Cervical Spine Injuries, Free CME Quiz, Earn Free CME Credit
This week's Med-Challenger free CME quiz - Cervical Spine Injuries - the quick quiz covers spinal imaging criteria used in pediatric patients, the importance of understanding the mechanism of injury to determine the likely stability of the injury, the appropriate trauma cervical spine imaging in the pregnant patient, and the determination of stability of spinal fractures using the 3-column method of Denis.
A free Cervical Spine Injuries question included below. The full Cervical Spine Injuries CME quiz is free online for a limited time. You can earn AMA CME credit - and now you can earn ANCC contact hours as well! Play now.
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Here's this week's sample CME board review question on Cervical Spine Injuries:
A 20-year-old woman experiences a spinal fracture.
Determining the stability of the fracture is key to management.
Admittedly, however, this can become a complex question.
One practical principle is the 3-column theory of Denis, where a violation beyond one column renders the fracture unstable.
Which of the following divisions into 3 segments (including the associated ligaments) is correct?
anterior two-thirds of the vertebral body, the posterior third of the vertebral body, and the posterior elements
vertebral body, the arch of the canal, and the spinous process
upper half of the vertebral body, the lower half of vertebral body, and the lower disc
anterior half of the vertebral body, the posterior half of the vertebral body plus the arch, and the spinal process
See the Answer:
The correct answer is:
Anterior two-thirds of the vertebral body, the posterior third of the vertebral body, and the posterior elements.
Review the determination of stability of spinal fractures using the 3-column method of Denis.
By determining which columns are disrupted, it is possible to assess fracture stability in most cases.
The Denis 3-column theory is classically described as follows (see Figure 1):
Anterior column: anterior two-thirds of the vertebral body and the anterior longitudinal ligament
Middle column: posterior one-third of the vertebral body, the posterior longitudinal ligament, and the arch elements (eg, transverse processes)
Posterior column: spinous processes and the posterior ligaments (eg, interspinous, nuchal)
It can seem difficult to use the theory if reviewing the original literature, because there are 20 subtypes. A principle that makes this easier is to remember that the 3 major ligaments count as much as anything.
The question to ask is: Is the anterior longitudinal ligament, the posterior longitudinal ligament, and/or the posterior interspinous ligaments likely disrupted? If the answer is yes to any two, then there is an unstable fracture.
A simple example can clarify this further. A small, simple anterior wedge fracture is caused by hyperflexion. It is an anterior column injury only. It is stable.
An anterior wedge fracture caused by severe flexion will also disrupt the middle column and the posterior ligaments (see Figure 2). This violates all 3 columns and is unstable.
It is worth noting that it is common to find incorrect explanations of the theory, eg, the columns defined by equal halves of the vertebral body or the "tree column" instead of the "three column" theory.
Kaji AH, Hockberger RS. Spinal injuries. In: Walls R, et al. Rosen's Emergency Medicine: Concepts and Clinical Practice. 9th ed., 2018:345-371.
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