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Subaxial Cervical Spine Injuries: Introduction
- Common cause of disability
- Most common causes:– RTA, Fall, Penetrating trauma, Sports
- Highly prone to traumatic injury:
- Mobile, relatively unprotected, and its high position
- 60% of all spinal injuries occur in the cervical spine
- Subaxial cervical spine injuries include:
- 2/3rd of all cervical fractures
- 75% of all cervical dislocations
- One third of injuries occur at the level of C2, and one half of injuries occur at the level of C6 or C7.
Subaxial Cervical Spine Injuries: Epidemiology
- Bimodal Peak
- Adolescents and Young Adults
- Middle Aged Individuals (55 years)
- Males accounts for 80% of injuries
Subaxial Cervical Spine Anatomy
- Subaxial Spine: C3 – C7 segments
- Denis’ 3 columns- Anterior, middle and Posterior
- Anterior- ALL, Ant 2/3 rd body & disc
- Middle- Post 1/3rd of body & disc, PLL
- Posterior- Pedicle, lamina, facet, transverse process, spinous process, Ligaments-Interspinous, lig.flavum
- Posterior column most important for stability
- Encasement of the vertebral arteries generally from C1 through C6 via the transverse foramina
- C7 has a transverse foramen, but the paired vertebral arteries generally do not course through them
- Exiting root corresponds to the lower vertebra (C6 root exits the C5-6) foramen
- C6 transverse process harbors an anterior tubercle : chassaignac tubercle –> carotid artery
- Most common injury happen at C6 or C7 level :
- exposed to great axial compression and flexion loads due to its location
- transition from a very mobile cervical to a rigid thoracic spine.
Cervical Spine : Radiological Anatomy
Mechanism of Subaxial Cervical Spine Injuries
Subaxial Cervical Spine Injuries: Clinical Features
- Neck pain
- Restriction of neck movements
- Neck tenderness
- Varying degrees of neurological deficits
- Complete cord syndrome
- Incomplete cord syndrome
- Central cord syndrome
- Brown-Sequard syndrome
- Anterior cord syndrome
- Combination of the above
Spinal Cord Injury Without Radiographic Abnormality (SCIWORA)
- Initially described by Pang et al, in 1982
- Spinal cord dysfunction without the presence of any fracture, dislocation, or ligamentous injury on x-rays or CT scans
- 20% to 35% of all paediatric spinal injuries
- Due to elastic ligamentous laxity and the immaturity of osseous structures
- can be an indication for MRI when there is a persisting, objective myelopathy after a traumatic event with normal plain film and CT findings
- Other related terms used to describe specific situations with advent of new imaging techniques
- Spinal cord injury without radiographic evidence of trauma (SCIWORET)
- SCIWOCTET (spinal cord injury without CT evidence of trauma)
- spinal cord injury without neuroimaging abnormality (SCIWONA): patients without traumatic signs using radiographs, CT and MRI.
- more accepted general term SCIWORA is usually used to describe all variants of clinico-radiological mismatches.
ASIA Impairment Scale
Subaxial Cervical Spine Injuries Classifications
AO Subaxial Cervical Spine Injuries Classification
Subaxial Cervical Spine Injuries Management
- All trauma patients are considered to have a cervical spine injury until proven otherwise
- Cervical spine clearance : confirming the absence of cervical spine injury
- It is important to clear cervical spine and remove collar in an efficient manner
- delayed clearance associated with increased complication rate
- cervical clearance can be performed with
- physical exam
- radiographically
NEXUS Low risk criteria
- No midline tenderness
- No intoxication
- Normal alertness
- No FND
- No distracting injuries (eg Upper torso injuries may be sufficiently painful to distract from a reliable cervical spine examination)
Missed cervical spine injuries
- may lead to permanent disability
- careful clinical and radiographic evaluation is paramount
- high rate of missed cervical spine injuries due to
- inadequate imaging of affected level
- loss of consciousness
- multisystem trauma
- cervical spine injury necessitates careful examination of entire spine
- noncontiguous spinal column injuries reported in 10-15% of patients
Clinical Cervical Clearance
- patient is awake, alert, and not intoxicated
- has no neck pain, tenderness, or neurologic deficits
- has no distracting injuries
Radiographic Cervical Clearance
Operative Treatment for Cervical Spine Surgeries