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Canadian C-Spine rules for cervical fracture The authors of this tool identified high- and low-risk criteria related to the necessity of radiography. High-risk criteria include: ● Age greater than 65. ● Dangerous mechanism of injury such as a fall from greater than one meter or greater than five stairs. ● Axial load to the head. ● Motor vehicle collision at more than 100 kilometers per hour or 62 miles per hour; ejection during collision; collision in recreational vehicles or bicycles. ● Paresthesia in the extremities. When present, low-risk criteria for cervical spine fractures decrease the likelihood that a cervical fracture is present. Low- risk criteria for cervical spine fracture include: ● Simple rear-end motor vehicle collision. ● Found to be in a sitting position in the emergency department. ● Ambulatory status at any time after the injury. ● Delayed onset of midline cervical spine tenderness. ● If these criteria are met, safe assessment of cervical range of motion is possible and rotation to 45 degrees bilaterally can be attempted. An absence of low-risk criteria or inability to rotate the spine is an indication for radiological evaluation (Garg et al., 2020). The advantages of this tool are its comprehensive and reproducible criteria, while its limitations include its applicability only in patients age 16 years and older, its longer time, and the need for an accurate history for clearance (Garg et al., 2020). The specificity for this tool ranges from 0.01 to 0.77, while the sensitivity ranges from 0.90 to 1.00 (Garg et al., 2020). C1 fractures Atlas injuries account for 2% to 13% of acute cervical spine (Mead et al., 2016). Typically, C1 fractures are caused by traumatic axial loading and are associated with other damage to the cervical spine (Mead et al., 2016). Common mechanisms of injury are diving into shallow water, falling, and a motor vehicle crash (Mead et al., 2016). Relevant anatomy for C1 fractures The atlas does not have vertebral body but consists of a posterior and anterior arch that encircles the spinal cord. It sits just below the occiput and articulates with the occipital condyles above and C2 below, effectively joining the skull to the spine. The dens of the axis is secured to the anterior arch of the atlas by the transverse odontoid ligament. The C1–C2 joint is highly mobile, with approximately 50% of cervical rotation occurring at this joint (Mead et al., 2016). The vertebral arteries pass through the transverse foramina of the atlas. In cases of traumatic fractures of the C1/C2 foramina, the vertebral artery is subject to blunt injury. These injuries can be asymptomatic and are often overlooked (Mead et al., 2016). Occlusion of bilateral vertebral arteries can be fatal (Mead et al., 2016). Single fractures to the ring of C1 are uncommon, and a ring disruption typically accompanies any fracture (Mead et al., 2016). A Jefferson fracture is a burst fracture of C1, described as a two-, three-, or four-part fracture involving the anterior and posterior arches (Squarza et al., 2019). Diagnosis Patients with C1 fractures present with pain in the upper neck and a history of trauma to the top of the head. The NEXUS algorithm can be used to rule out the possibility of a fracture, and the Canadian C-Spine Rules should be employed to determine the need for radiography. C1 fractures can be difficult to see on plain x-rays, and computed tomography (CT) is often required for definitive diagnosis (Mead et al., 2016). C2 fractures C2, or axis, fractures often occur with C1 fractures (Mead et al., 2016). According to Gonschorek et al. (2018), odontoid fractures account for up to 15% of cervical spine injuries. This is the most common type of cervical spine fracture in people who are older

than age 80 and can be fatal due to the proximity of the medulla oblongata (Gonschorek et al., 2018). Types of odontoid fractures A type I fracture is an avulsion of the odontoid tip by the alar ligament. This type of fracture is rare (Gronschorek et al., 2018) and is considered stable (Mead et al., 2016). Type II are the most common type of odontoid fracture. A type II fracture involves a fracture at the base of the dens. It is unstable and at risk for nonunion (Gronschorek et al., 2018). Type III fractures include the base of the odontoid and into the lateral masses of the axis. Type III fractures have good healing potential (Mead et al., 2016) because of the more extensive blood supply and larger surface area involved (Gronschorek et al., 2018). Because of reduced bone density, fall risk, and degenerative changes that affect the biomechanics of the cervical spine, elderly patients are at greater risk for atlantoaxial fractures (Squarza et al., 2019). C2 fractures due to falls are the most common injury of the cervical spine in the elderly (Gembruch et al., 2019). According to Tadros et al. (2019), more than half of C2 fractures sustained by older adults are due to a ground-level fall (compare this to younger adults—about 80% of their C2 fractures are due to motor vehicle crashes). Squarza et al. (2019) found that 1.26% of asymptomatic elderly patients were found to have C1–C2 fractures after minor head trauma. Healthcare consideration: Visualization of the upper cervical spine via radiograph can be difficult because of the skull. For that reason, open-mouth x-rays are used to visualize the upper cervical spine. This view focuses primarily on the odontoid process of C2 and is useful in visualizing odontoid and Jefferson fractures. This view is called the AP open mouth view or odontoid view (Murphy, 2021). Algorithm for Canadian C-Spine Rule: Any high-risk factors mandating radiography? • Fall from >1m/5 stairs.  If yes , imaging required

• Axial loading (e.g., diving). • Motor vehicle accident (MVA) > 100 km/h, rollover, ejection. • MVA in recreational vehicle. • Bicycle collision.

 NO  Any low-risk factors?

 If no , imaging required

• Simple rear-end MVA. • Sitting in the emergency department. • Ambulatory after injury. • Delayed onset neck pain. • Absence of midline tenderness.

If yes , able to rotate neck 45 degrees left and right  If yes , no imaging required

NEXUS versus Canadian C-Spine rules Michaleff et al. (2012) conducted a systematic review to compare the diagnostic accuracy of the Canadian C-Spine Rule and NEXUS. Although the methodologic quality of the studies included was modest, they found that the Canadian C-Spine Rule had better diagnostic accuracy than the NEXUS criteria. The Canadian C-Spine Rule and NEXUS are used to evaluate patients in the emergency department. For that reason, most patients with high-velocity injuries will be seen by a physician

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