Cervical spine fractures

• Epidemiology of Cervical Spine Injuries

Preadmission Immobilization

1. Hard cervical collar
2. Supportive blocks and tape
3. Back board and straps
4. "Neutral position"
   

The Initial Management of Acute Spinal Cord Injury

1. Airway (with Spine Precautions)
2. Breathing
3. Circulatory
4. Disability (Neurologic Exam)
5. Exposure

Motor Examination of the Upper Extremity

1. C5- elbow flexion
2. C6- wrist extension
3. C7- wrist flexion/ finger extension
4. C8- finger flexion
5. T1- Finger abduction
   

Motor Examination of the Lower Extremity

1. L2- hip abduction
2. L3- knee extension
3. L4- foot dorsiflexion
4. L5- ehl/ knee flexion
5. S1- fhl/ knee flexion

Sensory Examination

Pain and Temperature occurs via the spinothalamic tracts.  Proprioception and vibration occurs via the dorsal columns.  In the acute situation, sparing of sensation to pin prick in a motor segment w/ grade 0 power indicates an 85% chance of motor recovery to at least grade 3.  AR Poyton et al. JBJS 1997.

Reflex Examination

The Bulbocavernosus Reflex is Anal sphincter contraction in response to squeezing the glans penis, clitoris or tugging on the Foley.  It involves S-1, S-2, and S-3 nerve roots.  An absence of this reflex documents continuation of spinal shock or spinal injury at the level of the reflex arc itself.  Spinal Shock is Spinal cord concussion which usually involves 24-72 hour period of paralysis, hypotonia, & areflexia.  At its conclusion there may be hyperreflexia, hypertonicity, and clonus.  The return of reflex activity below level of injury (such as bulbocavernosus reflex) indicates end of spinal shock.  Spinal shock does not apply to lesions that occur below the cord

American Spine Injury Association (ASIA) Impairment Scale

• A = Complete
• B = Incomplete: sensory preserved; no motor
• C = Incomplete: motor preserved; but < grade 3
• D = Incomplete: motor preserved; > grade 3
• E = Normal

Incomplete SCI occurs when any spared motor or sensory function below level of injury iexists.  There is often good potential for recovery.

Brown Sequard

Central Cord

Anterior Cord

Complete SCI

Complete spinal cord injury is the total absence of distal motor or sensory function, together with recovery of the bulbocavernosus reflex.  An improvement of one nerve root level can be expected in 80% of patients, and approximately 20% will recover 2 additional levels.  Operative decompression can also allow recovery of an additional nerve root level

Early Management of Acute Cervical Spinal Cord Injury

AVOID HYPOTENSION! Furthermore, Maintain the MAP at 85-90 mm Hg for the first week.  Keep 100% O₂ saturation via nasal cannula.  Spinal dose steroids. Also perform early closed/open reduction and decompression if necessary.

Steroids in Acute SCI

NASCIS 1 (1984): N=330; RT. 

• High dose (1000mg bolus) MPSS vs. low dose (100mg bolus) MPSS. 
•  No improvement in neurological outcome was noted.  High dose: early case fatality & wound infection higher

NASCIS 2 (1992):RCT;

• treat within 12 hrs of SCI; n=487
• MPSS n=162, naloxone n=154, placebo n=171
• Post hoc analysis focused on pts who got drug within 8 hrs (n=193)
• At 1yr: motor scores changed "significantly"

NASCIS 3 (1997):RCT; n=499 (no placebo group)

• MPSS 24 hrs (n=166), MPSS 48 hrs (n=166), MPSS bolus + TRLZ (n=167)
• 48 hr MPSS ~ to 24 hr MPSS~TRLZ if started before 3 hrs
• 48 hr MPSS recovered more motor function if started 3-8 hrs after

Pneumonia and Sepsis was highest with 48 hr MPSS. 

In penetrating SCI, the lack of an effect and potential for deleterious effects on wound healing limits there use  

Timing of Decompression in Acute Spinal Cord Injury

• No standard of care
• Early surgery (<72 hrs) does not increase complications
• Biologic rational for early surgery based on animal models
• Urgent decompression recommended in setting of:Bilateral facet dislocation
• Incomplete SCI in a neurologically deteriorating patient Cervical Traction
  

Early closed reduction of cervical spine fracture-dislocation injuries is recommended in the awake patient.  This method restores anatomic alignment and increases width of spinal canal.  Decompression occurs through ligamentotaxis. If one is unable to follow neuro exam, a pre-reduction MRI should bew performed.  For cervical traction apply tongs with pin 2 cm above pinna, in line with the tragus.  Next =t ighten until 1mm exposed (mean pullout: 137 lbs.) Traction should be in line with the spine and the feet should be tied to the bed.  Be sure to keep the weight off floor and be sure to obtain baseline neurologic exam.  Add weight in 5-10 lbs. increments to gain a proper reduction.  Obtain portable x-ray and neuro exam at each increment.  Up to 2/3 body weight (or ~140 lbs.) may be added to obtain a proper reduction. 

Goals in C-Spine Injuries

1. Treat concomitant injuries
2. Preserve neurologic function
3. Enhance neurologic recovery
4. Maximize functional recovery

The goal is to provide a stable and pain free spine. Clinical instability is the inability of the spine to protect the spinal cord or nerve roots from initial or subsequent damage and prevent the development of incapacitating deformity or severe pain under physiological loads. White & Panjabi 1990

Element Point Value

• Anterior elements destroyed or unable to function 2
• Posterior elements destroyed or unable to function 2
• Positive stretch test 2

Radiographic Criteria

Flexion-extension radiographs

1. Sagittal plane translation > 3.5mm or 20%
2. Sagittal plane rotation > 20^o

Resting radiographs

1. Sagittal plane displacement > 3.5mm or 20%
2. Relative sagittal plane angulation > 11^o 
   

Developmentally narrow spinal canal

1. Sagittal diameter < 13mm
2. Torg/Pavlov ratio < 0.8
   

Abnormal disc narrowing 1

Spinal cord damage 2

Nerve root damage 1

Dangerous loading anticipated 1
Total of 5 or more points = unstable

Anatomic Lines

Atlas Fractures

• Avulsion injuries: soft collar for 4-6 weeks
• Posterior arch fracture: cervical orthosis
• Anterior Arch, Lateral Mass, Burst Fractures- Non or minimally displaced (<5mm) - cervical orthosis or halo vest for 3 months-Displaced or unstable - anatomic reduction using traction followed by:Halo (radiograph closely)Posterior fusionC1-C2 arthrodesis using transarticular screws (immediate mobility)Occiput-C2 arthodesis for:Progressive displacement
• Late C1-C2 instability
• Symptomatic C1 nonunion
  
  

Management of Odontoid Fractures

Cervical Collar

• Type I: ~100% Fusion
• Type II: 50-60% Fusion
• Type III: 50-65% Fusion

Halo Immobilization

• Type I: 100% Fusion
• Type II: 65% Fusion
• Type III: 84% Fusion

Neurosurgery March 2002 Sup. Surgical Management of Odontoid Fractures

Posterior Fixation

• Type II: 87-100% Fusion
• Type III: 100% FusionAnterior Fixation Type II: 79-100% Fusion (25% when fx > 6 months old)
• Type III: 100% Fusion

  
  

Surgical Management of Odontoid Fractures

Combined Atlas and Axis fractures are relatively common with24%-53% of pts with atlas fractures have odontoid fractures.  6%-26% of pts with hangman fractures have C1 fractures.  High mortality and morbidity.

Management of Odontoid Fractures in the Elderly

Gallie Fusion

Brooks

• Advantages:  Biomechanically superior
• Disadvantages:  Sublaminar wires, also Contraindicated in C1 arch fractures

Transarticular Screw Fixation

• Advantages:  Biomechanically superior than wiring with good maintenance of reduction.  The integrity of posterior C1 arch is not necessary.However it is technically demanding
• Surgical M&M: 2-4%Failed reduction, Vertebral artery injury, Neurologic deficit

Anterior Odontoid Screw Fixation

• Advantages:  Preserves C1-C2 motion segment with simple post-op care and immobilization. Less traumatic than other options.
• Contraindications:Anterior oblique fracturesWhen transverse ligament is disruptedWhen the fracture is older than 6 months.  This much more technically difficult.  Moreover this requires bi-planar fluoroscopy. 
  

Os Odontoideum 

This results from failure of fusion of the base of odontoid.  Also a possible fracture of odontoid synchondrosis occurs before closure at age 5-6 yr; - w/ growth the alar ligaments may carry the fragment away from its base.  Usually asymptomatic (but may present with neck pain, myelopathy).

Management:

• Asymptomatic: follow clinically and radiographically
• Neurologic symptoms/instability: posterior C1-C2 fusion (with post-op halo, unless using transarticular screws)

Cervicomedullary compression: occipitocervical fusion +/- decompression

HLA-B27

Affects: SI joints, hips, spine

Ossification of ligaments

Fracture with trivial trauma

> 50% have severe neurologic injury

#1 cause for neuro deterioration: secondary displacement (positioning)