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Neck Pain

Dr. Alex Jimenez’s collection of neck pain articles contain a selection of medical conditions and/or injuries regarding symptoms surrounding the cervical spine. The neck is made up of various complex structures; bones, muscles, tendons, ligaments, nerves, and other types of tissues. When these structures are damaged or injured as a result of improper posture, osteoarthritis, or even whiplash, among other complications, the pain and discomfort an individual experiences can be impairing. Through chiropractic care, Dr. Jimenez explains how the use of spinal adjustments and manual manipulations focuses on the cervical spine can greatly help relieve the painful symptoms associated with neck issues. For more information, please feel free to contact us at (915) 850-0900 or text to call Dr. Jimenez personally at (915) 540-8444.


The Way Aging Affects The Cervical Spine El Paso, TX.

The Way Aging Affects The Cervical Spine El Paso, TX.

Aging affects the entire body, which includes the spine, neck and shoulders, upper back, and arms.

It does not mean that everyone will develop neck pain, but the wear and tear put the spine can lead to degenerative spinal conditions.

Doctor of Chiropractic Dr. Alexander Jimenez discusses:

  • Cervical spine anatomy
  • Degenerative spinal disorders that cause
  • Neck pain
  • Diagnosis
  • Treatment of neck pain and symptoms

 

11860 Vista Del Sol Ste. 128 The Way Aging Affects The Cervical Spine El Paso, TX.

 

Anatomy

The cervical spine by the top 7 vertebrae of the spine.

Often referred to as C1-C7, with the “C” indicating cervical, and the numbers 1-7 indicate the level.

  • C1 is closest to the skull
  • C7 is closest to the thoracic chest/rib cage area

The cervical spine is particularly susceptible to degenerative problems because:

  • Highly mobile with a broad range of motion
  • Supports the skull
  • Neck anatomy is complex

Many degenerative problems, including osteophytes or bone spurs, can develop.

Neck Pain Symptoms

Several symptoms can occur and indicate the presence of a degenerative condition:

  • Neck pain
  • Pain around the back of the shoulder area
  • Arm pain, numbness, or weakness
  • Difficulty with hand dexterity or walking

Conditions That Affect the Neck

The degenerative process begins in any of the joints in the spine, but over time it can cause changes in the other joints.

An example is an intervertebral disc where:

The disc narrows and the normal movement becomes altered, and the adjacent joints are subjected to force and pressure, which can lead to degenerative arthritis joint inflammation.

Spondylosis or spinal osteoarthritis causing pain in the neck is common. The pain can radiate, or spread, into the shoulder/s or down the arm/s. Arm pain or weakness caused by a bone spur compressing a spinal nerve root can also occur.

 

Diagnosing Cervical Spine Conditions

Once examined one or more symptoms are likely to be present.

The doctor will ask the patient questions to learn the history of the patient.

A thorough evaluation of the patient will be conducted, including tests to identify the cause of pain and symptoms.

  • A neurologic examination is performed to rule out neurological disorders
  • Shoulder examination will also be done to ensure that the symptoms originate from the neck
  • Diagnostic tests

X-rays for:

  1. Narrow intervertebral disc space
  2. Anterior osteophytes or bone spurs
  3. Spondylosis (ie, arthritis) of the facet joints
  4. Osteophytes created from the uncovertebral joints

 

11860 Vista Del Sol Ste. 128 The Way Aging Affects The Cervical Spine El Paso, TX.

 

CT Scans or computed tomography can show bone changes associated with degenerative spondylosis. Osteophytes can be observed and evaluated.

CT does not provide an optimal evaluation but can sometimes show disc herniations.

 

MRI magnetic resonance imaging is a powerful tool for cervical spondylosis.

MRI can help doctors identify:

  • Disc herniation
  • Osteophytes
  • Joint arthrosis a type of osteoarthritis

MRI is best for soft disc herniation/s.

 

11860 Vista Del Sol Ste. 128 The Way Aging Affects The Cervical Spine El Paso, TX.

 

Myelogram/CT can be utilized in complex cases that involve multi-level spinal diseases.

It is very useful in delineating bone spurs from safe disc herniations.

 

 

Discography is used diagnostically when viewing the lumbar/low back and thoracic/mid-back spine, but using it in cervical spine imagery is debated among doctors.

 

 

Treatment Options

After the tests have been performed, a custom treatment plan is created.

Nonsurgical Neck Pain Treatment

Nonsurgical treatment of cervical degenerative disease has been proven to provide excellent results in over 85% of patients.

A multi-disciplinary approach:

Immobilization of the neck to reduce motion can be beneficial during acute episodes of pain.

Physical therapy (PT) and Chiropractic can be useful to decrease muscle spasms and return motion.

Both PT and chiropractic can use:

  • Heat
  • Electrical stimulation
  • Exercise

To help maximize benefits.

Medications like:

  • Analgesics
  • Nonsteroidal anti-inflammatories
  • Muscle relaxants
  • Opioids when absolutely necessary

Non-surgical treatment provides positive long-term pain and symptom relief.

Surgery

A surgeon is likely to consider surgery for a disorder if one or more of the following criteria are met:

  • Nonsurgical care has been tried and has not worked
  • Spinal cord dysfunction
  • Arm pain or weakness (neurological symptoms) that do not go away

Depending on the diagnosis, surgical procedures can vary:

  • One type of surgery is the removal of the bone spur(s)
  • Cervical spinal fusion that joins two or more vertebrae

But the surgical procedure is based on the way you the patient wants to go, the diagnosis, general health, and what the spine surgeon recommends.

The surgeon will explain the recommended procedure to you clearly.

Most of the time the preferred approach is anterior or from the front interbody fusion.

A cervical plate could be placed over the interbody device or graft to stabilize the neck. This can avoid the need for a brace after.

A posterior approach from the back of the spine is considered when a disc has herniated laterally or to the side.

 

Things You Can Do

Cervical spine disorders can be diagnosed and treated more accurately with today’s advancing technology.

With the guidance and treatment of an expert medical team, patients can expect to see a definite improvement in their condition and symptoms.


 

El Paso, TX Neck Pain Chiropractic Treatment

Sandra Rubio discusses the symptoms, causes, and treatments of neck pain. Headaches, migraines, dizziness, confusion, and weakness in the upper extremities are a few of the typical symptoms. Trauma from an accident, such as that from an automobile accident or a sports injury, or an aggravated illness because of improper posture can commonly cause neck pain and other ailments. Dr. Alex Jimenez uses spinal alterations and manual manipulations, one of other chiropractic treatment techniques like deep-tissue massage, to reestablish the alignment of the cervical spine and improve neck pain. Chiropractic care with Dr. Alex Jimenez is your non-surgical choice for restoring general patient well-being.

Neck pain is a frequent health issue, with roughly two-thirds of the people being influenced by neck pain at any time throughout their lifetimes. Numerous other health issues can cause pain arising in the upper back, or the spine. Neck pain can result emanating from the vertebrae, or because of muscular tightness in both the neck and the upper back. Joint disruption in the neck causes migraines, and headache, as does joint disturbance at the trunk, or can generate a variety of other symptoms. Neck pain affects about 5 percent of the worldwide population as of 2010, based on figures.


 

NCBI Resources

A chiropractor evaluates the spine as a whole because other regions of the neck (cervical), mid-back (thoracic) and low back (lumbar) can be affected as well. Along with treating the spine as a whole, chiropractic medicine treats the entire person and not just a specific symptom/s. Chiropractors may educate on nutrition, stress management, and lifestyle goals in addition to treating neck pain.

 

Cervical Radiculopathy/Radiating Neck Pain El Paso, TX.

Cervical Radiculopathy/Radiating Neck Pain El Paso, TX.

Cervical radiculopathy happens when a pinched nerve in the neck (cervical spine) causes pain.

Radicular pain can extend beyond the neck and radiate down:

  • The shoulders
  • Arms
  • Fingers

This type of nerve compression also causes:

  • Weakness
  • Numbness
  • Tingling
  • Reflex problems

The neck consists of 8 pairs of nerves that control several motor (strength) and sensory (feel) functions.

The cervical nerve roots at the top send movement and feeling signals to the head and neck, and the nerves at the bottom enable motor and sensory function to the arms and hands.

 

11860 Vista Del Sol, Ste. 128 Cervical Radiculopathy/Radiating Neck Pain El Paso, TX.

 

If one or more of the spinal nerves in the neck gets pinched, it can disturb its ability to function correctly.

This results in radiating pain in the neck and other areas of the body.

This condition can affect anyone but usually affects middle-aged adults.

Men also tend to develop cervical radiculopathy more than women.

Causes

The natural aging process on the spine is what usually causes cervical radiculopathy.

The spine goes through the aging process just like the rest of the body and even more as it is the basis of our structure.

This process can lead to several degenerative spinal disorders, that include:

  • Cervical spondylosis (osteoarthritis)
  • Spinal stenosis
  • Herniated discs

When nerve passageways begin to narrow, intervertebral discs begin to protrude,  and bone spurs, caused by these disorders can put pressure on the nerves in the neck.

The condition can also be caused by a traumatic injury to the neck like whiplash or sports injury.

Rarely is it caused by an infection or spinal tumor.

 

11860 Vista Del Sol, Ste. 128 Cervical Radiculopathy/Radiating Neck Pain El Paso, TX.

 

Symptoms

The primary symptom is pain radiating from the neck down to the:

  • Shoulders
  • Arms
  • Hands
  • Fingers

The above is an example of sensory function, which is related to feeling.

In addition to sensory symptoms, radiculopathy can also cause motor dysfunction.

Motor dysfunction relates to muscles and movement.

Reflex changes in the neck and upper body and weakness are examples of motor dysfunction.

Diagnosis

A spine specialist/chiropractor has several tools to diagnose cervical radiculopathy.

First and foremost your medical history will be reviewed and then will be:

  • Asked to describe symptoms

A physical exam will be conducted to recreate the pain in a controlled manner in the:

  • Neck
  • Shoulder
  • Arms

Example: Spurling’s maneuver, which gently rotates the head, while applying gentle pressure.

Once the information from the medical history and physical exam are done,  imaging tests such as an MRI may be ordered so they can pinpoint the location of the nerve compression.

MRI scans show the soft tissues in the spine, including the nerves.

The doctor may request a pair of diagnostic tests called electromyogram (EMG) and nerve conduction exam if there are significant upper nerve arm and neck pain.

These tests help understand if there is nerve damage, the cause of the damage and if the symptoms are related to the nerve damage.

EMG and nerve conduction tests are usually performed together to help in the diagnosis.

 

Emergency Symptoms

Once the spine specialist confirms the diagnosis, they will develop a treatment plan to relieve the nerve compression or prevent it from getting worse.

Most cases are taken care of with non-surgical treatment, however, if the following occurs you should contact your doctor:

  • Neck pain does not improve with treatment in the time your doctor expects.
  • Pain worsens regardless of treatment

Or you develop new:

  • Numbness
  • Weakness in the
  • Neck
  • Arms
  • Upper body
  • Develop fever

If you experience symptoms in the lower body like:

  • Weakness in the leg
  • Difficulty walking
  • Lack of bowel/bladder function, then seek medical attention immediately.

These symptoms may indicate cervical myelopathy, a more severe condition.

Cervical myelopathy is the compression of the spinal cord.

When the spinal cord gets compressed, it can generate widespread spine issues and usually requires surgery.

 

Treatment Cervical Radiculopathy

Like most types of spine pain, a doctor will recommend trying one or more conservative treatments first.

Conservative treatments are nonsurgical means.

It’s important to understand that just because a treatment is considered conservative does not mean it is ineffective.

In fact, it’s quite the opposite. Most people with nerve compression in their neck respond well to conservative therapies.

Though research on the efficacy of conservative treatments for cervical radiculopathy has produced mixed results, findings show that these therapies help eliminate pain and other nerve-related symptoms (like numbness and muscle weakness) in 40-80% of people.

11860 Vista Del Sol, Ste. 128 Cervical Radiculopathy/Radiating Neck Pain El Paso, TX.

 

The following are the most common conservative treatments:
  • Over-the-counter medications, like acetaminophen (Tylenol) or nonsteroidal anti-inflammatory medications (ibuprofen, Motrin)
  • Prescription medications, like steroids (prednisone), neuropathic agents (gabapentin, pregabalin), and muscle relaxants (baclofen, cyclobenzaprine)
  • Wearing a neck brace
  • Physical therapy and exercise, to strengthen the neck muscles and improve motion
  • Cervical spinal traction, that can be performed during physical therapy
  • Avoiding strenuous activity, but don’t avoid all activity, as too much rest can exacerbate the injury and extend the recovery time

These conservative treatments can go on for 6 to 8 weeks. If there is no improvement or it gets worse, then a doctor may want to step you up to the next level.

This may include steroid injections.

Spinal Injections

Cervical epidural steroid injections are considered a second-line treatment for radiculopathy that is not responding to conservative therapy. These injections send a dose of anti-inflammatory medicine into a specific nerve root’s that can relieve pain.

The number of injections differs from patient to patient. A doctor will make recommendations based on the condition and response to the first injection.

If the first injection reduces the pain and symptoms, a second or third injection might not be necessary unless symptoms recur.

If more than one is needed, they are given 3 weeks between each injection.

Injections can help manage pain and inflammation, but cannot strengthen or improve the flexibility of the cervical muscles.

Because of this, a doctor may prescribe physical therapy, chiropractic or an exercise program to condition the neck muscles.

Surgery Considered

When surgery is needed it is considered a last resort option. This is not a guaranteed solution and there are risks and complications.

Different types of surgical approaches are available. These procedures can be performed minimally invasively in a hospital setting or an outpatient surgery center.

Discussing options with a doctor and whether you are a candidate for minimally invasive surgery or not, along with other types of surgery e.g. artificial disc, is a discussion that is different for everybody, as some patients have existing medical conditions that can increase risks and complications.

Anterior cervical discectomy and fusion (ACDF)

This approach is the most widely used surgical approach.

The surgeon makes an incision through the front of the neck and removes the damaged intervertebral disc, fills the empty space with spacers to restore the height and attaches spinal instrumentation (plate, screws) for stabilization.

A bone graft is then packed into and around the body spacers for bone ingrowth and healing.

Posterior cervical foraminotomy

Here, the surgeon accesses one or more levels of the cervical spine with an incision in the back of the neck.

Foraminotomy decompresses the nerve root by removing whatever is compressing the nerve like a bone or soft tissue.

The procedure opens/widens the neural foramen or the nerve passageway where the nerve exits the spinal canal.

Cervical artificial disc replacement (C-ADR)

Here an artificial disc device is implanted in the empty disc space.

C-ADR is like a shock absorber and enables healthy movement the way that an actual disc does.

 

Conclusion

A compressed nerve in your neck can lead to radiating pain. This pain can make it almost unbearable to do simple tasks, even moving the neck from side to side or just opening a jar. Conservative treatment like chiropractic and exercise can ease the pain of this condition and restore function. Fortunately, surgery is rarely necessary.


 

El Paso, TX Neck Pain Chiropractic Treatment

 

Alfonso J. Ramirez now retired, found follow-up treatment with Dr. Alex Jimenez for his neck pain. Mr. Ramirez experienced chronic pain and headaches, but after receiving chiropractic care, he found relief from his symptoms. Ever since that time, Alfonso Ramirez has continued to maintain the alignment of his backbone with Dr. Jimenez. Mr. Ramirez is grateful for the chiropractic care he’s received for his neck pain and for his knee and shoulder pain. Alfonso J. Ramirez recommends Dr. Alex Jimenez as the non-invasive pick for neck pain.


 

NCBI Resources

Approximately two-thirds of the population being affected by neck pain at any time throughout their lives. Pain that originates in the cervical spine, or upper spine, can be caused by numerous other spinal health issues. Joint disruption in the neck can generate a variety of other common symptoms, which include headaches, head pain, and migraines. Neck pain affects about 5 percent of the global population, according to statistics.

 

Regularly Looking Down At Your Phone El Paso, TX.

Regularly Looking Down At Your Phone El Paso, TX.

Weighing an average of 10 pounds, the human head is heavier than most people think. The head can put a great deal of pressure on the neck when it is placed in different positions for prolonged periods – especially regularly looking down at your phone.

The damage caused to the neck from time spent staring at mobile screens has been given the name “Text Neck”, and it is a growing problem among not only teens but for everyone.

Regularly Looking Down at Your Phone Is Cause For Neck Injury

Your body is well-designed to bear the weight of your head when you maintain good posture – but tilting your head down to look at your phone is not good posture. In fact, for every inch you move angle your head downward, you double the pressure on your spine.

Looking at your phone can put an extra ten or twenty pounds of pressure on your neck. That would be worth noting even if you only did it occasionally, but most people spend hours looking at their phones throughout the day. That amounts to hours of excessive pressure on the soft tissues that make up your neck – pressure that will inevitably lead to inflammation and discomfort if left unchecked.

According to this article featured in the Washington Post, the pressure you put on your neck by bending and staring at your phone is much like bending your finger back as far as it will go, and then keeping it in that position for approximately an hour. Day after day, such stress is bound to lead to complications.

regularly looking down at your phone el paso, tx.

Resulting Injuries from Text Neck

The strain put on the neck by text neck is enough to cause mild to severe injuries, including:

  • Sore muscles
  • Inflamed Tissues
  • Pinched nerves
  • Herniated discs
  • Elimination of the natural curve of the neck

These injuries can cause considerable pain and discomfort and may lead to further health complications. They can lead to neck and back pain that can last for years.

Tips to Avoid Text Neck

Smartphones offer numerous benefits and opportunities for enjoyment, so it is unlikely that most people will stop using them. Luckily, there are things you can do to protect yourself, including:

Work Your Eyes, Not Your Neck

One of the simplest ways to avoid text neck is to look down with your eyes instead of tilting your head down. While it may not be practical to always use this technique, it is certainly useful in many circumstances. Your eyes can tilt down with little effort and can allow you to lessen the tilt of your neck as you use your phone.

Strength Train your Neck & Shoulder Muscles

You will inevitably do some head tilting as you use your phone throughout the day. Strengthening the muscles that support your head is one way to protect your delicate neck tissues and maintain mobility. Simple exercises like turning your head each way repeatedly and using your hands to provide resistance can make your neck much stronger. Your shoulders also provide a lot of support for your neck. Shoulder exercises can increase the stability of your neck as well.

Have an Awareness of Your Head Position

Just maintaining awareness of how your head is tilted as you use your phone can help you avoid excessive tilting. Practice looking at your smartphone with your head upright to remind yourself of what good posture feels like, and pay attention during the times you deviate from good posture.

Chiropractic Treatment

If you are experiencing neck pain from text neck, or from any other type of injury, chiropractic can help. Please contact us now to schedule your appointment and get some relief!

regularly looking down at your phone el paso, tx.

El Paso Back Clinic Playlist

What Patients of Chiropractic Want To Know About Text Neck

What Patients of Chiropractic Want To Know About Text Neck

Text neck is a very real condition that is caused by staying in a prolonged “texting” position – hunched shoulders and neck tilted forward. As a result, the back, neck, and shoulder muscles become overworked and your spinal structure is actually changed. Many people who spend a lot of time on their mobile devices such as smartphones and tablets, develop this condition (and others including “cellphone elbow” and tendinitis of the wrist and hand) and it can be very painful, even causing mobility problems. More than 95% of Americans have a smartphone or mobile device and most people spend a great deal of time on their devices – it is easy to see how this is a common problem.

What Exactly is Text Neck?

A normal human neck has a slight curve to it that travels along the spine. It is part of the intricate system that supports the head and body. However, a person with text neck will have a straight cervical spine. Their neck will not have that slight curve and that is a problem.

The cause of the absence of the curve is because of the position that the head stays in for such long periods of time. The average adult human head weighs between 10 and 12 pounds. When the head is upright, the neck supports it and the slight curve gives it the stability that it needs.

When you keep your head tilted forward, such as when you are hunched over your smartphone or mobile device, your head is thrust forward instead of sitting over the balanced curve of the cervical spine. The gravitational pull is greatly increased and the neck is already in an unnatural position. This combination places unnatural and damaging stress on your neck. It is like carrying around an additional 60 pounds on your neck.

Symptoms of Text Neck

In the early stages of text neck, a person may feel some tightness in their shoulders, neck, and upper back. This may progress to discomfort in those areas and eventually pain. If left untreated, you can develop pinched nerves and herniated discs.

Your central nervous system begins at the base of your skull, so it extends down your neck and upper back. When you put unnatural pressure on your neck, you are also affecting your nervous system, causing it to malfunction. This can lead to pain throughout your body, stiffness, headaches, low back pain, and problems with your hands and arms.

text neck chiropractic care, el paso, tx.

How to Prevent Text Neck

Text neck is surprisingly easy to prevent. Your first step is awareness. Over two or three days, take some time to be very aware of your body’s position. Carefully examine your posture while you go about all of your daily activities. It is important to remember that text neck is not strictly confined to texting. You can get it any time you have your head bent down for an extended period of time, such as when looking at a laptop screen or even writing for a long time.

The best way to avoid the problem is to keep your devices at eye level. If you have a handheld device, hold it up at the level of your eyes instead of bending your neck to look down. The same goes for your laptop; arrange it so that your screen is at eye level.

Chiropractic for Text Neck

If you are already suffering from the effects of text neck, your chiropractor can help reverse the condition if it hasn’t progressed to disc degeneration (even then he or she can help with associated pain). Regular chiropractic treatments, along with following expert recommendations for screen heights, can help reduce the pain and discomfort. It is smart to address these issues before they become a bigger problem. Your chiropractor can help.

Neck Pain Chiropractic Treatment

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What Is Cervical Spondylosis & Can Chiropractic Help? | El Paso, TX.

What Is Cervical Spondylosis & Can Chiropractic Help? | El Paso, TX.

As we age, specific changes take place in the body. The spine gets a lot of wear and tear because it is the primary supportive structure that does everything from keeping the head upright to providing a pathway for neural impulses, to providing mobility. It’s no wonder that there comes the point where the body does not function like it once did. Cervical spondylosis is a broad term describing a condition that is related to the natural wear and tear on the disks in the neck.

What is Cervical Spondylosis?

Also known as neck arthritis or cervical osteoarthritis, cervical spondylosis is very common in elderly patients, particularly in those over age 60. More than 85% of people over 60 years of age have some form of it, usually with few or no symptoms present. It does get worse with age, though, so it could progress to the point where the patient does experience pain, reduced flexibility, stiffness, lack of mobility, or other symptoms.

Cervical spondylosis is a blanket term that is used to describe some conditions, and while it is usually considered an age-related condition, it can have other causes as well including heredity. This condition often begins with changes in the disk.

With age, the disks in the spine and neck will dehydrate. This causes them to shrink, leaving little or no padding between the vertebrae. As a result, the patient may develop signs of osteoarthritis and in some cases, bone spurs. Depending on how the condition progresses and presents, it can be a cause of chronic pain.

What are the Treatments for Cervical Spondylosis?

Treatment for cervical spondylosis involves relieving the symptoms. There is no way to reverse the effects that it has on the body so treating the pain, stiffness, and other issues that accompany the condition is the course that is usually taken by doctors. Depending on the exact symptoms, treatment may include using an ice pack, bed rest, warm compress, and low impact exercise as the patient can handle it.

The doctor may recommend an analgesic or nonsteroidal anti-inflammatory drug (NSAID). In cases where the pain is severe and difficult to manage, they may prescribe a narcotic painkiller, steroids, or a muscle relaxant.

They might also combine drug therapy with physical therapy. In very severe cases the doctor may recommend spinal injections or surgery. Some common operations for cervical spondylosis include intervertebral disc arthroplasty, invertebral disc annuloplasty, and spinal fusion.

In many cases, soft collars, rigid orthoses, molded cervical pillow, or a Philadelphia collar may be recommended to provide support. However, many doctors believe that these methods are not entirely effective and that any benefit the patient receives is primarily due to a placebo effect.

This is because the neck is still mobile and does not have restrictions of movement. If used correctly, though, it can provide some support. This means that the patient needs to wear it as much as possible when they are not sleeping.

In many cases, the medications have unpleasant side effects, and some can even be harmful. This is especially true with prescription pain medications which can be addictive.

Surgery is also not a preferred treatment due to potential complications, the invasiveness of the procedure, and the length of time it takes to heal. Often patients seek other forms of treatment that are more natural and gentle on the body. Chiropractic is one of the most popular remedies for cervical spondylosis.

cervical spondylosis chiropractic care el paso tx.

Chiropractic for Cervical Spondylosis

Chiropractic is a popular treatment for cervical spondylosis. Many patients gravitate toward it because it is non-invasive and does not use harmful medications. Its natural, whole body approach makes it an appealing treatment method.

In addition to spinal manipulation, the chiropractor may use massage to help relieve stiffness and pain. He or she may also recommend ice or heat, rest, stretching, lifestyle changes, and even dietary modifications.

Patients may be advised to remove foods from their diet that increase inflammation and taught special exercises that help keep the neck supple. Some chiropractors recommend special supplements to help work with the body enabling its natural ability to heal itself.

Neck Pain Chiropractic Treatment

What Is Cervicalgia & Can Chiropractic Help? | El Paso, TX.

What Is Cervicalgia & Can Chiropractic Help? | El Paso, TX.

Have you ever had a pain in the neck? And your kids or significant other don’t count. If you’ve ever had a stiff, sore neck, then you’ve more than likely experienced cervicalgia. You’re not alone. The American Osteopathic Association estimates that more than 25% of Americans have experienced or chronically experience neck pain. Neck pain is one of the primary causes of chronic pain, ranking number three behind knee pain (number two) and back pain (number one). Chronic pain affects around 65% of people in the United States, ranging in age from 18 to 34. They either have experienced it firsthand or care for someone who has recently experienced it. That number increases as the population ages.

It is also worth noting that most doctors prescribe pain medications, but more than 33% of patients with chronic pain won’t take them because they are afraid of becoming addicted.

What is Cervicalgia?

Cervicalgia is a blanket term used to describe neck pain. It can range from a simple “crick in the neck” to severe pain that prevents you from turning your head.

Knowing the term for the pain, though, does not help when it comes to treatment because treatment lies in the cause of the pain. It can become quite complex because there are so many causes for the pain. Sometimes the cause itself must be eliminated before the treatments for the pain can be effective.

What are the Causes of Cervicalgia?

The causes of cervicalgia are vast and varied. A patient who sits at their desk for too long or sleeps in a poor position can develop neck pain.

Injuries such as sports injuries and whiplash fall at the more severe end of the spectrum. Even simple gravity can be a culprit.

The human head can weigh as much as 10 pounds, sometimes even more and the neck is tasked with keeping it upright. Just the action of fighting gravity and keeping the head erect for long periods of time (like all day) can cause the neck muscles to become strained and fatigued. This can also cause neck injuries to heal slower because the neck is almost always in use and under consistent stress.

cervicalgia neck pain chiropractic treatment el paso tx.

 

How is Cervicalgia Treated?

Treatment for cervicalgia depends on both the symptoms and the cause. If you have been injured, you should seek medical attention immediately to assess the severity of the injury.

You can apply ice to help reduce inflammation and swelling, but do not delay a medical evaluation. Some neck injuries can be severe, causing very serious conditions including paralysis.

After an assessment, your doctor may prescribe medication such as anti-inflammatories and stronger painkillers. A cervical collar may also be recommended since it allows the neck to rest which will promote healing.

If the pain is caused by other reasons such as stress, poor posture, or sleeping on the wrong pillow (in other words, you have a crick in your neck), you can use an over the counter anti-inflammatory medication and using a heating pad will help. Massage is also effective.

However, prevention is the best cure. When you know what is causing your cervicalgia, you can take steps to prevent it. Chiropractic can help both in prevent cervicalgia and in treating it.

Chiropractic for Cervicalgia

Chiropractic treatment can help relieve the pain from cervicalgia for many of the causes, including injury, stress, and misalignment. Depending on the cause, the chiropractor will use specific techniques to treat the root of the problem.

They will bring the body back into alignment which also helps to prevent the pain of cervicalgia. The most attractive aspect is that it allows for pain management without the use of any medications.

When you get regular chiropractic care, you can reduce your chances of experiencing pain in your neck and back. That is why so many people are choosing chiropractic care for their neck and back pain instead of turning to traditional medicine – because it works.

Neck Pain Chiropractic Treatment

Rheumatoid Arthritis of the Cervical Spine

Rheumatoid Arthritis of the Cervical Spine

Rheumatoid arthritis, or RA, is a chronic health issue which affects approximately 1 percent of the population in the United States. RA is an autoimmune disorder that causes the inflammation and degeneration of the synovial tissue, specific cells and tissue which form the lining of the joints within the human body. Rheumatoid arthritis may and generally does affect every joint in the body, especially as people get older. RA commonly develops in the joints of the hands and feet, severely restricting an individual’s ability to move, however, those with significant disease in the spine are at risk of damage like paraplegia. Rheumatoid arthritis of the spine is frequent in three areas, causing different clinical problems.

The first is basilar invagination, also referred to as cranial settling or superior migration of the odontoid, a health issue where degeneration from rheumatoid arthritis at the base of the skull causes the it to “settle” into the spinal column, causing the compression or impingement of the spinal cord between the skull and the 1st cervical nerves. The second health issue, and also the most frequent, is atlanto-axial instability. A synovitis and erosion of the ligaments and joints connecting the 1st (atlas) and the 2nd (axis) cervical vertebrae causes instability of the joint, which may ultimately result in dislocation and spinal cord compression. In addition, a pannus, or localized mass/swelling of rheumatoid synovial tissue, can also form in this region, causing further spinal cord compression. The third health issues is a subaxial subluxation which causes the degeneration of the cervical vertebrae (C3-C7) and often results in other problems like spinal stenosis.

Imaging studies are crucial to properly diagnose patients with rheumatoid arthritis of the cervical spine. X-rays will demonstrate the alignment of the spine, and if there is obvious cranial settling or instability. It can also be difficult to demonstrate the anatomy at the bottom of the skull, therefore, computed tomography scanning, or CT scan, with an injection of dye within the thecal sac is arranged. Magnetic resonance imaging, or MRI, is beneficial to assess the severity of nerve compression or spinal cord injury, and allows visualization of structures, including the nerves, muscles, and soft tissues. Flexion/extension x-rays of the cervical spine are usually obtained to evaluate for signs of ligamentous instability. These imaging studies entails a plain lateral x-ray being taken with the patient bending forward and the other lateral x-ray being taken with the individual extending the neck backwards. The scope of our information is limited to chiropractic, spinal injuries, and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .

Curated by Dr. Alex Jimenez

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Additional Topics: Neck Pain and Auto Injury

Whiplash is one of the most common causes of neck pain after an automobile accident. A whiplash-associated disorder occurs when a person’s head and neck moves abruptly back-and-forth, in any direction, due to the force of an impact. Although whiplash most commonly occurs following a rear-end car crash, it can also result from sports injuries. During an auto accident, the sudden motion of the human body can cause the muscles, ligaments, and other soft tissues of the neck to extend beyond their natural range of motion, causing damage or injury to the complex structures surrounding the cervical spine. While whiplash-associated disorders are considered to be relatively mild health issues, these can cause long-term pain and discomfort if left untreated. Diagnosis is essential.

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EXTRA EXTRA | IMPORTANT TOPIC: Neck Pain Chiropractic Treatment

Vertebral Fracture Diagnosis Imaging Studies

Vertebral Fracture Diagnosis Imaging Studies

A vertebral fracture is a common health issue which can often cause bone fragments to damage the spinal chord and nerve roots. Broken bones can occur due to trauma or injury from automobile accidents, slip-and-fall accidents, or sports injuries, among other causes. Depending on how severe the vertebral fracture is, individuals may have difficulty performing everyday activities. The purpose of the article below is to demonstrate and discuss vertebral fracture diagnosis imaging studies and their results.

 

Practice Essentials

 

Vertebral fractures of the thoracic and lumbar spine are usually associated with major trauma and can cause spinal cord damage that results in neural deficits. Each vertebral region has unique anatomical and functional features that result in specific injuries. See the image below.

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Figure 1: Anteroposterior and lateral radiographs of an L1 osteoporotic wedge compression fracture.

Signs and Symptoms

 

Symptoms of vertebral fracture can include pain or the development of neural deficits such as the following:

 

  • Weakness
  • Numbness
  • Tingling
  • Neurogenic shock – In this, hypotension is associated with relative bradycardia as a result of autonomic hyporeflexia
  • Spinal shock – The temporary loss of spinal reflex activity that occurs below a total or near-total spinal cord injury; initially results in hyporeflexia and flaccid paralysis; with time, the descending inhibitory influence is removed and hyperreflexive arches, even spasticity, may occur

 

An injury to the thoracic or lumbosacral cord would likely result in neural deficits at the trunk, genital area, and lower extremities. Specific syndromes, such as Brown-Séquard syndrome and anterior cord syndrome, may affect a compression part of the spinal cord.

 

See Overview for more detail.

 

Diagnosis

 

Laboratory Studies

 

Patients with vertebral or pelvic fractures resulting from a major trauma require serial hemoglobin determinations as an indicator of hemodynamic stability.

 

Other laboratory studies, including the following, aid in the evaluation of associated organ damage in patients with vertebral fracture:

 

  • Urinalysis or urine dip for blood – Can help to rule out associated kidney injury
  • Amylase and lipase levels – Elevated level of amylase or lipase may suggest pancreatic injury
  • Cardiac-marker levels – Elevated levels in the setting of chest trauma may indicate a cardiac contusion
  • Urine myoglobin and serum creatine kinase levels – Elevated level of urine myoglobin or serum creatine kinase in the context of a crush injury may indicate evolving rhabdomyolysis
  • Serum calcium level – In patients with metastatic disease to the bone and resultant pathologic fractures, a serum calcium determination is necessary; these patients may have hypercalcemia that requires medical attention
  • Pregnancy test – Should be obtained in females of childbearing age

 

Imaging Studies

 

  • Radiography – Plain radiographs are helpful in screening for fractures, but hairline fractures or nondisplaced fractures may be difficult to detect
  • Computed tomography (CT) scanning – CT scans can readily detect bony fractures and help with the assessment of the extent of fractures
  • Magnetic resonance imaging (MRI) – This is usually the study of choice for determining the extent of damage to the spinal cord; MRI is the most sensitive tool for detecting lesions of neural tissue and bone

 

See Workup for more detail.

 

Management

 

Nonsurgical Fracture Management

 

Minor fractures or those with column stability are treated without surgery. Nonoperative management of unstable spinal fractures involves the use of a spinal orthotic vest or brace to prevent rotational movement and bending.

 

Consideration should be given to the stabilization of patients with spinal cord injuries and paraplegia. These patients need to be stabilized sufficiently so that their upper body and axial skeleton are appropriately supported, which allows for effective rehabilitation.

 

Surgical Fracture Management

 

The goals of operative treatment are decompression of the spinal cord canal and stabilization of the disrupted vertebral column. The following basic approaches are used for surgical management of the thoracolumbar spine:

 

  • Posterior approach – Useful for stabilization procedures that involve fixation of the posterior bony elements; the posterior approach is used when early mobilization is considered and decompression of the spinal canal is not a major consideration
  • Posterolateral approach – Often used for high thoracic fractures such as T1 through T4; it may be combined with a posterior stabilization procedure when limited ventral exposure is needed
  • Anterior approach – Allows access to the vertebral bodies at multiple levels; the anterior approach is most useful for decompression of injuries and spinal canal compromise caused by vertebral body fractures

 

The 4 basic types of stabilization procedures are as follows:

 

  • Posterior lumbar interspinous fusion – Least-invasive method; involves the use of screws to achieve stability and promote fusion
  • Posterior rods – Effective in stabilizing multiple fractures or unstable fractures
  • Z-plate anterior thoracolumbar plating system – Has been used for the treatment of burst fractures
  • Cage

 

See Treatment for more detail.

 

Dr Jimenez White Coat

While automobile accidents, slip-and-fall accidents, and sports injuries can cause spinal injuries, osteoporosis has been described as the leading cause of non-traumatic vertebral fracture. Vertebral fractures can generally be overlooked due to non-specific presentation. Imaging diagnostics are essential in the case of trauma or injury to determine the presence of broken bones in the spine, among other health issues.

Dr. Alex Jimenez D.C., C.C.S.T.

 

Background

 

Vertebral fractures of the thoracic and lumbar spine are usually associated with major trauma and can cause spinal cord damage that results in neural deficits. Each vertebral region has unique anatomical and functional features that result in specific injuries. See Figure 1 above.

 

This article reviews the mechanisms and management of individual injuries in the thoracic and lumbar regions of the spine; information on cervical spine fractures is presented in Fracture, Cervical Spine.

 

For patient education resources, see the patient education article Vertebral Compression Fracture.

 

Epidemiology

 

Approximately 11,000 new spinal cord injuries occur each year, and approximately 250,000 people in the United States have a spinal cord injury. Approximately half the injuries occur in the thoracic, lumbar, and sacral areas; the other half occur in the cervical spine. The average age at injury is 32 years, and 55% of those injured are aged 16-30 years. Approximately 80% of patients in the US national database are male.

 

In a retrospective analysis of patients 55 years or older who had traumatic fracture to the lumbar spine, age 70 years or older was an independent predictor of mortality, whereas instrumented surgery and vertebroplasty or kyphoplasty were associated with decreased odds of death. [1]

 

Vehicular accidents account for approximately one third of reported cases, and approximately 25% of cases are due to violence. Other injuries are typically the result of falls or recreational sporting activities. The incidence of injuries due to violence has been increasing, while the incidence of injuries due to vehicular accidents has been declining.

 

The cost of a spinal cord injury that causes paraplegia is approximately $200,000 for the first year and $21,000 annually thereafter. The average lifetime cost of treating a patient with paraplegia is $730,000 for those injured at age 25 years and approximately $500,000 for those injured at age 50 years. The life expectancy for subjects with spinal cord injuries is shortened by 15-20 years compared with uninjured control subjects. The major causes of death are pneumonia, pulmonary embolism, and sepsis.

 

Etiology

 

Certain risk factors predispose the thoracic spinal cord to injury. The thoracic cord is the longest component of the spinal cord (12 segments), which results in an increased probability of injury compared to other spinal areas. The spinal canal and vertebral bodies are proportionately smaller than those of the lumbar region. Finally, the vascular supply is more tentative, with few collateral vessels, small anterior spinal arteries, and small radicular arteries. All of these factors make the thoracic cord more vulnerable to injury.

 

By comparison, the lumbar cord has a better vascular supply, including the large radicular vessel (usually at L2) known as the artery of Adamkiewicz. The lumbosacral enlargement is rather compact (5 lumbar spinal segments) and terminates in the conus medullaris. With a proportionately more generous spinal canal, the lumbar cord is less susceptible to direct traumatic injury or vascular insult.

 

Pathophysiology

 

Fractures of the thoracolumbar spine can be classified into 4 groups based on the mechanism of injury. The mechanism of injury is used interchangeably with the name of the fracture. These major fractures are presented in escalating order of severity.

 

Flexion-Compression Mechanism (Wedge or Compression Fracture)

 

This mechanism usually results in an anterior wedge compression fracture. As the name implies, the anterior column is compressed, with varying degrees of middle and posterior column insult. See Figure 1 above.

 

Ferguson and Allen have proposed a classification scheme that characterizes 3 distinct patterns of injury, as follows:

 

  • The first pattern involves anterior column failure while the middle and posterior columns remain intact. Imaging studies demonstrate wedging of the anterior component of the vertebral bodies. Loss of anterior vertebral body height is usually less than 50%. This is a stable fracture.
  • The second pattern involves both anterior column failure and posterior column ligamentous failure. Imaging studies demonstrate anterior wedging and may indicate increased interspinous distance. Anterior wedging can produce a loss of vertebral body height greater than 50%. This has an increased possibility of being an unstable injury.
  • The third pattern involves failure of all 3 columns. Imaging studies demonstrate not only anterior wedging, but also varying degrees of posterior vertebral body disruption. This is an unstable fracture. Additionally, the possibility exists for cord, nerve root, or vascular injury from free-floating fracture fragments dislodged in the spinal canal.

 

Axial-Compression Mechanism

 

This mechanism results in an injury called a burst fracture, and the pattern involves failure of both the anterior and middle columns. Both columns are compressed, and the result is loss of height of the vertebral body. Five subtypes are described, and each is dependent on concomitant, namely rotation, extension, and flexion. The 5 subtypes are (1) fracture of both endplates, (2) fracture of the superior endplate (most common), (3) fracture of the inferior endplate, (4) burst rotation fracture, and (5) burst lateral flexion fracture. [2]

 

McAfee classified burst fractures based on the constitution of the posterior column (stable or unstable). [3] In stable burst fractures, the posterior column is intact; in unstable burst fractures, the posterior column has sustained significant insult. Imaging studies of both stable and unstable burst fractures demonstrate loss of vertebral body height. Additionally, unstable fractures may have posterior element displacement and/or vertebral body or facet dislocation or subluxation. As with a severe wedge fracture, the possibility exists for a cord, nerve root, or vascular injury from posterior displacement of fracture fragments into the canal. Denis showed that the frequency rate of neurologic sequelae could be as high as 50%. [4] Current recommendations call for more detailed imaging studies to identify the possibility of canal impingement, which requires decompressive surgery.

 

Flexion-Distraction Mechanism

 

This mechanism results in an injury called a Chance (or seatbelt) fracture. This pattern involves failure of the posterior column with injury to ligamentous components, bony components, or both. The pathophysiology of this injury pattern is dependent on the axis of flexion. Several subtypes exist, and each is dependent on the axis of flexion and on the number and degree of column failure.

 

The classic Chance fracture has its axis of flexion anterior to the anterior longitudinal ligament; this results in a horizontal fracture through the posterior and middle column bony elements along with disruption of the supraspinous ligament. This is considered a stable fracture. Imaging studies show an increase in the interspinous distance and possible horizontal fracture lines through the pedicles, transverse processes, and pars interarticularis.

 

The flexion-distraction subtype has its axis of flexion posterior to the anterior longitudinal ligament. In addition to the previously mentioned radiographic findings, this type of injury also has an anterior wedge fracture. Because all 3 columns are involved, this is considered an unstable injury.

 

If the pars interarticularis is disrupted in either type of fracture, then the instability of the injury is increased, which may be radiographically demonstrated by significant subluxation. Neurologic sequelae, if they occur, appear to be related to the degree of subluxation.

 

Rotational Fracture-Dislocation Mechanism

 

The precise mechanism of this fracture is a combination of lateral flexion and rotation with or without a component of posterior-anteriorly directed force. The resultant injury pattern is failure of both the posterior and middle columns with varying degrees of anterior column insult. The rotational force is responsible for disruption of the posterior ligaments and articular facet. With sufficient rotational force, the upper vertebral body rotates and carries the superior portion of the lower vertebral body along with it. This causes the radiographic “slice” appearance sometimes seen with these types of injuries.

 

Denis subtyped fracture-dislocations into flexion-rotation, flexion-distraction, and shear injuries. [4] The flexion-rotation injury pattern results in failure of both the middle and posterior columns along with compression of the anterior column. Imaging studies may demonstrate vertebral body subluxation or dislocation, increased interspinous distance, and an anterior wedge fracture.

 

The flexion-distraction injury pattern represents failure of both the posterior and middle columns. The pars interarticularis is also disrupted. Imaging studies demonstrate an increased interspinous distance and fracture line(s) through the pedicles and transverse processes, with extension into the pars interarticularis and subsequent subluxation.

 

The shear (sagittal slice) injury pattern results in a 3-column failure. The combined rotational and posterior-to-anterior force vectors result in vertebral body rotation and annexation of the superior portion of the adjacent and more caudal vertebral body. Imaging studies demonstrate both the nature of the fracture and dislocation.

 

Each of these fractures is considered unstable. Neurologic sequelae are common.

 

Minor Fractures

 

Minor fractures include fractures of the transverse processes of the vertebrae, spinous processes, and pars interarticularis. Minor fractures do not usually result in associated neurologic compromise and are considered mechanically stable. However, because of the large forces required to cause these fractures, associated abdominal injuries may occur. In this context, the index of suspicion for associated injuries should increase and the physician should examine the patient for associated injuries.

 

Fractures Secondary to Osteoporosis

 

Osteoporosis causes fractures of the vertebrae and fractures of other bones such as the proximal humerus, distal forearm, proximal femur (hip), and pelvis (see Osteoporosis). Women are at greatest risk. The prevalence rate for these fractures increases steadily with age, ranging from 20% for 50-year-old women to 65% for older women. Most vertebral fractures are not associated with severe trauma. Many patients remain undiagnosed and present with symptoms such as back pain and increased kyphosis. The presence of a significant vertebral fracture is associated with increased mortality. Patients with these fractures have a relative risk of death that is 9 times greater than healthy counterparts. Approximately 20% of women with vertebral fractures have another fracture of a different bone within a year. [5]

 

Efforts are currently underway to reliably predict who is at risk for these fractures. Bone densitometry is used to assess relative bone strength and fracture risk. Risk factors for osteoporosis fractures include postmenopausal age, white race, and low bone density prior to menopause. Predicting which patients are at risk using risk factor analysis or bone imaging allows for the administration of specific treatments that promote bone deposition or delay resorption. Prevention of fractures is critical and should include exogenous calcium and an appropriate exercise regimen. Many hormonal therapies are also available, including raloxifene (Evista) and calcitonin (Miacalcin).

 

In 2008, the American College of Physicians developed a guideline for the pharmacologic treatment of low bone density or osteoporosis to prevent fractures. [6]

 

Pathologic Fractures

 

Pathologic fractures are the result of metastatic disease of primary cancers affecting the lung, prostate, and breast. Kaposi sarcoma can also result in vertebral body fractures. Occasionally, cancer affects the spine itself or is the result of meningeal neoplasia. Pathologic fractures tend to affect the vertebral body at both the thoracic and lumbar levels. They cause kyphotic deformity and may result in compression of the cord or cauda equina. If the patient has neurologic deficits, consider emergent radiotherapy, steroid use, and surgical decompression and stabilization. See the image below.

 

Figure 2: Fluoroscopic view of a kyphoplasty procedure.

Fractures Secondary to Infection

 

Pott disease (tuberculosis spondylitis) results from the hematogenous spread of microbacteria to the spine (see Pott Disease (Tuberculous Spondylitis)). Other bacteria can be spread to the spine and cause osteomyelitis. As bacteria proliferate, vertebral damage occurs and primarily affects the vertebral bodies. As in the case of pathologic fractures, associated fractures and an increase in kyphotic deformity may be present. Treatment includes antibiotics. The presence of a neurologic deficit may prompt instrumentation and stabilization of the spine.

 

Patients with Special Considerations

 

Elderly patients usually have significant osteoporotic disease and degenerative bone disease. These patients may experience a significant fracture even from a relatively minor, low-energy mechanism of injury. Compression fractures in both the thoracic and lumbar regions are common. These patients also may have pathological fractures. Central cord syndrome is common for patients who develop neurologic deficits. For elderly patients with stable fractures, early mobilization is important to decrease morbidity and mortality.

 

Special consideration should be given to pediatric patients with significant trauma to the thoracic or lumbar spine. Because the skeleton is immature and the ligaments are elastic, significant force must be generated to cause a fracture, especially those associated with neurologic deficits. One entity that occurs in pediatric patients is spinal cord injury without radiographic abnormality. If injury and neurologic deficits are strongly considered, perform imaging studies such as computed tomography (CT) or magnetic resonance imaging (MRI) scans. If the mechanism or circumstances are not consistent with the injury, consider abuse or neglect. Pediatric patients should be examined for additional injuries and bruises.

 

Patients in altered mental states pose a diagnostic challenge. In the absence of a reliable history and review of systems, findings from the physical examination and radiographic studies can help the physician assess vertebral injuries. In altered or intubated patients with other significant fractures such as pelvic fractures, multiple rib fractures, or scapular fractures, the physician should have a heightened index of suspicion for vertebral fractures. Once these patients have been stabilized, abdominal and chest radiographs may be supplemented with lateral views to reduce the likelihood of a missed vertebral fracture.

 

Dr Jimenez White Coat

Diagnosis is essential in order for the healthcare professional to determine the best treatment approach for the patient’s vertebral fracture. Spinal injuries which go undiagnosed and are therefore left untreated can have an increased chance of fracture in another vertebra and it may subsequently heighten the risk of hip fracture. Early detection of vertebral fractures can further improve quality of life.

Dr. Alex Jimenez D.C., C.C.S.T.

 

Presentation

 

Patient History

 

Details of the injury and mechanism of trauma are helpful in understanding the forces involved and the possible injury. Back pain in the setting of a major accident or a fall from a significant height (>10-15 ft) may increase the index of suspicion. The threshold for obtaining radiographic studies under these circumstances is lowered, and attention to spinal precautions and logrolling is increased. The concern is to not have iatrogenically induced deterioration of neurologic function or worsening of symptoms.

 

A major accident may involve significant vehicular damage, a head-on collision at high speed, vehicular rollover, or death at the scene. Accidents in which extrication, damage to the steering wheel or windshield, or passenger space intrusion occurred may produce spine injuries. Vehicular accidents involving motorcycles, bicycles, or pedestrians have a higher propensity for spine injuries. Questions about seatbelt use and airbag deployment are helpful in developing a high index of suspicion for vertebral injuries.

 

Symptoms include pain or the development of neural deficits such as weakness, numbness, and tingling. Even transient symptoms should be investigated. The morbidity of a spinal cord injury is so significant that even minor symptoms should be investigated.

 

Physical Examination

 

Patients with vertebral fractures secondary to trauma should be evaluated and treated in a systematic fashion as outlined by advanced trauma life-support protocols. At first, attention should be directed toward the patient’s airway, breathing, and circulation (ABC). Clinicians should adhere to cervical spine precautions. The patient can be logrolled off the spinal cord while radiographs are performed.

 

A neurologic examination should be performed as part of the expanded primary survey or secondary survey. The neurologic examination should include the cranial nerves, motor and sensory components, coordination, and reflexes. The physician should examine the pelvic areas, perineal areas, and extremities. A rectal examination is indicated, especially if the patient has weakness in the extremities. An injury to the thoracic or lumbosacral cord would likely result in neural deficits at the trunk, genital area, and lower extremities. Specific syndromes, such as Brown-Séquard syndrome and anterior cord syndrome, may affect a major part of the spinal cord (see Brown-Séquard Syndrome).

 

Associated Injuries

 

Patients with vertebral fractures typically experience significant force as the cause of injury. As such, they are likely to have associated injuries. Almost any organ can be affected, and the secondary survey should address these issues.

 

An altered patient may have an intercranial injury. Chest deformity, decreased breath sounds, low oximetry readings, or poor oxygen saturation are commonly associated with pulmonary injury. Consider cardiac injury if the patient has muffled heart tones, rhythm disturbances, or hemodynamic instability. Blunt or penetrating abdominal injury may be associated with spinal fractures; in these situations, conducting a neurologic examination and instituting spinal precautions is important until a spinal cord injury has been excluded. Orthopedic injuries require a significant force to fracture the bone and thus may be associated with vertebral fractures.

 

A correlation exists between fracture of the transverse process of L1 and same-side renal injury. Patients with calcareous injuries have approximately a 10% chance of associated lumbar vertebral injury. Patients involved in a motor vehicle accident while wearing a lap belt who sustained lumbar fractures are at significant risk for concomitant intra-abdominal injuries (eg, diaphragmatic, hollow viscus, or solid organ injuries).

 

Hemodynamic Instability

 

In the setting of a spinal cord injury with a neurologic deficit, close attention should be paid to the hemodynamic status of the patient. In the case of neurogenic shock, hypotension is associated with relative bradycardia as a result of autonomic hyporeflexia. The thoracic sympathetic chain is disrupted, which removes sympathetic tone and leaves unopposed vagal tone. This should be distinguished from hemorrhagic shock, in which a patient is tachycardic, hypotensive, and similarly unresponsive and flaccid. Thus, attention to the heart rate and a mechanism for exsanguination may help differentiate between these forms of shock.

 

Patients who are on beta-blockers may remain bradycardic despite being in hemorrhagic shock. A bedside ultrasound evaluation is a noninvasive screen for free fluid in the peritoneum. The more invasive peritoneal tap and lavage is the classic method of assessment for free fluid. Both types of shock require aggressive fluid and hemodynamic resuscitation.

 

Spinal shock refers to the temporary loss of spinal reflex activity that occurs below a total or near-total spinal cord injury. It initially results in hyporeflexia and flaccid paralysis. With time, the descending inhibitory influence is removed and hyperreflexive arches—even spasticity may occur. For patients with spinal shock, pressures may be used after obtaining the proper fluid balance.

 

Indications

 

Patients with vertebral fractures who are neurologically intact should be assessed for the need for emergent decompressive surgery. Once the patient is hemodynamically stable and life-threatening injuries have been controlled, attention should be directed to neurologic injuries. The second consideration is obtaining a mechanically stable weight-bearing construct that allows for mechanical stability. This facilitates future ambulation and rehabilitation.

 

Patients with incomplete neurologic injuries need to be assessed for emergent decompressive surgery. For these patients, surgery may help maximize salvage of neurologic function. The surgeon can combine decompressive and stabilization procedures of the spine.

 

A study by Baldwin et al assessed conservative treatment of thoracolumbar spinal fractures. [7] Given the shortage of neurosurgeons at many trauma centers in the United States, Baldwin et al designed a treatment protocol that used radiologic criteria to screen for potentially stable fractures and to guide treatment without spinal consultation. Using both prospective and retrospective evaluation, the study determined that use of a treatment protocol for stable thoracolumbar fractures appeared safe and could help conserve resources.

 

Surgery for patients with complete neurologic deficit and paraplegia for more than 2-3 days is controversial. Decompressive procedures have little merit. Spinal stabilization is helpful in achieving mechanical stability and allows for more effective rehabilitation.

 

Relevant Anatomy

 

Basic Vertebral Anatomy

 

The vertebral column has 2 major roles: (1) a structural, weight-bearing role as the centerpiece of the axial skeleton and (2) a role as the conduit for the spinal cord. The vertebral column has 31 vertebrae. The typical vertebral body consists of a ventral segment, the body, and a dorsal part, the vertebral arch. The vertebral arch consists of a pair of pedicles and laminae and encloses the vertebral foramen. The intervertebral disks form the fibrocartilaginous articulation of the vertebral bodies. The vertebral bodies are stabilized anteriorly by the anterior longitudinal ligament and posteriorly by the posterior longitudinal ligament. The spinal canal is formed by the longitudinal apposition of the vertebral bodies, arches, disks, and ligaments. The spinal cord, meninges, and nerve roots course in the spinal canal.

 

Thoracic Region

 

The thoracic region of the spine has a relatively high stability because of the stabilizing effects of the ribs and the rib cage. This region extends from the first thoracic vertebra (T1) down to the level of tenth thoracic vertebra (T10). Additional stabilizing effects are provided by the almost-vertical orientation of the articulating processes and the shinglelike oblique arrangement of the spinal processes. A significant force is required to cause a fracture or dislocation in this region. The low thoracic region has false ribs at levels T11 and T12; thus, this region of the spine is less stable. This region can be considered the transition zone between the thoracic and lumbar regions because it resembles the lumbar region in stability and mechanisms of injury.

 

Lumbar and Low Thoracic Regions

 

The lumbar and low thoracic vertebrae are larger and wider, which is an adaptation required for their weight-bearing role as supports for the upper body and axial skeleton. In contrast to the mid and upper thoracic regions, the lumbar and low thoracic areas lack the stabilizing effect of the rib cage. The spinous processes are more horizontal, which provides increased mobility but less mechanical stability. The lumbar and low thoracic areas have greater mobility, which allows for flexion, extension, and rotation of the upper skeleton in relation to the pelvis and lower extremities.

 

As a result of increased mobility, the low thoracic and lumbar regions are more susceptible to injury. The transition area between the low-mobility thoracic region (T1 through T10) and the highly mobile lumbar area (approximately T11 through L2) is susceptible to injury. In adults, the spinal cord ends at the lumbosacral enlargement and conus medullaris at approximately the vertebral level of L1. Consequently, injuries to the low thoracic spine and L1 can result in significant paralysis and paraplegia of the lower body because they injure the lumbosacral enlargement of the spinal cord. In contrast, the mid and low lumbar regions are more forgiving because the individual nerve roots of the cauda equina course in this region and they are smaller, more flexible, and more resistant to injury compared with the lumbosacral enlargement.

 

Three-Column Model of the Spine

 

In 1983, Denis proposed the 3-column model of the spine, which described both the functional units that contribute to the stability of the spine and the destabilizing effect of injuries to the various columns. Denis defines the anterior column as containing the anterior longitudinal ligament, the anterior half of the vertebral body, and the related portion of the intervertebral disk and its annulus fibrosus. The middle column contains the posterior longitudinal ligament, the posterior half of the vertebral body, and the intervertebral disk and its annulus. The posterior column contains the bony elements of the posterior neural arch and the ligamental elements, which include the ligamentum flavum, the interspinous ligaments, and the supraspinous ligaments. The joint capsule of the intervertebral articulations is also part of the posterior column. Disruption of 2 or more columns results in an unstable configuration.

 

Contraindications

 

Hemodynamically unstable patients should not be taken for operative treatment of vertebral fractures until their condition has stabilized. Patients with advanced age and those with significant comorbid conditions (eg, significant coronary artery disease, peripheral vascular disease, advanced pulmonary disease) are poor candidates for any surgery, including vertebral fracture stabilization surgery. Patients with stable fractures can be observed for the development of deformity and then assessed for surgical treatment.

 

In conclusion, a vertebral fracture can differ tremendously from a broken arm or leg. Because a fracture in the vertebra can cause bone fragments to damage the spinal chord or nerve roots, it’s essential to receive a proper diagnosis of the extent of the spinal injury. Imaging diagnostics can help doctors determine the health issues. The scope of our information is limited to chiropractic, spinal injuries, and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .

 

Curated by Dr. Alex Jimenez

 

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Additional Topics: Acute Back Pain

 

Back pain is one of the most prevalent causes of disability and missed days at work worldwide. Back pain attributes to the second most common reason for doctor office visits, outnumbered only by upper-respiratory infections. Approximately 80 percent of the population will experience back pain at least once throughout their life. The spine is a complex structure made up of bones, joints, ligaments, and muscles, among other soft tissues. Because of this, injuries and/or aggravated conditions, such as herniated discs, can eventually lead to symptoms of back pain. Sports injuries or automobile accident injuries are often the most frequent cause of back pain, however, sometimes the simplest of movements can have painful results. Fortunately, alternative treatment options, such as chiropractic care, can help ease back pain through the use of spinal adjustments and manual manipulations, ultimately improving pain relief.

 

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EXTRA EXTRA | IMPORTANT TOPIC: Chiropractic Neck Pain Treatment

Spine Trauma Imaging Diagnostics Evaluation

Spine Trauma Imaging Diagnostics Evaluation

Imaging diagnostics are an essential element in the evaluation of spine trauma. Over the last few decades, the rapid evolution of imaging technology has tremendously changed the assessment and treatment of spinal injuries. Imaging diagnostics utilizing CT and MRI, among others, are helpful in the acute and the chronic settings. Spinal cord and soft-tissue injuries are best evaluated by magnetic resonance imaging, or MRI, whereas computed tomography scanning, or CT scans, best evaluate spinal trauma or spine fracture. The purpose of the article below is to demonstrate the significance of imaging diagnostics in spine trauma.

 

Cervical Spine Fracture Evaluation

 

Practice Essentials

 

Approximately 5-10% of unconscious patients who present to the ED as the result of a motor vehicle accident or fall have a major injury to the cervical spine. Most cervical spine fractures occur predominantly at two levels: one-third of injuries occur at the level of C2, and one-half of injuries occur at the level of C6 or C7. Most fatal cervical spine injuries occur in upper cervical levels, either at craniocervical junction C1 or C2. [1, 2, 3, 4, 5, 6, 7, 8]

 

Anatomy

 

The normal anatomy of the cervical spine consists of 7 cervical vertebrae separated by intervertebral disks and joined by a complex network of ligaments. These ligaments keep individual bony elements behaving as a single unit. [7]

 

View the cervical spine as three distinct columns: anterior, middle, and posterior. The anterior column is composed of the anterior longitudinal ligament and the anterior two-thirds of the vertebral bodies, the annulus fibrosus and the intervertebral disks. The middle column is composed of the posterior longitudinal ligament and the posterior one-third of the vertebral bodies, the annulus, and intervertebral discs. The posterior column contains all of the bony elements formed by the pedicles, transverse processes, articulating facets, laminae, and spinous processes.

 

The anterior and posterior longitudinal ligaments maintain the structural integrity of the anterior and middle columns. The posterior column is held in alignment by a complex ligamentous system, including the nuchal ligament complex, capsular ligaments, and the ligamenta flava.

 

If one column is disrupted, other columns may provide sufficient stability to prevent spinal cord injury. If two columns are disrupted, the spine may move as two separate units, increasing the likelihood of spinal cord injury.

 

The atlas (C1) and the axis (C2) differ markedly from other cervical vertebrae. The atlas has no vertebral body; however, it is composed of a thick anterior arch with two prominent lateral masses and a thin posterior arch. The axis contains the odontoid process that represents fused remnants of the atlas body. The odontoid process is held in tight approximation to the posterior aspect of the anterior arch of C1 by the transverse ligament, which stabilizes the atlantoaxial joint. [9, 7]

 

Apical, alar and transverse ligaments provide further stabilization by allowing spinal column rotation; this prevents posterior displacement of the dens in relation to the atlas.

 

In pediatric patients, the spine is more flexible, and therefore, neural damage occurs much earlier than musculoskeletal injury in young patients. Because of this high flexibility, fatal consequences can occur with sometimes even minimal structural damage. Compared to adults, children have a different fulcrum because of a relatively large head, the vertebrae are not completely ossified, and the ligaments are firmly attached to articular bone surfaces that are more horizontal, making the pathophysiology of injury in children different from that in adults. [6, 10]

 
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The neck consists of seven bones, or the cervical vertebrae, which support the head and connect it the body. A cervical fracture is commonly referred to as a broken neck. Cervical spine fractures often occur due to trauma or injury, such as from automobile accidents or slip-and-fall accidents. Imaging diagnostics have advanced to be able to help healthcare professionals diagnose cervical spine health issues.

Dr. Alex Jimenez D.C., C.C.S.T.

 

Evaluation of injury

 

When a cervical spine injury is suspected, neck movement should be minimized during transport to the treating facility. Ideally, the patients should be transported on a backboard with a semirigid collar, with the neck stabilized on the sides of the head with sandbags or foam blocks taped from side to side (of the board), across the forehead.

 

If spinal malalignment is identified, place the patient in skeletal traction with tongs as soon as possible (with very few exceptions), even if no evidence of neurologic deficit exists. The specific injury involved and capabilities of the consulting staff guide further management.

 

Place tongs one finger width above the earlobes in alignment with the external auditory canal. The consultant applies the tongs for traction under close neurologic and radiograph surveillance. Care must be taken while managing the airway in patients with potential cervical spine injuries. Video-assisted intubation should be considered to limit cervical spine motion during the process of securing the airway. [11, 12, 13, 1]

 

Cervical spine injuries are best classified according to several mechanisms of injury. These include flexion, flexion-rotation, extension, extension-rotation, vertical compression, lateral flexion, and imprecisely understood mechanisms that may result in odontoid fractures and atlanto-occipital dislocation. [1, 14, 4, 5, 15, 7, 16]

 

Radiographic evaluation is indicated in the following:
[2, 2, 17, 18, 15, 19, 20]

 

  • Patients who exhibit neurologic deficits consistent with a cord lesion
  • Patients with an altered sensorium from head injury or intoxication
  • Patients who complain about neck pain or tenderness
  • Patients who do not complain about neck pain or tenderness but have significant distracting injuries

 

A standard trauma series is composed of 5 views: cross-table lateral, swimmer’s, oblique, odontoid, and anteroposterior. Approximately 85-90% of cervical spine injuries are evident in the lateral view, making it the most useful view from a clinical standpoint.

 

The advent of readily available multidetector computed tomography has supplanted the use of plain radiography at many centers. Recent literature supports CT as more sensitive with lower rates of missed primary and secondary injury. [14]

 

Thoracic Spinal Trauma Imaging

 

Computed Tomography

 

Findings

 

Thin-section axial CT performed by using a bone algorithm is the single most sensitive means by which to diagnose fractures of the thoracic spine. Routine helical CT scans of the thoracic spine are valuable because multisection CT scanners can generate high-resolution spinal images, even during a primary multisystemic trauma evaluation. [21, 22, 28, 29]

 

The CT images below display various thoracic spinal traumatic injuries.

Figure 1: Lateral 3-dimensional maximum intensity projection CT scan of multiple upper thoracic and lower cervical spinous process fractures. The force necessary to fracture the spinous processes of the upper thoracic spine may also involve the lower cervical spine.

Figure 2: Three-dimensional CT scan of complex mid-face fractures including a Le Fort I injury in a patient who had fractures of the upper thoracic and lower cervical spinous processes. Sudden deceleration of the face and skull resulted in severe stress forces on the spinous processes.

Figure 3: Axial CT scan of a T12 compression fracture demonstrates a fracture line through the anterior body of the T12 (white arrow), posterior displacement of the T12 vertebral endplate (black arrow) into the spinal canal, and a fracture of the left transverse spinous process.

Figure 4: Axial and sagittal CT images of an acute lower thoracic spine compression fracture. Note the paraspinal hematoma (white arrows) and the slight narrowing of the spinal canal at the level of the compression fracture (double yellow arrows).

Figure 5: Three-dimensional CT scan of the thoracic spine demonstrates a compression fracture.

Figure 6: Sagittal CT scan of the thoracic and lumbar spine demonstrates a complete distraction fracture at the L1-2 interspace (arrow).

Figure 7: Axial CT image of an unstable fracture of the thoracic spine. Note the association of compression of the vertebral body with laminar and pedicle fractures. Injury to the anterior, middle and posterior columns results in an unstable fracture.

Figure 8: Coronal multiplanar reformatted CT images of an unstable thoracic spinal fracture. The association of both anterior compression and lateral subluxation (arrows) indicates instability.

Figure 9: Volume maximum intensity projection CT image of the entire thoracic spine demonstrates spinous process fractures of the C7 through T7 vertebra. Although spinous process fractures of the T1 may occur in a manner similar to a clay shoveler’s fracture of the C6 or C7, middle and lower thoracic spinous process fractures most likely occur due to a combination of forward flexion and axial rotation. Note the lack of findings of compression vertebral body fractures.

Figure 10: Three-dimensional surface CT image of the cervical spine. Note the spinous process fractures of the C6, C7, and T1. CT examination of both the cervical and the thoracic spine was obtained as a single study using a multisection CT scanner. All images were obtained by using a 3-mm reconstruction with 1.5-mm collimation. Scanning times were 0.5 seconds per rotation. These 3-dimensional images were reconstructed by using an independent imaging workstation. In complex cases, reconstructed images are very useful in consultation with treating physicians.

Figure 11: Scout view image from a spiral CT scan shows a complete subluxation fracture (curved blue lines) of the lower thoracic spine. Such an injury combines lateral displacement with rotational injury (arrow).

Figure 12: Fracture dislocation of the lower thoracic spine. Axial CT image demonstrates the large distance that the lower thoracic spine has been displaced.

Figure 13: Axial CT myelogram in a patient with a gunshot wound to the thoracic spine. While a fracture is obvious, the injury also resulted in a dural tear with a freely leaking cerebrospinal fluid space (white arrow). The midline fracture of the vertebral body is noted in the lower image (black arrow).

Figure 14: Axial CT image demonstrates a complex fracture of the T12 with rotation subluxation. Air was introduced into the epidural space during the injury.

Figure 15: Sagittal multi-planar CT image of a burst fracture following fixation. The image has been cut in the sagittal plane. Surgical repair of unstable thoracic spine fractures, such as this burst fracture, usually involves placement of an interposition graft (double black arrow) together with a lateral plate held in position by screws placed into the vertebral body above and below the injury. A residual fragment of the burst fracture is seen anteriorly (white arrow). The double white arrow illustrates the restored spinal canal.

Figure 16: Shaded-surface 3-dimensional CT image of a burst fracture following fixation. The image has been cut in the sagittal plane. Surgical repair of unstable thoracic spine fractures, such as this burst fracture, usually involves placement of an interposition graft (double black arrow) together with a lateral plate held in position by screws placed into the vertebral body above and below the injury. A residual fragment of the burst fracture is seen anteriorly (white arrow).

Figure 17: Shaded-surface 3-dimensional CT image of a gunshot wound to the thoracic spine. Although the bullet passed into the interspace, causing a fracture of the vertebral body, the bullet stopped within the spinal canal. Note the outline drawn around the bullet (arrow).

Figure 18: Shaded-surface 3-dimensional CT scan of a gunshot wound to the thoracic spine. In other cases, the bullet may enter the spinal canal superior to the final position in the canal. The passage of the bullet within the spinal canal (yellow arrow) destroys the spinal cord and also may result in a fracture of the vertebral body. Note that the bullet has been darkened (blue arrow).

Figure 19: Axial CT image in a man with known pulmonary tuberculosis and back pain. Note the left-sided paraspinal abscess (arrow).

Figure 20: Sagittal shaded-surface 3-dimensional reconstruction CT scan of the lower thoracic spine. The spinal image has been cut in the midsagittal plane to demonstrate posterior displacement of the thoracic spinal vertebral body (arrow) and downward displacement of the superior endplate. Note the general wedge shape of the vertebral body.

Because of its superior contrast definition and the absence of superimposed structures, good-quality CT imaging depicts more thoracic spinal injuries than do conventional radiographic studies. However, the percentage of clinically important fractures that are seen on CT scans but not on radiographs is lower with thoracic than with cervical spinal fractures. Most of the fractures missed on radiographs were spinous process fractures, transverse processes fractures, and fractures in large patients. Because axial CT is performed with patients in a neutral position, bony distraction of the fracture fragments and subluxations of the spinal articulations may not be as significant on CT images as on they are on acute trauma-series radiographs. [22, 25, 28, 29, 30, 31, 32]

 

The level of a burst fracture and the percentage of spinal canal stenosis have been correlated with associated neurologic deficits. A significant correlation exists between neurologic deficit and the percentage of spinal canal stenosis. The higher the level of injury, the greater the probability of neurologic deficit. This association may be related to the smaller canal diameter in the upper thoracic spine. The severity of neurologic deficit cannot be predicted.

 

In patients with Chance-type fractures, CT scans often show a burst-type fracture with posterior cortex buckling or retropulsion, and serial transaxial CT images often show a gradual loss of definition of the pedicles. [23]

 

Dr Jimenez White Coat

The thoracic spine, located between the cervical and lumbar vertebrae, consists of 12 vertebrae levels. Thoracic spinal trauma, including spinal cord injuries along the middle of the spine, can generally be severe, however, with early treatment, long-term prognosis is good. Therefore, imaging diagnostics for thoracic spinal trauma are essential. Many healthcare professionals can provide patients with these services.

Dr. Alex Jimenez D.C., C.C.S.T.

 

Degree of Confidence

 

The confidence level for the diagnosis of a thoracic spinal fracture with 2-mm axial sections (possible with a multisection CT unit) is greater than 98% and reportedly 99%.

 

Because axial CT is performed with the patient in a neutral position, a bony distraction of the fracture fragments and subluxations of the spinal articulations may not be as significant on CT images as on acute trauma-series radiographs.

 

False Positives/Negatives

 

False-positive results may occur in patients with a Schmorl node, which is a chronic internal herniation of the vertebral disk into the thoracic vertebral body endplate and failure of the fusion of the anterior vertebral endplate epiphysis, resulting in a limbus vertebra. False-negative CT studies may occur in chronic stress injuries and severe generalized osteoporotic endplate fractures.

 

It has been reported that among trauma patients who had a chest and/or abdominal CT, fractures of the thoracic spine are frequently underreported. Sagittal reformats of the spine obtained from thin sections, and morphometric analysis using electronic calipers help to identify fractures that might otherwise not be identified. [25]

 

In conclusion, imaging diagnostics of spinal trauma or spine fracture are essential towards the assessment and treatment of patients. Magnetic resonance imaging, or MRI, is helpful in the evaluation of spinal cord and soft-tissue injuries whereas computed tomography scanning, or CT scans, is helpful in the evaluation of spinal trauma or spine fracture. The understanding of imaging technology has tremendously enhanced advances in treatment.  The scope of our information is limited to chiropractic, spinal injuries, and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .

 

Curated by Dr. Alex Jimenez

 

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Additional Topics: Acute Back Pain

 

Back pain is one of the most prevalent causes of disability and missed days at work worldwide. Back pain attributes to the second most common reason for doctor office visits, outnumbered only by upper-respiratory infections. Approximately 80 percent of the population will experience back pain at least once throughout their life. The spine is a complex structure made up of bones, joints, ligaments, and muscles, among other soft tissues. Because of this, injuries and/or aggravated conditions, such as herniated discs, can eventually lead to symptoms of back pain. Sports injuries or automobile accident injuries are often the most frequent cause of back pain, however, sometimes the simplest of movements can have painful results. Fortunately, alternative treatment options, such as chiropractic care, can help ease back pain through the use of spinal adjustments and manual manipulations, ultimately improving pain relief.

 

 
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EXTRA EXTRA | IMPORTANT TOPIC: Chiropractic Neck Pain Treatment

Imaging Diagnostics of Abnormalities of the Spine

Imaging Diagnostics of Abnormalities of the Spine

Imaging diagnostics of the spine consist from radiographies to computed tomography scanning, or CT scans, in which CT is utilized in conjunction with myelography and most recently with magnetic resonance imaging, or MRI. These imaging diagnostics are being used to determine the presence of abnormalities of the spine, scoliosis, spondylolysis and spondylolisthesis. The following article describes various imaging modalities and their application in the evaluation of common spinal disorders described.

 

Achondroplasia

 

  • Achondroplasia is the most common cause of rhizomelic (root/proximal) short-limb dwarfism. Patients are of normal intelligence. 
  • It shows multiple distinct radiographic abnormalities affecting long bones, pelvis, skull, and hands.
  • Vertebral column changes may present with significant clinical and neurological abnormalities. 
  • Achondroplasia is an autosomal dominant disorder with about 80% of cases from a random new mutation. Advanced paternal age is often linked. Achondroplasia results from a mutation in the fibroblast growth factor gene (FGFR3) which causes abnormal cartilage formation.
  • All bones formed by endochondral ossification are affected.
  • Bones that form by intra-membranous ossification are not normal.
  • Thus, skull vault, iliac wings develop normally vs. the base of the skull, some facial bones, vertebral column, and most tubular bones are abnormal.

 

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  • Dx: is usually made at birth with many features becoming apparent during the first few years of life.
  • Radiography plays an important part of clinical diagnosis.
  • Typical features include: shortening and widening of tubular bones, metaphyseal flaring, Trident hand with short, broad metacarpals and proximal and middle phalanges. Longer Fibular, Tibial bowing, markedly short humeri often with dislocated Radial head and elbow flexion deformity.

 

 

  • Spine: characteristic narrowing of L1-L5 interpedicular distance on AP views. Lateral view shows shortening of pedicles and vertebral bodies, “bullet shaped vertebrae” can be a characteristic feature. Early degenerative changes and canal narrowing occur. The horizontal sacral inclination is an important feature.
  • Skull demonstrates frontal bossing, midface hypoplasia and markedly narrow foramen magnum.
  • Pelvis is broad and short with characteristic “champagne glass” pelvis appearance.
  • Femoral heads are hypoplastic, but hip arthrosis is normally not observed even in older patients likely due to reduced leverage and lightweight (50kg) of patients.

 

Management of Achondroplasia

 

  • Recombinant human growth hormone (GH) is currently being used to augment the height of patients with achondroplasia.
  • Most complications of Achondroplasia are related to the spine: vertebral canal stenosis, thoracolumbar kyphosis, narrowed foramen magnum and others.
  • Laminectomy extending to pedicles/lateral recess with foraminotomies and discectomies can be performed.
  • Cervical manipulations are contraindicated.

 

Dr Jimenez White Coat

Imaging diagnostics play a fundamental role in the diagnosis the of scoliosis, an abnormality of the spine which is believed to occur due to an underlying health issue, although most cases of scoliosis are idiopathic. More over, radiographies, CT scans, and MRI, among others, can help monitor the changes of the deformity of the spine associated with this spinal manifestation. Chiropractors can provide imaging diagnostics to patients with scoliosis before proceeding with treatment. 

Dr. Alex Jimenez D.C., C.C.S.T.

 

Scoliosis

 

  • Scoliosis is defined as the abnormal lateral curvature of the spine >10-degree when examined by Cobb’s method of mensuration.
  • Scoliosis can be described as postural and structural.
  • Postural scoliosis is not fixed and can be improved by lateral flexion to the side of the convexity.
  • Structural scoliosis has multiple causes ranging from:
    􏰀 Idiopathic (>80%)
    􏰀 Congenital (wedge or hemivertebra, blocked vertebra, Marfan syndrome, skeletal dysplasias)
    􏰀 Neuropathic (neurofibromatosis, neurological conditions like tethered cord, spinal dysraphism, etc.)
    􏰀 Scoliosis d/t Spinal neoplasms
    􏰀 Post-traumatic etc.
  • Idiopathic scoliosis is the most common type (>80%).
  • Idiopathic scoliosis can be of 3-types ( infantile, juvenile, adolescent).
  • Idiopathic adolescent scoliosis if patients >10y.o.
  • Infantile scoliosis if <3 y.o. M>F.
  • Juvenile scoliosis if >3 but <10-y.o.
  • Idiopathic Adolescent scoliosis is the most common with F:M 7:1 (adolescent girls are at particular risk).
  • Etiology: unknown thought to be the result of some disturbance of proprioceptive control of the spine and spinal musculature, other hypotheses exist.
  • Most seen in the thoracic region and most commonly convex to the right.
  • Dx: full spine radiography with gonadal and breast shielding (preferably PA views to protect breast tissue).

 

Rx: 3-Os: Observation, Orthosis, Operative intervention

 

• Curves that are 50-degrees or greater and rapidly progressing will require operative intervention to prevent severe deformity of the thorax & ribs leading to cardiopulmonary abnormalities.
   􏰀 If curvature is < 20-degree, no treatment is required (observation).
   􏰀 For curves that are >20-40-degrees bracing may be used (orthosis).

 

 

  • Milwaukee (metal) brace (left).
  • Boston brace polypropylene lined with polyethylene (right) often preferred because it can be worn under clothing.
  • Bracing wearing is required for 24-hours for the duration of the treatment.

 

 

  • Note Cobb’s method of mensuration to record spinal curvature. It has some limitations: 2D imaging, not able to estimate rotation, etc.
  • Cobb’s method is still a standard evaluation performed in Scoliosis studies.
  • Nash-Moe method: determines pedicle rotation in scoliosis.

 

 

  • Risser index is used to estimate spinal skeletal maturity.
  • Iliac growth apophysis appears at ASIS (F- 14, M-16) and progresses medially and expected to be closed in 2-3-years (Risser 5).
  • Scoliosis progression ends at Risser 4 in females & Risser 5 in males.
  • During radiographic evaluation of scoliosis, it is crucial to report if Risser growth apophysis remains open or closed.

 

Dr Jimenez White Coat

Spondylolysis and spondylolisthesis are health issues which can result in back pain. Spondylolysis is believed to be caused by repeated microtrauma leading to stress fractures in the pars interarticularis. Patients with bilateral pars defects can develop spondylolisthesis, where the degree of slippage of the adjacent vertebrae can progress gradually over time. Patients with suspected spondylolysis and spondylolisthesis may initially be evaluated with pain radiography. Chiropractic care can also help provide imaging diagnostics for these health issues.

Dr. Alex Jimenez D.C., C.C.S.T.

 

Spondylolysis & Spondylolisthesis

 

  • Spondylolysis defect in pars interarticularis or osseous bridge between superior and inferior articular processes.
  • Pathology stress fracture of the pars, believed to be after repeated microtrauma on extensions Men > Women, affects 5% of the general population especially in athletic adolescents.
  • Clinically postulated that adolescent back pain cases may be related to this process.
  • Typically spondylolysis remains asymptomatic.
  • Spondylolysis can be present with or w/o spondylolisthesis.
  • Spondylolysis is found in 90% at L5 with the remaining 10% in L4.
  • Can be uni or bilateral.
  • In 65% of cases, spondylolysis is associated with spondylolisthesis.
  • Radiographic Features: break in the Scotty dog collar around the neck on oblique lumbar views.
  • Radiography has low sensitivity compared to SPECT. SPECT is associated with ionizing radiation, and MRI is currently a preferred method of imaging diagnosis.
  • MRI can help to show reactive marrow edema next to pars defect or w/o defect so-called pending or potential to develop spondylolysis.

 

Types of Spondylolisthesis

 

  • Type 1 – Dysplastic, rare and found in congenital dysplastic malformation of the sacrum allowing anterior displacement of L5 on S1. Often no pars defect.
  • Type 2 – Isthmic, most common, often the result of a stress fracture.
  • Type 3 – Degenerative from the remodeling of articular processes.
  • Type 4 – Traumatic in an acute posterior arch fracture.
  • Type 5 – Pathologic due to bone disease locally or generalized.

 

 

Grading of spondylolisthesis is based on the Myereding Classification.
This classification refers to the overhanging part of the superior body in relation to anterior-posterior part of the inferior body.

 

  • Grade 1 – 0-25% anterior slip
  • Grade 2 – 26-50%
  • Grade 3 – 51%-75%
  • Grade 4 – 76-100%
  • Grade 5 – >100% spondyloptosis

 

 

  • Note degenerative spondylolisthesis at L4 and retrolisthesis at L2, L3.
  • This abnormality develops due to degeneration of facets and disc with decreased local stability.
  • Rarely progresses beyond Grade 2.
  • Must be recognized in the imaging report.
  • Contributes to vertebral canal stenosis.
  • Canal stenosis is better delineated by cross-sectional imaging.

 

 

  • The inverted Napoleon hat sign – seen on the frontal lumbar/pelvic radiographs at L5-S1.
  • Represents bilateral spondylolysis with marked anterolisthesis of L5 on S1 often with spondyloptosis and marked exaggeration of the normal lordosis.
  • Spondylolysis resulting in this degree of spondylolisthesis is more often congenital and/or traumatic in origin and less often degenerative.
  • The “brim” of the hat is formed by the downward rotation of the transverse processes, and the “dome” of the hat is formed by the body of L5.

 

In conclusion, imaging diagnostics for the spine are recommended for patients with specific abnormalities of the spine, however, their increased use can help determine their best treatment option. Understanding the abnormalities of the spine described above can help healthcare professionals and patients create a treatment program to improve their symptoms. The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .

 

Curated by Dr. Alex Jimenez

 

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Additional Topics: Acute Back Pain

 

Back pain is one of the most prevalent causes of disability and missed days at work worldwide. Back pain attributes to the second most common reason for doctor office visits, outnumbered only by upper-respiratory infections. Approximately 80 percent of the population will experience back pain at least once throughout their life. The spine is a complex structure made up of bones, joints, ligaments, and muscles, among other soft tissues. Because of this, injuries and/or aggravated conditions, such as herniated discs, can eventually lead to symptoms of back pain. Sports injuries or automobile accident injuries are often the most frequent cause of back pain, however, sometimes the simplest of movements can have painful results. Fortunately, alternative treatment options, such as chiropractic care, can help ease back pain through the use of spinal adjustments and manual manipulations, ultimately improving pain relief.

 

blog picture of cartoon paper boy

EXTRA EXTRA | IMPORTANT TOPIC: Chiropractic Neck Pain Treatment

Cervical Spine Radiographs in the Trauma Patient

Cervical Spine Radiographs in the Trauma Patient

While computed tomography scanning, or CT scans, of the cervical spine are frequently utilized to help diagnose neck injuries, simple radiographs are still commonly performed for patients who have experienced minor cervical spine injuries with moderate neck pain, such as those who have suffered a slip-and-fall accident. Imaging diagnostic assessments may reveal underlying injuries and/or aggravated conditions to be more severe than the nature of the trauma. The purpose of the article is to demonstrate the significance of cervical spine radiographs in the trauma patient. 

Abstract

Significant cervical spine injury is very unlikely in a case of trauma if the patient has normal mental status (including no drug or alcohol use) and no neck pain, no tenderness on neck palpation, no neurologic signs or symptoms referable to the neck (such as numbness or weakness in the extremities), no other distracting injury and no history of loss of consciousness. Views required to radiographically exclude a cervical spine fracture include a posteroanterior view, a lateral view and an odontoid view. The lateral view must include all seven cervical vertebrae as well as the C7-T1 interspace, allowing visualization of the alignment of C7 and T1. The most common reason for a missed cervical spine injury is a cervical spine radiographic series that is technically inadequate. The “SCIWORA” syndrome (spinal cord injury without radiographic abnormality) is common in children. Once an injury to the spinal cord is diagnosed, methylprednisolone should be administered as soon as possible in an attempt to limit neurologic injury.

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Radiographs continue to be used as a first-line imaging diagnostic assessment modality in the evaluation of patients with suspected cervical spine injuries. The aim of cervical spine radiographs is to confirm the presence of a health issue in the complex structures of the neck and define its extent, particularly with respect to instability. Multiple views may generally be necessary to provide optimal visualization.

Dr. Alex Jimenez D.C., C.C.S.T.

Introduction

Although cervical spine radiographs are almost routine in many emergency departments, not all trauma patients with a significant injury must have radiographs, even if they arrive at the emergency department on a backboard and wearing a cervical collar. This article reviews the proper use of cervical spine radiographs in the trauma patient.

Low-risk criteria have been defined that can be used to exclude cervical spine fractures, based on the patient’s history and physical examination.1–6 Patients who meet these criteria (Table 1) do not require radiographs to rule out cervical fractures. However, the criteria apply only to adults and to patients without mental status changes, including drug or alcohol intoxication. Although studies suggest that these criteria may also be used in the management of verbal children,7–9 caution is in order, since the study series are small, and the ability of children to complain about pain or sensory changes is variable. An 18-year-old patient can give a more reliable history than a five-year-old child.

Some concern has been expressed about case reports suggesting that “occult” cervical spine fractures will be missed if asymptomatic trauma patients do not undergo radiography of the cervical spine.10 On review, however, most of the reported cases did not meet the low-risk criteria in Table 1. Attention to these criteria can substantially reduce the use of cervical spine radiographs.

Cervical Spine Series and Computed Tomography

Once the decision is made to proceed with a radiographic evaluation, the proper views must be obtained. The single portable cross-table lateral radiograph, which is sometimes obtained in the trauma room, should be abandoned. This view is insufficient to exclude a cervical spine fracture and frequently must be repeated in the radiographic department.11,12 The patient’s neck should remain immobilized until a full cervical spine series can be obtained in the radiographic department. Initial films may be taken through the cervical collar, which is generally radiolucent. An adequate cervical spine series includes three views: a true lateral view, which must include all seven cervical vertebrae as well as the C7-T1 junction, an anteroposterior view and an open-mouth odontoid view.13

If no arm injury is present, traction on the arms may facilitate visualization of all seven cervical vertebrae on the lateral film. If all seven vertebrae and the C7-T1 junction are not visible, a swimmer’s view, taken with one arm extended over the head, may allow adequate visualization of the cervical spine. Any film series that does not include these three views and that does not visualize all seven cervical vertebrae and the junction of C7-T1 is inadequate. The patient should be maintained in cervical immobilization, and plain films should be repeated or computed tomographic (CT) scans obtained until all vertebrae are clearly visible. The importance of obtaining all of these views and visualizing all of the vertebrae cannot be overemphasized. While some missed cervical fractures, subluxations and dislocations are the result of film misinterpretation, the most frequent cause of overlooked injury is an inadequate film series.14,15

In addition to the views listed above, some authors suggest adding two lateral oblique views.16,17 Others would obtain these views only if there is a question of a fracture on the other three films or if the films are inadequate because the cervicothoracic junction is not visualized.18 The decision to take oblique views is best made by the clinician and the radiologist who will be reviewing the films.

Besides identifying fractures, plain radiographs can also be useful in identifying ligamentous injuries. These injuries frequently present as a malalignment of the cervical vertebrae on lateral views. Unfortunately, not all ligamentous injuries are obvious. If there is a question of ligamentous injury (focal neck pain and minimal malalignment of the lateral cervical x-ray [meeting the criteria in Table 2]) and the cervical films show no evidence of instability or fracture, flexion-extension views should be obtained.17,19 These radiographs should only be obtained in conscious patients who are able to cooperate. Only active motion should be allowed, with the patient limiting the motion of the neck based on the occurrence of pain. Under no circumstance should cervical spine flexion and extension be forced, since force may result in cord injury.

Although they may be considered adequate to rule out a fracture, cervical spine radiographs have limitations. Up to 20 percent11,20,21 of fractures are missed on plain radiographs. If there is any question of an abnormality on the plain radiograph or if the patient has neck pain that seems to be disproportionate to the findings on plain films, a CT scan of the area in question should be obtained. The CT is excellent for identifying fractures, but its ability to show ligamentous injuries is limited.22 Occasionally, plain film tomography may be in order if there is a concern about a type II dens fracture (Figure 1).

While some studies have used magnetic resonance imaging (MRI) as an adjunct to plain films and CT scanning,23,24 the lack of wide availability and the relatively prolonged time required for MRI scanning limits its usefulness in the acute setting. Another constraint is that resuscitation equipment with metal parts may not be able to function properly within the magnetic field generated by the MRI.

Cervical Spine Radiography

Figure 2 summarizes the approach to reading cervical spine radiographs.

Lateral View

Alignment of the vertebrae on the lateral film is the first aspect to note (Figure 3). The anterior margin of the vertebral bodies, the posterior margin of the vertebral bodies, the spinolaminar line and the tips of the spinous processes (C2-C7) should all be aligned. Any malalignment (Figures 4 and 5) should be considered evidence of ligamentous injury or occult fracture, and cervical spine immobilization should be maintained until a definitive diagnosis is made.

Confusion can sometimes result from pseudosubluxation, a physiologic misalignment that is due to ligamentous laxity, which can occur at the C2-C3 level and, less commonly, at the C3-C4 level. While pseudosubluxation usually occurs in children, it also may occur in adults. If the degree of subluxation is within the normal limits listed in Table 2 and the neck is not tender at that level, flexion-extension views may clarify the situation. Pseudosubluxation should disappear with an extension view. However, flexion-extension views should not be obtained until the entire cervical spine is otherwise cleared radiographically.

After ensuring that the alignment is correct, the spinous processes are examined to be sure that there is no widening of the space between them. If widening is present, a ligamentous injury or fracture should be considered. In addition, if angulation is more than 11 degrees at any level of the cervical spine, a ligamentous injury or fracture should be assumed. The spinal canal (Figure 2) should be more than 13 mm wide on the lateral view. Anything less than this suggests that spinal cord compromise may be impending.

Next, the predental space—the space between the odontoid process and the anterior portion of the ring of C1 (Figure 2)—is examined. This space should be less than 3 mm in adults and less than 4 mm in children (Table 2). An increase in this space is presumptive evidence of a fracture of C1 or of the odontoid process, although it may also represent ligamentous injury at this level. If a fracture is not found on plain radiographs, a CT scan should be obtained for further investigation. The bony structures of the neck should be examined, with particular attention to the vertebral bodies and spinous processes.

The retropharyngeal space (Figure 2) is now examined. The classic advice is that an enlarged retropharyngeal space (Table 2) indicates a spinous fracture. However, the normal and abnormal ranges overlap significantly.25 Retropharyngeal soft tissue swelling (more than 6 mm at C2, more than 22 mm at C6) is highly specific for a fracture but is not very sensitive.26 Soft tissue swelling in symptomatic patients should be considered an indication for further radiographic evaluation. Finally, the craniocervical relationship is checked.

Odontoid View

The dens is next examined for fractures. Artifacts may give the appearance of a fracture (either longitudinal or horizontal) through the dens. These artifacts are often radiographic lines caused by the teeth overlying the dens. However, fractures of the dens are unlikely to be longitudinally oriented. If there is any question of a fracture, the view should be repeated to try to get the teeth out of the field. If it is not possible to exclude a fracture of the dens, thin-section CT scans or plain film tomography is indicated.

Next, the lateral aspects of C1 are examined. These aspects should be symmetric, with an equal amount of space on each side of the dens. Any asymmetry is suggestive of a fracture. Finally, the lateral aspects of C1 should line up with the lateral aspects of C2. If they do not line up, there may be a fracture of C1. Figure 6 demonstrates asymmetry in the space between the dens and C1, as well as displacement of the lateral aspects of C1 laterally.

Anteroposterior View

The height of the cervical spines should be approximately equal on the anteroposterior view. The spinous processes should be in midline and in good alignment. If one of the spinous processes is off to one side, a facet dislocation may be present.

Common Cervical Abnormalities

The most common types of cervical abnormalities and their radiographic findings are listed in Table 3. Except for the clay shoveler’s fracture, they should be assumed to be unstable and warrant continued immobilization until definitive therapy can be arranged. Any patient found to have one spinal fracture should have an entire spine series, including views of the cervical spine, the thoracic spine and the lumbosacral spine. The incidence of noncontiguous spine fractures ranges up to 17 percent.27,28 Figures 7 through 9 demonstrate aspects of common cervical spine fractures.

Initial Treatment of Cervical Spine and Cord

If a cervical fracture or dislocation is found, orthopedic or neurosurgical consultation should be obtained immediately. Any patient with a spinal cord injury should begin therapy with methylprednisolone within the first eight hours after the injury, with continued administration for up to 24 hours. Patients should receive methylprednisolone in a dosage of 30 mg per kg given intravenously over one hour. Over the next 23 hours, intravenous methylprednisolone in a dosage of 5.4 mg per kg per hour should be administered. This therapy has been shown to improve outcomes and minimize cord injury,29 although it is not without its problems. The incidence of pneumonia is increased in patients treated with high dosages of methylprednisolone.30

‘Sciwora’ Syndrome: Unique in Children

A special situation involving children deserves mention. In children, it is not uncommon for a spinal cord injury to show no radiographic abnormalities. This situation has been named “SCIWORA” (spinal cord injury without radiographic abnormality) syndrome. SCIWORA syndrome occurs when the elastic ligaments of a child’s neck stretch during trauma. As a result, the spinal cord also undergoes stretching, leading to neuronal injury or, in some cases, complete severing of the cord.31 This situation may account for up to 70 percent of spinal cord injuries in children and is most common in children younger than eight years. Paralysis may be present on the patient’s arrival in the emergency department. However, up to 30 percent of patients have a delayed onset of neurologic abnormalities, which may not occur until up to four or five days after the injury. In patients with delayed symptoms, many have neurologic symptoms at the time of the injury, such as paresthesias or weakness, that have subsequently resolved.32

It is important to inform the parents of young patients with neck trauma about this possibility so that they will be alert for any developing symptoms or signs. Fortunately, most children with SCIWORA syndrome have a complete recovery, especially if the onset is delayed.33 It is possible to evaluate these injuries with MRI, which will show the abnormality and help determine the prognosis: a patient with complete cord transection is unlikely to recover.3

The treatment of SCIWORA syndrome has not been well studied. However, the general consensus is that steroid therapy should be used.34 In addition, any child who has sustained a significant degree of trauma but has recovered completely should be restricted from physical activities for several weeks.34

Dr Jimenez White Coat

Cervical spine radiographs include three standard views, such as the coned odontoid peg view, the anteroposterior view of the entire cervical spine, and the lateral view of the entire cervical spine. Most qualified and experienced healthcare professionals, including chiropractors, offer additional views to visualize the cervicothoracic junction as well as to evaluate the proper alignment of the spine in all patients. 

Dr. Alex Jimenez D.C., C.C.S.T.

About the Authors

MARK A. GRABER, M.D., is associate professor of clinical family medicine and surgery (emergency medicine) at the University of Iowa Hospitals and Clinics, Iowa City. He received his medical degree from Eastern Virginia Medical School, Norfolk, and served a residency in family medicine at the University of Iowa College of Medicine, Iowa City.

MARY KATHOL, M.D., is associate professor of radiology at the University of Iowa Hospitals and Clinics. She is also head of the musculoskeletal radiology section. She received her medical degree from the University of Kansas School of Medicine, Kansas City, Kan., and served a residency in radiology at the University of Iowa College of Medicine.

Address correspondence to Mark A. Graber, M.D., Department of Family Medicine, Steindler Bldg., University of Iowa Hospitals and Clinics, Iowa City, Iowa 52242. Reprints are not available from the authors.

In conclusion, it is essential to evaluate all views of the cervical spine through imaging diagnostic assessments. While cervical spine radiographs can reveal injuries and conditions, not all neck injuries are detected through radiography. Computed tomography, or CT, scans of the cervical spine are highly accurate in the diagnosis of neck fractures which can help with treatment. The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .

Curated by Dr. Alex Jimenez

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Additional Topics: Acute Back Pain

Back pain is one of the most prevalent causes of disability and missed days at work worldwide. Back pain attributes to the second most common reason for doctor office visits, outnumbered only by upper-respiratory infections. Approximately 80 percent of the population will experience back pain at least once throughout their life. The spine is a complex structure made up of bones, joints, ligaments, and muscles, among other soft tissues. Because of this, injuries and/or aggravated conditions, such as herniated discs, can eventually lead to symptoms of back pain. Sports injuries or automobile accident injuries are often the most frequent cause of back pain, however, sometimes the simplest of movements can have painful results. Fortunately, alternative treatment options, such as chiropractic care, can help ease back pain through the use of spinal adjustments and manual manipulations, ultimately improving pain relief.

 

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EXTRA EXTRA | IMPORTANT TOPIC: Chiropractic Neck Pain Treatment

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References

1. Kreipke DL, Gillespie KR, McCarthy MC, Mail JT, Lappas JC, Broadie TA. Reliability of indications for cervical spine films in trauma patients. J Trauma. 1989;29:1438–9.

2. Ringenberg BJ, Fisher AK, Urdaneta LF, Midthun MA. Rational ordering of cervical spine radiographs following trauma. Ann Emerg Med. 1988;17:792–6.

3. Bachulis BL, Long WB, Hynes GD, Johnson MC. Clinical indications for cervical spine radiographs in the traumatized patient. Am J Surg. 1987;153:473–8.

4. Hoffman JR, Schriger DL, Mower W, Luo JS, Zucker M. Low-risk criteria for cervical-spine radiography in blunt trauma: a prospective study. Ann Emerg Med. 1992;21:1454–60.

5. Saddison D, Vanek VW, Racanelli JL. Clinical indications for cervical spine radiographs in alert trauma patients. Am Surg. 1991;57:366–9.

6. Kathol MH, El-Khoury GY. Diagnostic imaging of cervical spine injuries. Seminars in Spine Surgery. 1996;8(1):2–18.

7. Lally KP, Senac M, Hardin WD Jr, Haftel A, Kaehler M, Mahour GH. Utility of the cervical spine radiograph in pediatric trauma. Am J Surg. 1989;158:540–1.

8. Rachesky I, Boyce WT, Duncan B, Bjelland J, Sibley B. Clinical prediction of cervical spine injuries in children. Radiographic abnormalities. Am J Dis Child. 1987;141:199–201.

9. Laham JL, Cotcamp DH, Gibbons PA, Kahana MD, Crone KR. Isolated head injuries versus multiple trauma in pediatric patients: do the same indications for cervical spine evaluation apply? Pediatr Neurosurg. 1994;21:221–6.

10. McKee TR, Tinkoff G, Rhodes M. Asymptomatic occult cervical spine fracture: case report and review of the literature. J Trauma. 1990;30:623–6.

11. Woodring JH, Lee C. Limitations of cervical radiography in the evaluation of acute cervical trauma. J Trauma. 1993;34:32–9.

12. Spain DA, Trooskin SZ, Flancbaum L, Boyarsky AH, Nosher JL. The adequacy and cost effectiveness of routine resuscitation-area cervical-spine radiographs. Ann Emerg Med. 1990;19:276–8.

13. Tintinalli JE, Ruiz E, Krome RL, ed. Emergency medicine: a comprehensive study guide. 4th ed. New York: McGraw-Hill, 1996.

14. Gerrelts BD, Petersen EU, Mabry J, Petersen SR. Delayed diagnosis of cervical spine injuries. J Trauma. 1991;31:1622–6.

15. Davis JW, Phreaner DL, Hoyt DB, Mackersie RC. The etiology of missed cervical spine injuries. J Trauma. 1993;34:342–6.

16. Apple JS, Kirks DR, Merten DF, Martinez S. Cervical spine fractures and dislocations in children. Pediatr Radiol. 1987;17:45–9.

17. Turetsky DB, Vines FS, Clayman DA, Northup HM. Technique and use of supine oblique views in acute cervical spine trauma. Ann Emerg Med. 1993;22:685–9.

18. Freemyer B, Knopp R, Piche J, Wales L, Williams J. Comparison of five-view and three-view cervical spine series in the evaluation of patients with cervical trauma. Ann Emerg Med. 1989;18:818–21.

19. Lewis LM, Docherty M, Ruoff BE, Fortney JP, Keltner RA Jr, Britton P. Flexion-extension views in the evaluation of cervical-spine injuries. Ann Emerg Med. 1991;20:117–21.

20. Mace SE. Emergency evaluation of cervical spine injuries: CT versus plain radiographs. Ann Emerg Med. 1985;14:973–5.

21. Kirshenbaum KJ, Nadimpalli SR, Fantus R, Cavallino RP. Unsuspected upper cervical spine fractures associated with significant head trauma: role of CT. J Emerg Med. 1990;8:183–98.

22. Woodring JH, Lee C. The role and limitations of computed tomographic scanning in the evaluation of cervical trauma. J Trauma. 1992;33:698–708.

23. Schaefer DM, Flanders A, Northrup BE, Doan HT, Osterholm JL. Magnetic resonance imaging of acute cervical spine trauma. Correlation with severity of neurologic injury. Spine. 1989;14:1090–5.

24. Levitt MA, Flanders AE. Diagnostic capabilities of magnetic resonance imaging and computed tomography in acute cervical spinal column injury. Am J Emerg Med. 1991;9:131–5.

25. Templeton PA, Young JW, Mirvis SE, Buddemeyer EU. The value of retropharyngeal soft tissue measurements in trauma of the adult cervical spine. Cervical spine soft tissue measurements. Skeletal Radiol. 1987;16:98–104.

26. DeBehnke DJ, Havel CJ. Utility of prevertebral soft tissue measurements in identifying patients with cervical spine fractures. Ann Emerg Med. 1994;24:1119–24.

27. Powell JN, Waddell JP, Tucker WS, Transfeldt EE. Multiple-level noncontiguous spinal fractures. J Trauma. 1989;29:1146–50.

28. Keenen TL, Antony J, Benson DR. Non-contiguous spinal fractures. J Trauma. 1990;30:489–91.

29. Bracken MB, Shepard MJ, Collins WF Jr, Holford TR, Baskin DS, Eisenberg HM, et al. Methylprednisolone or naloxone treatment after acute spinal cord injury: 1-year follow-up data. Results of the second National Acute Spinal Cord Injury Study. J Neurosurg. 1992;76:23–31.

30. Galandiuk S, Raque G, Appel S, Polk HC Jr. The two-edged sword of large-dose steroids for spinal cord trauma. Ann Surg. 1993;218:419–25.

31. Grabb PA, Pang D. Magnetic resonance imaging in the evaluation of spinal cord injury without radiographic abnormality in children. Neurosurgery. 1994;35:406–14.

32. Pang D, Pollack IF. Spinal cord injury without radiographic abnormality in children—the SCIWORA syndrome. J Trauma. 1989;29:654–64.

33. Hadley MN, Zabramski JM, Browner CM, Rekate H, Sonntag VK. Pediatric spinal trauma. Review of 122 cases of spinal cord and vertebral column injuries. J Neurosurg. 1988;68:18–24.

34. Kriss VM, Kriss TC. SCIWORA (spinal cord injury without radiographic abnormality) in infants and children. Clin Pediatr. 1996;35:119–24.

The editors of AFP welcome the submission of manuscripts for the Radiologic Decision-Making series. Send submissions to Jay Siwek, M.D., following the guidelines provided in “Information for Authors.”

Coordinators of this series are Thomas J. Barloon, M.D., associate professor of radiology and George R. Bergus, M.D., assistant professor of family practice, both at the University of Iowa College of Medicine, Iowa City.

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Imaging the Spine in Arthritis: a Pictorial Review

Imaging the Spine in Arthritis: a Pictorial Review

Many types of arthritis can affect the structure and function of the muscles, bones and/or joints, causing symptoms such as, pain, stiffness and swelling. While arthritis can commonly affect the hands, wrists, elbows, hips, knees and feet, it can also affect the facet joints found along the length of the spine. One of the most well-known types of arthritis, known as rheumatoid arthritis or RA, is a chronic inflammatory disease of the joints which occurs when the human body’s own immune system attacks the synovium, the thin membrane that lines the joints. According to the article below, imaging the spine in arthritis is fundamental towards its proper treatment.

 

Abstract

 

Spinal involvement is frequent in rheumatoid arthritis (RA) and seronegative spondyloarthritides (SpA), and its diagnosis is important. Thus, MRI and CT are increasingly used, although radiography is the recommended initial examination. The purpose of this review is to present the typical radiographic features of spinal changes in RA and SpA in addition to the advantages of MRI and CT, respectively. RA changes are usually located in the cervical spine and can result in serious joint instability. Subluxation is diagnosed by radiography, but supplementary MRI and/or CT is always indicated to visualize the spinal cord and canal in patients with vertical subluxation, neck pain and/or neurological symptoms. SpA may involve all parts of the spine. Ankylosing spondylitis is the most frequent form of SpA and has rather characteristic radiographic features. In early stages, it is characterized by vertebral squaring and condensation of vertebral corners, in later stages by slim ossifications between vertebral bodies, vertebral fusion, arthritis/ankylosis of apophyseal joints and ligamentous ossification causing spinal stiffness. The imaging features of the other forms of SpA can vary, but voluminous paravertebral ossifications often occur in psoriatic SpA. MRI can detect signs of active inflammation as well as chronic structural changes; CT is valuable for detecting a fracture.

 

Keywords: Spine, Arthritis, Rheumatoid Arthritis, Spondyloarthropathies

 

Introduction

 

The spine can be involved in most inflammatory disorders encompassing rheumatoid arthritis (RA), seronegative spondyloarthritides (SpA), juvenile arthritides and less frequent disorders such as, arthro-osteitis and SAPHO (synovitis, acne, pustulosis, hyperostosis, osteitis) syndrome.

 

During the last decade, the diagnostic use of magnetic resonance imaging (MRI) and computed tomography (CT) has increased considerably, although radiography is still the recommended initial examination. It is therefore important to know the characteristic radiographic findings in arthritides in addition to the advantages of supplementary MRI and CT. This review will focus on the different imaging features and be concentrated on the most frequent inflammatory spinal changes seen in RA and SpA, respectively. These two entities display somewhat different imaging features, which are important to recognize.

 

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Rheumatoid arthritis is an autoimmune disease which causes the human body’s own immune system to attack and often destroy the lining of the joints. Although it commonly affects the small joints of the hands and feet, rheumatoid arthritis, or RA, can affect any joint in the human body. The neck, or cervical spine, can be affected more often than the lower back if rheumatoid arthritis affects the joints in the spine. 

Dr. Alex Jimenez D.C., C.C.S.T.

 

Rheumatoid Arthritis

 

Involvement in RA is usually located in the cervical spine where erosive changes are predominantly seen in the atlanto-axial region. Inflamed and thickened synovium (pannus) can occur around the odontoid process (dens) and cause bone erosion and destruction of surrounding ligaments, most seriously if the posterior transverse ligament is involved. Laxity or rupture of the transverse ligament causes instability with a potential risk of spinal cord injury. Cervical RA involvement is a progressive, serious condition with reduced lifetime expectancy [1], and its diagnosis is therefore important [2, 3].

 

Fig. 1 Standard radiography of the cervical spine in rheumatoid arthritis (RA). (a) Lateral radiographs in neutral position and (b) during flexion in addition to (c) lateral and (d) anterior-posterior (AP) open-mouth view of the atlanto-axial region (45-year-old woman). The flexion view (b) shows abnormal distance (>3 mm) between the posterior aspect of the anterior arc of the atlas and the anterior aspect of the dens (black line). Note that the spino-laminar line of the atlas (arrow) does not align with that of the other vertebrae, confirming the presence of anterior subluxation, but there is no stenosis of the atlanto- axial canal; the posterior atlanto-dental interval (white line) is >14 mm. The open-mouth view (d) shows erosion at the base of the dens (arrow). (a) and (b) show concomitant disc degenerative changes at the C4–C6 level.

Fig. 2 Lateral and rotatory atlanto-axial subluxation. AP open- mouth view in a 53-year-old man with RA. There is narrowing of the atlanto-axial joints with superficial erosions (black arrow) and lateral displacement of the axis with respect to the lateral masses of the atlas (white arrow); in addition signs indicating rotatory displacement with asymmetry of the distance between the dens and the lateral masses of the atlas.

 

Radiography of the cervical spine is mandatory in RA patients with neck pain [3]. It should always include a lateral view in a flexed position compared with a neutral position in addition to special views of the dens area to detect any lesions and/or instability (Fig. 1). A supplementary lateral view during extension can be useful to assess reducibility of atlanto-axial subluxation possibly limited by pannus tissue between the anterior arc of the atlas and dens.

 

Anterior atlanto-axial subluxation is the most frequent form of RA instability in the occipito-atlanto-axial region, but lateral, rotatory and vertical subluxation can also occur. The definition of the different forms of instability by radiography is as follows [3].

 

Anterior atlanto-axial subluxation. Distance between the posterior aspect of the anterior arc of the atlas and the anterior aspect of the dens exceeding 3 mm in a neutral position and/or during flexion (Fig. 1). It may cause stenosis of the atlanto-axial canal presenting as a posterior atlanto-dental interval<14 mm (Fig. 1).

 

Lateral and rotatory atlanto-axial subluxation. Displacement of the lateral masses of the atlas more than 2 mm in relation to that of the axis and asymmetry of the lateral masses relative to the dens, respectively (Fig. 2). Rotatory and lateral subluxation is diagnosed on open-mouth anterior-posterior (AP) radiographs. Anterior subluxation often coexists because of the close anatomical relation between the atlas and the axis.

 

Posterior atlanto-axial subluxation. The anterior arc of the atlas moves over the odontoid process. This is rarely seen, but may coexist with fracture of the dens.

 

Vertical atlanto-axial subluxation is also referred to as atlanto-axial impaction, basilar invagination or cranial setting, and is defined as migration of the odontoid tip proximal to McRae’s line corresponding to the occipital foramen. This line can be difficult to define on radiographs, and vertical subluxation has therefore also been defined by several other methods. Migration of the tip of the odontoid process >4.5 mm above McGregor’s line (between the postero-superior aspect of the hard palate and the most caudal point of the occipital curve) indicates vertical subluxation (Fig. 3).

 

Fig. 3 Vertical atlanto-axial subluxation, measurement methods. (a) Lateral normal radiograph in neutral position showing the location of McGregor’s line (black) between the postero-superior aspect of the hard palate and the most caudal point of the occipital curve. Migration of the tip of the dens >4.5 mm above McGregor’s line indicates vertical subluxation. The distance indicated by the white line between McGregor’s line and the midpoint of the inferior margin of the body of axis is used to evaluate vertical subluxation according to Redlund-Johnell and Pettersson’s method. A distance less than 34 mm in men and 29 mm in women indicates vertical subluxation. (b) Sagittal CT reconstruction of a normal cervical spine showing the location of McRae’s line corresponding to the occipital foramen and the division of the axis into three equal portions used by Clark’s method for diagnosing vertical subluxation. If the anterior arc of the atlas is in level with the middle or caudal third of the axis there is slight and pronounced vertical subluxation, respectively. (c) Ranawat’s method includes determination of the distance between the centre of the second cervical pedicle and the transverse axis of the atlas. A distance less than 15 mm in males and 13 mm in females indicates vertical subluxation [4].

Fig. 4 Vertical subluxation. (a) Lateral radiograph with McGregor’s line (black line; 61-year-old man with RA). The tip of the dens is difficult to define, but measurement according to Redlund-Johnell’s method (white line) results in a distance of 27 mm, which is below the normal limit. In accordance with this, the anterior arc of the atlas is level with the middle third of the axis. (b) Ranawat’s method, the distance between the centre of the second cervical pedicle and the transverse axis of the atlas is below the normal limit (9 mm). Thus, all measurements indicate vertical subluxation. Supplementary MRI, (c) sagittal STIR and (d) T1-weighted images show erosion of the dens and protrusion of the tip into the occipital foramen causing narrowing of the spinal canal to 9 mm, but persistence of cerebrospinal fluid around the cord. There is a 9-mm-thick mass of pannus tissue between the dens and anterior arc (black line) exhibiting small areas with high signal intensity on the STIR image (arrow) compatible with slight activity, but signal void fibrous pannus tissue predominates.

The occurrence of dens erosion can, however, make this measurement difficult to obtain. The Redlund-Johnell method is therefore based on the minimum distance between McGregor’s line and the midpoint of the inferior margin of the body of the axis on a lateral radiograph in a neutral position (Fig. 3) [4]. Visualisation of the palate may not always be obtained. Methods without dens and/or the palate as landmarks have therefore been introduced [4]. The method described by Clark et al. (described in [4]) includes assessment of the location of the atlas by dividing the axis into three equal portions on a lateral radiograph. Location of the anterior arc of the atlas in level with the middle or caudal third of the axis indicates vertical subluxation (Fig. 3). Ranawat et al. have proposed using the distance between the centre of the second cervical pedicle and the transverse axis of the atlas at the odontoid process (Fig. 3) [4]. To obtain the diagnosis of vertical subluxation a combination of the Redlund-Johnell, Clark and Ranawat methods has been recommended (described in [4]). If any of these methods suggests vertical subluxation MRI should be performed to visualize the spinal cord (Fig. 4). Using this combination of methods vertical subluxation will be missed in only 6% of patients [4]. It is mandatory to diagnose vertical subluxation; this can be fatal because of the proximity of the dens to the medulla oblongata and the proximal portion of the spinal cord. Risk of cord compression/injury occurs, especially in patients with flexion instability accompanied by erosive changes in the atlanto- axial and/or atlanto-occipital joints, causing the vertical subluxation with protrusion of the dens into the occipital foramen (Figs. 4, 5).

 

Subaxial RA changes also occur in the form of arthritis of the apophyseal and/or uncovertebral joints, appearing as narrowing and superficial erosions by radiography. It can cause instability in the C2-Th1 region, which is mainly seen in patients with severe chronic peripheral arthritis. Anterior subluxation is far more frequent than posterior subluxation. It is defined as at least 3 mm forward slippage of a vertebra relative to the underlying vertebra by radiography including a flexion view (Fig. 6). Changes are particularly characteristic at the C3–4 and C4–5 level, but multiple levels may be involved, producing a typical “stepladder” appearance on lateral radiographs. The condition is serious if the subaxial sagittal spinal canal diameter is <14 mm, implying a possibility of spinal cord compression [2]. The instability may progress over time, especially if the C1–C2 region is stabilized surgically (Fig. 6) [5].

 

Fig. 5 Vertical subluxation with spinal cord compression. MRI of the cervical spine in a 69- year-old woman with advanced peripheral RA, neck pain and clinical signs of myelopathy. (a) Sagittal STIR, (b) sagittal T1 and (c) axial T2 fat-saturated (FS) images show erosion of the dens and protrusion of the tip into the occipital foramen causing compression of the spinal cord, which exhibits irregular signal intensity (white arrows). The osseous spinal canal has a width of approximately 7 mm (black line). There is heterogeneous signal intensity pannus surrounding the dens compatible with a mixture of fibrotic and oedematous pannus tissue (black arrows) in the widened space between the dens and the anterior arc of the atlas.

 

Discitis-like changes and spinous process erosion may also be detected by radiography in RA, but are relatively rare, whereas concomitant degenerative changes occur occasionally (Fig. 1).

 

Cross-sectional imaging in the form of CT and MRI eliminates overprojecting structures and can improve the detection of RA changes. Osseous changes (erosions, etc.) can be clearly delineated by CT [6]. Additionally, MRI visualizes soft tissue structures (pannus; spinal cord, etc.), signs of disease activity and sequelae of inflammation in the form of fibrous pannus. These advantages of CT and MRI in patients with atlanto-axial involvement are illustrated in Figs. 7 and 8, including the possibility of detecting signs of arthritis by MRI before the occurrence of erosive changes (Fig. 8) [3].

 

Fig. 6 Subaxial instability. (a) Flexion view in a 64-year-old woman with advanced peripheral RA showing anterior atlanto-axial instability as well as subaxial instability at multiple levels. (b) Flexion view 2 years later after surgical stabilization of the atlanto-axial region demonstrates progression of the subaxial instability, especially between C3 and C4 (white arrow). There is a characteristic “stepladder” appearance, which also occurred on the initial radio- graphs (a), but is less pronounced.

Fig. 7 Advantages of CT and MRI. (a) Supplementary CT and (b-f) MRI of the patient shown in Fig. 1. CT demonstrates erosion not only at the base of the dens, but also at the tip and at the atlanto-axial and atlanto-occipital joints, which are difficult to visualize by radiography. MRI, (b) sagittal STIR and (c) sagittal T1 of the entire cervical spine and post-contrast T1FS images of the atlanto-axial region, (d) sagittal, (e) coronal and (f) axial. Oedematous voluminous pannus surrounding the dens is seen on the STIR and T1 images (black arrows) in addition to C4/5 and C5/6 disc degeneration with posterior protrusion of the disc at C4/5. The post-contrast T1FS images confirm the presence of vascularized enhancing pannus around the dens (white arrows) and demonstrate improved anatomical delineation compared with the STIR image. There is no sign of spinal cord compression.

Fig. 8 Non-radiographic MR findings. MRI in a 41-year-old woman with peripheral erosive RA and neck pain, but normal cervical radiography. (a) Post-contrast axial and (b) coronal TIFS images show signs of active arthritis with synovial contrast enhancement at the left atlanto-axial joint in addition to enhancing pannus tissue at the left side of the dens (white arrows). There is also a subchondral enhancing area in the axis (black arrow) compatible with a pre-erosive lesion.

 

A diagnostic strategy according to Younes et al. [3] is recommended (Fig. 9). This includes an indication for radiography in all RA patients with disease duration >2 years as cervical involvement may occur in over 70% of patients and has been reported to be asymptomatic in 17% of RA patients. It is recommended to monitor patients with manifest peripheral erosions accompanied by RF (rheumatoid factor) and antiCCP (antibodies to cyclic citrullinated peptide) positivity every second year and patients with few peripheral erosions and RF negativity at 5-year intervals. MRI is indicated in patients with neurological deficit, radiographic instability, vertical subluxation and subaxial stenosis [2, 3]. Visualisation of the spinal cord is especially important to detect cord injury or risk of injury. MRI should therefore always be performed in RA patients with neck pain and/or neurological symptoms [3, 7].

 

Seronegative Spondyloarthritides

 

According to European classification criteria [8, 9], SpA is divided into: (1) ankylosing spondylitis (AS), (2) psoriatic arthritis, (3) reactive arthritis, (4) arthritis associated with inflammatory bowel disorders (enteropathic arthritis) and (5) undifferentiated SpA. Inflammatory changes at the sacroiliac joints always occur in AS and are part of most other forms of SpA. Spinal changes are also a feature of SpA, especially in the late stages of AS.

 

Ankylosing Spondylitis

 

Ankylosing spondylitis is the most frequent and usually the most disabling form of SpA. It has a genetic predisposition in the form of a frequent association with the human leukocyte antigen (HLA) B27 [10]. AS often starts in early adulthood and has a chronic progressive course. It is therefore important to diagnose this disorder. According to the modified New York Criteria [11], the diagnosis of definite AS requires the following: manifest sacroiliitis by radiography (grade ≥2 bilateral or unilateral grade 3–4 sacroiliitis; Fig. 10) and at least one of the following clinical criteria: (1) low back pain and stiffness for more than 3 months improving with activity, (2) limited movement of the lumbar spine and (3) reduced chest expansion. These criteria are still used in the diagnosis of AS despite the increasing use of MRI to detect the disease early. It is therefore important to know both the characteristic radiographic features and the MR features of AS.

 

Early radiographic spinal changes encompass erosion of vertebral corners (Romanus lesions) causing vertebral squaring and eliciting reactive sclerosis appearing as condensation of vertebral corners (shiny corners; Fig. 10). These changes are caused by inflammation at the insertion of the annulus fibrosus (enthesitis) at vertebral corners provoking reactive bone formation [12]. Later on slim ossifications appear in the annulus fibrosus (syndesmo- phytes) (Fig. 11) [13]. With disease progression the spine gradually fuses because of syndesmophytes crossing the intervertebral spaces in addition to fusion of apophyseal joints, resulting in complete spinal fusion (bamboo spine; Fig. 12). In advanced disease the supra- and interspinous ligaments may ossify and be visible on frontal radiographs as a slim ossified streak (Fig. 12). The occurrence of a single central radiodense streak has, the “dagger sign”. When the ligamentous ossification occurs together with ossification of apophyseal joint capsules, there are three vertical radiodense lines on frontal radiography (trolley-track sign).

 

Fig. 9 Diagnostic strategy. According to Younes et al. [3] radiography of the cervical spine is indicated in all RA patients with disease duration >2 years. It should at least include open-mouth and lateral views in neutral and flexed positions. Because of the occurrence of asymptomatic cervical involvement in 17% of RA patients, it is recommended to monitor patients with intervals of 2–5 years depending on positivity for the rheumatoid factor. MRI is indicated in patients with neurological deficit, radiographic instability, atlanto-axial impaction and subaxial stenosis. CT may add information in rotatory and lateral subluxation because of the possibility of secondary reconstruction in arbitrary planes and a clear visualisation of the atlanto-occipital joints [6].

Erosive changes within intervertebral spaces (Andersson lesions) have been detected by radiography in approximately 5% of patients with AS [14], but more frequently by MRI (Fig. 11) [15].

 

Persistent movement at single intervertebral spaces may occur in an otherwise ankylosed spine, sometimes caused by non-diagnosed fractures. This can result in pseudo- arthrosis-like changes with the formation of surrounding reactive osteophytes due to excessive mechanical load at single movable intervertebral spaces [14]. The diagnosis of such changes may require a CT examination to obtain adequate visualization (Fig. 13).

 

One of the life-threatening complications of AS is spinal fracture. Non-fatal fractures have been reported to occur in up to 6% of AS patients, especially in patients with long disease duration [16]. Fractures may occur after minor trauma because of the spinal stiffness and frequently accompanying osteoporosis. Fractures often occur at intervertebral spaces, but usually involve the ankylosed posterior structures and are thereby unstable (Fig. 14). Obvious fractures can visualize by radiography, but fractures may be obscured. It is therefore mandatory to supplement a negative radiography with CT if fracture is suspected (in the case of trauma history or a change in spinal symptoms). The occurrence of cervico-thoracic fractures may cause spinal cord injury and be lethal even following minor trauma [17].

 

Cross-sectional CT or MR imaging can be advantageous in the diagnosis of AS changes. CT providing a clear delineation of osseous structures is the preferred technique for visualizing pseudo-arthrosis and detecting fractures (Figs. 13, 14). CT is superior to MRI in detecting minor osseous lesions such as erosion and ankylosis of the apophyseal, costo-vertebral and costo-transversal joints (Fig. 15). MRI can visualize signs of active inflammation in the form of bone marrow and soft tissue oedema and/or contrast enhancement. It has therefore gained a central role in the evaluation of disease activity [15]. MRI can, however, also detect sequelae of inflammation consisting of fatty deposition in the bone marrow and chronic structural changes such as erosion and fusion of vertebral bodies [15].

 

Characteristic MR findings early in the disease are activity changes mainly consisting of oedema at vertebral corners and/or costo-vertebral joints (Fig. 16) [13]. The inflammatory changes at vertebral corners are characteristic of AS. Based on the occurrence of severe or multiple (≥3) lesions in young patients, AS changes can be distinguished from degenerative changes with a high reliability [18].

 

Fig. 10 Relatively early changes in ankylosing spondylitis (AS). (a) AP radiograph of the sacroiliac joints in a 28-year-old man presenting with typical definite bilateral AS sacroiliitis (grade 3) in the form of bilateral joint erosion accompanied by subchondral sclerosis. (b) Initial spinal changes consisting of erosion of vertebral corners (Romanus lesion) with vertebral squaring corresponding to Th11, Th12, L4 and L5 accompanied by condensation of the vertebral corners—shiny corners (arrows).

During the disease course signs of activity can also occur at syndesmophytes, apophyseal joints and interspinous ligaments (Fig. 16). Detection of inflammation at apophyseal joints by MRI, however, demands pronounced involvement histopathologically [19]. The inflammation at vertebral corners is the most valid feature and has been observed related to the development of syndesmophytes by radiography [12], establishing a link between signs of disease activity and chronic structural changes.

 

Chronic AS changes detectable by MRI mainly consist of fatty marrow deposition at vertebral corners (Fig. 17), erosion (Fig. 11) and vertebral fusion in advanced disease (Fig. 12). Fatty marrow deposition seems to be an a sign of chronicity being significantly correlated with radiographic changes, in particular, vertebral squaring [15]. Erosions are more frequently detected by MRI than by radiography (Fig. 11) [15] and can present with signs of active inflammation and/or surrounding fatty marrow deposition compatible with sequels of osseous inflammation. Syndesmophytes, however, may not always be visible by MRI because they may be difficult to distinguish from fibrous tissue unless there is concomitant active inflammation or fatty deposition (Figs. 11, 16) [15, 20].

 

The possibility of visualizing disease activity by MRI has increased its use to monitor AS, especially during anti-TNF (anti-tumour necrosis factor) therapy [21, 22]. Several studies have shown that MR changes are frequent in the thoracic spine (Fig. 16) [15, 23]. It is therefore important to examine the entire spine using sagittal STIR or T2 fat-saturated (FS) and T1-weighted sequences. Supplementary axial slices can be necessary for visualising involvement of apophyseal, costo-vertebral and costo-transversal joints (Fig. 16) [24, 25]. Post-contrast T1FS sequences can sometimes be advantageous as they provide better anatomical delineation [26]. Additionally, dynamic contrast-enhanced MRI may be superior to static MRI in monitoring disease activity during anti-TNF therapy [27]. Whole-body MRI gives the possibility of detecting involvement in other areas without losing important information about spinal and sacroiliac joint involvement [28, 29].

 

Other Forms of SpA

 

Radiographic changes in reactive and psoriatic arthritis are often characterized by voluminous non-marginal syndesmophytes (parasyndesmophytes) or coalescing ossification of the paravertebral ligaments in addition to asymmetrical sacroiliitis (Fig. 18) [30].

 

Reactive arthritis is self-limiting in most patients. However, in patients with chronic reactive arthritis and HLA B27 the axial changes may progress to changes somewhat similar to those seen in AS and can then be regarded as AS elicited by infection [10].

 

Fig. 11 Syndesmophytes and erosions in AS. (a) Lateral radiograph in a 29-year-old man with the characteristic slim ossification (syndesmophytes) at the periphery of the annulus fibrosus (black arrows) in addition to erosion of the endplates at the intervertebral (iv) space between L3 and L4 (white arrow). Supplementary MRI, (b) sagittal STIR and (c) T1-weighted images show small oedematous areas in the erosion at iv L3/4 on the STIR image and surrounding fatty marrow deposition on T1 as a sign of previous osseous inflammation. There are additional erosive changes (black arrows, c) not clearly delineated by radiography and slight oedema at the vertebral corners (white arrows, b). Note that the syndesmophytes demonstrated by radiogra- phy are not visible on MRI.

Fig. 12 Advanced AS. (a) AP and (b) lateral radiograph in a 55-year-old man showing vertebral fusion due to syndesmophytes crossing the intervertebral spaces in addition to fusion of the apophyseal joints (bamboo spine). The interspinous ligaments are ossified, presenting as a slim ossified streak on the frontal radiograph (dagger sign; arrows). MRI, sagittal T1- weighted images of (c) the cervico-thoracic and (d) lumbar region, respectively, shows a general narrowing of the intervertebral discs with partial osseous fusion of the vertebral bodies, especially in the lumbar region (arrows). In addition a characteristic AS deformity with reduced lumbar lordosis and thoracic kyphosis.

Fig. 13 Pseudo-arthrosis-like changes in AS. (a) AP and (b) lateral radiograph showing vertebral fusion except at iv Th10/11. There is surrounding osteophyte formation at this iv space (arrows). Supplementary CT, (c) sagittal and (d) coronal 2D reconstruction, demonstrates lack of fusion of the vertebral bodies and apophyseal joints at this level (arrows). (e) 3D reconstruction clearly demonstrates the exuberant surrounding reactive osteophytes.

Fig. 14 Spinal fracture in AS. (a) AP and (b) lateral radiograph of the thoracic spine in a 64-year-old man with advanced AS and increasing back pain over 4 weeks. The lateral view demonstrates a slight malalignment at the anterior aspects of the vertebral bodies of Th9 and Th10, and the iv is irregularly narrowed on the AP view, all suggesting fracture (arrows). CT, (c) sagittal and (d) coronal reconstruction, shows fracture through the iv space and the posterior structures (arrows). There is widening of the intervertebral space anteriorly in the supine position used for CT compared with the upright position used during radiography.

Axial psoriatic arthritis (PsA) occurs in approximately 50% of patients with peripheral PsA [31]. It differs radiographically from AS by the voluminous paravertebral ossifications and the occurrence of spinal changes without concomitant sacroiliitis in 10% of patients [32]. Axial PsA may be clinically silent [33], and involvement of the cervical spine is frequent (atlanto-axial or apophyseal joint changes). The cervical recognize may include atlanto-axial instability as seen in RA (Fig. 19), but the pathogenesis and thereby imaging findings are different. In PsA radiography and CT usually visualize new bone formation in the region of the dens. This is elicited by osseous inflammation (osteitis) and/or inflammation at ligament/ tendon attachments (enthesitis) detectable by MRI (Fig. 19). Osteitis is often a feature of spinal PsA and can occur together with paravertebral ossification/para- syndesmophytes and erosion of vertebral plates (Fig. 20). , and illustrated MR findings in PsA are based on personal observations and seem to reflect the radiographic changes encompassing a mixture of osteitis, enthesitis and erosion. Unfortunately, there is a lack of systematic description of spinal changes in PsA by MRI. Some of the patients described under the term SAPHO (synovitis, acne, pustulosis, hyperostosis, osteitis) syndrome may have PsA. SAPHO is a collective term often used for inflammatory disorders primarily presenting with osseous hyperostosis and sclerosis, and they are frequently associated with skin disorders. The most commonly affected site in SAPHO is the anterior chest followed by the spine [34]. The PsA changes shown in Fig. 20 are characterized by hyperostosis and sclerosis, both main features of SAPHO. However, this patient did not have anterior chest involvement.

 

Fig. 15 CT detection of costo-vertebral changes in AS. Axial CT slices showing erosive changes (a) and ankylosis of costo-vertebral joints (b), respectively (arrows).

Fig. 16 Activity changes in AS by MRI. Sagittal STIR of (a) the cervico-thoracic and (b) the lumbar spine of the patients shown in Fig. 10 obtained 3 years before the radiography. There are multiple high signal intensity areas corresponding to vertebral corners (white arrows). Additionally, osseous oedema of the costo-vertebral joints (a, black arrows) seen on the lateral sagittal slice of the thoracic spine. (c) Axial post-contrast T1FS of an inflamed costo-vertebral joint confirmed the presence of joint inflammation in the form of osseous enhancement in both the vertebra and the rib (arrows) in addition to joint erosion. (d) Midline sagittal post-contrast T1FS shows an enhancing syndesmophyte. (e) Inflammatory changes at the apophy- seal joint in a 27-year-old man; sagittal STIR image of the lumbar region showing subchondral osseous oedema in the lower thoracic region (white arrows), and both osseous and soft tissue oedema corresponding to the lumbar apophyseal joints (black arrows). Note that the osseous oedema in the pedicle of Th12 extends to the region of the costo-vertebral joint. (f) Coronal post-contrast T1FS of the lumbar spine shows additional enhancement corresponding to the interspinous ligament between L2 and L3 (arrows).

Fig. 17 Chronic changes in AS by MRI. Sagittal T1 (a) the cervico-thoracic and (b) the lumbar spine of the patients shown in Fig. 10. There are multiple fatty marrow depositions at vertebral corners and also posteriorly in thoracic vertebral bodies (b, arrows). This was observed to have developed since the MRI performed 3 years previously (shown in Fig. 16 a-d) and corresponds to areas of previous inflammation.

In patients with enteropathic arthritis associated with Crohn’s disease or ulcerative colitis, the spine is often osteoporotic with various accompanying SpA features by radiography, mostly AS-like changes. However, by MRI there may be more pronounced inflammation in the posterior ligaments than seen in the other forms of SpA (Fig. 21).

 

Fig. 18 Psoriatic arthritis (PsA), paravertebral ossifications. (a) AP and (b) lateral radiograph of the lumbar spine in a 48-year-old man with PsA showing voluminous paravertebral new bone forma- tion (arrows) in addition to fusion of the second and third vertebral bodies. There was no concomitant sacroiliitis. (c) AP radiograph of the thoraco- lumbar junction in a female patient with axial PsA demon- strating coalescing paravertebral ossifications (arrows).

Fig. 19 Cervical PsA. (a) Lateral radiographs in the neutral position and (b) during flexion in a 61-year-old woman show atlanto-axial instability with a 4-mm distance between the anterior arc and the dens (white line). Additionally, ankylosis of the apophyseal joints (black arrows) and new bone formation anterior to the C4-7 vertebral bodies (white arrows). CT, (c) axial slice and coronal reconstruction of the dens area, demonstrates new bone formation in the atlanto-axial region (arrows); (d) coronal reconstruction of the lower cervical region shows voluminous new bone formation on the right side of the vertebral bodies (arrows). MRI, (e) sagittal STIR and (f) T1-weighted images, shows homogeneous osseous inflammation corresponding to the dens (arrows) with surrounding irregular oedema compatible with a mixture of osteitis and enthesitis. Note that the anterior new bone formation visualised by radiography is difficult to detect on MRI.

Fig. 20 Lumbar PsA. (a) AP and (b) lateral radiograph in a 50-year- old man show voluminous paravertebral ossifications anteriorly and at the right side of the third lumbar vertebra and adjacent iv spaces. MRI, (c) sagittal STIR, (d) T1 and (e) post-contrast T1-weighted images, demonstrates manifest osseous inflammation (osteitis) in the form of oedema and enhancement of the vertebral body, slight enhancement in the paravertebral new bone formation and erosion of the upper vertebral plate compatible with a mixture of osteitis, enthesitis and erosive changes.

Fig. 21 Enteropathic SpA. Sagittal STIR image of the lumbar spine in a 27-year-old man with ulcerative colitis demonstrates oedema corresponding to the interspinous ligaments (arrows) and spinous processes as signs of inflammation. There are only minimal activity changes corresponding to the vertebral bodies, located to the anterior vertebral corners.
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Rheumatoid arthritis of the spine can cause neck pain, back pain, and/or radiating pain in the upper and lower extremities. In severe cases, RA can also lead to the degeneration of the spine, resulting in the compression or impingement of the spinal cord and/or the spinal nerve roots. As a chiropractor, we offer diagnostic imaging to help determine a patient’s health issue, in order to develop the best treatment program.

Dr. Alex Jimenez D.C., C.C.S.T.

 

Conclusion

 

Radiography is still valuable in the diagnosis of spinal inflammatory disorders. It is necessary for visualizing instability and is superior to MRI for detecting syndesmophytes. However, MRI and CT can detect signs of spinal involvement before they can be visualized by radiography. MRI adds information about potential involvement of the spinal cord and nervous roots in addition to signs of disease activity and chronic changes such as fibrous pannus in RA and fatty marrow deposition, erosion and vertebral fusion in SpA. MRI is therefore widely used to monitor inflammatory spinal diseases, especially during anti-TNF therapy.

 

Computed tomography is particularly valuable in the detection of fracture and minor osseous lesions as well as in the evaluation of pseudo-arthrosis. In conclusion, rheumatoid arthritis most commonly affects the structure and function of your hands, wrists, elbows, hips, knees, ankles and feet, however, people with this chronic inflammatory disease can experience back pain. Imaging the spine in arthritis is fundamental to determine treatment. The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .

 

Curated by Dr. Alex Jimenez

 

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Additional Topics: Acute Back Pain

 

Back pain is one of the most prevalent causes of disability and missed days at work worldwide. Back pain attributes to the second most common reason for doctor office visits, outnumbered only by upper-respiratory infections. Approximately 80 percent of the population will experience back pain at least once throughout their life. The spine is a complex structure made up of bones, joints, ligaments, and muscles, among other soft tissues. Because of this, injuries and/or aggravated conditions, such as herniated discs, can eventually lead to symptoms of back pain. Sports injuries or automobile accident injuries are often the most frequent cause of back pain, however, sometimes the simplest of movements can have painful results. Fortunately, alternative treatment options, such as chiropractic care, can help ease back pain through the use of spinal adjustments and manual manipulations, ultimately improving pain relief.

 

 
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EXTRA IMPORTANT TOPIC: Sciatica Pain Chiropractic Therapy

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References

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2. Kim DH, Hilibrand AS (2005) Rheumatoid arthritis in the cervical spine. J Am Acad Orthop Surg 13(7):463–474
3. Younes M, Belghali S, Kriaa S, Zrour S, Bejia I, Touzi M et al (2009) Compared imaging of the rheumatoid cervical spine: prevalence study and associated factors. Joint Bone Spine 76 (4):361–368
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6. Iizuka H, Sorimachi Y, Ara T, Nishinome M, Nakajima T, Iizuka Y et al (2008) Relationship between the morphology of the atlanto-occipital joint and the radiographic results in patients with atlanto-axial subluxation due to rheumatoid arthritis. Eur Spine J 17(6):826–830
7. Narvaez JA, Narvaez J, Serrallonga M, De Lama E, de AM, Mast R et al (2008) Cervical spine involvement in rheumatoid arthritis:
correlation between neurological manifestations and magnetic resonance imaging findings. Rheumatology (Oxford) 47 (12):1814–1819
8. Dougados M, van der Linden S, Juhlin R, Huitfeldt B, Amor B, Calin A et al (1991) The European Spondylarthropathy Study Group preliminary criteria for the classification of spondylarthr- opathy. Arthritis Rheum 34:1218–1227
9. Rudwaleit M, van der Heijde D, Landewe R, Listing J, Akkoc N, Brandt J et al (2009) The Development of Assessment of SpondyloArthritis international Society (ASAS) classification criteria for axial spondyloarthritis (Part II): validation and final selection. Ann Rheum Dis 68(6):777–783
10. Sieper J, Rudwaleit M, Khan MA, Braun J (2006) Concepts and epidemiology of spondyloarthritis. Best Pract Res Clin Rheumatol 20(3):401–417
11. van der Linden S, Valkenburg HA, Cats A (1984) Evaluation of diagnostic criteria for ankylosing spondylitis. A proposal for modification of the New York criteria. Arthritis Rheum 27:361– 268
12. Maksymowych WP, Chiowchanwisawakit P, Clare T, Pedersen SJ, Ostergaard M, Lambert RG (2009) Inflammatory lesions of the spine on magnetic resonance imaging predict the development of new syndesmophytes in ankylosing spondylitis: evidence of a relationship between inflammation and new bone formation. Arthritis Rheum 60(1):93–102
13. Sieper J, Rudwaleit M, Baraliakos X, Brandt J, Braun J, Burgos- Vargas R et al (2009) The Assessment of SpondyloArthritis international Society (ASAS) handbook: a guide to assess spondyloarthritis. Ann Rheum Dis 68(Suppl 2:ii):1–44
14. Park WM, Spencer DG, McCall IW, Ward J, Buchanan WW, Stephens WH (1981) The detection of spinal pseudarthrosis in ankylosing spondylitis. Br J Radiol 54(642):467–472
15. Madsen KB, Jurik AG (2009) MRI grading method for active and chronic spinal changes in spondyloarthritis. Clin Radiol 65:6–14
16. Feldtkeller E, Vosse D, Geusens P, van der Linden S (2006) Prevalence and annual incidence of vertebral fractures in patients with ankylosing spondylitis. Rheumatol Int 26(3):234–239
17. Thomsen AH, Uhreholt L, Jurik AG, Vesterby A (2010) Traumatic death in ankylosing spondylitis—a case report. J Forensic Sci 55(4):1126–1129
18. Bennett AN, Rehman A, Hensor EM, Marzo-Ortega H, Emery P, McGonagle D (2009) Evaluation of the diagnostic utility of spinal magnetic resonance imaging in axial spondylarthritis. Arthritis Rheum 60(5):1331–1341
19. Appel H, Loddenkemper C, Grozdanovic Z, Ebhardt H, Dreimann M, Hempfing A et al (2006) Correlation of histopathological findings and magnetic resonance imaging in the spine of patients with ankylosing spondylitis. Arthritis Res Ther 8(5):R143
20. Braun J, Baraliakos X, Golder W, Hermann KG, Listing J, Brandt J et al (2004) Analysing chronic spinal changes in ankylosing spondylitis: a systematic comparison of conventional x rays with magnetic resonance imaging using established and new scoring systems. Ann Rheum Dis 63(9):1046–1055
21. Baraliakos X, Listing J, Brandt J, Haibel H, Rudwaleit M, Sieper J et al (2007) Radiographic progression in patients with ankylosing spondylitis after 4 years of treatment with the anti- TNF-alpha antibody infliximab. Rheumatology (Oxford) 46 (9):1450–1453
22. Lambert RG, Salonen D, Rahman P, Inman RD, Wong RL, Einstein SG et al (2007) Adalimumab significantly reduces both spinal and sacroiliac joint inflammation in patients with ankylos- ing spondylitis: a multicenter, randomized, double-blind, placebo- controlled study. Arthritis Rheum 56(12):4005–4014
23. Baraliakos X, Landewe R, Hermann KG, Listing J, Golder W, Brandt J et al (2005) Inflammation in ankylosing spondylitis: a systematic description of the extent and frequency of acute spinal changes using magnetic resonance imaging. Ann Rheum Dis 64
(5):730–734
24. Khanna M, Keightley A (2005) MRI of the axial skeleton
manifestations of ankylosing spondylitis. Clin Radiol 60(1):135–136
25. Levine DS, Forbat SM, Saifuddin A (2004) MRI of the axial skeletal manifestations of ankylosing spondylitis. Clin Radiol 59
(5):400–413
26. Baraliakos X, Hermann KG, Landewe R, Listing J, Golder W,
Brandt J et al (2005) Assessment of acute spinal inflammation in patients with ankylosing spondylitis by magnetic resonance imaging: a comparison between contrast enhanced T1 and short tau inversion recovery (STIR) sequences. Ann Rheum Dis 64 (8):1141–1144
27. Gaspersic N, Sersa I, Jevtic V, Tomsic M, Praprotnik S (2008) Monitoring ankylosing spondylitis therapy by dynamic contrast- enhanced and diffusion-weighted magnetic resonance imaging. Skeletal Radiol 37(2):123–131
28. Weber U, Maksymowych WP, Jurik AG, Pfirrmann CW, Rufibach K, Kissling RO et al (2009) Validation of whole-body against conventional magnetic resonance imaging for scoring acute inflammatory lesions in the sacroiliac joints of patients with spondylarthritis. Arthritis Rheum 61(7):893–899
29. Weber U, Hodler J, Jurik AG, Pfirrmann CW, Rufibach K, Kissling RO et al (2010) Assessment of active spinal inflamma- tory changes in patients with axial spondyloarthritis: validation of whole body MRI against conventional MRI. Ann Rheum Dis 69 (4):648–653
30. Helliwell PS, Hickling P, Wright V (1998) Do the radiological changes of classic ankylosing spondylitis differ from the changes found in the spondylitis associated with inflammatory bowel disease, psoriasis, and reactive arthritis? Ann Rheum Dis 57(3):135–140
31. Chandran V, Barrett J, Schentag CT, Farewell VT, Gladman DD (2009) Axial psoriatic arthritis: update on a longterm prospective study. J Rheumatol 36(12):2744–2750
32. Lubrano E, Marchesoni A, Olivieri I, D’Angelo S, Spadaro A, Parsons WJ et al (2009) Psoriatic arthritis spondylitis radiology index: a modified index for radiologic assessment of axial involvement in psoriatic arthritis. J Rheumatol 36(5):1006–1011
33. Hanly JG, Russell ML, Gladman DD (1988) Psoriatic spondy- loarthropathy: a long term prospective study. Ann Rheum Dis 47 (5):386–393
34. Takigawa T, Tanaka M, Nakanishi K, Misawa H, Sugimoto Y, Takahata T et al (2008) SAPHO syndrome associated spondylitis. Eur Spine J 17(10):1391–1397

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The Role of Emergency Radiology in Spinal Trauma

The Role of Emergency Radiology in Spinal Trauma

Spinal trauma consists of spine fractures, or spinal fractures, and spinal cord injuries. Approximately 12,000 spinal trauma cases are reported in the United States every year. While the most prevalent causes of spinal cord injuries and spine fractures are automobile accidents and falls, spinal trauma can also be attributed to assault, sports injuries, and work-related accidents. Diagnosis of spinal trauma includes imaging and assessment of nerve function, such as reflex, motor, and sensation. The following article discusses the role of emergency radiology in spinal trauma. Chiropractic care can help provide diagnostic evaluations for spinal trauma.

Abstract

Spinal trauma is very frequent injury with different severity and prognosis varying from asymptomatic condition to temporary neurological dysfunction, focal deficit or fatal event. The major causes of spinal trauma are high- and low- energy fall, traffic accident, sport and blunt impact. The radiologist has a role of great responsibility to establish the presence or absence of lesions, to define the characteristics, to assess the prognostic influence and therefore treatment. Imaging has an important role in the management of spinal trauma. The aim of this paper was to describe: incidence and type of vertebral fracture; imaging indication and guidelines for cervical trauma; imaging indication and guidelines for thoracolumbar trauma; multidetector CT indication for trauma spine; MRI indication and protocol for trauma spine.

Introduction

The trauma of the spine weighs heavily on the budget of social and economic development of our society. In the USA, 15–40 cases per million populations with 12,000 cases of paraplegia every year, 4000 deaths before admission and 1000 deaths during hospitalization are estimated. The young adult population is the most frequently involved in road accidents, followed by those at home and at work, with a prevalence of falls from high and sports injuries.1

Imaging has an important role in the management of spinal trauma. Quick and proper management of the patients with trauma, from diagnosis to therapy, can mean reduction of the neurological damage of vital importance for the future of the patient. Radiologists have a role of great responsibility to establish the presence or absence of lesions, defining the characteristics, assessing the prognostic influence and therefore treatment.

The aim of this paper was to describe:

  • incidence and type of vertebral fracture
  • imaging indication and guidelines for cervical trauma
  • imaging indication and guidelines for thoracolumbar trauma
  • multidetector CT (MDCT) pattern for trauma spine
  • MRI pattern for trauma spine.
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Spinal trauma, including spine fractures and spinal cord injuries, represent about 3 percent to 6 percent of all skeletal injuries. Diagnostic assessments are fundamental towards the complex diagnosis of spinal trauma. While plain radiography is the initial diagnostic modality used for spine fractures and/or spinal cord injuries, CT scans and MRI can also help with diagnosis. As a chiropractic care office, we can offer diagnostic assessments, such as X-rays, to help determine the best treatment.

Dr. Alex Jimenez D.C., C.C.S.T.

Vertebral Fracture Management and Imaging Indication and Evaluation

The rationale of imaging in spinal trauma is:

  • To diagnose the traumatic abnormality and characterize the type of injury.
  • To estimate the severity, potential spinal instability or damaged stability with or without neurological lesion associated, in order to avoid neurological worsening with medical legal issue.
  • To evaluate the state of the spinal cord and surrounding structures (MR is the gold standard technique).

Clinical evaluation involving different specialities—emergency medicine, trauma surgery, orthopaedics, neurosurgery and radiology or neuroradiology—and trauma information is the most important key point in order to decide when and which type of imaging technique is indicated.2

A common question in patients with spine trauma is: is there still a role for plain-film X-ray compared with CT?

In order to clarify when and what is more appropriate for spinal trauma, different guidelines were published distinguishing cervical and thoracolumbar level.

Cervical Spinal Trauma: Standard X-Ray and Multidetector CT Indication

For cervical level, controversy persists regarding the most efficient and effective method between cervical standard X-ray with three film projections (anteroposterior and lateral view plus open-mouth odontoid view) and MDCT.

X-ray is generally reserved for evaluating patients suspected of cervical spine injury and those with injuries of the thoracic and lumbar areas where suspicion of injury is low. Despite the absence of a randomized controlled trial and thanks to the high quality and performance of MDCT and its post-processing (multiplanar reconstruction and three-dimensional volume rendering), the superiority of cervical CT (CCT) compared with cervical standard X-ray for the detection of clinically significant cervical spine injury is well demonstrated.

Figure 1. (a–l). A 20-year-old male involved in a motorbike accident. The multidetector CT with multiplanar reformatted and three- dimensional volume-rendering reconstructions (a–d) showed traumatic fracture of C6 with traumatic posterior spondylolisthesis grade III with spinal cord compression. The MRI (e–h) confirmed the traumatic fracture of C6 with traumatic posterior spondylolisthesis grade III with severe spinal cord compression. The post-surgical treatment MRI control (i–l) showed the sagittal alignment of cervical level and severe hyperintensity signal alteration of the spinal cord from C3 to T1.

In order to reduce the patient radiation exposure, it is important to determine and to select patients who need imaging and those who do not, through the clinical evaluation and probability of cervical spine injury, using only MDCT for the appropriate patient as is more cost-effective screening.3

First of all, it is necessary to distinguish the type of trauma:

  • minor trauma (stable patient, mentally alert, not under the influence of alcohol or other drugs and who has no history or physical findings suggesting a neck injury)
  • major and severe trauma (multitrauma, unstable patient with a simple temporary neurological dysfunction, with focal neurological deficit or with a history or mechanism of injury sufficient to have exceeded the physiologic range of motion).

Second, it is important to establish if trauma risk factors are presents, such as:

  • violence of trauma: high-energy fall (high risk) or low-energy fall (low risk)
  • age of the patient: <5years old, >65 years old 
  • associated lesions: head, chest, abdomen (multitrauma) etc.
  • clinical signs: Glasgow Coma Scale (GCS), neurological deficit, vertebral deformation.

Combining these elements, patients can be divided into “low
risk” and “high risk” for cervical injury.

The first group consists of patients who are awake (GCS 15), alert, cooperative and non-intoxicated without any distract- ing injury.

The second group consists of unconscious, sedated, intoxicated or non-cooperative patients or those with a distracting injury or an altered mental state (GCS ,15) with a 5% chance of cervical spine injuries.3,4

CCT has a wider indication than X-ray for patients at very high risk of cervical spine injury (major trauma or multitrauma). No evidence suggests CCT instead of X-ray for a patient who is at low risk for cervical spine injury.5

Figure 2. (a–g). A 30-year-old male involved in a motorbike accident. The multidetector CT with multiplanar reformatted and three-dimensional volume-rendering reconstructions (a–d) showed traumatic burst fracture of L1 (A2-type Magerl class) with posterior bone fragment dislocation into spinal canal. The MRI (e–g) confirmed the burst fracture of L1 with moderate spinal cord compression.
Figure 3. (a–d) A 50-year-old male involved in a motorbike accident with acute spinal cord compression symptoms on anticoagulation treatment. The MRI showed an acute haemorrhagic lesion at the C2–C4 posterior epidural space, hypointense on sagittal T1 weighted (a) and hyperintense on T2 weighted (b) with spinal cord compression and dislocation on axial T2* (c) and T2 weighted (d).

In 2000, the National Emergency X-Radiography Utilization (NEXUS) study, analysing 34,069 patients, established low-risk criteria to identify patients with a low probability of cervical spine injury, who consequently needed no cervical spine imaging. To meet the NEXUS criteria, a patient must have the following conditions:

  1. no tenderness at the posterior midline of the cervical spine
  2. no focal neurologic deficit
  3. normal level of alertness
  4. no evidence of intoxication
  5. no clinically apparent painful injury that might distract the patient from the pain of a cervical spine injury.6

If all of these roles are present, the patient does not need to undergo X-ray because he has a low possibility of having a cervical spine injury with a sensitivity of 99% and a specificity of 12.9%.7

In 2001, the Canadian C-spine rule (CCSR) study developed a second decision rule using the risk factor of the trauma: three high-risk criteria (age $ 65 years, dangerous mechanism and paraesthesias in extremities), five low-risk criteria (simple rear-end motor vehicle collision, sitting position in emergency department, ambulatory at any time, delayed onset of neck pain and absence of midline cervical spine tenderness) and the ability of the patient to actively rotate his or her neck to determine the need for cervical spine radiography. In practice, if one of these risk factors is present, the patient needs to undergo imaging evaluation. On the other hand, if the risk factors are not present, the use of the NEXUS criteria plus a functional evaluation of the cervical spine is needed (left and right cervical spine rotation .45°); if this functional evaluation is possible, imaging is unnecessary. If an incomplete cervical movement is present, then the patient needs to be checked with imaging. The results showed the criteria to have a sensitivity of up to 100% and a specificity of up to 42.5%.8

Applying these criteria, before cervical spine imaging, the authors report a decrease of about 23.9% in the number of negative CCT, and applying a more liberal NEXUS criteria including the presence or absence of pain, limited range of motion or posterolateral cervical spine tenderness, they report a decrease of up to 20.2% in the number of negative studies.2

If these clinical criteria cannot be applied, CCT must be performed.

Major and severe traumas request a direct CCT screening, especially because there could be associated lesions, according to the high-risk criteria developed by Blackmore and Hanson to identify patients with trauma at high risk of c-spine injury who would benefit from CT scanning as the primary radiological investigation9 Figure 1.

Thoracolumbar Spinal Trauma: Standard X-Ray and Multidetector CT Indication

For thoracolumbar level, MDCT is a better examination for depicting spine fractures than conventional radiography. It has wider indication in the diagnosis of patients with thoracolumbar trauma for bone evaluation. It is faster than X-ray, more sensitive, thanks to multiplanar reformatted or volume-rendering reconstruction detecting small cortical fracture, and the sagittal alignment can be evaluated with a wide segment evaluation.10

It can replace conventional radiography and can be performed alone in patients who have sustained severe trauma.10

In fact, thoracolumbar spinal injuries can be detected during visceral organ-targeted CT protocol for blunt traumatic injury.

Figure 4. A 55-year-old female involved in a car accident with acute left cervical brachialgia. The sagittal T2 weighted (a) and axial T2 weighted (b) MRI showed a post-traumatic posterolateral herniated disc with spinal cord compression and soft hyper signal alteration on the C3–C4 spinal cord.

Thanks to multidetector technology, images reconstructed using a soft algorithm and wide-display field of view that covers the entire abdomen using a visceral organ-targeted protocol with 1.5-mm collimation are sufficient for the evaluation of spine fractures in patients with trauma, given that multiplanar reformatted images are provided without performing new CT study and without increasing radiation dose11 Figure 2.

With MDCT there is no information about spinal cord status or ligament lesion or acute epidural haematoma; it can only evaluate bone status. Spinal cord injury is suspected only by clinical data.

CCT is strictly recommended in patients affected by blunt cerebrovascular injuries. Both lesions can be strictly correlated and generally; contrast medium administration to exclude hemorrhagic brain lesion and cervical fracture is not needed.10

Dr Jimenez White Coat

Magnetic resonance imaging, or MRI, is a medical diagnostic assessment technique utilized in radiology to create pictures of the anatomy and the physiological processes of the human body. Alongside radiography and CT scans, MRI can be helpful in the diagnosis of spinal trauma, including spine fractures and spinal cord injuries. Magnetic resonance imaging may not be necessary for all cases of spinal trauma. However, it could provide detailed information on the other soft tissues of the spine. 

Dr. Alex Jimenez D.C., C.C.S.T.

Spinal Trauma and MRI

Even if MDCT is the first imaging modality in a patient with trauma, MRI is essential for the soft assessment of the ligament, muscle or spinal cord injury, spinal cord, disc, ligaments and neural elements, especially using T2 weighted sequences with fat suppression or T2 short tau inversion recovery (STIR) sequence.12 MRI is also used to classify burst fracture, obtaining information about the status of the posterior ligamentous complex, a critical determinant of surgical indication even if the diagnosis of ligament injuries remains complex, and its grade is also underestimated using high-field MRI.13

Figure 5. A 65-year-old female involved in domestic trauma with spinal cord symptoms. The sagittal T1 weighted (a) and T2 weighted (b) MRI showed a traumatic T12–L1 spinal cord contusion hypointense on T1 weighted and hyperintense on T2 weighted.

In the management of patients with polytrauma, MDCT total-body scan is necessary in an emergency condition, and MRI whole-spine indication is secondary to the clinical status of the patient: spinal cord compression syndrome Figure 3–5 MRI protocols recommended for patients affected by spinal injury and trauma are the following:13,14

  • Sagittal T1 weighted, T2 weighted and STIR sequence for the bone marrow and spinal cord injury or spinal cord compression evaluation owing to epidural haematoma or traumatic herniated disc
  • Sagittal gradient echo T2* sequence for haemorrhage evaluation of the spinal cord or into the epidural–subdural space
  • Sagittal diffusion-weighted imaging helpful when evaluating spinal cord injury, differentiating cytotoxic from vasogenic oedema, assisting in detecting intramedullary haemorrhage. It can help to evaluate the degree of compressed spinal cord.
  • Axial T1 weighted and T2 weighted sequence for the right localization of the injury. Recently, for patients affected by acute blunt trauma and cervical spinal cord injury, the axial T2 weighted sequence has been shown to be important for trauma-predicting outcomes. On axial T2 weighted imaging, five patterns of intramedullary spinal cord signal alteration can be distinguished at the injury’s epicentre. Ordinal values ranging from 0 to 4 can be assigned to these patterns as Brain and Spinal Injury Center scores, which encompassed the spectrum of spinal cord injury severity correlating with neurological symptoms and MRI axial T2 weighted imaging. This score improves on current MRI-based prognostic descriptions for spinal cord injury by reflecting functionally and anatomically significant patterns of intramedullary T2 signal abnormality in the axial plane.15
Figure 6. A 20-year-old female involved in domestic trauma with back pain resistance to medical therapy. The standard antero- posterior–laterolateral X-ray (a) showed no vertebral fractures. The MRI showed a bone marrow alteration at lumbar vertebral body hyperintense on T2 weighted (T2W) (a), hypointense on T1 weighted (T1W) (b) and short tau inversion recovery (STIR) (c).

MRI has also an important role in case of discordance between clinical status and CT imaging. In the absence of vertebral fracture, patients can suffer from back pain resistant to medical therapy owing to bone marrow traumatic oedema that can be detected only using STIR sequence on MRI Figure 6.

In spinal cord injury without radiologic abnormalities (SCI- WORA), MRI is the only imaging modality that can detect intramedullary or extramedullary pathologies or show the absence of neuroimaging abnormalities.16 SCIWORA refers to spinal injuries, typically located in the cervical region, in the absence of identifiable bony or ligamentous injury on complete, technically adequate, plain radiographs or CT. SCIWORA should be suspected in patients subjected to blunt trauma who report early or transient symptoms of neurologic deficit or who have existing findings upon initial assessment.17

Vertebral Fracture Type and Classification

The rationale of imaging is to distinguish the vertebral fracture type into two groups:

• vertebral compression fracture as vertebral body fracture
compressing the anterior cortex, sparing the middle posterior
columns associated or not with kyphosis
• burst fracture as comminuted fracture of the vertebral body
extending through both superior and inferior endplates with kyphosis or posterior displacement of the bone into the canal. and to distinguish which type of treatment the patient needs; by imaging, it is possible to classify fractures into stable or unstable fracture, giving indication to conservative or surgical therapy.

Figure 7. (a–f) A 77-year-old female involved in domestic trauma with back pain resistance to medical therapy. The multidetector CT (a) showed no vertebral fractures. The MRI showed a Magerl A1 fracture with bone marrow oedema at T12–L1 vertebral body hypointense on T1 weighted (b), hyperintense on T2 weighted (c) and short tau inversion recovery (d) treated by vertebroplasty (e–f).
Figure 8. (a–d) A 47-year-old male involved in a motorbike accident with back pain resistance to medical therapy. The MRI showed a Magerl A1 fracture with bone marrow oedema at T12 vertebral body hypointense on T1 weighted (a) hyperintense on T2 weighted (b) and short tau inversion recovery (c) treated by assisted-technique vertebroplasty—vertebral body stenting technique (d).

Using MDCT and MRI, thanks to morphology and injury distribution, various classification systems have been used for identifying those injuries that require surgical intervention, distinguishing among stable and unstable fractures and surgical and non-surgical fractures.1

Denis proposed the “three-column concept”, dividing the spinal segment into three parts: anterior, middle and posterior columns. The anterior column comprises the anterior longitudinal ligament and anterior half of the vertebral body; the middle column comprises the posterior half of the vertebral body and posterior longitudinal ligament; and the posterior column comprises the pedicles, facet joints and supraspinous ligaments. Each column has different contributions to stability, and their damages may affect stability differently. Generally, if two or more of these columns are damaged, the spine becomes unstable.18

Magerl divided the vertebral compression fracture (VCF) into three main categories according to trauma force: (a) compression injury, (b) distraction injury and (c) rotation injury. Type A has conservative or non-surgical mini-invasive treatment indication.19

The thoracolumbar injury classification and severity score (TLICS) system assigns numerical values to each injury based on the categories of morphology of injury, integrity of the posterior ligament and neurological involvement. Stable injury patterns (TLICS,4) may be treated non-operatively with brace immobilization. Unstable injury patterns (TLICS.4) may be treated operatively with the principles of deformity correction, neurological decompression if necessary and spinal stabilization.20

The Aebi classification is based on three major groups: A = isolated anterior column injuries by axial compression, B = disruption of the posterior ligament complex by distraction posteriorly and C = corresponding to group B but with rotation. There is an increasing severity from A to C, and within each group, the severity usually increases within the subgroups from 1 to 3. All these pathomorphologies are supported by the mechanism of injury, which is responsible for the extent of the injury. The type of injury with its groups and subgroups is able to suggest the treatment modality.21

Thoracolumbar Fracture and Mini-Invasive Vertebral Augmentation Procedure: Imaging Target

Recently, different mini-invasive procedures called assisted- technique vertebroplasty (balloon kyphoplasty KP or kyphoplasty-like techniques) have been developed in order to obtain pain relief and kyphosis correction as alternative treatment for non-surgical but symptomatic vertebral fracture.

The rationale of these techniques is to combine the analgesic and vertebral consolidation effect of vertebroplasty with the restoration of the physiological height of the collapsed vertebral body, reducing the kyphotic deformity of the vertebral body, delivering cement into the fractured vertebral body with a vertebral stabilization effect compared with conservative therapy (bed rest and medical therapy).22

From interventional point of view, imaging has an important role for treatment indication together with clinical evaluation. Both MDCT and MRI are recommended Figure 7 and 8.

In fact, MDCT has the advantage of diagnosing VCF with kyphosis deformity easily, while MRI with STIR sequence is useful to evaluate bone marrow oedema, an important sign of back pain.

Patients affected by vertebral fracture without bone marrow oedema on STIR sequence are not indicated for interventional procedure.

According to imaging, Magerl A1 classification fractures are the main indication of treatment.

However, the treatment must be performed within 2–3 weeks from trauma in order to avoid sclerotic bone response: the younger the fractures, the better the results and easier the treatment and vertebral augmentation effect. To exclude sclerotic bone reaction, CT is recommended.

Conclusion

The management of spinal trauma remains complex. MDCT has a wide indication for bone evaluation in patients affected by severe trauma or patients with high risk of spine injury. MRI has a major indication in the case of spinal cord injury and the absence of bone lesion. Diagnostic assessment of spinal trauma, including radiography, CT scans, and MRI are fundamental towards the diagnosis of spine fractures and spinal cord injury for treatment. The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .

Curated by Dr. Alex Jimenez

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Additional Topics: Acute Back Pain

Back pain is one of the most prevalent causes of disability and missed days at work worldwide. Back pain attributes to the second most common reason for doctor office visits, outnumbered only by upper-respiratory infections. Approximately 80 percent of the population will experience back pain at least once throughout their life. The spine is a complex structure made up of bones, joints, ligaments, and muscles, among other soft tissues. Because of this, injuries and/or aggravated conditions, such as herniated discs, can eventually lead to symptoms of back pain. Sports injuries or automobile accident injuries are often the most frequent cause of back pain, however, sometimes the simplest of movements can have painful results. Fortunately, alternative treatment options, such as chiropractic care, can help ease back pain through the use of spinal adjustments and manual manipulations, ultimately improving pain relief.

 

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EXTRA IMPORTANT TOPIC: Sciatica Pain Chiropractic Therapy

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References
  1. Pneumaticos SG, Triantafyllopoulos GK, Gian- noudis PV. Advances made in the treatment of thoracolumbar fractures: current trends and future directions. Injury 2013; 44: 703–12. doi: 10.1016/j.injury.2012.12.005

  2. Griffith B, Bolton C, Goyal N, Brown ML, Jain R. Screening cervical spine CT in a level I trauma center: overutilization? AJR Am J Roentgenol 2011; 197: 463–7.doi: 10.2214/ AJR.10.5731

  3. Hanson JA, Blackmore CC, Mann FA, Wilson AJ. Cervical spine injury: a clinical decision rule to identify high-risk patients for helical CTscreening. AJR Am J Roentgenol 2000; 174: 713–17.

  4. Saltzherr TP, Fung Kon Jin PH, Beenen LF, Vandertop WP, Goslings JC. Diagnostic imaging of cervical spine injuries following blunt trauma: a review of the literature and practical guideline. Injury 2009; 40: 795–800. doi: 10.1016/j.injury.2009.01.015

  5. Holmes JF, Akkinepalli R. Computed to- mography versus plain radiography to screen for cervical spine injury: a meta-analysis. J Trauma 2005; 58: 902–5. doi: 10.1097/01. TA.0000162138.36519.2A

  6. Hoffman JR, Wolfson AB, Todd K, Mower WR. Selective cervical spine radiography in blunt trauma: methodology of the National Emergency X-Radiography Utilization Study (NEXUS). Ann Emerg Med 1998; 32: 461–9. doi: 10.1016/S0196-0644(98)70176-3

  7. Dickinson G, Stiell IG, Schull M, Brison R, Clement CM, Vandemheen KL, et al. Retro- spective application of the NEXUS low-risk criteria for cervical spine radiography in Canadian emergency departments. Ann Emerg Med 2004; 43: 507–14. doi: 10.1016/j. annemergmed.2003.10.036

  8. Stiell IG, Wells GA, Vandemheen KL, Clem- ent CM, Lesiuk H, De Maio VJ, et al. The Canadian C-spine rule for radiography in

alert and stable trauma patients. JAMA 2001;

286: 1841–8. doi: 10.1001/jama.286.15.1841 9. Berne JD, Velmahos GC, El-Tawil Q, Deme- triades D, Asensio JA, Murray JA, et al. Value

of complete cervical helical computed to- mographic scanning in identifying cervical spine injury in the unevaluable blunt trauma patient with multiple injuries: a prospective study. J Trauma 1999; 47: 896–902. doi: 10.1097/00005373-199911000-00014

10. Wintermark M, Mouhsine E, Theumann N, Mordasini P, van Melle G, Leyvraz PF, et al. Thoracolumbar spine fractures in patients who have sustained severe trauma: depiction with multi-detector row CT. Radiology 2003; 227: 681–9. doi: 10.1148/radiol.2273020592

11. Kim S, Yoon CS, Ryu JA, Lee S, Park YS, Kim SS, et al. A comparison of the diagnostic performances of visceral organ-targeted ver- sus spine-targeted protocols for the evalua- tion of spinal fractures using sixteen-channel multidetector row computed tomography: is additional spine-targeted computed tomog- raphy necessary to evaluate thoracolumbar spinal fractures in blunt trauma victims? J Trauma 2010; 69: 437–46. doi: 10.1097/ TA.0b013e3181e491d8

12. Pizones J, Castillo E. Assessment of acute thoracolumbar fractures: challenges in mul- tidetector computed tomography and added value of emergency MRI. Semin Musculoskelet Radiol 2013; 17: 389–95. doi: 10.1055/s- 0033-1356468

13. Emery SE, Pathria MN, Wilber RG, Masaryk T, Bohlman HH. Magnetic resonance imag- ing of posttraumatic spinal ligament injury. J Spinal Disord 1989; 2: 229–33. doi: 10.1097/ 00002517-198912000-00003

14. Zhang JS, Huan Y. Multishot diffusion- weighted MR imaging features in acute trauma of spinal cord. Eur Radiol 2014; 24: 685–92. doi: 10.1007/s00330-013-3051-3

15. Talbott JF, Whetstone WD, Readdy WJ, Ferguson AR, Bresnahan JC, Saigal R, et al. The Brain and Spinal Injury Center score:
a novel, simple, and reproducible method for assessing the severity of acute cervical spinal cord injury with axial T2-weighted MRI findings. J Neurosurg Spine 2015; 23: 495–504. doi: 10.3171/2015.1.SPINE141033

16. Boese CK, Oppermann J, Siewe J, Eysel P, Scheyerer MJ, Lechler PJ. Spinal cord injury without radiologic abnormality in children: a systematic review and meta-analysis. Trauma Acute Care Surg 2015; 78: 874–82. doi: 10.1097/TA.0000000000000579

17. Brown RL, Brunn MA, Garcia VF. Cervical spine injuries in children: a review of
103 patients treated consecutively at a level 1 pediatric trauma center. J Pediatr Surg 2001; 36: 1107–14. doi: 10.1053/jpsu.2001.25665

18. Denis F. The three column spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine (Phila Pa 1976) 1983; 8: 817–31. doi: 10.1097/ 00007632-198311000-00003

19. Magerl F, Aebi M, Gertzbein SD, Harms J, Nazarian S. A comprehensive classification of thoracic and lumbar injuries. Eur Spine J 1994; 3: 184–201.

20. Patel AA, Dailey A, Brodke DS, Daubs M, Harrop J, Whang PG, et al; Spine Trauma Study Group. Thoracolumbar spine trauma classification: the Thoracolumbar Injury Classification and Severity Score system and case examples. J Neurosurg Spine 2009; 10: 201–6. doi: 10.3171/2008.12.SPINE08388

21. Aebi M. Classification of thoracolumbar fractures and dislocations. Eur Spine J 2010; 19(Suppl. 1): S2–7. doi: 10.1007/s00586-009-1114-6

22. Muto M, Marcia S, Guarnieri G, Pereira V. Assisted techniques for vertebral cementoplasty: why should we do it? Eur J Radiol 2015; 84: 783–8. doi: 10.1016/j.ejrad.2014.04.002

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Neck Pain Treatment Management

Neck Pain Treatment Management

I do recommend that you seek a specialist, in this case, it would be Dr. Alex Jimenez. His techniques to work on the cervical area or your neck are just amazing. He has been able to treat migraines, shoulder pain, when people didn’t know it was just a simple cause…spraining their neck.

Sandra Rubio

Have you ever woken up with a stiff neck, unable to turn it to one side or another? Does your child appear to have an abnormal head or neck posture? A variety of factors can cause injuries and/or conditions which may result in neck pain, such as torticollis, a painful health issue that can result in the shortening of the complex structures of the neck.

The neck, known as the cervical spine, consists of vertebrae that start in the upper region of the spine and finish at the base of the skull. Each bony vertebrae connects with ligaments, comparable to thick rubber bands, muscles and other soft tissues like tendons, which provide stability to the backbone. These structures ultimately permit for movement and support.

The neck supports the weight of the head and provides significant motion. Because it is less protected than the rest of the spine, the neck may be vulnerable to injury or conditions. For many individuals, neck pain is a temporary condition that vanishes with time. However, others need diagnosis and treatment to relieve their symptoms. Below, we will discuss some of the most common causes of neck pain, including torticollis.

Common Causes of Neck Pain

Neck pain may result from abnormalities in the soft tissues, such as the muscles, ligaments, tendons and even the nerves, as well as in the bones and intervertebral discs of the spine. The most frequent causes of neck pain are soft-tissue abnormalities due to trauma, known as a sprain or strain, or due to prolonged wear and tear or degeneration. In rare cases, infection or tumors can cause neck pain. In certain people, neck problems may be the origin of pain at the back, shoulders, or upper extremities.

Cervical Disk Degeneration (Spondylosis)

The intervertebral discs act as shock absorbers between the bones in the neck. In cervical disk degeneration, which generally occurs in people over the age of 40, the gel-like center of the disc degenerates and the distance between the vertebrae narrows. When the disc space becomes narrower, stress accumulates in the joints of the spine, resulting in degenerative diseases, such as cervical disk degeneration or spondylosis. Once the outer layer of the disc weakens, stress may also protrude and place pressure on the spinal cord or nerve roots. This is known as a herniated disc.

Neck Injury

Since the primary function of the neck is to support the head and provide movement, it’s very flexible, however, because of this, it’s incredibly vulnerable to injury. Automobile accidents, slip-and-fall incidents, and sports injuries may commonly cause neck pain. The regular use of safety belts in motor vehicles can help prevent neck injury. A “rear end” car crash may result in whiplash, a common neck injury characterized by a sudden, back-and-forth jerk of the neck and head from a sheer force. Most neck injuries involve the soft tissues. Severe neck injuries with dislocation or a fracture of the neck may damage the spinal cord and cause paralysis.

Torticollis

Torticollis is a medical health issue characterized by a “twisted neck”. There are two kinds of the condition, congenital, meaning present at birth, and acquired, involving damage or trauma from an injury or condition. For many infants, torticollis develops in the womb several weeks before their birth at which neck and the head are positioned in an angle.

Children have also been born with the health issue due to difficulties during delivery, diminished blood supply to the neck muscles, muscular fibrosis or congenital spine anomalies. According to research studies, torticollis sometimes develops in children that spend too much time sitting in strollers, swings, bouncers, car seats, laying on their back, or putting them on mats if a child is born with abnormal head and neck positioning.

While nearly all people who experience torticollis are babies or children, anyone can experience neck pain and restricted range of motion connected with that. A musculoskeletal or nervous system injury can make it difficult to position your head or to straighten your neck. This kind of damage may be associated with prolonged ailments, car accidents or other injuries.

When to Seek Treatment for Neck Pain?

If severe neck pain occurs after a neck injury due to an automobile accident, diving injury, or slip-and-fall incident, a trained professional, such as a paramedic, should trap the patient to prevent the risk of further harm and possible paralysis. Immediate medical assistance should be considered. Healthcare professionals, like chiropractors, can also treat neck injuries.

Immediate medical care must also be sought when an injury causes pain in the neck which radiates down the arms and legs. Radiating pain or tingling sensations in your arms and legs resulting in weakness and numbness without especially neck pain should also be assessed as soon as possible. If there is no injury, you should seek medical attention when neck pain is:

  • Constant and persistent
  • Severe
  • Accompanied by pain which radiates down the arms or legs
  • Accompanied by headaches, tingling, weakness or numbness

Many patients seek treatment for neck pain with healthcare professionals that are specially trained to diagnose, treat, and prevent problems between the muscles, bones, joints, ligaments, tendons, and nerves. Many treat a wide variety of injuries and conditions. Chiropractic care is a popular, alternative treatment option which can help treat neck pain.

Torticollis Treatment

For most adults, torticollis will solve itself on its own in a couple of days. However, it is essential to seek treatment on behalf of babies or children who are currently experiencing this kind of neck or head positioning. Infants may suffer permanent disability because of shortening neck muscles if left without treatment for torticollis.

One of the first treatments doctors advocate stretching exercises designed to lengthen and strengthen the neck muscles holding the head in the position. About 80 percent of all children respond well to this kind of treatment program and don’t experience any effects. Once completed, the infant might require other treatment modalities to prevent the problem from recurring and to strengthen their neck muscles.

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Neck pain is one of the most common health issues treated with chiropractic care. According to the National Institute of Health Statistics, neck pain is the second most prevalent form of pain in the United States, following back pain associated with migraine and headaches. Chiropractic care can help treat a variety of injuries and conditions which may be causing neck pain, including torticollis.

Dr. Alex Jimenez D.C., C.C.S.T.

Chiropractic Care for Torticollis

Chiropractic care is a well-known, alternative treatment approach designed to increase range of motion, decrease muscle stiffness and improve fine and gross motor abilities needed for neck and head placement. A chiropractor will first conduct an assessment to test the patient’s range of motion and evaluate any other problems associated with neck pain.

In the case of torticollis, by way of instance, complications may include plagiocephaly, abnormal head shape, or a misalignment of the hip joint, known as hip dysplasia. When the evaluation is done, the healthcare professional will discuss a potential treatment plan and their findings.

Chiropractic care utilizes spinal adjustments and manual manipulations as well as exercises to increase range of motion and strengthen the patient’s neck muscles. These can consist of passive stretches designed to strengthen muscles which are used to maintain the posture of the neck. In infants who do not appear to be strong enough to hold their head, stretching exercises may correct the problem. Early intervention is recommended.

If you or your child are experiencing debilitating neck pain or incorrect positioning of the head and neck, contact a healthcare professional immediately. The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .

Curated by Dr. Alex Jimenez

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Additional Topics: Acute Back Pain

Back pain is one of the most prevalent causes of disability and missed days at work worldwide. Back pain attributes to the second most common reason for doctor office visits, outnumbered only by upper-respiratory infections. Approximately 80 percent of the population will experience back pain at least once throughout their life. The spine is a complex structure made up of bones, joints, ligaments, and muscles, among other soft tissues. Because of this, injuries and/or aggravated conditions, such as herniated discs, can eventually lead to symptoms of back pain. Sports injuries or automobile accident injuries are often the most frequent cause of back pain, however, sometimes the simplest of movements can have painful results. Fortunately, alternative treatment options, such as chiropractic care, can help ease back pain through the use of spinal adjustments and manual manipulations, ultimately improving pain relief.

 

blog picture of cartoon paper boy

EXTRA IMPORTANT TOPIC: Neck Pain Chiropractic Treatment

What to Know About Cervical Facet Joint Pain

What to Know About Cervical Facet Joint Pain

Cervical facet joint syndrome, or cervical facet osteoarthritis, is a degenerative condition marked by stiffness and pain in the cervical region (neck) of the spine. Individuals can gain relief from various types of treatment, including chiropractic care.

 

Facet joint problems are among the most common sources of lower back and neck pain. They can cause debilitating, chronic problems with the neck and back and can lead to other more severe conditions and symptoms that can be disabling.

 

What is Cervical Facet Joint Pain?

 

The spine, comprised of a chain of bones known as vertebrae. Each one has two facet joints on the back side and a large disc on the front side, allowing the vertebrae to stack neatly, one on top of the other, providing stabilization for the entire body.

 

The facet joints are synovial joints, like other joints in the body and sometimes they can become inflamed or injured, causing pain and stiffness. Cervical facet joint pain is, quite literally, a pain in the neck. It means that the joints in the neck area have become injured or inflamed. Suffering from this condition can make it difficult for the patient to turn their head from side to side, or to move it up and down.

 

The cervical facet joints are almost always working. They undergo repetitive, constant motion and over time they can become torn or worn down. Problems within the joint can cause movement to be restricted, or it can have too much, both of which can cause pain.

 

Injury, such as whiplash, to the area, can also cause problems. If not treated appropriately the condition can be degenerative, and the patient can lose both flexibility and mobility, as well as suffer from chronic pain.

 

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Symptoms of Cervical Facet Joint Pain

 

The symptoms of cervical facet joint pain tend to vary from patient to patient. A patient may experience one or several of these symptoms:

 

  • Tingling, weakness, or pain in the hand and arm
  • Neck pain
  • Upper back pain that can affect the shoulders
  • Pain between the shoulder blades
  • Headaches, typically located in the back of the head
  • Swelling and tenderness at the site of the inflamed facet joint
  • Decreased range of motion and flexibility in the neck

 

Treatment for Cervical Facet Joint Pain

 

When a patient diagnosed with cervical facet joint pain, the treatment is usually fairly conservative. Their doctor may recommend soft tissue massage, physical therapy, and posture correction. Combined with medications such as an anti-inflammatory like ibuprofen, or muscle relaxers to ease muscle spasms in the muscles that surround the affected joint.

 

If those methods do not give the patient relief, the doctor may take a more aggressive approach, prescribing facet joint injections that use steroid medications injected into the affected joint. This approach is intended to keep the pain localized while reducing it. The procedure can be performed in an outpatient setting and has a good record of being useful, but the results are temporary.

 

Chiropractic for Cervical Facet Joint Pain

 

Chiropractors have had much success in treating cervical facet joint pain. They can manipulate the areas that are affected, restoring painful, restricted facet joints to a point where they can move much more natural and without pain. Over time, with regular chiropractic treatments, they can help to reestablish range of motion in the neck area for their patients. All done without any medications or injections. It is a natural, gentle, effective method for relieving the pain and helping the patient enjoy a better quality of life.

 

Injury Medical Clinic: Facet Syndrome Treatment