Cervical Spine InjuriesClassification and Non-operative

TreatmentDr. Heather Roche

Dec. 12, 2002

Evaluation• MVA, diving accidents most common cause• should suspect in anyone with head or high energy

trauma or neurological deficit• can be missed with multiple trauma and if non-

contiguous vertebrae involved or altered consciousness

• 16% people will have non-contiguous spine fractures

• 50% will have other skeletal or visceral injuries

History• MVA• thrown from car strike head

– any paralysis at time of injury– if currently paralyzed was there any indication of

movement at time of accident

• Physical– full neuro exam including rectal and

bulbocavernosus– r/o other injuries

Radiography

• Initial– cross table lateral 70-79%– AP and open mouth increases yield to 90-95%– swimmer’s view for C7-T1

• Other– Ct scan bony anatomy and lower c-spine – Flex-extension

• controversial in acute setting• only in alert and cooperative patients without neurological deficit with

neck pain• false negatives due to muscle spasm

MRI

• Patients with complete or incomplete neurulogical deficit, deterioration in neurological function or suspected posterior ligamentous injury despite negative plain radiographs

Radiographic evidence of Instability

• Angulation between vertebral bodies that is 11 greater than adjacent segment

• AP translation > 3.5mm• spinous process widening on lateral• facet joint widening• malalignment of spinous process on anterior view• rotation of facets on lateral• lateral tilting of vertebral body on anterior view

Instability

Initial Treatment

• Immobilization– rigid cervical orthosis- Philadelphia collar– unstable injury this is inadequate often and cervical

traction required• halo traction or gardner-wells tongs• 1cm posterior to external auditory meatus and just above

the pinna• should be MRI compatible• 10-15 pounds usually appropriate• post alignment xray and neuro exam

Closed Reduction• Injuries demonstrating angulation, rotation or shortening• restore normal alignment therefore decompressing the

spinal canal and enhancing neuro recovery preventing further injury

• need neuro monitoring and radiography• awake, alert and cooperative patient to provide feedback• traction, positioning and weights ( 10 pds head and 5 pds

each level below) xray after new weight applied• maintain after with 10-15 lbs traction

Spinal Cord Injury• Maintain SBP > 90mmHg• 100% O2 saturation• early diagnosis by xray• methylprednisolone bolus 30mg/kg then infusion 5.4mg/kg

– Corticosteroids benefit in recovery– Nascis-2 data showed methylprednisolone within 8 hours of

injury had better recovery of neurologic function at 6 weeks, 6 months and 1 year after injury compared to other substances like naloxone and placebo

– injury < 3 hrs continue for 24 hors and > 3 hrs for 48

Anatomy of Upper cervical spine

Injuries to Upper cervical Spine• Occipitoatlantal Dislocation

– hyperextension distraction and rotation of craniovertebral junction

– severe neurological injuries from complete C1 quadriplegia to incomplete syndromes

– xray• diastasis at craniovertebral junction

• Powers ratio– distance between basion and post arch of atlas by distance between opisthion

and ant arch atlas with > 1 abnormal

• avoid traction and stabilize head to neack with halo

• surgical Rx required as primarily a ligamentous injury

Occipital-atlantal Dissociation

Atlas Fractures

• Axial compression injuries• neurological injury rare• 3 types

– Jefferson fracture- direct compression and lateral masses forced apart

– asymmetric load fracture ant or post to mass and displaces it

– posterior arch fractures with an extension moment through it

• Rx ? Transverse ligament intact– avulsion at insertion on CT

– lateral overhang of C1 over outer edges of C2

– > 6.9 mm= rupture

– ADI > 4mm

– MRI visualization of ligament

• Ligament intact– cervical orthosis ( Philadelphia, SOMI, Minerva) for posterior arch or

undisplaced Jefferson

– Halo - asymmetric lateral mass or displaced Jefferson fractures

• No ligament– Fusion

Odontoid Fracture

• 15 % all cervical fractures• usually MVA or blow to the head Three types

– Type 1 Avulsion off tip by alar ligament

– Type 2 fracture at junction of dens with the central body

– Type 3 fracture in body of axis and primarily cancellous bone

• usually hyperflexion with anterior displacement• assoc injuries to C1 common• neurological deficit in 15-25% cases

Odontoid Fractures

Treatment

• Type 1 - – Philadelphia collar for 6-8 weeks

• Type 3 -– collar inadequate– Halo vest immobilization after reduction in

traction 80 % union rate ( 3-4 months)

Treatment con’t

• Type 2 – high rate of non-union ( up to 40% in displaced) due to small

area of bony contact and watershed blood supply to the waist of odontoid

– Increased non-union with displacement, smoker and advanced age

– undisplaced - halo immobilization

– displaced -

• ? Traction for reduction then halo immobilization

• ? Primary C1-C2 fusion after reduction in traction

– most recommend if displacement > 4-5mm

Hangman’s FractureTraumatic spondylolithesis

• Type 1

– isolated minimally displaced fracture of ring with no angulation

• Type 2

– more unstable

– flesion type/extension type or listhetic type

– displaced > 3mm and angulation of C2-C3 disk space

– ALL, PLL Disc can be interrupted

• Type 3– rare

– anterior dislocation of C2 facets on C3 with 2 extension fracturing neural arch

Hangman’s Fracture

Treatment

• Type 1– rigid cervical orthosis

• Type 2– closed reduction with trection and position opposite

direction instability– halo vest immobilization– follow for loss of reduction

• Type 3– reduction of facet dislocation with traction– C2 -C3 fusion after pre-op MRI

Sub axial Spine

• bodies articulate by intervertebral disc, ALL and PLL

• facet joints are in a coronal plane 45 to horizontal allowing flexion and extension 14 degrees in sagittal plane

• due to 45 incline lateral tilt accompanied by rotation

• 9 degrees in coronal plane and 5 rotation in each segment

• vertebral foramen in lateral mass contain vertebal artery which transverses C6 through C1

Biomechanics• Denis

– three column spine for TL spine now applied to c-spine– Anterior region

• disk and centrum resist compression

• ALL, anterior annulus resist distraction

– Middle• post vertebral body and uncovertebral joints

• PLL and Annulus resist distraction

– Posterior• facet joints and lateral mass compression

• facet capsule, intra and supraspinous ligaments

ClassificationFerguson and Allen

• Based on position of neck at time of injury and dominant force

• 2 column theory– everything anterior to PLL ant column

• most patients have a combination of patterns

Compression and Flexion

• Level C4-5 and C5-6• compression of ant column and distraction of post• different stages with later stages having more post

involvement and displacement of vertebral body• MRI to evaluate post ligaments• intact - HALO sufficient• not - risk of late kyphotic deformity therefore

fusion

Vertical Compression• C6-7 most common

• shortening of ant and post columns

• stage 1 - – cupping of end plate with partial failure anteriorly and normal post

ligaments

– rigid orthosis

• stage 3 - – fragmentation and displacement of body “ burst”

– neurologic injury common with assoc post element fractures

– anterior corpectomy and reconstruction for neuro recovery plus post fusion to prevent kyphosis

Distraction Flexion

• Most common pattern• tensile failure and lengthening of post column

with possible compression of ant column• ant translation superior vertebra • 25% facet subluxation• 50% unilateral facet dislocation• > 50% bilateral dislocation• full body displacement

Treatment

• Closed reduction initially max weight controversial

• successful

– non-operative treatment 64% late instability

– fusion recommended

• unsuccessful

– open reduction and fusion

Flexion distraction con’t

• 50-80% assoc acute disk herniation at level of injury

• awake closed reduction has not shown worsening of neuro deficit and should not undergo major delay in reduction while waiting for MRI

• MRI prerequisite to open reduction• Disk present ant cervical diskectomy prior to

reduction

Compression Extension

• Early compressive failure of post column and late tensile failure ant column

• late stages body displacement unstable and require anterior fusion

Compression Distraction

• Tensile failure of both ant and post columns bony or ligamentous

• stage1– no body displacement on static or flexion/ext – rigid orthosis

• Stage 2– displacement present– fusion

Lateral Flexion

• Asymmetric loading in coronal plane

• displacement – fusion

Halo Skeletal Fixation