Detailed Subject seminar on Evaluation and management of traumatic cervical spine injuries

1. SRI SIDDHARTHA MEDICAL COLLEGE,TUMKUR
DEPARTMENT OF ORTHOPAEDICS
TOPIC:
Cervical Spine Injury: Evaluation & Management
Chairperson:
prof. & HOD Dr.Mahesh K.U
Dept. of Orthopaedics
Moderator:
prof. Dr. Govindaraju D.K
Dept. of Orthopaedics
Presenter:
Dr. Jaipalsinh Mahida
Dept. of Orthopaedics

2. EVALUATION OF CERVICAL SPINE INJURY
 Prehospital care
 Hospital care
 History and physical examination.
 Neurological examination
 Sensation to light touch , Pinprick
 Motor strength
 Deep tendon reflexes and pathological reflexes also should be checked.
 Motor and sensory evaluation of the rectum and perirectal area is
mandatory.
 bulbocavernous reflex
 bowel or bladder

4. Neurological evaluation
G L A S G O W C O M A S C A L E
Eyes Open Spontaneous 4
To sound 3
To pain 2
Never 1
Best Verbal Response Oriented 5
Confused conversation 4
Inappropriate words 3
Incomprehensible words 2
None 1Best Motor Response Obeys commands 6
Localizes pain 5
Flexion withdrawal 4
Abnormal 3
Extension 2
None 1

5. Sensory examination
 performed with light touch, then pinpricks (using a sterile needle), beginning at
the head and neck and progressing distally, to examine specific dermatome
distributions
 Important dermatome landmarks are the
nipple line (T4),
xiphoid process (T7),
umbilicus (T10),
inguinal region (T12, L1),
perineum and perianal region (S2, S3, and S4).
 The skin should be marked where sensation is present before proceeding to
motor examination.
 Evidence of sacral sensory sparing establishes the diagnosis of an incomplete
spinal cord injury.
 The only area of sensation distal to an obvious cervical lesion in a quadriplegic
patient may be in the perianal region

7. M o t o r e x a m i n a t i o n
 should be systematic, beginning with the upper extremities.
 A protruded cervical disc /unilateral dislocated facet may produce
an isolated nerve root paralysis.
 key muscle groups and their corresponding nerve root levels
 +/- of sacral motor sparing should be determined by voluntary
rectal sphincter / toe flexor contractions.
 prognosis for recovery of motor function is good if present
 reflexes should be documented.

9. IMAGING STUDIES
 CT scans for screening, considered more cost-effective as well as more
sensitive compared to plain radiographs.
 radiographs often fail to capture the occipitocervical and cervicothoracic
junctions.
 Occipital condylar fractures, occipitocervical dislocations, and upper
cervical injuries are often underappreciated on radiographs.
 Radiographs may be used for screening
 A lateral radiograph can be used in polytrauma patients presenting in
extremis.
 The necessity for plain film imaging may be informed by the NEXUS low-
risk criteria or the Canadian C-spine rules.
 MRI is the most sensitive to evaluate the cervical spine and will detect
discoligamentous injuries that would otherwise be missed by CT scanning
alone.

11. RADIOGRAPHS
 VIEWS: -
 AP
 lateral
 open-mouth odontoid views
 Oblique
 Flexion & extension
 Swimmer’s view

15.  Oakley introduced a simple system (radiological ABC) for analyzing plain films:
 A1: appropriateness:
correct indication and right
patient
 A2: adequacy: extent
(occiput to T1, penetration,
rotation/projection)
 A3: alignment:
 anterior aspect of vertebral
bodies,
 posterior aspect of vertebral
bodies,
 spinolaminar line (bases of
spinous process),
 tips of spinous process,

16.  B: bones
 C: connective tissues:
 pre-vertebral soft tissue,
 pre-dental space,
 intervertebral disc
spaces,
 interspinous gaps

17. LATERAL VIEW
 Power Ratio
 Calculated by dividing
distance between basion &
posterior C1 arch by
distance between opisthion
& anterion C1 arch.
 Ratio >1 means
atlantooccipital dislocation
 Harris measurement also called rule
of “12”
 measurement of the Basion-Axis
Interval and the Basion-Dens
Interval, both of which should
measure less than 12 mm if the
occipitocervical articulation is
intact.

18. LATERAL VIEW
 Atlanto-Dens interval(ADI)
 Measured from posterior
surface on anterior C1 arch
to anterior surface of
odontoid process.
 Normal - < 3mm
 Widening indicates
disruption of transverse
ligamnet.
 Posterior Atlanto – Dens interval (PADI)
 measured from posterior surface of
dens to anterior portion of C1
posterior arch,
 Represents AP diameter of spinal
canal at C1
 Normal - < 13mm

19.  A+B > 7mm indicates rupture
of transverse ligament

20.  At the C2 level, displacement and angulation of odontoid fractures are
thought to influence the risk of nonunion and direct the need for surgical
intervention.
 The Spine Trauma Study Group recommends that displacement of odontoid
fractures be measured between two tangents drawn along the anterior cortex
of the odontoid and C2 vertebral body, respectively
 Angulation is determined by the angle created by the intersection of
extrapolated lines drawn along the posterior cortex of the odontoid and the
C2 vertebral body.

21.  For pars interarticularis fractures, the so-called hangman’s
fracture, angulation may be assessed by the endplate method or
posterior tangent technique.
 The endplate method uses the angle created by lines extrapolated
from the inferior endplates of C2 and C3
 posterior tangent technique utilizes lines extrapolated from the
C2 and C3 posterior vertebral bodies .

22.  For subaxial cervical evaluation,
 Comminution of fracture fragments should be appreciated if present and
primary fracture lines outlined.
 Segmental kyphosis can be
determined using an endplate
(Cobb) technique or
 posterior vertebral body tangent
similar to that described for
hangman’s fractures.

23.  Subaxial cervical translation is assessed by determining the
distance between extrapolated lines extending from the posterior
vertebral bodies
 White and Panjabi advised that translation greater than 3.5 mm
was suggestive of mechanical instability.

24.  Determination of vertebral body height loss is performed by
measuring the percentage difference between anterior and
posterior vertebral body heights at the injured level
 compared with an average measurement obtained from
adjacent levels above and below.

25. PRE VERTEBRAL SOFT TISSUE SHADOWS
 Nasopharyngeal space (C1) - 10 mm
(adult)
 Retropharyngeal space (C2-C4) - 5-7 mm
 Retrotracheal space (C5-C7) - 14 mm
(children), 22 mm (adults)
 Extremely variable and nonspecific
 Contour is more important than
measurements

26.  The laminar space is the distance
from
 posterior aspect of the articular
pillars (1) to
 the spinolaminar line (2)
 indicate rotational injuries of the
cervical spine
 A line (white line ) drawn through
C1-3 should intercept the C2
spinolaminar line.
 displacement in this line may be an
indication of subtle traumatic
vertebral injury/dislocation.
 A displacement more than 2 mm, is
abnormal

27. Anteroposterior view
 assess
 alignment
 symmetry of pedicles
 contour of bodies
 Vertebral body height should be uniform.
 height of disc spaces
 Disc space should be uniform
 central position of spinous processes
 facet joints oriented at 45 degree angle from coronal plane -- thus not seen on AP
view
 if facet is clearly identified on ap, articular pillar or pedicle fracturex with rotation is
likely

28. Flexion-Extension Films
 May be helpful in ligament injuries
 But Frequently useless due to muscle spasm
 Should not be done in acute setting
 Patient must be alert, awake, not intoxicated, able to sit or stand,
able to understand commands, and without neurologic deficit.

29. COMPUTED TOMOGRAPHY
 CT scans are more sensitive than plain radiographs in identifying
fractures and subtle osseoarticular abnormalities.
 Facet, lamina, and pedicle fractures are notorious difficult to
identify on plain radiographs but may be more easily appreciated
on axial CT studies.
 Spinous process fractures will also be easily visualized.
 Vertebral body translation and frank dislocation are also
demonstrable on axial CT scans.
 The absence of opposed articular surfaces may result in an “empty
facet sign.”
 In facet dislocations, the inferior articular process of the level
above will be visualized anterior to the superior articular process of
the caudal vertebrae.

30.  Paramedian sagittal cuts through the
facet joints may help appreciate
dislocations, subluxations, and
estimations of fracture fragment size
 Retropulsion of fracture fragments
into the canal, and resultant
compromise, can best be estimated on
a midsagittal CT scan.

31. MEGNETIC RESONANCE IMAGING
 MRI is known to be superior to computed tomography in terms
of visualizing cervical soft-tissue structures,
 spinal cord,
 cervical nerve roots,
 intervertebral discs, and
 posterior ligamentous complex (PLC),
 epidural hematomas, and
 vertebral artery injury ,
 undisplaced fractures of the vertebral bodies.

32.  MRI scan is obtained in cases of cervical spine trauma when any of the
following criteria are met:
1. the patient presents with a neurologic deficit,
2. the integrity of the PLC is unclear and injury to this structure would
have a direct influence on treatment, such as determining the need
for surgery, and
3. the patient presents with a facet dislocation where there is concern
regarding disc herniation into the spinal canal that may prevent safe
reduction and cause difficulty in deciding on the correct approach for
surgical intervention.
 Magnetic resonance arteriography can be employed in the assessment of
vertebral artery injury and patency.

34. TREATMENT OPTIONS
 primary goal is maintenance, or restoration, of neurologic function
& reduce pain.
 By decompression of the spinal cord and neural structures or
 reduction and realignment of facet dislocations or
 displaced fractures.
 In most instances, stability is restored via surgical intervention and
instrumentation of the spine, although closed means, such as halo-
fixation have been employed effectively in the past.

35.  Secondary goals include
 fracture healing,
 diminution of pain,
 mitigation of disability, and
 restoration of function.
 Even after complete spinal cord injury, surgical intervention and spinal
fusion may be necessary to allow a patient to sit upright in a wheelchair,
maintain forward gaze, and ameliorate long-term issues such as chronic
pain or Charcot arthropathy of the spine.
 In patients with stable cervical fractures, in the absence of neurologic
impairment, bracing and external orthoses have been employed
successfully to potentiate healing.

36. Non-operative Treatment Modalities
CERVICAL ORTHOSES
 Most cervical orthotics use three-point pressure to restrict motion,
1. mandible and occiput proximally,
2. Clavicle and the sternal notch anteroinferiorly, and
3. T3 spinous process and scapular spines posteriorly.
 Cervical orthoses limit movement of the cervical spine by
buttressing structures at both ends of the neck, such as the chin and
the thorax.
 Used for stable fractures.

37.  However, applied pressure over time can lead to complications
such as:
 pressure sores and skin ulcers
 weakening and atrophy of neck muscles
 contractures of soft tissues
 decrease in pulmonary function
 chronic pain syndrome

38.  Collars
 Soft collars have a limited effect on controlling neck motion.
 The Philadelphia collar has been shown to control neck motion,
especially in the flexion/extension plane, much better than the soft collar.
 Disadvantages of the Philadelphia collar are the lack of control for
flexion/extension control in the upper cervical region and lateral
bending and axial rotation.

39. CERVICOTHORASIC ORTHOSES:
 Minerva Brace/Cast
 A Minerva cervical brace is a cervicothoracal orthosis with mandibular,
occipital and forehead contact points.
• This brace provides adequate immobilization between C1 and C7, with
less rigid immobilization of the occipital-C1 junction.
• The addition of the forehead strap and occipital flare assists in
immobilizing C1–C2.

40.  Traction:
 The Gardner-Wells tongs can be applied using local anesthesia.
 The pin application sites should be a finger breadth above the pinna of
the auricle of the ear in line with, or slightly posterior to, the external
auditory canal.
 Rule out atlanto-occipital dislocation or discoligamentous disruption
before applying traction.

41.  application of gardner – wells tongs can be useful in reducing fracture and
dislocation.

42.  Halo
 The halo vest is the first
conservative choice for
unstable lesions.
 Its clinical failure is due
to:
 pin track problems
 accurate fitting of the
vest
 a lack of patient
compliance

44. SURGICAL TREATMENT
APPROACHES:
A. Anterior approache:
1. Occiput to C3
a. Anterior transoral approach
b. Anterior retropharyngeal
approach
2. C2 to C7
3. C3 to C7
4. Cervicothorasic junction, C7 to
T1

45. Retropharyngeal approach

46. C3 to C7

47. Cervicothorasic junction

48. B. Posterior Approach
1. Occiput to C2
2. C3 to C7

49. SURGICAL PROCEDURES:
1. Anterior Decompression
2. Reconstruction
3. Anterior Instrumentation
4. posterior Decompression
5. Posterior Instrumentation and Fusion of the Cervical
Spine

50. COMPLICATIONS OF SURGERY
 COMPLICATIONS WITH ANTERIOR APPROACH:
 Dysphagia
 Recurrent laryngeal nerve palsy –> dysphonia
 Superior laryngeal nerve injury – rare -> dysphagia and loss of
high phonation
 Horner’s syndrome
 damage to the vertebral artery or esophagus -> life thretaning

51.  COMPLICATIONS WITH POSTERIOR APPROACH:
 Vertebral artery damage
 The risk of postoperative infection; wound problems, such as
hematoma or dehiscence; pulmonary complications; and venous
thromboembolic disease have been reported to be higher with a
posterior approach relative to the anterior approach.
 persistent CSF leak following durotomy with the posterior
approach

52. TREATMENT OPETIONS FOR SPECIFIC
INJURIES
OCCIPITOCERVICAL DISLOCATIONS(C0-C1):
 These injuries are grossly unstable, primarily
ligamentous, and have little chance of healing
with external immobilization alone.
Nonoperative Treatment :Indications
• Little role
• Halo immobilization is most often used as a
temporary means of stabilization, or a means of
reducing injury, until surgery can be safely
performed.
• Longitudinal traction is contraindicated in this
setting.

53. OPERATIVE TREATMENT: Indications
• Recently, wiring contoured rods to the vertebrae provided
more mechanical stability, but the fixation was insufficient to
obviate the need for external immobilization.

54. OPERATIVE TREATMENT: Indications
• The introduction of plate and screw fixation was an immediate precursor
to modern screw-rod systems.
• The so-called “Y” plate allowed screws to be inserted directly into the
occiput, Cl, and C2 and provided rigid internal fixation,
• although fatigue fracture was a common complication due to stresses across
the occipitocervical junction.

55.  The current generation of occipital plates can be connected to
polyaxial screws in the upper cervical spine and have been found
to result in extremely stable and versatile constructs

56. OCCIPITAL CONDYLE FRACTURE:

57. ATLAS FRACTURE(C1):

58. ATLANTOAXIAL INSTABILITY
 Atlantoaxial instability results from either:
 a purely ligamentous injury or
 avulsion fractures.
 These injuries are significant, because complete bilateral
dislocation of the articular processes can occur at
approximately 65° of atlantoaxial rotation.
 When the transverse ligament is intact, a significant
narrowing of the spinal canal and subsequent potential spinal
cord damage is possible

59.  With a deficient transverse ligament, complete unilateral
dislocation can occur at approximately 45° with similar
consequences.
 In addition, the vertebral arteries can be compromised by
excessive rotation which may result in brain stem or
cerebellar infarction and death.
 As an adjunct to both operative or nonoperative manage-
ment, traction can be an effective method of reducing
sagittal C1-C2 instability.

60. Nonoperative Treatment :
• In a patient who is neurologically intact, nonoperative
treatment in a collar or a halo vest can be used, provided the
ADI can be held in a reduced position.
Operative Treatment:
• Surgical treatment of sagittal C1-C2 instability without frac-
ture usually consists of posterior atlantoaxial stabilization
and fusion.
• If a patient has an associated spinal cord injury, surgical treatment
should be strongly considered regardless of the degree of
instability.
• Patients with ADIs greater than 5 mm should also undergo C1-C2
fusion.

61. ODONTOID FRACTURES(C2):

62. Dens Fractures

63. Dens Fractures

64. Dens Fractures

65. HANGMAN’S FRACTURE(TRAUMATIC
SPONDYLOLISTHESIS, (C2-C3):

66. SUAXIAL CERVICAL FRACTURES & DISLOCATIONS(C3-C7):
Compression Fractures:
Nonoperative Treatment Indications
• Patients with cervical compression fractures without posterior
ligamentous injury
• For C3-C6 injuries, a rigid cervical collar usually suffices.
• For injuries of C7 or Tl, a cervicothoracic brace may provide better
immobilization.
• Attempts to correct minor kyphotic deformities are usually fruitless
and ultimately unnecessary.
• Compression fractures are usually healed by 3 months, at which tithe
flexion-extension views should be obtained to rule out occult
instability.

67. Compression Fractures:
Operative Treatment Indications
 Surgical stabilization via an anterior or posterior approach should
be considered for patients with evidence of posterior ligamentous
injury.
 Posterior ligamentous injury is suggested by a segmental
kyphosis greater than 11 degrees or a substantial amount of
vertebral body wedging;
 Threshold values for the degree of height loss or PLC injury
beyond which surgery is indicated; have not been defined.
 MRI can be used as a means to determine the integrity of posterior
soft-tissue structures in a compression fracture.

68. SUAXIAL CERVICAL FRACTURES & DISLOCATIONS(C3-C7):
 BURST Fractures:
Nonoperative Treatment Indications
• In neurological intact patients with little vertebral body comminution
and only the mildest degree of canal compromise.
• Any kyphotic deformity should measure less than 5 degrees, and there
should be, no indication of posterior ligamentous injury.
• Patients should be followed weekly for the first month and
immobilization maintained for at least 12 weeks.
• Any subsidence, focal collapse or kyphosis is a strong indication for
surgery.

69. Compression Fractures:
Operative Treatment Indications
 Anterior Corpectomy and Stabilization :
 Patients with neurologic deficit, regardless of the integrity of the PLC,
should be surgically stabilized Posteriorly displaced vertebral body
fragments are most readily removed through a direct anterior approach.
 The anterior column reconstructed with a bone graft or strut.
 Insert a rigid titanium mesh cage filled with salvaged bone in addition
to cancellous iliac crest autograft.
 Bone should be tightly packed into the cage, which may also enhance
the surface area contact with the endplates.
 An anterior cervical-plate is then applied to restore anterior stability.
 If the PLC appears to be disrupted, perform a posterior instrumented
fusion, either during the same operation or in a staged fashion

70. Compression Fractures:
Operative Treatment Indications
 Posterior Instrumentation and Fusion :
 reserved for patients who are neurologically intact and
demonstrate evidence of posterior ligamentous disruption.
 If posterior fixation is planned as the only treatment, the
vertebral burst fracture should demonstrate biomechanical
integrity, with no comminution, kyphosis, or posterior
retropulsion of fragments. Otherwise, the posterior
construct will have a high risk of failure.

71. SUAXIAL CERVICAL FRACTURES & DISLOCATIONS(C3-C7):
 Flexion-Type Teardrop Fractures:
Nonoperative Treatment Indications
• Definite role for nonoperative, treatment
• Minimally displaced fractures with little kyphosis and no PLC injury
are stable.
• treated with rigid cervical collar or CTO, depending on the level of
injury.
• Halo treatment can also be used to treat these injuries.
• Halo maintained for 3 months, provided acceptable alignment has been
maintained.
• After the, halo has been removed flexion-extension radiographs are
necessary to confirm that stability has been achieved.

72. Flexion-Type Teardrop Fractures:
Operative Treatment Indications
 In patients with a neurologic deficit, anterior corpectomy is usually
performed to remove the posteriorly displaced vertebral body
followed by anterior strut grafting and rigid plate fixation.
 In unstable teardrop fracture and neurologically intact patient.
 anterior surgery entails a nondecompressive corpectomy, with resection
of the majority of the vertebral body back to, but not through, the
posterior wall.
 translational deformity, exceeding 3 to 3.5 mm, and the facet joints
appear to be widened,
 posterior surgery is recommended as an adjunct to provide
additional stability.

73. SUAXIAL CERVICAL FRACTURES & DISLOCATIONS(C3-C7):
 Facet Fractures :

74. SUAXIAL CERVICAL FRACTURES & DISLOCATIONS(C3-C7):
 Facet Dislocations:

75. Thank You