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Cervical Spine Injuries Classification and Non-operative Treatment Dr. Heather Roche Dec. 12, 2002 Slide 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 Slide 3 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 Slide 4 Radiography Initial cross table lateral70-79% 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 negatives due to muscle spasm Slide 5 MRI Patients with complete or incomplete neurulogical deficit, deterioration in neurological function or suspected posterior ligamentous injury despite negative plain radiographs Slide 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 Slide 7 Instability Slide 8 Slide 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 Slide 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 10-15 lbs traction Slide 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 for 48 Slide 12 Anatomy of Upper cervical spine Slide 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 Slide 14 Occipital-atlantal Dissociation Slide 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 Slide 16 Slide 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 Slide 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 Slide 19 Odontoid Fractures Slide 20 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) Slide 21 Treatment cont 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 Slide 22 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 Slide 23 Hangmans Fracture Slide 24 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 Slide 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 Slide 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 Slide 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 Slide 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 Slide 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 Slide 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 Slide 31 Slide 32 Slide 33 Treatment Closed reduction initially max weight controversial successful non-operative treatment 64% late instability fusion recommended unsuccessful open reduction and fusion Slide 34 Flexion distraction cont 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 Slide 35 Compression Extension Early compressive failure of post column and late tensile failure ant column late stages body displacement unstable and require anterior fusion Slide 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 Slide 37 Lateral Flexion Asymmetric loading in coronal plane displacement fusion Slide 38 Halo Skeletal Fixation