Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Cervical spine injuries


Published on

Published in: Education, Health & Medicine
  • Login to see the comments

Cervical spine injuries

  1. 1. CERVICAL SPINE INJURIES By Dr.Tejaswi Dussa Pg In Ms Ortho
  2. 2. C-SPINE VERTEBRAL FRACTURES • • • • 1.Occipital Condyle Fractures 2.Atlanto Occipital Dislocation 3.Atlas Fractures 4.Axis Fractures -Odontoid Fracures - # Of Lateral Mass - pars fracture • 5.Atlanto Axial Combined #s • 6.Subaxial # And Dislocations
  3. 3. OCCIPITAL CONDYLE CLASSIFICATION • • • • # Rare And Frequently Missed May Be Presented As Lower Cranial Nerves Palsy Delayed Hypoglosal Nerve Palsy Alone Usually Results From ‘Axial Loading’ And ‘Lateral Bending’ ANDERSON MANTESANO’S CLASSIFICATION: • Type I - impaction # • typeII - basilar skull # • typeIII - occipital condyle avulsion #
  4. 4. TYPE I : • impaction # • comminution of occ.condyle with minimal or no displacement • stable
  5. 5. TYPE II • -basilar skull # • -linear skull # extending through the condyle into the F.magnum • stable
  6. 6. Type III : -avulsion # of occ.condyle by alar ligament -unstable
  7. 7. TREATMENT: • Type I and type II # are stable # can treated - rigid cervical orthrosis -halo vest • Type III # is unstable immobilization for 12wks in halo vest, instability on flx & ext. films --> OCCIPITAL-C2 FUSION
  8. 8. ATLANTO OCCIPITAL DISLOCATION • Usually fatal, many patients die immediately As a result of complete resp.arrest caused by brain stem compression TRAYNALIS & CO WORKERS CLASSIFICATION: Type I : anterior displacement of occiput Type II : longitudinal distraction Type III: posterior displacement
  9. 9. Type I:anterior Displacement Of Occiput
  10. 10. Type II :- Longitudinal Displacement -Cervical Traction Is obsolutely Contraindicated
  11. 11. TREATMENT • consist of reduction and stabilization of atlantooccipital joint • Cervical Traction Is Contraindicated Because Of Severe Instability • It require applying of pressure against the skull to reduce the tendency for the to be distracted from the spine by the weight of the head • “Immediate application of halo vest is recommonded” • Instability is evedenced by bradycardia or episodes of brady cardis followed by asystole • Early surgical stabilization of atlantooccipital is adviced because ligamentous heaing ina halovest is unpredictable
  12. 12. • Posterior Cervical Arthrodesis - using large cartical cancellous grafts with stabilization by dual plates screwed to posterior occiput and attached to lateral mass screws
  13. 13. Wertheim And Bohlman Occipitocervical Fusion • Wires passed through theouter table of occiput ,undeer the arch of atlas and spinous process of the axis • Unicortical cancellous graft placed on wires tightened to secure graft in place
  14. 14. ATLAS FRACTURES Axial loading Associated with other spinal # (53%) -type 1 traumatic spondylilisthesis of axis posteriorly displaced type II & type II dens # • LANDELL’S AND VON PETEGHAM CLASSIFICATION: Type I : posterior arch# (usually stable) Type II : jefferson # (anterior and posterior arch #) Type III: lateral atlantal mass #
  15. 15. Type I-posterior Arch # • Stable injury • Usually occur at the junction of the posterior arch and the lateral mass • Unrecognised Posterior arch # may associated with C2 # may cause clinical instability after surgery  in this case external immobilization of c-spine until healing of C1 ring # should be done before proceeding with C2# stabilization (because occiput C2 stabilization results severe restriction of cspine motion)
  16. 16. Type II (Jefferson #) • Burst fracture • Characterized by four fracture –two in the anterior arch ,two in the posterior arch • Stable # :transverse ligament is intact • Unstable # :transverse liament is ruptured • Stable • Unstable
  17. 17. Type III (Lateral Mass Fracture) • usually occur on one side only with the # line passing either through the articular surface or just anterior and posterior to the lateral mass on one side •
  18. 18. treatment • Most atlas fracture can be treated with immobilization in a rigid cervical arthrosis or a halo vest. • Isolated posterior arch fractures are stable injuries can be treated by immobilization in cervical collor for 8-12wks • Non displaced , minimally displaced # can be treated by collor immobilization • # in which Lateral mass Displaced >7mm beyond the articular surface of the axis halo traction 3-6 wks halovest • If the lateral mass over hangs the articular surface of the axis >7mm, a transverse ligament is likely ruptured causes C1-2 instability transarticular C1-2 fixation.
  19. 19. RUPTURE OF TRANSVERSE LIGAMENT • Results from a fall with blow from the back of the head • For ligamentous injury nonoperative treatment is ineffective
  20. 20. CLASSIFICATION OF TRANSVERSE LIGAMENT (DICKMAN GREENE AND SONNTAG) • typeI :disruption of substance of ligament • Type II :avulsion from the lateral mass of C1
  21. 21. • Anterior subluxation of the ring of C1 can be detected on flexion films,instability is reduced in extesionon lateral film check for retropharyngeal hematoma. Primary indication for surgery is instability atC1-2 on flexion,extension views • An anterior widening of the atlanto-dens inderval of more than 5mm on flexion suggests that the transverse ligament is incompetent
  22. 22. TREATMENT • Initial treatment consists of immobilization through skull traction • Type I injuries incapable of healing wirthout internal fixation • typeII injuries intially treated with rigid cervical arthrosis for 3-4months • Who had nonunion and persistant instability-> posterior stabilization of C1-2 complex with - gallie type of posterior C1-2 arthrodesis -brooks and jennings fusion by bone block technique
  23. 23. Gallie Fusion • Wire loop under the arch of atlas pass the free end of wire through the loop grasping the arch of C1 • Place the corticocancellous graft against the lamina of C2 and arch od C1 beneath the wires
  24. 24. Gallie Fusion
  25. 25. Broock And Jennings Type Fusion (Bone Block Technique) • Insertion of wires under the atlas and axis • Full thickness rectangular iliac bone graft between arch of atlas and each lamina of axis • Graft is secured in place by wire tightening over them
  26. 26. Broock And Jennings Type Fusion (Bone Block Technique)
  27. 27. ROTARY SUBLUXATION OF C1 ON C2 • Pt presented with torticolis and restricted neck motion • An open mouth odontoid radiograph may reveal the ‘wink sign’ caused overriding of the C1-2 joint on one siden and normal configuration on other side
  28. 28. FIELDING AND HAWKINS CLASSIFICATION: Type 1 - simple rotary subluxation without anterior shift - odontoid acts as pivot Type 2 - rotary displacement with anterior displacement of 3-5mm - lateral articular process act as pivot type 3 - rotary displacement with anterior displacement of >5mm Type 4 - rotary displacement with posterior displacement
  29. 29. TYPE I • simple rotary subluxation without anterior shift • odontoid acts as pivot
  30. 30. TYPE II • rotary displacement with anterior displacement of 3-5mm • lateral articular process act as pivot
  31. 31. TYPE III • rotary displacement with anterior displacement of >5mm
  32. 32. TYPE IV • rotary displacement with posterior displacement
  33. 33. TREATMENT • Acute rotary subluxation if C1-2 can be reduced by closed reduction  immobilization in halo vest for 8-12 wks • If Closed reduction is not obtained open reduction by posterior approach Stabilization of C1-2 complex by posterior cervical arthrodesis using autogenous iliac bone grafting & oblique wiring. • Halovast is recommonded for 8-12 wks
  34. 34. C1-2 TRANSARTICULAR SCREW FIXATION (MAGERL AND SEEMANN TECHNIQUE • Provides Exelent rotational stability • Halovest is unnecessary • Cervical collor may be worn for 8-12wks
  35. 35. AXIS FRACTURE 1.Odontoid Fractures 2.Lateral mass fracture fracture
  36. 36. 1. ODONTOID FRACTURES ANDERSON D’ALANZO CLASSIFICATION: Type I : avulsion of distal odontoid process Type II : # through the base of the odontoid process Type III: # extending into body of C2
  37. 37. TYPE I FRACTURES: • Uncommon • Usually seen above the transvers ligament • No instability even after nonunion occurs
  38. 38. TYPE II FRACTURES: • Most common • Nonunion rate 36% • Significant displacement >5mm seem to have more Nonunion • Posteriorly displaced dens #s are more likely to have Fracture Of The Ring Of C1
  39. 39. ANTERIOR SCREW FIXATION OF DENS # CONTRAINDICATIONS: • Oblique # configuration • Associated unstable atlas # • Pathological #s • Nonunion of dens #
  40. 40. TYPE III FRACTURES: • Have large cancellous base • Heals without surgery (90%)
  41. 41. Treatment: • Goal of treatment in displaced dens # is to correct the angulation in a halo vest • Non displaced # are stable that heals with 812 wks of immobilisation in halovest or cervical collor
  42. 42. C1-2 Transarticular Screw Fixation (Magerl And Seemann Technique)
  43. 43. 2.Lateral Mass Fracture • Axial compression and lateral bending • Presented with neck pain ,limited motion no nuerological injury • A depression fracture of the C2articular surface is common • TREATMENT • ranges from collor immobilisation to late fusion for chronic pain
  44. 44. 3.PARS FRACTURE • Traumatic spondylolesthesis of the axis (hangman fracture) • M.c.c is motor vehicle accident with hyperextension of the head on the neck • Occipout forced down against the posterior arch of the atlas which is forced against the pedicle of C2
  45. 45. LEVINE & EDWARD CLASSIFICATION: • Type I : pars # <2mm dislocation • Type II : pars # disrupted PLL c2-3 disc disruption Possible ALL disruption or avulsion from C3 • Type IIA : same as type II but Less displacement and more angulation • Type III : initial disruption of C2,C3 facet capsules then pars # after dislocation
  46. 46. TYPE I • Caused by hyperextension and axial loading With failure of nueral arch in tension • Because of ligamentous injury is minimal these fractures are stable • TREATMENT • immobilization in rigid cervical arthosis for 12wks and usually heal
  47. 47. TYPE II • >3mm of anterior translation and significant angulation • Results from hyperextension and axial loading that cause the nueral arch to fail with vertical fracture line • Followed by significant flexion results stretching og posterior annulus of the disc and the significant anterior translation and angiulation • C2-3 disc nmay disrupted by acute flexion component • TREATMENT • Skull traction through tong / • Halo ring in slight extension of the neck over a rolled-up towel for 3-6 wks Immobilization in a halovest for 3-6 months usually unites
  48. 48. Type IIA • Flexion distraction injury • Variant of type II fracture • Shows severe angulation betweenC2-3 with minimal translation • Usually more horizontal # line than vetrical through C2 arch • It is imp. To identify this # that traction can cause marked widening of C2-3 disc space and displacement TREATMENT: • Halo vest immobilization with slight compression under image intensification to achieve and maintain the reduction if reduction btained contiue halovest for 12 wks
  49. 49. Type III • It is cimbined bipedicular fracture with posterior facet injuries • Severe angulation and translation of nueral arch • Associated U/L or B/L facet dislocation at C2-3 • Frequently associated with nuerological deficit TREATMENT: • Type 3 is the only hangmann # commonly require surgical stabilization • Open reduction and internal fixation and b/l obliue wiring • Posterior cervical fusion and halo vest immobilization for 3months
  50. 50. ATLATO AXIAL COMBINED FRACTURES • Neurological injury is common DICKMAN AND COLLEAGUE CLASSIFICATION ATLAS # posterior arch # Jefferson # Lateral mass # + AXIS # type 2,type 3 odontoid # hang man # other C2 #
  51. 51. SUB AXIAL #s AND DISLOCATIONS INTRODUCTION • cervical injuries are m.c caused by hyperextension injury in older pts with spondylolytic disease, • In youger pts with congenitically narrowed spinal canal • C2 and C5 two m.c areas of cervical spine injuries • M.c level affected is C5 & C7 • Associated with profound neurological deficit
  52. 52. CLASSIFICATION OF C-SPINE INJURIES ALLEN CLASSIFICATION • It is a mechanistic classification • Classified as 6 m.c pattern of c-spine injuries 1.flexion compression 2.vertical compression 3.flexion distraction 4.compressive extension 5.distractive extension 6.lateral flexion
  53. 53. Flexion Injuries • Simple wedge compression fracture without posterior disruption • Anterior subluxation • Bilateral facet dislocation • Flexion teardrop fracture • Clay shoveler fracture • Anterior atlantoaxial dislocation
  54. 54. Vertical Compression/ Axial Loading • • • • Jefferson fracture Burst fracture Atlas fracture Isolated fracture of the lateral mass of C1 (pillar fracture)
  55. 55. 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
  56. 56. Distractive flexion Injury • u/l facet dislocation • b/l facet dislocation • Postrerior ligamentous complex injury: -manifested by widening of the interspinous process space during flexion -disruption of posterior ligamentous complex may cause u/l or b/l facet dislocation Treatment: -healing is unlikely with external immobilization -posterior cervical fusion with inter spinous process wiring /oblique facet joint wiring
  57. 57. Lateral Flexion Injuries • Unilateral fracture of the occipital condyle • Lateral mass of C1 • Eccentric fracture of the superior articular process of C2 • Combination of the above mentioned injuries
  58. 58. Extension Injuries ▪ Hyperextension sprain dislocation ▪ Hyperextension fracture dislocation ▪ Laminar fracture ▪ Hangman fracture ▪ Extension teardrop fracture ▪ Avulsion horizontal fracture, anterior arch of C1 ▪ Fracture of the posterior arch of C1 (posterior neural arch fracture of C1) ▪ Posterior atlantoaxial dislocation
  59. 59. Flexion Rotation Injuries • Unilateral facet dislocation • Rotary atlantoaxial dislocation
  60. 60. ALLEN’S CO WORKERS CLASSIFICATION: 1. 2. 3. 4. 5. 6. Simple Compression # Burst # Tear Drop # U/L, B/L Locked Facets Hyper Flexion Injury Clay Shoveler’s #
  61. 61. Simple compression # • Anterior-superior margin of the body is fractured. • If loss of height less than 50%, one column injury and so stable. • If height loss greater than 50%, posterior ligaments presumed torn and so 3 column unstable injury. • If 3 bodies fractured, unstable even if less than 50% height loss each.
  62. 62. Burst fractures • Fracture of C3-C7 from axial loadinng • Spinal cord injury is common from posterior displacement of fragments • # is Stable if ligaments intact • 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.
  63. 63. • CT more accurately displays the fracture pattern and the very important degree of narrowing of the spinal canal. • Treatment: • Anterior decompression and fusion with tricortical iliac bone graft halovest for 8-12 wks
  64. 64. Anterior Decompression With Fusion (with tricortical iliac bone graft)
  65. 65. Flexion Teardrop # – Flexion injury causing a fracture of the anteroinferior portion of the vertebral body – Unstable because usually associated with ligamentous injury
  66. 66. Extension Teardrop Fracture • avulsion fracture caused by anterior longitudinal ligament. • vertical narrow fracture of anterior-inferior corner of body. • most common site is c2. • unstable.
  67. 67. U/L Facet Dislocation • Results from flexion-rotation injury • M.c site of dislocation is at C5-6 • Pt may present with nerve root injury or incomplet nuerological deficit • UID is not stable, as the contralateral capsule ligaments are torn. • Cord injury is uncommon, but root injury is common,
  68. 68. Treatment: • Reduction is difficult with skeletal traction • Closed reduction may attemted to unlock (50%) if reduced halovest immonbilization for 3months (stability would be obtained by spontaneous fusion ) • Open reduction internal fixation • Open redution and posterior cervical fusion either with triple wiring or oblique facet wiring, post operative rigid cervical arthrosios for 6-8 wks
  69. 69. Bilateral Facet Dislocation – Flexion rotation injury – also called “locked facets” – Subluxation of dislocated vertebra of greater than ½ the AP diameter of the vertebral body below it – High incidence of spinal cord injury (2/3) - It is a severe 3 column injury that is completely unstable. Treatment: – Some heal with spontaneous interbody fusion (unpredictable) – Closed traction reduction is associated with increased risk of anterior disc herniation -ORIF with interspinous wiring -(bohlman triple wiring oblique wiring-(inf.facet upper level spinous process of lower level) -
  70. 70. Bohlman Triple Wire Technique • Wire is wrapped through and around spinous processes above and below • Another 2 wire are added to secure thick unicortical cancellous graft against posterior elements
  71. 71. Hyperflexion Sprain • Tear of the posterior (stable), posterior/ middle (unstable) and posterior/ middle/ anterior (unstable) ligaments without fracture. • One column stable, 2 or 3 unstable. • Delay in healing with eventual surgical fusion fairly common. • Can be a difficult diagnosis.
  72. 72. Clay Shoveler’s # – – – – Flexion fracture of spinous process C7>C6>T1 Stable # Treatment: rigid cervical arthrosis or halove st umtil union occurs
  73. 73. SCIWORA • Spinal Cord Injury With Out Radiographic Abnormolity • 12% spinal cord injury • DEFINITION “Objective Signs Of Myelopathy As A Result Of Trauma With No Evidence Of Fracture Or Ligamentous Instability On Plain X-ray And Tomography” • Spinal cord is vulnerable to injury with out vertebral colomn disruption • Occur predominantly in children – Because of inherent elasticity,Children have vertebrae that can dislocate and quickly relocate. Cord gets damaged but shows an aligned vertebral column. – Cord can be transected or compressed.
  74. 74. • On MRI parenchymatous hemorrhage and contusions has bad results • finding of fracture, subluxation, or abnormal intersegmental motion at level of neurological injury excludes sciwora as a diagnosis experimentally, • osteo-cartilaginous 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
  75. 75. DEFINITION OF INSTABILITY • The loss of the ability of spine under physiological load to maintain the relationships between vertebrae In such a way that the spinal cord or roots are not damaged or irritated and deformity or paindoes not developed
  76. 76. CAUSE OF INSTABILITY • • • • Traumatic Neoplastic Infectious disease Iatrogenic Acute :- bone or ligamentous disruption Chronic :- progressive deformity
  77. 77. MOTION SEGMENT: • Two adjacent vertebrae and intervening soft tissue • In lower cervical spine it is devided into -Anterior elements -Posterior elements STABLE: • All the anterior elements and one posterior element intact • All posterior elements and one anterior element intact UNSTABLE: • All the anterior or posterior elements are not functional
  78. 78. PANJABI AND WHITE-CHECKLIST FOR DIAGNOSIS OF CLINIAL INSTABILITY OF LOWER C-SPINE • • • • • • • • • ELEMENT POINT VALUE Anterior Elements Destroyed Or 2 Unable To Function Posterior Elements Destroted Or 2 Unable To Function Relative Sagittal Plane Translation >3.5mm 2 Ralative Sagittal Plane Rotation >11 Deg 2 Positive Stretch Test 2 Medullary (Cord) Damage 2 Root Damage 1 Abnormal Disc Narrowing 1 Dangerous Loading Anticipated 1
  79. 79. A Score Of 5 Or More Indicates INSTABILITY Translation >3.5 mm rotation >11deg
  80. 80. THREE COLUMN THEORY OF DENIS • ANTERIOR COLUMN -ALL -Anterior half of the annulus fibrosus -Anterior half of the vertebral body • MIDDLE COLUMN -PLL -Posterior half of the annulus fibrosus -Posterior half of the vertebral body • POSTERIOR COLUMN -inter transverse ligament -Ligamentum flavum -joint capsule -Inter spinous ligament -Supra spinous ligament -Nueral arch
  81. 81. • 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)
  82. 82. 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
  83. 83. • • • • • • 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
  84. 84. GOALS OF TREATMENT OF C-SPINE INJURIES 1. To realign the spine 2. To prevent loss of function of undamaged nuerological tissue 3. To improve nuerological recovery 4. To obtain and maintain spinal stability 5. To obtain early functional recovery
  85. 85. Pharmacological Management • Methylprednisolone sodium succinate (MPSS) – Within 3 hours 30mg/kg bolus + 5.4mg/kg/hr infusion for 24 hours. – During 3~8 hours  30mg/kg bolus + 5.4mg/kg/hr infusion for 48 hours. – suppress inflammatory response and vasogenic edema
  86. 86. Initial Treatment Immobilization • Rigid cervical collor (philadelphia collor) • Poster braces • Cervico thoracic arthrosis • Halo device  In unstable injury this is inadequate,cervical traction required – Skin (glisson’ traction) – Skeletal • halo traction or gardner-wells tongs • Crutchfield tongs
  87. 87. Glisson’s Cervical Traction
  88. 88. CrutchField Traction
  90. 90. Reduction By Cranial Skeletal Traction • After initial stabilization and documentation of nuerological function • Spinal alignment is obtained by skeletal traction through Garden-well Tongs
  91. 91. 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
  92. 92. • Add wieght upto 10lb and increase the traction in 5lb increments with 5min of interval • Repeating the lateral view each addition of weight • Weight can be increased upto 1/3 of body weight or 65lbs is reached • After each adition of weight Check for any change is nuerological status • A general guideline is 10lbs for head and 5lb for each additional level of injury • If test is positive should be discontinued -if any nuerological change is occur -if any abnormal separation of elements Stress test is positive: - if interspace separation are more than 1.7mm of - If the angle between prestreched and after application of max weight is more than 7.5 deg • Stress test is contraindicated in an obviously unstable injury
  93. 93. • If spinal realignment is abtained with traction and is documented radiographically,weight is reduced to 50% to maintain alignment to prevent traction on vessels • If alignment cannot be obtained open reduction and stabilization is usually by posterior approach
  94. 94. Non Operative Management • For stable c-spine injury with no compression of neural elements • Immobilization in a rigid cervical orthrosis for 8-12 wks -Rigid cervical brace -halovest • Evaluated by serial radiograph -weekly for 3 months,Then at 6wks,3 months,6months,1yr • Second complete evaluation should be performed with in 3wks of injury to ruleout/evaluate SUBACUTE INSTABILITY
  95. 95. Surgical Decompression 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
  96. 96. • 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.
  97. 97. • Anterior approach is favoured; • posterior laminectomy has no benefit and worse cord compression. • the only accepted indication for emergent surgical treatment is progressive neurological deterioration--- such as fracture displacement, epidural hematoma, spinal cord edema or infarction.
  98. 98. • Middle and lower cervical spine m.c exposed through anterior approach • Anterior decompression and placement of strut graft is safe and effective without internal fixation • If posterior elements are stable addition of anterior plate fixation to structural bone grafting reduces motion at that level
  99. 99. Posterior Cervical Plating ( lateral Mass Screw Fixation) • Lateral mass plating provides rigid internal fixation and provides fusion when spinous process are incompetent or laminectomy has previously done
  100. 100. Anterior Decompression With Fusion (with tricortical iliac bone graft)
  101. 101. Reflex Anterior Cervical Plating System • offers an integrated locking mechanism with a convergence of 6 deg in the axial plane and variability of 0-10 deg in sagital plane • if corpectomy is done, graft can be secured to plate through imtermediate holes
  102. 102. TAKE HOME MESSAGE • If have high enough index of suspicion to get x-rays, then do not accept inadequate one • know your pediatric anatomical variations • do not forget nonskeletal injuries: -ligamentous instability and -sciwora • If a spinal fracture is identified at any level, the entire spine should be examined with antero-posterior 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