PATHOLOGY AND MEDICAL
MANAGEMENT OF THE CERVICAL SPINE
PTP 521, MUSCULOSKELETAL DISEASES AND
DISORDERS
Symbols
2
this is for your information only,
it won’t be used for the exam
important to know for exam
Cervical Spine Pathology
3
Bone
Trauma
Fractures
Joint
Soft Tissue
Disk
Arthritic
Conditions
Rheumatoid
Arthritis
DJD/Osteoarthritis
Degenerative
Disk Disease
Spinal Stenosis
Disk Bulge,
Herniation
C2-C7
Radiculopathy
Whiplash
Post Concussion
Syndrome
Headaches
Other
Other
Hypomobility
Facet Syndrome
Impingement
Syndrome
Canadian Cervical
Spine Rule for
Radiographic
Examination
Sensitivity: 99.4%
Specificity: 45.1%
Stiell IG, Clement C, et al. The Canadian
C-Spine Rule versus the Nexus Low-Risk
Criteria in Patients with Trauma.
JAMA 2003, 349;26
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Canadian Cervical Spine Rule for Radiographic
Examination
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 Stiell et al in 2003 examined patients to determine
the characteristics of those who had positive cervical
spine fractures versus those who were negative.
 By following these rules, the number of unnecessary
radiographs for the cervical spine was decreased
dramatically
 http://content.nejm.org/cgi/content/full/349/26/25
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 (full text article)
Importance
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 By following the Canadian Cervical Spine Rules, A
clinician can be reasonably certain that a patient
needs a radiograph of the cervical spine.
 Sensitivity is high, - SnNout- therefore, if following
these rules and the tests are negative, and you send
the patient for a radiograph, only 1% will have a
fracture. 99% will not have a fracture.
 Specificity is mid range - SpPin - therefore, if the
tests are positive, you send the patient for a
radiograph, only 45% will have a fracture.
Fractures of the Cervical Spine
7

Musculoskeletal Practice Pattern G

75% of all spine fractures occur in the cervical
spine due to the instability of the atlantooccipital joints
Jefferson’s Fracture:
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 Burst Fracture of C1.
 Head holder, so fragments everywhere, very unstable, neck
brace or halo.
1. MOI: Axial Compression
2. Radiograph: odontoid view, greater than 7
mm difference between both lateral masses
of the atlas and those of the axis.
3. Unstable Fracture
Jefferson’s Fractures: Burst!
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Hangman’s Fracture:
10
 Fracture of the neural arch of the axis, fractures the
pedicles of C2 with dislocation of C2 on C3
1. MOI: Hyperextension

a blow on the forehead forcing the neck into extension is a classic
mechanism of injury producing fractures thru the pedicles
2. Radiograph: lateral view shows bilateral
disruption through the pedicles of the axis
3. Unstable fracture
Hangman’s Fractures
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Hangman’s Fracture
12
Dens Fractures
Type 1: (A ) avulsion of the
tip of the dens as a
result of apical or alar
ligament
stress
Type 2: (B) fracture of the
junction of the dens
with the body of the
axis.
Type 3: (C) fracture deep
within the body below
the dens.
Type 4: see below
13
Dens Fractures
 Left: Type 2 dens
fracture at the junction
of the dens with the
vertebral body with
posterior displacement
 Right: fracture of the
dens with posterior
displacement of the
atlas causing a small
degree of spinal canal
compression
14
15
CT scan of odontoid
Fractures Type 3
Notice on this CT scan
The foramen for the
Vertebral artery
emedicine.medscape.com/article/94234-media
Dens Fracture
Type 4: sagittal or
parasagittal fracture
extending from a point
lateral to the dens
vertically or diagonally to
the inferior surface of C2
16
Os Odontoideum:
 Congenital Disorder
 Failure of the dens to
unite with the body of
the vertebrae.
1. Radiograph:
Odontoid view
-Tell it is not a dens
fracture by the
smoothness around
parts
17
Wedge Fracture:
MOI: Hyperflexion
and Compression
1.
1.
-Like a crunch, diving
Radiograph: lateral
view, the anterior
height of the vertebral
body is shorter by
3mm than the
posterior border
Stable fracture
2.
3.
2.
-If it has no neuro s(x),
then will not do
anything, end with a
little kyphosis curve
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Wedge Fracture
 This fracture is easy to
see compared to some.
In comparing anterior
height to posterior
height, you should see
a difference.
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Burst Fracture of the Vertebral Body
Lower cervical
vertebrae
1. MOI: Axial
Compression
2. Radiograph: lateral
view, comminuted
vertebral body is
flattened centrally
3. Can be stable or
unstable

3.
-Described by presence of
neuro s(x), impingement
of the spinal canal.
20
 Radiograph: lateral
view, comminuted
vertebral body is
flattened centrally
emedicine.medscape.com/article/94234-media
21
Clay-Shoveler’s Fracture
 Avulsion fracture of
the Spinous Process
1. MOI:
a. Hyperflexion
-Where the pulley is overused and detaches
-Trapezius, Rhomboids,
Para spinals
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Hypomobility of the
Cervical Spine
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1. Pathology: tightness of the capsule of one of the
synovial facet joints
2. Radiographic signs: generally none
3. Clinical Symptoms: aching, dull, stiff feeling in
the neck *Headaches*
4. Clinical Signs: loss of movement in a capsular
pattern for the facet joints
Joint play is decreased at the segmental level
Capsular end feel
Pattern: Upper Cervical: limited lateral flexion and
rotation equally limited %-wise, then extension
limited less.




-Lower cervical is opposite
Facet Syndrome
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Joint
Dysfunction
Pathology: joint capsules are stretched from joint
subluxations or distension of the joint with fluid.
-Looser the capsule gets, tight Para spinals.
 Body will protect the area with posture and muscle
spasms of the paravetebral muscles which leads to
a decrease in spinal mobility and a secondary
muscle fatigue.
Facet Syndrome
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 Occurs early in the degenerative process for the
young or middle aged patient
 Loading patterns change which lead to cartilage
degeneration, facet hypertrophy and bony
adaptation in the form of sclerosis or spurring
(ostephyte formation).
 Alters joint function which alters disc function
Radiographic Signs: Oblique view:
26
a.
Hypertrophy of the facet joint
b.
Osteophyte formation at the superior and inferior
articulating processes
c. Decrease in joint space
Clinical Symptoms of Facet Syndrome
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 Presentation is variable, generally a steady ache with
long periods of inactivity.
 Pain present after activity, not during.


Progression of pain gets more sever over time
Pain will come and go with activity demands and disease
progression.
 Sharp pain with abrupt movements.
 Catching or locking sensation.
 Some radiation of pain may occur if nerve root is
involved
Clinical Signs of Facet Syndrome
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 Muscle spasms in the paraspinals
 Decrease lordosis
 Decrease ROM all directions particularly with
extension and rotation to one side
 Pain with extension
 Neurological exam is normal initially, may be
abnormal eventually with osteophyte formation.
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Impingement Syndrome
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1. Onset: sudden, often without a memorable trauma
2. Radiographic Signs: generally none
3. Clinical Symptoms: sharp, unilateral pain, stiff
neck and c/o loss of movement
Signs of Impingement Syndrome
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 ROM limited in area’s that close or compress the
facet joint on the painful side.
 Extension and rotation to the side of dysfunction
are limited
 Lateral flexion may be painful, not as limited
 Compression increases pain, distraction decreases
pain.
 Muscle guarding during passive and active
movement.
Osteoarthritis,
Degenerative Joint Disease
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Joint
Dysfunction
Pathology: progressive
degeneration as a natural
consequence of aging, loss of
flexibility or movement occurs as the
disease progresses
-Look for osteophyte formation, anteriorly first
bridging between vertebrae.
Osteoarthritis: oblique view
33
 Osteophyte formation is
usually seen as bridging
the vertebrae – carefully
review the shape of the
vertebrae in this view
 Encroachment of the
neural foramen is also
noted
emedicine.medscape.com/article/3051
45-media
Cervical Spinal
Stenosis:
Joint
Dysfunction
34
 Pathology: narrowing of the central spinal canal or
the intervetebral foramina

Increase in bone formation around the nueral foramen.
 Etiology:
 Developmental, congenital, or traumatic, age related
 Can be caused by intervetebral disc disease or osteoarthritis
Symptoms and Signs of Spinal Stenosis
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 Symptoms:
 Radiating arm pain and numbness in nerve root distribution
 Clumsiness if severe enough
 Signs
 Myotomal weakness
 Hyperreflexia: will increase foramen space, so will look down,
and adjust entire posture to compensate.
 Clonus
-May think that it is a “Disk Herniation”, but way to differentiate
is an MRI
Imaging Studies
36
 MRI: imaging study of choice
 CT myelogram can be used but will be invasive so
may not be the one of choice
Disc Herniation Causing Impingement of
Specific Spinal Nerve
37

Can occur with or without radiculopathy. Less
common in the cervical spine than in the lumbar
spine.

Individual nerve roots may be impinged or
tethered within the foramin.
3. Herniation Sites
38
a.
b.
c.
d.
C1-2: no disc
C2-3: rare
C3-4: rare
C4-5:
1) clinical symptoms
2) signs: Motor
Sensory
Reflexes
Herniated Disc: MRI
39
 Look at the spinal cord
by C4-5 and C5-6. C4-5
is a larger herniation.
This one is impinging on
the spinal cord.

Consider the clinical
symptoms this patient
may have.
 C5-6 slightly smaller and
may only be a bulge.
Disc Herniation
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 MRI: encroachment by
the disc on the spinal
canal
 Stenosis of the canal is
also occurring giving the
spinal cord a strangled
appearance
www.mayfieldclinic.com/
PE-HCDisc.htm
MRI
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 Best able to detect




C5-6 disc herniation extending
Posterior into the canal

Disk height loss
Annular fissures
Osteophytosis
End plate changes
Herniation

APTA 2009 CRHazle
Pathological Findings
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 Winking Owl Sign:


Metastatic cancer to the
spine can show up initially
as a missing pedicle
It gives the impression
that the one of the “eyes”
is closed.
= pedicle
www.medscape.com/viewarticle/421516_6
Whiplash: Musculoskeletal
Practice Pattern 4E
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Definition: cervical strains or acceleration injuries
“whiplash”
MOI: Sudden Acceleration-Deceleration movement of the
head and neck
Causes: Falls, car accidents, sports injuries
Head inertia creates a high velocity force or acceleration
Results in severe overstretch injury
Age of patient, general health, direction of forces and magnitude of
forces determines the extent of injury and the tissues that are
involved
Soft tissue structures which can be potentially injured include: disc,
spinal ligaments, capsule, muscles, nerves, spinal cord and
vertebrae
Radiographic signs:
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 Changes in cervical curve






on x-ray
Fanning of interspinous
spaces (great space,
curve in opposite
direction)
Increased prevertebral
space
Acute loss of disc height
Displaced prevertebral
fat space
Vacuum cleft sign
Paraspinals go into sever
Force
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 Amount of force= weight of head plus speed that the
head moves.
 Direction of Force:




Where was the car hit
Symmetry of impact
Double injury – hit from behind, pushed into another vehicle
Position of person in relation to impact
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C. Onset: may not be for several hours after an
accident
D.
Symptoms: pain, stiffness, and muscle spasm in
the cervical spine, headaches
are usually
posterior, may have some dysphagia
-Spasms are the Hallmark, extreme tenderness to
palpation.
Post Concussion Syndrome
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1.
2.
Soft
Tissue
Pathology: blow to the head
Onset: develops after the concussion within a 48
hour period after trauma

May last several weeks or months after injury
3. Symptoms: persistent headaches, inability to
concentrate, irritability and fatigue
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Medical Tests: CT scan usually negative for any
brain injury
Specific Conditions related to return to play
4.
5.
•
•
Dependent upon severity of concussion – mild, moderate,
or severe
Number of concussions a player has had in a season
Grade I: Mild Concussion
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•
Momentary confusion, no loss of consciousness, symptoms
disappear within 15 minutes
•
First concussion: return to play if asymptomatic for one week
Second: return to play in 2 weeks if asymptomatic for 1-2
weeks
Third: terminate season, may return to play next season if
asymptomatic
•
•
Grade II: Moderate Concussion
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 Brief concussion, no loss of consciousness,
symptoms last longer than 15 minutes



First concussion: return to play if asymptomatic for one week
Second: minimum of 1 month off play and asymptomatic for 1
week. If not asymptomatic, terminate season
Third: terminate season, may return next season
Grade III: Severe Concussion
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 Loss of consciousness – briefly or prolonged
 First concussion: return to play after a minimum of one
month off and asymptomatic for one week

Second: terminate season, may return to play next season if
asymptomatic
Post Dural
Puncture Headache
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 Spinal headache
 Risk Factors:
 Anyone who has an epidural or spinal tap procedure
 SX: severe, dull, non-throbbing pain, usually in
fronto-occipital region
 Signs: aggravated by upright position, decreased
in supine position
 May have nausea, vomiting, visual disturbance
and/or auditory disturbance
 Self-limiting usually
 Tell them to drink Mt. Dew (Caffine)
Other Dx
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 RA: particularly in the C spine can lead to spinal cord
injuries, death if forced into hyper extension due to
fragilely of the joints.
 Other types of headaches covered in Neuro:



Migraines
Cluster Headaches
Postural Headaches
Cervical Spine: Radiology
Typical Views
Special Views
 Open Mouth View
 Lateral Flexion
 AP view
 Lateral Extension
 Lateral View
 Right Oblique
 Left Oblique
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Evaluation using ABCDS
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 Odontoid or Open Mouth
View




Patient Position: Supine,
mouth open
Beam: directed downward
into the open mouth
Film placed between
posterior C-spine and
table
-For Evaluating stability of
upper cervical spine.
Alignment:
56
 Demonstrate odontoid and lateral masses of C1.
 Draw around the odontoid, and body of C2, draw the
lateral masses of C1.
 Look at the alignment between the lateral masses of
C1 and the body of C2, these should match up
 There shouldn’t be any overhanging edges laterally,
if there is, this may suggest a burst fracture of C1
 Look at the medial edges of the C1 lateral masses and
the body of the dens, these should be symmetrical
with the dens centered between them.
Bone Density and Dimension
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 Odontoid should have
NO lucencies in superior
portion, base, or
vertebral body
 Bones should have equal
density, consistent with
no unexpected lucencies
Cartilage and Soft Tissue:
58
 Cartilage: No intervertebral disk, can evaluate facet
joints. These should be parallel and equally spaced
 Soft Tissue: not applicable in this view
AP View, Alignment
59
 Patient Sitting or Supine
 Assesses C3-C7
 Alignment:
 Draw a vertical line superior to inferior along the spinous
processes to assess segmental rotation – SP are bifid
 Identify Pedicles: look for rotation
 Vertebral Bodies: Size, C3-C7
 Uncinate joints: for osteophyte formation
60
61
Bone Density and Dimension
62
 Evaluate each pedicle and vertebral body for a
change in density or dimensions. Compare with
segments above and below to see if there are any
asymmetries in size or position and measure
horizontal and vertical dimensions
Cartilage and Soft Tissue
63
 Cartilage: evaluated on lateral view, not assessed in
AP view
 Soft Tissue: identify bottle shaped trachea

Should be mid line, if not mid line, it may indicate the
presence of a tumor, pneumothorax or hemothorax
Lateral View, Alignment
64
 Patient Position
 Lateral standing
 Supine cross table view
 Alignment:
 Line 1: anterior borders of vertebral bodies
 Line 2: posterior borders of vertebral bodies
 Line 3: spinolaminar line: junction of lamina at the spinous
processes
 These three lines help to assess for several types of
pathologies that can be found on this view such as
spondylolisthesis or burst fractures
Alignment cont.
65
 Check for the normal lordosis:
 Flat C spine: indicates muscle spasms from trauma
 Increased lordosis:
 Kyphosis: anterior segmental compression fracture
66
 ADI: Atlantodens
Interval: space MUST
not exceed 3 mm. Any
greater distance and this
must be evaluated by a
physician for C1 or C2
instabilities.
emedicine.medscape.com/article/93546-media
Alignment cont.
67
 Look at the margins of each vertebrae for possible
osteophyte formation
 Evaluate the facet joints and look for possible
osteophyte formation
68
Bone Density and Dimensions
69
 Evaluate the density of each cervical vertebrae for
changes in density
 Measure the vertebral body height anteriorly and
posteriorly
Cartilage and Soft Tissue
70
 Cartilage:

Assess disk height
 Soft Tissue:



Prevertebral tissue
Fanning of cervical
vertebrae may
demonstrate interspinous
ligaments
Retropharyngeal space
should measure 7mm or
less
71
 Retropharyngeal space:
measure less than 7 mm
 Space between C2
anterior vertebral body
and the posterior
pharyngeal wall
 Retrotracheal space:
should measure no more
than 22 mm in adults
and 14 mm in children
 Space between C6
anterior vertebral body
and the posterior
tracheal wall
Oblique Radiographs
72
 Patient Position:



Posterioanterior or
Anterioposterior
Standing, sitting, or
supine
Patient rotated 45 dg to
one side and demonstrates
opposite side neural
foramina
 Primarily used to
evaluate the
intervertebral foramina
Alignment
73
 Evaluate both oblique views and compare side to
side
 Draw each foramen on the oblique radiograph,
evaluate for narrowing of the foramen, osteophyte
formation, and anterior movement of one vertebrae
over the other
 Can also look at the pedicles and laminae
Left Oblique
74
Right Oblique
75
Special Views
76
 Lateral Flexion and
Extension Stress Views:
observe joint alignment
with movement, largely
replaced with
fluoroscopy as you can
watch the movement
occur
 Pillar View: view the
lateral masses of the
cervical vertebrae,
patient is turned to one
side about 45 dg and
extended about 30 dg.
Special Views cont.
77
 Swimmers view:




Patient prone on table
with arm abducted to 180
dg
Cross table radiograph
with central beam directed
to the axis
Film on opposite side
Visualizes C7, T1 and T2
vertebrae
www.biomedcentral.com/.../2/figure/F1?highres=y
Cervical Spine: CT
 Sagittal Slice:
78
 Orientate by finding the dens, C1 is
just anterior to the tip of the dens,
C3-C6 bodies of the vertebrae can
be seen on this view.
 Spinous processes are posterior to
the spinal canal
 Small circle at the top of the
Largest spinous process is the
posterior arch of C1
 Good view to see bone intruding
into the spinal canal
Anterior arch of
C1
Trans axial CT: Intervertebral Space
79
 Body of Vertebrae
 Facet joints
 Spinal canal
 Lamina
 Bifed Spinous process
emedicine.medscape.com/article/1264627-overview
MRI of the Cervical Spine
80

T2 weighted sagittal MRI of the cervical
spine

Orientate by finding the dens, anterior
arch of C1, posterior arch of C1, cervical
vertebaral bodies of C3-C7, T1-T5

Spinous processes

Spinal Cord, canal – any buckling of
the cord? Any encroachment by the
vertebral bodies into the canal? Check
out C5-6. What do you think?

Disk Space: evenly spaced? Disk
height is similar?

Soft tissue
Cervical Spine: MRI
81
www.gehealthcare.com/.../products/ci
mages.html
 Body of vertebrae is very
dark in this MRI
 Spinal Canal/Cord is
lighter
 As pictures progress, can
see more of the spinal
nerve appearing and its
attachment to the cord
 Muscle