Elective tracheal intubation in cervical spine injuries

Patients presenting for surgical stabilisation of an unstable cervical spine are at risk of sustaining a further iatrogenic spinal cord injury during intubation of the trachea. Controversy exists regarding the optimal anaesthetic technique for securing the airway. We reviewed the techniques employed for intubating the trachea in our hospital over a five year period. Tracheal intubation was achieved using two different techniques: awake fibre-optic intubation with local anaesthesia, and general anaesthesia via the intravenous or inhalational route with neuromuscular blockade. Forty five patients were included. 16 patients demonstrated a pre-operative neurological deficit. Awake fibre-optic intubation was used in 27 cases, general anaesthesia was employed via the intravenous route in 17 cases and the inhalational route in 1 case. Weighted traction was employed in all cases to immobilize the cervical spine during intubation. There was no new neurological sequelae with any of these techniques. Our study suggests that there is no optimal anaesthetic technique for intubating the trachea in patients with cervical spine injuries and it is noteworthy that in line traction was used in every case.     

Indications for surgical management of injuries of the cervical spine

The indication for operative treatment of serious injuries to the cervical spine is basically determinated by instability and dislocation. Timing of the operation is based on the neurological deficit. If there is a chance for recovery operative treatment is urgent. For the upper cervical spine defined indications are existing for type-2-fractures of the dens and C 2/C 3-instabilities of the hangman-type with major dislocation. Fractures of C 0 and C 1 are preferably treated by conservative methods. Only cases with compound injury patterns with a high degree of ligamentous instability may require dorsal fusion. For serious injuries of the lower cervical spine operative treatment is needed in most instances. Conservative treatment is only indicated if functional stability can be proofed and injuries to the discs and compression to the myelon are ruled out.     

Clearing cervical spine injuries: a discussion of the process and the problems

This article identifies and describes the standards of care in treating, diagnosing, and managing suspected cervical spine injuries. Staff experience, nursing, and medical literature provide insight into the complications associated with spine immobilization. Review of medical literature provides background on the standard diagnostic exams utilized and the rationale for the number and variety of tests included in the clearance process. Opportunities for reviewing practice, with an emphasis on limiting the effects of immobilization, can provide future challenges to nursing.     

Symptoms of the cervical spine in temporomandibular and cervical spine disorders

This study was performed to assess the prevalence of signs and symptoms related to cervical spine disorders (CSD) in subgroups of patients with temporomandibular disorders (TMD) and to compare TMD patients and CSD patients with regard to the results of orthopaedic cervical spine tests. One hundred and eleven consecutive patients with TMD and 103 consecutive patients with signs and symptoms of CSD were examined. The results indicated that there is a considerable overlap in the signs and symptoms of patients with TMD and patients with CSD. Signs and symptoms on neck extension occurred more often in CSD patients than in subgroups of TMD patients. No significant differences in upper cervical extension, neck flexion, and shoulder girdle function were found between CSD patients and subgroups of patients with TMD. Patients with CSD reported neck pain during active and passive movements of the neck more often than the subgroups of patients with TMD. TMD patients and CSD patients did not differ with regard to pain on shoulder girdle function and palpation of the shoulder girdle. Logistic regression analyses showed that orthopaedic tests of the cervical spine are of minor importance in discriminating between patients with TMD and patients with CSD. It is concluded that TMD with a myogenous involvement in contrast to TMD with only an arthrogenous involvement should no longer be viewed as a local disorder of the stomatognathic system. The upper quarter, including the stomatognathic system, cervical spine, and shoulder girdle, should be evaluated in patients with more complex or persistent symptoms in the head and neck region.     

Thoracolumbar spine injuries

This article reviews some of the anatomic and mechanical aspects of thoracolumbar injuries as they relate to classification systems and stability. In addition, an overview of the initial management including surgical and conservative treatment options is provided.     

Rugby injuries to the cervical spine and spinal cord: a 10-year review

A 10-year review (1987-1996) of injuries sustained to the spine and spinal cord in rugby players with resultant paralysis has been undertaken. This article reviews that the incidence of serious rugby spine and spinal cord injuries in South Africa has increased over the 10-year period reviewed, despite stringent new rules instituted in an attempt to decrease the incidence of these injuries. The mechanisms of injury, as previously reported, remain the same as well as the phases of game responsible for injury of the tight scrum, tackle, rucks, and mauls. Two new observations are reported: the first is related to the occurrence of spinal cord concussion with transient paralysis, and the second is related to the increased incidence of osteoarthritis of the cervical spine in rugby players.     

The pathomechanics of compression injuries in the cervical spine. Nondestructive and destructive investigative methods

Biomechanical analysis using nondestructive and destructive investigative methods was performed to evaluate the mechanisms of cervical compression injuries. These injuries produce two basic modes of failure: 1) anterior dislocation; and 2) rupture of the anterior ligamentous complex of the vertebral body. Distribution of these two failure patterns was determined by the initial cervical spine position; translational alignment did not have a significant effect. Different results were observed between spines positioned in flexion and extension, indicating that the most important factor determining the mode of failure was rotational alignment in the sagittal plane.     

Long-term evaluation of vertebral artery injuries following cervical spine trauma using magnetic resonance angiography

STUDY DESIGN: A prospective study to determine the long-term outcome of traumatically induced vertebral artery injuries. Magnetic resonance angiography was performed at the time of cervical injury and at a follow-up office visit. OBJECTIVE: To determine the long-term outcome in terms of arterial flow competency of traumatically induced vertebral artery injuries. SUMMARY OF BACKGROUND DATA: Vertebral artery injury associated with cervical spine trauma has been well documented; however its healing or nonhealing potential has not been elucidated. METHODS: During the 7-month period from July 1993 to January 1994, all patients admitted to the authors' institution with cervical spine injuries underwent magnetic resonance imaging and magnetic resonance angiography of the cervical spine to determine the patency of their vertebral arteries. Magnetic resonance angiography was performed at the time of injury and at a follow-up office visit. Twelve of 61 patients were found to have a lack of signal flow within one of their vertebral vessels during this study period. RESULTS: Eighty-three percent of the patients (five of six) who were available for follow-up observation in this study did not manifest flow reconstitution of their vertebral arteries after an average 25.8-month follow-up period. CONCLUSIONS: According to these data, most patients with vertebral artery injuries after nonpenetrating cervical spine trauma do not reconstitute flow in the injured vertebral arteries. This lack of flow must be considered if future surgery in this region of the cervical spine is contemplated.     

Ventral interbody spondylodesis in injuries of the cervical spine. Indications, surgical technique and results

OBJECTIVE: To consider evidence for the effectiveness of psychosocial interventions in reducing the risk of infection with HIV of injecting drug users. METHOD: We reviewed 19 published studies of the effectiveness of individual counselling, HIV testing, group interventions, street outreach, and a 'social' intervention designed to change norms for safer behaviours. RESULTS: Eight of 15 studies that examined behavioural outcomes provided evidence of the effectiveness of an experimental intervention, compared with a control or comparison group. In four of these studies, however, serious design limitations made results difficult to interpret. In the other four studies without design limitations, the success of the experimental interventions may have been due to their greater length and intensity as well as to having been conducted with stable and well-motivated populations. Nine of the 15 studies showed evidence of marked behaviorial changes in both experimental and comparison group(s), with the changes in many cases being sustained for upwards of 12 months. CONCLUSIONS: A close examination of the evidence and competing hypotheses for the pattern of results suggests that participating in evaluation research may itself be a valuable intervention. Implications for the development of interventions include the potential efficacy of health risk assessment. Implications for evaluation of interventions include the need for developing unobtrusive measures and for assessing the impact of behavioural assessments. Despite the large behavioural changes reported in most of the studies, a substantial proportion of subjects receiving interventions reported unacceptably high levels of risk behaviours. New, more potent interventions are needed, such as those designed to change the norms of entire communities of drug users concerning safer injection and safer sex.     

Whiplash injuries of the cervical spine. Neurologic contribution to diagnosis. Therapy and expert evaluation

The cervical spine is an extremely complex functional unit and has always been the subject of impassioned discussions among surgeons, orthopedic specialists and neurologists. In the presence of injuries affecting this section of the spine, which sometimes have grave consequences--including implications for legal insurance aspects, neurologists are usually at the end of the line when it comes to diagnosis and treatment. In fact, in view of the clinical and technical neurophysiological options available to neurologists, it would be desirable for them to be involved as early as possible. In this paper the relative value of neurology, compared with orthopedics and surgery, in the diagnosis and treatment of whiplash injury to the cervical spine is discussed. The newer options available--particularly in neurophysiology--are highlighted, as are the differential diagnosis and problems concerned with official expert assessments, which also involve other specialties.     

Variation in surgical opinion regarding management of selected cervical spine injuries. A preliminary study

STUDY DESIGN: The opinions of orthopedic surgeons and neurosurgeons were compared regarding appropriate management of selected cervical injuries and the timing of stabilization. OBJECTIVE: To determine whether there is consistency of opinion regarding the management of cervical trauma. SUMMARY OF BACKGROUND DATA: Numerous forms of management for cervical trauma exist, but there are few consistent recommendations. No previous study has been done to determine uniformity of preferences of the surgeons who manage these injuries. METHODS: Thirty-one orthopedic surgeons and neurosurgeons were given a brief clinical situation and pertinent radiographic studies of five selected cervical injuries. Management options included halo and nonhalo orthoses, traction, and various forms of anterior and/or posterior procedures. The surgeons rated, in whole numbers from 1 to 10, their opinions on the appropriateness of each technique. Each surgeon was given a case of a "generic" cervical injury, in which stabilization was required and for which preoperative alignment was adequate in traction. They gave opinions on the timing of stabilization, with a choice of four time frames. Four neurologic situations were rated, ranging from intact to complete cord injury. RESULTS: Of 46 possible responses to the five test cases regarding appropriateness, 18 ranged from 1 to 10, the largest possible variation. Only 2 had a range of 5 or less, implying better consensus among tested surgeons. Mean values ranged from 1.9 to 9.5. Agreementamong respondents regarding appropriateness was slight with a range of kappa statistics from 0.09 to 0.14. Of 16 possible responses regarding timing, 14 were within a range of 8 or higher. Within 24 to 72 hours was the generally preferred time frame, with all possible responses showing a range of 3 or 4. Results of a multiple analysis of variance showed no significant differences among respondents. CONCLUSION: There is a large variety of opinion regarding appropriateness of specific operative and nonoperative management procedures and surgical timing among the surgeons polled who manage cervical trauma. This implies that there is no widely accepted standard management procedure for many of these injuries.     

Athletes with cervical spine injury

Athletic injuries to the cervical spine are infrequent, but can present difficulty in both diagnosis and management. We designed a simple classification system consisting of three broad types of injuries to facilitate management decisions. Also included is a discussion of variations among injuries within each type and recommendations regarding the athlete's return to competition.     

Inflammatory disorders of the cervical spine

The most common inflammatory disorders affecting the cervical spine include adult and juvenile rheumatoid arthritis, ankylosing spondylitis, Reiter's syndrome, and psoriatic arthritis. These disorders are characterized by typical deformities and instabilities of the cervical spine that result from the destruction caused by synovitis in bony and ligamentous structures in the neck. The treatment of these inflammatory lesions differs from the treatment of similar lesions found in the posttraumatic or degenerative spine. This article attempts to outline the epidemiology, clinical manifestations, and natural history of these conditions. Various radiographic parameters for evaluating disease progression have been used over the years, and their usefulness is reviewed in the context of recent studies better defining the radiographic natural history of these lesions. An algorithm for the use of the various imaging methods including magnetic resonance scanning is provided, and recent progress in delineating the proper timing of surgical intervention and the predictors of neurologic recovery is presented. The current surgical procedures available to treat these conditions are discussed with emphasis on distinguishing those cases in which stabilization alone is required from those in which a decompression procedure is also necessary.     

Clinical and technical assessment of the cervical spine

In analysis of the cervical and cervicobrachial syndrome with or without signs of compression of the nerve root or spinal cord, functional assessment of the cervical spine is of great importance. Comparisons between actively performed and passively induced motion can be verified by using standardized computer-assisted assessment allowing precise documentation of the range of motion and coupled motion. The age-related normal values should be considered. The neurological assessment includes not only the cranial nerves and upper extremities but also lower extremities to avoid overlooking the signs of cervical myelopathy. In patients with compression of nerve roots or the spinal cord neurophysiology might be helpful in identifying or verifying compression. In patients with suspected myelopathy sensory evoked potentials will allow assessment of the function of the ascending spinal pathways and motor evoked potentials, assessment of the function of the descending cortical spinal pathways.