Cervical Spine Injuries Classification and Non-operative ...


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Cervical Spine Injuries Classification and Non-operative ...

  1. 1. Cervical Spine Injuries Classification and Non-operative Treatment Dr. Heather Roche Dec. 12, 2002
  2. 2. Evaluation <ul><li>MVA, diving accidents most common cause </li></ul><ul><li>should suspect in anyone with head or high energy trauma or neurological deficit </li></ul><ul><li>can be missed with multiple trauma and if non-contiguous vertebrae involved or altered consciousness </li></ul><ul><li>16% people will have non-contiguous spine fractures </li></ul><ul><li>50% will have other skeletal or visceral injuries </li></ul>
  3. 3. History <ul><li>MVA </li></ul><ul><li>thrown from car strike head </li></ul><ul><ul><li>any paralysis at time of injury </li></ul></ul><ul><ul><li>if currently paralyzed was there any indication of movement at time of accident </li></ul></ul><ul><li>Physical </li></ul><ul><ul><li>full neuro exam including rectal and bulbocavernosus </li></ul></ul><ul><ul><li>r/o other injuries </li></ul></ul>
  4. 4. Radiography <ul><li>Initial </li></ul><ul><ul><li>cross table lateral 70-79% </li></ul></ul><ul><ul><li>AP and open mouth increases yield to 90-95% </li></ul></ul><ul><ul><li>swimmer’s view for C7-T1 </li></ul></ul><ul><li>Other </li></ul><ul><ul><li>Ct scan bony anatomy and lower c-spine </li></ul></ul><ul><ul><li>Flex-extension </li></ul></ul><ul><ul><ul><li>controversial in acute setting </li></ul></ul></ul><ul><ul><ul><li>only in alert and cooperative patients without neurological deficit with neck pain </li></ul></ul></ul><ul><ul><ul><li>false negatives due to muscle spasm </li></ul></ul></ul>
  5. 5. MRI <ul><li>Patients with complete or incomplete neurulogical deficit, deterioration in neurological function or suspected posterior ligamentous injury despite negative plain radiographs </li></ul>
  6. 6. Radiographic evidence of Instability <ul><li>Angulation between vertebral bodies that is 11 greater than adjacent segment </li></ul><ul><li>AP translation > 3.5mm </li></ul><ul><li>spinous process widening on lateral </li></ul><ul><li>facet joint widening </li></ul><ul><li>malalignment of spinous process on anterior view </li></ul><ul><li>rotation of facets on lateral </li></ul><ul><li>lateral tilting of vertebral body on anterior view </li></ul>
  7. 7. Instability
  8. 9. Initial Treatment <ul><li>Immobilization </li></ul><ul><ul><li>rigid cervical orthosis- Philadelphia collar </li></ul></ul><ul><ul><li>unstable injury this is inadequate often and cervical traction required </li></ul></ul><ul><ul><ul><li>halo traction or gardner-wells tongs </li></ul></ul></ul><ul><ul><ul><li>1cm posterior to external auditory meatus and just above the pinna </li></ul></ul></ul><ul><ul><ul><li>should be MRI compatible </li></ul></ul></ul><ul><ul><ul><li>10-15 pounds usually appropriate </li></ul></ul></ul><ul><ul><ul><li>post alignment xray and neuro exam </li></ul></ul></ul>
  9. 10. Closed Reduction <ul><li>Injuries demonstrating angulation, rotation or shortening </li></ul><ul><li>restore normal alignment therefore decompressing the spinal canal and enhancing neuro recovery preventing further injury </li></ul><ul><li>need neuro monitoring and radiography </li></ul><ul><li>awake, alert and cooperative patient to provide feedback </li></ul><ul><li>traction, positioning and weights ( 10 pds head and 5 pds each level below) xray after new weight applied </li></ul><ul><li>maintain after with 10-15 lbs traction </li></ul>
  10. 11. Spinal Cord Injury <ul><li>Maintain SBP > 90mmHg </li></ul><ul><li>100% O2 saturation </li></ul><ul><li>early diagnosis by xray </li></ul><ul><li>methylprednisolone bolus 30mg/kg then infusion 5.4mg/kg </li></ul><ul><ul><li>Corticosteroids benefit in recovery </li></ul></ul><ul><ul><li>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 </li></ul></ul><ul><ul><li>injury < 3 hrs continue for 24 hors and > 3 hrs for 48 </li></ul></ul>
  11. 12. Anatomy of Upper cervical spine
  12. 13. Injuries to Upper cervical Spine <ul><li>Occipitoatlantal Dislocation </li></ul><ul><ul><li>hyperextension distraction and rotation of craniovertebral junction </li></ul></ul><ul><ul><li>severe neurological injuries from complete C1 quadriplegia to incomplete syndromes </li></ul></ul><ul><ul><li>xray </li></ul></ul><ul><ul><ul><li>diastasis at craniovertebral junction </li></ul></ul></ul><ul><ul><ul><li>Powers ratio </li></ul></ul></ul><ul><ul><ul><ul><li>distance between basion and post arch of atlas by distance between opisthion and ant arch atlas with > 1 abnormal </li></ul></ul></ul></ul><ul><ul><ul><li>avoid traction and stabilize head to neack with halo </li></ul></ul></ul><ul><ul><ul><li>surgical Rx required as primarily a ligamentous injury </li></ul></ul></ul>
  13. 14. Occipital-atlantal Dissociation
  14. 15. Atlas Fractures <ul><li>Axial compression injuries </li></ul><ul><li>neurological injury rare </li></ul><ul><li>3 types </li></ul><ul><ul><li>Jefferson fracture- direct compression and lateral masses forced apart </li></ul></ul><ul><ul><li>asymmetric load fracture ant or post to mass and displaces it </li></ul></ul><ul><ul><li>posterior arch fractures with an extension moment through it </li></ul></ul>
  15. 17. <ul><li>Rx ? Transverse ligament intact </li></ul><ul><ul><li>avulsion at insertion on CT </li></ul></ul><ul><ul><li>lateral overhang of C1 over outer edges of C2 </li></ul></ul><ul><ul><li>> 6.9 mm= rupture </li></ul></ul><ul><ul><li>ADI > 4mm </li></ul></ul><ul><ul><li>MRI visualization of ligament </li></ul></ul><ul><li>Ligament intact </li></ul><ul><ul><li>cervical orthosis ( Philadelphia, SOMI, Minerva) for posterior arch or undisplaced Jefferson </li></ul></ul><ul><ul><li>Halo - asymmetric lateral mass or displaced Jefferson fractures </li></ul></ul><ul><li>No ligament </li></ul><ul><ul><li>Fusion </li></ul></ul>
  16. 18. Odontoid Fracture <ul><li>15 % all cervical fractures </li></ul><ul><li>usually MVA or blow to the head Three types </li></ul><ul><ul><li>Type 1 Avulsion off tip by alar ligament </li></ul></ul><ul><ul><li>Type 2 fracture at junction of dens with the central body </li></ul></ul><ul><ul><li>Type 3 fracture in body of axis and primarily cancellous bone </li></ul></ul><ul><li>usually hyperflexion with anterior displacement </li></ul><ul><li>assoc injuries to C1 common </li></ul><ul><li>neurological deficit in 15-25% cases </li></ul>
  17. 19. Odontoid Fractures
  18. 20. Treatment <ul><li>Type 1 - </li></ul><ul><ul><li>Philadelphia collar for 6-8 weeks </li></ul></ul><ul><li>Type 3 - </li></ul><ul><ul><li>collar inadequate </li></ul></ul><ul><ul><li>Halo vest immobilization after reduction in traction 80 % union rate ( 3-4 months) </li></ul></ul>
  19. 21. Treatment con’t <ul><li>Type 2 </li></ul><ul><ul><li>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 </li></ul></ul><ul><ul><li>Increased non-union with displacement, smoker and advanced age </li></ul></ul><ul><ul><li>undisplaced - halo immobilization </li></ul></ul><ul><ul><li>displaced - </li></ul></ul><ul><ul><ul><li>? Traction for reduction then halo immobilization </li></ul></ul></ul><ul><ul><ul><li>? Primary C1-C2 fusion after reduction in traction </li></ul></ul></ul><ul><ul><ul><ul><li>most recommend if displacement > 4-5mm </li></ul></ul></ul></ul>
  20. 22. Hangman’s Fracture Traumatic spondylolithesis <ul><li>Type 1 </li></ul><ul><ul><li>isolated minimally displaced fracture of ring with no angulation </li></ul></ul><ul><li>Type 2 </li></ul><ul><ul><li>more unstable </li></ul></ul><ul><ul><li>flesion type/extension type or listhetic type </li></ul></ul><ul><ul><li>displaced > 3mm and angulation of C2-C3 disk space </li></ul></ul><ul><ul><li>ALL, PLL Disc can be interrupted </li></ul></ul><ul><li>Type 3 </li></ul><ul><ul><li>rare </li></ul></ul><ul><ul><li>anterior dislocation of C2 facets on C3 with 2 extension fracturing neural arch </li></ul></ul>
  21. 23. Hangman’s Fracture
  22. 24. Treatment <ul><li>Type 1 </li></ul><ul><ul><li>rigid cervical orthosis </li></ul></ul><ul><li>Type 2 </li></ul><ul><ul><li>closed reduction with trection and position opposite direction instability </li></ul></ul><ul><ul><li>halo vest immobilization </li></ul></ul><ul><ul><li>follow for loss of reduction </li></ul></ul><ul><li>Type 3 </li></ul><ul><ul><li>reduction of facet dislocation with traction </li></ul></ul><ul><ul><li>C2 -C3 fusion after pre-op MRI </li></ul></ul>
  23. 25. Sub axial Spine <ul><li>bodies articulate by intervertebral disc, ALL and PLL </li></ul><ul><li>facet joints are in a coronal plane 45 to horizontal allowing flexion and extension 14 degrees in sagittal plane </li></ul><ul><li>due to 45 incline lateral tilt accompanied by rotation </li></ul><ul><li>9 degrees in coronal plane and 5 rotation in each segment </li></ul><ul><li>vertebral foramen in lateral mass contain vertebal artery which transverses C6 through C1 </li></ul>
  24. 26. Biomechanics <ul><li>Denis </li></ul><ul><ul><li>three column spine for TL spine now applied to c-spine </li></ul></ul><ul><ul><li>Anterior region </li></ul></ul><ul><ul><ul><li>disk and centrum resist compression </li></ul></ul></ul><ul><ul><ul><li>ALL, anterior annulus resist distraction </li></ul></ul></ul><ul><ul><li>Middle </li></ul></ul><ul><ul><ul><li>post vertebral body and uncovertebral joints </li></ul></ul></ul><ul><ul><ul><li>PLL and Annulus resist distraction </li></ul></ul></ul><ul><ul><li>Posterior </li></ul></ul><ul><ul><ul><li>facet joints and lateral mass compression </li></ul></ul></ul><ul><ul><ul><li>facet capsule, intra and supraspinous ligaments </li></ul></ul></ul>
  25. 27. Classification Ferguson and Allen <ul><li>Based on position of neck at time of injury and dominant force </li></ul><ul><li>2 column theory </li></ul><ul><ul><li>everything anterior to PLL ant column </li></ul></ul><ul><li>most patients have a combination of patterns </li></ul>
  26. 28. Compression and Flexion <ul><li>Level C4-5 and C5-6 </li></ul><ul><li>compression of ant column and distraction of post </li></ul><ul><li>different stages with later stages having more post involvement and displacement of vertebral body </li></ul><ul><li>MRI to evaluate post ligaments </li></ul><ul><li>intact - HALO sufficient </li></ul><ul><li>not - risk of late kyphotic deformity therefore fusion </li></ul>
  27. 29. Vertical Compression <ul><li>C6-7 most common </li></ul><ul><li>shortening of ant and post columns </li></ul><ul><li>stage 1 - </li></ul><ul><ul><li>cupping of end plate with partial failure anteriorly and normal post ligaments </li></ul></ul><ul><ul><li>rigid orthosis </li></ul></ul><ul><li>stage 3 - </li></ul><ul><ul><li>fragmentation and displacement of body “ burst” </li></ul></ul><ul><ul><li>neurologic injury common with assoc post element fractures </li></ul></ul><ul><ul><li>anterior corpectomy and reconstruction for neuro recovery plus post fusion to prevent kyphosis </li></ul></ul>
  28. 30. Distraction Flexion <ul><li>Most common pattern </li></ul><ul><li>tensile failure and lengthening of post column with possible compression of ant column </li></ul><ul><li>ant translation superior vertebra </li></ul><ul><li>25% facet subluxation </li></ul><ul><li>50% unilateral facet dislocation </li></ul><ul><li>> 50% bilateral dislocation </li></ul><ul><li>full body displacement </li></ul>
  29. 33. Treatment <ul><li>Closed reduction initially max weight controversial </li></ul><ul><li>successful </li></ul><ul><ul><li>non-operative treatment 64% late instability </li></ul></ul><ul><ul><li>fusion recommended </li></ul></ul><ul><li>unsuccessful </li></ul><ul><ul><li>open reduction and fusion </li></ul></ul>
  30. 34. Flexion distraction con’t <ul><li>50-80% assoc acute disk herniation at level of injury </li></ul><ul><li>awake closed reduction has not shown worsening of neuro deficit and should not undergo major delay in reduction while waiting for MRI </li></ul><ul><li>MRI prerequisite to open reduction </li></ul><ul><li>Disk present ant cervical diskectomy prior to reduction </li></ul>
  31. 35. Compression Extension <ul><li>Early compressive failure of post column and late tensile failure ant column </li></ul><ul><li>late stages body displacement unstable and require anterior fusion </li></ul>
  32. 36. Compression Distraction <ul><li>Tensile failure of both ant and post columns bony or ligamentous </li></ul><ul><li>stage1 </li></ul><ul><ul><li>no body displacement on static or flexion/ext </li></ul></ul><ul><ul><li>rigid orthosis </li></ul></ul><ul><li>Stage 2 </li></ul><ul><ul><li>displacement present </li></ul></ul><ul><ul><li>fusion </li></ul></ul>
  33. 37. Lateral Flexion <ul><li>Asymmetric loading in coronal plane </li></ul><ul><li>displacement </li></ul><ul><ul><li>fusion </li></ul></ul>
  34. 38. Halo Skeletal Fixation