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Operative Treatment For Cervical Spine Fractures

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Presentation on theme: "Operative Treatment For Cervical Spine Fractures"— Presentation transcript:

1 Operative Treatment For Cervical Spine Fractures
Dr. T. G. Hogan

2 Occipito-cervical Dissociation

3 Occipitocervical Instability
Basion-Dens-Interval <12 mm. >12 mm. Suggests Vertical Instability Basion-Axial-Interval < 12mm >12mm. Suggests Anterior Instability <0mm. Suggests Posterior Instability Occipitocervical Instability Basion Basion Axis Int <12 BDI < 12

4 Occipitocervical Dislocation
Mechanism Unclear Rotation & Distraction Neurological Deficits Confusing High Tetraplegia Cruciate Paralysis Wallenberg’s Syndrome Ligamentous Injuries = Unstable Avoid Traction

5 Atlas Fractures: Extension
Anterior Arch Hyper-extension Avulsion of Longus Colli R/O Other Injuries 65% (Landells) Stewart G, Radiology 1977

6 Atlas Fractures: Extension
Posterior Arch Fractures Occipital Pain & Numbness Stable R/O Other Injuries (Odontoid #)

7 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

8 Lateral Mass Fractures of C-1
Free-Floating Lateral Mass of C-1 Often Comminuted Segal & Stauffer, JBJS, 1987

9 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

10 Anderson & D’Alonzo Classification (JBJS, 1974)
Type I Type II Type III

11 Odontoid fractures Type 1 Type 2 Type 3
From Anderson and D’Alonzo JBJS (1974) 56A cited in Chapman and Anderson, Cervical Spine Trauma chapter in Frymoyer JW ed The Adult Spine Second Edition 1997 Lippincott-Raven, Philadelphia

12 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

13 Type II Odontoid Direct Screw Fixation Preserves C1-2 Motion
No Bone Graft Required Avoid Non-Unions Avoid Reverse Oblique # Aebi, Spine 1989

14 Type II Odontoid Posterior Fusion Trans-articular Facet Screws
Primary for Non or Delayed Union Trans-articular Facet Screws 96% Fusion Rate Restricted Rotation

15 C2 Magerl screw fixation
Good stability Does not need odontoid C1 arch C2 arch Challenging

16 Odontoid stabilisation
Osteosynthesis: odontoid screw fixation Arthrodesis: Magerl screw fixation - challenging Good stability Does not need odontoid, C1 arch or C2 arch

17 Traumatic Spondylolisthesis C-2 (Levine & Edwards, JBJS, 1985)

18 Traumatic Spondylolisthesis C-2 (Levine & Edwards, JBJS, 1985)

19 Traumatic Spondylolisthesis C-2 (Levine & Edwards, JBJS, 1985)

20 Traumatic Spondylolisthesis C-2 (Levine & Edwards, JBJS, 1985)

21 Subaxial C-Spine

22 Flexion-compression... Allen B, The Cervical Spine (Chapter 6) ed Sherk et al, Lippincott, Philadelphia, 1989 Stages of compressive flexion When to refer…….most GPs would likely refer from stage 3 on, when the anterior column compression is becoming a burst fracture, and when we would begin to add a CT for evaluation and determination of the type of brace or other treatment. 3 4 2 5 1

23 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

24 Sensitivity Settings

25 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

26 Cervical Measurements

27 Mr. Roeth. C-4 Fracture

28 Mr. Roeth. C-4 Fracture

29 CSLP Ant. & Post Instability

30 Mr. R. Co. C5 & 6 Fractures

31 Mr. R. Co. C5 & 6 Fractures

32 Mr G H C4-5 Facet Dislocation

33 Mr G H C4-5 Facet Dislocation





38 Cervical trauma Case presentations

39 Cervical trauma Case 1

40 Patient JM, 16yrs C6 C6 Fell boarding 2/52 ago Full ROM Not tender
“winded” continued 2/7 hemoptysis 4/7 saw GP neck xrayed Full ROM Not tender C6 C6

41 Patient JM, 16yrs C6 C7 Spot lateral

42 Patient JM, 16yrs C6 C6 C7 C7 Extension Flexion

43 Patient JM, 16yrs C6 C7 CT reformats

44 New or old injury? Observe only? Stabilise? Snowboarding 2wks ago?
Dirtbike 2yrs ago? Observe only? Advice and precautions Risks Stabilise? Anterior or posterior

45 Patient EC, 72f Initial Xray C5

46 Patient EC, 72f C5 Left CT Right

47 Patient EC, 72f T2 MRI C5 C5 Postreduction

48 EC C5 Postop Findings: Interspinous lig torn facet capsules torn
Lig flavum peeled off upper lamina Postop

49 Cervical trauma Case 3

50 Patient M, 65yrs Initial CT

51 Patient M, 65yrs Initial CT Left Right

52 Patient M, 65yrs Intraoperative Postop

53 Patient M, 65yrs Initial CT

54 Patient BB, 32yrs

55 15lbs 20lbs 10lbs 25lbs 25lbs + 1 day BB

56 BB

57 3 months 6 months BB

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