Cervical rachidian traumatism

The traumatisms of the cervical rachis are frequent possibilities. They can engage the functional forecast and the vital prognosis. However, they are benign most of the time. The diagnosis can not be made in time, which can have serious consequences. It is evoked systematically in front of:

a patient who has a traumatic history and pains of the cervical Rachis.
One polytraumatized or an unconscious patient whatever is the reason # Accident of the public highway, facial Traumatism, cranial traumatism, wound of the face, wound of the scalp.

The presence of a lesion of the cervical rachis is in general painful and is accompanied by stiffness. These signs are sensitive, but nonspecific. They can however miss, especially at the traumatized unconscious one or in a context of polytraumatism.

Diagnosis

To evoke the diagnosis, it is:

To seek from the start of the central nervous system disorders:

driving Deficit of the members and the trunk sensitive deficit Périnéaux disorders: urinary Incontinence, anal tonicity, Reflex S périnéaux Disorders of tonicity with type rather of hypotonia that pyramidal Syndrome

To carry out stereotypes of good quality

1.Rachis cervical of profile: is the stereotype by far most useful; it must allow the visualization of the Occiput the disc C7 - D1. In the contrary case, it should be remade. Among certain patients with the neck runs, the visualization of C7 - D1 is impossible. One carries out a stereotype in the position of the swimmer, but one runs the risk to move an unstable lesion, and especially in the event of evocative clinical context (pain, central nervous system disorders) one passes directly to the scanner of the hinge cervico-dorsal.
2.Rachis cervical of face: show the cervical rachis well low, but not the cervical rachis high. Interpretation is obstructed by the superposition of the articular ones.
3.Cliché known as “flank profile stops open”

4.Clichés of cervical rachis of 3/4: are useful, but nonessential ===Immobiliser the patient===

Thanks to a prefabricated plastic minerve. The setting in traction is not indicated because it is dangerous in certain lesions. The stereotypes of cervical rachis are difficult to interpret. An interpreted stereotype as normal can appear pathological after second reading when a precise anomaly is sought. A normal and read again stereotype as such does not eliminate the presence from a seuse Lésion Os or soft parts discovered on later stereotypes. However, the unstable lesions of the cervical rachis presenting of the neurological risks are visible on the initial stereotypes after serious reading with a minimum of care. The initial stereotype of cervical Rachis of profile must make it possible to eliminate a risk from occurred of neurological lesion if it is read correctly. In case of doubt diagnosis, the scanner whose level is directed by the Radiographie S is the examination of choice

Interpretation of the standard stereotypes of the cervical rachis

The lesions are often small and badly visible; it is their effect on the balance of the unit cervical Rachidien which is often most obvious. Stereotype of profile: by far most important. On this stereotype one appreciates: Regularity of the 7 longitudinal lines reference mark:

Space clearly pre vertebral
Alignment of the former edge of the bodies
posterior Walls of the bodies
former Edge of the articular solid masses
posterior Edge of the articular solid masses
posterior Limit of the channel (former of the blades, quite visible edge)
Alignment of the ends of the thorny apophyses

Regularity of the stacking of the articular solid masses without located unroofing, and regularity of spacing inter thorn-bush. Especially, the conjunction of the irregularities on the same level strongly makes suspecter an osseous lesion or Ligament surface.

It is necessary to insist on the detection of a Antélisthésis (displacement of a vertebral body ahead on the vertebral body under unclaimed) quite visible on the alignment of the posterior edges of the vertebral bodies. A antélisthésis of more than 2 mm in lower part this C4 and 4 mm above C4 is pathological in the adult. The majority of the osseous lesions are accompanied in rule by a antélisthésis. Associations of Fracture S on different levels are frequent and they should be sought systematically.

Stereotyped of face: one appreciates with identical the regularity of the various levels. A irregularity on only one level strongly makes suspecter a lesion. In particular, the articular line spaces of the side solid masses visible because are not superimposed and oblique; when an isolated line space becomes visible, therefore too horizontal, suspecter is needed an osseous lesion.

Stereotyped of 3/4: allow each level to see the Foramen and its possible filling by material fracturaire; one also appreciates very well the alignment of the posterior edges of the vertebral bodies in conjunction with the stereotype of profile.

Cliché known as flank profile stops open makes it possible to see the features of fracture of the flank profile, while being wary of the dental superpositions, and to appreciate the symmetry of the side solid masses of the atlas.

In front of a patient who has cervicalgies, a stiffness of the cervical rachis, any normal central nervous system disorder and stereotypes, one is thus careful and one immobilizes in a relative way by a plastic minerve for a few days with an antalgic treatment and AINS. If the clinical context is evocative, i.e.:

important and focused Pain; or:
important Stiffness; or:
Neuralgia cervico brachiale systematized or neuralgia of Arnold

… one carries out new stereotypes of face, profile and three quarters and a scanner whose level is guided by the stereotypes or, in the absence of radiological index, by the data of the clinical examination (level of the neuralgia).

The majority of the cervical pains of traumatic origin yield after a few days of immobilization: perfectly flexible and painless cervical rachis do not require complementary exploration.

After a time of a few days allowing the sedation of the initial stiffness and the pain, one re-examines the patient. If an embarrassment persists and/or a stiffness, which is frequent, one carries out dynamic stereotypes closely connected to detect an instability due to a lesion of the soft parts (known as “serious” distorsion cervical in opposition to the “benign” distorsions cervical which are not accompanied by instability). These stereotypes are carried out with a precise methodology: strict profile, mobilization by the patient himself in sitting position, Inflection and maximum Extension permitted by the pain. One can carry out these stereotypes in an earlier way, but in front of painful rachis and enraidi one will obtain only stereotypes in amplitude under - maximum which will not bring information and are likely to eliminate the diagnosis wrongly.

The dynamic stereotypes are read same manner as the standard stereotypes while appreciating moreover the regularity of the curve. It happens that certain osseous traumatic lesions are uncovered only on the dynamic stereotypes (fractures articular, certain thorny fractures of Apophyse S).

When the dynamic stereotypes are normal and of good quality, and that persist not systematized pain and stiffness, one carries the diagnosis by defect “of benign Entorse”. It is probably about lesions of the intervertebral discs or ligamentaires at the origin of irradiated pains. Symptomatology is usually rich: Cephalgia S, Insomnia S, pains nucales, dorsals, pseudo-Lhermitte… and can evolve to the sinistrose and the claim. The duration of evolution is in general prolonged, up to 18 months. The early mobilization in the form of daily exercises and the weaning of the application as of the sedation of cramp improve the evolution of these patients in a statistically significant way. There is not other effective cure. In particular, there is no surgical treatment in the absence of instability.

When symptomatology is prolonged, it is especially important not to pass beside an other diagnosis, without médicaliser in an excessive way. It arrives, indeed, that a osteoid Ostéome is responsible for cervical pains which are put on the account of an old traumatism. It should be noted that, sometimes, some Entorse S “serious” uncover in a way delayed, several weeks or several months after the traumatism, with constitution of a yawn inter-thorn-bush localized and unroofing of the articular ones. These delayed instabilities are in rule persons in charge of cervicalgies and stiff neck with repetition and can require a surgical stabilization.

Pathological stereotypes:

To know the Pathology, it is to know what it is necessary to seek, requirement to affirm the nonpathological character of stereotypes carried out in urgency. Image in “dunce's cap”, an analogy which evokes perfectly the abnormal visualization of both Apophyse S articular higher than the same level on the stereotype of profile, this is pathognomonic of a unilateral luxation of the cervical rachis.

Image of “square solid mass” on the stereotype of face, visualization of two adjacent articular line spaces due to the rocker of the articular, typical solid mass of the fracture - separation of the articular solid mass, can be also seen in certain fractures - avulsion of the articular solid mass. “Tear drop”, image of separation “in drop of tear” of the corner antéro-inferior of a vertebra, usually C5, C4 or C6, corresponding to a very unstable fracture frequently accompanied by serious central nervous system disorders. The same image can be also seen in C2, corresponding to a fracture less seriously unstable.

Particular cases

Fracture of the Flank profile: not moved, are difficult to see, but it is important not to miss the diagnosis. The risk is less sudden and unverifiable displacement, that a risk of Pseudarthrose which, it, will be able to be unstable and to move at the time of a new traumatism, with serious consequences. Moved (> 4 mm), very unstable, require a specialized assumption of responsibility, with rather broad operational indications. The Fracture S moved are in general quite visible on radiographies, but one needs a careful reading of the profile and face “stops open”, on a stereotype of good quality free from dental superpositions or occiput.

Luxations. They can be plain or bilateral. Unilateral luxations can be not easily visible on the initial stereotypes (antélisthésis moderate, image in “dunce's cap”) and are accompanied rather by radicular disorders. Bilateral luxations are more easily diagnosed (antélisthésis quite visible on the profile), and is more frequently accompanied by medullary disorders.

Fractures bursting: in rule are easily diagnosed on the stereotype of profile, but it is necessary to be wary in C7. They are more rarely accompanied by central nervous system disorders than the fractures “tear-drop”.

Case of the fractures being accompanied by central nervous system disorders

Patient ambulatory, conscious, radicular disorders of type painful, overdrawn sensitive or overdrawn engines. These disorders can be of appearance delayed of several hours after the traumatism. The pain and the sensitive deficit follow a precise way irradiated towards the shoulder, the arm or before arm, to the hand according to the territory. The driving deficit with the upper limb is concordant. Driving topography with the upper limb is indicated in the following table:

TABLE I: key movements of score ASIA and their metameric correspondence

Inflection of the elbow

Extension of the wrist

Extension of the elbow

Inflection of P3 3rd finger

Abduction of the 5th finger

The lesions generally responsible for post-traumatic Névralgie cervico-brachiale are the fractures of articular Apophyse, the fractures - separation of an articular solid mass, the Hernie S of the intervertebral discs post-traumatic, the unilateral Luxation S. The diagnosis is based, in addition to standard radiographies, on the scanner in urgency.

Post-traumatic acute medullary disorders. It is generally about flask paraplegia in a dramatic context. It is capital to appreciate the complete or incomplete character by examining the Périnée. The persistence of a sensitivity, even thin, or of a tonicity sphinctérien under the lesion signs the incomplete character, by knowing that sometimes the phase of “shock spinal” initial mask the métamères saved under organic during several hours after the traumatism. The lesions generally at the origin of medullary disorders are the fractures “tear-drop”, the fractures bursting, bilateral luxations. The incomplete character of the attack makes immediately consider the reduction in urgency either in traction after radiological diagnosis, or surgical by reduction and instrumented stabilization, or both within the shortest possible time. The complete medullary lesions, taking into account the importance of the disorders and death rate, and taking into account the morbidity of the surgery in urgency, are more of the patients dealt with by the reanimator than by the surgeon in the immediate future.

Patient presenting of the disorders of the conscience in a post-traumatic context, or origin of the disorders of unspecified conscience. The traumatic etiology is to be evoked systematically. It is useful to carry out stereotypes of the cervical, but so dorsal or lumbar rachis if the context is evocative or unknown. The case of the patient hospitalized in acute ethyl state after a fall in the staircases last unperceived is traditional recurring. There are many others of it.

The diagnosis of lesion of the cervical Rachis is that which is generally missed after a traumatism. The reading of the stereotypes is difficult, the misleading clinical context. The indeed benign Pathologie is extremely frequent. The clinical examination with the Urgences is the gesture which gives the most information, and most capable to rectify an abusive diagnosis of benignity. The standard stereotypes, if they do not make it possible to see the lesions ligamentaires in urgency, nor even all the osseous lesions, must make it possible to eliminate an unstable lesion at the neurological risk. The immediate goal being not to let set out again a patient with a lesion potentially at the risk of displacement with which has occurred of central nervous system disorders.

Algorithm of assumption of responsibility

References

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See too

Civière with paddles
cervical Collier
Matelas immobilisator with depression, known as “mattress cockles”
hard Plan (or dorsal board, board “Olivier” or “Berbier-Kind”)
road Traumatologie

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