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Cervical Spine Injuries
Classification and Non-operativeTreatmentDr. Heather Roche
Dec. 12, 2002
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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 spinefractures
50% will have other skeletal or visceral
injuries
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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
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Radiography
Initial
cross table lateral 70-79%
AP and open mouth increases yield to 90-95%
swimmers 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 ne atives due to muscle s asm
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MRI Patients with complete or incomplete
neurulogical deficit, deterioration in
neurological function or suspected posterior
ligamentous injury despite negative plain
radiographs
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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
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Instability
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Initial Treatment
Immobilization
rigid cervical orthosis- Philadelphia collar
unstable injury this is inadequate often andcervical 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
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Closed Reduction
Injuries demonstrating angulation, rotation orshortening
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
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Spinal Cord Injury
Maintain SBP > 90mmHg
100% O2 saturation
early diagnosis by xray
methylprednisolone bolus 30mg/kg then infusion5.4mg/kg
Corticosteroids benefit in recovery
Nascis-2 data showed methylprednisolone within 8
hours of injury had better recovery of neurologicfunction 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
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Anatomy of Upper cervical spine
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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
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Occipital-atlantal Dissociation
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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
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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 Jeffersonfractures
No ligament
Fusion
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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
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Odontoid Fractures
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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)
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Treatment cont Type 2
high rate of non-union ( up to 40% in displaced) due to
small area of bony contact and watershed blood supplyto 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
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Hangmans 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
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Hangmans Fracture
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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
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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 insagittal 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
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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
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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
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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
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Vertical Compression
C6-7 most common shortening of ant and post columns
stage 1 -
cupping of end plate with partial failure anteriorly andnormal 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
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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
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Treatment
Closed reduction initially max weight
controversial
successful
non-operative treatment 64% late instability
fusion recommended
unsuccessful open reduction and fusion
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Flexion distraction cont 50-80% assoc acute disk herniation at level of
injury
awake closed reduction has not shown worseningof 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
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CompressionE
xtension Early compressive failure of post column
and late tensile failure ant column
late stages body displacement unstable and
require anterior fusion
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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
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Lateral Flexion Asymmetric loading in coronal plane
displacement
fusion
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Halo Skeletal Fixation