Cervical spine injuries and its management

Dr.Prashanth kumar1st yr pg

• 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.

• 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 C1 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 inone of two ways: (a) a fall onto the head or the back ofthe neck; and (b) a blow on the forehead, which forcesthe neck into hyperextension

PRINCIPLES OF DIAGNOSIS ANDINITIAL 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

• If two or three columns injured-lesion is unstable

• Works well for C3 to T1.• Does not work so well for

C1-2, (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

• 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

Alignment

Lateral viewTop of T1 visibleThree smooth arcs maintainedVertebral bodies of uniform heightOdontoid intact and closely applied to C1

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• An adequate film should include the

entire odontoid and the lateral borders of C1-C2.

• Occipital condyles should line up with the lateral masses and superior articular facet of C1.

• The distance from the dens to the lateral masses of C1 should be equal bilaterally.

• The tips of lateral mass of C1 should line up with the lateral margins of the superior articular facet of C2.

• The odontoid should have uninterrupted cortical margins blending with the body of C2.

Swimmers view

Key Things to Identify

• Predental space – should be 3mm or less

• Prevertebral soft tissue swelling– May be due to

hematoma from a fracture

– Soft tissue swelling may make fracture diagnosis difficulty

• Disc spaces should be the equal and symmetric

Diagnostic pitfalls in children

• Children are often distressed and difficult to examine;

• more than usual reliance may be placed on the x-rays.

• It is well to recall some common pitfalls.• An increased atlanto-dental interval (up to

4.5mm)

• may be quite normal; this is because the skeleton is incompletely ossified and the ligaments relatively lax during childhood.

• There may also be apparent subluxation of C2 on C3 (pseudosubluxation).

• An increased retropharyngeal space can be brought about by forced expiration during crying.

• Growth plates and synchondroses can be mistaken for fractures..

• The normal synchondrosis at the base of the dens has usually fused by the age of 6 years, but it can be mistaken for an undisplaced fracture.

• The spinous process growth plates also resemble fractures; and the growth plate at the tip of the odontoid can be taken for a fracture in older children

• SCIWORA is an acronym for spinal cord injury without obvious radiographic abnormality.

• Normal radiographs in children do not exclude the possibility of spinal cord injury

FINDING OF FRACTURE, SUBLUXATION, OR ABNORMAL INTERSEGMENTAL MOTION AT LEVEL OF NEUROLOGICAL INJURY EXCLUDES SCIWORA AS A DIAGNOSIS

• EXPERIMENTALLY, OSTEOCARTILAGINOUS STRUCTURES IN SPINAL COLUMN CAN STRETCH 2 INCHES WITHOUT DISRUPTION -- SPINAL CORD RUPTURES AFTER 1/4 INCH

• ANATOMICALLY, CERVICAL SPINAL CORD IS RELATIVELY TETHERED - SPINAL NERVES, DURAL ATTACHMENT TO FORAMEN MAGNUM, AND BRACHIAL PLEXUS

• PRESENTING NEURO EXAM CORRELATES TO OUTCOME

• MRI FINDINGS (OR LACK OF) MAY BE MORE PREDICTIVE OF OUTCOME

• NO CHILD HAS BEEN DOCUMENTED TO DEVELOP SPINAL INSTABILITY AFTER DX OF SCIWORA

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 3~8 hours 30mg/kg bolus +

5.4mg/kg/hr infusion for 48 hours.– suppress inflammatory response and vasogenic

edema

Initial TreatmentImmobilization• 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

CrutchField Traction

HALO TRACTION

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.

• The diagnosis can sometimes be made on the lateral cervical radiograph:

• the tip of the odontoid should be no more than 5mm in vertical alignment and 1mm in horizontal alignment from the basion (anterior rim of the foramen magnum).

• Greater distances are allowable in children. • CT scans are more reliable.

The injury is likely to be unstable and requires immediate reduction (without traction!) and stabilization with a halo-vest, pending surgical treatment.

After appropriate attention to the more serious softtissue injuries and general resuscitation, the dislocation should be internally fixed;

specially designed occipito-cervical plates and screws are available for the purpose.

In severely unstable injuries, halo-vest stabilization should be retained for another 6–8 weeks.

Occipito–cervical fusion X-ray showing one ofthe devices used for internal fixation in occipito-cervicalfusion operations

• C1 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.

• A CT 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 C1/2 fixation and fusion is needed.

• A hyperextension injury can fracture either the anterior or posterior arch of the atlas.

• These injuries are usually relatively stable and are managed with a halo-vest or semi-rigid collar until union occurs.

• Fractures of the atlas are associated with injury elsewhere in the cervical spine in up to 50 per cent of cases.

• 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

• Undisplaced fractures which are shown to be stable on supervised flexion–extension views (less than 3mm of C2/3 subluxation) can be treated in a semi-rigid orthosis until united (usually 6–12 weeks).

• Fractures with more than 3mm displacement but no kyphotic angulation may need reduction;

• however, because the mechanism of injury usually involves distraction, traction must be avoided.

• After reduction, the neck is held in a halo-vest until union occurs. C2/3 fusion is sometimes required for persistent pain and instability (‘traumatic spondylolisthesis’).

• Occasionally, the ‘hangman’s fracture’ is associated with a C2/3 facet dislocation.

• This is a severely unstable injury; open reduction and stabilization is required

C2 Odontoid process fracture

• Odontoid fractures are uncommon. • They usually Occur as flexion injuries in

young adults after highvelocity injuries.• However, they also occur in elderly,

osteoporotic people as a result of low-energy trauma in which the neck is forced into hyperextension, e.g. a fall onto the face or forehead

• A displaced fracture is really a fracture-dislocation of the atlanto-axial joint in which the atlas is shifted forwards or backwards, taking the odontoid process with it.

• At this level about a third of the internal diameter of the atlas is free space, a third filled with the odontoid and a third with the cord;

• thus there is room for displacement without neurological injury.

• However,cord damage is not uncommon and in old people there is a considerable mortality rate

Classification

• • Type I – An avulsion fracture of the tip of the odontoid process due to traction by the alar ligaments.

• The fracture is stable (above the transverse ligament) and unites without difficulty.

• .

• • Type II – A fracture at the junction of the odontoid process and the body of the axis.

• This is the most common (and potentially the most dangerous) type.

• The fracture is unstable and prone to non-union

• • Type III – A fracture through the body of the axis.

• The fracture is stable and almost always unites with immobilization.

Fractured odontoid process (a) Anteroposterior‘open-mouth’ x-ray showing a Type II odontoid fracture.(b) Lateral x-ray of the same patient.

• Clinical features• The history is usually that of a severe neck strain followed by

pain and stiffness due to muscle spasm.• The diagnosis is confirmed by high quality x-ray examination;• it is important to rule out an associated occipito-cervical

injury which commands immediate attention. In some cases the clinical features are mild and continue to be overlooked for weeks on end.

• Neurological symptoms occur in a significant number of cases.

• Imaging• Plain x-rays usually show the fracture, although the

extent of the injury is not always obvious – e.g. there may be an associated fracture of the atlas or displacement at the occipito-atlanto level.

• Tomography is helpful but MRI has the advantage that it may reveal rupture of the transverse ligament; this can cause instability in the absence of a fracture.

• Treatment• Type I fractures Isolated fractures of the

odontoid tip are uncommon. • They need no more than immobilization in a

rigid collar until discomfort subsides.

• Type II fractures These are often unstable and prone to non-union, especially if displaced more than 5 mm.

• Undisplaced fractures can be held by fitting a halo-vest or – in elderly patients – a rigid collar.

• Displaced fractures should be reduced by traction and can then be held by operative posterior C1/2 fusion; a drawback is that neck rotation will be restricted.

• 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 reducedby skull traction and held by fixing the spinous process of C1 to that of C2 with wires. (c) An undisplaced Type II fracture,which was suitable for (d) anterior screw fixation.

• Type III 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

Posterior ligament injury

• Sudden flexion of the mid-cervical spine can result in damage to the posterior ligament complex (the interspinous ligament, facet capsule and supraspinous ligament).

• The upper vertebra tilts forward on the one below, opening up the interspinous space posteriorly

Cervical spine – posterior ligament injury(a) The film taken in extension shows no displacement ofthe vertebral bodies, but there is an unduly large gapbetween the spinous processes of C4 and 5. (b) With theneck slightly flexed the subluxation is obvious.NB: flexion–extension views are potentially dangerous andshould be used only in specific situations under directsupervision of an experienced surgeon.

• 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.

• The assessment of stability is essential in these cases.

• If the angulation of the vertebral body with its neighbour exceeds 11 degrees, if there is anterior translation of one vertebral body upon the other of more than 3.5 mm or if the facets are fractured or displaced, then the injury is unstable and it should be treated as a subluxation or dislocation.

•

• If it is certain that the injury is stable, a semi-rigid collar for 6 weeks is adequate;

• if the injury is unstable then posterior fixation and fusion is advisable

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.

• A note of warning: The x-ray should be carefully examined to exclude damage to the middle column and posterior displacement of the vertebral body fragment, i.e. features of a burst fracture (see below)which is potentially dangerous. If there is the least doubt, an axial CT or MRI should be obtained

Cervical compression fracture A wedge compressionfracture of a single cervical vertebral body. This isa stable injury because the middle and posterior elementsare 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).

• If there is any deterioration of neurological status while the fracture is believed to be unstable, and the MRI shows that there is a threat of cord compression,then urgent anterior decompression is considered anterior corpectomy, bone grafting and plate fixation, and sometimes also posterior stabilization.

Tear-drop fracture (a) This comminuted vertebral body fracture has produced a large anterior fragment and obviousposterior displacement of the posterior fragment. (b) In this case the anterior ‘tear-drop’ was noted but the severity ofthe injury was underestimated; careful examination shows that the main body fragment is displaced slightly posteriorly.The patient was treated in a collar; 3 weeks later (c) the fracture had collapsed and the large body fragment was nowvery obviously tilted and displaced posteriorly. By then he was complaining of tingling and weakness in his right arm.Beware the innocent tear-drop!

Hyperextension injury

• Hyperextension strains of soft-tissue structures are common and may be caused by comparatively mild acceleration forces. Bone and joint disruptions, however,are rare.

• The more severe injuries are suggested by the history and the presence of facial bruising or lacerations.

• The posterior bone elements are compressed and may fracture;

• the anterior structures fail in tension, with tearing of the anterior longitudinal ligament or an avulsion fracture of the anterosuperior or anteroinferior edge of the vertebral body, opening up of the anterior part of the disc space, fracture of the back of the vertebral body and/or damage to the intervertebral disc

• . In patients with pre-existing cervical spondylosis, the cord can be pinched between the bony spurs or disc and the posterior ligamentum flavum;

• oedema and haematomyelia may cause an acute central cord syndrome (quadriplegia, sacral sparing and more upper limb than lower limb deficit,a flaccid upper limb paralysis and spastic lower limb paralysis).

• These injuries are stable in the neutral position, in which they should be held by a collar for 6–8 weeks.

• Healing may lead to spontaneous fusion between adjacent vertebral bodies

Hyperextension injuries (a) The anterior longitudinal ligament has been torn; in the neutral position the gap willclose and reduction will be stable, but a collar or brace will be needed until the soft tissues are healed. (b) X-ray in thiscase showed a barely visible flake of bone anteriorly at the C6/7 disc space. (c) 1 month later the traction fracture at C6/7was more obvious, as was the disc lesion at C5/6. (d) A year later C6/7 has fused anteriorly; the patient still has neck paindue to the C5/6 disc degeneration.

Avulsion injury of the spinous process

• Fracture of the C7 spinous process may occur with severe voluntary contraction of the muscles at the back of the neck; it is known as the clay-shoveller’s fracture.

• The injury is painful but harmless.• No treatment is required; • as soon as symptoms permit, neck exercises

are encouraged.

Avulsions (a) The clay-shoveller’s fracture.Jerking the neck backwards has resultedin avulsion of one of the spinous processes – abenign injury. (b) This patient might bethought to have a similar fracture, but a subsequentflexion film (c) shows the serious natureof the injury – a severe fracture-dislocation

SPRAINED NECK (WHIPLASH INJURY)

• Soft-tissue sprains of the neck are so common aftermotor vehicle accidents that they now constitute a veritable epidemic.

• There is usually a history of a lowvelocity rear-end collision in which the occupant’s body is forced against the car seat while his or her head flips backwards and then recoils in flexion.

• This mechanism has generated the imaginative term whiplash injury, which has served effectively to enhance public apprehension at its occurrence.

• .

• However, similar symptoms are often reported with flexion and rotation injuries.

• Women are affected more often than men, perhaps because their neck muscles are more gracile

• There is disagreement about the exact pathology but it has been suggested that the anterior longitudinal ligament of the spine and the capsular fibres of the facet joints are strained and in some cases the intervertebral discs may be damaged in some unspecified manner.

• There is no correlation between the amount of damage to the vehicle and the severity of complaints.

Clinical features

• Often the victim is unaware of any abnormality immediately after the collision.

• Pain and stiffness of the neck usually appear within the next 12–48 hours, or occasionally only several days later.

• Pain sometimes radiates to the shoulders or interscapular area and may be accompanied by other, more ill-defined, symptoms such as headache, dizziness, blurring of vision, paraesthesia in the arms, temporomandibular discomfort and tinnitus.

• Neck muscles are tender and movements often restricted; the occasional patient may present with a ‘skew neck’. Other physical signs – including neurological defects – are uncommon.

• X-ray examination may show straightening out of the normal cervical lordosis, a sign of muscle spasm; in other respects the appearances are usually normal.

• In some cases, however, there are features of longstanding intervertebral disc degeneration or degenerative changes in the uncovertebral joints; it may be that these patients suffer more, and for longer spells,than others.

• Proposed grading of whiplash-associated• injuries• Grade Clinical pattern• 0 No neck symptoms or signs• 1 Neck pain, stiffness and tenderness No physical

signs• 2 Neck symptoms and musculoskeletal signs• 3 Neck symptoms and neurological signs• 4 Neck symptoms and fracture or dislocation

Differential diagnosis

• The diagnosis of sprained neck is reached largely by a process of exclusion, i.e. the inability to demonstrate any other credible explanation for the patient’s symptoms.

• X-rays should be carefully scrutinized to avoid missing a vertebral fracture or a mid-cervical subluxation.

• The presence of neurological signs such as muscle weakness and wasting, a depressed reflex or definite loss of sensibility should suggest an acute disc lesion and is an indication for MRI.

• Seat-belt injuries often accompany neck sprains.• They do not always cause bruising of the chest,

but they can produce pressure or traction injuries of the suprascapular nerve or the brachial plexus, either of which may cause symptoms resembling those of a whiplash injury.

• The examining doctor should be familiar with the clinical features of these conditions.

Treatment

• Collars are more likely to hinder than help recovery.• Simple pain-relieving measures, including analgesic

medication, may be needed during the first few weeks.• However, the emphasis should be on graded exercises,• beginning with isometric muscle contractions and postural

adjustments, then going on gradually to active movements and lastly movements against resistance.

• The range of movement in each direction is slowly increased without subjecting the patient to unnecessary pain. Many patients find osteopathy and chiropractic treatment to be helpful.

• 1-5% OF CSI ARE MISSED - MAINTAIN APPROPRIATE LEVEL OF SUSPICION IF SEEING A PATIENT WITH CONTINUED NECK PAIN AFTER BEING “CLEARED” -- KNOW THE BASIC MANAGEMENT GUIDELINES FOR CLEARING THE C-SPINE

• If a spinal fracture is identified at any level, the entire spine should be examined with antero-posterior and lateral views to document the presence or absence of spinal fractures at other levels

TAKE HOME MESSAGE

• MISSED/DELAYED CSI OCCURS DUE TO LACK OF AN APPROPRIATE INDEX OF SUSPICION, INADEQUATE PLAIN FILMS, AND MISREAD STUDIES

• IF HAVE HIGH ENOUGH INDEX OF SUSPICION TO GET XRAYS, THEN DO NOT ACCEPT INADEQUATE ONES

• IN “CLEARING” THE C-SPINE, DO NOT FORGET NONSKELETAL INJURIES: LIGAMENTOUS INSTABILITY, CERVICAL STENOSIS, AND SCIOWRA

• KNOW YOUR PEDIATRIC ANATOMICAL VARIATIONS

• DON’T BE IN A HURRY TO CLEAR THE CERVICAL SPINE - CAN ALWAYS LEAVE IN A HARD COLLAR

• Progressive neurological deficit in cord compression needs early surgical decompression.

• Anterior decompression is better.• Early surgical intervention for instability

prevents deterioration