Cervical spine injuries

Cervical spine injuries. Yash parikh pimsr.

• The cervical vertebrae are the smallest of the moveable vertebrae, and are characterized by a foramen in each transverse process. • The first, second and seventh have special features . • The third, fourth and fifth cervical are almost identical, and the sixth, while typical in its general features, has minor distinguishing differences..

Anterior Anterior arch Lateral (a) S•.erior view of Anterior Anterior arch articular facet Transv«u foramen Pnterior arch pnterior Fovea dentis (fEet for prxess) Transverse foramen arch Lateral hferior articular Posterior (b) Inferior view Of atlas articular articular Spinous (c) view Of axis (C2).

Anterior Anterior arch Anterior (a) view of atlas Anterior Anterior arch Fovea dentis for foramen Posterior arch Lateral Inferior articular surface articular P%terior (b) Inferior view Of atlas articular Transverse foramen arch Dens SL«ior articular Transverse Lamina Spinous (c) view Of axis (C2).

• Readily identified by the foramen transversarium perforating the transverse processes. This foramen transmits the vertebral artery, the vein,and sympathetic nerve fibres • Spines are small and bifid (except Cl and C7 which are single) • Articular facets are relatively horizontal.

• Nodding and lateral flexion movements occur at the atlanto-occipital joint • Rotation of the skull occurs at the atlanto-axial joint around the dens, which acts as a pivot.

MECHANISM OF INJURY • Traction injury • Direct injury: Penetrating injuries to the spine, particularly from firearms and knives, are becoming increasingly common.

• Indirect injury: Most common cause. A variety of forces may be applied to the spine (often simultaneously): — axial compression flexion — lateral compression — flexion-rotation — Shear — flexion-distraction — Extension • Insufficiency fractures may occur with minimal force in bone which is weakened by osteoporosis or a pathological lesion.

Mechanism of injury The spine is usually injured in one of two ways: (a) a fall onto the head or the back of the and (b) a blow on the which forces the neck into hyperextension.

PRINCIPLES OF DIAGNOSIS AND INITIAL MANAGEMENT • Diagnosis and management go hand in hand • Inappropriate movement and examination can irretrievably change the outcome for the worse • Early management — Airway, Breathing and Circulation — Slightest possibility of a spinal injury in a trauma patient, the spine must be immobilized until the patient has been resuscitated and other life- threatening injuries have been identified and treated..

THREE COLUMN THEORY OF DENIS Ant. column Ant Longit Lig Ant annulus Ant 2/3 vert body Middle column Post 1/3 of vert body Post annulus, Post Longit Lig Post. column Posterior elements edicles, facets. - Pamina - spinous Posterior ligaments.

• If two or three columns injured-lesion is unstable • Works well for C3 to T 1. • Does not work so well for CI-2, (so consider most or all injuries here unstable) • Only 10 per cent of spinal fractures are unstable • Less than 5 per cent are associated with cord damage Anterior.

' A stable injury is one in which the vertebral components will not be displaced by normal movements; In a stable injury, if the neural elements are undamaged there is little risk of them becoming damaged. An unstable injury is one in which there is a significant risk of displacement and consequent damage — or further damage — to the neural tissues..

RADIOLOGY Lateral view Top of Tl visible Three smooth arcs maintained Vertebral bodies of uniform height Odontoid intact and closely applied to Cl Alignment.

AP View • The height of the cervical vertebral bodies should be approximately equal • The height of each joint space should be roughly equal at all levels • Spinous process should be in midline and in good alignment.

Odontoid View adequate film SjO*lttpeCllUaqeeral Boersenr! CI-C2. Occipital cond les should line up with the latera masses an superior articu ar tacetot 1. The distance from the dens to the CI Should be tace The odontoid should Fave uninterrupted cortica margins blending with the body of C2..

• Prevertebral soft tissue swelling — May be due to hematoma from a fracture — Soft tissue swelling may make fracture diagnosis difficulty naso- Race aryng o a.

• Disc spaces should be the equal and symmetric.

24 Normal Cervical Spine Soft Tissue Measurements Predental Spre Retropharyngeal Svnce Anterior to O Retrotrsrheal Anterior to C6 Adult s 3mm s 7mm s 22mm Gild s 5mm s 7mm s 14mm.

TREATMENT • NO CONSENSUS: BUT HARD COLLAR IMMOBILIZATION FOR 12 WEEKS AND AVOIDANCE OF FLEX/EXT ACTIVITIES FOR ANOTHER 12 WEEKS HAS NOT BEEN ASSOCIATED WITH RECURRENT INJURY.

• PRINCIPLES OF DEFINITIVE • TREATMENT • The objectives of treatment are: • to preserve neurological function; • • to minimize a perceived threat of neurological compression; • to stabilize the spine; • to rehabilitate the patient.

• The indications for urgent surgical stabilization are: • (a) an unstable fracture with progressive neurological deficit and MRI signs of likely further neurological deterioration; and (b) controversially an unstable fracture in a patient with multiple injuries.

Pharmacological Management • Methylprednisolone sodium succinate (MPSS) — Within 3 hours +30mg/kg bolus + 5.4mg/kg/hr infusion for 24 hours. — During 3N8 hours 30mg/kg bolus + 5.4mg/kg/hr infusion for 48 hours. — suppress inflammatory response and vasogenic edema.

Initial Treatment Immobilization • Rigid cervical collor (philadelphia collor) • Poster braces • Cervico thoracic arthrosis • Halo device In unstable injury this is inadequate,cervical traction required — Skin (glisson' traction) — Skeletal • halo traction or gardner-wells tongs • Crutchfield tongs.

Glisson's Cervical Traction 11 11 2005.

CrutchFieId Traction.

HALO TRACTION.

Table 35-7 - Traction Recommended for Levels of Injury Level First cervical vertebra Second cewical vertebra Third cer,'ical vertebra Fourth cewical vertebra Fith cervical vertebra Sixth cerv'ical vertebra Minimum Weight in Pounds (kg) Maximum Weight in Pounds (kg) 5 (2.3) 6 (2.7) 8 (3.6) 10 (4.5) 12 (5.4) 15 (6.8) Seventh cervical vertebra 18 (8.1) 10 (4.5) 10-12 (4.5-5.4) 10-15 (4.5-6.8) 15-20 (6.8-9.0) 20-25 (9011.3) 20-30 (9.0-13.5) 25-35(11.3-15.8).

UPPER CERVICAL SPINE • Occipital condyle fracture: • This is usually a high-energy fracture and associated skull or cervical spine injuries must be sought. • The diagnosis is likely to be missed on plain x-ray examination and CT is essential. • Impacted and undisplaced fractures can be treated by brace immobilization for 8—12 weeks. Displaced fractures are best managed by using a halo- vest or by operative fixation..

• Occipito-cervical dislocation: • This high-energy injury is almost always associated with other serious bone and/or soft-tissue injuries, including arterial and pharyngeal disruption, and the outcome is often fatal. • Patients are best dealt with by a multidisciplinary team of surgeons and physicians..

Occipito—cervical fusion X-ray showing one of the devices used for internal fixation in occipito-cervical fusion operations.

• Cl ring fracture: • Sudden severe load on the top of the head may cause a 'bursting' force which fractures the ring of the atlas (Jefferson's fracture). There is no encroachment on the neural canal and, usually, no neurological damage. • The fracture is seen on the open-mouth view (if the lateral masses are spread away from the odontoid peg) and the lateral view. • ACT scan is particularly helpful in defining the fracture..

• If it is undisplaced, the injury is stable and the patient wears a semi-rigid collar or halo-vest until the fracture unites. • If there is sideways spreading of the lateral masses (more than 7 mm on the open-mouth view), the transverse ligament has ruptured; • this injury is unstable and should be treated by a halo-vest for several weeks. • If there is persisting instability on x-ray, a posterior Cl/2 fixation and fusion is needed..

• C2 pars interarticularis fractures: • In the true judicial 'hangman's fracture' there are bilateral fractures of the pars interarticularis of C2 and the C2/3 disc is torn; • the mechanism is extension with distraction. • In civilian injuries, the mechanism is more complex, with varying degrees of extension,compression and flexion..

• This is one cause of death in motor vehicle accidents when the forehead strikes the dashboard. • Neurological damage, however, is unusual because the fracture of the posterior arch tends to decompress the spinal cord. • Nevertheless the fracture is potentially unstable.

.

.

abstract.

abstract.

• Anterior screw fixation is suitable for Type II fractures that run from anterior-superior to posterior-inferior,provided the fracture is not comminuted, that the transverse ligament is not ruptured, that the fracture is fully reduced and the bone solid enough to hold a screw; in that case neck rotation is retained. • If full operative facilities are not available, immobilization can be applied by using a halo- vest with repeated x-ray monitoring to check for stability..

Fractured odontoid — treatment (a) A severely displaced Type II odontoid fracture. (b) The fracture was reduced by skull traction and held by fixing the spinous process of Cl to that of C2 with wires. (c) An II fracture, which was suitable for (d) anterior screw fixation..

Type Ill fractures If undisplaced, these are treated in a halo-vest for 8—12 weeks. • If displaced, attempts should be made at reducing the fracture by halo traction, which will allow positioning in either flexion or extension, depending on whether the displacement is forward or backward; the neck is then immobilized in a halo-vest for 8—12 weeks. • For elderly patients with poor bone a collar may suffice, though this carries a higher risk of non-union..

LOWER CERVICAL SPINE • Fractures of the cervical spine from C3 to C7 tend to produce characteristic fracture patterns, depending on the mechanism of injury: . flexion, • axial compression, • flexion—rotation or hyperextension.

• The patient complains of pain and there may be localized tenderness posteriorly. • X-ray may reveal a slightly increased gap between the adjacent spines; • however, if the neck is held in extension this sign can be missed, so it is always advisable to obtain a lateral view with the neck in the neutral position.

A flexion view would, of course, show the widened interspinous space more clearly, but flexion should not be permitted in the early post-injury period. • This is why the diagnosis is often made only some weeks after the injury,when the patient goes on complaining of pain..

Wedge compression fracture • A pure flexion injury results in a wedge compression fracture of the vertebral body • The middle and posterior elements remain intact and the injury is stable. • All that is needed is a comfortable collar for 6— 12 weeks..

Cervical compression fracture A wedge compression fracture of a single cervical vertebral body. This is a stable injury because the middle and posterior elements are intact..

Burst and compression-flexion ('teardrop') fractures These severe injuries are due to axial compression of the cervical spine, usually in diving or athletic accidents If the vertebral body is crushed in neutral position of the neck the result is a 'burst fracture'. With combined axial compression and flexion,an antero-inferior fragment of the vertebral body is sheared off, producing the eponymous 'tear-drop' on the lateral x-ray. • In both types of fracture there is a risk of posterior displacement of the vertebral body fragment and spinal cord injury..

• Plain x-rays show either a crushed vertebral body (burst fracture) or a flexion deformity with a triangular fragment separated from the antero-inferior edge of the fractured vertebra (the innocent-looking 'teardrop'). • The x-ray images should be carefully examined for evidence of middle column damage and posterior displacement (even very slight displacement) of the main body fragment. • Traction must be applied immediately • and CT or MRI should be performed to look for retropulsion of bone fragments into the spinal canal..

• TREATMENT • If there is no neurological deficit, the patient can be treated surgically or by confinement to bed and traction for 2—4 weeks, followed by a further period of immobilization in a halo-vest for 6—8 weeks. (The halo-vest is unsuitable for initial treatment because it does not provide axial traction)..