upper cervical spine injuries - fisiokinesiterapia · 2017-01-12 · physical exam 1st, detailed...

UPPER CERVICAL UPPER CERVICAL SPINE INJURIESSPINE INJURIES

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OverviewOverview

Introduction Introduction Anatomy Anatomy Evaluation & early managementEvaluation & early managementCervicocranialCervicocranial injuriesinjuries•• OccipitocervicalOccipitocervical dissociationdissociation•• Occipital Occipital condylecondyle fracturesfractures•• Atlas fracturesAtlas fractures•• AtlantoaxialAtlantoaxial instabilityinstability•• Axis fracturesAxis fractures

IntroductionIntroduction

40% risk of 40% risk of neuroneuro deficits with deficits with cervical spine injuriescervical spine injuriesCost per injured pt= incredibly highCost per injured pt= incredibly highEtiology: MVA 45%, falls 20%, Etiology: MVA 45%, falls 20%, sports 15%, violence 15%sports 15%, violence 15%

AnatomyAnatomy

-atlanto-odontoid joint= synovial-tectorial membrane= cephalad continuation of PLL

AnatomyAnatomy

-extrinsic ligaments (nuchae, joint capsules)= weaker-intrinsic ligaments= within spinal canal, majority of ligamentous stability

3 layers: 1)tectorial membrane 2)cruciate ligament 3)odontoid ligaments

AnatomyAnatomy

Range of MotionRange of Motion

OcciputOcciput--atlasatlas•• Flexion/extension: 25degFlexion/extension: 25deg•• Lateral bending: 5deg each sideLateral bending: 5deg each side•• Rotation: 5deg each sideRotation: 5deg each side

AtlantoaxialAtlantoaxial•• Flexion/extension: 20degFlexion/extension: 20deg•• Lateral bending: 5degLateral bending: 5deg•• Rotation: 40 degRotation: 40 deg

Range of MotionRange of Motion

AlarAlar ligaments and ligaments and tectorialtectorialmembrane limit distraction to >2mmmembrane limit distraction to >2mmTranslation (limited by facet joints Translation (limited by facet joints and and alar/tectorialalar/tectorial ligaments) should ligaments) should not exceed 1mmnot exceed 1mm

Cervical Spine EvaluationCervical Spine Evaluation

Primary surveyPrimary survey•• ABCDEABCDE

Physical exam 1Physical exam 1stst, detailed history , detailed history laterlater•• NeuroNeuro examexam

Initial xInitial x--rayray-- lateral clateral c--spine film, spine film, must include C7must include C7--T1 junctionT1 junctionMaintain airway with jaw thrust, Maintain airway with jaw thrust, not not head tilthead tilt methodmethod

NeuroNeuro ExamExam

-cranial nerves: VI, VII, IX, XI, XII-reflexes: DTR’s, cremasteric (T12,L1), anal wink (S2,3,4), BC (S3,4)

RadiographsRadiographs

Complete CComplete C--spine= xspine= x--table lateral, table lateral, swimmers if needed, AP, swimmers if needed, AP, OdontoidOdontoidNearly 100% sensitive if all these Nearly 100% sensitive if all these views obtainedviews obtainedCT: for CT: for atlantoaxial/cervicothoracicatlantoaxial/cervicothoracicjunctions, equivocal C1junctions, equivocal C1--2 x2 x--raysraysMRI: disc pathology, ligament injury, MRI: disc pathology, ligament injury, spinal cord injuryspinal cord injury

Lateral CLateral C--spine Filmspine FilmAnterior vertebral Anterior vertebral linelinePosterior vertebral Posterior vertebral linelineSpinolaminarSpinolaminar linelineADI (ADI (nlnl=2.5=2.5--3.0mm)3.0mm)Retropharyngeal Retropharyngeal soft tissue >5mm soft tissue >5mm is abnormalis abnormal

AP CAP C--spine filmspine film

Least Least infomativeinfomativeVertebrae heightVertebrae heightSpinousSpinous process process alignment & alignment & spacingspacingUniform disc and Uniform disc and uncovertebraluncovertebralspacingspacing

Open Mouth Open Mouth OdontoidOdontoid

Lateral mass Lateral mass overlap should be overlap should be less than 7mm less than 7mm totaltotalLook for Look for odontoidodontoidtilttilt

Early ManagementEarly Management

Goal=prevent further damageGoal=prevent further damageMethylprednisoloneMethylprednisolone•• 30 mg/kg bolus30 mg/kg bolus•• 5.4 mg/kg/hr for 23 hrs5.4 mg/kg/hr for 23 hrs•• Only effective under 8 hoursOnly effective under 8 hours•• 11--3 hrs: continue 24 hrs3 hrs: continue 24 hrs•• 33--8 hrs: continue 48 hrs8 hrs: continue 48 hrs

Early ManagementEarly Management

-Gardner Wells tongs: for unstable or malaligned injuries needing tractionpre-op or reduction

-below temporal ridges 2cm above external auditory meatus-start with 10 lbs, add 5 lb increments, PATIENT AWAKE

General Treatment GoalsGeneral Treatment Goals

1)Protect neural structures1)Protect neural structures2)Reduce and stabilize injured 2)Reduce and stabilize injured segmentsegment3)Provide long term stability3)Provide long term stability

OccipitocervicalOccipitocervical DissociationDissociationExtremely rare Extremely rare ligamentousligamentous injury with high injury with high mortality ratemortality rate55--12% of cervical injuries in autopsy studies12% of cervical injuries in autopsy studiesMechanism: Mechanism: pedspeds vs. auto (vs. auto (hyperexthyperext/distraction)/distraction)Anterior (most common), posterior, longitudinalAnterior (most common), posterior, longitudinalKids predisposedKids predisposed•• Ligament laxityLigament laxity•• Immature OC jointsImmature OC joints•• Larger head to body size ratioLarger head to body size ratio

PowerPower’’s Ratios RatioBC/OA ratio less BC/OA ratio less than 1=normalthan 1=normalIf more than 1, If more than 1, anterior dislocation anterior dislocation existsexistsCan be misleading Can be misleading with posterior with posterior dislocatondislocaton, , odontoidodontoid fxfx, , congencongen. anomalies. anomalies

Harris Rule of 12Harris Rule of 12Better measurementBetter measurementAdults and kids >13yoAdults and kids >13yoThree landmarksThree landmarks•• BasionBasion•• OdontoidOdontoid tiptip•• Posterior axial linePosterior axial line

1) 1) BasionBasion--axial axial intervalinterval2) 2) BasionBasion--dental dental intervalintervalBoth should be Both should be <12mm<12mm

Odontoidtip Basion

Posterior axialline

OccipitocervicalOccipitocervical Dissociation Dissociation Clinical findings range from mild to catastrophicClinical findings range from mild to catastrophic•• Death by medulla oblongata Death by medulla oblongata transectiontransection and respiratory and respiratory

failurefailure

Cranial nerve injuriesCranial nerve injuries•• AbducensAbducens (VI) most often(VI) most often

Vertebral artery injuriesVertebral artery injuries•• ALC, ALC, nystagmusnystagmus, ataxia, , ataxia, diplopiadiplopia, , dysarthriadysarthria

Treatment:Treatment:•• Respiratory supportRespiratory support•• Early halo vs. traction stabilizationEarly halo vs. traction stabilization•• PSF vs. prolonged halo PSF vs. prolonged halo

NonNon--op op txtx rarely results in stabilityrarely results in stability

Occipital Occipital CondyleCondyle FracturesFractures

Often in conjunction with other cOften in conjunction with other c--spine spine fxfx’’ssUsually found on CT, hard to find on Usually found on CT, hard to find on xx--rayrayUsually axial compressionUsually axial compressionDxDx: look for : look for prevertebralprevertebral swelling, swelling, torticollistorticollis, CN XI, CN XI--XII (acute or XII (acute or delayed)delayed)

Occipital Occipital CondyleCondyle Fractures:Fractures:ClassificationClassification

Anderson and Montesano, based on Anderson and Montesano, based on CT findingsCT findings•• Type I: impaction of Type I: impaction of condylecondyle, stable, stable•• Type II: associated basilar skull fractureType II: associated basilar skull fracture

Stable unless entire Stable unless entire condylecondyle separatedseparated

•• Type III: avulsion Type III: avulsion fxfx via via alaralar ligamentsligamentsCan be bilateralCan be bilateralIn 30In 30--50% of 50% of atlantoatlanto--occipital dislocationsoccipital dislocations


Treatment:Treatment:•• Types I & II: halo vest 6Types I & II: halo vest 6--12 weeks 12 weeks

depending on stabilitydepending on stability•• Type III: potentially unstable, require at Type III: potentially unstable, require at

least 12 weeks halo vestleast 12 weeks halo vest


-MVA, neck pain, C5-6 translation on lateral film-dysarthria due to XII (hypoglossal) palsy from type I OCF noted on CT

Atlas FracturesAtlas Fractures

10% of cervical spine injuries10% of cervical spine injuriesNeurologicNeurologic injury is rareinjury is rare•• Ring tends to expand with injury Ring tends to expand with injury

allowing more room for the cordallowing more room for the cord

High incidence of associated injuryHigh incidence of associated injuryUp to seven typesUp to seven types•• Each has a predictable mechanismEach has a predictable mechanism


Burst fracture Burst fracture (33%)(33%)““Jefferson Jefferson FxFx””Symmetric axial Symmetric axial loadload3 or 4 parts3 or 4 partsLeast likely to Least likely to cause cause neuroneuro injuryinjury


Transverse Transverse ligament can fail ligament can fail (tension from (tension from lateral masses), lateral masses), defining unstable defining unstable fracturefractureApical and Apical and alaralarligaments sparedligaments spared


Burst Burst fxfx treatmenttreatment•• Stable: non or minimally displaced lateral Stable: non or minimally displaced lateral

masses (<5mm) masses (<5mm) Collar or halo 3 Collar or halo 3 mosmosHigh union rateHigh union rate

•• Unstable: >5mm displacement due to Unstable: >5mm displacement due to transverse ligament disruptiontransverse ligament disruption

Reduction by traction, then halo or surgeryReduction by traction, then halo or surgeryNeed 4Need 4--6 weeks traction prior to halo to hold 6 weeks traction prior to halo to hold reductionreductionSurgery= C1Surgery= C1--2 fusion2 fusion


Posterior arch Posterior arch fracture (28%)fracture (28%)Hyperextension Hyperextension with axial load with axial load injuryinjuryStable:Stable:•• Lateral masses and Lateral masses and

anterior arch intactanterior arch intact

Atlas FractureAtlas Fracture

Posterior arch Posterior arch fracturefractureTreatment:Treatment:•• Collar for 10Collar for 10--12 12

weeks until unionweeks until union•• High union rateHigh union rate

Atlas FracturesAtlas FracturesComminuted/lateral Comminuted/lateral mass fracture (22%)mass fracture (22%)Axial compression Axial compression with lateral flexionwith lateral flexionUsually with Usually with transveretransvereligament avulsion ligament avulsion fxfxMost likely to result in Most likely to result in nonunion and poor nonunion and poor functional outcomefunctional outcomeTxTx: same as burst : same as burst fractures (depends on fractures (depends on lateral mass lateral mass displacement)displacement)


Anterior arch Anterior arch fractures fractures ““blow outblow out”” fxfxmay see may see odontoidodontoidfxfxReduction requires Reduction requires flexionflexionHalo vest in flexion Halo vest in flexion vs. PSFvs. PSF

Atlas FracturesAtlas FracturesTransverse process Transverse process fracturesfracturesUnilateral or bilateralUnilateral or bilateralAvulsion or lateral Avulsion or lateral bendingbendingAlong with other Along with other avulsion avulsion fxfx’’ss, treat , treat symptomatically with symptomatically with soft collar 4soft collar 4--6 weeks6 weeks

Transverse LigamentTransverse LigamentSpence JBJS 1970Spence JBJS 1970•• Burst Burst fxfx with intact ligament: less than 5.7 with intact ligament: less than 5.7

mm mm atlantoaxialatlantoaxial offsetoffset•• Burst Burst fxfx with ruptured ligament: greater than with ruptured ligament: greater than

6.9 mm offset6.9 mm offsetHyperflexionHyperflexion injury injury •• Different than burst, Different than burst, alaralar/apical ligaments can /apical ligaments can

be affected, more unstablebe affected, more unstable•• Translation <5mm, transverse ligament only Translation <5mm, transverse ligament only

disrupteddisrupted•• Translation >7mm, loss of Translation >7mm, loss of alaralar ligament and ligament and

tectorialtectorial membranemembrane

Transverse LigamentTransverse Ligament

ADI:ADI:•• NormalNormal

Adults <3mmAdults <3mmChildren <5mm Children <5mm

•• >3mm on flex/ext >3mm on flex/ext xx--rays= transverse rays= transverse ligament rupturedligament ruptured

•• >5mm, accessory >5mm, accessory ligaments rupturedligaments ruptured

OdontoidOdontoid FracturesFractures

88--12% cervical 12% cervical fxfx’’ss1010--20% have 20% have neuroneuro deficitsdeficitsOdontoidOdontoid with transverse ligament with transverse ligament prevent anterior/posterior dislocationprevent anterior/posterior dislocationFxFx mechanism unclearmechanism unclear•• Flex/ext/rotation comboFlex/ext/rotation combo•• Usually MVAUsually MVA

OdontoidOdontoid FracturesFracturesType IType I•• Least commonLeast common•• Stable, avulsion?Stable, avulsion?

Type IIType II•• Most commonMost common•• Least likely to heal Least likely to heal

nonoperativelynonoperatively

Type IIIType III•• More stable than More stable than

type II with higher type II with higher union rateunion rate


Type I treatmentType I treatment•• If not part of a more serious injury, If not part of a more serious injury,

immobilize in cervical immobilize in cervical orthosisorthosis 66--8 8 weeksweeks

•• May represent OC dislocation with May represent OC dislocation with alaralarligament disruptionligament disruption

This requires occiputThis requires occiput--C2 fusionC2 fusion


Type III treatmentType III treatment•• Usually seen in kids <7yo= Usually seen in kids <7yo= epiphysealepiphyseal

separationsseparations•• May require traction to reduce fracture May require traction to reduce fracture

if displaced >5mm or angulated >10degif displaced >5mm or angulated >10deg•• Halo vest for 8Halo vest for 8--12 weeks12 weeks•• Union rates exceed 95%Union rates exceed 95%


Type II treatmentType II treatment•• Nonunion rates 10Nonunion rates 10--77%77%

Risk factors: initial displacement >5mm, Risk factors: initial displacement >5mm, posterior displacement, posterior displacement, comminutioncomminution, , inability to reduce, age >50yoinability to reduce, age >50yo

•• NonNon--displaced: halo vest 12 weeks with displaced: halo vest 12 weeks with frequent xfrequent x--raysrays

•• With displaced then anatomically With displaced then anatomically reduced fractures, union 84reduced fractures, union 84--100%100%

OdontoidOdontoid FracturesFracturesVascular insult Vascular insult theories for high Type theories for high Type II nonII non--union rateunion rate•• Damage to ascending Damage to ascending

artery as it artery as it pasespases basebase

But But angioangio and autopsy and autopsy in nonin non--unions have unions have shown rich blood shown rich blood supply and no AVNsupply and no AVNInterposed soft Interposed soft tissue? tissue? IntraarticularIntraarticular??


Type II treatmentType II treatment•• High risk fracturesHigh risk fractures

Collar= bad, high nonunionCollar= bad, high nonunionHalo= not tolerated well in elderlyHalo= not tolerated well in elderlyOdontoidOdontoid screw= high union rate (79screw= high union rate (79--100%), preserves AA motion, bad with 100%), preserves AA motion, bad with osteopeniaosteopenia/big chests/ posterior /big chests/ posterior displacementdisplacementC1C1--2 PSF= high union rate (872 PSF= high union rate (87--100%), 100%), sacrifices AA motionsacrifices AA motion


-posterior displaced type II treated with bone block construct andSublaminar/subarch wires

Traumatic Traumatic SpondylolisthesisSpondylolisthesisof the Axisof the Axis

““HangmanHangman’’s Fractures Fracture””•• Radiology similar, mechanism differentRadiology similar, mechanism different•• Hanging= violent hyperextension/distraction with Hanging= violent hyperextension/distraction with

complete disruption of disc & ligaments between C2 and complete disruption of disc & ligaments between C2 and C3, spinal cord severedC3, spinal cord severed

•• MVA= combo of ext/axial compress/ flexion with varying MVA= combo of ext/axial compress/ flexion with varying disc injurydisc injury

NeurologicNeurologic injury uncommon, spinal canal injury uncommon, spinal canal decompresseddecompressedAxis vulnerable as transition vertebrae between Axis vulnerable as transition vertebrae between mobile elements above and fixed elements belowmobile elements above and fixed elements below•• Transition of articulations from front to backTransition of articulations from front to back•• Fracture through pars Fracture through pars intraarticularisintraarticularis


Classification:Classification:•• Type I= fracture through neural arch, no Type I= fracture through neural arch, no

angulationangulation, up to 3mm displacement, up to 3mm displacement•• Type IA= atypical, recently recognized, Type IA= atypical, recently recognized,

elongation of C2 body, extension into elongation of C2 body, extension into transverse foramen can injure vertebral A.transverse foramen can injure vertebral A.

•• Type II= significant Type II= significant angulationangulation and and displacementdisplacement

•• Type IIA= minimal displacement, severe Type IIA= minimal displacement, severe angulationangulation

•• Type III= combined bilateral facet dislocation Type III= combined bilateral facet dislocation C2C2--3 with axis neural arch 3 with axis neural arch fxfx


Type I Type II

Type IIA Type III


Type IType I•• Bilateral pars Bilateral pars fxfx’’ss•• C2C2--3 disc/ligaments 3 disc/ligaments

intact, major injury intact, major injury to boneto bone

•• Treat with collar Treat with collar immobilizationimmobilization

•• Treat IA the sameTreat IA the same


Type IIType II•• C2C2--3 disc & PLL 3 disc & PLL

disrupted allowing disrupted allowing translation >3mmtranslation >3mm

•• ALL intact but stripped ALL intact but stripped from bonefrom bone

•• Gentle traction Gentle traction reductionreduction

Add extension with Add extension with bolster behind bolster behind shouldersshoulders

•• Halo vest 6Halo vest 6--8 weeks8 weeks


Type IIType II•• If displaced >5mm If displaced >5mm

or angled >10degor angled >10degTraction to reduceTraction to reduceRecumbantRecumbant bedrestbedrest44--6 weeks6 weeksHalo vest 6Halo vest 6--8 weeks8 weeksSurgical stabilization Surgical stabilization an option, but an option, but spontaneous anterior spontaneous anterior fusion=common fusion=common (favors non(favors non--op)op)


-transpedicular lag screw fixation of a type II hangman’s fracture


Type IIAType IIA•• Less common than Less common than

type IItype II•• FxFx more obliquemore oblique•• Avoid tractionAvoid traction, will , will

diplacediplace fxfx•• Reduction: Reduction:

extension and extension and gentle gentle axial loadaxial load

•• Halo vest 6Halo vest 6--8 8 weeksweeks


Type IIIType III•• Very unstableVery unstable•• Most common with Most common with

assoc assoc neuroneuro injuryinjury•• Irreducible closedIrreducible closed

Inferior facets of C2 Inferior facets of C2 floating freefloating free

•• TxTx: ORIF with : ORIF with wiring or plating wiring or plating based on facet & based on facet & lamina integritylamina integrity


Results:Results:•• No long term studiesNo long term studies•• Levine 4.5 year Levine 4.5 year f/uf/u

Type I: 90% healed, 10% with degenerative Type I: 90% healed, 10% with degenerative changeschangesType II: 70% developed spontaneous Type II: 70% developed spontaneous anterior fusionanterior fusionType III: overall poor prognosis due to Type III: overall poor prognosis due to neurologicneurologic deficitsdeficits

upper cervical spine injuries - fisiokinesiterapia · 2017-01-12 · physical exam 1st, detailed...

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