Operative Treatment For Cervical Spine Fractures Dr. T. G. Hogan.
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Transcript of Operative Treatment For Cervical Spine Fractures Dr. T. G. Hogan.
Operative Treatment For Cervical Spine Fractures
Dr. T. G. Hogan
Occipito-cervical Dissociation
Occipitocervical Instability Basion
BDI < 12
Basion Axis Int <12
Basion-Dens-Interval <12 mm.
>12 mm. Suggests Vertical Instability
Basion-Axial-Interval < 12mm
>12mm. Suggests Anterior Instability
<0mm. Suggests Posterior Instability
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
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– 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
Arthrodesis: Magerl screw fixation - challenging
– Good stability – Does not need odontoid, C1 arch or
C2 arch
Osteosynthesis: odontoid screw fixation
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...
1
3
2 4
5
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 – “winded”– continued 2/7– hemoptysis 4/7– saw GP– neck xrayed
• Full ROM• Not tender
Patient JM, 16yrs
C6
C7Spot lateral
Patient JM, 16yrs
C6
CC77
Extension
C6
CC77
Flexion
Patient JM, 16yrs
CC77
CC66
CT reformatsCT reformats
• New or old injury?–Snowboarding 2wks ago?–Dirtbike 2yrs ago?
• Observe only?–Advice and precautions–Risks
• Stabilise?–Anterior or posterior–Risks
Patient EC, 72f Initial Xray Initial Xray
C5
Patient EC, 72f
CTCTLeftLeft RightRight
CC55
Patient EC, 72f
PostreductionPostreduction
CC55
T2 MRIT2 MRI
CC55
EC
PostopPostop
CC55
Cervical trauma
Case 3
Patient M, 65yrs Initial CT Initial CT
Patient M, 65yrs Initial CT Initial CT
Left Right
Patient M, 65yrs Intraoperative Intraoperative
PostopPostop
Patient M, 65yrs Initial CT Initial CT
Patient BB, 32yrs
25lbs + 1 day
25lbs
20lbs
15lbs
BB
10lbs
BB
BB
6 months
3 months