1. Cervical spine Nipon Pantarote,MD.

2. Cervical Spine Fracture

3. Anatomy

7. Epidemiology Incidence : 28-50 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%

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

9. 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

10. 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

11. 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

12. 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

13. 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

14. Swimmer’s view

15. Bones

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

18. 3 Atlantodental interval (ADI)

19. 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

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

21. 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

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

23. 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

24. การส่งตรวจพิเศษ (Diagnostic Imaging) Computed Tomography Magnetic Resonance Imaging

25. 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

26. Jefferson fracture of Atlas (C1 Burst fracture)

27. 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

28. 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

29. 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

30. Odontoid fracture type II

31. 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

32. Hangman fracture

33. Vertebral body fracture

34. Compression fracture C5

35. 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

36. 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

37. Closed reduction by skull traction 5 kgs8 kgs 13 kgs

41. Cervical Spondylotic Radiculopathy

42. Cervical Spondylotic Myelopathy

67. External Immobilization of the Cervical Spine Skull Traction Halo Immobilization

68. Operative positioning for posterior approach Dislocated facets Surgical Treatment

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

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

74. Postoperative X-rays

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

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

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

80. Take Home Messages

89. Thank you for your attention