c spine injury non operative

8/8/2019 c Spine Injury Non Operative

1/38

Cervical Spine Injuries

Classification and Non-operativeTreatmentDr. Heather Roche

Dec. 12, 2002


2/38

Evaluation

MVA, diving accidents most common cause

should suspect in anyone with head or high

energy trauma or neurological deficit

can be missed with multiple trauma and if

non-contiguous vertebrae involved or

altered consciousness

16% people will have non-contiguous spinefractures

50% will have other skeletal or visceral

injuries


3/38

History MVA thrown from car strike head

any paralysis at time of injury if currently paralyzed was there any indication

of movement at time of accident

Physical

full neuro exam including rectal and

bulbocavernosus

r/o other injuries


4/38

Radiography

Initial

cross table lateral 70-79%

AP and open mouth increases yield to 90-95%

swimmers view for C7-T1

Other

Ct scan bony anatomy and lower c-spine

Flex-extension

controversial in acute setting

only in alert and cooperative patients without

neurological deficit with neck pain

false ne atives due to muscle s asm


5/38

MRI Patients with complete or incomplete

neurulogical deficit, deterioration in

neurological function or suspected posterior

ligamentous injury despite negative plain

radiographs


6/38

Radiographic evidence of

Instability

Angulation between vertebral bodies that is 11

greater than adjacent segment

AP translation > 3.5mm

spinous process widening on lateral

facet joint widening

malalignment of spinous process on anterior view

rotation of facets on lateral

lateral tilting of vertebral body on anterior view


7/38

Instability


8/38


9/38

Initial Treatment

Immobilization

rigid cervical orthosis- Philadelphia collar

unstable injury this is inadequate often andcervical traction required

halo traction or gardner-wells tongs

1cm posterior to external auditory meatus and just

above the pinna should be MRI compatible

10-15 pounds usually appropriate

post alignment xray and neuro exam


10/38

Closed Reduction

Injuries demonstrating angulation, rotation orshortening

restore normal alignment therefore decompressing

the spinal canal and enhancing neuro recovery

preventing further injury need neuro monitoring and radiography

awake, alert and cooperative patient to provide

feedback

traction, positioning and weights ( 10 pds head

and 5 pds each level below) xray after new weight

applied

maintain after with 10-15 lbs traction


11/38

Spinal Cord Injury

Maintain SBP > 90mmHg

100% O2 saturation

early diagnosis by xray

methylprednisolone bolus 30mg/kg then infusion5.4mg/kg

Corticosteroids benefit in recovery

Nascis-2 data showed methylprednisolone within 8

hours of injury had better recovery of neurologicfunction at 6 weeks, 6 months and 1 year after injury

compared to other substances like naloxone and

placebo

injury < 3 hrs continue for 24 hors and > 3 hrs for 48


12/38

Anatomy of Upper cervical spine


13/38

Injuries to Upper cervical Spine Occipitoatlantal Dislocation

hyperextension distraction and rotation of

craniovertebral junction

severe neurological injuries from complete C1

quadriplegia to incomplete syndromes xray

diastasis at craniovertebral junction

Powers ratio

distance between basion and post arch of atlas by distance

between opisthion and ant arch atlas with > 1 abnormal

avoid traction and stabilize head to neack with halo

surgical Rx required as primarily a ligamentous

injury


14/38

Occipital-atlantal Dissociation


15/38

Atlas Fractures Axial compression injuries

neurological injury rare

3 types

Jefferson fracture- direct compression and

lateral masses forced apart

asymmetric load fracture ant or post to mass

and displaces it

posterior arch fractures with an extension

moment through it


16/38


17/38

Rx ? Transverse ligament intact

avulsion at insertion on CT lateral overhang of C1 over outer edges of C2

> 6.9 mm= rupture

ADI > 4mm

MRI visualization of ligament

Ligament intact

cervical orthosis ( Philadelphia, SOMI, Minerva) for

posterior arch or undisplaced Jefferson

Halo - asymmetric lateral mass or displaced Jeffersonfractures

No ligament

Fusion


18/38

Odontoid Fracture 15 % all cervical fractures

usually MVA or blow to the head Three types

Type 1 Avulsion off tip by alar ligament

Type 2 fracture at junction of dens with the central

body

Type 3 fracture in body of axis and primarily

cancellous bone

usually hyperflexion with anterior displacement

assoc injuries to C1 common

neurological deficit in 15-25% cases


19/38

Odontoid Fractures


20/38

Treatment Type 1 -

Philadelphia collar for 6-8 weeks

Type 3 -

collar inadequate

Halo vest immobilization after reduction in

traction 80 % union rate ( 3-4 months)


21/38

Treatment cont Type 2

high rate of non-union ( up to 40% in displaced) due to

small area of bony contact and watershed blood supplyto the waist of odontoid

Increased non-union with displacement, smoker and

advanced age

undisplaced - halo immobilization displaced -

? Traction for reduction then halo immobilization

? Primary C1-C2 fusion after reduction in traction

most recommend if displacement > 4-5mm


22/38

Hangmans Fracture

Traumatic spondylolithesis Type 1

isolated minimally displaced fracture of ring with no

angulation

Type 2

more unstable

flesion type/extension type or listhetic type

displaced > 3mm and angulation of C2-C3 disk space

ALL, PLL Disc can be interrupted

Type 3

rare

anterior dislocation of C2 facets on C3 with 2 extension

fracturing neural arch


23/38

Hangmans Fracture


24/38

Treatment Type 1

rigid cervical orthosis

Type 2 closed reduction with trection and position opposite

direction instability

halo vest immobilization

follow for loss of reduction

Type 3

reduction of facet dislocation with traction

C2 -C3 fusion after pre-op MRI


25/38

Sub axial Spine

bodies articulate by intervertebral disc, ALL and

PLL

facet joints are in a coronal plane 45 to horizontal

allowing flexion and extension 14 degrees insagittal plane

due to 45 incline lateral tilt accompanied by

rotation

9 degrees in coronal plane and 5 rotation in each

segment

vertebral foramen in lateral mass contain vertebal

artery which transverses C6 through C1


26/38

Biomechanics

Denis three column spine for TL spine now applied to

c-spine

Anterior region

disk and centrum resist compression

ALL, anterior annulus resist distraction

Middle

post vertebral body and uncovertebral joints PLL and Annulus resist distraction

Posterior

facet joints and lateral mass compression

facet capsule, intra and supraspinous ligaments


27/38

Classification

Ferguson and Allen Based on position of neck at time of injury

and dominant force

2 column theory

everything anterior to PLL ant column

most patients have a combination of

patterns


28/38

Compression and Flexion Level C4-5 and C5-6

compression of ant column and distraction of post

different stages with later stages having more post

involvement and displacement of vertebral body

MRI to evaluate post ligaments

intact - HALO sufficient not - risk of late kyphotic deformity therefore

fusion


29/38

Vertical Compression

C6-7 most common shortening of ant and post columns

stage 1 -

cupping of end plate with partial failure anteriorly andnormal post ligaments

rigid orthosis

stage 3 -

fragmentation and displacement of body burst

neurologic injury common with assoc post element

fractures

anterior corpectomy and reconstruction for neuro

recovery plus post fusion to prevent kyphosis


30/38

Distraction Flexion Most common pattern

tensile failure and lengthening of post column

with possible compression of ant column

ant translation superior vertebra

25% facet subluxation

50% unilateral facet dislocation > 50% bilateral dislocation

full body displacement


31/38


32/38


33/38

Treatment

Closed reduction initially max weight

controversial

successful

non-operative treatment 64% late instability

fusion recommended

unsuccessful open reduction and fusion


34/38

Flexion distraction cont 50-80% assoc acute disk herniation at level of

injury

awake closed reduction has not shown worseningof neuro deficit and should not undergo major

delay in reduction while waiting for MRI

MRI prerequisite to open reduction

Disk present ant cervical diskectomy prior to

reduction


35/38

CompressionE

xtension Early compressive failure of post column

and late tensile failure ant column

late stages body displacement unstable and

require anterior fusion


36/38

Compression Distraction Tensile failure of both ant and post columns

bony or ligamentous

stage1

no body displacement on static or flexion/ext

rigid orthosis

Stage 2

displacement present

fusion


37/38

Lateral Flexion Asymmetric loading in coronal plane

displacement

fusion


38/38

Halo Skeletal Fixation

c spine injury non operative

Documents