Cervical Spine injuries

Exceptional anatomic features

EVALUATION OF SPINAL INJURY
 (I) Clinical Evaluation Of
Spinal Injury

1.Assessment and
resuscitation according to
the ATLS protocol.
2.Evaluation consciousness
level
3.A detailed history
4.Physical Examination .
4.Neurological Evaluation
Spine Immobilization
The protocol for spinal
immobilization is as follows
1. Maintain neutral head and neck
alignment with a cervical collar
in place
2. Logroll the patient onto the
backboard
3. Secure the torso with spider
straps or buckle straps
4. Secure the head to the
backboard with foam blocks or
towel rolls
5. Secure the legs to the
backboard
Neurological Evaluation
 How To Calculate ASIA Score?
1. First determine sensory levels for 5. Determine ASIA impairment
right and left side scale dgrading
2. Determine motor level and muscles is injury complete?
grading for both sides
3. single neurological levels If yes→
If NO
4. S.c Injury is Complete or GRADE
motor function below A
Incomplete ?
neurologic level
By definition, an incomplete spinal
cord injury is one in which some includes S4-5 If no→
motor or sensory function is GRADE
spared distal to the cord injury If yes B
Injury is complete if there is
1.No voluntary anal contraction Are at least half of
2. no anal sensation the key muscles If no →
3.S4-5 sensory scores = 0 below the GRADE
Otherwise injury is incomplete neurological level C
graded 3 or better?
If yes→
Normal: motor and sensory GRADE D
function →GRADE E
Clearance of cervical spine
injury in conscious patient
Unconscious patient
(II) Imging of c spine

• Radiographs

• CT

• MRI
 Plain radiographs
1. Plain radiographic studies remain the
primary Diagnostic spine evaluation
Minimum standard views •
– in all trauma patients
Lateral through C7
•if high-energy injuries include
– AP thoracic and lumbar spine
– Odontoid
Supplementary views
–
.
Bilateral obliques, in specific cases
– Swimmer’s, to examine C7 if necessary
– Flex ion and extension,
+
 Cervical Spine radiograph

• Predental space
(distance from dens
to C1 body)
max 3 mm in adults
and 5mm in children
Atlanto-occipital
alignment

The anterior margin of the

foramen magnum should
line up with the dens.

• The posterior margin of

foramen magnum should
line up with the C1
spinolaminar line.
    Wachenheim's line
          - usded to determine
anterior / posterior subluxation
          - this line is drawn down
the posterior surface of the
clivus and its inferior extension
should barely touch the
posterior aspect  of the
odontoid tip;
          - this relationship does
not change in flexion and
extension;      
thus if this line runs
behind the odontoid, posterior
subluxation has occured and
vice versa;
     -
Powers Ratio
          - identifies anterior
subluxation & is described
as ratio of BC/OA;
          - BC is the distance
from the basion to the
midvertical portion of
posterior laminar line of the
atlas;
          - OA is distance from
opisthion to midvertical
portion of posterior surface
of anterior ring of Atlas;
          - if this ratio is greater
than 1, anterior subluxation
exists;
 Prevertebral soft tissue
space

1. Nasopharyngeal space
(C1) - 10 mm (adult)
2. Retropharyngeal space
(C2-C4) - 5-7 mm
3. Retrotracheal space
(C5-C7) - 14 mm
(children), 22 mm
(adults
 Imaging Evaluation
1. the National Emergency X-radiography
Use Study (NEXUS) Low Risk Criteria

2. and the Canadian C-Spine Rule (CCR)

 NEXUS Low Risk Criteria
1. Absence of midline cervical tenderness
2. Normal level of alertness
3. No intoxication
4. No focal neurologic deficits
5. No painful distracting injury
• Patient with all of these findings needs
no imaging of the C-spine - a low risk pt.
 Canadian C-Spine Rule
• Any high risk factor mandating radiography?
(Age >65 or dangerous mechanism or
paresthesias in extremities. )
if yes→do radiography
• Any low-risk factor that allows safe assessment
of range of motion?
if no→do radiography
• Able to rotate neck actively (45 degrees L and r)
if no→do radiography
 WHAT I PREFER
cervical x-rays
• in all trauma patients (lateral, AP, odontoid, b/l oblique)
• if high-energy injuries include thoracic and lumbar spine
CT
• cranio-cervical junction in intubated patients.
• If the patient requires a head CT,obtain a screening CT
of the cervical spine visualizing skull to T4.
• all regions of the spine suspected or recognized to have
an injury.
CT
 MRI scan of the cervical spine

• in all patients with a cervical-level spinal cord injury.

• who require surgical stabilization of cervical injuries.
• For decision on anterior versus posterior surgical
approach.
• after closed reduction in patients with a cervical level
neurologic deficit to assess residual neural compression
and plan surgery.
• MRI scan of the entire spine in patients with ankylosing
spondylitis or other conditions that make x-ray
interpretation uncertain.
MRI scan
 Classification
A ;Upper Cervical Spine
injuries C1-C2
1. Occipital condyle fractures
2. Dislocations of the
Atlantooccipital Joint
3. Occipito-atlantal instability
4. Atlas fractures
5. Subluxation of C1 on C2
6. Dens Fracture
7. Traumatic Spondylolisthesis
of the Axis (Hangman's
Fractures)
B ; subaxial cervical spine
injuriesC3-C7
(Allen et al )
1. Compressive Flexion
2. Distractive Flexion
3. Compressive Extension
4. Distractive Extension
5. Vertical CompressioN
6. Lateral Flexion
 I Compressive Flexion
Compressive flexion stage 1—
1. blunting of the anterosuperior
vertebral margin
Compressive flexion stage 2—
1. stage1 +
2. obliquity of the anterior
vertebral body
3. loss of some anterior height of
the centrum.
4. “beak” appearance,
5. concavity of the inferior end
plate,
6. vertebral body may have a
vertical fracture
Compressive flexion stage3
1. stage 2 injury+
2. fracture line passing
obliquely from the anterior
surface of the vertebra
through the centrum and
extending through the inferior
subchondral plate,
3. fractutear-drop fracture re of
the beak (tear-drop fracture )
Compressive flexion stage 4
1. stage 3 features+
2. posterior translation of the
upper vertebra measuring
less than 3 mm.
Compressive flexion stage 5
1. Posterior translation of the
upper vertebral measuring 3
mm or greater,
2. facet gapping, indicating
anterior and posterior
ligamentous injury.
 II Vertical Compression
• Stage 1: Central superior
or inferior endplate
fracture with a “cupping”
deformity.
• stage 2; Stage 1+
• Fracture lines through
the centrum may be
present, but displacement
is minimal.
• Stage 3: Vertebral body
comminution, with or
without retropulsion of
fragments (burst-type
cervical fracture), with or
without kyphotic (late
flexion type) or
translational (late
extension type) deformity
 III Distractive Flexion
stage 1—
• failure of the posterior ligamentous complex
(facet subluxation in),
• abnormal divergence of the spinous
process.
Stage 2:
• Unilateral facet dislocation,
• posterior ligamentous complex is intact,
• rotational deformity
Stage 3:
• Bilateral facet dislocations,
• 50% translation of upper vertebral body on
lower one.
Stage 4: Close to 100% translation of upper
vertebral body on lower one, appearance of
a so-called floating vertebra
 IV Compressive
Extension
• Stage 1: unilateral vertebral arch fracture
that may be facet, pedicle, or lamina fracture
(lateral mass fractures). can result in mild
anterior translation
• Stage 2: Bilateral lamina fractures, without
evidence of other tissue failure . can be
multiple levels
• stage 3 —bilateral vertebral arch fractures
• Stage 4: as for CF stage 3, with partial
anterior vertebral body displacement
• Stage 5: as for CF stage 3, with 100%
anterior vertebral body displacement
 V Distractive Extension
• Stage 1: Abnormal widening of the
disc space(usually failure of the
anterior ligamentous complex or a
transverse fracture of the
centrum ),
• Stage 2: stage 1 plus + posterior
translation
 VI Lateral Flexion
• stage 1 —asymmetrical
compression fracture of the
centrum and ipsilateral
vertebral arch fracture,
• Stage 2: Vertebral body or
posterior arch fractures with
lateral translation or unilateral
facet gapping, coronal angular
deformity is noted on an AP x-
ray
PRINCIPLES OF TREATMENT
• Cervical injuries associated with malalignment require
skull traction (Closed reduction ), except injuries with
complete ligamentous disruption, usually indicated by
distraction between vertebrae on imaging studies .
• Closed reduction improves stability, preventing
neurologic deterioration in the interval preceding
definitive treatment .
• Distraction injuries are the most unstable spine injuries.
Skull traction in these patients will lead to catastrophic
neurologic deterioration or even fatal vascular injury
thats why it require compression for reduction, not
further traction.
• Compression across the cervical spine can be applied by
a halo vest
 Initial
treatmen

i/v steroids
Vasopressors
With in 8 hours immobilization
If neurogenic shock

Stable inury
Unstable injury
1. Soft collar
Skull traction with
2. Hard collar
tongs
3. Halo vest
 Treament

Non operative Operative

Stable injuries Unstable injuries

Upper servical spinec Lower servical spine

C1-c2 C3-c7

Atlanto axial fusion Posterior stabilization

Occipito-cervical
Anterior stabiliation
fusion

Anterior decompression
C1-c3 fusion Posterior fusion
 skull traction
• Traction pins for skull tongs
are placed in-line with the
external auditory meatus, 1 cm
above the pinna.
• Carbon fiber tongs with
titanium pins should be used
initially to permit subsequent
MRI evaluation if necessary
• Ten pounds of traction weight
is applied, then weight is
added in 5-lb increments, with
lateral radiographs after each
addition, until the spine is
realigned
• If spinal realignment is
obtained with traction and is
documented radiographically,
weight is reduced by 50% to
maintain alignment
• If spinal realignment cannot be
obtained by traction, open
reduction and stabilization,
usually through a posterior
approach, are indicated
skull traction
 Nonoperative Treatment
Immobilization in a rigid cervical orthosis for 8
to 12 weeks may be sufficient for a stable
cervical spine injury with no compression
of the neural elements
Indications,
1. Stable compression fractures of the
vertebral bodies
2. undisplaced fractures of the laminae,
3. Stable fractures of lateral masses
4. fractures of spinous processes
5. Unilateral facet dislocations that are
reduced in traction
6. stable Jefferson fractures,
7. stable hangman's fractures
8. stable type II and type III odontoid
fractures
• Patients with spinal fractures that are
treated nonoperatively must be observed
closely.
• Serial radiographs should be obtained
weekly for the first 3 weeks and then at 6
weeks, 3 months, 6 months, and 1 year,
• contraindication to closed treatment is
unstable purely ligamentous spinal column
injury
 Operative Treatment
• Unstable injuries of the cervical spine, with or without
neurological deficit, generally require operative
treatment.
• In general, posterior stability should be obtained first,
followed by anterior decompression and fusion if
indicated
• It allows rapid mobilization of the patient in a cervical
orthosis, and healing usually occurs within 8 to 12 weeks
• The critical role of time is increasingly being recognized
as potentially pivotal in affecting neurologic recovery
• .
 Approaches-
• posterior, anterior, or combined procedures done in a
staged manner or sequentially in one procedure under a
single anesthetic
1. Posterior stabilization procedures usually are indicated
for posterior ligamentous instability
2. Anterior decompression and fusion, with or without
internal fixation, are most often indicated for burst
fractures of the cervical spine with documented
compression of the neural elements by retropulsed bone
or disc fragments and an incomplete neurological deficit.
3. Combined anterior decompression and posterior fusion
are indicated for patients who have severe instability and
a significant neurocompressive pathological condition
 Dislocations of the Atlantooccipital Joint
(Head slips forward on C1)

are uncommon and usually is fatal

• Cervical traction is contraindicated. Immediate
application of a halo vest is recommended to
stabilize the joint
• this instability may be evidenced by bradycardia or
episodes of bradycardia followed by asystole
• early surgical stabilization of the atlantooccipital
joint is recommend because ligamentous healing in
a halo vest is unpredictable
• Stabilization is obtained by posterior cervical
arthrodesis using large cortical cancellous bone
grafts with stabilization by dual plates screwed to
the posterior occiput and attached to lateral mass
screws
• The patient is placed in a cervicooccipital orthosis
for 8 to 12 weeks, or until a good fusion mass is
present. Smoking and the use of nonsteroidal
antiinflammatory drugs are avoided.
 Atlas Fractures
• Types
•Anterior Arch
(1) posterior arch fracture
(2) lateral mass fracture
(3) burst fracture (Jefferson
fracture), which is characterized Posterior Arch Fracture
by four fractures—two in the
posterior arch and two in the
anterior arch
Lateral Mass Fractures

Jefferson Fractures
(transverse ligament
stable unstable ruptured
• Nondisplaced or minimally displaced fractures of
the lateral mass and Jefferson fractures can be
treated by collar immobilization
• Fractures in which the lateral mass of the atlas is
displaced laterally more than 7 mm beyond the
articular surfaces of the axis (C1-2 instability )
should be reduced with halo traction for 3to 6 weeks
before application of a halo vest
• Isolated posterior arch fractures are stable injuries
that can be treated in a cervical collar for 8 to 12
weeks
• External immobilization of the cervical spine until
healing of the C1 ring fracture occurs should be
done before proceeding with surgical
stabilization(fusion) of the C2 fracture.to avoid loss
of reduction
ATLAS FRACTURES
 Rupture of the Transverse
Ligament
• It most commonly results from a fall with a blow to
the back of the head
• Anterior widening of the atlanto-dens interval of
more than 5 mm on the flexion view suggests that
the transverse ligament is incompetent
• type I, disruptions of the substance of the
ligament(are incapable of healing without internal
fixation)
• type II, fractures and avulsions involving the
tubercle insertion of the transverse ligament on the
lateral masses of C1..( should be treated initially
with a rigid cervical orthosis ) reserving surgery for
patients who had a nonunion and persistent
instability after 3 to 4 months with immobilization
• Surgical stabilization ;
Initial treatment consists of immobilization through
skull traction and then posterior stabilization of the
C1-2 complex with a Gallie type of posterior C1-2
Wiring
Rotary Subluxation of C1 on C2
• patient presents with torticollis and restricted neck motion
• An open-mouth odontoid radiograph may reveal the “wink sign” caused
by overriding of the C1-2 joint on one side and a normal configuration
on the other side
Fielding and Hawkins classification
1. Type I —simple rotary displacement without anterior shift;
odontoid acts as pivot.
2. Type II —rotary displacement with anterior displacement of 3 to 5
mm; lateral articular process acts as pivot.
3. Type III —rotary displacement with anterior displacement of more
than 5 mm.
4. Type IV —rotary displacement with
posterior displacement
•
• Acute rotary subluxation of C1-2 can be reduced by closed means
1. apply a halo ring
2. Using gentle traction, use the halo ring to derotate the skull and C1
3. assistant pushes on the anteriorly displaced lateral mass through
the posterior pharynx
4. Apply topical anesthesia to the posterior pharynx to help in
diminishing the gag reflex.
5. Reduction is accompanied by an audible “pop” and loss of the
posterior pharyngeal mass
• If closed reduction is unsuccessful, or if the injury has not been
detected until late, open reduction can be attempted
Stabilize the C1-2 complex with a posterior cervical arthrodesis using
autogenous iliac bone grafting

• If stable reduction is obtained ,Immobilization in a halo vest is

recommended for 8 to 12 weeks to allow consolidation of the bone
graft.
 Occipital Condyle Fractures
• Palsies of lower cranial nerves may be the
only symptom of the fracture
• These injuries usually result from axial
loading and lateral bending during which
force is applied to the head and neck
• type I, impaction stable a rigid
• type II, basilar skull fracture cervical orthosis
or halo vest
• type III, avulsion fracture Unstable
immobilization for 12
weeks in a halo vest is
recommended
If instability is indicated on flexion and extension films after an adequate
period of immobilization in a halo vest, occipital-to-C2 fusion may be
 Dens Fracture
• Type I ;(2 %) oblique fracture
through upper part of odontoid
process
even if nonunion occurs after
inadequate immobilization, no
instability results.
• Type II (50-75 %) fracture at
junction of odontoid process and
body
36% nonunion rate .
• Type III (15-25 %) fracture
through upper body of vertebra.
fractures have a large
cancellous base and
heal without surgery
in 90% of patients
 Type II Fracture Nonunion
Risk Factors

Nonunion 10-70%
Initial displacement >
6mm
Age > 60 yr old
Delay Diagnosis > 3 wk
Angulation > 10°
Posterior displacement
 Treatment Options
Type 1
Philadelphia collar
Type 2
posterior cervical fusion
Type 3 Nondisplaced fractures are stable injuries

that heal with 8 to 12 weeks of immobilization

in either a halo vest or a cervical collar
Type 3 displaced dens fractures is correction of
angulation in a halo vest, while allowing the
fracture to settle until union occurs
Anterior Odontoid Screw Fixation
Indications
• Displaced Type II, Shallow Type III
• Polytrauma patient
• Unable to tolerate halo-vest
• Early displacement despite halo-
vest
Contraindications
• Non-reducible odontoid fracture
• Body habitus (Barrel chest )
• Subacute injury (> 6 months)
• Reverse oblique
 Posterior Odontoid Fixation
• Options
1,Brooks and Jenkins
technique of atlantoaxial
fusion (Bone grafts secured
by wires (anteroposterior
and lateral)
2 Gallie wiring
3(Magerl and Seemann )
C1-2 transarticular
screws, + posterior C1-2
fusion using either the
Gallie or the Brooks
technique
 Traumatic Spondylolisthesis of the
Axis (Hangman's Fractures
• Type I fractures are minimally
displaced , these fractures are stable
and usually heal with 12 weeks of
immobilization in a rigid cervical
orthosis.
• Type II fractures have more than 3 mm
of anterior translation and significant
angulation Treatment consists of
application of skull traction with slight
extension of the neck over a rolled-up
towel for 3 to 6 weeks The patient can
be mobilized in a halo vest for the rest
of the 3-month period
• Type IIA fractures are a variant of
type II fractures that show severe
angulation between C2 and C3
with minimal translation.
Treatment is application of a halo
vest with slight compression
applied under image
intensification to achieve and
maintain anatomical reduction.
Then halo vest immobilization is
continued for 12 weeks until union
occurs.

Dislocated
• Type III injuries combine a bipedicular fracture
with unilateral or bilateral facet injury or
dislocation at C2-3 .
Open reduction and internal fixation usually are
required because of inability to obtain or
maintain reduction of the C2-3 facet dislocation
After posterior cervical fusion at the C2-3 level,
halo vest immobilization for 3 months is
necessary
Type I Type II
Angulation and
Undisplaced displacement

Type IIA
Only angulation Type III
Bilat facet dislocation