The document discusses the anatomy, biomechanics, classification systems, and management of injuries to the subaxial cervical spine (C3-C7). Key points include: the subaxial spine consists of 7 vertebrae joined by ligaments and disks; common injury mechanisms are flexion, extension, compression, and rotation; the Allen-Ferguson and AO classification systems describe injury patterns; clinical instability is defined as loss of ability to avoid neurologic injury or deformity; the SLIC score guides treatment; and initial management priorities are airway control, immobilization, and prevention of hypoxia.

1. Sub axial cervical spine
DR.SHAMEEJ MUHAMED KV
SENIOR RESIDENT
NEUROSURGERY DEPARTMENT
GOVT MEDICAL COLLEGE , CALICUT

2. • The normal anatomy of the cervical spine consists of 7 cervical
vertebrae separated by intervertebral disks and joined by a complex
network of ligaments.
• These ligaments keep individual bony elements behaving as a single
unit.

3. • The anterior and posterior longitudinal ligaments maintain the
structural integrity of the anterior and middle columns.
• The posterior column is held in alignment by a complex ligamentous
system, including the nuchal ligament complex, capsular ligaments,
and the ligamentum flavum.
• If one column is disrupted, other columns may provide sufficient
stability to prevent spinal cord injury.
• If 2 columns are disrupted, the spine may move as 2 separate units,
increasing the likelihood of spinal cord injury.

4. • The atlas (C1) and the axis (C2) differ markedly from other cervical
vertebrae.
• The atlas has no vertebral body; however, it is composed of a thick anterior
arch with 2 prominent lateral masses and a thin posterior arch.
• The axis contains the odontoid process that represents fused remnants of
the atlas body. The odontoid process is held in tight approximation to the
posterior aspect of the anterior arch of C1 by the transverse ligament,
which stabilizes the atlanto-axial joint.
• Apical, alar, and transverse ligaments provide further stabilization by
allowing spinal column rotation; this prevents posterior displacement of
the dens in relation to the atlas.

5. The sub axial spine is from C3-C7 . The subaxial spine is distinct from axial
spine so it is taken as separate entity.

6. Osseous Anatomy
• Uncovertebral Joint(JOINT OF
LUSCHKA)
– Lateral projections of body
– Medial to vertebral artery
• Facet joints
– Sagittal orientation at 30-45
degrees
• Spinous processes
– Bifid C3-5,
prominent C7

7. The Facet Joints
• Also called ZYGAPOPHYSEAL JOINTS.
• The facet joints are formed by the articular processes of adjacent
vertebrae.
• The inferior articular process of a vertebra articulates with the
superior articular process of the vertebra below.
• These are synovial gliding joints
• Facet joints are oriented in different planes depending on their
anatomic location. Sagittal orientation at 30-45 degrees

8. Lateral Mass Anatomy
• Medial border - Lateral edge of
the lamina
• Lateral border - watch for
bleeders
• Superior/Inferior borders -
facets
• C7 frequently has abnormal
anatomy
• Vertebral artery is just anterior
to the medial border of the
lateral mass, enters at C6
• Nerve runs dorsal to the artery
and anterior to the inferior half
of the lateral mass
• 4 quadrants of the lateral mass
with the supero-lateral quadrant
being “safe”

9. Ligamentous Anatomy
• Anterior – ALL, PLL,
intervertebral disc
• Posterior– Nuchal Ligaments
ligamentum nuchae,
supraspinous ligament,
interspinous ligament
• Ligamentum flavum and the
facet joint capsules

10. Vascular Anatomy
Vertebral Artery
– Originates from subclavian
– Enters spine at C6 foramen
– At C2 it turns posterior and
lateral
– Forms Basilar Artery
Foramen Transversarium
– Gradually moves anteriorly
and medially from C6 to C2

11. NEUROANATOMY
• Spinal cord diameter subaxial: 17-22mm
• Occupies ~ 50% of canal
• Neural Foramen
– Pedicles above and below
– Facets posteriorly
– Disc, body and uncinate process anteriorly

12. Denis -3 column model
• View the cervical spine as 3 distinct columns: anterior, middle, and
posterior.
• The anterior column is of the anterior longitudinal ligament and the
anterior two thirds of the VB, the annulus fibrosus and the
intervertebral discs.
• The middle column is composed of the posterior longitudinal
ligament and the posterior one third of the VB, the annulus and
intervertebral discs.
• • The posterior column contains all of the bony elements formed by
the pedicles, transverse processes, articulating facets, laminae, and
spinous processes.

14. Classifications
• Although numerous classification systems have been developed over time, there is
currently no universally accepted subaxial injury classification system.
• Allen and Ferguson Spine 1982
• Harris et al OCNA 1986
• Anderson Skeletal Trauma 1998
• Stauffer and MacMillan Fractures
1996
• AO/OTA Classification
• SLIC
• Most are based on mechanism of
injury
• SLIC is not mechanism based

15. Mechanism of Injury
• Hyperflexion
• Axial Compression
• Hyperextension

16. HYPER FLEXION INJURIES
• Distraction creates tensile forces
in posterior column
• Can result in compression of
body (anterior column)
• Most commonly results from
MVC and falls

17. AXIAL COMPRESSION
Result from axial loading
Commonly from diving, football,
MVA
– Injury pattern
depends on initial head position
– May create burst,
wedge or compression fx’s

18. HYPEREXTENSION INJURIES
• Impaction of posterior arches and
facet compression causing many
types of fx’s
lamina
spinous processes
pedicles
• With distraction get disruption
of ALL
• Evaluate carefully for stability
• LOOK FOR CENTRAL CORD
SYNDROME

19. AO SYSTEM
• Based on two column concept
• And the concept that the stable spine acts to resist three
core forces:
axial compression
axial distraction
torsional forces
• Not specific for cervical spine
• Provides some treatment guidelines

20. • Type A – Axial loading;
compression; stable
• Type B – Bending type injuries
• Type C – Circumferential injuries;
multi-axial

21. Type A compression injuries
• result in failure of the anterior structures (vertebral body)
and/or the posterior structures (spinous processes, lamina),
with varying degrees of severity

22. AO
Relatively minor injuries result in
isolated lamina or spinous process
fractures

23. A1
Compression fractures involving a
single end plate without
involvement of the posterior
wall of the vertebral body

24. A2
Coronal split or pincer fractures
involving both end plates without
involvement of the posterior wall of the
vertebral body

25. A3 Subtype A4
Burst fracture or sagittal split injury
involving both end plates

26. Type B
• Tension Band Injuries /Bending type injuries
• Tension band injures involve either the anterior or posterior
tension band of the cervical spine

27. Subtype B2
• Complete disruption or
separation of the posterior
capsule-ligamentous or bony
structures

28. B3 anterior tension band injury
• Anterior tension band injuries involve physical disruption of either the vertebral body or disk, with
an intact posterior hinge that prevent complete displacement

29. Type C Translational Injuries
• Translational injuries result from displacement of one vertebral body
relative to another
• This can occur in any direction (anterior, posterior, lateral, vertical),
and frequently can have an associated vertebral body or posterior
element fracture as well
• highly unstable injuries

31. Allen and Ferguson

32. Allen and Ferguson

33. C-Spine Trauma :
Injury Mechanism Classification
• Flexion
Anterior subluxation
Bilateral interfacetal dislocation
Wedge fracture vertebral body
Flexion teardrop fracture
Clay Shoveler's fracture
• Extension
Extension teardrop fracture
Hangman's fracture
Posterior atlantal arch fracture

34. C-Spine Trauma :
Injury Mechanism Classification (cont.)
• Rotation
Unilateral facet dislocation
Unilateral pillar fracture
• Vertical compression
Burst fracture of vertebral body

35. C-Spine Injuries :Degree of Stability
A. Stable
1. Anterior subluxation
2. Unilateral facet dislocation
3. Simple wedge fracture
4. Burst fracture of lower cervical vertebrae
5. Pillar fracture
6. Clay-Shoveler's fracture
B. Unstable
1. Bilateral facet dislocation
2. teardrop fracture (unstable in flexion,stable in extension)
3. Hyperextension fracture - dislocation

36. Compression Fractures
• Collapse of vertebra as a result
of axial loading forces upon a
flexed spine
• # appear as wedge deformity of
VB
• Stability determines treatment

37. BURST COMPRESSION FRACTURES
• Axial loading forces overcome the middle column disrupting the
discoligamentous complex resulting in deformity and instability of the
cervical spine.
• high-energy compression fractures
• involve the middle column and disrupt the posterior vertebral body
wall, the posterior ligamentous complex is often intact.
• In neurologically intact patients without significant vertebral body
height loss (< 40%) or kyphosis (< 20 degrees), the injury may be
amenable to treatment with external immobilization in a semirigid or
rigid (Halo or Minerva) cervical orthosis.

38. • Burst fractures resulting in incomplete spinal cord injury necessitate early
closed and open reduction and decompression.
• common surgical technique to decompress the spinal canal is through an
anterior approach in order to directly access and remove the intruding
fragments.
• Achieved with a corpectomy and subsequent reconstruction and
stabilization using ventral instrumentation.
• Patients presenting with complete spinal cord injury, Early decompression
does not pertain to improved neurologic outcomes in comparison to
delayed decompression, but surgical intervention may result in
improvement of one to two root levels below the level of injury compared
to conservative management.

40. Clay Shoveler’s Fracture
• Spinous process fractures are
most commonly seen at C6 and
C7 and is classically known as
the “clay shoveler fracture”
• Hyperflexion associated avulsion
of the spinous process-MOI
• Stable fracture

41. Flexion Teardrop Fracture
• High energy flexion,compressive
force
• Flexion injury causing # of the
anteroinferior portion of the VB
• most commonly seen at the C5-6
• the anterior, middle, and
posterior columns are frequently
involved with concomitant
disruption of the PLC
• Unstable

42. • Treatment is generally surgical as disruption of the posterior
ligamentous complex correlates with anatomic instability.
• Surgical treatment of teardrop fractures may be performed through
an anterior approach with a corpectomy and ventral instrumentation.
• Injury to the PLC increases the risk of delayed spinal instability and
circumferential fusion is indicated in more severe forms of teardrop #.
• In circumferential fusion, the ventral approach is performed first for
direct decompression of the spinal canal and placement of a graft
subsequently followed by posterior stabilization with a long segment
instrumentation and fusion

43. EXTENSION TEARDROP FRACTURE
• is a less severe form of injury arising secondary to forced extension of
the neck
• resulting in avulsion of the anterior inferior edge of the VB at the
attachment of the anterior longitudinal ligament.
• present more commonly with acute central cord syndrome

44. FACET FRACTURES
• Unilateral Facet Dislocation
• Arise secondary to rotational injuries in combination with either
flexion or extension.
• Small and minimally displaced # are often considered stable and
most are adequately treated with an external cervical orthosis for 6 to
12 week .
• closely follow patients suffering facet fractures with frequent upright
radiographs (often at 2 to 4 week intervals).

45. • Spector and colleagues studied 24 unilateral facet fractures and found
that fractures involving greater than 40% of the facet or an absolute
height of 1 cm were associated with increased risk of nonoperative
treatment failure requiring surgical stabilization
• Facet fractures with significant displacement or evidence of
neurologic or anatomic instability are indications for surgical
intervention.
• Anterior procedures usually consist of a single level interbody fusion
with arthrodesis, whereas posterior constructs can be achieved with
bilateral lateral mass screws stabilized by rods.

46. Bilateral Facet Dislocation
• Flexion injury
• Subluxation of dislocated
vertebra of greater than ½ the
AP diameter of the VB below it
• High incidence of spinal cord
injury
• Extremely unstable

47. • Facet dislocations and flexion distraction injuries represent stages along a
continuum.
• In lower energy injuries, a unilateral facet subluxation may be observed
secondary to disruption of the facet capsule.
• This can occur with or without associated catastrophic posterior
ligamentous complex disruption and presents with less than 25% of VB
subluxation.
• Higher energy injuries produce bilateral facet subluxation, which is
invariably associated with severe posterior ligamentous disruption and may
result in perched or jumped facets.
• In contrast to unilateral facet dislocations, bilateral facet dislocations
present with 50% or greater VB subluxation

48. STABILITY
• Evaluation of stability should include
anatomic components (bony and ligamentous)
static radiographic evaluation of displacement
dynamic evaluation of displacement
(controversial)
neurologic status (unstable if neurologic injury)
future anticipated loads.

49. • “Clinical instability is defined as the loss of the spine’s ability under
physiologic loads to maintain its patterns of displacement, so as to
avoid initial or additional neurologic deficits, incapacitating deformity
and intractable pain.”
White and Panjabi 1987

50. White and Punjabi Criteria
• Guidelines for daignosing clinical instability of mid and lower C-spine

52. • If there is inadequate information for any item, add half of the value
for that item to the total.
• In cervical spine , posterior elements are anantomic components that
are posterior to PLL .
• Stretch test: apply incremental cervical traction loads of 10 pounds
for 5 minutes upto 33% of body weight(65pounds max). Check x.ray
and neuro examination after each.
• Positive if in seperation > 1.7mm or angle >7.5 degrees on x.ray or
change in neurological examn.

53. • Pavlov ratio: ratio of the spinal canal diameter to width of verteberal
body. If <0.8 it is indicative of spinal canal stenosis.
• Unstable if total points ≥5

54. SLICS (Subaxial Injury Classification and Severity Scale) was developed in 2007
by the Spine Trauma Study Group

55. Interpretation
SLIC score management
1-3 Non surgical
4 Not specified
≥5 surgical

56. Definite Signs of Unstable C-spine Injury
• All anterior or posterior elements fractured
> 3.5 mm horizontal vertebral body displacement
> 11 degrees of kyphotic angulation

57. Clinical assessment
• Advance Trauma Life Support (ATLS) guidelines
• Primary and secondary surveys
• Adequate airway and ventilation are the most important factors
• Supplemental oxygenation
• Early intubation is critical to limit secondary injury from hypoxia

58. • PROTECTION PRIORITY
• Detection Secondary
• Log rolling

59. Physical examination
• Information
• Mechanism- high /low energy
• Direction of Impact
• Associated Injuries
• Inspection and palpation
– Occiput to Coccyx
– Soft tissue swelling and bruising
– Point of spinal tenderness
– Gap or Step-off
– Spasm of associated muscles
Neurological assessment
– Motor sensation and reflexes
– PR

60. Neurologic assessment
• American Spinal Injury Association grade – Grade A – E

61. Neurologic assessment
• FRANKEL GRADING

62. • Plain films
AP, lateral and open mouth view
Optional: Oblique and Swimmer’s
• CT
Better for occult fractures
• MRI
Very good for spinal cord, soft tissue and ligamentous injuries
• Flexion-Extension Plain Films
to determine stability

63. Radiographic imaging
• Who needs an x- ray of the spine ?
• NEXUS Criteria:
1. Absence of tenderness in the posterior midline
2. Absence of a neurological deficit
3. Normal level of alertness (GCS score = 15)
4. No evidence of intoxication (drugs or alcohol)
5. No distracting injury/pain
• Patient who fulfilled all 5 of the criteria were considered low risk for C-
spine injury
No need C-spine X-ray
• For patients who had any of the 5 criteria radiographic imaging was
indicated

64. • Canadian C spine Rule (CCR) were developed and validated to
exclude significant injury rapidly on clinical grounds or suggest further
radiographic studies in low-risk trauma patients
• CCR more sensitive than NEXUS

66. Primary Management
• A - Airway control with C-spine immobilisation
• B- Avoid hypoxaemia-
• will further worsen the prognosis of an injured spinal cord
Injury above C5 will cause respiratory insufficiency
50% of C3 quadriplegics need permanent ventilation
• C- Need to minimise secondary ischemic injury to the cord -
Aim MAP > 100mmHg
SCI above C6 associated with loss of cardiac sympathetic supply leading to
hypotension & bradycardia
Loss of sympathetic vasoconstriction leads to vasodilation & venodilation
relative hypovolaemia needing plasma volume expansion& vasoconstrictors

67. Management of SCI
• Look for other injuries: “Life over Limb”
• Transport to appropriate SCI center once stabilized
• Consider high dose methylprednisolone
– Controversial as recent evidence questions benefit
– Must be started < 8 hours of injury
– Do not use for penetrating trauma
– 30 mg/kg bolus over 15 minute
– After bolus: infusion 5.4mg/kg IV for 23 hours

68. • Spinal motion restriction: immobilization devices (cervical collars,
spine boards)
• ABCs
– Increase FiO2
– Assist ventilations as needed with c-spine control
– Indications for intubation :
Acute respiratory failure
GCS <9
Increased RR with hypoxia
PCO2 > 50
-IV Access & fluids titrated to BP ~ 90-100 mmHg

69. Non-operative Care
• Rigid collars
– Conventional collars offer little
stability to subaxial spine and
transition zones
– May provide additional stability
with attachments
– Good for post-op immobilization
• Halo
– Many complications
– Better for upper cervical spine
injuries

71. Treatment Guidelines
• Anterior Approach
– Burst fx w/SCI
– Disc involvement
– Significant compression of anterior column
• Posterior Approach
– Ligamentous injuries
– Lateral mass Fx
– Dislocations

72. Anterior Surgery
Advantages
Anterior decompression
Trend towards improved neuro
outcome
Atraumatic approach
Supine position
Disadvantages
Limited as to number of motion
segments included
Potential for increased
morbidity

73. Posterior surgery
• Advantages
– Rigid fixation
– Foraminal decompression
– Deformity correction
– May extend to occiput and CT
transition zones
– Implant choices
• Disadvantages
– Minimal anterior cord
decompression
– Prone positioning
– Trend towards increased blood
loss

74. Anterior Approach
• Does not depend on integrity of posterior elements to achieve
stability.
1. Fractured VB with bone retropulsed into spinal canal (Burst fracture)
2. Most extension injuries
3. Severe fractures of posterior elements that precludes posterior stabilization
and fusion
4. May be used for traumatic subluxation of the cervical spine.

75. Usually consist of
1. Corpectomy (suggested to be done no wider than 3mm lateral to the
medial edge of longus coli muscles, this leaves 5mm margin of safety to
the foramen transversarium).
2. Bone graft or cage with plate fixation.
3. Followed by external immobilization.
4. Corpectomy of >2 levels or posterior elements injury is an indication
for augmentation with posterior instrumentation.

76. Posterior Approach
• Indication:
• 1. Procedure of choice for most flexion injuries.
• 2. When there is minimal injury to VB and in abscence of anterior
compression of spinal cord and nerves.
• 3. Posterior ligamentous instability, traumatic subluxation, unilateral
or bilateral locked facet, simple wedge compression fracture.

77. • Common techniques:
1. Open or closed reduction followed by lateral mass screws and rods
2. Interlaminar Halifax clamps are an alternative.
3. If anterior weight bearing column is significantly damaged or if there
is absence or compromise of lamina or spinous proceses, then either a
combined anterior-posterior approach is needed or posterior rigid
instrumentation(e.g lateral mass screw-plate or rod fixation) with
fusion is recomended.

78. Unilateral Facet DislocationTreatment
Cervicothoracic brace or halo x 12 weeks
Need anatomic reduction
closely follow patients suffering facet fractures with frequent upright
radiographs (often at 2 to 4 week intervals).
Spector and colleagues studied 24 unilateral facet fractures and found that
fractures involving greater than 40% of the facet or an absolute height of 1
cm were associated with increased risk of nonoperative treatment failure
requiring surgical stabilization
Facet fractures with significant displacement or evidence of neurologic or
anatomic instability are indications for surgical intervention.
Anterior procedures usually consist of a single level interbody fusion with
arthrodesis, whereas posterior constructs can be achieved with bilateral
lateral mass screws stabilized by rods

79. Bilateral Facet Dislocation
• Traction & reduction
• Timing for reduction
Spinal cord injury may be reversible at 1-3 hours
• Traction is contraindicated in occipital cervical dissociation or severely
angulated traumatic spondylolisthesis of the axis.
• Need for MRI
– If significant cord deficits, reduce prior to MRI
– If during awake reduction, paresthesias or declining status
– Difficult closed reduction
– If neurologically stable, perform MRI prior to operative treatment (loss of reduction?)

80. • For patients too sick to undergo surgical stabilization or for those
without neurologic compromise, nonoperative treatment of mild
unilateral facet subluxations or dislocations may be attempted.
• External immobilization is often considered inadequate for jumped or
dislocated facets, therefore surgical stabilization is the basis of
management especially for bilateral injury.
• In the presence of a herniated disc in association with facet
dislocations, surgical reduction and decompression may be
performed through an anterior approach.
• After discectomy, a lamina spreader or Caspar pins may be used to
distract the injured segments and unlock the dislocation.

81. Reccomendations
• Irreducible injuries should be attempted with a posterior approach
where resection of the superior articulating facet may be required for
reduction
• Augmentation of posterior stabilization even with successful
decompression and stabilization through a ventral technique is
recommended .
• posterior reduction and stabilization over anterior approaches alone
in the absence of a traumatic herniated disc .

82. • Despite the biomechanical advantage of posterior techniques, in
severe cases the development of segmental kyphosis is common;
therefore, circumferential fusion must be carefully considered
especially in bilateral facet injuries
• A lateral intraoperative radiograph should always be obtained to
confirm reduction.
• Care must also be taken to avoid over distraction that can exacerbate
neurologic injury.

83. SLIC ALGORITHM

84. SLIC ALGORITHM

85. SLIC ALGORITHM FOR HYPER EXTENSION
INJURIES

86. Lateral Mass Fractures
• lateral mass fractures are Considered stable fractures
• however, they too are frequently associated with more severe
injuries.
• Secondary to a hyperextension or rotational injury
• Treated with close follow-up in an external cervical orthosis

87. FLOATING LATERAL MASS
• Comminuted lateral mass #, especially if the articular facet is involved
or in cases with coexistent fractures through the ipsilateral lamina
and pedicle(“floating lateral mass”)
• This isolated fragment no longer allows the zygapophyseal
articulations to contribute to overall cervical stability—unstable #.
• Significant evidence of motion or kyphosis is an indication for surgical
stabilization.
• Surgical stabilization is generally performed via an anterior approach,

88. SUB AXIAL SPINE FIXATION
TECHNIQUES

89. Subaxial Cervical Fixation Techniques
• Ventral stablization
• Posterior stabilization
• Combined (360) stabilization

90. Anterior Fixation Techniques
• First introduced (1955) by Smith & Robinson
• Then popularized by Cloward
1. Anterior distraction (resisting compression),
2. Anterior compression (tension band),
3. Anterior cantilever beam fixation.

91. Anterior Distraction implants
• 1. Interbody struts:
– Bone,
– Cages,
– Acrylic, or
– Metal implants
• 2. Screw-plate construct:
– Fixed-moment arm,
– Non-fixed-moment arm,
– Applied-moment arm, or
– dynamic mode.

92. Inter body implants(STRUTS)
• Bone Graft
– Autograft (illiac crest )
– Allograft
• Cages (Graft substitutes)
– Carbon fiber reinforced polymers
– Polyetheretherketone (PEEK)
– Acrylic
– Titanium

93. Cage
• 1. Threaded (Screw cages)
• 2. Non-threaded
– Box-shaped
– Vertical ring designs

94. Anterior Compression (Tension Band) Fixation
• +/- interbody struts
• Allows the application of
compression using a screw-rod
construct,
• Thereby enabling preloading of
bone graft, increasing bone
healing.

95. Anterior screw-plate construct
• Plates Types:
• 1. Nonconstrained Plates:First-generation
• 2. Constrained (rigid) Plates -Second-generation (static)
• 2. Semiconstrained (semirigid)- Third-generation (dynamic)

96. First-Generation Plates
• First anterior cervical plates
were unlocked and required
bicortical purchase.
• Bohler (1967) first use
• •Orozco and Houet (1970s) :
– One-third tubular plate
– ‘H’ and ‘HH’ plates

97. Second-Generation Plates
(Constrained-rigid plates)
• Screw convergence
• Ventral distraction fixation in
neutral position.
• Usually with interbody graft
• In extension, resist distraction
(tension-band)

98. Third-Generation Plates
(Dynamic semi-constrained)
• Prevent stress shielding
• Allow subsidence
• Mechanisms of dynamism :
1. screw toggling
2. Allowance of axial settling

99. Advantages of Anterior Cervical Plates
• Enhancing solid fusion
• Resisting kyphosis
• Reduce external bracing
• Mobilization of adjacent segments
• Reduce risk of graft extrusion
• Reduce rate of nonunion.

100. Disadvantages of
Anterior Cervical Plates
• Increased cost
• Special instruments and training
• Plate-specific complications:
– screw loosening or fracture,
– infection,
– neural injury

101. Posterior Cervical Fixation Techniques
• 1. Wiring: (Historical)
– Sublaminar
– Facet
– Interspinous
• 2. Laminar screw fixation,
• 3. Lateral Mass:
– Plate
– Rod
• 4. Pedicle Screws

102. WIRING
• Intact posterior elements-pre
requisite
• Restore posterior tension band
• After soft tissue injury
• Augment other anterior or
posterior fixation techniques

103. Rogers’ interspinous wiring
• Burr hole at the base of the
upper and lower spinous
processes.
• Stainless steel or titanium wire
or cable through the burr holes
in a figure eight pattern.
• Wire is tightened using a
Tensioner.

104. Triple-wiring
• As the Rogers’ technique.
• 2nd wire through upper burr hole
and looped around upper spinous
process.
• 3rd wire through lower burr hole
and looped around the lower
spinous process.
• These two wires are passed
through two autologous bone graft
struts, lateral to spinous processes.
• Wires are tightened under tension

105. Posterior cervical screw fixation
• 1. Laminar screw,
• 2. Lateral Mass Screw:
– Plate
– Rod
• 3. Pedicle Screws

106. LAMINAR SCREWS
(Translaminar screw fixation)
• Uncommon in subaxial spine
• C7 has larger laminar size– high
unilateral screw placement success
rate:
• 100% for 3.5 mm screw,
• 92% for 4.0 mm screw
• – moderate bilateral screw
placement success rate
• 90% for 3.5 mm,
• 68.8% for 4.0 mm.
• At C3-C6, success rates much
lower.

107. • Utilized in only selected cases
• Deficient lateral masses
• Failure to place a lateral mass screw
• Requires intact posterior elements, specifically intact laminae

108. Complications of laminar screw
• laminar cortical breach:
– medial cortex (thecal and
cord injury)
• Violation of the facet joint
• Screw loosening
• hardware failure

109. Lateral mass screw fixation
• widely considered the mainstay technique for posterior fixation of the
subaxial spine
• With high fusion rates, (85-100%)
• ADVANTAGES
• Restore posterior column tension band
• Rotational & axial stability
• Greater stability in lateral bending
• Applicable C3 to C7 levels
• No need for intact lamina

110. METHOD OF AN
• ENTRY:-1 MM medial to the
midpoint of the lateral mass.
• in the cranio-caudal direction ,
mid point is used
• Trajectory:-15 degree cephalad&
30 degree laterally
• Screws 3.5mm diameter , 14-16
mm length
• Rod size 3.5mm rods

111. LATERAL MASS SCREW- TECHNIQUES

112. 360 Stabilization
• Provides very strong construct in severe cervical instability
• An anterior standalone bone graft will not be sufficient for fixation….
WHY?
– Graft extrusion,
– Kyphotic deformity
– Significant risk of neural injury.
• To avoid dislocation and graft extrusion :
• 1. Anterior plating
• 2. Supplemental posterior fixation,
• 3. Rigid external orthosis (halo vest)

113. • As a rule Any stand-alone posterior fixation technique, is insufficient
to restore stability in cases involving the anterior and/or middle
columns.

114. COMPLICATIONS
• EXPOSURE INJURIES
• Perforation of aero digestive tract
• Vocal cord paresis
• Vertebral artery injury
• Carotid injury
• CSF fistula
• Horner’s syndrome
• Thoracic duct injury

115. • Spinal cord injury or nerve root injury
• Bone fusion problems
• Failure of fusion
• Kyphotic deformity
• Graft extrusion
• Donor site complications(hematoma, seroma, infection)
• Miscellaneous:
• Wound infection
• Post of hematoma
• Dysphagia and hoarseness

116. REFERENCES
• BENZEL’S SPINE SURGERY – FOURTH EDITION
• SCHMIDEK & SWEET OPERATIVE NEUROSURGICAL TECHNIQUES
• GREENBERG –HANDBOOK OF NEUROSURGERY

117. • Thank u