Subaxial Cervical Spine Truama

Sub-axial cervical spine trauma
Dr Wasim R. Issa
Physical exam
– Palpation
• Neck pain / tenderness
– 84% patients with a clinical exam and fracture have
midline neck pain
– 20% of patients with a clinically significant cervical
spine fracture with negative plain films have a fracture
on CT scan
• Step off between spinous processes
• Crepitus
– Range of motion .
?Which films
• Traditionally : AP, lat and open mouth
– only 30–60 % sensitivity in evaluating for ligamentous
injuries and fractures
• Flexion/Extension
– Controversial as to timing
– Only in cooperative alert patient with pain and
negative 3 view
– Negative study does not rule out injury
– If painful, keep immobilized, reevaluate
• CT
– powerful tool in the initial diagnostic workup
– characterize fracture pattern and degree of canal
compromise more clearly .
– Sensitivity of 99 % and specificity of 100 %
• MRI
– For more detailed about canal compromised
Mechanism of Injury
• Hyperflexion
• Axial Compression
• Hyperextension
Hyperflexion
– Distraction creates
tensile forces in
posterior column
– Can result in
compression of
body (anterior
column)
– Most commonly
results from MVC
and falls
Compression
– Result from axial
loading
– Commonly from
diving, football, MVA
– Injury pattern
depends on initial
head position
– May create burst,
wedge or
compression fx’s
Hyperextension
– Impaction of posterior
arches and facet
compression causing
many types of fx’s
• lamina
• spinous
processes
• pedicles
– With distraction get
disruption of ALL
– Evaluate carefully for
stability
– LOOK FOR CENTRAL
CORD SYNDROME
Classification
• Allen and Ferguson Spine 1982
• Harris et al OCNA 1986
• Anderson Skeletal Trauma 1998
• Stauffer and MacMillan Fractures
1996
• AO/OTA Classification
– Most are based on mechanism of
injury
• SLICS is not mechanism based
– Sub-axial cervical spine injury classification system
Allen and Ferguson
– 6 categories
• Compressive flexion
• Vertical compression
• Distractive flexion
• Compression
extension
• Distractive extension
• Lateral flexion
Allen and Ferguson Spine 1982

AO/OTA Classification
•• Type
Not Aspecific for cervical spine
– Axial loading; compression; stable
• Provides some treatment guidelines
• Type B
– Bending type injuries
• Type C
– Circumferential injuries; multi-axial
Unilateral Facet Dislocation
• Distraction
Flexion/rotation injury
• Painful neck
• 70% radiculopathy, 10%
SCI
• Easy to miss-supine
position can reduce
injury!
• “Bow tie” sign: both facets
visualized, not overlapping
Bilateral Facet Dislocation
• Injury to cord is
common
• 10-40% herniated
disk into canal
Bilateral Facet Dislocation
• Timing for reduction
– Spinal cord injury may be reversible at 1-3 hours
• Need for MRI

– If during awake reduction, paresthesias or
declining status
– Difficult closed reduction
– If neurologically stable, perform MRI prior to
operative treatment (loss of reduction?)
Facet Dislocation
Treatment
• Non-operative
– Cervicothoracic brace or halo x 12 weeks
– Need anatomic reduction
• OR approach and treatment depends on

pathology
– Anterior diskectomy and fusion w/plate
– Posterior foraminotomy and fusion with
segmental stabilization
Compression Fractures
• Flexion force
• The question is one of
ligamentous
damage/posterior
instability
• Stability determines
treatment
Compression
Rizzolo SJ, Cotler JM. Unstable cervical spine injuries: specific treatment approaches. J Am Acad Orthop Surg 1993; 1:57-66
Compression-Flexion
Rizzolo SJ, Cotler JM. Unstable cervical spine injuries: specific treatment approaches. J Am Acad Orthop Surg 1993; 1:57-66
Burst Fractures
• Comminuted body
fracture with
retropulsion
• Treatment based on
neuro status and
instability
Burst Fractures Treatment
• Surgical treatment
routine for high grade
burst fractures
• Most commonly
treated with
corpectomy, anterior
grafting of some type
and rigid plate fixation
• Supplemental posterior
fixation if patient
osteopenic or injury to
posterior structures
warrants stabilization
Teardrop Fracture
– Extension (upper
cervical spine)
• Usually benign
• Avulsion type
– Flexion (lower
cervical spine)
• Anterior wedge or
quadrangular
fragment
• Unstable
Teardrop Fracture
• High energy
flexion,compressive force
• Often posterior element

disruption
– Unstable injury
• Routinely requires surgery

Cervical Lateral Mass Fracture Separation
• affect 2 levels (2 adjacent motion segments)

– because of involvement of the superior facet and
inferior facet on either side of the fractured
articular mass
• location
– C6 > C5 > C7 > C4 > C3
Kotani Classification
• neurologic symptoms common (up to 66%)
– radicular pain, radiculopathy or spinal cord
injury/myelopathy
• Physical exam inspection

– torticollis, paravertebral muscle spasm
• Nonoperative
– NSAIDS, rest, immobilization
• indications
– stable injuries without neurological deficit
• techniques
– Miami J collar
– halo vest
• outcomes
– long term results of non-operative treatment are less
desirable
– may be successful in the absence of instability
– spontaneous fusion rate is only 20%
posterior decompression and two-level
instrumented fusion
• indications
– most cases require surgery
– main injured structures are posterior, thus
preferred approach is posterior
• techniques
– two-level lateral mass or pedicle screw and rod
fixation
– lateral mass plating
• two-level ACDF indications
– if mostly reduced and dont need posterior
approach to obtain direct reduction
– controls anterior collapse and rotation
• techniques
– using iliac crest bone graft
• single posterior pedicle screw indications
– Type A Separation fracture without instability
• Complications :
– Vertebral artery injury
• from pedicle screw placement
– Late kyphotic deformity
– Late instability (anterior translation)
– Chronic neck pain and radiculopathy
Clay-shoveler Fracture
• Clay-shoveler Fracture (Cervical Spinous
Process Fractures)
– Avulsion-type spinous process fracture in the
lower cervical or upper thoracic spine
– Prognosis
• stable injury in isolation
• very rarely assoicated with neurological injury
• high union rate
• Nonoperative
– NSAIDS, rest, immobilization in hard collar for
comfort
• indications
– most common treatment for pain control
• modalities
– short term treatment with hard collar
• outcomes
– usually high union rates and excellent clincal outcomes
• Operative
– surgical excision
• indications
– persistent pain or non-union
– failed conservative treatment

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Subaxial Cervical Spine Truama

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Sub-axial cervical spine trauma

Allen and Ferguson Spine 1982

• Need for MRI

• OR approach and treatment depends on

• Often posterior element

• Routinely requires surgery

• affect 2 levels (2 adjacent motion segments)

• Physical exam inspection

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