Cervical spine Nipon Pantarote,MD.

Cervical Spine Fracture

Anatomy

Epidemiology Incidence : cases per million Male to Female ratio 4:1 The most common cause of spinal injury Motor vehicle accident 40%-50% Falls 20%-25% Gunshot wounds 10-14% Sport 10%

Epidemiology Level of injury,commonly Cervical 55% Thoracic 30% Lumbar 15% 95% one spinal region

Acute cervical strain เกิดจาก soft tissue injury ที่ไม่รุนแรงมากนัก หรือถูก stretch เป็นเวลานานๆ ความเจ็บปวด เกิดจากการขาดเลือดมาเลี้ยง ของกล้ามเนื้อ ทำให้กล้ามเนื้อขาดอาหาร, ออกซิเจน และการคั่งของ metabolic products เกิดการอักเสบขึ้น Rx: – ทานยา NSAIDS, Analgesic, Rest – PT (superficial & deep heat) – Cervical collar

Whiplash injury Rear-end vehicle injury Sudden hyperextension- hyperflexion of the neck เกิดภยันตรายต่อ soft tissue บริเวณต้นคอ, intervertebral discs, articular cartilage of the facet joints, facet capsules Chronic neck pain Rx: medication, physical therapy

การส่งตรวจทางรังสี (Plain X- rays) Lateral view – Adequacy – Prevertebral soft-tissue shadow – Alignment, curvature – Bony structure Fracture-dislocation Displacement AP view Open-mouth view Swimmer view

Adequacy Must visualize entire C-spine A film that does not show the upper border of T1 is inadequate Caudal traction on the arms may help If can not, get swimmer’s view or CT

Alignment The anterior vertebral line, posterior vertebral line, and spinolaminar line should have a smooth curve with no steps or discontinuities Malalignment of the posterior vertebral bodies is more significant than that anteriorly, which may be due to rotation A step-off of >3.5mm is significant anywhere

Swimmer’s view

Bones

Disc Disc Spaces – Should be uniform Assess spaces between the spinous processes

3 Atlantodental interval (ADI)

Lateral Cervical Spine X-Ray Anterior subluxation of one vertebra on another indicates facet dislocation – < 50% of the width of a vertebral body  unilateral facet dislocation – > 50%  bilateral facet dislocation

Prevertebral soft tissue C1-C3 : 5-6 mm. Subaxial spine : 15 mm.

Nasopharyngeal space (C1) – 10 mm (adult) Retropharyngeal space (C2- C4) – 5-7 mm Retrotracheal space (C5-C7) – 14 mm (children) – 22 mm (adults) Prevertebral soft tissue

AP C-spine Films Spinous processes should line up Disc space should be uniform Vertebral body height should be uniform. Check for oblique fractures.

Open mouth view : all of the dens and lateral borders of C1 & C2 Adequacy: all of the dens and lateral borders of C1 & C2 : lateral masses of C1 and C2 Alignment: lateral masses of C1 and C2 Bone: Inspect dens for lucent fracture lines

การส่งตรวจพิเศษ (Diagnostic Imaging) Computed Tomography Magnetic Resonance Imaging

Atlas fracture (C1) Anterior or Posterior arch fracture Lateral mass fracture Jefferson’s fracture – Burst fracture of C1 – Both anterior and posterior arch are fractured – With or without transverse atlantal ligament rupture – Most are conservative Rx, except TAL rupture

Jefferson fracture of Atlas (C1 Burst fracture)

Jefferson Fracture Burst fracture of C1 ring Unstable fracture Increased lateral ADI on lateral film if ruptured transverse ligament and displacement of C1 lateral masses on open mouth view Need CT scan

Atlantoaxial (C1-2) subluxation Spontaneous or after traumatic events Neck pain, torticollis Asymmetry of the space between C1 lateral mass & dens Rx: – Closed reduction – Operative C1-2 fusion

Odontoid fracture Type I Type IIType III Type I : stable fracture  cervical traction, orthosis Type II : high-risk nonunion  operative fixation, C1-2 fusion Type III: cervical traction, halo immobilization

Odontoid fracture type II

Traumatic spondylolisthesis of the Axis (Hangman’s fracture) Hyperextension of the occiput & C1  impact to C2 pedicle Fracture, angulation, displacement of C2 Most treated with rigid immobilization except concomitant facet dislocation  require operative reduction & fixation

Hangman fracture

Vertebral body fracture

Compression fracture C5

Unilateral facet dislocation Flexion-distraction injury stage 3 การหลุดของ facet ข้างหนึ่ง มีการหมุน ของ vertebral body โดยมีจุดหมุนอยู่ที่ facet อีกข้างหนึ่งที่ ยังปกติ Anterior displacement <25% ของ AP diameter Rx : closed or open reduction & fusion

Bilateral facet dislocation Flexion-distraction injury stage 4 Anterior vertebral displacement >50% ของ AP diameter การฉีกขาดของ ligaments ทุกเส้น รวมทั้ง disc High risk of SCI Rx : closed or open reduction, surgical fusion

Closed reduction by skull traction 5 kgs8 kgs 13 kgs

Cervical Spondylotic Radiculopathy

Cervical Spondylotic Myelopathy

External Immobilization of the Cervical Spine Skull Traction Halo Immobilization

Operative positioning for posterior approach Dislocated facets Surgical Treatment

Operative reduction of the dislocated facets Instrumented fusion with bone-graft & wiring Surgical Treatment

Surgical Treatment of Type II Odontoid Fracture Osteosynthesis (Fracture fixation) C1-2 Fusion (Arthrodesis)

Postoperative X-rays

Principle of Treatment 1.Patient Education 2.Medication 3.Rehabilitation 4.Surgery

Indication for Surgery 1.Failed Conservative treatment for 3 month 2. Progressive Neurological Deficit 3. Positive finding by Imaging

Surgery 1.Disectomy 2.Laminectomy 3.Laminoplasty 4.Fusion 5.Instrumentation 6.Disc Replacement

Take Home Messages

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