Cervical Spine Injuries Classification and Non operative Treatment

Cervical Spine Injuries Classification and Non-operative Treatment Dr. Heather Roche Dec. 12, 2002 Evaluation • MVA, diving accidents most common cause • should suspect in anyone with head or high energy trauma or neurological deficit • can be missed with multiple trauma and if non-contiguous vertebrae involved or altered consciousness • 16% people will have non-contiguous spine fractures • 50% will have other skeletal or visceral injuries History • MVA • thrown from car strike head – any paralysis at time of injury – if currently paralyzed was there any indication of movement at time of accident • Physical – full neuro exam including rectal and bulbocavernosus – r/o other injuries Radiography • Initial – cross table lateral 70-79% – AP and open mouth increases yield to 90-95% – swimmer’s view for C7-T1 • Other – Ct scan bony anatomy and lower c-spine – Flex-extension • controversial in acute setting • only in alert and cooperative patients without neurological deficit with neck pain • false negatives due to muscle spasm MRI • Patients with complete or incomplete neurulogical deficit, deterioration in neurological function or suspected posterior ligamentous injury despite negative plain radiographs Radiographic evidence of Instability • Angulation between vertebral bodies that is 11 greater than adjacent segment • AP translation > 3.5mm • spinous process widening on lateral • facet joint widening • malalignment of spinous process on anterior view • rotation of facets on lateral • lateral tilting of vertebral body on anterior view Instability Initial Treatment • Immobilization – rigid cervical orthosis- Philadelphia collar – unstable injury this is inadequate often and cervical traction required • halo traction or gardner-wells tongs • 1cm posterior to external auditory meatus and just above the pinna • should be MRI compatible • 10-15 pounds usually appropriate • post alignment xray and neuro exam 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 Spinal Cord Injury • • • • Maintain SBP > 90mmHg 100% O2 saturation early diagnosis by xray methylprednisolone bolus 30mg/kg then infusion 5.4mg/kg – Corticosteroids benefit in recovery – Nascis-2 data showed methylprednisolone within 8 hours of injury had better recovery of neurologic function at 6 weeks, 6 months and 1 year after injury compared to other substances like naloxone and placebo – injury < 3 hrs continue for 24 hors and > 3 hrs for 48 Anatomy of Upper cervical spine Injuries to Upper cervical Spine • Occipitoatlantal Dislocation – hyperextension distraction and rotation of craniovertebral junction – severe neurological injuries from complete C1 quadriplegia to incomplete syndromes – xray • diastasis at craniovertebral junction • Powers ratio – distance between basion and post arch of atlas by distance between opisthion and ant arch atlas with > 1 abnormal • avoid traction and stabilize head to neack with halo • surgical Rx required as primarily a ligamentous injury Occipital-atlantal Dissociation Atlas Fractures • Axial compression injuries • neurological injury rare • 3 types – Jefferson fracture- direct compression and lateral masses forced apart – asymmetric load fracture ant or post to mass and displaces it – posterior arch fractures with an extension moment through it • Rx ? Transverse ligament intact – – – – – avulsion at insertion on CT lateral overhang of C1 over outer edges of C2 > 6.9 mm= rupture ADI > 4mm MRI visualization of ligament • Ligament intact – cervical orthosis ( Philadelphia, SOMI, Minerva) for posterior arch or undisplaced Jefferson – Halo - asymmetric lateral mass or displaced Jefferson fractures • No ligament – Fusion Odontoid Fracture • 15 % all cervical fractures • usually MVA or blow to the head Three types – Type 1 Avulsion off tip by alar ligament – Type 2 fracture at junction of dens with the central body – Type 3 fracture in body of axis and primarily cancellous bone • usually hyperflexion with anterior displacement • assoc injuries to C1 common • neurological deficit in 15-25% cases Odontoid Fractures Treatment • Type 1 – Philadelphia collar for 6-8 weeks • Type 3 – collar inadequate – Halo vest immobilization after reduction in traction 80 % union rate ( 3-4 months) Treatment con’t • Type 2 – high rate of non-union ( up to 40% in displaced) due to small area of bony contact and watershed blood supply to the waist of odontoid – Increased non-union with displacement, smoker and advanced age – undisplaced - halo immobilization – displaced • ? Traction for reduction then halo immobilization • ? Primary C1-C2 fusion after reduction in traction – most recommend if displacement > 4-5mm • Type 1 – isolated minimally displaced fracture of ring with no angulation • Type 2 – more unstable – flesion type/extension type or listhetic type – displaced > 3mm and angulation of C2-C3 disk space – ALL, PLL Disc can be interrupted Hangman’s Fracture Traumatic spondylolithesis • Type 3 – rare – anterior dislocation of C2 facets on C3 with 2 extension fracturing neural arch Hangman’s Fracture Treatment • Type 1 – rigid cervical orthosis • Type 2 – closed reduction with trection and position opposite direction instability – halo vest immobilization – follow for loss of reduction • Type 3 – reduction of facet dislocation with traction – C2 -C3 fusion after pre-op MRI Sub axial Spine • bodies articulate by intervertebral disc, ALL and PLL • facet joints are in a coronal plane 45 to horizontal allowing flexion and extension 14 degrees in sagittal plane • due to 45 incline lateral tilt accompanied by rotation • 9 degrees in coronal plane and 5 rotation in each segment • vertebral foramen in lateral mass contain vertebal artery which transverses C6 through C1 Biomechanics • Denis – three column spine for TL spine now applied to c-spine – Anterior region • disk and centrum resist compression • ALL, anterior annulus resist distraction – Middle • post vertebral body and uncovertebral joints • PLL and Annulus resist distraction – Posterior • facet joints and lateral mass compression • facet capsule, intra and supraspinous ligaments Classification Ferguson and Allen • Based on position of neck at time of injury and dominant force • 2 column theory – everything anterior to PLL ant column • most patients have a combination of patterns Compression and Flexion • Level C4-5 and C5-6 • compression of ant column and distraction of post • different stages with later stages having more post involvement and displacement of vertebral body • MRI to evaluate post ligaments • intact - HALO sufficient • not - risk of late kyphotic deformity therefore fusion Vertical Compression • C6-7 most common • shortening of ant and post columns • stage 1 – cupping of end plate with partial failure anteriorly and normal post ligaments – rigid orthosis • stage 3 – fragmentation and displacement of body “ burst” – neurologic injury common with assoc post element fractures – anterior corpectomy and reconstruction for neuro recovery plus post fusion to prevent kyphosis 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 Treatment • Closed reduction initially max weight controversial • successful – non-operative treatment 64% late instability – fusion recommended • unsuccessful – open reduction and fusion Flexion distraction con’t • 50-80% assoc acute disk herniation at level of injury • awake closed reduction has not shown worsening of neuro deficit and should not undergo major delay in reduction while waiting for MRI • MRI prerequisite to open reduction • Disk present ant cervical diskectomy prior to reduction Compression Extension • Early compressive failure of post column and late tensile failure ant column • late stages body displacement unstable and require anterior fusion Compression Distraction • Tensile failure of both ant and post columns bony or ligamentous • stage1 – no body displacement on static or flexion/ext – rigid orthosis • Stage 2 – displacement present – fusion Lateral Flexion • Asymmetric loading in coronal plane • displacement – fusion Halo Skeletal Fixation