![CASE
A 71-year-old woman presented after an automotive accident with an
incomplete spinal cord injury (American Spine Injury Association
Impairment Scale [AIS] grade B).
(A, B) A distractive injury is identified at C6–7 in the sagittal CT scan
reconstruction (white arrow).
The Subaxial Injury Classification score was 3 points (distractive injury)
+ 2 points (discoligamentous complex injury) + 3 points (incomplete
neurologic deficits) = 8 points — surgical treatment was performed.
Postoperative sagittal(C) and 3-D reconstruction (D) CT scans showing
reestablishment of cervical alignment and facet joint congruence, with
lateral mass screws at C5 and C6 and pedicle screws at C7 and T1. After
6 months of followup, she had some neurologic improvement (AIS grade
C).](data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7)
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- 1. SUBAXIAL CERVICAL FRACTURES: Clinical Evaluation, Diagnosis and Treatment Methods Team: Spine VI/MX Mod: SV Supervisor: dr. Jainal Arifin, M.Kes, Sp.OT(K)Spine Monday, November 9th 2020
- 2. CASE A 71-year-old woman presented after an automotive accident with an incomplete spinal cord injury (American Spine Injury Association Impairment Scale [AIS] grade B). (A, B) A distractive injury is identified at C6–7 in the sagittal CT scan reconstruction (white arrow). The Subaxial Injury Classification score was 3 points (distractive injury) + 2 points (discoligamentous complex injury) + 3 points (incomplete neurologic deficits) = 8 points — surgical treatment was performed. Postoperative sagittal(C) and 3-D reconstruction (D) CT scans showing reestablishment of cervical alignment and facet joint congruence, with lateral mass screws at C5 and C6 and pedicle screws at C7 and T1. After 6 months of followup, she had some neurologic improvement (AIS grade C).
- 4. INTRODUCTION Cervical spine trauma is one of the most common sites of spinal cord injury (SCI). Anatomically, subaxial cervical spine trauma consists of injuries from C3 to C7 with more than 50% of the cervical spine injuries located between C5 and C7. Fracture patterns vary by mechanism and include: compression fracture burst fracture flexion teardrop fracture extension teardrop avulsion fracture
- 5. Classification Descriptive classification (subaxial cervical spine injuries) includes compression fracture burst fraction flexion-distraction injury facet dislocation (unilateral or bilateral) facet fracture Allen and Ferguson classification
- 8. DIAGNOSIS Cervical Spine Injury Severity Score (CSISS) Subaxial Cervical Spine Injury Classification (SLIC)
- 9. Cervical Spine Injury Severity Score (CSISS) The cervical spine is conceptualized in terms of four columns (anterior, posterior, and right and left lateral columns). Each column is scored from 0 to 5 using an analog scale based on degree of osseous displacement and ligamentous injury. The resulting injury severity score ranges from 0 (no injury) to 20 (most severe injury). Scores of 7 or more generally require surgery and scores less than 5 are generally treated nonoperatively.
- 12. Subaxial Cervical Spine Injury Classification (SLIC)
- 13. Total score ≤3 : nonoperative treatment is recommended 4 : either surgery or nonoperative treatment is indicated, ≥5 : surgery is recommended
- 14. Cervical Facet Dislocations & Fractures Represent spectrum of osteoligamentous pathology that includes unilateral facet dislocation bilateral facet dislocation facet fractures Pathophysiology Mechanism flexion and distraction forces +/- an element of rotation
- 15. Clinical presentation Monoradiculopathy spinal cord injury symptoms seen with bilateral dislocations symptoms worsen with increasing subluxation
- 16. Treatment Nonoperative cervical orthosis or external immobilization (6-12 weeks) indications facet fractures without significant subluxation, dislocation, or kyphosis
- 17. Operative immediate closed reduction, then MRI, then surgical stabilization indications bilateral facet dislocation with deficits in awake and cooperative patient unilateral facet dislocation with deficits in awake and cooperative patient immediate MRI then open reduction surgical stabilization Indication facet dislocations (unilateral or bilateral) in patient with mental status changes patients who fail closed reduction
- 18. Cervical Lateral Mass Fracture Separation mechanism of injury traffic accident, falls, heavy object landing on head hyperextension, lateral compression and rotation of the cervical spine
- 19. Clinical presentation Symptoms Neurologic symptoms common (up to 66%) radicular pain, radiculopathy or spinal cord injury/myelopathy can be classified by Frankel grade or ASIA impairment scale Physical exam Inspection torticollis, paravertebral muscle spasm Neurovascular radicular pain and numbness myelopathy
- 20. Treatment Nonoperative NSAIDS, rest, immobilization Operative Posterior decompression and two-level instrumented fusion Anterior plating and interbody fusion Single posterior pedicle screw Anterior and posterior decompression and fusion
- 21. Subaxial Cervical Vertebral Body Fractures Mechanism: 1. Compression fracture Characterized by Compressive failure of anterior vertebral body without disruption of posterior body cortex and without retropulsion into canal Cften associated with posterior ligamentous injury
- 22. 2. Burst fracture Characterized by fracture extension through posterior cortex with retropulsion into the spinal canal often associated with posterior ligamentous injury Prognosis often associated with complete and incompete spinal cord injury Treatment unstable and usually requires surgery
- 23. 3. Flexion teardrop fracture Characterized by anterior column failure in flexion/compression posterior portion of vertebra retropulsed posteriorly posterior column failure in tension larger anterior lip fragments may be called 'quadrangular fractures’ Prognosis associated with SCI Treatment unstable and usually requires surgery
- 24. 4. Extension teardrop avulsion fracture Characterized by small fleck of bone is avulsed of anterior endplate usually occur at C2 must differentiate from a true teardrop fracture Mechanism extension Prognosis stable injury pattern and not associated with SCI Treatment cervical collar
- 25. TREATMENT METHODS Nonoperative Collar immobilization for 6 to 12 weeks Indications Stable mild compression fractures (intact posterior ligaments & no significant kyphosis) Anterior teardrop avulsion fracture External halo immobilization Indications Only if stable fracture pattern (intact posterior ligaments & no significant kyphosis)
- 26. TREATMENT METHODS Operative Anterior decompression, corpectomy, strut graft, & fusion with instrumentation Indications Compression fracture with 11 degrees of angulation or 25% loss of vertebral body height Unstable burst fracture with cord compression Unstable tear-drop fracture with cord compression Minimal injury to posterior elements Posterior decompression, & fusion with instrumentation Indications Significant injury to posterior elements Anterior decompression not required
- 28. 1. A 40-year-old male sustains subaxial cervical spine fracture and after a motor vehicle accident. Physical exam is significant for an incomplete upper cervical spinal cord injury. Which of the following CT scans is associated with the worst ultimate clinical outcome? 1 Figure A 2 Figure B 3 Figure C 4 Figure D 5 Figure E
- 29. A E D C B
- 30. 1. A 40-year-old male sustains subaxial cervical spine fracture and after a motor vehicle accident. Physical exam is significant for an incomplete upper cervical spinal cord injury. Which of the following CT scans is associated with the worst ultimate clinical outcome? 1 Figure A 2 Figure B 3 Figure C 4 Figure D 5 Figure E
- 31. Figure B is an axial CT scan demonstrating bilateral facet dislocations, which is associated with more severe initial neurologic injury and inferior outcomes compared to patients with cervical spine injuries without facet dislocations.
- 32. 2. A 40-year-old male patient fell asleep at the wheel and was involved in a motor vehicle accident. At the emergency room, he presented with an ASIA C spinal cord injury. An AP radiograph is shown in Figure A. An axial CT scan at the C5 level is shown in Figure B. Management of this injury should include: 1. Anterior cervical discectomy and fusion of C5-6 2. Corpectomy of C5 and instrumented fusion C5-6 3. Corpectomy of C5 and instrumented fusion C4-5 4. Posterior instrumented fusion of C4-6 5. Posterior instrumented fusion of C5-6
- 33. A B
- 34. 2. A 40-year-old male patient fell asleep at the wheel and was involved in a motor vehicle accident. At the emergency room, he presented with an ASIA C spinal cord injury. An AP radiograph is shown in Figure A. An axial CT scan at the C5 level is shown in Figure B. Management of this injury should include: 1. Anterior cervical discectomy and fusion of C5-6 2. Corpectomy of C5 and instrumented fusion C5-6 3. Corpectomy of C5 and instrumented fusion C4-5 4. Posterior instrumented fusion of C4-6 5. Posterior instrumented fusion of C5-6
- 35. This patient has fracture separation of the lateral mass. This is best treated with posterior two-level fusion involving both the level above and the level below.
- 36. 3. A 24-year-old male sustains the injury shown in Figure A. What was the most likely mechanism of injury? 1. Hyperextension 2. Flexion-distraction 3. Flexion-compression 4. Rotational 5. Pure axial load
- 38. 3. A 24-year-old male sustains the injury shown in Figure A. What was the most likely mechanism of injury? 1. Hyperextension 2. Flexion-distraction 3. Flexion-compression 4. Rotational 5. Pure axial load
- 39. Figure A shows a quadrangular fracture pattern of C5. These injuries are observed with flexion-compression loads.
- 40. THANK YOU