Cervical spine injuries initial evaluation

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Cervical spine injuries initial evaluation

  1. 1. CERVICAL SPINE INJURIES By Dr.Upender satelli PG IN (MS ORTHO) Gandhi medical college
  2. 2. EPIDEMIOLOGY  ~ 40 % of all spinal trauma is found in the polytrauma patient  2-3 % of all polytrauma victims have associated cervical spine injuries  ~30,000 cervical spine injuries are documented annually  Most common site ---- cervical 60%,thoraco lumbar junction 20%, thoracic15%, lumbo sacral spine 5%  16% people will have non-contiguous spine fractures  50% will have other skeletal or visceral injuries
  3. 3.  5% unstable  2/3rd of this do not have neurolgical deficit  Most common missed severe injury  Commonly missed in polytrauma,unconscious pts
  4. 4. E T I O L O G Y  Most frequent cause motor vehicle crashes 37.4%  violence -25.9%,  Falls- 21.5%,  sports,  other  Severity of injury –complete quadriplegia (23.3%),quadriparesis( 30.2%),paraplegia 26.1%,paraparasis(19.7%)
  5. 5. A G E & S E X  Mean age is 32 yrs  Highest incidence-16-30 yrs  Male :female ratio 3:1  Elderly more likely to have SCI than young more due to falls rather than violence & sports
  6. 6. MORTALITY  Life expectancy decreases with severity &age of pt  Least in ventilatory dependent pts  Greater who survive 1 yr after spinal injury  During 1 st yr cause of death are – respiratory& cardiac cause  Mortlity decreased but life expectancy decreses
  7. 7. ATLS  Airway  Breathing  Circulation // Cervical spine ----------------------------------- Field intubation: Avoid head tilt / chin lift Early identification of SCI ‗in the field‘ --- Avoid hypotension and hypoxia
  8. 8. ATLS SECONDARY SURVEY  Disability---complete neuro exam  Motor/ sensory/ reflexes  Perineal sensory/ anal wink/ bulbocavern. reflex  Exposure  Fully disrobe and log roll  Direct palpation of spine, collar removed  Fracture identification
  9. 9. SPINAL BOARD
  10. 10. HISTORY  A detailed history of the mechanism of injury is important, but frequently is unobtainable at the initial examination.  suspected in any patient with a head injury or severe facial or scalp lacerations.  In any patient with recent trauma, complaints of neck pain or spinal pain should be considered indicative of a spinal injury until proved otherwise.  Other risk factors associated with spinal injury, , include an inability to assess neck pain because of a secondary distracting injury,  abnormal neurological findings,  history of transient neurological symptoms,  physical signs of spinal trauma (e.g., ecchymosis and abrasions), unreliable examination  inconsolable child
  11. 11. PHYSICAL EXAMINATION  supine.  mental status also should be assessed  The head – for lacerations and contusions and palpated for facial fractures.  The ear canals should be inspected to rule out leakage of spinal fluid or blood behind the tympanic membrane, which is suggestive of a skull fracture.  The spinous processes should be palpated from the upper cervical to the lumbosacral region. A painful spinous process may indicate a spinal injury.  Palpable defects in the interspinous ligaments may indicate disruption of the supporting ligamentous complex.
  12. 12. • tenderness on palpation of the cervical spine should be considered indicative of a spinal injury requiring collar immobilization. • neck motion should not be evaluated until the spine is cleared. Neck motion should be undertaken only after the patient reports no pain or tenderness during examination of the neck. •An assistant should hold the neck steady in a neutral position while it is being palpated. The neck also should be held steady while the torso and the thoracic, lumbar, and sacral spinal areas are exposed for inspection and palpation •. Sensation to light touch should be documented comparing each spinal level. Pinprick sensibility should be determined with a sterile needle if necessary •. Motor strength should be examined sequentially. • Deep tendon reflexes and pathological reflexes also should be checked. • Motor and sensory evaluation of the rectum and perirectal area is mandatory. • The patient should be evaluated for posturing. The elbows may be flexed if a spinal cord injury causes loss of function below the biceps, or they may be extended if the paralysis is higher. • Penile erection and incontinence of the bowel or bladder suggest a significant spinal injury. Quadriplegia is indicated by flaccid paralysis of the extremities.
  13. 13. •Initial blood pressure may be decreased without a compensatory increase in pulse because of spinal cord shock. • BRADYCARDIA OR EPISODES OF ASYSTOLE MAY BE THE ONLY FINDING OF SIGNIFICANT INJURY TO THE AXIAL REGION OF THE CERVICAL SPINE. •The chest, abdomen, and extremities should be examined for occult injuries. •The spine should be protected during this initial assessment;
  14. 14. NEUROLOGICAL EVALUATION The patient's mental status and the level of consciousness should be determined quickly, including pupillary size and reaction –G L A S G O W C O M A S C A L E Eyes Open Spontaneous 4 To sound 3 To pain 2 Never 1 Best Verbal Response Oriented 5 Confused conversation 4 Inappropriate words 3 Incomprehensible words 2 None 1 Best Motor Response Obeys commands 6 Localizes pain 5 Flexion withdrawal 4 Abnormal 3 Extension 2 None 1
  15. 15. SENSORY EXAMINATION  performed with light touch, then pinpricks (using a sterile needle), beginning at the head and neck and progressing distally, to examine specific dermatome distributions  Important dermatome landmarks are the nipple line (T4), xiphoid process (T7), umbilicus (T10), inguinal region (T12, L1), perineum and perianal region (S2, S3, and S4).  The skin should be marked where sensation is present before proceeding to motor examination.  Evidence of sacral sensory sparing establishes the diagnosis of an incomplete spinal cord injury.  The only area of sensation distal to an obvious cervical lesion in a quadriplegic patient may be in the perianal region
  16. 16. M O TO R E X A M I N AT I O N  should be systematic, beginning with the upper extremities.  complete / incomplete spinal cord injuries /pure nerve root lesions.  A protruded cervical disc /unilateral dislocated facet may produce an isolated nerve root paralysis.  key muscle groups and their corresponding nerve root levels  +/- of sacral motor sparing should be determined by voluntary rectal sphincter / toe flexor contractions.  If voluntary contraction of the sacrally innervated muscles is present with sacral sensation, the prognosis for recovery of motor function is good.  + OF anal reflex without sacral sensation is consistent with a complete injury  Finally, reflexes should be documented.  Paralyzed patients usually are areflexic, and flexion withdrawal of the legs to pinprick does not indicate voluntary motion. Hyperreflexia, clonus, and pathological reflexes, such as a Babinsky reflex in the lower extremities or a Hoffman sign in the upper extremities, indicate chronic spinal cord compression. This may be @ the findings of a central cord syndrome. 
  17. 17. K E Y M U S C L E G R O U P S C5 ---Elbow flexors (biceps, brachialis) C6--- Wrist extensors (extensor carpi radialis longus and brevis) C7-- Elbow extensors (triceps) C8 ---Finger flexors (flexor digitorum profundus to the middle finger) T1 ---Small finger abductors (abductor digiti minimi) L2 ---Hip flexors (iliopsoas) L3--- Knee extensors (quadriceps) L4 ---Ankle dorsiflexors (tibialis anterior) L5 ---Long toe extensors (extensor hallucis longus) S1 ----Ankle plantarflexors (gastrocnemius, soleus)
  18. 18.  Although spinal shock generally resolves within 24 hours, it may last longer. A positive bulbocavernosus reflex /return of the anal wink reflex indicates the end of spinal shock.  If no motor or sensory function below the level of injury can be documented when spinal shock ends, a complete spinal cord injury is present, and the prognosis is poor for recovery of distal motor or sensory function.
  19. 19. ANAL WINK BULBOCAVERNOUS REFLEX GLANS COMPRESSION ANAL SPHINCTER CONTRACTI
  20. 20. American Spinal Injury Association Scale: Classification of Spinal Cord Injuries According to the Level of Impairment Grade Motor Score* Sensory Deficit* A 0/5 Complete B 0/5 Incomplete C <3/5 Incomplete D >3/5 Incomplete E 5/5 None
  21. 21. SPINAL CORD INJURIES TERMINOLOGY  Neurological level = most caudal segment with normal sensori-motor exam- bilaterally  Complete SCI = absence of sensori- motor function in the lowest sacral segment  Incomplete SCI = partial preservation of sensory and/or motor below the defined neurological level, includes the lowest sacral segment
  22. 22. SPINAL CORD INJURIES TERMINOLOGY  Neurogenic shock = immediate loss of sympathetic tone after SCI. Loss of vasomotor and cardiac innervation. Clinically: hypotension w/out tachycardic response Fluid resus.; may need vasopressor augment  Spinal shock = transient period of areflexia. While in shock, unable to predict likelihood of recovery . Rarely > 48 hours
  23. 23. INCOMPLETE CORD SYNDROMES  CENTRAL CORD SYNDROME  BROWN SEQUARD CORD SYNDROME  ANTERIOR CORD SYNDROME  POSTERIOR CORD SYNDROME  Cauda equina syndrome  Conus medullaris syndrome
  24. 24. CENTRAL CORD SYNDROME most common. destruction of the central area of the spinal cord, including gray and white matter centrally located arm tracts in the cortical spinal area are the most severely affected, and the leg tracts are affected to a lesser extent. Generally, patients have a quadriparesis involving the upper extremities to a greater degree than the lower. Sensory sparing varies, but usually sacral pinprick sensation is preserved. frequently show immediate partial recovery after being placed in skeletal traction through skull tongs. Prognosis varies, but more than 50% of patients have return of bowel and bladder control, become ambulatory, and have improved hand function. usually results from a hyperextension injury in an older individual with preexisting osteoarthritis of the spine. The spinal cord is pinched between the vertebral body anteriorly and the buckling ligamentum flavum
  25. 25. BROWN SEQUARD SYNDROME is an injury to either half of the spinal cord usually is the result of a unilateral laminar or pedicle fracture, penetrating injury, / rotational injury resulting in a subluxation. SENSORY:  Ipsilateral loss of proprioception due to posterior column involvement.  Contralateral loss of pain and temperature due to involvement of lateral spinothalamic tract. MOTOR:  Ipsilateral spastic weakness due to descending corticospinal tract involvement  LMN signs at the level of lesion. Prognosis for recovery is good, with significant neurological improvement often occurring
  26. 26. ANTERIOR CORD SYNDROME  hyperflexion injury in which bone or disc fragments compress the anterior spinal artery and cord.  characterized by complete motor loss and loss of pain and temperature discrimination below the level of injury.  The posterior columns are spared to varying degrees resulting in preservation of deep touch, position sense, and vibratory sensation.  Prognosis is poor.
  27. 27. POSTERIOR CORD SYNDROME Involve dorsal columns SENSORY :  Impaired position and vibration sense in LL  Tactile and postural hallucinations can occur.  Numbness or paresthesia are frequent complaints..  Sensory ataxia.  Positive rhomberg sign.  Positive lhermittes sign. es the dorsal columns of the spinal cord  Urinary incontinence  Absent knee and ankle jerk (Areflexia, Hypotonia
  28. 28. CONUS MEDULLARIS & CAUDA EQUINA SYNDROMES
  29. 29.  CM: Lies opposite to vertebral bodies of T12 and L1.  Contributes to 25% of spinal cord injuries.  Caused by flexion distraction injuries and burst fractures.  Both UMN and LMN deficits occur.  Development of neurogenic bladder. CONUS MEDULLARIS SYNDROME
  30. 30.  CE: Begins at L2 disk space distal to conus medullaris.  CE syndrome occurs due to:  Acute disk herniation  Epidural haematoma  Tumour CAUDA EQUINA SYNDROME
  31. 31. MOTOR :  Flaccid lower extremities.  Knee and ankle jerk absent. SENSORY :  Asymmetrical sensory loss  Saddle anaesthesia  Loss of sensation around perineum, anus, genitals. CAUDA EQUINA SYNDROME
  32. 32. AUTONOMIC:  Loss of bladder and bowel function.  Urinary retention. CAUDA EQUINA SYNDROME
  33. 33. DDX: CONUS VS CAUDA FEATURE CONUS MEDULARIS CAUDA EQUINA PRESENTATION Sudden & Bilateral Gradual & Unilateral REFLEXES Knee present, Ankle – (If the epiconus is involved, patellar reflex maybe absent but bulbocavernosus is spared) Knee & Ankle – Bulbocavernosus reflex is absent in low CE (sacral) lesions RADICULAR PAIN Less severe More severe LOW BACK ACHE More Less
  34. 34. FEATURE CONUS MEDULARIS CAUDA EQUINA SENSORY SYMPTOMS Numbness tends to be more localized to perianal area; symmetrical and bilateral; sensory dissociation occurs. Sensory loss of pin prick & temperature sensations (Tactile sensation is spared.) Numbness tends to be more localized to saddle area; asymmetrical, maybe unilateral; no sensory dissociation; loss of sensation in specific dermatomes in lower extremities with numbness and paresthesia; possible numbness in pubic area, including glans penis or clitoris.
  35. 35. FEATURE CONUS MEDULARIS CAUDA EQUINA MOTOR SYMPTOMS Typically symmetric, distal paresis of lower limbs that is less marked; fasciculations may be present. Asymmetric areflexic paraplegia that is more marked; fasciculations rare; atrophy more common . IMPOTENCE Frequent Less frequent; ED is common erectile dysfunction that includes inability to have erection, inability to maintain erection, lack of sensation in pubic area (including glans penis or clitoris), and inability to ejaculate.
  36. 36. FEATURE CONUS MEDULARIS CAUDA EQUINA SPHINCTER DYSFUNCTION Urinary retention and atonic anal sphincter cause overflow urinary incontinence and fecal incontinence Tend to present early in course of disease. Urinary retention Tends to present late in course of disease EMG Mostly normal lower extremity with external anal sphincter invlmnt Multiple root level involvement; sphincters may also be involved. OUTCOME Less favourable More Favourable
  37. 37. TO X-RAY OR NOT TO X-RAY  Canadian C-Spine Rules  NEXUS study (a) midline pain or bony tenderness, crepitus, or step-off; (b) neurologic deficit; (c) presence of distracting injuries; (d) altered mental status (including intoxication); (e) complaint of paresthesia or numbness
  38. 38. IMAGING MODALITIES  Plain films – Lateral, AP, and Odontoid  CT  MRI
  39. 39. LATERAL TO BE ADEQUATE: : OCCIPUT ALL 7 VERTEBRAE SUP. ENDPLATE OF T1  this is main view  Where 90% lesions are  detected Adequacy Alignment Bones Cartilage Soft Tissue
  40. 40. ALIGNMENT
  41. 41. BONES
  42. 42. CARTILAGE  Predental Space should be no more than 3 mm in adults and 5 mm in children  Increased distance may indicate fracture of odontoid or transverse ligament injury  Disc Spaces  Should be uniform  Assess spaces between the spinous processes
  43. 43. LATERAL VIEW: C1 AND C2  Basion-dens distance: average 8mm, top normal 12mm.  C1: Anterior and posterior arch.  C2: Dens, Harris‘ ring, body especially ant/inf corner, pars and posterior arch.
  44. 44. PREDENTAL SPACE  In an adult, upper normal is 2.5mm. Space is parallel or narrow ―V‖ shape.  In a young child, upper normal is 4.5mm.  increase in predental space suspect jafferson #
  45. 45. LATERAL VIEW: PREDENTAL SPACE
  46. 46. PRE VERTEBRAL SOFT TISSUE SHADOWS Nasopharyngeal space (C1) - 10 mm (adult) Retropharyngeal space (C2-C4) - 5-7 mm Retrotracheal space (C5-C7) - 14 mm (children), 22 mm (adults) Extremely variable and nonspecific Contour is more important than measurements
  47. 47. The laminar space is the distance from the posterior aspect of the articular pillars (1) to the spinolaminar line (2 indicate rotational injuries of the cervical spine displacement in this line may be an indication of subtle traumatic vertebral injury/dislocation. A line (white line in B) drawn through C1-3 spinolaminar lines (white dots in A) should intercept the C2 spinolaminar line. A displacement of the C2 spinolaminar line of more than 2 mm, compared with a line drawn between the spinolaminar lines of C1 and C3, is abnormal
  48. 48. The normal AP diameter of the cervical canal is stated to be 12 to 21 mm. anteroposterior width of the canal with that of the vertebral body. The normal ratio of the spinal canal (white arrow) to the vertebral body (black arrow) is 0.8 or more.
  49. 49. AP VIEW  ASSESS FOR:  ALIGNMENT  SYMMETRY OF PEDICLES  CONTOUR OF BODIES  HEIGHT OF DISC SPACES  CENTRAL POSITION OF SPINOUS PROCESSES FACET JOINTS ORIENTED AT 45 DEGREE ANGLE FROM CORONAL PLANE -- THUS NOT SEEN ON AP IF FACET IS CLEARLY IDENTIFIED ON AP, ARTICULAR PILLAR OR PEDICLE FX WITH ROTATION IS LIKELY
  50. 50. AP VIEW  Spinous processes should line up.  Disc space should be uniform  Vertebral body height should be uniform. Check for oblique fractures.
  51. 51. ODONTOID VIEW/OPEN MOUTH VIEW  Adequacy: all of the dens and lateral borders of C1 & C2  Alignment: lateral masses of C1 and C2  Bone: Inspect dens for lucent fracture lines
  52. 52.  A+B > 7mm indicates rupture of transverse ligament
  53. 53.  Reverse Waters view is supplementary, to see top half of dens ONLY.
  54. 54. FLEXION-EXTENSION FILMS  May be helpful in ligament injuries -but are-  Frequently useless due to muscle spasm  Should not be done in acute setting
  55. 55. FLEXION-EXTENSION FILMS  Rules: Patient must be alert, awake, not intoxicated, able to sit or stand, able to understand commands, and without neurologic deficit.
  56. 56. SWIMMER’S VIEW  A SUPPLEMENTARY view to see C7-T1 in lateral projection. NOT a substitute for a bad lateral. One arm must be elevated, so THEORETICALLY could worsen a mechanical or neurological injury.  A state-of-the-art CT sagittal reformat is preferable: don’t need to move patient and imaging easier and better.
  57. 57. CT: SAGITTAL REFORMATTING  Reconstructed by computer from axial data: no additional imaging needed.  Outstanding ―lateral/swimmer‘s‖ imaging.
  58. 58. CT: CORONAL REFORMATTING  Excellent ―OMO‖  Excellent ―AP‖
  59. 59. INDICATION OF CT CERVICAL SPINE  1. Alert, cervical tenderness, paresthesias in hands or feet.  2. Unconscious  3. Impaired sensorium (including alcohol and/or drugs).  4. Impaired sensorium (alcohol and/or drugs), neurologic findings.
  60. 60.  Uncertain plain radiographic findings  In presence of osseous injury by plain films to provide details & aid in surgeryplanning  inadequate visualization by plain films  Localize foreign bodies& bone fragments in neural elements  Pts having high risk of spinal injury, fall from height from 10 feet,closed head injury  Pts with neurologic findings,negative plain films, negative non contrast CT where MRI is not feasible
  61. 61. MRI  Gold standard for cord, thecal sac, nerve root and disc injuries.  Very good for ligament injuries.  Fairly good for fractures, but does miss some. CT much better.
  62. 62. MULTIPLE SPINAL #  If a spinal fracture is identified at any level, the entire spine should be examined with anteroposterior and lateral views to document the presence or absence of spinal fractures at other levels
  63. 63.  In pattern A,  the primary lesion occurs between C5 and C7, with secondary injuries at T12 or the lumbar spine.  In pattern B,  the primary injury occurs at T2 and T4, with secondary injuries in the cervical spine.  In pattern C, the primary injury occurs between T12 and L2, with secondary injuries from L4 to L5
  64. 64. CERVICAL INJURIES  Common MOIs  Axial Loading  Flexion Force  Hyperextension Force  Flexion-Rotation Force  Hyperextension-Rotation  Lateral Flexion
  65. 65. C-SPINE/NECK INJURIES  Cervical Strain  Active motion most painful  Cervical Sprain (Whiplash)  Passive and active motion painful  Torticollis (WryNeck)  Muscle spasm and facet irritation  Brachial Plexus Stretch or Compression  Contusions to Throat
  66. 66. C-SPINE INJURIES  Cervical Fracture or Dislocation  Weakness or Paralysis  Cervical Nerve Root Injury  Herniated Disc  Laceration  Cord Shock (Central Cord Syndrome)  Hemorrhage  Contusion  Cervical Stenosis
  67. 67. CERVICAL SPINE CURVATURE  Normal cervical spine has lordotic curve  Increased lordotic curve (forward head) indicative of poor posture and muscular weakness or imbalance  Lessened lordotic curve indicative of muscular spasm/guarding and/or nerve root impingement
  68. 68. ASSOCIATED SOFT TISSUE INJURY  Carotid and vertebral artery injuries have been found to be alarmingly frequent with cervical spinal injuries. This injury is associated with a small but potentially devastating risk of stroke or death  Tracheal injuiry
  69. 69. WHIPLASH INJURY  Caused due to sudden deceleration injury  Sudden stopping of a moving vehicle  The head goes into hyperflexion and then hyper extension
  70. 70. WHIPLASH CAN CAUSE  Rupture of interspinous ligaments in the posterior side of c-spine  Unlocking of facet joints  Rupture of disc or fracture of vertebrae anteriorly
  71. 71. CLINICAL FEATURES  Severe neck pain and stiffness  May present with quadreplegia  X-ray may be normal  M R I – may show the soft tissue injury and hemorrhage below the longitudinal ligaments  May present with quadreplegia with out any radiological changes – due to cord contusion
  72. 72. TREATMENT  Cervical traction  Anti – edema measures  Immobilization  Wait for the neurological recovery
  73. 73. THE INJURIES  C1 and C2: by anatomic location  C3 to T1: by mechanism of injury (Modified from the classification of John Harris, et al.)
  74. 74. ATLANTOOCCIPITO DISSOCIATION  Often fatal but in children survivable  complete disruption of all ligamentous relationships between the occiput and the atlas  Death usually occurs immediately from stretching of the brainstem, which can result in respiratory arresttation & Distraction  ICA & vertebral injuries are common  Fatal cases often show contusions in pons, medulla ,spinal cord  Neurological Deficits Confusing  High Tetraplegia  Cruciate Paralysis  Wallenberg’s Syndrome  Avoid Traction  Always severe retropharyngeal swelling  Distance from basion to odontoid < 12mm
  75. 75. The Power ratio is calculated by dividing the distance between the basion and the posterior C1 arch by the distance between the opisthion and the anterior C1 arch. A ratio greater than 1 is suggestive of an atlanto-occipital dislocation. Harris measurements, also known as the ―rule of twelve,‖ include the BAI (basion-axis interval) and the BDI (basion- dens interval). The BAI is the measured distance between the basion and a perpendicular line drawn in relation to the posterior vertebral body tangent line of C2. The BDI is the measured distance between the basion and the tip of dens. Both distances should normally be
  76. 76. CLASSIFICATION
  77. 77. TREATMENT  Non operative;  Halovest  Operative  stabilization with a plate-screw-rod construct and fusion with iliac crest bone graft.
  78. 78. THE ATLAS AND THE AXIS  C1 and C2 injuries differ from the rest of the cervical spine and are considered separately.  Although controversial, best to consider ALL C1 and C2 injuries as UNSTABLE in the acute trauma setting.
  79. 79. THE ATLAS: C1  Anterior arch fracture: extension, uncommon.  Posterior arch fracture: extension, more common.  JEFFERSON fracture: axial load, common
  80. 80. C1: ISOLATED ARCH FRACTURES  Anterior arch  Posterior arch  CAUTION: You may be dealing with a Jefferson fracture with occult components:  Best to CT all C1 fractures.  Non operative if no instability
  81. 81. JEFFERSON FRACTURE: C1  Axial loading/burst #  Lateral view: anterior and posterior arch fractures  OMO view: lateral displacement of C1 lateral masses  The lateral masses of C1 and C2 must be aligned on the OMO view.  1-2mm of lateral displacement on one side and an EQUAL medial displacement on the other is head rotation.  ANY other pattern: lateral displacement on both sides or lateral on one side, and none on the other is abnormal.  cord injury in 15% cases
  82. 82. JEFFERSON FRACTURE CT  Classical Jefferson: 4 fractures, 2 ant./2 post.  Jefferson variants: 2 or 3 fractures, but at least 1 ant. & 1 post.  The distinction between stable and unstable Jefferson or burst fractures is the integrity of the transverse ligaments. The transverse ligament is disrupted in tension with lateral displacement of the fragment fragments, which can lead to C1-C2 instability
  83. 83. TREATMENT  Stable Jefferson or burst fractures can be treated nonoperatively in a rigid cervical collar for 8 to 12 weeks.  Unstable fractures can be reduced in halo traction, followed by placement in a halo vest  Surgery Posterior atlantoaxial stabilization and fusion is an effective treatment of residual C1-C2 instability
  84. 84. THE AXIS: C2  Odontoid fractures  Pars fractures  Extension teardrop fractures
  85. 85. ODONTOID#  Complex mechanism of injury  Generally unstable
  86. 86. ANDERSON & D‘ALONZO CLASSIFICATION (JBJS, 1974)  Type I  1 fracture through the tip  rare Rigid cervical collar for 8 wks  Type II  Type 2 fracture through the base  Most common  Type III  Type 3 fracture through the base and body of axis  Best prognosis
  87. 87. TREATMENT  type I-hard cervical collar for eight weeks  Most nondisplaced type II fractures in young patients are treated in halo vest  most nondisplaced type III fractures are treated a hard cervical collar.  Displaced type II and III fractures in young patients are first reduced using halo traction.  posterior C1-C2 stabilization and fusion in those with neurological deficits
  88. 88. C2: PARS FRACTURE/HANGMANS#  Called Hangman‘s or pedicle fracture, both wrong.  Extension injury.  Cord injury in 15%.  Non-displaced, displaced, subluxed.
  89. 89. LEVINE & EDWARDS CLASSIFIACTION type I is a minimally or nondisplaced with no evidence of translation or angulation and thus no substantial injury to the C2-C3 disc space. Type II both angulation and translation and presumably occur from an extensions mechanism. They incur substantial injury to the C2-C3 interspace. In contrast, type IIa fractures occur via a flexion mechanism and are characterized by marked angulation with minimal translational deformity. Type III fractures include any C2 pars fracture associated with a dislocation
  90. 90. TREATMENT  Type 1  rigid cervical orthosis  Type 2  closed reduction with traction and position opposite direction instability  halo vest immobilization  follow for loss of reduction  Type 3  reduction of facet dislocation with traction  early posterior open reduction and fixation using lateral mass screw fixation of C2 and C3  C2 -C3 fusion after pre-op MRI
  91. 91. C2: EXTENSION TEARDROP FRACTURE  Avulsion by the anterior longitudinal ligament of the anterior-inferior corner of the body.  Extension mechanism.  Cord injury is low.  Unstable.
  92. 92. LOWER CERVICAL SPINE C3-C7 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
  93. 93. 1.COMPRESSION FLEXION CF Stage 1: Blunting of the anterosuperior vertebral body margin CF Stage 2: Beak-appearance of the anterosuperior vertebral body margin, a sagittal vertebral body split may also be present CF Stage 3: Oblique primary fracture line that extends from the anterior vertebral body to the inferior endplate. CF Stage 4: In addition to stage 3 features, posterior translation of the upper vertebra measuring less than 3 mm CF Stage 5: Posterior translation of the upper vertebral measuring 3 mm or greater, facet gapping, indicating anterior and posterior ligamentous injury
  94. 94. 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
  95. 95. VERTICAL COMPRESSION VC Stage 1: Central superior or inferior endplate fracture VC Stage 2: Superior and inferior endplate fractures, sometimes with vertebral body fracture lines that give the appearance of a quadrangular fracture fragment VC Stage 3: Vertebral body comminution, with or without retropulsion of fragments (This has been by others as a burst- type cervical fracture), with or without kyphotic (late flexion type) or translational (late extension type)
  96. 96. 2.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
  97. 97. VERTICAL COMPRESSION  ―Burst‖ fractures explode the body.  All are very unstable and cause cord injury in 2/3 (except C1).  There is usually an element of flexion also.
  98. 98. BURST FRACTURES On lateral, body is compressed anteriorly, inferior end plate often fractured, posterior body contour is convex. On AP, body fracture is vertical or oblique and pedicles spread.
  99. 99. BURST FRACTURES  CT more accurately displays the fracture pattern and the very important degree of narrowing of the spinal canal.
  100. 100. 3.DISTRACTIVE FLEXION  DF Stage 1: Facet subluxation, gapping of the spinous process ligaments, indicating failure of the PLC, with or without some blunting of anterosuperior vertebral body (like CF stage 1)  DF Stage 2: Unilateral facet dislocation, usually PLC is intact, rotational deformity  DF Stage 3: Bilateral facet dislocations, 50% translation of upper vertebral body on lower one  DF Stage 4: Close to 100% translation of upper vertebral body on lower one, apperance of a so- called floating vertebra
  101. 101. 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
  102. 102. FLEXION DISTRACTION  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
  103. 103. TREATMENT  Closed reduction initially max weight controversial  successful  non-operative treatment 64% late instability  fusion recommended  unsuccessful  open reduction and fusion
  104. 104. UNILATERAL INTERFACETAL DISLOCATION  UID is not stable, as the contralateral capsule ligaments are torn.  Cord injury is uncommon, but root injury is common,  Findings can be subtle: less than 50% subluxation, malalignment of spinous processes.
  105. 105. CT: THIS IS A NORMAL FACET JOINT, NORMAL “HAMBURGER SIGN”
  106. 106. UID  CT: UID has ―reversed hamburger sign‖ of facet joint.  CT is also more sensitive for associated lateral mass fractures.
  107. 107. UID  Oblique view  CT Sagittal Reformat
  108. 108. REDUCTION MANOUVRE
  109. 109. BILATERAL INTERFACETAL DISLOCATION  BID, also called ―locked facets‖ is anything but locked. It is a severe 3 column injury that is completely unstable.  Cord is injured in 2/3.  Body is subluxed anteriorly at least 50%.  Marked posterior distraction.
  110. 110. 4.COMPRESSIVE EXTENSION CE Stage 1: Posterior arch fracture that may be facet, pedicle, or lamina fracture, with or without rotation that can result in mild anterior translation. (These are more commonly referred to as lateral mass fractures.) CE Stage 2: Bilateral lamina fractures, can be multiple levels CE Stage 3: Bilateral lamina, facet, pedicle fractures without vertebral body displacement. Although admittedly “hypothetical… having not been encountered” in their review, the injury may be described as a floating lateral mass fracture CE Stage 4: As for CF stage 3, with partial anterior vertebral body displacement
  111. 111. POSTERIOR ARCH FRACTURES  Plain films are insensitive, CT is outstanding.  Isolated: pedicle, lateral mass, lamina or spinous process.  Multiple fractures are common. Pedicle/lamina fractures cause free- floating lateral mass.  May be additional element of lateral bending.  Stability depends on what is fractured.
  112. 112. 5.DISTRACTIVE EXTENSION DE Stage 1: Abnormal widening of the disc space, may or may not be avulsion fractures of the anterior vertebral body margin, no posterior translation DE Stage 2: DF stage 1 plus posterior translation
  113. 113. CHILDREN  Cervical spine fractures are uncommon in children. The overall incidence of spinal fractures in pediatric trauma patients is <1%  In addition, the injury patterns are different, with cranio-cervical junction injuries being more prevalent in this group
  114. 114.  CSI IS RARE IN CHILDREN: 1% OF ALL PEDS FRACTURES AND 2% OF ALL SPINE FRACTURES  BY AGE 8-10, NO ANATOMICAL OR BIOMECHANICAL DIFFERENCES PEDS < 10 Y.O. ARE FUNDAMENTALLY DIFFERENT DUE TO ANATOMICAL VARIATIONS OF THE DEVELOPING SPINE, AND TO A LESSER EXTENT, THE DIFFERENCES IN MECHANISMS OF INJURY INHERENTLY MORE MOBILE: GENERALIZED LAXITY OF INTERSPINOUS LIGAMENTS AND JOINT CAPSULES THICK CARTILAGINOUS ENDPLATES INCOMPLETE VERTEBRAL OSSIFICATION (WEDGE-SHAPED VERTEBRAL BODIES) SHALLOW ANGLED FACET JOINTS, ESPECIALLY B/W OCCIPUT AND C4 HEAD DISPROPORTIONATELY LARGE
  115. 115. PSEUDOSUBLUXATION PERSISTENT SYNCHONDROSES ANTERIOR ANGULATION OF DENS FOCAL KYPHOSIS OF MID- CERVICAL SPINE DIFFERENT SOFT TISSUE MEASUREMENTS PEAD ANATOMIC VARIANTS -NON TRAUMATIC INJURY
  116. 116. SCIWORA  DEFINED BY PANG AND WILBERGER, 1982: ―Objective Signs Of Myelopathy As A Result Of Trauma With No Evidence Of Fracture Or Ligamentous Instability On Plain Xray And Tomography‖  FINDING OF FRACTURE, SUBLUXATION, OR ABNORMAL INTERSEGMENTAL MOTION AT LEVEL OF NEUROLOGICAL INJURY EXCLUDES SCIWORA AS A DIAGNOSIS
  117. 117.  EXPERIMENTALLY, OSTEOCARTILAGINOUS STRUCTURES IN SPINAL COLUMN CAN STRETCH 2 INCHES WITHOUT DISRUPTION -- SPINAL CORD RUPTURES AFTER 1/4 INCH  ANATOMICALLY, CERVICAL SPINAL CORD IS RELATIVELY TETHERED - SPINAL NERVES, DURAL ATTACHMENT TO FORAMEN MAGNUM, AND BRACHIAL PLEXUS
  118. 118. SPECIAL CONSIDERATION  SCIWORA = Spinal Cord Injury Without Radiographic Abnormalities  Children have vertebrae that can dislocate and quickly relocate. Cord gets damaged but shows an aligned vertebral column.  Cord can be transected or compressed.
  119. 119. STABILITY OF SPINE
  120. 120. THREE COLUMN THEORY OF DENIS  Spinal column divided into 3 columns;  Anterior column; The anterior longitudinal ligament, anterior 2/3 of the body and disc.  Middle column; Posterior longitudinal ligament and posterior 1/3 of body and disc.  posteriorcolumn; The posterior osseous arch and ligaments.  Injury to one column is stable, two or three are unstable.
  121. 121. DOES IT WORK? If two or three columns injured, lesion is unstable: Works well for C3 to T1. Does not work so well for C1-2, so consider most or all injuries here unstable.
  122. 122. PANJABI AND WHITE: CLINICAL INSTABILITY IN THE LOWER CERVICAL SPINE  Anterior elements Destroyed or Unable to Function 2  Posterior Elements Destroyed of Unable to Function2  Relative Sagittal Plane Translation > 3.5mm 2  Relative Sagittal Plane Rotation > 11deg 2  Positive Stretch Test 2  Medullary (Cord) Damage 2  Root Damage 1
  123. 123. PLAIN RADIOGRAPHY & CT - INSTABILITY  Anterior translation of the vertebral body a distance >3.5 mm relative to the subjacent vertebra  ▪ Vertebral body shows > 20 degrees of angulation relative to the adjacent vertebra  ▪ Vertebral body shows >11 degrees of angulation relative to the adjacent vertebral body pairs  ▪ Increase in atlantoaxial distance (>3 mm)  ▪ Hangman fracture with >3 mm of fragment displacement or >a 15-degree angle at the fracture site  ▪ Hangman fracture with abnormal C2-3 disc space or with C2-3 dislocation  ▪ Anterior or posterior displacement of the C2 spinolaminar line of >2 mm relative to a line drawn between the spinolaminar lines of C1 and C3
  124. 124.  Basion-dental interval (BDI) >12 mm  ▪ Basion-axial line interval (BAI) >12 mm  ▪ Unilateral facet dislocation  ▪ Bilateral facet dislocation  Widening of the uncovertebral joints  Sum of C1 lateral mass offset in excess of 7 mm (adding the amount of lateral displacement of each C1 lateral mass)  ▪ Odontoid fracture type I or II  ▪ Occipital condyle fracture type III
  125. 125. 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
  126. 126. 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
  127. 127. STABILIZATION  Traction  Skin  Skeletal  Halo traction  Crutchfield tongs
  128. 128. STABILIZATION (1)  In incomplete lesion, early stabilization prevent repetitive injury of the spinal cord and improve neurological outcome.  Delayed neurological deterioration--- 5%. Improper immobilization.  Early mobilization and rehabilitation.  Stabilization had benefit in all spinal injury patients.
  129. 129. STABILIZATION (2)  Immediate correction with external orthotic device or operative fixation  External orthoses vs surgical intervention  Surgical stabilization better than external orthoses only  Early stabilization better than late stabilization in post-surgical neurological deterioration
  130. 130. CERVICAL TRACTION
  131. 131. CRUTCH FIELD TONGS
  132. 132. HALO TRACTION
  133. 133. PHARMACOLOGICAL MANAGEMENT  NASCIS I,II,III---randomized, prospective, double-blinded---Methylprednisolone sodium succinate (MPSS)  Within 3 hours, MPSS 30mg/kg bolus + 5.4mg/kg/hr infusion for 24 hours.  During 3~8 hours, MPSS 30mg/kg bolus + 5.4mg/kg/hr infusion for 48 hours.  Effect of neurogenic improvement: suppress inflammatory response and vasogenic edema.
  134. 134. SURGICAL DECOMPRESSION (1)  Cervical spinal cord injury----  During complete injury, no neurological improvement in early or later decompression.  During incomplete injury, controversial in surgical decompression.  Laminectomy may result in neurological deterioration.  Anterior cervical decompression may improve function in incomplete quadriplegics.
  135. 135. SURGICAL DECOMPRESSION (2)  Experimental models-- rapid decompression better than later intervention.  Human model— early reduction within 8 hours brings significant recovery in one study; however, some others against it.  Increased risk such as pulmonary morbidity associates early surgery.
  136. 136. SURGICAL DECOMPRESSION (3)  Anterior approach is favored; posterior laminectomy has no benefit and worse cord compression.  As a consensus, the only accepted indication for emergent surgical treatment is progressive neurological deterioration--- such as fracture displacement, epidural hematoma, spinal cord edema or infarction.
  137. 137. TAKE HOME MESSAGE  IF HAVE HIGH ENOUGH INDEX OF SUSPICION TO GET XRAYS, THEN DO NOT ACCEPT INADEQUATE ONE  KNOW YOUR PEDIATRIC ANATOMICAL VARIATIONS  DO NOT FORGET NONSKELETAL INJURIES: LIGAMENTOUS INSTABILITY, AND SCIW0RA  If a spinal fracture is identified at any level, the entire spine should be examined with anteroposterior and lateral views to document the presence or absence of spinal fractures at other levels  DON’T BE IN A HURRY TO CLEAR THE CERVICAL SPINE - ALWAYS LEAVE IN A HARD COLLAR  Progressive neurological deficit in cord compression needs early surgical decompression.  Anterior decompression is better.  Early surgical intervention for instability prevents deterioration

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