Cervical Spinal Injuries

Cervical spine: Atlas, Axis, and sub-axial cervical spine classification and management portion are discussed in detail.

Cervical spinal injury mechanisms, imagings, and diagnostic pitfalls are discussed in this link.

Atlas fractures ( C1 Fractures)

It may be associated with cranial nerve lesion (VI-XII) and neuropraxia of the suboccipital and greater occipital nerves.

Classifications: Levine Classification

1. Isolated Bony apophysis fractures
2. Isolated posterior arch fractures
3. Isolated anterior arch fractures
4. Community lateral mass fractures
5. Burst fracture aka Jefferson fractures

C2 Odontoid Process fractures:

Usually flexion injury

Elderly / osteoporotic people

Anderson’s and D’Alonzo’s classification:

Type I:

Avulsion by alar ligament

Tip of odontoid àunless with/out difficulty

Treatment: immobilization in a rigid collar

Type II:

Fracture @ junction of odontoid and body of the axis

          (most common and dangerous)

Prone to non-union

If displaced > 4mm, tilted >11°

Treatment: non-operatively with traction followed by collar/ halo vest

Type III:

 Through the body of the axis

(stable and united with immobilization)

Treatment: Halo vest for 8-12 weeks

Traumatic Spondylolisthesis of C₂ – C₃(Hangman’s fracture)

(Hangman’s fractures)

Hanging mechanisms involves hyperextension and distraction injury –>Patient may experience B/L pedicle fractures + complete disruption of disc and ligament between C2- C3.

Classifications:

Treatment according to Levine and Edwards classification

Type I

Rigid Cervical Orthosis (4-6 weeks)

Type II

If < 5mm displacement àreduction with traction then Halo immobilization 6-12 weeks

If  >5 mm displacement then go for surgery / prolonged traction

Type IIa

Avoid traction

Reduction with gentle axial load + hyperextension then compression Halo immobilization

Sub-Axial Cervical Spine Injury

Classification:

< 4: Non-operative

4=Surgeon choice

>4: Operative

Allen-Ferguson Classification of cervical Spine:

1. Compression Flexion:
   • Shear mechanism results in teardrop fractures
2. Vertical Compression: (burst fractures)
3. Distractive flexions
4. Compression flexions
5. Distractive Extension
6. Lateral Flexions

Clay-slover fractures: Avulsion of the spinous process of the lower cervical and upper thoracic vertebrae

Treatment of Cervical Spinal Injuries

Immobilization with

• Cervical orthosis: for stable #
• Skull traction: for unstable #

Before CT evaluation/other systemic evaluation

Gardeners well tong:

• 1 finger width above the pinna

• 10lb for head and 5 lb for each successful interface

Halo-crown/vest assembly

• Halo ring- applied 1 cm above ears

Suspected Neurological Shock: Vasopressure support is indicated

Use of intravenous methylprednisolone as per recommended dose:

Most undergo conservative management with orthosis:

1. Soft collar ( soft cervical orthosis): supportive t/t for minor injuries
2. Rigid Cervical orthosis:(Philadelphia collar): controls flexion/ extension but little rotation àrotation, lateral bending
3. Poster brace: effective in controlling mid-cervical flexion with fair control in other planes of motion
4. Cervico-thoracic Orthosis: effective in flexion and extension and rotational control, limited lateral control
5. Halo devices: most rigid immobilization among external devices

Patients with neuro deficits from burst-type injuries

Traction is used to stabilize with decompress the canal via ligamentotaxis

Patient with unilateral or bilateral facet dislocations and complete neural deficit:

• Garners-Well tongs and reduction by sequential increasing the amount of traction are indicated
• Radiographs must be performed after the 1^st 10 lb of weight is applied to R/O occult occipital cervical dislocation
• Weight ↑es in 5 lb increase with radiographs obtained after each vertebrae increases.

Incomplete neural deficit/ neurologically intact with unilateral bilateral facet dislocationà Require MRI to evaluate Herniated Disc.

Traction is CONTRAINDICATED in distractive cervical spine injuries and Type IIA spondylolisthesis injuries of C2.

Halo is recommended in:

1. Isolated Occipital condyle fractures
2. Unstable Atlas ring fractures
3. Odontoid fractures
4. Displaced neural arch fractures of axis

Stabilization of the Upper Cervical Spine (Occiput- C2)

Due to the normally wide spinal canal diameter, decompression of neural elements is not commonly required for traumatic conditions

The mainstay of treatment:

 Fusion with Instrumentations-most commonly (posterior approach)

Atlanto-axial fusion-Occipito-cervical fusion:- less common (C1-C3 fusion)

Posterior Approach:

1. Modified Brooks or Gallie arthrodesis used sublaminar wires and bone graft between the arches of and C2
2. Flexion controlàobtained via the wires
3. Extension via the blocks
4. Rotation via friction between the bone blocks and the posterior arches
5. Transarticular Screw (Magrel) are effective
6. If posterior elements of C1 and C2 are fractured
7. Lateral mass screw @C1

Pedicle screw fixation @C2

Between C1 and C2–Rod fixations (Harm’s fixation)

Osteosynthesis

2 indications for direct fracture repair in the upper cervical spine

1. Type II odontoid fractures
2. Type II traumatic spondylolisthesis of C2 with interfering screw fixation

Anterior approach:

3 main indications for anterior upper cervical spinal approach

1. Screw fixation for Type II odontoid fractures
2. Anterior interbody Fusion + plating of C2- C3 interspace for Type IIA or III Hangman fractures
3. For failed posterior atlantoaxial fusion (salvage procedure)—Anterior arthrodesis

Stabilization of the Lower Cervical Spine (C3-C7)

Between facet articulation

• 50 % of flexion-Extension
• 50% of rotation

Posterior decompression with fusion

Posterior cervical fusion and instrumentation with lateral mass fixation

Anterior decompression and fusion

Double Injuries: Whiplash Injury

Sprained Neck/ Cervical Acceleration / Deceleration Injury

History of low-velocity rear collision in which occupant’s body is forced against the car seat

Head flips backward and recoils inflection

[Strain of ALL, facet capsule]

Clinical features:

Pain/stiffness after 12-48 hr

On examinations:

Neck muscles are tender and movements are often restricted

The patient may present with skew neck

Symptoms:

• Occipital headache
• Neck stiffness
• Auditory/visual disturbances

Treatment:

• Collars (1^st 3 days)
• NSAIDS
• Graded Exercise
  • Short arc to active movements
  • Active ROM exercises slowly
• Isometric exercises
• USG
• Tractions
• Manipulation
• Massage

Whiplash-associated disorder (Chronic whiplash Syndrome)

In absence of clinical, radiological / objectives signs

Continue to complaints of pain, restriction of movement, loss of function, depression, and inability to work

For compensation claims, legal cost

Still doubtful: physical insufficiency or behavioral disorder