Cervical fractures

CERVICAL FRACTURESBy

Dr. Tarek A. ElHewalaLecturer of Orthopaedic Surgery

Faculty of Medicine, Zagazig University

ZAGAZIG UNIVERSITYFACULTY OF MEDICINE

ORTHOPAEDIC DEPARTMENT

Spinal Injuries

• Less common than

traumatic injuries of the

extremities but:– Have the lowest functional

outcomes and the lowest rates

of return to work after injury

in all major organ systems.

Major Trauma• High energy trauma.• Polytrauma patients.• Neurological involvement.

Spinal Injuries

• Incidence of spinal fracture in (NA): 64/100000

• Trend:– Decrease in high income countries.– Strong increase in medium and low

income countries.

Cervical Spine Injuries

• Account for one-third of all spinal injuries.• The most commonly injured vertebrae(1) are:

– C2: where one-third of which are odontoid fracture.– C6,C7: are the most frequently affected levels in the

subaxial spine (vertebral body fracture) • A neurological injury occurs in about 15% of

spine trauma patients.• A low GCS indicates a high risk for a concomitant

cervical injury.1- Goldberg W, Mueller C, Panacek E, Tigges S, Hoffman JR, Mower WR (2001) Distribution and patterns of blunt traumatic cervical spine injury. Ann Emerg Med 38:17–21

Normal Anatomy

• Functionally, the cervical spine is divided into:– The upper cervical spine [occiput (C0)–C1–C2]– The lower (sub-axial) cervical spine (C3–C7).

Normal Anatomy• Upper Cervical Spine:

• The atlas-occiput junction primarily allows flexion/extension and limited rotation.

• Axial rotation at the craniocervical junction is restricted by osseous as well as ligamentous structures.

Normal Anatomy

• Upper Cervical Spine:• The atlantoaxial joint is

composed of lateral mass articulations with loosely associated joint capsules and an atlantodental articulation

Normal Anatomy• Lower (Subaxial) Cervical Spine:• The vertebrae of the lower cervical spine have a

superior cortical surface which is concave in the coronal plane and convex in the sagittal plane.

• This configuration allows flexion, extension, and lateral tilt by gliding motion of the facets.

Normal Anatomy

• Lower (Subaxial) Cervical Spine:• The C5/6 level exhibits the largest range of

motion, which in part explains its susceptibility to trauma and degeneration.

• The facet joint capsules are stretched in flexion and therefore limit rotation in this position.

Biomechanics of Cervical Spine Trauma

• The conditions under which neck injury occurs include several key variables such as:– impact magnitude.– impact direction.– point of application.– rate of application.

Biomechanics of Cervical Spine Trauma

• For example in lower cervical spine:• Vertical loading of the lower cervical spine in

the forward flexed position reproduce pure ligamentous injuries.

• This mechanism produced bilateral dislocation of the facets without fracture.

• A unilateral dislocation was produced if lateral tilt or axial rotation occurred as well.

Biomechanics of Cervical Spine Trauma

• Axial loading less than 1 cm anterior to the neural position produced anterior compression fractures of the vertebral body.

• Burst fractures can be produced by direct axial compression of a slightly flexed cervical spine.

• Tear-drop fracture results from a flexion/compression injury with disruption of the posterior ligaments.

Spinal Cord Injury

• It is now well accepted that acute spinal cord injury (SCI) involves both:– Primary injury mechanisms.– Secondary injury mechanisms.

Spinal Cord Injury• The primary injury of the spinal cord results in local

deformation and energy transformation at the time of injury and is irreversible. It can therefore not be repaired by surgical decompression.

• The injury is caused by:– In the vast majority of cases bony fragments that acutely compress

the spinal cord.– acute spinal cord distraction.– acceleration-deceleration with shearing.– laceration from penetrating injuries.

• The injury directly damages cell bodies and/or processes of neurons.

Spinal Cord Injury

• Immediately after the primary injury, secondary injury mechanisms may initiate, leading to delayed or secondary cell death that evolves over a period of days to weeks.

• These secondary events are potentially preventable and reversible.

Spinal Cord Injury• A variety of complex chemical pathways are likely

involved including:– hypoxia and ischemia– intracellular and extracellular ionic shifts– lipid peroxidation– free radical production– excitotoxicity– eicosanoid production– neutral protease activation– prostaglandin production– programmed cell death or apoptosis

Spinal Cord Injury

• In the case of a lesion of the cord cranial to T1, a complete loss of sympathetic activity will develop that results in loss of compensatory vasoconstriction (leading to hypotension) and loss of cardiac sympathetic activation (leading to bradycardia).

• Secondary deteriorations of spinal cord function that result from hypotension and inadequate tissue oxygenation have to be avoided.

Spinal Cord Injury

• Injuries to the spinal cord often result in spinal shock.

• The phenomenon of spinal shock is usually described as: – loss of sensation – flaccid paralysis – absence of all reflexes below the spinal cord injury.

• It is thought to be due to a loss of background excitatory input from supra-spinal axons

Spinal Cord Injury

• Spinal shock is considered the first phase of the response to a spinal cord injury, hyper-reflexia and spasticity representing the following phases.

• When spinal shock resolves, reflexes will return and residual motor functions can be found.

History• The cardinal symptoms of an acute cervical

injury are:– pain– loss of function (inability to move the head)– numbness and weakness– bowel and bladder dysfunction.

History• In patients with evidence for neurological deficits, the

history should include:– time of onset (immediate, secondary)– course (unchanged, progressive, or improving)

• The history should include a detailed assessment of the injury:– type of trauma (high vs. low-energy)– mechanism of injury (compression, flexion/distraction,

hyperextension, rotation, shear injury)

History• In polytraumatized or unconscious patients, patients must

be considered to have sustained a cervical injury until proven otherwise.

• The history should also comprehensively assess details of collision and injury such as:– type of collision (rear-end, frontal or side impact)– use of headrest/seat belt– position in the car– injury pattern for all passengers– head contusion– severity of impact to the vehicle

Initial Management• Primary survey• A full general and neurological assessment must be

undertaken in accordance with the principles of advanced trauma life support (ATLS).

• Spinal trauma is frequently associated with multiple injuries.

• As always, the patient’s airway, breathing and circulation (“ABC”—in that order) are the first priorities in resuscitation from trauma.

Initial Management

• Secondary survey• Once the immediately life-threatening injuries

have been addressed, the secondary (head to toe) survey that follows allows other serious injuries to be identified.

• If neurological symptoms or signs are present, a senior doctor should be present and a partial roll to about 45˚ may be sufficient.

Initial Management• Secondary survey• specific signs of injury including:

– local bruising– deformity of the spine (e.g. a gibbus or an increased interspinous gap)– vertebral tenderness.

• The whole length of the spine must be palpated, another spinal injury at a different level.

• Priapism and diaphragmatic breathing invariably indicate a high spinal cord lesion.

• The presence of warm and well-perfused peripheries in a hypotensive patient should always raise the possibility of neurogenic shock attributable to spinal cord injury in the differential diagnosis.

Initial Management

• Secondary survey• At the end of the secondary survey, examination of

the peripheral nervous system must not be neglected.

• Diagnosis of intra-abdominal trauma often difficult because of:– impaired or absent abdominal sensation– absent abdominal guarding or rigidity, because of flaccid

paralysis– paralytic ileus

Neurological assessment• In spinal cord injury the neurological examination must

include assessment of the following:

– Sensation to pin prick (spinothalamic tracts)– Sensation to fine touch and joint position sense (posterior

columns)– Power of muscle groups according to the Medical Research

Council scale (corticospinal tracts)– Reflexes (including abdominal, anal, and bulbocavernosus)– Cranial nerve function (may be affected by high cervical

injury).

Neurological assessment• By examining the dermatomes and myotomes, the level

and completeness of the spinal cord injury and the presence of other neurological damage such as brachial plexus injury are assessed.

• The last segment of normal spinal cord function, as judged by clinical examination, is referred to as the neurological level of the lesion.

• This does not necessarily correspond with the level of bony injury, so the neurological and bony diagnoses should both be recorded. Sensory or motor sparing may be present below the injury.

Neurological assessment

• The differentiation of a complete and incomplete paraplegia is important for the prognosis.

• It is mandatory to exclude a spinal shock which can mask remaining neural function and has an impact on the treatment decision and timing.

• The first reflex to return is the bulbocavernosus reflex in over 90%of cases.

Neurological assessment

No voluntary sensory (sacral sparing) or motor sparing

bulbocavernosus reflex is present

spinal shock is resolved, and a complete cord lesion is confirmed.

Neurological assessment• The American Spinal Injury Association (ASIA)

has now produced the ASIA impairment scale modified from the Frankel grades.

Neurological assessment

Neurological assessment

Conclusions Primary Assessment

• ATLS is the guiding principle:– First life, then limb.

• Spinal fractures can be missed easily during initial assessment:– Every HET patient has spinal injury until it is disproved.

• There is no reliable way of determining the neurologic status with certainty at the admission.

• There is no place for fatalism as far as the neurology is concerned– Give your patients the benefit of doubt.

Diagnostic Work-up

In 2001, a highly sensitive decision rule (“Canadian C-Spine Rule”) was derived, for use in cervical spine radiography in alert and stable trauma patients.

Standard Radiographs• At least three views are recommended for alert and

stable trauma patients:– anteroposterior view– cross-table lateral view– open-mouth dens view

Standard Radiographs• Oakley introduced a simple system (radiological

ABC) for analyzing plain films:– A1: appropriateness: correct indication and right

patient– A2: adequacy: extent (occiput to T1, penetration,

rotation/projection)– A3: alignment:

• anterior aspect of vertebral bodies,• posterior aspect of vertebral bodies,• spinolaminar line (bases of spinous process),• tips of spinous process,• craniocervical and other lines and relationships

– B: bones– C: connective tissues:

• pre-vertebral soft tissue,• pre-dental space,• intervertebral disc spaces,• interspinous gaps

Standard Radiographs

• The most common causes of missed cervical spine injury are:– not obtaining radiographs– making judgments on technically suboptimal films

The latter cause most commonly occurs at the cervico-occipital and cervico-thoracic

junction levels.

Standard Radiographs

Helpful signs to diagnose cervical spine instability:

Standard Radiographs• For the upper cervical spine, White and Panjabi

suggested criteria indicative of instability based on conventional radiography.

Standard Radiographs

Computed Tomography

• CT is the first choice for unconscious or polytraumatized patients.– the ease of performance,– speed of study, – the greater ability of CT to detect fractures other than

radiography.• The craniocervical scans should be of a maximum

2 mm thickness, because dens fractures can even be invisible on 1-mm slices with reconstructions

Computed Tomography• Computed tomography scans are sensitive for detecting

characteristic fracture patterns not seen on plain films:– the mid-sagittal fracture through the posterior vertebral wall

and lamina.– rotatory instability at the atlantoaxial joints.– shows if the dens separates from the anterior arch of C1 with

increased rotation.

• Importantly, all the injuries that were missed by plain films required treatment.

Computed Tomography

MRI

• Magnetic resonance imaging is the imaging study of choice to exclude discoligamentous injuries, if lateral cervical radiographs and CT are negative.

• MRI is the modality of choice for evaluation of patients with neurological signs or symptoms to assess soft tissue injury of the cord, disc and ligaments.

• Particularly, STIR sequences are very helpful in visualizing posterior soft tissue injuries and thereby helping to diagnose unstable fractures (especially if conservative treatment is decided)

MRI

Neck Pain Task Force

Neck Pain Task Force

General objectives of treatment

• restoration of spinal alignment• preservation or improvement of neurological

function• restoration of spinal stability• restoration of spinal function• resolution of pain

Non-operative Treatment Modalities

• Cervical orthoses limit movement of the cervical spine by buttressing structures at both ends of the neck, such as the chin and the thorax.

• However, applied pressure over time can lead to complications such as:– pressure sores and skin ulcers– weakening and atrophy of neck muscles– contractures of soft tissues– decrease in pulmonary function– chronic pain syndrome

Non-operative Treatment Modalities

• Collars– Soft collars have a limited effect on controlling neck

motion.

– The Philadelphia collar has been shown to control neck motion, especially in the flexion/extension plane, much better than the soft collar.

– Disadvantages of the Philadelphia collar are the lack of control for flexion/extension control in the upper cervical region and lateral bending and axial rotation.

Non-operative Treatment Modalities

• Minerva Brace/Cast– A Minerva cervical brace

is a cervicothoracal orthosis with mandibular, occipital and forehead contact points.

• This brace provides adequate immobilization between C1 and C7, with less rigid immobilization of the occipital-C1 junction.

• The addition of the forehead strap and occipital flare assists in immobilizing C1–C2.

Non-operative Treatment Modalities

• Traction:– The Gardner-Wells tongs can be applied using local

anesthesia. – The pin application sites should be a finger breadth

above the pinna of the auricle of the ear in line with, or slightly posterior to, the external auditory canal.

– Rule out atlanto-occipital dislocation or discoligamentous disruption before applying traction.

Non-operative Treatment Modalities

• Halo– The halo vest is the

first conservative choice for unstable lesions.

– Its clinical failure is due to:

• pin track problems• accurate fitting of the

vest• a lack of patient

compliance

Occipital Condyle Fracture

• This type of fracture is a rare injury.• They often are discovered on a head CT scan in an

unconscious patient; cervical radiographs rarely show these fractures.

• Conscious patients complaining of an occipital headache should be suspected of having an occipital condyle fracture until proven otherwise.

• Though cranial nerves IX-XII are sometimes affected, neurological examination is often normal.

Occipital Condyle Fracture

Occipital Condyle Fracture

Atlanto-occipital Dislocation

• Rare survivors usually have a neurological deficit, particularly with cranial nerves VII to X.

• Frequent diagnosis is at autopsies following death related to a spinal injury.

• High-resolution CT efficiently illustrates the injury.

• Treatment includes closed reduction and surgical stabilization—often occiput to C2.

Atlanto-occipital Dislocation

• Traynelis et al. classification:– Type I: anterior dislocation.– Type II: vertical dislocation.– Type III: posterior dislocation.

Atlanto-occipital Dislocation

Occiput to C2 Fixation

Fractures of the Atlas

• Fractures of the atlas account for approximately 1–2% of all fractures.

• These fractures are frequently associated with other cervical fractures or ligamentous traumatic injuries.

• Burst fractures of the atlas are caused by massive axial loads.

Fractures of the Atlas

Fractures of the Atlas• The literature does not allow treatment

recommendations to be given on solid scientific evidence.

• It is recommended to treat isolated fractures of the atlas with intact transverse alar ligaments (implying C1–C2 stability) with cervical immobilization alone.

• It is recommended to treat isolated fractures of the atlas with disruption of the transverse ligament with atlantoaxial screw fixation and fusion (a Magerl C2 and C1 transfacet screw fixation technique).

Atlantoaxial Instabilities

• Atlantoaxial instability results from either:– a purely ligamentous injury or – avulsion fractures.

• While atlantoaxial dislocation and subluxation is relatively common in patients with rheumatoid arthritis, a traumatic origin due to a rupture of the transverse ligament is rare.

Atlantoaxial Instabilities

• These injuries are significant, because complete bilateral dislocation of the articular processes can occur at approximately 65° of atlantoaxial rotation.

• When the transverse ligament is intact, a significant narrowing of the spinal canal and subsequent potential spinal cord damage is possible

Atlantoaxial Instabilities

• With a deficient transverse ligament, complete unilateral dislocation can occur at approximately 45° with similar consequences.

• In addition, the vertebral arteries can be compromised by excessive rotation which may result in brain stem or cerebellar infarction and death.

Atlantoaxial Instabilities• Atlantoaxial instabilities can be classified according to

the direction of the dislocation as:

– anterior (transverse ligament disruption, dens or Jefferson fracture)

– posterior (dens fracture, see Fielding Type IV)– lateral (lateral mass fracture of C1, C2, or unilateral alar

ligament ruptures)– rotatory (see Fielding Types I–III)– vertical (rupture of the alar ligaments and tectorial

membrane)

Atlantoaxial Instabilities• Rotatory Atlantoaxial Instability

• A special form of atlantoaxial instability which may occur with or without an initiating trauma.

• This subluxation is more common in children than in adults.

• Non-traumatic etiologies include:– juvenile rheumatoid arthritis– surgical interventions such as tonsillectomy or mastoidectomy– infections of the upper respiratory tract (“Grisel syndrome”).

Atlantoaxial Instabilities

• According to Fielding et al. four types can be differentiated:

Atlantoaxial Instabilities

• Common complaints are neck pain with evidence of torticollis, suboccipital pain, and limited cervical rotation.

• Radiographic diagnosis includes:– open-mouth odontoid view, – lateral cervical spine with or without flexion–

extension views, – dynamic (rotation to the right then the left) CT scan,– MRI.

• Surgical treatment involves a C1-C2 fusion.

Dens Fractures

• The most common axis injury is a fracture through the odontoid process.

• Translational motion of C1 on C2 is restricted by the transverse atlantal ligaments that center the odontoid process to the anterior arch of C1.

• With a fracture of the odontoid process, restriction of translational atlantoaxial movement is lost.

Dens Fractures• According to the

classification of Anderson and D’Alonzo:– Type I: oblique fractures

through the upper portion of the odontoid process.

– Type II: across the base of the odontoid process at the junction with the axis body.

– Type III: through the odontoid that extends into the C2 body.

Dens Fractures• A variety of non-operative and operative treatment

alternatives have been proposed for odontoid fractures based on:– fracture type– degree of (initial) dens displacement– extent of angulation– patient’s age

• Type II and Type III odontoid fractures should be considered for surgical fixation in cases of:– dens displacement of 5 mm or more– dens fracture (Type IIA)– inability to achieve fracture reduction– inability to achieve main fracture reduction with external

immobilization

Dens Fractures

Dens Fractures

Dens Fractures

Dens Fractures

• Anterior transarticular screw fixation: As an augmentation of the anterior dens screw or in cases of a salvage procedure.

• Screws can be inserted over Kirschner wires from a medial-anterior-caudal to a lateral-posterior-cranial direction crossing the atlantoaxial joint.

Dens Fractures

Traumatic Spondylolisthesis of the Axis

• Traumatic fractures of the posterior elements of the axis may occur after hyperextension injuries as seen in:– motor vehicle accidents,– diving,– Falls,– judicial hangings.

• Therefore, the term “hangman’s fracture” was coined by Schneider in 1965.

Traumatic Spondylolisthesis of the Axis

• Effendi et al. described three types of fractures which are mechanism based:– Type I:

• isolated hairline fractures of the ring of the axis with minimal displacement of the body of C2.

• These injuries are caused by axial loading and hyperextension.

Traumatic Spondylolisthesis of the Axis

• Type II: • displacement of the anterior

fragment with disruption of the disc space below the axis.

• These injuries are a result of hyperextension and rebound flexion.

• Type IIA: • displacement of the anterior

fragment with the body of the axis in a flexed position without C2–C3 facet dislocation.

Traumatic Spondylolisthesis of the Axis

• Type III:– displacement of the

anterior fragment with the body of the axis in a flexed position in conjunction with C2–C3 facet dislocation.

– These injuries are caused by primary flexion and rebound extension.

Traumatic Spondylolisthesis of the Axis

• Most patients with traumatic spondylolisthesis reported in the literature were treated with cervical immobilization with good results.

• Most traumatic spondylolisthesis heals with 12 weeks of cervical immobilization with either a rigid cervical collar or a halo immobilization device.

• Surgical stabilization is a preferred treatment option in cases with:– severe angulation (Effendi Type II)– disruption of the C2–C3 disc space (Effendi Type II and III)– inability to establish or maintain fracture alignment with external

immobilization.

Traumatic Spondylolisthesis of the Axis

Subaxial Cervical Trauma

• Common.

• Usually Cx-Th junction fracture is missed in diagnosis if no appropriate X-rays are ordered.

• There are many controversy on the best line of treatment.

Subaxial Cervical Trauma• Allen and Ferguson classification of compression–flexion injuries.

Subaxial Cervical Trauma• Allen and Ferguson classification of vertical compression injuries.

Subaxial Cervical Trauma• Allen and Ferguson classification of distraction–flexion injuries.

Subaxial Cervical Trauma• Allen and Ferguson classification of compression–extension injuries.

Subaxial Cervical Trauma• Allen and Ferguson classification of distraction–extension injuries.

Subaxial Cervical Trauma• Allen and Ferguson classification of lateral flexion injuries.

Subaxial Cervical Trauma

• Cervical Spine Injury Severity Score:• The Cervical Spine Injury Severity Score (CSISS)

is based on independent analysis of four columns (anterior, posterior, right column, and left lateral column).

Subaxial Cervical Trauma

• Anderson and colleagues assessed reliability of this classification.

• They found construct validity was also good as all patients with scores equal to 7 had surgery.

• They found a significant correlation with high CSISS scores (>11) to a posterior or combined anteroposterior approach.

Subaxial Cervical Trauma• Subaxial Cervical Spine Injury Classification

• The Subaxial Cervical Spine Injury Classification system (SLIC) evaluates:– fracture morphology, – the discoligamentous complex,– neurologic function.

• Creating a comprehensive system to aid treatment decision making

Subaxial Cervical Trauma

Subaxial Cervical Trauma

• Anterior Column Injuries

• Anterior column injuries include:– Compression fractures,– Burst fractures, – Flexion axial loading injury.– Disc distraction injuries.

– Transverse process fractures are included in this group, although they have no effect on spinal stability but may be associated with vertebral artery injury.

Anterior Column Injuries

Anterior Column Injuries

Subaxial Cervical Trauma

• Posterior Column Injuries

• Isolated injuries to the posterior column are less common than those that are combined with other fractures.

• Isolated injuries include:– spinous process and lamina fractures.– Disruption of the posterior ligamentous complex

without facet subluxation.

Posterior Column Injuries

Posterior Column Injuries

Subaxial Cervical Trauma• Lateral Column Injuries• Injuries to the lateral column are being recognized more

frequently, likely due to better restraint systems that are preventing the more serious injuries and by increasing recognition from the use of diagnostic CT.

• Anatomically the lateral column consists of the lateral masses with their superior and inferior articular process projections.

• Lateral column injuries include:– isolated facet fractures without subluxation,– lateral mass fractures,– unilateral and bilateral dislocation with and without fractures.

Lateral Column Injuries

Lateral Column Injuries

Subaxial Cervical Trauma

Subaxial Cervical Trauma

Subaxial Cervical Trauma

Subaxial Cervical Trauma