum. Lumbosacralparaspinal muscle spasm was noted. Straight leg raising signs were positive at 55° bilaterally. The motor examination of her lower extremities was normal. Tendon reflexes at the knees were normal and were slightly depressed at the ankles. On sensory examination, there was a slight diminution of pinprick perception over the saddle area bilaterally. A distended urinary bladder was palpable through the anterior abdominal wall and her anal tone was patulous. The urinary bladder was catheterized and 800 cc of urine was obtained. X-RAY: Plain lumbosacral spine x-rays were normal without evidence of fractures or dislocation. A pantopaoue myelogram demonstrated a complete block at L4-5. The block appeared to be extradural in nature (Figures 29.1A and 29.2B) . HOSPITAL COURSE: The patient was taken directly to the operating room where a large herniated L4-5 disc fragment was removed via an L5 laminectomy. Postoperatively her neurological status was unchanged except that the zone of saddle sensory loss was complete. TWELVE MONTH FOLLOWUP: The patient as neurological status was unchanged, In that she still had saddle anesthesia. She was, however, free of pain and had returned to work. She had voluntary control of voiding but had occasional urinary and fecal incontinence with coughing or straining. QUESTIONS
- At surgery, lumbar disc herniations causing cauda equinas compression originate centrally as opposed to laterally. (True or False)
FALSE The point of lumbar disc herniation in patients with CES is usually lateral. In ten patients surgically explored only one had herniation originating from a defect in the midline annulus fibrosis.
CASE 29: Post-traumatic Lumbar Herniated Disc with Cauda Equina Compression HISTORY: Twenty-four hours prior to hospital admission, this 42-year-old previously healthy female Was accidentally knocked over by her dog. She landed directly on her lower sacral region and experienced sudden low back and bilateral posterior thigh pain. The pain persisted and, although she noted no leg weakness, she became concerned because of difficulty emptying her bladder. She had a sensation of fullness in her lower abdomen and was able, in the last hours before admission, to feel her distended bladder. EXAMINATION: On admission, the patient was in obvious discomfort and efforts to move were accompanied by further complaints of pain. There was no point tenderness in her lumbar region although there was an ecchymosis over her lower sacrum. Lumbosacralparaspinal muscle spasm was noted. Straight leg raising signs were positive at 55° bilaterally. The motor examination of her lower extremities was normal. Tendon reflexes at the knees were normal and were slightly depressed at the ankles. On sensory examination, there was a slight diminution of pinprick perception over the saddle area bilaterally. A distended urinary bladder was palpable through the anterior abdominal wall and her anal tone was patulous. The urinary bladder was catheterized and 800 cc of urine was obtained. X-RAY: Plain lumbosacral spine x-rays were normal without evidence of fractures or dislocation. A pantopaoue myelogram demonstrated a complete block at L4-5. The block appeared to be extradural in nature (Figures 29.1A and 29.2B) . HOSPITAL COURSE: The patient was taken directly to the operating room where a large herniated L4-5 disc fragment was removed via an L5 laminectomy. Postoperatively her neurological status was unchanged except that the zone of saddle sensory loss was complete. TWELVE MONTH FOLLOWUP: The patient as neurological status was unchanged, In that she still had saddle anesthesia. She was, however, free of pain and had returned to work. She had voluntary control of voiding but had occasional urinary and fecal incontinence with coughing or straining. QUESTIONS
- Recovery of voluntary urination in this patient probably reflects full recovery of neurogenic bladder control. (True or False)
FALSE Normal bladder function does not occur with the saddle anesthesia of CES. Normal bladder emptying depends on reflex contraction and external compression of the bladder. Saddle anesthesia indicates that the pathway for the afferent limb of reflex bladder contractions is abolished. However, as with this patient, recovery of independent urinary voiding may be achieved by teaching the patient to empty the bladder with methods which increase intraabdominal pressure and compress the bladder. Thus, effective voluntary bladder emptying is achieved in a high proportion of patients as they learn crede and valsalva maneuvers. Assessment of bladder dysfunction may be accomplished by measuring of postvoiding residual, urine volume, cystoscopy and cystometrographic analysis.
CASE 29: Post-traumatic Lumbar Herniated Disc with Cauda Equina Compression HISTORY: Twenty-four hours prior to hospital admission, this 42-year-old previously healthy female Was accidentally knocked over by her dog. She landed directly on her lower sacral region and experienced sudden low back and bilateral posterior thigh pain. The pain persisted and, although she noted no leg weakness, she became concerned because of difficulty emptying her bladder. She had a sensation of fullness in her lower abdomen and was able, in the last hours before admission, to feel her distended bladder. EXAMINATION: On admission, the patient was in obvious discomfort and efforts to move were accompanied by further complaints of pain. There was no point tenderness in her lumbar region although there was an ecchymosis over her lower sacrum. Lumbosacralparaspinal muscle spasm was noted. Straight leg raising signs were positive at 55° bilaterally. The motor examination of her lower extremities was normal. Tendon reflexes at the knees were normal and were slightly depressed at the ankles. On sensory examination, there was a slight diminution of pinprick perception over the saddle area bilaterally. A distended urinary bladder was palpable through the anterior abdominal wall and her anal tone was patulous. The urinary bladder was catheterized and 800 cc of urine was obtained. X-RAY: Plain lumbosacral spine x-rays were normal without evidence of fractures or dislocation. A pantopaoue myelogram demonstrated a complete block at L4-5. The block appeared to be extradural in nature (Figures 29.1A and 29.2B) . HOSPITAL COURSE: The patient was taken directly to the operating room where a large herniated L4-5 disc fragment was removed via an L5 laminectomy. Postoperatively her neurological status was unchanged except that the zone of saddle sensory loss was complete. TWELVE MONTH FOLLOWUP: The patient as neurological status was unchanged, In that she still had saddle anesthesia. She was, however, free of pain and had returned to work. She had voluntary control of voiding but had occasional urinary and fecal incontinence with coughing or straining. QUESTIONS
- In the cauda equina syndrome, a good correlation exists between deficits of bladder control, anal control and sexual function (True or False)
FALSE Erection and ejaculation are possible in the presence of bladder dysfunction and saddle anesthesia associated with CES from a herniated lumbar disc. In fact, sexual function is usually adequate in these patients. Similarly, bowel and anal symptoms are less frequent with CES than bladder distances
CASE 30: Lap-type Seat Belt Injury HISTORY: A 17-year-old female was involved in a head-on automobiie collision. She was the front seat passenger and was wearing a snugly applied lap-type seat belt at the time of the accident. Her only complaint following the accident was of severe low back pain. EXAMINATION: on examination in emergency vital signs were stable. She had an ecchymosis extending across the lower abdomen between the superior iliac crests. There was tenderness over the mid lumbar spinal area. Otherwise her general physical and neurological examination was normal X-RAY: Lumbar spine x-rays showed a transverse fracture through the posterior elements of L4 with anterior angulation of L3 on L4 2nd anterior wedging of the body of L4. There was no subluxation (Figures 30.1A and 30.1B). QUESTIONS
- Lumbar fracture with lap-type seat belt injury is usually associated with visceral injury. (True or False)
FALSE Only approximately 15% of patients with lumbar fractures from lap-type seat belt injuries have associated visceral injuries. Visceral injuries are more commonly associated with improper seat belt placement (too high, too loose).
CASE 30: Lap-type Seat Belt Injury HISTORY: A 17-year-old female was involved in a head-on automobiie collision. She was the front seat passenger and was wearing a snugly applied lap-type seat belt at the time of the accident. Her only complaint following the accident was of severe low back pain. EXAMINATION: on examination in emergency vital signs were stable. She had an ecchymosis extending across the lower abdomen between the superior iliac crests. There was tenderness over the mid lumbar spinal area. Otherwise her general physical and neurological examination was normal X-RAY: Lumbar spine x-rays showed a transverse fracture through the posterior elements of L4 with anterior angulation of L3 on L4 2nd anterior wedging of the body of L4. There was no subluxation (Figures 30.1A and 30.1B). QUESTIONS
- As with this patient, the vertebral level usually involved with lap-type seat belt injuries in L4. (True or False)
FALSE Although vertebral fractures associated with lap-type scat be it injuries are seen from T12 to L5 they are most commonly at L1, L2 and L3.
CASE 30: Lap-type Seat Belt Injury HISTORY: A 17-year-old female was involved in a head-on automobiie collision. She was the front seat passenger and was wearing a snugly applied lap-type seat belt at the time of the accident. Her only complaint following the accident was of severe low back pain. EXAMINATION: on examination in emergency vital signs were stable. She had an ecchymosis extending across the lower abdomen between the superior iliac crests. There was tenderness over the mid lumbar spinal area. Otherwise her general physical and neurological examination was normal X-RAY: Lumbar spine x-rays showed a transverse fracture through the posterior elements of L4 with anterior angulation of L3 on L4 2nd anterior wedging of the body of L4. There was no subluxation (Figures 30.1A and 30.1B). QUESTIONS
- The absence of neurological injury seen with this patient is the rule for vertebral fractures associated with the use of lap-type seat belts. (True or False)
TRUE Only 15-20% of spinal fractures associated with lap-type seat belt injuries had associated weakness or sensory impairment below the level of the injury.
CASE 30: Lap-type Seat Belt Injury HISTORY: A 17-year-old female was involved in a head-on automobiie collision. She was the front seat passenger and was wearing a snugly applied lap-type seat belt at the time of the accident. Her only complaint following the accident was of severe low back pain. EXAMINATION: on examination in emergency vital signs were stable. She had an ecchymosis extending across the lower abdomen between the superior iliac crests. There was tenderness over the mid lumbar spinal area. Otherwise her general physical and neurological examination was normal X-RAY: Lumbar spine x-rays showed a transverse fracture through the posterior elements of L4 with anterior angulation of L3 on L4 2nd anterior wedging of the body of L4. There was no subluxation (Figures 30.1A and 30.1B). QUESTIONS
- The lumbar vertebral injury related to the use of lap-type seat belts is characterized by (Select one or more)
A. ruptures of posterior ligaments and facet joints
B. fractures of posterior elements and facet joints
C. compression of the vertebral body
D. subluxation of vertebral elements
E. none of the above
(A, B) In the usual hyperflexion injury of the lumbar spine (i.e. fracture associated with a fall), the stress forces rotate around a fulcrum within the vertebral elements themselves causing compression fracture. In lap-type seat belt injuries, the fulcrum of forces is displaced anteriorly to the point of contact between the seat belt and the anterior abdominal wall. Because the spine is completely behind this fulcrum, all of its elements are subjected to tension (e.g. fission, pulling apart) stress as the upper and lower parts of the body are thrown forward at the time of deacceleration of the vehicle. The tension stress causes distraction of vertebral elements with rupture of nonbony elements (i.e. posterior ligaments, facet ligaments). If the ligaments remain intact, fission-type fractures of the posterior bony elements and, at times, the vertebral body may ensue. Therefore, the lap-tvpe seat belt vertebral injury is usually a distraction of ligamentous, facet or bony elements without compression or subluxation.
CASE 30: Lap-type Seat Belt Injury HISTORY: A 17-year-old female was involved in a head-on automobiie collision. She was the front seat passenger and was wearing a snugly applied lap-type seat belt at the time of the accident. Her only complaint following the accident was of severe low back pain. EXAMINATION: on examination in emergency vital signs were stable. She had an ecchymosis extending across the lower abdomen between the superior iliac crests. There was tenderness over the mid lumbar spinal area. Otherwise her general physical and neurological examination was normal X-RAY: Lumbar spine x-rays showed a transverse fracture through the posterior elements of L4 with anterior angulation of L3 on L4 2nd anterior wedging of the body of L4. There was no subluxation (Figures 30.1A and 30.1B). QUESTIONS
- Therapeutic management of this patient might reasonably include (Select one or more)
A. early mobilization and discharge
B. prolonged bed rest in the hyperextended position and or bracing or casting in the hyperextended position
C . operative fusion
D. laminectomy combined with fusion
E. none of the above
(B, C) There are no reports of long term follow up for these patients. Presumably, however, such fractures are initially unstable particularly if there is ligamentous or facet disruption and they require some form of stabilization. Management has, therefore, consisted of bed rest or hyperextension casting or operative fusion. Laminectomy might be indicated if there is deterioration of neurological function below the level of the injury.
CASE 31: Spinal Injury Associated with Gunshot Wound HISTORY: A 22-year-old male was struck from the rear, by a bullet, in the upper lumbar region. He was knocked over by the impact and noted immediate tingling in both lower extremities and had difficulty moving his right leg. By the time he arrived in the emergency room, the tingling was predominantly in the right leg. EXAMINATION In the emergency room, his vital signs were normal ana stable. The bullet entry wound was noted at the right dorsal paramidline upper lumbar region. Rectal tone and voluntary sphincter contractions were normal and the patient was able to urinate upon request. His neurological examination was abnormal in the lower extremities. There was 4+/5 weakness in his anterior tibial, extensor hallucis longus, peroneus longus, posterior tibial and gastrocnemius muscles in the right kg. Knee reflexes were normal; the right ankle reflex was slightly diminished Hyperpathia was noted over the whole of the right leg from the L2 region down to and including the sacral, perianal region. Hypalgesia was noted over the same disiribution on the right and over the L2-S1 dermatomes on the left. joint position sense was normal. X-RAY: AP and lateral lumbosacral x-rays showed a fragmented bullet in the spinal canal at the L2 level. There was.no evidence of bony disruption (Figures 31.1A and 31.1B). The patient was observed for several hours and showed no signs i neurological deterioration. The entry wound was superficially debrided and further surgery was not recommended. QUESTIONS
- The lack of a fracture identified on plain x-rays may be misleading in this patient. (True or False)
TRUE It is not unusual that fractures are detected at surgery which were not seen on plain x-rays.
CASE 31: Spinal Injury Associated with Gunshot Wound HISTORY: A 22-year-old male was struck from the rear, by a bullet, in the upper lumbar region. He was knocked over by the impact and noted immediate tingling in both lower extremities and had difficulty moving his right leg. By the time he arrived in the emergency room, the tingling was predominantly in the right leg. EXAMINATION In the emergency room, his vital signs were normal ana stable. The bullet entry wound was noted at the right dorsal paramidline upper lumbar region. Rectal tone and voluntary sphincter contractions were normal and the patient was able to urinate upon request. His neurological examination was abnormal in the lower extremities. There was 4+/5 weakness in his anterior tibial, extensor hallucis longus, peroneus longus, posterior tibial and gastrocnemius muscles in the right kg. Knee reflexes were normal; the right ankle reflex was slightly diminished Hyperpathia was noted over the whole of the right leg from the L2 region down to and including the sacral, perianal region. Hypalgesia was noted over the same disiribution on the right and over the L2-S1 dermatomes on the left. joint position sense was normal. X-RAY: AP and lateral lumbosacral x-rays showed a fragmented bullet in the spinal canal at the L2 level. There was.no evidence of bony disruption (Figures 31.1A and 31.1B). The patient was observed for several hours and showed no signs i neurological deterioration. The entry wound was superficially debrided and further surgery was not recommended QUESTIONS
- A lumbar puncture to evaluate the presence of blood and subbarachnoid spinal block (Queckenstedt test) is indicated in this patient. (True or False)
FALSE Neither the presence nor the absence of blood nor subarachnoid spinal block (as determined by the Queckenstedt test) has been of value in determining prognosis. Therefore, lumbar puncture is of little use in further management decisions and is not indicated.
CASE 31: Spinal Injury Associated with Gunshot Wound HISTORY: A 22-year-old male was struck from the rear, by a bullet, in the upper lumbar region. He was knocked over by the impact and noted immediate tingling in both lower extremities and had difficulty moving his right leg. By the time he arrived in the emergency room, the tingling was predominantly in the right leg. EXAMINATION In the emergency room, his vital signs were normal ana stable. The bullet entry wound was noted at the right dorsal paramidline upper lumbar region. Rectal tone and voluntary sphincter contractions were normal and the patient was able to urinate upon request. His neurological examination was abnormal in the lower extremities. There was 4+/5 weakness in his anterior tibial, extensor hallucis longus, peroneus longus, posterior tibial and gastrocnemius muscles in the right kg. Knee reflexes were normal; the right ankle reflex was slightly diminished Hyperpathia was noted over the whole of the right leg from the L2 region down to and including the sacral, perianal region. Hypalgesia was noted over the same disiribution on the right and over the L2-S1 dermatomes on the left. joint position sense was normal. X-RAY: AP and lateral lumbosacral x-rays showed a fragmented bullet in the spinal canal at the L2 level. There was.no evidence of bony disruption (Figures 31.1A and 31.1B). The patient was observed for several hours and showed no signs i neurological deterioration. The entry wound was superficially debrided and further surgery was not recommended QUESTIONS
- Myelography is indicated in this patient. (True or False)
FALSE Myelography may be used to localize the spinal cord level of a lesion however, plain x-ray findings, including bullet fragments and fractures if seen, as well as clinical findings usuallv adequately determine the level.
CASE 31: Spinal Injury Associated with Gunshot Wound HISTORY: A 22-year-old male was struck from the rear, by a bullet, in the upper lumbar region. He was knocked over by the impact and noted immediate tingling in both lower extremities and had difficulty moving his right leg. By the time he arrived in the emergency room, the tingling was predominantly in the right leg. EXAMINATION In the emergency room, his vital signs were normal ana stable. The bullet entry wound was noted at the right dorsal paramidline upper lumbar region. Rectal tone and voluntary sphincter contractions were normal and the patient was able to urinate upon request. His neurological examination was abnormal in the lower extremities. There was 4+/5 weakness in his anterior tibial, extensor hallucis longus, peroneus longus, posterior tibial and gastrocnemius muscles in the right kg. Knee reflexes were normal; the right ankle reflex was slightly diminished Hyperpathia was noted over the whole of the right leg from the L2 region down to and including the sacral, perianal region. Hypalgesia was noted over the same disiribution on the right and over the L2-S1 dermatomes on the left. joint position sense was normal. X-RAY: AP and lateral lumbosacral x-rays showed a fragmented bullet in the spinal canal at the L2 level. There was.no evidence of bony disruption (Figures 31.1A and 31.1B). The patient was observed for several hours and showed no signs i neurological deterioration. The entry wound was superficially debrided and further surgery was not recommended QUESTIONS
- Absolute indications for surgery in patients with gunshot wounds to the spine include (Select one or more)
A. laminectomy and exploration to assess the degree of neural injury in order to determine the patient’s prognosis
B. laminectomy and exploration to repair possible disruption of dura to prevent infection
C. exploration to determine the extent of bone injury with the intent to fuse if instability is demonstrated
D. decompressive laminectomy and exploration in a patient demonstrating progressive neurological deficit
E. debridement and exploration in cases of massive compound injuries
F. exploration to remove bullet and/or bone fragments
G. decompressive laminectomy to improve prognosis with regard to neurological function H. none of the above
(D,E) Evaluation of gross spinal cord pathology at surgery does not provide an index of prognosis. Persistent deficit may occur in patients found to have normal appearing spinal elements at surgery. Dural closure has not been demonstrated to decrease the incidence of meningitis in these patients. Heiden, et al. suggest that appropriate antibiotics, thorough debridement and meticulous wound closure are the most important determinants for the prevention of infection. Spinal instability and the need for fusion from gunshot wounds are extremely rare. Moreover, bony injury might exist, particularly from a ventral entry wound, which would not be visible at surgery. Tomography may be helpful. Progressive neurological deficit is an indication for surgery; however, progressive neurological deficit occurs rarely with gunshot wounds. Thorough debridement and optimal wound closure is indicated in massive open gunshot wounds to prevent infection. Although bullet or bone fragments theoretically compress neural elements, removal of the offending objects has not been shown to significantly alter return of neurological function.
CASE 31: Spinal Injury Associated with Gunshot Wound HISTORY: A 22-year-old male was struck from the rear, by a bullet, in the upper lumbar region. He was knocked over by the impact and noted immediate tingling in both lower extremities and had difficulty moving his right leg. By the time he arrived in the emergency room, the tingling was predominantly in the right leg. EXAMINATION In the emergency room, his vital signs were normal ana stable. The bullet entry wound was noted at the right dorsal paramidline upper lumbar region. Rectal tone and voluntary sphincter contractions were normal and the patient was able to urinate upon request. His neurological examination was abnormal in the lower extremities. There was 4+/5 weakness in his anterior tibial, extensor hallucis longus, peroneus longus, posterior tibial and gastrocnemius muscles in the right kg. Knee reflexes were normal; the right ankle reflex was slightly diminished Hyperpathia was noted over the whole of the right leg from the L2 region down to and including the sacral, perianal region. Hypalgesia was noted over the same disiribution on the right and over the L2-S1 dermatomes on the left. joint position sense was normal. X-RAY: AP and lateral lumbosacral x-rays showed a fragmented bullet in the spinal canal at the L2 level. There was.no evidence of bony disruption (Figures 31.1A and 31.1B). The patient was observed for several hours and showed no signs i neurological deterioration. The entry wound was superficially debrided and further surgery was not recommended QUESTIONS
- As a general rule, initial neurological deficits caused byhigh velocity missiles, such as those seen in wartime, are more likely to improve than comparable deficits caused by low velocity missiles, such as those caused by handheld guns in the civilian population. (True or False)
TRUE The low velocity of civilian firearm bullets necessitates direct hits to cause neural damage, whereas high velocity military missiles can cause temporary injury by the concussive effects of a bullet trajectory which passes near but does not directly strike neural elements. The latter type of injury is, therefore, occasionally rapidly and spontaneously reversible.
