1. Cervical Spine Injuries Classification and Non-operative Treatment
Dr. Heather Roche
Dec. 12, 2002

2. 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

3. History MVA thrown from car strike head Physical
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

4. Radiography Initial Other 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

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

6. 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

7. Instability

9. 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

10. 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 lbs traction

11. 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

12. Anatomy of Upper cervical spine

13. 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

14. Occipital-atlantal Dissociation

15. 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

17. 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

18. 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

19. Odontoid Fractures

20. Treatment Type 1 - Type 3 - Philadelphia collar for 6-8 weeks
collar inadequate
Halo vest immobilization after reduction in traction 80 % union rate ( 3-4 months)

21. 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

22. Hangman’s Fracture Traumatic 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

23. Hangman’s Fracture

24. Treatment Type 1 Type 2 Type 3 rigid cervical orthosis
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

25. 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

26. 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

27. Classification Ferguson 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

28. 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

29. 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

30. 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

33. Treatment Closed reduction initially max weight controversial
successful
non-operative treatment 64% late instability
fusion recommended
unsuccessful
open reduction and fusion

34. 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

35. Compression Extension
Early compressive failure of post column and late tensile failure ant column
late stages body displacement unstable and require anterior fusion

36. 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

37. Lateral Flexion Asymmetric loading in coronal plane displacement
fusion

38. Halo Skeletal Fixation