Operative Treatment For Cervical Spine Fractures

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					Operative Treatment For
Cervical Spine Fractures
      Dr. T. G. Hogan
Occipito-cervical Dissociation
Basion-Dens-Interval <12 mm.
>12 mm. Suggests Vertical
Instability
                         Instability Basion
        Occipitocervical Basion Axis
Basion-Axial-Interval < 12mm   Int <12
                                         BDI < 12
>12mm. Suggests Anterior
Instability
<0mm. Suggests Posterior
Instability
   Occipitocervical Dislocation
• Mechanism Unclear
  – Rotation & Distraction
• Neurological Deficits Confusing
  – High Tetraplegia
  – Cruciate Paralysis
  – Wallenberg’s Syndrome
• Ligamentous Injuries = Unstable
• Avoid Traction
   Atlas Fractures: Extension
• Anterior Arch

  – Hyper-extension
  – Avulsion of Longus
    Colli
  – R/O Other Injuries
  – 65% (Landells)

     • Stewart G, Radiology
       1977
     Atlas Fractures: Extension
• Posterior Arch Fractures

• Occipital Pain &
  Numbness
• Stable
• R/O Other Injuries
  (Odontoid #)
          Jefferson Fractures
• Four Part Burst

• Axial Load

• 6.9 mm Overhang
  – Spence KF, JBJS,
    1970


• 8.1 mm Overhang
  – Heller JG, J Spinal
    Disord, 1993
  Lateral Mass Fractures of C-1
• Free-Floating
  Lateral Mass of C-1

• Often Comminuted

  – Segal & Stauffer,
    JBJS, 1987
  Treatment & Results C-1 #’s
• Good Results Reported with
  – Halo Traction + Vest
  – Rigid or Simple Orthoses


• Late Pain:
  – Ant/Post Arch      50%
  – Jefferson          70%
  – Lateral Mass             33%
     • Landells, VanPeteghem, Spine 1987
 Anderson & D’Alonzo
Classification (JBJS, 1974)
• Type I



• Type II



• Type III
Odontoid fractures

      Type 1


      Type 2


      Type 3
           Type II Odontoid
• Halo-Thoracic Brace

• Non-union Rate 14-32-75%
• Risk Factors:
  – Failure to Treat
  – 5mm Displacement
  – >10 deg. Angulation
  – Posterior Displacement
  – Elderly
             Type II Odontoid
• Direct Screw Fixation

•   Preserves C1-2 Motion
•   No Bone Graft Required
•   Avoid Non-Unions
•   Avoid Reverse Oblique #

    – Aebi, Spine 1989
           Type II Odontoid
• Posterior Fusion
  – Primary
  – for Non or Delayed Union


• Trans-articular Facet Screws
• 96% Fusion Rate
• Restricted Rotation
        C2 Magerl screw fixation
• Good stability
•   Does not need
    – odontoid
    – C1 arch
    – C2 arch
•   Challenging
   Odontoid stabilisation
                  Osteosynthesis: odontoid
                  screw fixation




Arthrodesis: Magerl screw fixation - challenging
    – Good stability
    – Does not need odontoid, C1 arch or
      C2 arch
Traumatic Spondylolisthesis C-2
    (Levine & Edwards, JBJS, 1985)
Traumatic Spondylolisthesis
                    C-2
    (Levine & Edwards, JBJS, 1985)
Traumatic Spondylolisthesis C-2
    (Levine & Edwards, JBJS, 1985)
  Traumatic Spondylolisthesis C-2
        (Levine & Edwards, JBJS, 1985)




Dislocated
Subaxial C-Spine
Flexion-compression...




            3
        2       4

    1               5
         Checklist Approach
• Applies to trauma and degenerative
  disease
• The more points the more unstable
• 5 points does not mean surgery
  occasionally <5 need Sx
                >5 don’t need Sx
• Currently investigated by CSRS
• Different considerations for different levels
• 2-column VS 3-column
Sensitivity Settings
                      C2-T1
•   Usually for trauma, but applies to all
•   Ant./post. Element failure
•   Stretch test (1.7mm, >7.5 degrees)
•   X-Ray (>3.5mm, 11 degrees)
•   Flex/ext x-ray (>3.5mm, 20 degrees)
•   Pavlov’s ratio (<0.8) sagittal diameter <13
•   Narrow disc
•   Cord damage
•   Root damage
•   Dangerous loading anticipated
Cervical Measurements
Mr. Roeth. C-4 Fracture
Mr. Roeth. C-4 Fracture
CSLP Ant. & Post Instability
Mr. R. Co. C5 & 6 Fractures
Mr. R. Co. C5 & 6 Fractures
Mr G H C4-5 Facet Dislocation
Mr G H C4-5 Facet Dislocation
Cervical trauma

Case presentations
Cervical trauma

     Case 1
Patient JM, 16yrs
     • Fell boarding
       2/52 ago
       –   “winded”
       –   continued 2/7
       –   hemoptysis 4/7
       –   saw GP
       –   neck xrayed      C6
     • Full ROM
C6   • Not tender
Patient JM, 16yrs


                C6


               C7
Spot lateral
   Patient JM, 16yrs

            C6
                           C6
       C7
                       C7
Extension        Flexion
Patient JM, 16yrs

               C6


                   C7
    CT reformats
• New or old injury?
 –Snowboarding 2wks ago?
 –Dirtbike 2yrs ago?
• Observe only?
 –Advice and precautions
 –Risks
• Stabilise?
 –Anterior or posterior
 –Risks
  Patient EC, 72f
Initial Xray

                C5
   Patient EC, 72f
       C5



Left        CT   Right
      Patient EC, 72f


                C5
      C5
Postreduction        T2 MRI
EC

         C5


Postop
Cervical trauma

     Case 3
Patient M, 65yrs
           Initial CT
  Patient M, 65yrs
             Initial CT




Left              Right
Patient M, 65yrs
Intraoperative

                 Postop
Patient M, 65yrs
            Initial CT
Patient BB, 32yrs
10lbs

        15lbs

                20lbs


   BB                   25lbs

                                25lbs + 1 day
BB
       3
     months




       6
     months

BB