Operative Treatment For Cervical Spine Fractures Dr. T. G. Hogan
Occipito-cervical Dissociation
Occipitocervical Instability Basion-Dens-Interval <12 mm. >12 mm. Suggests Vertical Instability Basion-Axial-Interval < 12mm >12mm. Suggests Anterior Instability <0mm. Suggests Posterior Instability Occipitocervical Instability Basion Basion Axis Int <12 BDI < 12
Occipitocervical Dislocation Mechanism Unclear Rotation & Distraction Neurological Deficits Confusing High Tetraplegia Cruciate Paralysis Wallenberg’s Syndrome Ligamentous Injuries = Unstable Avoid Traction
Atlas Fractures: Extension Anterior Arch Hyper-extension Avulsion of Longus Colli R/O Other Injuries 65% (Landells) Stewart G, Radiology 1977
Atlas Fractures: Extension Posterior Arch Fractures Occipital Pain & Numbness Stable R/O Other Injuries (Odontoid #)
Jefferson Fractures Four Part Burst Axial Load 6.9 mm Overhang Spence KF, JBJS, 1970 8.1 mm Overhang Heller JG, J Spinal Disord, 1993
Lateral Mass Fractures of C-1 Free-Floating Lateral Mass of C-1 Often Comminuted Segal & Stauffer, JBJS, 1987
Treatment & Results C-1 #’s Good Results Reported with Halo Traction + Vest Rigid or Simple Orthoses Late Pain: Ant/Post Arch 50% Jefferson 70% Lateral Mass 33% Landells, VanPeteghem, Spine 1987
Anderson & D’Alonzo Classification (JBJS, 1974) Type I Type II Type III
Odontoid fractures Type 1 Type 2 Type 3 From Anderson and D’Alonzo JBJS (1974) 56A 1663-1674 cited in Chapman and Anderson, Cervical Spine Trauma chapter in Frymoyer JW ed The Adult Spine Second Edition 1997 Lippincott-Raven, Philadelphia
Type II Odontoid Halo-Thoracic Brace Non-union Rate 14-32-75% Risk Factors: Failure to Treat 5mm Displacement >10 deg. Angulation Posterior Displacement Elderly
Type II Odontoid Direct Screw Fixation Preserves C1-2 Motion No Bone Graft Required Avoid Non-Unions Avoid Reverse Oblique # Aebi, Spine 1989
Type II Odontoid Posterior Fusion Trans-articular Facet Screws Primary for Non or Delayed Union Trans-articular Facet Screws 96% Fusion Rate Restricted Rotation
C2 Magerl screw fixation Good stability Does not need odontoid C1 arch C2 arch Challenging
Odontoid stabilisation Osteosynthesis: odontoid screw fixation Arthrodesis: Magerl screw fixation - challenging Good stability Does not need odontoid, C1 arch or C2 arch
Traumatic Spondylolisthesis C-2 (Levine & Edwards, JBJS, 1985)
Traumatic Spondylolisthesis C-2 (Levine & Edwards, JBJS, 1985)
Traumatic Spondylolisthesis C-2 (Levine & Edwards, JBJS, 1985)
Traumatic Spondylolisthesis C-2 (Levine & Edwards, JBJS, 1985) Dislocated
Subaxial C-Spine
Flexion-compression... Allen B, The Cervical Spine (Chapter 6) ed Sherk et al, Lippincott, Philadelphia, 1989 Stages of compressive flexion When to refer…….most GPs would likely refer from stage 3 on, when the anterior column compression is becoming a burst fracture, and when we would begin to add a CT for evaluation and determination of the type of brace or other treatment. 3 4 2 5 1
Checklist Approach Applies to trauma and degenerative disease The more points the more unstable 5 points does not mean surgery occasionally <5 need Sx >5 don’t need Sx Currently investigated by CSRS Different considerations for different levels 2-column VS 3-column
Sensitivity Settings
C2-T1 Usually for trauma, but applies to all Ant./post. Element failure Stretch test (1.7mm, >7.5 degrees) X-Ray (>3.5mm, 11 degrees) Flex/ext x-ray (>3.5mm, 20 degrees) Pavlov’s ratio (<0.8) sagittal diameter <13 Narrow disc Cord damage Root damage Dangerous loading anticipated
Cervical Measurements
Mr. Roeth. C-4 Fracture
Mr. Roeth. C-4 Fracture
CSLP Ant. & Post Instability
Mr. R. Co. C5 & 6 Fractures
Mr. R. Co. C5 & 6 Fractures
Mr G H C4-5 Facet Dislocation
Mr G H C4-5 Facet Dislocation
Cervical trauma Case presentations
Cervical trauma Case 1
Patient JM, 16yrs C6 C6 Fell boarding 2/52 ago Full ROM Not tender “winded” continued 2/7 hemoptysis 4/7 saw GP neck xrayed Full ROM Not tender C6 C6
Patient JM, 16yrs C6 C7 Spot lateral
Patient JM, 16yrs C6 C6 C7 C7 Extension Flexion
Patient JM, 16yrs C6 C7 CT reformats
New or old injury? Observe only? Stabilise? Snowboarding 2wks ago? Dirtbike 2yrs ago? Observe only? Advice and precautions Risks Stabilise? Anterior or posterior
Patient EC, 72f Initial Xray C5
Patient EC, 72f C5 Left CT Right
Patient EC, 72f T2 MRI C5 C5 Postreduction
EC C5 Postop Findings: Interspinous lig torn facet capsules torn Lig flavum peeled off upper lamina Postop
Cervical trauma Case 3
Patient M, 65yrs Initial CT
Patient M, 65yrs Initial CT Left Right
Patient M, 65yrs Intraoperative Postop
Patient M, 65yrs Initial CT
Patient BB, 32yrs
15lbs 20lbs 10lbs 25lbs 25lbs + 1 day BB
BB
3 months 6 months BB