C Spine Injury Non Operative

Cervical Spine Injuries
Classification and Non-operative

Treatment
Dr. Heather Roche
Dec. 12, 2002
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
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
Radiography
• Initial
– cross table lateral 70-79%
– 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
MRI
• Patients with complete or incomplete
neurulogical deficit, deterioration in
neurological function or suspected posterior
ligamentous injury despite negative plain
radiographs
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
Instability
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
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
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 continue for 24 hors and > 3 hrs for 48
Anatomy of Upper cervical spine
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
Occipital-atlantal Dissociation
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
• 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
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
Odontoid Fractures
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)
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
Hangman’s Fracture
•
Traumatic
Type 1
spondylolithesis
– 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
Hangman’s Fracture
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
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
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
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
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
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
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
Treatment
• Closed reduction initially max weight controversial

• successful
– non-operative treatment 64% late instability
– fusion recommended
• unsuccessful
– open reduction and fusion
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
Compression Extension
• Early compressive failure of post column
and late tensile failure ant column
• late stages body displacement unstable and
require anterior fusion
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
Lateral Flexion
• Asymmetric loading in coronal plane
• displacement
– fusion
Halo Skeletal Fixation

C Spine Injury Non Operative

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Cervical Spine Injuries

Classification and Non-operative

• Closed reduction initially max weight controversial

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