Download a study of the pattern of cervical spine injuries in head injured

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A STUDY OF THE PATTERN OF CERVICAL SPINE
INJURIES IN HEAD INJURED PATIENTS AS SEEN AT
THE KENYATTA NATIONAL HOSPITAL.
A DISSERTATION SUBMITTED IN PART
FULFILMENT OF THE REQUIREMENTS
FOR THE AWARD OF MASTER OF MEDICINE IN
SURGERY AT THE UNIVERSITY OF NAIROBI.
BY
DR PETER KAMAU NJOROGE
MBChB(NBI)
2003
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DECLARATION
I certify that this dissertation is my original work
and has not been presented for a degree in any other
university
Signed--------------------------- -------DR KAMAU P NJOROGE
MBChB(NBI)
This dissertation has been submitted for
examination with my approval as the university
supervisor.
Signed------------------------------------
MR VINCENT MUOKI MUTISO
MBChB(NBI),MMED(NBI), FELLOW A-O
INTERNATIONAL,ORTH&TRAUMA(UK).
CONSULTANT ORTHOPAEDIC SURGEON,
DEPARTMENT OF ORTHOPAEDIC SURGERY
COLLEGE OF HEALTH SCIENCES UNIVERSITY
OF NAIROBI
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ACKNOWLEDGMENT
I sincerely thank my supervisor Mr Vincent M Mutiso, Lecturer
department of orthopaedic surgery for his encouragement, guidance
and and able supervision during preparation for this dissertation.
My sincere gratitude to Dr Othieno of radiology department KNH
for assisting in the interpretation of radiographs.
I’m grateful to Mr Thiongo the head porter on the surgical floor
and his team for their invaluable assistance in taking patients for Xrays.
I’m grateful to the Kenyatta National Hospital Ethical and
Research Committee for their constructive corrections and allowing
me to proceed with this study.
Finally I am deeply indebted to my sister Wangui, my wife Mercy
and my little son Mark for their constant encouragement.
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DEDICATION
This work is dedicated to my father Njoroge Gathua for his
constant encouragement, support and advice through out my
studies.
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LIST OF ABBREVIATIONS
AP View
Anteroposterior view.
C1, C2
First cervical vertebrae, Second cervical vertebra etc.
CT
Computer Tomography.
H.D.U
High Dependency Unit.
I.C.U
Intensive Care Unit.
I.V
Intravenous.
KNH
Kenyatta National Hospital.
MRI
Magnetic Resonance Imaging.
RTA
Road Traffic Accidents.
SCIWORA
Spinal Cord Injury Without Radiological Abnormality.
SPSS
Statistical Package for Social Sciences.
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TABLE OF CONTENTS
TITLE
1
DECLARATION
2
AKNOWLEDGMENT
3
DEDICATION
4
LIST OF ABBREVIATIONS
5
TABLE OF CONTENTS
6
LISTS OF TABLES AND FIGURES
8
SUMMARY
10
INTRODUCTION AND LITERATURE REVIEW
12
STUDY JUSTIFICATION AND RESEARCH QUESTION
60
MAIN AND SPECIFIC OBJECTIVES
61
MATERIALS AND METHODS
62
Study design
62
Area of study
62
Study population
63
Study instruments and methods
63
Eligibility criteria
64
Exclusion criteria
64
Constraints
65
Data
66
Ethical considerations
66
RESULTS
DISCUSSION
67
84
CONCLUSIONS
90
RECOMMENDATIONS
91
REFERENCES
92
APPENDIX 1; QUESTIONNAIRE
99
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APPENDIX 2; INFORMED CONSENT FORM
102
APPENDIX 3 ; PATIENT INFORMATION FORM
103
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LISTS OF TABLES AND FIGURES
TABLE 1: Measurable parameters of the cervical spine
46
TABLE 2: Incidence of cervical spine injury
67
TABLE 3: Sex and frequency of cervical spine
70
TABLE 4: Causes of Cervical injury
73
TABLE 5: Cervical spine injury versus severity of head injury
74
TABLE 6: Region of scalp injured versus cervical spine injury
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TABLE 7: Skull fracture versus cervical spine injury
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TABLE 8: Type of skull fracture versus cervical spine injury
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TABLE 9: Level of injury versus type of cervical spine injury
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TABLE 10: Cervical spine protection on arrival at casualty
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TABLE 11: Whether KNH primary or referral hospital
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TABLE 12: Retropharyngeal widening versus cervical injury
82
TABLE 13: Loss of normal lordosis versus cervical injury
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TABLE 14: Spinal cord injuries
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TABLE 15: Treatment offered for cervical spine injury
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FIGURE 1: Parts of typical cervical vertebrae
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FIGURE 2: The three column spine
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FIGURE 3: Blood supply to the spinal cord
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FIGURE 4: Compressive flexion injuries
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FIGURE 5: Stages of vertical compression
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FIGURE 6: Stages of distractive flexion
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FIGURE 7: Stages of compression extension
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FIGURE 8: Stages of distractive extension
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FIGURE 9: Stages of lateral flexion Injury
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FIGURE 10: Schematic lateral view of the cervical spine
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FIGURE 11: Sex distribution of head injuries
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FIGURE 12: Sex distribution of cervical spine injuries
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FIGURE 13: Age distribution of cervical and head injuries
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FIGURE 14: Age distribution of head injuries
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FIGURE 16: Vertebral level of injury
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FIGURE 17: Unit X-rays ordered from
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SUMMARY
The study is a cross sectional prospective study was carried out
on the pattern of cervical spine injury in head injured patients as
seen at Kenyatta National Hospital (KNH).
The aims and objectives of the study were to determine the
relative frequency of cervical injury in head injured patients, the age
and sex distribution, the pattern of cervical spine injuries as related
to the cause and severity of head injury and the pre hospital care
given to protect the cervical spine before arrival at KNH.
All patients with head injury admitted to KNH, who qualified for
the
study,
and
consented
to
participate,
were
recruited.
Demographic information (age, sex) and clinical information( cause
of head injury, evidence of intoxication, pre-hospital care given,
level
of
consciousness,
neurological deficit,
Neck
pain
or
tenderness, Type and area of scalp injury, and all other relevant
parameters) were then obtained.
Investigations done were mainly plain radiography (three views
for the skull and a lateral, antero-posterior and odontoid view for the
cervical spine). CT scan was obtained where possible.
Three hundred and sixty one cases were recruited over a period
of 10 weeks. Of this number 19, (5.3%) were found to have cervical
spine injury. Most of the head injuries were secondary to assault
(51%), followed by road traffic accidents (41%) while fall from height
was 7.8%. Road traffic accidents contributed 57% of all the cervical
spine injuries seen.
Most of those having heads injuries were male (90%) and 10%
were female, however 26% of the cervical spine injuries seen were
female while 74% were male. The peak age range for cervical spine
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injury was 21 to 35 years. The youngest was 4.5 years and the
oldest 65 years. KNH was the primary hospital for 94% of all head
injuries seen. None had any form of cervical spine protection on
arrival. Only 18%of those referred from other hospitals had cervical
collars on arrival at the Accident & Emergency department of KNH.
The majority (78%) of the cervical spine injuries were in the lower
cervical spine (C3 to C7) with 22% in the upper cervical region (C1
to C2).Only one patient had spinal cord injury- which was mild.
The incidence of cervical spine injury in head injured patients at
KNH is 5.3%. For most of these patients (94%) KNH is the primary
hospital; none of these patients at presentation have any cervical
spine protection. Females with head injury were found to be
significantly more at risk of having cervical spine injury compared to
the males.
There is very poor pre-hospital care of the cervical spine. A lot of
emphasis on teaching the basic care of the injured and cervical
spine immobilization, to the public, police and first aid providers is
recommended.
A post mortem study of fatal head injuries would reveal the
incidence and severity of cervical spine injury in this group.
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INTRODUCTION AND LITERATURE REVIEW
INTRODUCTION
Injuries of the cervical spine are among the most common and
potentially devastating injuries involving the axial skeleton. It is a
common associated injury in patients with head trauma. The force
producing a serious head injury (e.g. a road traffic accident or a fall
from a height onto the head) may also injure the neck. One should
assume a cervical spine injury is present until proven otherwise in
patients presenting at an emergency medical facility with a history of
a high-velocity motor vehicle accident, significant head or facial
trauma, a neurological deficit, or neck pain 1. While assessment of
airway, breathing, and hemodynamic stability (A B C’s of trauma)
continue to be the highest priority in caring for the patient with
multiple traumatic injuries, central nervous system evaluation
follows closely behind. The central nervous system assessment
begins in the field. The cervical spine should be protected until
work-up proves that it is not injured.
History of the injury: The Edwin Smith papyrus (2800 BC)
referred to spinal cord injury as a disease not to be treated. Galen,
in 177 AD, reported on his experiments in animals and described
loss of movement and sensibility below the level of cord transection
until breathing stopped at higher levels. Charles-Edouard BrownSequard did experimental work on hemisection of the cord and
described his findings in papers in 1850-1851.2
Operative stabilization of the cervical spine was introduced by
Hadra in 1891, when he wired the spinous processes of a child who
had a fracture dislocation with progressive neurologic deterioration.
This was the first surgical procedure of its kind recorded in the
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literature. Further refinement in the application of internal fixation
was documented by Rogers in 1942 with a simple wire technique.
Bohlman's technique involved using separate wires for fixation of
the
adjacent
spinous
corticocancellous
grafts
processes
and
against
the
compression
spinous
of
two
processes.
Biomechanically, this was thought to provide better flexural and
torsional stiffness than Rogers' simple wiring. Weiland and McAfee
reported 100% fusion rates in 60 patients using this means of
fixation in the subaxial cervical spine. 2
Roy-Camille pioneered the use of posterior cervical plates to
manage a variety of injuries involving the posterior subaxial spine.
Magerl and Anderson have proposed variations of screw insertion
techniques.
Skull traction using modified ice tongs was introduced by
Crutchfield in 1933. Nickel and Perry pioneered the halo device in
the late 1950s, primarily to immobilize the cervical spine affected by
polio. Its application extended to trauma cases, providing a better
means of immobilization2.
The incidence of cervical spine injuries is on the increase in
many countries. This has been especially so in the last 40yrs due to
an increase in both use and volume of motor vehicles
3,4
. There is a
proportional loss in valuable manpower as most of the injured
patients are in the most productive years of their life.
Few diseases or injuries have greater potential for causing death
or devastating effects to the quality of life than cervical spine
trauma. Head injuries primarily have a high rating in both mortality
and morbidity. Together they create a devastating duo. It is
therefore of paramount importance for surgeons and emergency
unit
13
workers
to
be
conversant
with
the
relationship
and
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management of these two conditions especially when they present
together.
RELEVANT ANATOMY
The human spine comprises 24 movable presacral vertebrae, a
sacrum and a coccyx. The 24 movable presacral vertebrae comprise 7 cervical, 12 thoracic, and 5 lumbar. The five vertebrae
immediately below the lumbar are fused in the adult to form the
sacrum. The lowermost four, fused in later life, form the coccyx 5.
Vertebrae of each group can usually be identified by special
characteristics.
Furthermore,
individual
vertebrae
have
distinguishing characteristics of their own.
The vertebral column is flexible because it is composed of many
slightly movable parts-the vertebrae. Its stability however depends
largely upon ligaments and muscle. Strength, however, is provided
by the structure of the column and its constituent parts5.
PARTS OF A TYPICAL CERVICAL VERTEBRA
A typical vertebra consists of a body, a vertebral arch and
several processes for muscular and articular connections. There
are two transverse processes and one spinous process. Each lever
is acted upon by several muscles or muscle slips.
The body of the vertebra is the part that gives strength and
supports weight. It consists mostly of spongy bone that contains red
marrow. The body is separated from that above and below it by the
intervertebral disc 5,6.
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FIG: 1 Parts of typical cervical vertebrae lateral and superior
surfaces.
Posterior to the body is the vertebral arch, which, with the
posterior surface of the body, forms the walls of the vertebral
foramen. These walls enclose and protect the spinal cord.
The vertebral arch is composed of right and left pedicles and
right and left lamina. In intact vertebral columns, the series of
vertebral foramina together form the vertebral canal. A spinous
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process (vertebral spine) projects backward from each vertebral
arch at the junction of the two laminae. Transverse processes
project on either side from the junction of the pedicle and the lamina
superior and inferior articular processes on each side bear superior
and inferior articular facets respectively.
A deep notch is present on the lower edge of each pedicle, and
a shallow notch on the upper edge of each pedicle. Two adjacent
notches, together with the intervening body of the intervertebral
disc, form an interverterbral foramen, which transmits a spinal nerve
and its accompanying vessels.
The seven cervical vertebrae consist of 3 atypical and 4 typical
vertebrae.
The first cervical vertebra is called the atlas (named after Atlas,
who, according to a Greek mythology, was reputed to support the
heavens). The skull rests on it and articulates through the atlantooccipital joint. The second cervical vertebra is called the axis, because it forms a pivot around which the atlas turns and carries the
skull, and the seventh (C7) is a transitional vertebra. The third to the
sixth cervical vertebrae are regarded as typical.5,6
Atlas:- The atlas has neither spine nor body. It consists of two
lateral masses connected by a short anterior arch and by a long
posterior arch. The atlas is the widest of the cervical vertebrae. On
its upper surface it has kidney shaped articular surfaces that
articulate with the condyles of the skull. This joint allows for nodding
movements but virtually no rotation on the vertical axis can occur
here. On its lower surface the flatter configuration of its articular
surfaces allow for rotational movement between it and the axis this
is the atlanto axial joint.
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Axis; -The axis is characterized by the dens or odontoid peg, which
projects from the upper part of the body (it is the vertebral body of
the atlas developmentally). It articulates in front with the anterior
arch of the atlas, posteriorly it is separated by a bursa from the
transverse ligament of the atlas.
The apical ligament anchors the tip of the dens to the front margins
of the foramen magnum; the alar ligaments anchor it to the lateral
margins.
The lower part of the axis resembles that of a typical vertebra its
other characteristic feature is its prominent bifid spinous process,
this is the attachment of muscles and strong ligaments and shows
prominently in the lateral x-ray of the cervical spine. It however has
the smallest transverse processes of any belonging to a cervical
vertebra.
Third to sixth cervical vertebrae: -The third to sixth cervical
vertebrae each has a short broad body and a large triangular
vertebral foramen. Their spines are short and the ends of the spines
are bifid, these are usually palpable. The transverse processes are
pierced by foramen transversarium where the vertebral artery
passes through .The upper borders of the bodies are raised behind,
and especially at the sides. They are depressed in front .The raised
margins are sometimes called uncal processes.
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Seventh cervical vertebra:- The seventh cervical vertebra is
characterized by a long spine that is not bifid but ends in a tubercle
that gives attachment to ligamentum nuchae. This vertebra is known
as the vertebrae prominens because its spinous process is
prominent at the back of the neck being visible especially when the
neck is flexed.
The cervical spine can also be divided into the lower and upper
cervical spine; upper cervical spine is C 1 to C 2 whilst lower cervical
spine is C3 to C7.2
ARTICULATIONS AND LIGAMENTS
The bodies of adjacent vertebral bodies are held together by the:
1.Intervertebral discs:- The strong intervertebral disc is a
secondary fibrocartilaginous joint or symphysis.The upper and lower
parts are covered completely by a thin layer of hyaline cartilage
these two layers are united peripherally by a strong ring of fibrous
tissue called the annulus fibrosus. Inside the annulus is a bubble of
semi liquid gelatinous substance known as nucleus pulposus. It is
derived from the notochord and though central in the foetus
differential growth makes it ‘migrate’ closer to the back of the disc.
Herniation is more likely to be posterior and thus to the vertebral
canal compressing on the spinal cord. Liquid is not compressible so
the shock absorbing property of the disc is rendered by the annulus
fibrosus which is stronger that the vertebral body5,6.
2.Longitudinal ligaments; -The bodies are further held together by
longitudinal ligaments namely: The anterior longitudinal ligament extends from the anterior tubercle
of the atlas all the way to the front of the upper part of the sacrum. It
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is firmly adherent to the periosteum of the bodies but free over the
discs.
The posterior longitudinal ligament extends from the back of the
body of the axis to the sacral canal, it has serrated margins
broadest over the intervertebral disc to which they are firmly
adherent it narrows over the vertebral bodies from which it is
separated by the emerging basivertebral veins.
3.Facet joints;-The other articulation between the vertebrae is
through the facet joints these are
gliding
movements
and
their
synovial joints. They permit
configuration
determines
the
movements at different spinal levels. At the cervical level
movements possible includes extension, flexion, lateral flexion and
a degree of rotation.
4.Ligaments of the neural arch and spine; -Several ligaments
attach the adjacent neural arches, they are from posterior the:Supraspinous ligament, this is a strong band of white fibrous tissue
joining the adjacent spinous processes; they are lax in the extended
spine and taut in the flexed spine.
Interspinous ligaments, these are relatively weak sheets of fibrous
tissue joining the adjacent spinous processes along their adjacent
borders. They fuse with the supraspinous ligaments
Ligamentum flava , is yellow in colour and joins the contiguous
borders of adjacent laminae. They have a high content of elastic
fibers and are stretched by flexion giving increasing anti gravity
support.
Intertransverse ligaments these are weak fibers joining the
transverse processes along their adjacent borders.
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BLOOD SUPPLY OF THE VERTEBRAL COLUMN
The vertebra and the longitudinal muscles attached to them are
supplied by segmental arteries. The ascending cervical, the
intercostal and the lumbar arteries give multiple small branches to
the vertebral bodies.5,6
Venous drainage; -The richly supplied red marrow of the
vertebral body drains almost wholly by a pair of large basi-vertebral
veins into the internal vertebral plexus. Drainage of the neural arch
and of the attached muscles is into the external vertebral plexus.
The internal and external vertebral plexuses together drain into the
regional segmental veins.
THE MUSCLES OF THE VERTEBRAL COLUMN
The movements of the vertebral column are produced by
muscles.
Running along the whole length of the spine, from skull to
sacrum, is a posterior mass of longitudinal extensor muscles known
collectively as the erector spinae. The erector spinae consists of
three layers; these are the deepest, intermediate and superficial.
At the front of the vertebral column are some flexor muscles
derived from the innermost of the three layers of the body wall,
constituting the prevertebral rectus. Longus capitis, longus colli and
psoas belong to this group.
The vertebral column acts as a support structure for the body
(axial skeleton) and also acts as a protective structure for the spinal
cord and the cauda equina.
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THE CONCEPT OF A THREE COLUMN SPINE
The cervical spine can be viewed as 3 distinct columns: anterior,
middle, and posterior7,8. The anterior column is composed of two
thirds of the vertebral bodies, the annulus fibrosus, intervertebral
disks, and anterior longitudinal ligament. The middle column is
composed of one third of the vertebral bodies, the annulus,
intervertebral disk, and posterior longitudinal ligament. The posterior
column contains all of the remaining posterior elements formed by
the pedicles, transverse processes, articulating facets, laminae, and
spinous processes.
FIG 2: -The three column spine.
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,
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including the nuchal ligament complex, capsular ligaments, and
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 2 separate units, increasing the likelihood of
spinal cord injury7,8.
ANATOMY OF THE SPINAL CORD
The spinal cord is a cylinder somewhat flattened antero
posteriorly extending from the medulla oblongata cranially to the
lower end which tapers into a cone. In the adult the spinal cord ends
at the L1-L2 level and in children it is found a bit lower at the level of
L2-L3
It has two enlargements, which occupy the regions of limb
plexuses. These
are the cervical (C5-T1) and lumbar (L2-S3)
enlargements, their vertebral level however is at C3-T1 and T9-L1
respectively; the enlargements are due to greatly increased mass of
motor cells, which supply the upper and lower limbs respectively.
Histologically the spinal cord consists of a central mass of grey
matter surrounding the central canal, enclosed in a cylindrical mass
of white matter.
The white matter has specific tracts that are very important. Of
the many tracts in the spinal cord, only three can be readily
assessed clinically, and are of fundamental importance in clinical
assessment of spinal cord injury; they are:1.
The corticospinal tract.
2.
The spinothalamjc tract.
3.
The posterior columns.
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Each is a paired tract that may be injured on one or both sides
of the cord.
The corticospinal tract, which lies in the posterolateral segment
of the cord, controls motor power on the same side of the body and
is tested by voluntary muscle contractions or involuntary response
to painful stimuli.
The spinothalamic tract, in the anterolateral aspect of the cord,
transmits pain and temperature sensation from the opposite side of
the body. Generally it is tested by pinprick and light touch.
The posterior columns carry position sense (proprioception),
vibration sense, and some light-touch sensation from the same side
of the body, and these columns are tested by position sense in the
toes and fingers or by vibration sense using a tuning fork.
If there is no demonstrable sensory or motor function below a
certain level, this is referred to as a complete spinal cord injury. If
any motor or sensory function remains, this is an incomplete injury
and the prognosis for recovery is significantly better. Sparing of
sensation in the perianal region (sacral sparing) may be the only
sign of residual function. Sacral sparing may be demonstrated by
preservation of some sensory perception in the perianal region and /
or voluntary contraction of the rectal sphincter.1,7
BLOOD SUPPLY OF THE SPINAL CORD
The spinal cord is supplied by a single anterior and two posterior
spinal arteries, which descend from the level of the foramen
magnum. The anterior spinal artery is the larger and supplies most
of the spinal cord (Fig 3). The posterior spinal arteries consist of
one or two vessels on each side which branch from the posterior
inferior cerebellar or vertebral artery at the foramen magnum.They
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supply the posterior columns, both grey and white, of the spinal
cord. They receive a ‘booster supply from spinal branches
segmentally.
FIG 3: -Blood supply to the spinal cord.
The anterior spinal artery is a midline vessel that lies on the
anterior median fissure. It is formed at the foramen magnum by
union of two arteries, one from each vertebral artery, It supplies the
whole cord anterior to the posterior grey columns. It also receives
segmental booster supply; those at Th.
1
and Th11 are especially
large and are known as the arteries of Adamkiewicz.6
Spinal Veins. As is usual in the body, even when arterial input
is by end arteries, the emerging veins anastomose freely. The
spinal veins form loose-knit plexuses anteriorly and posteriorly. On
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each side the posterior spinal veins are double, straddling the
posterior nerve roots. Both anterior and posterior spinal veins drain
along the nerve roots through the intervertebral foramina and so into
the segmental veins.
CERVICAL SPINE INJURIES & HEAD INJURY
The head is very vulnerable to injury, often with severe
consequences. It is particularly susceptible to acceleration deceleration and rotational forces because it is heavy in relation to
its size (3-6 kg, average 4.5 kg or 10 lb).
The cervical spine is important to consider in positioning the
head in space. The dominant motion in the lower cervical spine is
flexion-extension, but the cervical spine's anatomy permits a fair
amount of motion in all planes .It is freely mobile in 3 dimensions
and occupies a relatively unstable position, being secured only by
the neck muscles and ligaments. This section of the spine connects
the base of the head to the thorax and, with the help of soft tissues,
supports the head. In high-speed injuries, the head can act as a
significant lever arm on the cervical spine and, depending on the
mechanism, can create a wide array of injury patterns. 2
The cervical spine is therefore very vulnerable and injury occurs
when the forces it is subjected to exceed its ability to dissipate
energy.
Regardless of the cause, cervical spine fractures are serious
injuries; they may involve spinal cord damage that can result in
partial or complete paralysis or even death, especially in high
cervical cord lesions.
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Most Cervical spine injuries occur during motor vehicle
accidents when the head is violently jerked either backwards or
forwards. This type of accident may not cause a fracture but instead
injure the muscles and ligaments of the neck. The resulting injury is
a neck sprain, which is commonly called whiplash.
Another common cause is violent collision that compresses the
cervical spine against the shoulders. This force can be so great that
a vertebra fractures or even bursts into small fragments e.g., striking
the head against the bottom of a pool in shallow water diving or
“spear”" tackling during contact games like rugby and American
football. This mechanism is implicated is most sports injuries
involving the neck.9
Cervical spine injury can have devastating consequences. If
present or if not ruled out, the patient’s neck will be immobilized and
this may hinder emergency measures like intubation. Krista et al
10
found that intubation with a cervical collar on can be unsuccessful in
up to 46% of cases, even when multiple attempts were found to
have been made, this was especially so in pre-hospital attempts.
Securing an air way is important as some studies have found the
incidence of hypoxia at 22% at the time of evaluation.
11
Other
studies have even reported higher figures of 30% to 40% in patients
with severe head injury12. For patients with head injury hypoxia
increases the mortality by 85%, with survivors having a higher rate
of permanent disability.13,14 Thus a lot of effort has been put to trying
to make protocols on the handling of the cervical spine in
emergency situations especially when there is head trauma. This is
because the patient will usually have a decreased level of
consciousness and thus not amenable to clinical clearance of
cervical injury.
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INCIDENCE OF CERVICAL SPINE INJURY IN HEAD TRAUMA
Head injury can be defined as any alteration in mental or
physical functioning related to a blow to the head15. Loss of
consciousness does not need to occur. Severity of head injuries
most commonly is classified by the initial post resuscitation Glasgow
Coma Scale (GCS) score, which generates a numerical summed
score for eye, motor, and verbal abilities. A score of 13-15 indicates
mild injury, a score of 9-12 indicates moderate injury, and a score of
8 or less indicates severe injury.1,15
The Advanced trauma life support (ATLS) course manual 1 gives
the incidence of cervical spine injury in head injured patients at
around 5-10%. It also states that any injury above the clavicle
should prompt a search for cervical spine injury, which may be
present in up to 15% of such patients. Several other studies done
support this and the figures range from 3% to as high as 24% in
fatal trauma cases.16,17,18,19
The incidence of spinal injury increases with severity with most
studies showing an incidence of between 7% to 10% in severe head
injuries, 16 and around 2%-4% for moderately head injured patients.
Most head injury related cervical spine injuries occur at the
upper levels C 1-C3.Shrago
20
found 56%in upper cervical 34%mid
cervical 10% lower cervical. Other studies have come up with
similar results. 21,22
At least 25% to 30 % of patients with cervical spine or cord injury
will have will have at least a mild head injury.1,20
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AETIOLOGY
Most cervical spine injuries in patients with head trauma are
secondary to RTA (road traffic accidents). With an average of 52%
of the above injuries being secondary to RTAs associated
trauma,20,21 falls constitute around 33% with the rest being attributed
to sports and other causes20. Gun shot wounds to the head have a
very low incidence of cervical spine injury10.
In general the cervical spine is the site of injury in 37 % to 55 %
of all spine injuries. Causes include RTAs 50%, Falls 20%,
Sports15% and 10% other causes6. RTAs are implicated in most of
the severe forms of injury.16,21,22
In a retrospective study by Musau
23
, he found that locally at the
KNH and Spinal Injury unit. RTAs accounted for 54.1%, fall from a
height 31.8%, assaults +gunshots 7.9%, falling objects5.3%. Peak
age was found to be 20-40 yrs with a male: female ratio at 4.5:1.
Other figures given show the following distribution the age
frequency peaks are 15-39 years. The type of accidents included
motor vehicle
accidents (50%-70%), falls
(6%-10%), diving
accidents, blunt head and neck traumas, penetrating neck injuries
and contact sports injuries taking the rest. 24
The majority occur at the C1 to C2 or C 5 to C7 level 1.C1- C 2 level
is more common in paediatrics 25.This is due to shifting of the
fulcrum effect in the cervical spine from the upper cervical spine i.e.
C 1- C 2 in children to the C 5 –C 7 level in the adult6.
At least 20% of the patients will have more than one cervical
spine fractures. Twenty percent to 75% of cervical spine fractures
are considered unstable and 30%-70% of these have associated
neurologic injuries to the spinal cord.24
28
29
Injuries of the cervical spine produce neurological damage in
approximately 40% of patients. Approximately 10% of traumatic
cord injuries have no obvious roentgenographic evidence of
vertebral injury, this type of injury is called; Spinal Cord Injury
Without Radiological Abnormality (SCIWORA). 24, 25
In traumatized patients, 3%-25% of spinal cord injuries occur
during field stabilization, transit to the hospital, or early in the course
of therapy.1 This implies that, in order to prevent additional
neurologic disability, care of any severely injured patient must
include neck stabilization until cervical fracture is ruled out.
Since the prognosis for recovery from complete cervical cord
lesions is poor, emphasis must be placed first on preventing injury
and second on preventing extension of neurologic injury once
trauma has occurred. Some patients are more prone to cord injury
especially those caused by hyperextension in older patients with
spondylolitic disease or in younger patients with congenitally
narrowed spinal canals.
CLASSIFICATION
Numerous classifications of cervical spine injuries have been
formulated, but the mechanistic classification proposed by
Allen,26 appears to be the most complete. In a review of 165 lower
cervical spine injuries, they identified the following six common
patterns of injury, each of which is subdivided into stages based on
the degree of injury to osseous and ligamentous structures.
Compressive flexion (CF)—five stages
CF stage 1: blunting of the anterosuperior vertebral margin to a
rounded contour, with no evidence of failure of the posterior
ligamentous complex.
29
30
FIG 4:-compressive flexion injuries
CF stage 2: obliquity of the anterior vertebral body with loss of
some anterior height of the centrum, in addition to the changes seen
in stage 1.
CF stage 3: fracture line passing obliquely from the anterior
surface of the vertebra through the centrum and extending through
the inferior subchondral plate, and a fracture of the beak, in addition
to the characteristics of a stage 2 injury.
CF stage 4: deformation of the centrum and fracture of the beak
with mild (less than 3 mm) displacement of the inferoposterior
vertebral margin into the spinal canal.
CF stage 5: bony injuries as in stage 3 but with more than 3 mm
of displacement of the posterior portion of the vertebral body
posteriorly into the spinal canal. The vertebral arch remains intact,
the articular facets are separated, and the interspinous process
space is increased at the level of injury, suggesting a posterior
ligamentous disruption in a tension mode.
Vertical compression (VC)—three stages
VC stage 1: fracture of the superior or inferior end plate with a
‘‘cupping’’ deformity. Failure of the end plate is central rather than
anterior, and posterior ligamentous failure is not evident.
30
31
VC stage 2: fracture of both vertebral end plates with cupping
deformities. Fracture lines through the centrum may be present, but
displacement is minimal.
FIG 5: Stages of Vertical compression
VC stage 3: progression of the vertebral body damage
described in stage 2. The centrum is fragmented, and the
displacement is peripheral in multiple directions the ligamentous
disruption is between the fractured vertebra and the one below it.
Distractive flexion (DF)—four stages
DF stage 1: failure of the posterior ligamentous complex, as
evidenced by facet subluxation in flexion, with abnormal divergence
of the spinous
process.
FIG 6: - stages of Distractive flexion
31
32
DF stage 2: unilateral facet dislocation (the degree of posterior
ligamentous failure ranges from partial failure sufficient only to
permit the abnormal displacement to complete failure of both the
anterior
and
posterior
ligamentous
complexes,
which
is
uncommon). Subluxation of the facet on the side opposite the
dislocation suggests severe ligamentous injury. In addition, a small
fleck of bone may be displaced from the posterior surface of the
articular process, which is displaced anteriorly.
DF stage 3: bilateral facet dislocations, with approximately 50%
anterior subluxation of the vertebral body. Blunting of the
anterosuperior margin of the inferior vertebra to a rounded corner
may or may not be present.
DF stage 4: full vertebral body width displacement anteriorly or a
grossly unstable motion segment, giving the appearance of a
‘‘floating’’ vertebra.
Compression extension (CE)—five stages
CE stage 1: Unilateral vertebral arch fracture; may be through
articular process (stage la), pedicle (stage lb), or lamina (stage Ic);
there may be rotary spondylolisthesis of centrum.
CE stage 2: Bilaminar fractures without evidence of other tissue
failure. Typically the laminar fractures occur at multiple contiguous
levels.
CE stage 3: Bilateral vertebral arch fractures with fracture of the
articular processes, pedicles, lamina, or some bilateral combination,
without vertebral body displacement.
CE stage 4: Bilateral vertebral arch fractures with partial
vertebral body width displacement anteriorly.
32
33
FIG 7:- Stages of compression extension.
.
CE stage 5: Bilateral vertebral arch fracture with full vertebral
body width displacement anteriorly.The posterior portion of the
vertebral arch of the fractured vertebra does not displace, and the
anterior portion of the arch remains with the centrum. Ligament
failure occurs at two levels: posteriorly between the fractured
vertebra and the one above it and anteriorly between the fractured
vertebra and the one below it. Characteristically, the anterosuperior
portion of the vertebra below is sheared off by the anteriorly
displaced centrum.
Distractive extension (DE)—two stages
DE stage 1: either failure of the anterior ligamentous complex or a
transverse
fracture
of
the
centrum.
The
injury
usually
is
ligamentous, and there may be a fracture of the adjacent anterior
vertebral margin. The roentgenographic clue to this injury is
abnormal widening of the disc space.
33
34
FIG 8: -Stages of distractive extension
DE stage 2: evidence of failure of the posterior ligamentous
complex,with displacement of the upper vertebral body posteriorly
into the spinal canal, in addition to the changes seen in stage 1
injuries. Because displacement of this type tends to reduce
spontaneously when the head is placed in a neutral position,
roentgenographic evidence of the displacement may be minimal,
rarely greater than 3 mm on initial films, with the patient supine.
Lateral flexion (LF)—two stages
LF stage 1: asymmetrical compression fracture of the centrum
and ipsilateral vertebral arch fracture, without displacement of the
arch on the anteroposterior view. Compression of the articular
process or comminution of the corner of the vertebral arch may be
present.
LF stage 2: lateral asymmetrical compression of the centrum and
either ipsilateral displaced vertebral arch fracture or ligamentous
failure on the contralateral side with separation of the articular
processes. Both ipsilateral compressive and contralateral disruptive
vertebral arch injuries may be present.
34
35
FIG 9: -stages of lateral flexion Injury
OTHER FRACTURES UNIQUE TO THE UPPER CERVICAL
SPINE
Injuries at the upper cervical level are considered unstable
because of their location. Nevertheless, since the diameter of the
spinal canal is greatest at the level of C2, spinal cord injury from
compression is the exception rather than the rule. Incompletely
understood mechanisms or a combination of them usually produces
injuries encountered at this level.
Common injuries include fracture of the atlas, atlantoaxial
subluxation, odontoid fracture, and hangman fracture. Less
common injuries include occipital condyle fracture, atlanto-occipital
dislocation, atlantoaxial rotary subluxation
Atlas (C1) fractures
Four types of atlas fractures (I, II, III, IV) result from impaction of
the occipital condyles on the atlas, causing single or multiple
fractures around the ring. The first 2 types of atlas fracture are
stable and include isolated fractures of the anterior and posterior
arch of C1, respectively. Anterior arch fractures usually are avulsion
35
36
fractures from the anterior portion of the ring and have a low
morbidity rate and little clinical significance. The third type of atlas
fracture
is
a
fracture
through
the
lateral
mass
of
C1.
Radiographically, asymmetric displacement of the mass from the
rest of the vertebra is seen in odontoid view. This fracture also has
a low morbidity rate and little clinical significance. The fourth type of
atlas fracture is the burst fracture of the ring of C1 and also is
known as a Jefferson fracture. This is the most significant type of
atlas fracture from a clinical standpoint because it is associated with
neurologic impairment.
Initial management of types I, II, and III atlas fractures consists of
placement of a cervical orthosis. Type IV fracture, or Jefferson
fracture, is managed with cervical traction.
Atlantoaxial subluxation
When flexion occurs without a lateral or rotatory component at
the upper cervical level, it can cause an anterior dislocation at the
atlantoaxial joint if the transverse ligament is disrupted. Because
this joint is near the skull, shearing forces also play a part in the
mechanism causing this injury, as the skull grinds the C1- C2
complex in flexion. Since the transverse ligament is the main
stabilizing force of the atlantoaxial joint, this injury is unstable.
Neurologic injury may occur from cord compression between the
odontoid and posterior arch of C 1. Radiographically, this injury is
suspected if the predental space is more than 3.5 mm (5 mm in
children). Computerized tomography to confirms the diagnosis.
These injuries may require fusion of C1 and C 2 for definitive
management.
36
37
Atlanto-occipital dislocation
When severe flexion or extension exists at the upper cervical
level, atlanto-occipital dislocation may occur. Atlanto-occipital
dislocation
involves
complete
disruption
of
all
ligamentous
relationships between the occiput and the atlas. Death usually
occurs immediately from stretching of the brainstem, which causes
respiratory arrest. Radiographically, disassociation between the
base of the occiput and the arch of C1 is seen. Cervical traction is
absolutely contraindicated, since further stretching of the brainstem
can occur.7
Odontoid process fractures
The 3 types of odontoid process fractures are classified based
on the anatomic level at which the fracture occurs.7,25
Type I odontoid fracture is an avulsion of the tip of the dens at
the insertion site of the alar ligament. Although a type I fracture is
mechanically stable, it often is seen in association with atlantooccipital dislocation and this must be ruled out because it is life
threatening.
Type II fractures occur at the base of the dens and are the most
common odontoid fractures. This type is associated with a high
prevalence of nonunion because of the limited vascular supply and
a small area of cancellous bone.
Type III odontoid fracture occurs when the fracture line extends
into the body of the axis. Nonunion is not a major problem with
these injuries because of a good blood supply and the greater
amount of cancellous bone.
With type II and III fractures, the fractured segment may be
displaced anteriorly, laterally, or posteriorly. Since posterior
37
38
displacement of segment is more common, the prevalence of spinal
cord injury is as high as 10% with these fractures.
Initial management of a type I dens fracture is use of a cervical
orthosis. Types II and III fractures are managed by applying traction.
Occipital condyle fracture
Occipital condyle fractures are caused by a combination of
vertical compression and lateral bending. Avulsion of the condylar
process or a comminuted compression fracture may occur
secondary to this mechanism. These fractures are associated with
significant head trauma and usually are accompanied by cranial
nerve deficits. Radiographically, they are difficult to delineate, and
CT scan may be required to identify them.
These
mechanically
stable
injuries
require
only
orthotic
immobilization for management, and most heal uneventfully. These
fractures are significant because of the injuries that usually
accompany them.
INSTABILITY
White and Panjabi28 defined clinical instability as the loss of the
ability of the spine under physiological loads to maintain
relationships between vertebrae in such a way that the spinal cord
or nerve roots are not damaged or irritated and deformity or pain
does not develop. Clinical instability may be caused by trauma,
neoplastic or infectious disorders, and iatrogenic causes. Instability
may be acute or chronic. Acute instability is caused by bone or
ligament disruption that places the neural elements in danger of
injury with any subsequent loading or deformity. Chronic instability
is the result of progressive deformity that may cause neurological
38
39
deterioration, prevent recovery of injured neural tissue, or cause
increasing pain or decreasing function.
A motion segment is made up of two adjacent vertebrae and the
intervening soft tissues. If a motion segment has two of the three
columns intact, it will remain stable under physiological loads. If two
or all three columns are disrupted then instability of the motion
segment will result. White et al
28
proposed a scoring system for the
diagnosis of clinical instability of the lower cervical spine, in which a
score of 5 or more indicates instability. See check list below
Checklist for diagnosis of clinical instability in lower cervical
spine
Elements
Point value
Anterior elements destroyed or unable to function
2
Posterior elements destroyed or unable to function
2
Relative sagittal plane translation >3.5 mm
2
Relative sagittal plane rotation >11 degrees
2
Positive stretch test
2
Medullary (cord) damage
2
Root damage
1
Abnormal disc narrowing
1
Dangerous loading anticipated
1
Total of 5 or more = unstable.
39
40
CLINICAL ASSESMENT & PHYSICAL EXAMINATION
A general physical examination is performed with the patient
supine. The head should be examined for lacerations and
contusions and palpated for facial fractures. The ear canals should
be inspected to rule out leakage of spinal fluid or blood behind the
tympanic membrane, suggestive of a skull fracture. The spinous
processes should be palpated from the upper cervical to the
lumbosacral region. A painful spinous process may indicate a spinal
injury. Palpable defects in the interspinous ligaments may indicate
disruption of the supporting ligamentous complex. Careful and
gentle rotation of the head may elicit pain; however, excessive
flexion and extension of the neck should be avoided.
Penile erection and incontinence of the bowel or bladder
suggest a significant spinal injury. Quadriplegia is indicated by
flaccid paralysis of the extremities.
Once spinal cord injury has been identified and the appropriate
precautions taken, the patient should be moved from the spine
board as soon as possible to decrease the risk of decubitus
ulcers.1,29
NEUROLOGICAL EVALUATION
The level of consciousness should be determined quickly,
including pupillary size
and
reaction. Epidural or subdural
hematoma, a depressed skull fracture, or other intracranial
pathological conditions may cause progressive deterioration in
neurological function. The Glasgow coma scale is useful in
determining
40
the
level of
consciousness.
A
detailed,
initial
41
neurological examination, including sensory, motor, and reflex
function, is important in determining prognosis and treatment.
The presence of an incomplete or complete spinal cord injury
must be determined and documented by meticulous neurological
examination. Sensory examination is performed with pinpricks,
beginning at the head and neck and progressing distally
The skin should be marked where sensation is present before
proceeding to motor examination. Evidence of sacral sensory
sparing can establish the diagnosis of an incomplete spinal cord
injury. The only area of sensation distal to an obvious cervical lesion
in a quadriplegic patient may be in the perianal region. Motor
examination should be systematic, beginning with the upper
extremities. During motor examination it is important to differentiate
between complete and incomplete spinal cord injuries and pure
nerve root lesions. A protruded cervical disc or a unilateral
dislocated facet may produce an isolated nerve root paralysis. 25,29,30
Useful grading of neurological status can be achieved using
Frankels scale.25
There are 5 categories in the scale (a to e):
(a) No motor or sensory function below the level of injury.
(b) Sensation but no motor function.
(c) Motor function present but useless.
(d) Useful motor function present.
(e) Normal motor and sensory.
41
42
Non-Radiographic ("clinical") Spine Clearance
Only when all five of the following criteria have been met can a
patient's cervical spine be cleared clinically:
1. No peripheral neurologic deficit or complaint on history or
examination.
2. No posterior neck pain or tenderness.
3. No recent use of intoxicants (cocaine, opiates, ethanol,
benzodiazepines, etc.)
4. No closed head injury (GCS must be > 13)
5. No major distracting injuries (e.g.: open femur fracture,
multiple rib fractures)
If all five of the above criteria are reliably met, cervical spine
precautions may be discontinued without any further testing.31
George C. Velmahos et al 32 on 540 alert patients with negative
clinical examination found no radiological abnormality. Thus patients
meeting above criteria can have their cervical spine cleared
clinically and do not need radiological exam.
Roentgenographic Evaluation of a Suspected Cervical
Spine Injury
In the conscious patient the following three-step approach is
followed:
1. Standard 3-view series (AP + lateral + open-mouth
odontoid).
2. Swimmer's view when lower spine (C7 to T1) cannot be
adequately seen on lateral view
3. If above are normal but patient complains of neck pain, obtain
lateral flexion/extension views. This is best done under
42
43
fluoroscopic control, studies done33 shows that it is easy
effective and devoid of complications.
In the unconscious patient the following steps are followed:
1. Standard 3-view series (AP + lateral + open-mouth
odontoid).
2. Swimmer's view when lower spine (C7 to T1) cannot be
adequately seen on lateral view.
3. CT scan with thin axial cuts through C 1 - C 2.34
Any neurologically impaired patient, with the deficit attributable
to cervical cord injury should remain in full spine protection and
undergo immediate evaluation by the neurosurgical service. The
standard 3-view films are obtained initially.
CLINICAL PRINCIPLES
i) Because "positive mechanism" for spine injury is, by necessity,
a vague term, emphasis in field assessment has been placed on
clinical criteria31. Specific clinical criteria provide safe, accurate, and
dependable assessment of possible unstable spine injury when the
trauma victim is calm, cooperative, sober, and alert. These clinical
criteria can also be applied to the majority of trauma patients with
uncertain or non-specific mechanisms of injury.
ii) The pain response is often abnormal in victims of significant
trauma during the time period immediately following injury. Fear,
confusion, and multiple or distracting injuries often result in an
acute, autonomic type of stress reaction (Acute Stress Reaction)
and a variable period of "pain-masking." For this reason, all victims
of severe trauma who have a "positive mechanism" for spine injury
43
44
generally should be treated with full-spine immobilization during the
initial phase of patient management.32
iii) Extended patient management during delayed or prolonged
transport provides the opportunity for repeated examination of the
injured patient over a period of time. With the progression of time,
the patient examination can become reliable as the patient becomes
more alert and responses to pain can be reproduced. The clinical
treatment can then be modified according to changes in the
patient's condition.31
iv) If spinal injury cannot be localized or if the examination is
unreliable, the entire spine should be immobilized. If spine injury
can be localized accurately and reliably, the injured part can be
immobilized, applying the concept of the spine as a long bone with a
joint at either end.
DEFINITIONS
“Positive mechanism” is a mechanism of injury with a
reasonable potential to cause an unstable injury to the spine.
Positive mechanisms include:
a) Fall from a significant height (greater than three meters).
b) High-impact motor vehicle crashes.
c) High-impact explosions/blast injuries.
d) Direct blunt or penetrating injuries near the spine.
e) Other high-velocity/high-impact injuries.
“Negative mechanism” is a mechanism of injury with no
reasonable potential to cause an unstable spinal injury. Negative
mechanisms generally include:
44
45
a) Forces or impacts that are known to be very minor.
b) Forces or impacts that are known to involve only specific and
limited areas of the body and do not include the head, neck, or
back.
Positive examination includes one or more of the following:
a) Spine pain.
b) Spine tenderness.
c) Abnormal motor or sensory function.
“Negative examination” includes all of the following:
a) No spine pain.
b) No spine tenderness.
c) Normal motor and sensory function.
“Reliable examination” is where the patient meets all of the
following criteria:
a) Calm.
b) Cooperative.
c) Sober.
d) Alert.
“Unreliable examination” is caused by the presence of one or
more of the following:
a) Brain injury.
b) Intoxication.
c) Severe multi-system injuries or severe distracting injury.
d) Severely altered mental status or reduced level of
consciousness.
45
46
e) Acute Stress Reaction (ASR) and "pain-masking" that
generally occurs during the initial phase of severe trauma.
ROENTGENOGRAPHIC ASSESMENT
The views required to radiographically exclude a cervical spine
injury include an anteroposterior view, a lateral view, and an
odontoid view. However an oblique view and/or a swimmers view
may also be done when above views are not adequate. The lateral
view must include all seven cervical vertebrae as well as the C 7-T1
interspace, allowing visualization of the alignment of C 7 and T1. The
most common reason for a missed cervical spine injury is a cervical
spine
roentgenographic
series
that
is
technically
inadequate.25,30,34,35.
TABLE 1: Measurable parameters in a cervical spine
Measurable Parameters of Normal Cervical Spines
46
Parameter
Adults
Children
Predental space
3 mm or less
4 to 5 mm or less
C2-C3
pseudosubluxation
3 mm or less
4 to 5 mm or less
Retropharyngeal space
Less than 6 mm at C2,
less than 22 mm at C6*
1/2 to 2/3 vertebral body
distance anteroposteriorly
Angulation of spinal
column at any single
interspace level
Cord dimension
Less than 11 degrees
Less than 11 degrees
10 to 13 mm
Adult size by 6 years of
age
47
Lateral view
Three aspects of the cervical spine lateral view should be
carefully analyzed namely:
1.Cervical spine curvature; If normal lordotic curvature is
replaced with kyphotic flattening, this may be due to spasm
secondary to injury.
FIG10:-Schematic lateral view of the cervical spine. Note the odontoid (dens),
the predental space and the spinal canal. (A=anterior spinal line; B=posterior
spinal line; C=spinolaminar line; D=clivus base line)
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
47
48
should be considered evidence of ligamentous injury or occult
fracture, and cervical spine immobilization should be maintained
until a definitive diagnosis is made. 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 should be more than 13 mm wide on the lateral
view. Anything less than this suggests that spinal cord compromise
may be impending.
2. Intervertebral disc interspaces; Variation in interspace
thickness or variation in alignment of prevertebral, postvertebral and
anterior spinal tissues
may
suggest injury. Atlanto-occipital
disassociation can be very difficult to diagnose and is easily missed.
The distance from the occiput to the atlas should not exceed 5mm
anywhere on the film.
3. Soft tissue; The retropharyngeal soft tissue thickness is
normally 4 to 7 mm at C 3 with a smooth widening to 18 to 20 mm at
C 7. Retropharyngeal soft tissue swelling (more than 6 mm at C 2,
more than 22 mm at C6) is highly specific for a fracture but is not
very sensitive. Soft tissue swelling in symptomatic patients should
be considered an indication for further radiographic evaluation. A
simple mnemonic is 6mm at C 2 and 22mm at C6. 34
Odontoid view
The dens is next examined for fractures. If it is not possible to
exclude a fracture of the dens, thin-section CT scans or plain film
tomography is indicated.
48
49
The lateral aspects of C 1 are examined next; these should be
symmetrical, with an equal amount of space on each side of the
dens. Any asymmetry is suggestive of a fracture. Finally, the lateral
aspects of C 1 should line up with the lateral aspects of C2. If they do
not line up, there may be a fracture of C 1.
Note that the Open Mouth (OM) view of the odontoid peg is
usually difficult to obtain and of poor quality in unconscious patients,
especially if intubated. A CT Scan of C1- C2 should be performed in
these patients, as well as scanning areas found to be abnormal on
the plain films. Sagittal and coronal reconstructions may help in
cases of suspected odontoid injury.34
Anteroposterior view
The height of the bodies of the cervical vertebrae 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.29,34
CTscan imaging
This is indicated where unclear imaging on plain radiography is
not obtained, where burst fractures are suspected and where bone
fragment protrusion into the neural canal is suspected, CT-scanning
provides an excellent imaging of bone.1, 25,27,35
Helical CT imaging
This new, faster and more versatile type of CTscanning has
revolutionized critical care in trauma centers (where available) as it
has high resolution and fast acquisition thus allowing expeditious
radiologic diagnosis of cervical spine fractures, and other traumatic
49
50
injuries36,37. Selective use of helical CT increases the accuracy of
diagnosis of cervical spine injuries to 100%. 38
MRI scanning
In the presence of neurological deficits, MRI provides the most
accurate data. It however is frequently not feasible in unstable
patients.39
'SCIWORA' SYNDROME
A special situation mostly involving children deserves mention.
In children, it is not uncommon for a spinal cord injury to show no
radiographic abnormalities.40 This situation has been named
"SCIWORA" (Spinal Cord Injury Without Radiographic Abnormality)
syndrome. Although most common in children some case have
been reported in adults a predisposing factor being congenitally
narrowed spinal canals. 9,41
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.
Several structural differences between pediatric and adult
cervical spines explain this phenomenon and alter injury patterns
and cause distinct pathology in young children6. These are:
1. The
more
elastic
intervertebral
ligaments
and
more
horizontally aligned facet joints in young children predispose
them to subluxation of the cervical spine without bony injury.
2. Immature neck muscles and a proportionally large head
further compound this effect, making pediatric cervical spines
act like a fulcrum and increasing the chance of injury.
50
51
3. This fulcrum starts in the upper cervical levels and changes
progressively to lower levels as the pediatric cervical spine
matures, until it reaches adult levels at C5 -C 6. Most injuries
occur at the C 1-C 3 levels in children younger than 8 years.
SCIWORA syndrome may account for up to 70 percent of spinal
cord injuries in children and is most common in children younger
than 8 years 40. Paralysis may be present on 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 will have had neurologic symptoms at the time of
the
injury,
such
as
paresthesias
or
weakness
that
have
subsequently resolved.
Fortunately, most children with SCIWORA syndrome have a
complete recovery, especially if the onset is delayed. 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
The treatment of SCIWORA syndrome has not been well
studied. However, the general consensus is that steroid therapy
should be used. 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. 40,41
GENERAL MANAGEMENT
Management can be divided into the acute, delayed and longterm. It is important however to emphasize that the eventual
outcome and prevention of further injury is dependent on proper
51
52
handling of the patient from the site of the accident, during transport
to hospital, at the accident and emergency units and eventually at
the specialized unit where definitive management will take place.
Immobilization
Any patient with suspected cervical spine injury should be
immobilized below and above the site until injury is ruled out
clinically and through x-rays. This should be done in the neutral
position without bending or rotating the patient. Cervical spine
collars and sand bags are the usual mode of immobilization. Hard
cervical collars however should not be left on for too long a duration
as they are known to cause pressure sores and in a recent study
have actually been shown to cause intracranial hypertension.42
A patent airway is of critical importance in spinal cord injured
patients and especially so where there is head injury1. Intubation
has however been found to be difficult when attempted with a
cervical collar and this further emphasizes the importance of early
cervical spine clearance.10,11,12
Of
special
concern
is
the
maintenance
of
adequate
immobilization in the restless agitated or violent person. This
condition may be due to pain or confusion associated with hypoxia
or hypotension, alcohol or drug intoxication or even a personality
disorder. The cause if possible should be found. Sedatives or a
paralytic agent may be used ensuring that other vital parameters
e.g. airway control and ventilation are maintained.
Resuscitation
Once airway and ventilation are secure circulation is to be
stabilized and maintained. Intravenous (IV) fluids usually are limited
52
53
to maintenance volumes unless there is shock. Shock can be
neurogenic or hypovolaemic in nature. Neurogenic shock is of
special importance especially in spinal injury, due to loss of both
vascular and cardiac sympathetic tone. If there is no response to
fluid challenge then judicious use of vasopressors can be
employed.1,43,44
Hypothermia is another danger in patients with cord injury.
These patients
tend to
be
poikilothermic due
to loss
of
vasoconstriction where sympathetic tone is lost. These patients
should therefore be kept warm.43
Transfer
This is employed where the primary health institution is
inadequately equipped for definitive management. Care should be
taken to ensure that the patient is both well immobilized and
stabilized during transport with qualified personnel in attendance.
The referral institution should be alerted. And given details of the
injury and status of the patient.1
Medical treatment
In case of non penetrating spinal cord injury the use of high dose
methyl prednisolone within the first 8 hours of injury and
continuation into the first 24 hrs is the accepted treatment in USA,
though still controversial in many countries and hardly ever used at
KNH at the time of this dissertation. It is given at a dose of 30mg/kg
within the first 15 minutes, followed by 5.4 mg/kg per hr for the next
23 hrs .It is not to be started if 8 hrs have elapsed after injury.1,45
53
54
Most patients with acute spinal cord injury will develop stress
ulcers in the stomach and thus use of H2 receptor antagonists or
proton pump inhibitors may be indicated.44
SURGICAL TREATMENT
Surgical treatment involves, reduction, decompression and or
fixation both external and internal. This can be grouped into
operative and non operative methods.25,30,35,43,44
Indications for surgical intervention include:
1. Progression of neurological deficit. This requires emergency
intervention
with
the
details
of
exact
injury
being
demonstrated in a CT scan or MRI of the lesion.
2. In patients who have partial neurologic deficit but show no
improvement, surgery is indicated if radiologic studies then
demonstrate some extrinsic compression.
3. Open injury from stabs or gunshot injuries.
4. Evidence of spinal instability.43
The goals of surgical treatment of cervical spine injuries are:
(1) To realign the spine.
(2) To prevent loss of function of undamaged neurological
tissue.
(3) To improve neurological recovery.
(4) To obtain and maintain spinal stability.
(5) To obtain early functional recovery.
.Non-operative treatment
After
initial
medical
stabilization
and
documentation
of
neurological function, spinal alignment can be obtained by:
Skull traction; this is through skull calipers, which come in many
forms and types. Crutchfield 1938 is the oldest and has fallen out of
54
55
favor, as it is clumsy to insert and falls out easily, Blackburns
penetrate the skull easily and are therefore dangerous for that
reason. The most widely used and accepted is the spring-loaded
Gardner-Wells tongs. This is despite the disadvantage of protruding
widely from the side of the head and interfering with nursing. Once
inserted the calipers should be pain free if there is pain look out for
slipping of the tongs on the scalp or for infection.43,44
Continuous monitoring during reduction is essential to prevent
iatrogenic injury from over distraction or for unstable motion
segment. It is usual practice to weight to a maximum of 2.25 kg per
each level below the occiput i.e. 13.6 kgs at C6 level. It is advised
however to start at 4.5 kgs and under x-ray (lateral view) control
gradually add the weight to the maximum as necessary.43
For a stable cervical spine injury with no compression of the
neural elements, a rigid cervical brace or halo for 8 to 12 weeks
usually produces a stable, painless spine without residual deformity.
Stable compression fractures of the vertebral bodies, undisplaced
fractures of the laminae, lateral masses, or spinous processes and
unilateral facet dislocations that are reduced in traction may be
immobilized in a halo vest for 8 to 12 weeks.
Patients with spinal fractures that are treated non-operatively
must be observed closely. Serial x-rays should be obtained weekly
for the first 3 weeks, and then at 6 weeks, 3 months, 6 months, and
1 year. Subacute instability of the cervical spine after initial
radiological evaluation that showed no bony or soft tissue
abnormalities has been demonstrated. Because subacute instability
may occur despite adequate initial physical and radiological
examinations, a second complete evaluation should be performed
within 3 weeks of injury.
55
56
Halo vest immobilization; the halo orthosis was first used by
Perry and Nickels in 1959 for stabilization after cervical spine fusion
in patients with poliomyelitis. Use of the halo vest has expanded
considerably since then, and it is used in the treatment of many
cervical spine injuries25. It however was not in use at KNH at the
time of this dissertation.
Operative treatment.
Decompression is done where bony fragments protrude into the
spinal canal thus causing narrowing and compression .It is also
indicated where there is compression of a nerve root at the level of
the neural canal.
Unstable injuries of the cervical spine, with or without
neurological deficit, generally require operative treatment. In most
patients early open reduction and internal fixation are indicated to
obtain stability and allow early functional rehabilitation. Cervical
spine fractures may be stabilized through an anterior, a posterior, or
a combined approach. This allows rapid mobilization of the patient
in a cervical orthosis, and healing usually occurs within 8 to 12
weeks. In the case where there is compression the timing of surgery
is still controversial. In a multi center retrospective study by Fehlings
et al
48
. It was found that there is very little agreement in timing of
surgery with some authorities advocating immediate –within 24 hrs
(emergency surgical intervention) while others advocate delayed
surgery, up to 40 % being delayed by up to more than 5 days. In a
literature review by Fehlings et al 49 again no clear consensus could
be drawn as to the timing of surgery, different authorities again
having varied opinions. However as it is known that the degree of
56
57
spinal cord injury as well as the duration of compression affects
prognosis, urgent decompression is still favored where obvious
compression is causing deteriorating neurological status.35,48
In general, posterior stability should be obtained first, followed
by anterior decompression and fusion if indicated.
Imaging
studies
such
as
MRI, myelography,
and
post
myelogram CT scanning should be performed to determine if a disc
is herniated. Iatrogenic neurological injuries have been documented
in patients in whom reduction and posterior stabilization were
carried
out
before
anterior
decompression.
These
authors
recommend discectomy and interbody fusion with anterior internal
fixation, followed by posterior stabilization, as optimal treatment. 25
APPROACHES
The choice of surgical approaches depends on the pattern of
injury. There are three approaches: Anterior, posterior and
combined anterior and posterior.
Anterior decompression and fusion, with or without internal
fixation, are most often indicated for burst fractures of the cervical
spine with documented compression of the neural elements by
retropulsed
bone
or
disc
fragments
and
an
incomplete
neurological deficit.25,44
For posterior ligamentous
or bony
instability, posterior
stabilization with internal fixation and bone grafting are indicated.
Laminectomy as a posterior approach has a limited role in the
treatment of cervical fractures or dislocations and may contribute
to clinical instability and neurological deficit. It occasionally may be
indicated if posterior bone fragments from the neural arch are
compressing the neural elements. 25
57
58
Combined anterior decompression and posterior fusion are
indicated for patients who have severe instability and a significant
neurocompressive pathological condition. The advent of rigid
anterior and posterior spinal internal fixation has reduced the
complications related to graft extrusion.25
Rehabilitation
Post head injury complications are very few following mild head
injury but increase dramatically in severe head injury
15
. Most of
these complications cause severe disabilities with a lot of
dependence on rehabilitative as well as long term medical care.
This causes serious challenges when associated with cervical
injuries.
For cervical lesions the degree of permanent disability increases
markedly with each segment that is involved with reasonable
sparing of upper limb function if the lesion is at C8, while injury at
the level of C4 or C5 leaves the patient severely handicapped.50
The life expectancy after cord injury has changed dramatically
from the 1940’s and 50’s when it was very dismal. This followed
better understanding, improved nursing and rehabilitation, which
have improved both the survival time and quality of life of these
patients.
Patients with spinal cord injury will require a long-term therapy.
Important aspects are nursing, psychotherapy, physiotherapy,
occupational therapy, with the duration depending on the severity of
the cord injury and therefore the prognosis of neurological recovery.
Complete loss or transection of the cord will require special care in
spinal units.
Important complications and anticipated problems include:
58
59
1. Skincare; meticulous attention to pressure areas will avoid the
development of pressure sores which seriously complicate the
recovery and rehabilitation of this patients.
2. Bladder care; urinary tract problems are a major cause of
potential morbidity and mortality. After the acute injury there is acute
retention of urine, this is managed by catheterization. In the long
term an indwelling catheter poses many dangers most important
being infection. The use of clean intermittent catherization has
revolutionized long-term bladder care and has cut down on the rate
of infections.23
3. Limb care; It is essential that the paralyzed limbs be put through
their full range of movement. Regular physiotherapy is especially
useful. This is especially important if there is some recovery
expected. 43,44
4. Chronic debilitating pain; Even patients without actual cord injury
may have long term complications which in most cases will be
chronic pain, whiplash injuries are notorious for this, costing many
man hours lost in work places and a major costs medical-legally. In
a15 yr follow up study by Squires et al
51
they found that 70% of
patients had symptoms 15 years after whiplash injury. The
symptoms were persistent even after settlement of litigation, ruling
out malingering.
59
60
STUDY JUSTIFICATION
Head injury patients are frequently seen at the casualty
department of Kenyatta National Hospital. Cervical spine injuries
are a serious co-morbidity likely to influence the critical care and
outcome of head injured patients. The incidence in severely head
injured patients being as high as 7%-10% in studies done
elsewhere.
Despite this the incidence and pattern of this injury in head
injured patients is unknown in our set up. There is no study in the
past that has specifically targeted cervical spine injuries in head
injury. There is need therefore to do a study on this injury and its
unique relationship with head injury and, its role in emergency and
critical care.
It is the aim of this study to determine the pattern of cervical
spine injury in head injured patients as seen at KNH
RESEARCH QUESTION
What is the relative frequency of cervical spine injury in head
injured patients and what is the pattern as related to the cause and
severity of head injury?
60
61
MAIN OBJECTIVE
The study objective is to increase the understanding of cervical
spine injury in head injured patients as seen at the Kenyatta
National Hospital.
.
SPECIFIC OBJECTIVES
1. To determine the relative frequency and severity of cervical spine
injury in head injured patients as seen at Kenyatta National
Hospital.
2. To determine the age and sex distribution.
3. To determine relationship between the cause of head injury and
the pattern of cervical spine injury.
4. To establish the type of pre-hospital care given to protect the
cervical spine of the patients before they arrive at the emergency
department.
61
62
MATERIALS AND METHODS
STUDY DESIGN
This is a hospital based prospective cross sectional study with
limited follow up.
AREA OF STUDY
The study was undertaken at the Kenyatta National Hospital(KNH),
a national referral and teaching hospital for the University of Nairobi
Medical School. KNH also receives and deals with most of the acute
trauma patients around Kenyas capital city of Nairobi.
Patients were recruited to the study at the casualty department, the
surgical wards, the intensive care unit (ICU) and the high
dependency unit (HDU).
STUDY POPULATION
All patients admitted to KNH with head injury during the study period
were recruited into the study.
Head injury was defined as any patient who suffered trauma to the
head resulting in any of the following:
 history of loss of consciousness after a blow to the head.

signs of increased intracranial pressure.

skull fractures.
 any alteration in mental or physical functioning related to a
blow to the head,
62
63
STUDY PERIOD
The study covered a 10-week period of recruitment from the sixth of
December 2002 to thirty first January 2003, and eighth to twenty
fourth of March 2003
STUDY INSTRUMENTS AND METHODS
The admissions register at the casualty department was used to
identify all patients admitted with a diagnosis of head injury. A
physical search was also made in ICU, HDU, general surgical,
paediatric surgical and the orthopedic wards for patients who were
admitted under a different coding in the register, or those who were
omitted from the register.
All patients admitted at the hospital with head injury were examined
and assessed by the principle investigator.
History of the pre-hospital events was taken where available.
Details of the cause and time of head injury were recorded.
Demographic indices such as age and sex were recorded.
Note of evidence of intoxication was taken.
Severity of the head injury using the Glasgow coma scale on arrival
at the casualty department was noted. This was again noted during
physical exam by the researcher at casualty where feasible, or
within eight hours from time of admission. Neurological status was
noted and
physical neck
examination
where
feasible
was
undertaken.
The questionnaire was used to record all other parameters relevant
to the study.
Investigations were mainly plain radiography, with all patients with
head injury having plain skull x-rays done in three views.
63
64
Cervical spine x-rays were taken with three basic views, a cross
table lateral, an AP view and open mouth view. This investigation
was sought whenever a patient was found to be intoxicated, having
an altered mental state, having concomitant severe injuries e.g.
fracture of long bones and when physical examination was positive
for neck pain or tenderness.
All the x-rays showing any abnormality were discussed by with a
radiologist from the x-ray department
Specialized investigations were sought where available including,
CT scanning of cervical spine.
ELIGIBILITY CRITERIA.
All patients admitted to KNH with head injury during the period of
study.
Patients referred from other institutions with cervical spine injury
and concomitant head injury.
EXCLUSION CRITERIA.
All patients with insignificant head injuries who were discharged
home at the casualty department.
All patients with head injury who were dead on arrival at the
casualty department
All patients with head injury who died at the casualty department
before any investigations were carried out –these were mostly
patients who died at initial resuscitation before any radiological
Investigations are carried out.
All patients who declined to participate in the study.
64
65
CONSTRAINTS
Unavailability of routine CT scans limited the detailed description of
some the injuries.
Some occult injuries may have been missed as plain radiography
has 70-80% sensitivity.
Inability to include patients who had severe head injuries but died
before investigations were carried out.
SAMPLE SIZE
The following formula was used for calculating the sample size: 2
n =  P(1-P)
d2
where
n = sample size to be determined
 = Standard errors from the mean
corresponding to 95% confidence
level
P
= Prevalence of head injuries in
trauma patients (14%).
d
= required precision
n = (1.96)2 x 0.1275
(0.05) 2
=
3.84 x 0.489804
0.0025
= 196
All eligible patients within the study period of two and a half months
were included. The total number recruited was 361 patients.
65
66
DATA MANAGEMENT
Data was extracted from the proforma questionnaire using dummy
tables .The data was analyzed using SPSS version 10.0. The
information was then presented as tables, graphs and charts.
Where indicated, test of significance was applied using Chi-Square
(X2) analysis. Statistical significance was defined as a p-value less
than 0.05.
ETHICAL CONSIDERATIONS.
Permission to carry out the study was sought from the Ethical and
Research Committee of the KNH.
1. All information obtained from the study was treated with outmost
confidentiality and will be available only to the university and the
medical fraternity.
2. Consent was sought from the patient or next of kin where
available. Where next of kin was not available and patient was
confused or unconscious, consent was sought from the
consultant in the respective unit.
3. Access to my findings will be through the University Of Nairobi
Department Of Surgery.
66
67
RESULTS
A total of 361 patients were recruited to the study, all these patients
fulfilled the selection criteria.
Fifteen patients with severe head injuries died at casualty during
resuscitation before any investigations were carried out. These
patients were excluded from the study (as per the exclusion
criteria).
Two patients with severe head injuries died at ICU without any
radiological investigations, these patients were also excluded.
FREQUENCY OF CERVICAL SPINE INJURY IN HEAD INJURY
The total number of patients with head injury patients recruited was
three hundred and sixty one. Of these nineteen (5.3%) were found
to have cervical spine injury.
TABLE 2: incidence of cervical spine injury.
67
Cervical spine
injury present
Frequency
Percent
Yes
19
5.3
No
342
94.7
Total
361
100.0
68
SEX DISTRIBUTION OF HEAD INJURIES
Of the three hundred and sixty one patients with head injuries, three
hundred and twenty five (90%) were male. Thirty six (10%) were
female.
FIGURE 11: Sex distribution for head injury patients.
frequency
10%
male
female
90%
68
69
SEX DISTRIBUTION FOR CERVICAL SPINE INJURED
PATIENTS.
Of the nineteen patients with cervical spine injury fourteen (74%)
were male and five (26 %) were female.
FIGURE 12: Sex distribution for cervical spine injured patients.
Frequency
26%
male
female
74%
69
70
FREQUENCY OF CERVICAL SPINE INJURY IN MALES AND
FEMALES
Of the three hundred and sixty-one patients with head injury, three
hundred and twenty five (90%) were male and thirty-six (10%) were
female.
Of the thirty-six females with head injury, five (13.9%) had cervical
spine injury; of the three hundred and twenty five males fourteen
(4.3%) had cervical spine injuries. Significantly more females with
head injury have cervical spine injury. Chi-square analysis; P=0.015
(95% confidence interval).
TABLE 3: Sex and frequency cervical spine injury.
Cervical spine injury present
Yes
No
Total
Male
14
311
325
Female
5
31
36
Total
19
342
361
Sex
70
71
FIGURE 13: Sex and frequency cervical spine injury.
120.00%
percentage of total w ith cervical injury
100.00%
80.00%
60.00%
95.70%
87%
40.00%
20.00%
0.00%
71
4.30%
13%
Male
Female
No cervical
spine injury
Cervical
spine injury
present
72
AGE DISTRIBUTION OF HEAD INJURIES AND CERVICAL
SPINE INJURIES
The age range for head injuries was 4 months to 74 years with a
mean age of 26years. The age range of cervical injuries was 4
years to 64 years with a mean age of 34 years.
Of the head injuries the majority (77.5%) were in the16 to 40 year
age groups. The majority of cervical spine injuries (59%) were in the
21 to 35 years age group, with another peak at the sixty one to sixty
five age group (10.5 %).
FIGURE 14: Age distribution of head injuries & cervical spine
injuries.
72
73
CAUSE OF HEAD INJURY AND FREQUENCY OF CERVICAL
SPINE INJURY
Of the three hundred and sixty one patients, 4 had unclear cause of
head injury. Of the remaining three hundred and fifty seven, there
were a total of one hundred and forty-six patients (40.8%) with head
injury secondary to road traffic injury. One hundred and eighty one
(50.7%) secondary to assault. Those injured from falling from a
height were twenty-eight (7.8%). Of the road traffic accident group
eleven (7.5%) had cervical spine injury, compared to six (3.3%) in
those in the assault group. One patient (3.5%) in the fall from height
group sustained cervical spine injury.
TABLE 4: Causes of cervical injury.
Head injury
Cervical spine injury present
Frequency
%
Yes
No
% Yes
Road
Traffic
accidents
Fall from
height
146
40.8
11
135
7.5
28
7.8
1
27
3.5
Assault
181
50.7
6
175
3.3
Falling
object
2
0.6
0
2
0
Total
357
100
18
338
73
74
SEVERITY OF HEAD INJURY-GCS AND CERVICAL SPINE
INJURY
Of the 361 one patients with head injury, 279 (77.3%) had mild head
injury, 43 (11.9%) had moderate head injury and 39 (10.8%) had
severe head injury. Of the 279 patients with mild head injury, 12
(4.3%) had cervical spine injury. In the moderately head injured
group 4 of the 43 (9.3%) had cervical spine injury, while 3 of the 39
(7.7%) who were severely head injured had cervical spine injury.
Chi-square analysis; p=0.131 (confidence interval 95%).
TABLE 5: Frequency of Cervical spine injury versus severity of head
injury
Cervical spine injury present
Severity of
head injuryGCS
74
Yes
No
Total
% Yes
13-15
12
267
279
4.3
9-12
4
39
43
9.3
3-8
3
36
39
7.7
Total
19
342
361
75
REGION OF SCALP INJURED AND FREQUENCY OF CERVICAL
SPINE INJURY.
Of 34 patients with occipital injuries, 5 (14.7%) had cervical spine
injury, 8 of 88 (9%) in frontal injuries, 4 out of 159 (2.5%) in
temporal-parietal injuries and two out of eighty (2.5%) in multiple
site scalp injury. Using a 2 by 2 table, the difference between
occipital and none occipital scalp injury was statistically significant.
Chi square analysis, P=0.012 (95% confidence interval).
TABLE 6: Region of scalp injured and frequency of cervical spine
injury
Cervical spine injury present
Yes
No
Total
% Yes
Occipital
5
29
34
14.7
Frontal
8
80
88
9
4
155
159
2.5
2
78
80
2.5
19
342
361
Region of Parietal/Temp
oral
skull
Multiple site
injuries
Total
.
75
76
FRACTURE SKULL AND CERVICAL SPINE INJURY
There were 245 patients with no skull fractures; of these 13 (5.3%)
had cervical spine injury. One hundred and sixteen had skull
fractures present; out of this 6 (5.2%) had a cervical spine injury.
TABLE 7: Skull fracture versus cervical spine injury
Cervical spine injury present
Radiological
No
findings on fracture
skull
Fracture
present
Total
76
Yes
No
Total
%yes
13
232
245
5.3
6
110
116
5.2
19
342
361
77
TYPE OF SKULL FRACTURE AND CERVICAL SPINE INJURY
Of the patients with skull fractures 67 had linear fractures of which 4
(6.0%) had cervical spine injury, 43 had depressed skull fractures
and 2 (4.7 %) out of this group had cervical spine injury. 16 had
fracture base of skull, and 2 (12.5%) had cervical spine injury. Using
a 2 by 2 table the difference in the incidence of cervical spine injury
in base of skull fractures versus other fractures was statistically
significant. Chi-square analysis, P=0.002 (confidence interval 95%).
TABLE 8: Type of skull fracture versus cervical spine injury
Cervical spine injury present
Type of
skull
fracture
77
Yes
No
Total
%Yes
Base of skull
2
14
16
12.5
Linear
4
63
67
6.0
Depressed
2
41
43
4.7
Total
6
110
116
78
VERTEBRAL LEVEL OF INJURY
Majority of the injuries were at fifth cervical vertebra (C5), and the
two adjacent vertebrae fourth (C4) and sixth (C6). Eight patients out
of the nineteen (42%) had injury at C5, four (21%) had injury at C6,
four (21%) had injury at level C2, three (16%) had injury at C4.
Three patients had injuries at multiple levels.
FIGURE 15: Vertebral level of injury
N=19
Frequency
8
7
6
5
4
Frequency
3
2
1
0
C1
78
C2
C3
C4
C5
C6
C7
79
TYPE OF CERVICAL SPINE INJURY
In all the seven patients with subluxation injury the lesions were at
the C4-C5 and C5-C6 vertebral levels. The degree of subluxation in
all the cases was below 25% of the vertebral width. One was a
unifacet dislocation. The others had no significant facet dislocation.
Fifteen of the patients had fractures. The C1 injury was a burst
fracture, of the four C2 fractures two were tear drop, while the other
two were fractures of the spinous process. The C3 fracture was an
anterior wedge collapse. The fractures on C5, C6 level were varying
degrees of vertebral body compression, ranging from mild lipping to
wedge collapse, in one there was fracture of the left lamina of C6.
The fracture at C7 was on the spinous process. Three of the
patients had injuries at multiple levels.
TABLE 9: Vertebral level of injury versus type of cervical spine
injury.
Number with cervical spine
injury
Fracture
Subluxation
Vertebral
level of
injury
79
C1
1
0
C2
4
0
C3
1
0
C4
0
3(C4 on C5)
C5
4
4(C5 on C6)
C6
4
0
C7
1
0
80
CERVICAL PROTECTION BEFORE ARRIVAL AT KNH
Only four patients of the three hundred and sixty one patients in the
study group came to casualty with cervical collars applied. Of the
four, two were later confirmed to have cervical spine injury. All the
rest had no form of cervical spine support or immobilization on
arrival. All the four patients who came with cervical spine protection
were referrals from other hospitals. Twenty-two (6%) of all patients
with head injury at KNH were referrals whilst 339(94%) came to
KNH as the primary hospital.
TABLE 10: Cervical spine protection on arrival at casualty.
Cervical spine injury present
Cervical
collar
before
arrival
Yes
No
Total
Yes
2
2
4
No
17
340
357
Total
19
342
361
TABLE 11: Cervical collar before arrival and whether KNH primary
or referral hospital.
KNH primary or referral hospital.
Cervical
collar before
arrival
80
Primary
Referral
Total
Yes
0
4
4
No
339
18
357
Total
339
22
361
81
CERVICAL SPINE XRAYS; WHERE ORDERED FROM.
Thirty five (23%) of the 153 patients who had cervical spine X-rays
done had this investigation requested in the wards/units admitted to
after admission. Nine of the 35 were found to have cervical spine
injury on radiological investigation.
Ideally all should have been investigated in casualty.
FIGURE 16: Unit cervical spine x-rays ordered from
n= 153
23%
wards
casualty
77%
81
82
SIGNIFICANCE OF RADIOLOGICAL FINDINGS
Retropharyngeal soft tissue widening as an indicator of cervical
spine injury had a sensitivity of 58% and a specificity of 100 %(
table 12). Loss of normal lordosis had a sensitivity of 74% and a
specificity of 42% (table 13).
TABLE 12: Retropharyngeal space widening versus cervical injury
Cervical spine injury
Retro
pharyngeal
space
widening
Yes
No
Total
Yes
11
0
11
No
8
134
142
Total
19
134
153
TABLE 13: loss of normal lordosis versus cervical injury.
Cervical spine injury
Loss of
normal
lordosis
82
Yes
No
Total
Yes
14
19
33
No
5
116
121
Total
19
135
154
83
SPINAL CORD INJURIES
Only one patient of the nineteen with cervical spine injuries (a 65 yr
old man) had a neurological deficit attributable to cord injury, it
affected only his upper limbs where there was loss of motor function
(muscle power grade 2) but normal sensation; this was consistent
with central cord syndrome. A CT scan of the brain ruled out an
intracranial lesion.
TABLE14: Spinal cord injuries
Neurological
deficit
Yes
1
No
Total
18
19
TREATMENT OFFERED FOR CERVICAL SPINE INJURY.
Of the nineteen patients 17 (90%) received hard cervical collars as
definitive management. Of the two patients put on traction one
patient who had teardrop fracture of C2 had traction for six weeks.
The other patient had unifacet dislocation of C5-C6 level, which was
reduced on skull traction.
TABLE 15: Treatment offered for cervical spine injury.
Type of
treatment
83
Frequency
Percent
Cervical
collar
Traction
17
90
2
10
Operation
0
0
Total
19
100.0
84
DISCUSSION
Head injury is a common injury, constituting approximately14% of
all trauma cases seen at KNH (KNH statistics, 2000, 2001). In the
study period of two and a half months; 361 patients were recruited.
This gave an average of 144 patients per month. Cervical spine
injury is a serious co-morbidity if present and its presence should be
anticipated, recognized and managed promptly.
The potential implications of a cervical spine injury in head injured
patients have been recognized and deliberated on by various
trauma committees e.g. the American college of surgeons
committee on trauma; this has lead to the formulation of protocols
that help in the management of this injury.1
The incidence of cervical spine injuries in head injured patients
has been reported by various studies and authorities at between 3%
in general head trauma to as high as 24% in a series on fatal cranial
cervical injuries following road traffic accidents(RTAs) 18, with most
studies giving the incidence between 5% to 10%1. In this study the
incidence was found to be 5.3%. There were a total number of 19
patients from the 361 patients with head injury studied.
The severity of head trauma has been found to be related to the
incidence of cervical spine injury, Holly LT et al21 in a study on 447
patients with moderate to severe head injury found that patients with
Glasgow coma scale under 8 were more likely to have cervical
spine injury, Hills M W et al in a 4 year prospective study on 1269
head injury made a similar observation16. In the present study the
incidence of cervical spine injury was 4.3% in mild head injury, 9.3%
in moderate head injury and 7.7% in severe head injury. The trend
84
85
was suggestive of an increase in the incidence with severity. Chisquare analysis did not show a statistical significance p=0.131
(confidence interval 95%). During the study period 15 patients with
severe head injury died at casualty during resuscitation, before any
investigations were undertaken they were therefore not included in
the study. It is possible that the high mortality of the severely head
injured before admission may explain the lower incidence in the
severely head injured patients.
In the sex distribution, of the nineteen patients with cervical
spine injuries five 26.3% were females and fourteen 73.7 % were
male, giving a male: female ratio of 3:1. These results are similar to
those by Michael W Hills et al where he found males constituting
78%. Females however constituted only 10% of the total number of
head injuries in the present study. The incidence of cervical spine in
head injury was 13% in the female population and 4.3% in the male
population.
This
difference
was
statistically
significant
p=0.015(confidence interval 95%) Females with head injury were
found to have a higher risk of having cervical spine injury. P=0.015
(confidence interval 95%).
In the present study most cervical spine injuries occurred in the
age bracket of 21 to 35 years (57.9%) with a mean of 32 years, a
similar pattern is given in most literature
Musau
23
1,16,24,30
. In a local study by
the peak age was 20-40 yrs (this was however on cervical
spine in general).
In this study most of head injuries, 50.7%, were secondary to
assault a close second 40.8% being secondary to Road traffic
accidents, while fall from a height constituted 7.8% .The incidence
of cervical spine injury in the above groups was found to be 3.3%,
7.5% and 3.6% respectively. The trend suggests a higher incidence
85
86
in road traffic accidents as a cause of cervical spine injury
compared to assaults and falls from height. The incidence of 7.5 %
in head injury secondary to road traffic accidents closely agrees with
Holly LT et al on a series of 447 head injuries where he found the
incidence to be 8.2%21. Chi square analysis on the present study
however did not reveal a statistical significance between road traffic
accidents and non-road traffic accident causes, p=0.067(confidence
interval 95%).
Of the total number of cervical spine injuries 57% were secondary
to road traffic accidents, 31% secondary to assaults, 5% from falls
from height. The findings in other studies show a similar distribution
for road traffic accidents but marked contrast on assault cases.
Most other studies show less contribution from assault cases. Emilio
Belavo et al summarized the causes as road traffic accidents, 50%,
fall 20%, Sports15% and 10% other causes7. Musau
23
found that
locally at the KNH and Spinal Injury unit, road traffic accidents
accounted for 54.1%, fall from a height 31.8%, assaults +gunshots
7.9%, falling objects 5.3%. A review article
24
, gives the following
distribution motor vehicle accidents (50%-70%), falls (6%-10%),
diving accidents, blunt head and neck traumas, penetrating neck
injuries and contact sports injuries taking the rest. In the present
study there is a large number of cervical spine injuries secondary to
assault. This could be due to the fact that approximately 50% of
head injuries in our set up are secondary to assaults. Sporting
injuries gave a negligible contribution to head injury numbers at
KNH, of the entire 361 patient recruited only one had sustained
head injury from sporting activity. This could be due to the fact that
most people who play contact sport e.g. rugby or diving come from
higher social economic class and may seek medical attention in
86
87
private hospitals. A similar study conducted the private sector
hospitals could answer this question.
Of different scalp site injuries occipital scalp injuries had the
highest association with cervical injuries with a percentage of
14.7%, frontal injuries 9%, 2.5% in parietal injuries and 2.5% in
multiple site injuries. Application of chi-square analysis showed
statistical significance, p=0.012(confidence interval 95%).
There was no evidence that patients with skull fractures had any
significantly higher risk of having a cervical spine injury as
compared to those without fractures. Out of the 240 patients without
skull fractures 13(5.3%) had cervical spine injury compared to 6 out
of 116(5.1%) in those with skull fractures. These findings agree with
a study by Oller DW et al, his study found that there was no
relationship between the presence or absence of skull fracture in
head trauma and the presence of a c spine injury54.
However of those with skull fractures there was a higher rate of
cervical spine injury in those with fracture base of skull 2 out of
sixteen (12.5 %) compared to linear fractures 4 out of 67(6.0%) and
2 out of 43 (4.7%) in depressed skull fractures. P=0.002(confidence
interval 95%)
The majority (78%) of the cervical spine injuries in the present
study occurred in the lower cervical spine (third to seventh cervical
vertebrae). Most of this lower cervical spine injuries occurred
between the fourth cervical vertebrae to the sixth with the majority
(42% of the total) at fifth cervical vertebrae. Only 21% occurred in
the upper cervical spine (occiput to second cervical vertebrae) with
the majority at the second cervical vertebrae (15% of the total). A
total of 12(63%) of the cervical spine injuries were associated with
mild head injury. Shrago et al in a study on 50 patients with cervical
87
88
spine injury found that 56% of patients with head trauma had injury
at upper cervical level and 44% lower cervical level20. Hideo Ida et
al in a study on 188 cervical spine injuries with associated head
injury found that there was a higher incidence of upper cervical
injury in those with severe head injury while mild head injuries were
found to be associated with a higher rate of lower cervical spine
injury19.
This low number of upper cervical spine injuries in the present
study could be due to the fact that upper cervical spine injuries are
associated with a higher rate of spinal cord and cardiopulmonary
arrest. This was shown by Davis et al17 in a study on fatal cranial
spinal injuries. The likelihood of a high spinal cord injury reaching
the hospital in our setup would be very small. This is supported by
the finding below where, in the present study only 4 (1%) out of the
361 patient in the study group had cervical collars or any other form
of neck protection at arrival in casualty. These 4 happened to be
referrals from other health institutions. KNH was the primary
hospital to 339 (94%) of all patients with head injury, while 22(6%)
were referrals from other institutions. The patients who came in to
KNH as the primary hospital were brought in by members of the
general public or the police. In the absence of cervical spine
protection and the unwitting manhandling of these patients by
untrained rescuers, any patient with a severe head injury, an upper
cervical spine injury with cord injury is unlikely to survive the trip
from the site of injury to the hospital. No study of fatal cranial
cervical injuries has been conducted in our setup.
Twenty two percent of cervical spine x-rays done were ordered
from the units, these were patients who had missed having this
investigation done at casualty on first contact with the physician
88
89
despite not meeting the criteria of clinical clearance. Nine patients in
this group were found to have cervical spine injury.
Of the nineteen patients with cervical injuries only one was found
to have neurological deficit, This was a 65-year old male who
received a blow to the head (frontal) with hyperextension of the
neck, he sustained a depressed frontal skull fracture. His injury was
consistent with central cord injury with loss of upper limb strength
(Frankels grade 2) at admission. He however had improved to
Frankel grade 3 after 10 days post injury. Two patients out of the
nineteen were managed on traction one being a unilateral facetal
dislocation and the other a tear drop fracture of the second cervical
vertebrae. All the others were managed on cervical collars.
In the present study retropharyngeal soft tissue widening was
found to be highly specific (100 percent) but not very sensitive
(58%) for cervical spine injury this was statistically significant (p=
<0.001) and is consistent with available literature34. Loss of normal
lordosis as an indicator for cervical spine injury had a sensitivity of
74% and a specificity of 42%. This again is consistent with available
literature.34
89
90
CONCLUSIONS
1. The incidence of cervical spine injuries in head injury at KNH
is 5.3 percent, which falls within the range given in most
literature.
2. KNH is the primary hospital for the majority (94%) of patients
seen with head injuries. None had cervical protection.
3. A large proportion of cervical spine injuries (47%) were
missed at the Accident and emergency department of KNH.
4. Of the patients with cervical spine injury males are more than
females by ratio of 3:1. While in head injury male are more
than female by a ratio of 9:1. Significantly more females with
heads injury have associated cervical spine injury.
5. Those patients with skull fractures have no significantly higher
risk of having a cervical spine injury as compared to those
without fractures.
6. Patients with occipital injuries stand a significantly higher
chance of having cervical spine injury than those in other
regions of the scalp.
7. Most of the cervical spine injuries seen were mild and majority
were in the lower cervical spine.
8. Retropharyngeal
soft
tissue
widening
on
lateral
radiograph was highly specific for cervical spine injury.
90
view
91
RECOMMENDATIONS
1. Increased emphasis should be put on educating the public
and the police force on basic care of the injured and spine
protection. Widely available quick response by trained
paramedics should be the goal. This might increase the
number of cervical spine injured who reach hospital.
2. A study on fatal cranial injuries is recommended to give an
idea of how many severely head injured patients who die
before hospital admission actually have cervical spine injuries.
3. A similar study conducted in the private hospitals can give a
view as to the distribution of causes of injury in the private
sector.
4. A similar study with ready availability of CT scanning for
suspected cervical spine injury after negative plain radiology
can give an idea of the accuracy of the standard three views
in detecting cervical spine injury.
91
92
REFERENCES
1. American college of surgeons committee on trauma.
Advanced trauma life support (ATLS).1997: 215-230
2. Goodrich J., Riew D . Lower cervical spine fractures and
dislocations. eMedicine Journal.2002;3:5.
3. Gerhrig R., Michielis L. S. Statistics of acute tetraplegia and
quadrilplegia on a national scale. Paraplegia. 1968; 6:93-95.
4. Michelis L. S. Epidemiology of spinal cord injuries. Handbook
of clinical neurology. North Holland Puplishing Co: 141-143.
5. Gardner E., Gray D. J. Anatomy, A regional study of human
structure. Forth edition. W.B. Saunders Company. 1975: 509-516,
525-536.
6. R. J. Last. ANATOMY Regional and Applied .7th edition.
ELBS & Churchill: 461-473, 538-540.
7. Belavo E., Roy S. Fractures of cervical spine. eMedicine
Journal. 29 2002; 3 :4
8. Francis Denis. Spinal instability as defined by the threecolumn spine concept in acute spinal trauma. Clinical
orthopaedics and related research. 1984; 189: 65-76.
9. Harries M., Williams C., William D. S. et al. Oxford textbook
of sports medicine. 1st edition. Oxford University Press.1996: 686696.
92
93
10. Krista L. K., James W. Davis. Patients with gun shot wounds
to the head do not require cervical spine immobilization and
evaluation. J Trauma .1998; 5:44: 865-867
11. Chesnut R. M., Marshall L. F., Klauber M. R. et al. The role
of secondary brain injury in determining outcome from severe head
injury. J trauma 1993; 34: 216
12. Unterberg A., Baethmann A., Lankscht W. Prevention and
treatment
of
secondary
brain
damage:
clinical
aspects.
Chest.1991; 100:200S.
13. Chesnut R. M. Secondary brain insults after head injury:
Clinical perspectives. New Horizon. l995; 3:366.
14. Brain Trauma foundation. Resuscitation of blood pressure
and oxygenation. Guidelines for the management of severe head
injury. New York Brain and trauma foundation. 1995:1-11.
15. Olson D. A., Carcione J. Head injury. eMedicine Journal .
2002;3:5
16. Hills M. W., Deane S. A. Head injury and facial injury: is there
an increased risk of cervical spinal injury? J Trauma.1993; 34 (4):
549-554
17. Davis D., Bolman H., Walker E. et al. The pathological
findings of fatal cranial spinal injuries.J Neurosurg.1971;34: 603613.
93
94
18. Bulcholz R. W., Burkhead W. Z., Graham W. et al. Occult
cervical spine injuries in fatal traffic accidents Trauma .1979;19:
768.
19. Hideo I., Shigekuni T., Takao K. Association of head trauma
with cervical spine injury, spinal cord or both. J Trauma.1999;
46(3): 450-452.
20. Shrago G. Cervical spine injuries: association with head
trauma. Am J Roentgenol.1973; 188:670-673.
21. Holly L. T., Kelly D. F., Counelis G. J. et al. Cervical spine
trauma associated with moderate and severe head injury:
incidence, risk factors, and injury characteristics. J
Neurosurg.2002; 96 (3): 285-91
22. Davidson J. S., Birdsell D. C. Cervical spine injury in
patients with facial skeletal trauma. J Trauma. 1989; 29(9): 12761278
23. Musau C. K. .Spinal injuries and their urological complications
as seen at the KNH and the national spinal injuries hospital.
M.Med dissertation University of Nairobi.1988
24. Georges Desjardins. Injuries to the cervical spine. J
Anaesthesia and critical care.1999; 4.
94
95
25. Canale
S.
T.
CAMBELLS
Textbook
of
Operative
Orthopaedics. Ninth edition. Mosby CD online. Chapters 55-56.
26. Allen B. L. Jr., Ferguson, R. L., Lehmann T. R. et al. A
mechanistic
classification
of closed, indirect
fractures
and
dislocations of the lower cervical spine. Spine. 1982; 7:1-27.
27. Howard S., Simpson J. Micheal. Surgery of the cervical
spine. Fourth edition. William & Witkins. 1980: 30.
28. White A.A., Southwick W.O., Panjabi M. M. Clinical
instability in the lower cervical spine; a review of past and present
concets. Spine.1976; 1:15.
29. Herzenberg J. E., Hensinger R. N., Dedrick D. K. et al.
Emergency transport and positioning of young children who have
an injury of the cervical spine. The standard backboard may be
hazardous. Journal of Bone and Joint Surgery. 1989; 71: 15-22.
30. Louis Solomon, David J. Warwick, Selvadurai Nayagam.
Apleys System of Orthopaedics and Fractures. Seventh edition.
Arnold.London.2001: 643-658.
31. Goth P., Garnett G. Clinical guidelines for delayed or
prolonged transport in spine injury. Prehospital and Disaster
Medicine.1993; Oct-Dec.
32. Velmahos G. C., Demetrios T., Rayntoldt T. et al.
Radiographic cervical spine injury in the alert asymptomatic blunt
trauma victim: Much ado about nothing. J Trauma. 1996; 40:768777
95
96
33. Robert I., Kearny Q., Ricciardi J. et al. Occult ligamentous
injury of the cervical spine. Southern Medical Journal. 2000; 93
(10)
34. Graber M. A., Kathol M. Cervical Spine Radiographs in the
Trauma Patient. American academy of family physicians. Jan
1999.
35. Daffner R. H. Identifying patients at low risk for cervical spine
injury, The Canadian C-spine rule for radiography. JAMA. 2001;
286:15.
36. LeBlang S. D,,Nunez D. B. Jr. Helical CT of c-spine and soft
tissue injuries of the neck. J Radiologic Clinics of North America.
1999; 37(3):515-532.
37. Flanders A. E., Spettell C. M., Friedman D. P. et al. The
relationship between the functional abilities of patients with cervical
spinal cord injury and the severity of damage revealed by MRI
imaging. J Neurology (US). 1999; 20(5): 926-934.
38. Barba C. A., Taggert J., Morgan A. S. et al. A new cervical
spine clearance protocol using Computed Tomography. J Trauma;
2001; 51(4): 652-656
39. Selden N. R., Quint D. G., PateL. N. et al. Emergency MRI
of C-spine injuries: clinical correlation. J Neurosurgery (US). 1999;
44(4): 785-792.
96
97
40. Scott Moses. Paediatric spine injury (SCIWORA). Family
Practice notebook. @Family practice .com
41. Kothari P., Freeman B., Gravitt M. et al. Injury to the spinal
cord without radiological abnormality (SCIWORA) in adults.
Journal of Bone and Joint Surgery. 2000; 82: 1034-1037.
42. Mobbs R. J., Stoodley M. A., Fuller J. Effect of cervical
collar on intra cranial pressure after head injury, ANZ J Surg.
2002;72 (6):389-391.
43. Andrew W. H. Kaye. Essential Neurosurgery; spinal injuries.
Second edition. Churchill Livingstone.1997: 329-341.
44. Eurig Jeffreys. Disorders of the cervical spine. Second
Edition. Butterworth and Heinmann. 1993: 54-66.
45. Delamater R. B., Coyle J. Acute. Management of cervical
spine injury. J American Academy of Orthopaedic Surgeons.1999;
7(3): 166-175.
46. Charles V. Mann, Russell R.C.G, Norman S. Williams.
Bailey & Love’s short practice of surgery. 22 nd edition. Arnold.
1999: 354-374.
47. Rizzolo S. J., Corler J. M. Unstable cervical spine injuries:
specific treatment approaches. Journal of American Academy of
Orthopaedic Surgery .1993; 1:57-66.
97
98
48. Fehlings M. G., Rao S. C., Tator C. H. et al. The optimal
radiologic method for assessing spinal canal compromise and cord
compression in patients with cervical spinal cord injury. J Spine
(US). 1999; 24(6): 605-613.
49. Fehlings M. G., Tator C. H. Evidence based review of
decompressive surgery in acute spinal cord injury. J Neurology
(US) .1999; 91.
50. The Royal College of Surgeons of Edinburgh. Spinal
injuries: Proceedings of a symposium. (Edited by Phillip Harris).
1963: 140.
51. Squires B., Gargan M. F., Bannister G. C. Soft tissue
injuries of the cervical spine. Journal of Bone and Joint surgery
(British). 1996; 78B: 955-957.
52. Fehlings. M. G., Thorpe K., Taylor W. et al. Current use and
timing of spinal surgery for management of acute spinal surgery for
management of acute spinal cord injury in North America. J
Neurosurg. (US) .1999; 91.
53. Mizuno J., Nakagawa H. Risk of early closed reduction in
cervical spine subluxation injuries. J Neurolgia Medico-chirurgica
(Japan).1999; 39(6): 434-439.
54. Oller D W. The relationship between face and skull fractures
and cervical spine and spinal cord injuries: Accid Anal Prev.1992 ;
24:187
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99
APPENDIX 1
QUESTIONAIRE
DATE OF DATA COLLECTION -----/-----/2002
A. Study code number;
B. IP. number;
-----------
----------
C. Date and time of accident; Date ----- / ------- / ---------- Time------------(24Hrs)
D. KNH Primary Hospital
Referral from other hospital
E. Demographic characteristics:
Sex;
male
F. Date of birth
female
------/---------/-----------
G. Date of admission;-- ----/--------/ 2002
H. Date of discharge…/…/2002
I. Cause of head injury:
I.
R.T.A ;
If RTA: - PASSENGER
- If Passenger: Front seat
II.
PEDESTRIAN
Back seat
CYCLIST
Back ofP/U or
lorry
Fall from height
-if fall - Height: < 3 meters
3-10 meters
>10meters
III.
Object falling on head
IV.
Assault :
V.
.Blunt object ---------.Sharp object---------
VI.
Explosion/blast ---------
VII.
Gunshot ------------
VIII.
Other.Specify -------------------------------------------------------------------------------
99
100
J. Cervical collar applied before arrival.
If YES
Soft collar-
Yes
No
Hard collar -
K. Conscious level at Admission
 Alert
 Drowsy  Unconscious
L. Drug / Alcohol intoxication:
Yes
None -
M. Neck pain on movement(unaided): Yes
N. Neck tenderness: Yes
No
None
O. Neurological deficit by history, examination or complaint: Yes
-
No
P. Sensory level if Neurological deficit present
Q. Motor level if neurological deficit present
R. Severity of head injury [ G.S.C]- eye opening
- motor response
- verbal response
-Total
S. Type of STI on scalp : Cuts
Hematoma
Bruises
Friction burns
T. Radiological findings of skull:
No #s
-Linear #s.
Depressed #s
Stellate #s
-Region of skull Specify---------------------------------------------------------------------Fracture base of skull: Yes
No
U. CT scan findings of head---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
100
101
V. Radiological examination of C-spine [x-ray] done: Yes
I.
Loss of normal lordosis : yes
II.
Retropharygeal space widening :–
No
No
Width at c2 in mm- ------- width at c7 in millimeters-------Width in mm at level of injury-------------III.
Subluxation --below 25% of vertebral width-
Above 25%-
IV.
Wedge collapse
V.
Loss of vertebral height
VI.
Fracture of dens
VII.
Vertebral spine fracture --
VIII.
x-ray report by radiologist ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
W. C.T scan findings(c-spine) : ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
X. If unstable cervical spine injury, treatment offered :
 . Cervical collar
 . Traction
 . Halo  . ORIF(specify) . OTHER.( Specify ); -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------
101
102
APPENDIX 2
INFORMED CONSENT FORM
I (patient) / Parent/ Guardian/next of kin (delete as applicable)
of--------------------------------------------------------of----------------------------------------, do hereby freely consent to participate in this
research study on CERVICAL SPINE INJURY IN HEAD
INJURED PATIENTS AS SEEN AT THE KENYATA NATIONAL
HOSPITAL, by Dr Kamau. He has explained to me the nature of
the study to me. I also understand that participation in this study
will not affect my medical care in any way whatsoever. I also
understand that I can withdraw from the study at any time if I so
wish, without giving any explanation, again without any adverse
consequences. I also understand that all information about
myself/ my child/ my next of kin (delete as applicable) will be
treated with the strictest of confidence.
Signed------------------------------------- Date -----------------------------
Witnessed------------------------------------------I Dr Kamau P. Njoroge, (Tel. Number 0722867169) confirm that
I have clearly explained to the patient the nature of this study
and the contents of this consent form.
Signed ---------------------------------- Date ----------------------------
102
103
APPENDIX 3
PATIENT INFORMATION FORM

This is a study on CERVICAL SPINE INJURY IN HEAD INJURED
PATIENTS AS SEEN AT THE KENYATA NATIONAL HOSPITAL.

The study is being undertaken at Kenyatta National Hospital by Dr
Kamau between December (2002) and March (2003).

You will only be enrolled for this study after giving your informed
consent.

You are not obliged to enroll for this study.

By enrolling onto this study, you will be asked a few questions by the
researcher. The rest of the data will be provided by the medical staff
looking after you.

This could benefit you directly by being under closer extra surveillance
by the researcher.

This study will have important benefits on the quality of service provided
to the patients with cervical spine injury and head injury seeking medical
care at KNH.

This study will not affect your treatment in any deleterious way
whatsoever.

You will not be subject to any extra tests by the researcher. Whatever
will be done will be at the discretion of the doctors of the ward under
whose care you are.

It is within your rights to refuse to participate in or to withdraw from the
study if and when you wish.

All information gathered in this study will be treated in the strictest
confidence.
 Thank you for your time.
103