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

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Presentation on theme: "Cervical Spine Injuries Classification and Non-operative Treatment Dr. Heather Roche Dec. 12, 2002."— Presentation transcript:

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 –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 –cross table lateral70-79% –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

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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 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 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

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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 - –Philadelphia collar for 6-8 weeks Type 3 - – 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 –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

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

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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


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