This document provides information on orthopaedic spinal injuries from Zagazig University in Egypt. It discusses several topics in 3 paragraphs or less: Spinal injuries are less common than extremity injuries but have worse functional outcomes. They involve the cervical, thoracic, and lumbar spine. Neurological involvement is common in high-energy trauma or polytrauma patients. Cervical spine injuries account for one-third of spinal injuries. The C2 vertebrae and lower C6-C7 vertebrae are most commonly injured. A neurological injury occurs in 15% of spine trauma patients. Exam of the peripheral nervous system is important to fully assess injuries. Initial management follows ATLS protocols - stabilize

1. ORTHOPAEDIC
DEPARTMENT
ZAGAZIG UNIVERSITY
FACULTY OF MEDICINE
By
Dr. Tarek A. ElHewala
Lecturer of Orthopaedic Surgery
Faculty of Medicine, Zagazig University

2. Spinal Injuries
• Less
common
than
traumatic injuries of the
extremities but:
– Have the lowest functional
outcomes and the lowest rates
of return to work after injury
in all major organ systems.

3. Major Trauma
• High energy trauma.
• Polytrauma patients.
• Neurological involvement.

4. Spinal Injuries
• Incidence of spinal fracture in (NA):
64/100000
• Trend:
– Decrease in high income countries.
– Strong increase in medium and low
income countries.

5. Cervical Spine Injuries
• Account for one-third of all spinal injuries.
• The most commonly injured vertebrae(1) are:
– C2: where one-third of which are odontoid fracture.
– C6,C7: are the most frequently affected levels in the
subaxial spine (vertebral body fracture)
• A neurological injury occurs in about 15% of spine
trauma patients.
• A low GCS indicates a high risk for a concomitant
cervical injury.
1- Goldberg W, Mueller C, Panacek E, Tigges S, Hoffman JR, Mower WR (2001) Distribution and patterns of blunt traumatic cervical
spine injury. Ann Emerg Med 38:17–21

6. Normal Anatomy
• Functionally, the cervical spine is divided into:
– The upper cervical spine [occiput (C0)–C1–C2]
– The lower (sub-axial) cervical spine (C3–C7).

7. Normal Anatomy
• Upper Cervical Spine:
• The atlas-occiput
junction primarily allows
flexion/extension and
limited rotation.
• Axial rotation at the
craniocervical junction is
restricted by osseous as
well as ligamentous
structures.

8. Normal Anatomy
• Upper Cervical Spine:
• The atlantoaxial joint is
composed of lateral mass
articulations with loosely
associated joint capsules
and an atlantodental
articulation

9. Normal Anatomy
• Lower (Subaxial) Cervical Spine:
• The vertebrae of the lower cervical spine have a
superior cortical surface which is concave in the
coronal plane and convex in the sagittal plane.
• This configuration allows flexion, extension, and
lateral tilt by gliding motion of the facets.

10. Normal Anatomy
• Lower (Subaxial) Cervical Spine:
• The C5/6 level exhibits the largest range of
motion, which in part explains its
susceptibility to trauma and degeneration.
• The facet joint capsules are stretched in
flexion and therefore limit rotation in this
position.

11. Biomechanics of Cervical Spine
Trauma
• The conditions under which neck injury occurs
include several key variables such as:
– impact magnitude.
– impact direction.
– point of application.
– rate of application.

12. Biomechanics of Cervical Spine
Trauma
• For example in lower cervical spine:
• Vertical loading of the lower cervical spine in
the forward flexed position
reproduce
pure ligamentous injuries.
• This mechanism produced bilateral dislocation
of the facets without fracture.
• A unilateral dislocation was produced if lateral
tilt or axial rotation occurred as well.

13. Biomechanics of Cervical Spine
Trauma
• Axial loading less than 1 cm anterior to the
neural position
produced anterior
compression fractures of the vertebral body.
• Burst fractures can be produced by
direct
axial compression of a slightly flexed cervical
spine.
• Tear-drop fracture results from
a flexion/compression injury with disruption
of the posterior ligaments.

14. Spinal Cord Injury
• It is now well accepted that acute spinal cord
injury (SCI) involves both:
– Primary injury mechanisms.
– Secondary injury mechanisms.

15. Spinal Cord Injury
• The primary injury of the spinal cord results in local
deformation and energy transformation at the time of
injury and is irreversible. It can therefore not be
repaired by surgical decompression.
• The injury is caused by:
– In the vast majority of cases bony fragments that acutely
compress the spinal cord.
– acute spinal cord distraction.
– acceleration-deceleration with shearing.
– laceration from penetrating injuries.
• The injury directly damages cell bodies and/or processes of
neurons.

16. Spinal Cord Injury
• Immediately after the primary injury,
secondary injury mechanisms may initiate,
leading to delayed or secondary cell death
that evolves over a period of days to weeks.
• These secondary events are potentially
preventable and reversible.

17. Spinal Cord Injury
• A variety of complex chemical pathways are likely
involved including:
–
–
–
–
–
–
–
–
–
hypoxia and ischemia
intracellular and extracellular ionic shifts
lipid peroxidation
free radical production
excitotoxicity
eicosanoid production
neutral protease activation
prostaglandin production
programmed cell death or apoptosis

18. Spinal Cord Injury
• In the case of a lesion of the cord cranial to T1, a
complete loss of sympathetic activity will develop
that results in loss of compensatory
vasoconstriction (leading to hypotension) and
loss of cardiac sympathetic activation (leading to
bradycardia).
• Secondary deteriorations of spinal cord function
that result from hypotension and inadequate
tissue oxygenation have to be avoided.

19. Spinal Cord Injury
• Injuries to the spinal cord often result in spinal
shock.
• The phenomenon of spinal shock is usually
described as:
– loss of sensation
– flaccid paralysis
– absence of all reflexes below the spinal cord injury.
• It is thought to be due to a loss of background
excitatory input from supra-spinal axons

20. Spinal Cord Injury
• Spinal shock is considered the first phase of
the response to a spinal cord injury, hyperreflexia and spasticity representing the
following phases.
• When spinal shock resolves, reflexes will
return and residual motor functions can be
found.

21. History
• The cardinal symptoms of an acute cervical
injury are:
– pain
– loss of function (inability to move the head)
– numbness and weakness
– bowel and bladder dysfunction.

22. History
• In patients with evidence for neurological deficits, the
history should include:
– time of onset (immediate, secondary)
– course (unchanged, progressive, or improving)
• The history should include a detailed assessment of the
injury:
– type of trauma (high vs. low-energy)
– mechanism of injury (compression, flexion/distraction,
hyperextension, rotation, shear injury)

23. History
• In polytraumatized or unconscious patients,
patients must be considered to have sustained a
cervical injury until proven otherwise.
• The history should also comprehensively assess
details of collision and injury such as:
–
–
–
–
–
–
type of collision (rear-end, frontal or side impact)
use of headrest/seat belt
position in the car
injury pattern for all passengers
head contusion
severity of impact to the vehicle

24. Initial Management
• Primary survey
• A full general and neurological assessment must
be undertaken in accordance with the principles
of advanced trauma life support (ATLS).
• Spinal trauma is frequently associated with
multiple injuries.
• As always, the patient’s airway, breathing and
circulation (“ABC”—in that order) are the first
priorities in resuscitation from trauma.

25. Initial Management
• Secondary survey
• Once the immediately life-threatening injuries
have been addressed, the secondary (head to
toe) survey that follows allows other serious
injuries to be identified.
• If neurological symptoms or signs are present,
a senior doctor should be present and a
partial roll to about 45˚ may be sufficient.

26. Initial Management
• Secondary survey
• specific signs of injury including:
– local bruising
– deformity of the spine (e.g. a gibbus or an increased
interspinous gap)
– vertebral tenderness.
• The whole length of the spine must be palpated, another
spinal injury at a different level.
• Priapism and diaphragmatic breathing invariably indicate a
high spinal cord lesion.
• The presence of warm and well-perfused peripheries in a
hypotensive patient should always raise the possibility of
neurogenic shock attributable to spinal cord injury in the
differential diagnosis.

27. Initial Management
• Secondary survey
• At the end of the secondary survey, examination
of the peripheral nervous system must not be
neglected.
• Diagnosis of intra-abdominal trauma often
difficult because of:
– impaired or absent abdominal sensation
– absent abdominal guarding or rigidity, because of
flaccid paralysis
– paralytic ileus

28. Neurological assessment
• In spinal cord injury the neurological examination must
include assessment of the following:
– Sensation to pin prick (spinothalamic tracts)
– Sensation to fine touch and joint position sense (posterior
columns)
– Power of muscle groups according to the Medical Research
Council scale (corticospinal tracts)
– Reflexes (including abdominal, anal, and bulbocavernosus)
– Cranial nerve function (may be affected by high cervical
injury).

29. Neurological assessment
• By examining the dermatomes and myotomes, the
level and completeness of the spinal cord injury and
the presence of other neurological damage such as
brachial plexus injury are assessed.
• The last segment of normal spinal cord function, as
judged by clinical examination, is referred to as the
neurological level of the lesion.
• This does not necessarily correspond with the level of
bony injury, so the neurological and bony diagnoses
should both be recorded. Sensory or motor sparing
may be present below the injury.

30. Neurological assessment
• The differentiation of a complete and
incomplete paraplegia is important for the
prognosis.
• It is mandatory to exclude a spinal shock
which can mask remaining neural function
and has an impact on the treatment decision
and timing.
• The first reflex to return is the
bulbocavernosus reflex in over 90%of cases.

31. Neurological assessment
No voluntary sensory (sacral sparing) or motor
sparing
bulbocavernosus
reflex is present
spinal shock is resolved, and a complete cord
lesion is confirmed.

32. Neurological assessment
• The American Spinal Injury Association (ASIA)
has now produced the ASIA impairment scale
modified from the Frankel grades.

33. Neurological assessment

34. Neurological assessment

35. Conclusions Primary Assessment
• ATLS is the guiding principle:
– First life, then limb.
• Spinal fractures can be missed easily during initial
assessment:
– Every HET patient has spinal injury until it is disproved.
• There is no reliable way of determining the
neurologic status with certainty at the admission.
• There is no place for fatalism as far as the
neurology is concerned
– Give your patients the benefit of doubt.

36. Diagnostic Work-up
In 2001, a highly sensitive decision rule (“Canadian C-Spine Rule”) was derived,
for use in cervical spine radiography in alert and stable trauma patients.

37. Standard Radiographs
• At least three views are recommended for alert
and stable trauma patients:
– anteroposterior view
– cross-table lateral view
– open-mouth dens view

38. Standard Radiographs
• Oakley introduced a simple system (radiological
ABC) for analyzing plain films:
– A1: appropriateness: correct indication and right
patient
– A2: adequacy: extent (occiput to T1,
penetration, rotation/projection)
– A3: alignment:
•
•
•
•
•
anterior aspect of vertebral bodies,
posterior aspect of vertebral bodies,
spinolaminar line (bases of spinous process),
tips of spinous process,
craniocervical and other lines and relationships
– B: bones
– C: connective tissues:
•
•
•
•
pre-vertebral soft tissue,
pre-dental space,
intervertebral disc spaces,
interspinous gaps

39. Standard Radiographs
• The most common causes of missed cervical
spine injury are:
– not obtaining radiographs
– making judgments on technically suboptimal films
The latter cause most commonly occurs at
the cervico-occipital and cervico-thoracic
junction levels.

40. Standard Radiographs
Helpful signs to diagnose cervical spine instability:

41. Standard Radiographs
• For the upper cervical spine, White and Panjabi
suggested criteria indicative of instability based on
conventional radiography.

42. Standard Radiographs

43. Computed Tomography
• CT is the first choice for unconscious or
polytraumatized patients.
– the ease of performance,
– speed of study,
– the greater ability of CT to detect fractures other than
radiography.
• The craniocervical scans should be of a maximum
2 mm thickness, because dens fractures can even
be invisible on 1-mm slices with reconstructions

44. Computed Tomography
• Computed tomography scans are sensitive for
detecting characteristic fracture patterns not
seen on plain films:
– the mid-sagittal fracture through the posterior
vertebral wall and lamina.
– rotatory instability at the atlantoaxial joints.
– shows if the dens separates from the anterior arch of
C1 with increased rotation.
• Importantly, all the injuries that were missed by
plain films required treatment.

45. Computed Tomography

46. MRI
• Magnetic resonance imaging is the imaging study
of choice to exclude discoligamentous injuries, if
lateral cervical radiographs and CT are negative.
• MRI is the modality of choice for evaluation of
patients with neurological signs or symptoms to
assess soft tissue injury of the cord, disc and
ligaments.
• Particularly, STIR sequences are very helpful in
visualizing posterior soft tissue injuries and
thereby helping to diagnose unstable fractures
(especially if conservative treatment is decided)

47. MRI

48. Neck Pain Task Force

49. Neck Pain Task Force

50. General objectives of treatment
• restoration of spinal alignment
• preservation or improvement of neurological
function
• restoration of spinal stability
• restoration of spinal function
• resolution of pain

51. Non-operative Treatment Modalities
• Cervical orthoses limit movement of the cervical
spine by buttressing structures at both ends of
the neck, such as the chin and the thorax.
• However, applied pressure over time can lead to
complications such as:
–
–
–
–
–
pressure sores and skin ulcers
weakening and atrophy of neck muscles
contractures of soft tissues
decrease in pulmonary function
chronic pain syndrome

52. Non-operative Treatment Modalities
• Collars
– Soft collars have a limited effect on controlling neck
motion.
– The Philadelphia collar has been shown to control
neck motion, especially in the flexion/extension plane,
much better than the soft collar.
– Disadvantages of the Philadelphia collar are the lack
of control for flexion/extension control in the upper
cervical region and lateral bending and axial rotation.

53. Non-operative Treatment Modalities
• Minerva Brace/Cast
– A Minerva cervical
brace
is
a
cervicothoracal orthosis
with
mandibular,
occipital and forehead
contact points.
• This brace provides adequate immobilization between C1
and C7, with less rigid immobilization of the occipital-C1
junction.
• The addition of the forehead strap and occipital flare assists
in immobilizing C1–C2.

54. Non-operative Treatment Modalities
• Traction:
– The Gardner-Wells tongs can be applied using
local anesthesia.
– The pin application sites should be a finger
breadth above the pinna of the auricle of the ear
in line with, or slightly posterior to, the external
auditory canal.
– Rule out atlanto-occipital dislocation or
discoligamentous disruption before applying
traction.

55. Non-operative Treatment Modalities
• Halo
– The halo vest is the
first conservative
choice for unstable
lesions.
– Its clinical failure is
due to:
• pin track problems
• accurate fitting of the
vest
• a lack of patient
compliance

56. Occipital Condyle Fracture
• This type of fracture is a rare injury.
• They often are discovered on a head CT scan in
an unconscious patient; cervical radiographs
rarely show these fractures.
• Conscious patients complaining of an occipital
headache should be suspected of having an
occipital condyle fracture until proven otherwise.
• Though cranial nerves IX-XII are sometimes
affected, neurological examination is often
normal.

57. Occipital Condyle Fracture

58. Occipital Condyle Fracture

59. Atlanto-occipital Dislocation
• Rare survivors usually have a neurological
deficit, particularly with cranial nerves VII to X.
• Frequent diagnosis is at autopsies following
death related to a spinal injury.
• High-resolution CT efficiently illustrates the
injury.
• Treatment includes closed reduction and
surgical stabilization—often occiput to C2.

60. Atlanto-occipital Dislocation
• Traynelis et al. classification:
– Type I: anterior dislocation.
– Type II: vertical dislocation.
– Type III: posterior dislocation.

61. Atlanto-occipital Dislocation

62. Occiput to C2 Fixation

63. Fractures of the Atlas
• Fractures of the atlas account for
approximately 1–2% of all fractures.
• These fractures are frequently associated with
other cervical fractures or ligamentous
traumatic injuries.
• Burst fractures of the atlas are caused by
massive axial loads.

64. Fractures of the Atlas

65. Fractures of the Atlas
• The
literature
does
not
allow
treatment
recommendations to be given on solid scientific
evidence.
• It is recommended to treat isolated fractures of the
atlas with intact transverse alar ligaments (implying
C1–C2 stability) with cervical immobilization alone.
• It is recommended to treat isolated fractures of the
atlas with disruption of the transverse ligament with
atlantoaxial screw fixation and fusion (a Magerl C2 and
C1 transfacet screw fixation technique).

66. Atlantoaxial Instabilities
• Atlantoaxial instability results from either:
– a purely ligamentous injury or
– avulsion fractures.
• While atlantoaxial dislocation and subluxation
is relatively common in patients with
rheumatoid arthritis, a traumatic origin due to
a rupture of the transverse ligament is rare.

67. Atlantoaxial Instabilities
• These injuries are significant, because
complete bilateral dislocation of the articular
processes can occur at approximately 65° of
atlantoaxial rotation.
• When the transverse ligament is intact, a
significant narrowing of the spinal canal and
subsequent potential spinal cord damage is
possible

68. Atlantoaxial Instabilities
• With a deficient transverse ligament,
complete unilateral dislocation can occur at
approximately 45° with similar consequences.
• In addition, the vertebral arteries can be
compromised by excessive rotation which may
result in brain stem or cerebellar infarction
and death.

69. Atlantoaxial Instabilities
• Atlantoaxial instabilities can be classified
according to the direction of the dislocation as:
– anterior (transverse ligament disruption, dens or
Jefferson fracture)
– posterior (dens fracture, see Fielding Type IV)
– lateral (lateral mass fracture of C1, C2, or unilateral
alar ligament ruptures)
– rotatory (see Fielding Types I–III)
– vertical (rupture of the alar ligaments and tectorial
membrane)

70. Atlantoaxial Instabilities
• Rotatory Atlantoaxial Instability
• A special form of atlantoaxial instability which may
occur with or without an initiating trauma.
• This subluxation is more common in children than in
adults.
• Non-traumatic etiologies include:
– juvenile rheumatoid arthritis
– surgical interventions such as tonsillectomy or
mastoidectomy
– infections of the upper respiratory tract (“Grisel
syndrome”).

71. Atlantoaxial Instabilities
• According to Fielding et al. four types can be
differentiated:

72. Atlantoaxial Instabilities
• Common complaints are neck pain with evidence
of torticollis, suboccipital pain, and limited
cervical rotation.
• Radiographic diagnosis includes:
– open-mouth odontoid view,
– lateral cervical spine with or without flexion–
extension views,
– dynamic (rotation to the right then the left) CT scan,
– MRI.
• Surgical treatment involves a C1-C2 fusion.

73. Dens Fractures
• The most common axis injury is a fracture
through the odontoid process.
• Translational motion of C1 on C2 is restricted
by the transverse atlantal ligaments that
center the odontoid process to the anterior
arch of C1.
• With a fracture of the odontoid process,
restriction of translational atlantoaxial
movement is lost.

74. Dens Fractures
• According to the
classification of Anderson
and D’Alonzo:
– Type I: oblique fractures
through the upper portion of
the odontoid process.
– Type II: across the base of
the odontoid process at the
junction with the axis body.
– Type III: through the
odontoid that extends into
the C2 body.

75. Dens Fractures
• A variety of non-operative and operative treatment
alternatives have been proposed for odontoid fractures
based on:
–
–
–
–
fracture type
degree of (initial) dens displacement
extent of angulation
patient’s age
• Type II and Type III odontoid fractures should be
considered for surgical fixation in cases of:
–
–
–
–
dens displacement of 5 mm or more
dens fracture (Type IIA)
inability to achieve fracture reduction
inability to achieve main fracture reduction with external
immobilization

76. Dens Fractures

77. Dens Fractures

78. Dens Fractures

79. Dens Fractures
• Anterior transarticular screw fixation: As an augmentation of
the anterior dens screw or in cases of a salvage procedure.
• Screws can be inserted over Kirschner wires from a medialanterior-caudal to a lateral-posterior-cranial direction crossing
the atlantoaxial joint.

80. Dens Fractures

81. Traumatic Spondylolisthesis of the Axis
• Traumatic fractures of the posterior elements
of the axis may occur after hyperextension
injuries as seen in:
– motor vehicle accidents,
– diving,
– Falls,
– judicial hangings.
• Therefore, the term “hangman’s fracture” was
coined by Schneider in 1965.

82. Traumatic Spondylolisthesis of the Axis
• Effendi et al. described three
types of fractures which are
mechanism based:
– Type I:
• isolated hairline fractures of the
ring of the axis with minimal
displacement of the body of C2.
• These injuries are caused by axial
loading and hyperextension.

83. Traumatic Spondylolisthesis of the Axis
• Type II:
•
• displacement of the anterior
fragment with disruption of
the disc space below the axis.
• These injuries are a result of
hyperextension and rebound
flexion.
Type IIA:
•
displacement of the anterior
fragment with the body of the axis
in a flexed position without C2–C3
facet dislocation.

84. Traumatic Spondylolisthesis of the Axis
• Type III:
– displacement of the
anterior fragment with
the body of the axis in a
flexed position in
conjunction with C2–C3
facet dislocation.
– These injuries are caused
by primary flexion and
rebound extension.

85. Traumatic Spondylolisthesis of the Axis
• Most patients with traumatic spondylolisthesis
reported in the literature were treated with cervical
immobilization with good results.
• Most traumatic spondylolisthesis heals with 12 weeks
of cervical immobilization with either a rigid cervical
collar or a halo immobilization device.
• Surgical stabilization is a preferred treatment option in
cases with:
– severe angulation (Effendi Type II)
– disruption of the C2–C3 disc space (Effendi Type II and III)
– inability to establish or maintain fracture alignment with
external immobilization.

86. Traumatic Spondylolisthesis of the Axis

87. Subaxial Cervical Trauma
• Common.
• Usually Cx-Th junction fracture is missed in
diagnosis if no appropriate X-rays are ordered.
• There are many controversy on the best line of
treatment.

88. Subaxial Cervical Trauma
• Allen and Ferguson classification of compression–flexion injuries.

89. Subaxial Cervical Trauma
• Allen and Ferguson classification of vertical compression injuries.

90. Subaxial Cervical Trauma
• Allen and Ferguson classification of distraction–flexion injuries.

91. Subaxial Cervical Trauma
• Allen and Ferguson classification of compression–extension injuries.

92. Subaxial Cervical Trauma
• Allen and Ferguson classification of distraction–extension injuries.

93. Subaxial Cervical Trauma
• Allen and Ferguson classification of lateral flexion injuries.

94. Subaxial Cervical Trauma
• Cervical Spine Injury Severity Score:
• The Cervical Spine Injury Severity Score (CSISS)
is based on independent analysis of four
columns (anterior, posterior, right column, and
left lateral column).

95. Subaxial Cervical Trauma
• Anderson and colleagues assessed reliability
of this classification.
• They found construct validity was also good as
all patients with scores equal to 7 had surgery.
• They found a significant correlation with high
CSISS scores (>11) to a posterior or combined
anteroposterior approach.

96. Subaxial Cervical Trauma
• Subaxial Cervical Spine Injury Classification
• The Subaxial Cervical Spine Injury Classification
system (SLIC) evaluates:
– fracture morphology,
– the discoligamentous complex,
– neurologic function.
• Creating a comprehensive
treatment decision making
system
to
aid

97. Subaxial Cervical Trauma

98. Subaxial Cervical Trauma
• Anterior Column Injuries
• Anterior column injuries include:
–
–
–
–
Compression fractures,
Burst fractures,
Flexion axial loading injury.
Disc distraction injuries.
– Transverse process fractures are included in this group,
although they have no effect on spinal stability but may be
associated with vertebral artery injury.

99. Anterior Column Injuries

100. Anterior Column Injuries

101. Subaxial Cervical Trauma
• Posterior Column Injuries
• Isolated injuries to the posterior column are less
common than those that are combined with
other fractures.
• Isolated injuries include:
– spinous process and lamina fractures.
– Disruption of the posterior ligamentous complex
without facet subluxation.

102. Posterior Column Injuries

103. Posterior Column Injuries

104. Subaxial Cervical Trauma
• Lateral Column Injuries
• Injuries to the lateral column are being recognized
more frequently, likely due to better restraint systems
that are preventing the more serious injuries and by
increasing recognition from the use of diagnostic CT.
• Anatomically the lateral column consists of the lateral
masses with their superior and inferior articular
process projections.
• Lateral column injuries include:
– isolated facet fractures without subluxation,
– lateral mass fractures,
– unilateral and bilateral dislocation with and without
fractures.

105. Lateral Column Injuries

106. Lateral Column Injuries

107. Subaxial Cervical Trauma

108. Subaxial Cervical Trauma

109. Subaxial Cervical Trauma

110. Subaxial Cervical Trauma