Cervical spine fractures. Diagnostics & Therapy
If there is a suspicion of a cervical spine fracture or injury, a doctor should be consulted as soon as possible for clarification. Because when it comes to a spinal cord injury, in addition to nerve damage and impaired breathing, even paraplegia in the worst case may occur. Therefore, a careful diagnosis is necessary to be able to choose the appropriate therapy. If a cervical spine fracture is diagnosed, the treatment depends on kind and degree of stability of the fracture.
Stable fractures of the cervical spine often can be immobilized with a neck brace and treated with physiotherapy. For complicated or unstable fractures, however, an operation of the fractured vertebra is required. The injured segments are surgically fixed to prevent further injury and damage to the spinal cord.
Diagnostics, treatment & therapy of cervical spine fractures.
Diagnostics. How cervical spine fractures detected
How injuries to the cervical spine are identified.
If it is suspected that your cervical spine has been injured, the physician will carefully give you a physical examination first of all that includes a functional assessment of the nervous system. In this physical examination, the painful points will be palpated and the limbs will be assessed to check whether movement and sensation is normal. Large range movements of the head and neck are usually avoided. If the cervical spine does need to be moved over a large range, for example, when you have to be moved into another position, this should only be done under light neck traction. A manual (physical) examination can never completely exclude the presence of cervical spine injury and is the reason why radiological diagnostics always follow the physical exam in cases of suspected cervical spine injury.
Radiological diagnostics. X-rays of the cervical spine
These examinations are always carried out in both planes, in other words the images are taken from the front and from the side. These images can exclude gross malpositioning at a minimum. In most cases, the overlapping of other structures makes it difficult to evaluate the junction between the back of the head and the upper cervical spine and the junction between the cervical spine and thoracic spine in particular. Dentures or jewellery frequently cause overlapping in the upper cervical spine. Most of the time the overlapping of the shoulders makes it impossible to evaluate the junction between the lower cervical spine and the thoracic spine so that it is almost impossible to evaluate the two lowest cervical vertebrae using conventional x-rays. The lower segments of the cervical spine can sometimes be demonstrated on the side-view images when both shoulders are lowered. If this does not work, an image from the so-called "swimmer´s" view can be taken with one arm positioned next to the body and the other stretched above the head. These examinations are alternative techniques that cannot fully exclude injury. Further diagnostics should therefore always be carried out using computer tomography or magnetic resonance imaging when in doubt.
In addition to conventional x-ray imaging, special types of imaging also exist:
- "So-called open mouth atlas and odontoid projections". The x-ray machine´s central ray is pointed towards the joint between the first and second cervical vertebrae.
- Oblique images of the cervical spine at a 15° angle to better demonstrate the joint surfaces, and at a 45° angle to show the holes through which the nerves exit. When the image is taken from the left, the right-hand holes through which the nerves exit will be seen, and vice-versa.
Further diagnostics using computer tomography are usually carried out to provide answers for the following:
- To check the junction between the back of the head and the cervical spine and the junction between the cervical and thoracic spines
- For the detailed diagnosis of suspected injuries or injuries that have already been identified using conventional diagnostics so that further treatment can be planned - conservative or operative
- For the detailed diagnosis of cervical spine dislocation or malpositioning
- To identify the extent and cause of spinal canal narrowing
Functional images of the cervical spine.
Your physician may sometimes recommend that so-called functional images be taken if conventional x-rays and computer tomographies have excluded more obvious injuries to the cervical spine. These images either prove or exclude the presence of cervical spine instability as a result of injury to the ligaments or intervertebral discs. In this procedure your physician will ask you to lie down on a treatment couch and will hold onto your head securely with both hands. He/she will then assess your head under the continual monitoring of a so-called x-ray imaging converter. Similar to a film, this procedure makes it possible to observe and monitor the movement of individual cervical vertebrae in relation to each other during full neck extension and flexion movements. An increase in range of movement and the injury-related displacement of the neighbouring vertebra indicate that a ligament or disc has been torn. There is no risk of the examination aggravating symptoms or causing injury when it is carried out carefully on conscious patients.
Magnetic resonance imaging (MRI).
Magnetic resonance imaging is carried out to:
- Explain why there is a loss of neural function following injury
- Provide a detailed diagnosis regarding injury to ligaments and discs
- When tumours or inflammatory changes are present in the region of the cervical spine
- Evaluate injuries or changes to the spinal cord (tumour, bleeding, inflammation)
Therapy. Treatment of cervical spine fractures
Upper cervical spine.
The most common injuries in the upper section of the neck include fractures of the atlas (1st cervical vertebra), the odontoid process and fractures of the so-called arch belonging to the 2nd cervical vertebra. We are able to divide these fractures into stable and unstable types based on the fracture form and the possible presence of displacement. An atlas fracture is said to be stable and is able to be treated conservatively when the individual parts of the fracture have not been largely displaced and the transverse ligament behind the odontoid process has not been damaged. Unstable injuries must undergo surgical treatment to prevent the further displacement of fragments or vertebrae in relation to one another, something that could otherwise endanger the spinal cord. Fractures in the odontoid process of the 2nd cervical vertebra are one of the most common fracture types in the upper cervical spine and the type of fracture that is most often wrongly diagnosed. They are divided into three groups.
Treatment according to the type of injury.
- Type I = Avulsion of the tip
- Type II = Fracture between the odontoid process and the body of the 2nd cervical vertebra
- Type III = Fracture extending into the body of the 2nd cervical vertebra
Type I and III are treated conservatively with a cervical collar for 8-12 weeks and do not require surgery. Type II fractures require surgery due to their instability and tendency to heal incorrectly. The standard procedure is screw fixation from the front. Fractures in the arch of the 2nd cervical vertebra are also called "hangman´s fractures".
The disc between the 2nd and 3rd cervical vertebrae is the crucial factor when deciding whether to treat surgically or conservatively. If the disc has not been damaged, the injury is stable and is treated conservatively. Tearing of the disc either tilts or displaces the 2nd cervical vertebra in relation to the 3rd cervical vertebra. This unstable injury is treated surgically, usually by blocking the 2nd and 3rd cervical vertebrae from the front or with screw fixation at the arch from the rear.
Lower cervical spine.
Injuries associated with the compression of the vertebra´s end plate are stable. Their treatment is the same as for simple avulsion injuries of the tip of the vertebra (spinal process) and can be treated conservatively with a cervical collar. Functional images must always be taken using image conversion to exclude the presence of instability in these types of injuries, as is described above. Complex injuries are sometimes hidden behind the simple avulsion of bone. A typical example of this type of injury is the "teardrop phenomenon" where a small fragment of bone can be seen on the x-ray at the front edge of the body of a cervical vertebra. The injury could therefore be considered harmless. Yet experts know that this actually corresponds to the avulsion of bone at the anterior longitudinal ligament and shows that the cervical spine has suffered a hyperextension injury. The ligaments and disc have been torn and indicates that the cervical spine has been seriously injured.
Treatment of stable injuries in the cervical spine.
Stable injuries are immobilised for the first six weeks with a soft cervical collar. Patients will also be sent to stabilising physical therapy sessions during this period. Once unstable injuries have been successfully stabilised surgically they are also treated with a soft cervical collar. When bones are of bad quality and the screws are therefore unable to hold as well, a soft cervical collar may sometimes have to be prescribed for 6 - 12 weeks as well.
Treatment of unstable injuries in the cervical spine.
Unstable injuries of the lower cervical spine are usually treated via the front of the neck. During these procedures, damaged intervertebral discs and broken parts of the vertebra are removed and replaced with an artificial vertebral body implant made of titanium or plastic. A plate is used to bridge over the front of defective zone and is fixed with screws placed in the vertebral bodies above and below.
Treatment of highly unstable injuries in the cervical spine.
Highly unstable fractures are mostly the result of additional rotation of the head and neck that can also destroy structures at the rear (spinal processes, joint surfaces and arches). These fractures usually require additional stabilisation from the rear. To do this, screws are fixed in the parts of the bone that are still intact and are connected together with metal rods.
Advancements in therapy.
Over the last 5-10 years, great progress has particularly been made in the surgical treatment of cervical spine injuries. Before this period, spinal fusion surgery to stiffen large sections of the cervical spine could sometimes not be avoided. In comparison, modern spinal surgery aims to only stabilise the injured part, when possible, and connect it permanently to one or two of the neighbouring vertebrae at the most.
The use of navigation devices during spinal surgery particularly makes the placement of screws safe and precise, so that a fractured vertebra can be screwed together and its anatomy, stability and function restored. This means that permanent post-operative functional disorders, such as limited mobility, are kept to a minimum.
Rehabilitation after cervical spine fracture.
Rehab after a cervical spine injury.
In addition to acute treatment, rehabilitation also plays an important role in the treatment of cervical spine injury. While spinal injury victims with no neurological deficits are initially physically affected by the injury, many of them are also psychologically "impacted".
Important: Unimpaired bone and wound healing.
In addition to ensuring unimpaired bone and wound healing, rehabilitation therapy will therefore focus on gradually resuming the activities of everyday life. In the first six weeks after surgery, the patient will be instructed in behaviours that protect the spine. During this time there will also be a programme to build up muscle stability, in the course of which patients will also rebuild confidence in their spine.
Improving the range of function of the injured cervical spine.
If the healing progresses as planned (this will be checked once again based on x-rays after six weeks), the next six weeks will be devoted to improving the range of function - in other words, the mobility - of the cervical spine by means of targeted physical therapy. Towards the end of this phase, the patient will then be able to resume less physically stressful sports such as running, cross country skiing and cycling. Generally, contact sports should not be resumed until six months have passed.
Cervical spine fractures
Cervical spine injuries not only affect the mobility of the head. Also, nerves and the spinal cord can be damaged.
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