cervical spine injuries initial evaluation

CERVICAL SPINE INJURIES

By Dr.Upender satelliPG IN (MS ORTHO)Gandhi medical college

EPIDEMIOLOGY

~ 40 % of all spinal trauma is found in the polytrauma patient

2-3 % of all polytrauma victims have associated cervical spine injuries

~30,000 cervical spine injuries are documented annually

Most common site ---- cervical 60%,thoraco lumbar junction 20%, thoracic15%, lumbo sacral spine 5%

16% people will have non-contiguous spine fractures

50% will have other skeletal or visceral injuries

5% unstable 2/3rd of this do not have neurolgical

deficit Most common missed severe injury Commonly missed in

polytrauma,unconscious pts

ET IOLOGY

Most frequent cause motor vehicle crashes 37.4%

violence -25.9%, Falls- 21.5%, sports, other Severity of injury –complete quadriplegia

(23.3%),quadriparesis( 30.2%),paraplegia 26.1%,paraparasis(19.7%)

AGE & SEX

Mean age is 32 yrs Highest incidence-16-30 yrs Male :female ratio 3:1 Elderly more likely to have SCI than

young more due to falls rather than violence & sports

MORTALITY

Life expectancy decreases with severity &age of pt

Least in ventilatory dependent pts Greater who survive 1 yr after spinal

injury During 1 st yr cause of death are –

respiratory& cardiac cause Mortlity decreased but life expectancy

decreses

ATLS

Airway Breathing Circulation // Cervical spine -----------------------------------Field intubation: Avoid head tilt / chin

liftEarly identification of SCI ‘in the field’

---Avoid hypotension and hypoxia

ATLSSECONDARY SURVEY

Disability---complete neuro exam Motor/ sensory/ reflexes Perineal sensory/ anal wink/

bulbocavern. reflex Exposure

Fully disrobe and log roll Direct palpation of spine, collar

removed Fracture identification

SPINAL BOARD

H ISTORY A detailed history of the mechanism of injury is important, but

frequently is unobtainable at the initial examination.

suspected in any patient with a head injury or severe facial or scalp lacerations.

In any patient with recent trauma, complaints of neck pain or spinal pain should be considered indicative of a spinal injury until proved otherwise.

Other risk factors associated with spinal injury, , include an inability to assess neck pain because of a secondary distracting injury,

abnormal neurological findings,

history of transient neurological symptoms,

physical signs of spinal trauma (e.g., ecchymosis and abrasions), unreliable examination

inconsolable child

PHYSICAL EXAMINATION

supine. mental status also should be assessed

The head – for lacerations and contusions and palpated for facial fractures.

The ear canals should be inspected to rule out leakage of spinal fluid or blood behind the tympanic membrane, which is suggestive of a skull fracture.

The spinous processes should be palpated from the upper cervical to the lumbosacral region. A painful spinous process may indicate a spinal injury.

Palpable defects in the interspinous ligaments may indicate disruption of the supporting ligamentous complex.

• tenderness on palpation of the cervical spine should be considered indicative of a spinal injury requiring collar immobilization.

• neck motion should not be evaluated until the spine is cleared. Neck motion should be undertaken only after the patient reports no pain or tenderness during examination of the neck.

•An assistant should hold the neck steady in a neutral position while it is being palpated. The neck also should be held steady while the torso and the thoracic, lumbar, and sacral spinal areas are exposed for inspection and palpation

•. Sensation to light touch should be documented comparing each spinal level. Pinprick sensibility should be determined with a sterile needle if necessary•. Motor strength should be examined sequentially.• Deep tendon reflexes and pathological reflexes also should be checked.

• Motor and sensory evaluation of the rectum and perirectal area is mandatory.

• The patient should be evaluated for posturing. The elbows may be flexed if a spinal cord injury causes loss of function below the biceps, or they may be extended if the paralysis is higher.• Penile erection and incontinence of the bowel or bladder suggest a significant spinal injury. Quadriplegia is indicated by flaccid paralysis of the extremities.

•Initial blood pressure may be decreased without a compensatory increase in pulse because of spinal cord shock.• BRADYCARDIA OR EPISODES OF ASYSTOLE MAY BE THE ONLY FINDING OF SIGNIFICANT INJURY TO THE AXIAL REGION OF THE CERVICAL SPINE.

•The chest, abdomen, and extremities should be examined for occult injuries.

•The spine should be protected during this initial assessment;

NEUROLOGICAL EVALUATION The patient's mental status and the level of consciousness should be

determined quickly, including pupillary size and reaction –G L A S G O W C O M A S C A L E

Eyes Open Spontaneous 4 To sound 3 To pain 2 Never 1 Best Verbal Response Oriented 5 Confused conversation 4 Inappropriate words 3 Incomprehensible words 2 None 1 Best Motor Response Obeys commands 6 Localizes pain 5 Flexion withdrawal 4 Abnormal 3 Extension 2 None 1

SENSORY EXAMINATION

performed with light touch, then pinpricks (using a sterile needle), beginning at the head and neck and progressing distally, to examine specific dermatome distributions

Important dermatome landmarks are the nipple line (T4), xiphoid process (T7), umbilicus (T10), inguinal region (T12, L1), perineum and perianal region (S2, S3, and S4).

The skin should be marked where sensation is present before proceeding to motor examination.

Evidence of sacral sensory sparing establishes the diagnosis of an incomplete spinal cord injury.

The only area of sensation distal to an obvious cervical lesion in a quadriplegic patient may be in the perianal region

MOTOR EXAMINAT ION should be systematic, beginning with the upper extremities. complete / incomplete spinal cord injuries /pure nerve root

lesions. A protruded cervical disc /unilateral dislocated facet may

produce an isolated nerve root paralysis. key muscle groups and their corresponding nerve root levels +/- of sacral motor sparing should be determined by voluntary

rectal sphincter / toe flexor contractions. If voluntary contraction of the sacrally innervated muscles is

present with sacral sensation, the prognosis for recovery of motor function is good.

+ OF anal reflex without sacral sensation is consistent with a complete injury

Finally, reflexes should be documented. Paralyzed patients usually are areflexic, and flexion

withdrawal of the legs to pinprick does not indicate voluntary motion. Hyperreflexia, clonus, and pathological reflexes, such as a Babinsky reflex in the lower extremities or a Hoffman sign in the upper extremities, indicate chronic spinal cord compression. This may be @ the findings of a central cord syndrome.

KEY MUSCLE GROUPS

C5 ---Elbow flexors (biceps, brachialis) C6--- Wrist extensors (extensor carpi radialis longus

and brevis) C7-- Elbow extensors (triceps) C8 ---Finger flexors (flexor digitorum profundus to

the middle finger) T1 ---Small finger abductors (abductor digiti minimi) L2 ---Hip flexors (iliopsoas) L3--- Knee extensors (quadriceps) L4 ---Ankle dorsiflexors (tibialis anterior) L5 ---Long toe extensors (extensor hallucis longus) S1 ----Ankle plantarflexors (gastrocnemius, soleus)

Myotomes

Although spinal shock generally resolves within 24 hours, it may last longer. A positive bulbocavernosus reflex /return of the anal wink reflex indicates the end of spinal shock.

If no motor or sensory function below the level of injury can be documented when spinal shock ends, a complete spinal cord injury is present, and the prognosis is poor for recovery of distal motor or sensory function.

ANAL WINK

BULBOCAVERNOUS REFLEX

GLANS COMPRESSION

ANAL SPHINCTER CONTRACTION

American Spinal Injury Association Scale: Classification of Spinal Cord Injuries According to the Level of Impairment

Grade Motor Score* Sensory Deficit*

A 0/5 Complete

B 0/5 Incomplete

C <3/5 Incomplete

D >3/5 Incomplete

E 5/5 None

SPINAL CORD INJURIESTERMINOLOGY

Neurological level = most caudal segment with normal sensori-motor exam- bilaterally

Complete SCI = absence of sensori-motor function in the lowest sacral segment

Incomplete SCI = partial preservation of sensory and/or motor below the defined neurological level, includes the lowest sacral segment

SPINAL CORD INJURIESTERMINOLOGY

Neurogenic shock = immediate loss of sympathetic tone after SCI. Loss of vasomotor and cardiac innervation. Clinically: hypotension w/out tachycardic response Fluid resus.; may need vasopressor augment

Spinal shock = transient period of areflexia. While in shock, unable to predict likelihood of recovery . Rarely > 48 hours

INCOMPLETE CORD SYNDROMES

CENTRAL CORD SYNDROME BROWN SEQUARD CORD SYNDROME ANTERIOR CORD SYNDROME POSTERIOR CORD SYNDROME Cauda equina syndrome Conus medullaris syndrome

CENTRAL CORD SYNDROMEmost common. destruction of the central area of the spinal cord,

including gray and white matter centrally located arm tracts in the cortical spinal

area are the most severely affected, and the leg tracts are affected to a lesser extent.

Generally, patients have a quadriparesis involving the upper extremities to a greater degree than the lower. Sensory sparing varies, but usually sacral pinprick sensation is preserved.

frequently show immediate partial recovery after being placed in skeletal traction through skull tongs.

Prognosis varies, but more than 50% of patients have return of bowel and bladder control, become ambulatory, and have improved hand function.

usually results from a hyperextension injury in an older individual with preexisting osteoarthritis of the spine.

The spinal cord is pinched between the vertebral body anteriorly and the buckling ligamentum flavum posteriorly

It also may occur in younger patients with flexion injuries.

BROWN SEQUARD SYNDROME

is an injury to either half of the spinal cord usually is the result of a unilateral laminar or pedicle fracture, penetrating

injury, / rotational injury resulting in a subluxation.

SENSORY:

Ipsilateral loss of proprioception due to posterior column involvement.

Contralateral loss of pain and temperature due to involvement of lateral

spinothalamic tract.

MOTOR:

Ipsilateral spastic weakness due to descending corticospinal tract

involvement

LMN signs at the level of lesion.

Prognosis for recovery is good, with significant neurological improvement often occurring

ANTERIOR CORD SYNDROME

hyperflexion injury in which bone or disc fragments compress the anterior spinal artery and cord.

characterized by complete motor loss and loss of pain and temperature discrimination

below the level of injury. The posterior columns are spared to varying

degrees resulting in preservation of deep touch, position sense, and vibratory sensation.

Prognosis is poor.

POSTERIOR CORD SYNDROME

Involve dorsal columns

SENSORY :

Impaired position and vibration sense in LL

Tactile and postural hallucinations can occur.

Numbness or paresthesia are frequent complaints..

Sensory ataxia.

Positive rhomberg sign.

Positive lhermittes sign. es the dorsal columns of the spinal

cord

Urinary incontinence

Absent knee and ankle jerk (Areflexia, Hypotonia

CONUS MEDULLARIS & CAUDA EQUINA SYNDROMES

CM: Lies opposite to vertebral bodies of T12 and L1.

Contributes to 25% of spinal cord injuries.

Caused by flexion distraction injuries and burst fractures.

Both UMN and LMN deficits occur.

Development of neurogenic bladder.

CONUS MEDULLARIS SYNDROME

CE: Begins at L2 disk space distal

to conus medullaris.

CE syndrome occurs due to:

Acute disk herniation

Epidural haematoma

Tumour

CAUDA EQUINA SYNDROME

MOTOR :

Flaccid lower extremities.

Knee and ankle jerk absent.

SENSORY :

Asymmetrical sensory loss

Saddle anaesthesia

Loss of sensation around perineum, anus, genitals.


AUTONOMIC:

Loss of bladder and bowel function.

Urinary retention.


DDX: CONUS VS CAUDA

FEATURE CONUS MEDULARIS CAUDA EQUINA

PRESENTATION Sudden & Bilateral Gradual & Unilateral

REFLEXES Knee present, Ankle –

(If the epiconus is

involved, patellar reflex

maybe absent but

bulbocavernosus is

spared)

Knee & Ankle –

Bulbocavernosus reflex

is absent in low CE

(sacral) lesions

RADICULAR PAIN Less severe More severe

LOW BACK ACHE More Less


SENSORY SYMPTOMS

Numbness tends to be more localized to perianal area; symmetrical and bilateral; sensory dissociation occurs.

Sensory loss of pin prick & temperature sensations (Tactile sensation is spared.)

Numbness tends to be more localized to saddle area; asymmetrical, maybe unilateral; no sensory dissociation; loss of sensation in specific dermatomes in lower extremities with numbness and paresthesia; possible numbness in pubic area, including glans penis or clitoris.


MOTOR SYMPTOMS

Typically symmetric, distal paresis of lower limbs that is less marked; fasciculations may be present.

Asymmetric areflexic paraplegia that is more marked; fasciculations rare; atrophy more common .

IMPOTENCE Frequent Less frequent; ED is commonerectile dysfunction that includes inability to have erection, inability to maintain erection, lack of sensation in pubic area (including glans penis or clitoris), and inability to ejaculate.


SPHINCTER

DYSFUNCTION

Urinary retention and

atonic anal sphincter

cause overflow

urinary incontinence

and fecal

incontinence

Tend to present

early in course of

disease.

Urinary retention

Tends to present late in

course of disease

EMG Mostly normal lower

extremity with

external anal

sphincter invlmnt

Multiple root level

involvement; sphincters

may also be involved.

OUTCOME Less favourable More Favourable

TO X-RAY OR NOT TO X-RAY Canadian C-Spine

Rules NEXUS study(a) midline pain or bony

tenderness, crepitus, or step-off;

(b) neurologic deficit; (c) presence of

distracting injuries; (d) altered mental

status (including intoxication);

(e) complaint of paresthesia or numbness

IMAGING MODALITIES

Plain films – Lateral, AP, and Odontoid

CT

MRI

LATERAL

TO BE ADEQUATE: :OCCIPUT

ALL 7 VERTEBRAE

SUP. ENDPLATE OF T1 this is main view Where 90% lesions are detected

Adequacy Alignment Bones Cartilage

Soft Tissue

ALIGNMENT

CARTILAGE

Predental Space should be no more than 3 mm in adults and 5 mm in children

Increased distance may indicate fracture of odontoid or transverse ligament injury

Disc Spaces Should be uniform

Assess spaces between the spinous processes

LATERAL VIEW: C1 AND C2

Basion-dens distance: average 8mm, top normal 12mm.

C1: Anterior and posterior arch.

C2: Dens, Harris’ ring, body especially ant/inf corner, pars and posterior arch.

PREDENTAL SPACE

In an adult, upper normal is 2.5mm. Space is parallel or narrow “V” shape.

In a young child, upper normal is 4.5mm.

increase in predental space suspect jafferson #

LATERAL VIEW: PREDENTAL SPACE

PRE VERTEBRAL SOFT TISSUE SHADOWS

Nasopharyngeal space (C1) - 10 mm (adult)

Retropharyngeal space (C2-C4) - 5-7 mm

Retrotracheal space (C5-C7) - 14 mm (children), 22 mm (adults)

Extremely variable and nonspecific

Contour is more important than measurements

The laminar space is the distance from the posterior aspect of the articular pillars (1) to the spinolaminar line (2indicate rotational injuries of the cervical

spine

displacement in this line may be an indication of subtle traumatic vertebral injury/dislocation. A line (white line in B) drawn through C1-3 spinolaminar lines (white dots in A) should intercept the C2 spinolaminar line. A displacement of the C2 spinolaminar line of more than 2 mm, compared with a line drawn between the spinolaminar lines of C1 and C3, is abnormal

The normal AP diameter of the cervical canal is stated to be 12 to 21 mm.

anteroposterior width of the canal with that of the vertebral body. The normal ratio of the spinal canal (white arrow) to the vertebral body (black arrow) is 0.8 or more.

AP VIEW

ASSESS FOR: ALIGNMENT SYMMETRY OF PEDICLES CONTOUR OF BODIES HEIGHT OF DISC SPACES CENTRAL POSITION OF SPINOUS PROCESSES

FACET JOINTS ORIENTED AT 45 DEGREE ANGLE FROM CORONAL PLANE -- THUS NOT SEEN ON AP

IF FACET IS CLEARLY IDENTIFIED ON AP, ARTICULAR PILLAR OR PEDICLE FX WITH ROTATION IS LIKELY

AP VIEW

Spinous processes should line up.

Disc space should be uniform

Vertebral body height should be uniform. Check for oblique fractures.

ODONTOID VIEW/OPEN MOUTH VIEW

Adequacy: all of the dens and lateral borders of C1 & C2

Alignment: lateral masses of C1 and C2

Bone: Inspect dens for lucent fracture lines

A+B > 7mm indicates rupture of transverse ligament

Reverse Waters view is supplementary, to see top half of dens ONLY.

FLEXION-EXTENSION FILMS

May be helpful in ligament injuries

-but are-

Frequently useless due to muscle spasm

Should not be done in acute setting

FLEXION-EXTENSION FILMS

Rules: Patient must be alert, awake, not intoxicated, able to sit or stand, able to understand commands, and without neurologic deficit.

SWIMMER’S VIEW

A SUPPLEMENTARY view to see C7-T1 in lateral projection. NOT a substitute for a bad lateral. One arm must be elevated, so THEORETICALLY could worsen a mechanical or neurological injury.

A state-of-the-art CT sagittal reformat is preferable: don’t need to move patient and imaging easier and better.

CT: SAGITTAL REFORMATTING

Reconstructed by computer from axial data: no additional imaging needed.

Outstanding “lateral/swimmer’s” imaging.

CT: CORONAL REFORMATTING

Excellent “OMO”

Excellent “AP”

INDICATION OF CT CERVICAL SPINE 1. Alert, cervical tenderness, paresthesias in

hands or feet.

2. Unconscious

3. Impaired sensorium (including alcohol and/or drugs).

4. Impaired sensorium (alcohol and/or drugs), neurologic findings.

Uncertain plain radiographic findings In presence of osseous injury by plain films to

provide details & aid in surgeryplanning inadequate visualization by plain films Localize foreign bodies& bone fragments in

neural elements Pts having high risk of spinal injury, fall from

height from 10 feet,closed head injury Pts with neurologic findings,negative plain films,

negative non contrast CT where MRI is not feasible

MRI

Gold standard for cord, thecal sac, nerve root and disc injuries.

Very good for ligament injuries.

Fairly good for fractures, but does miss some. CT much better.

MULTIPLE SPINAL #

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

In pattern A, the primary lesion occurs

between C5 and C7, with secondary injuries at T12 or the lumbar spine.

In pattern B, the primary injury occurs at

T2 and T4, with secondary injuries in the cervical spine.

In pattern C, the primary injury occurs

between T12 and L2, with secondary injuries from L4 to L5

CERVICAL INJURIES

Common MOIs Axial Loading Flexion Force Hyperextension Force Flexion-Rotation Force Hyperextension-Rotation Lateral Flexion

C-SPINE/NECK INJURIES

Cervical Strain Active motion most painful

Cervical Sprain (Whiplash) Passive and active motion painful

Torticollis (WryNeck) Muscle spasm and facet irritation

Brachial Plexus Stretch or Compression Contusions to Throat

C-SPINE INJURIES

Cervical Fracture or Dislocation Weakness or Paralysis

Cervical Nerve Root Injury Herniated Disc Laceration Cord Shock (Central Cord

Syndrome) Hemorrhage Contusion Cervical Stenosis

CERVICAL SPINE CURVATURE

Normal cervical spine has lordotic curve

Increased lordotic curve (forward head) indicative of poor posture and muscular weakness or imbalance

Lessened lordotic curve indicative of muscular spasm/guarding and/or nerve root impingement

ASSOCIATED SOFT TISSUE INJURY

Carotid and vertebral artery injuries have been found to be alarmingly frequent with cervical spinal injuries. This injury is associated with a small but potentially devastating risk of stroke or death

Tracheal injuiry

WHIPLASH INJURY

Caused due to sudden deceleration injury

Sudden stopping of a moving vehicle The head goes into hyperflexion and

then hyper extension

WHIPLASH CAN CAUSE

Rupture of interspinous ligaments in the posterior side of c-spine

Unlocking of facet joints Rupture of disc or fracture of vertebrae

anteriorly

CLINICAL FEATURES

Severe neck pain and stiffness May present with quadreplegia X-ray may be normal M R I – may show the soft tissue injury and

hemorrhage below the longitudinal ligaments

May present with quadreplegia with out any radiological changes – due to cord contusion

TREATMENT

Cervical traction Anti – edema measures Immobilization Wait for the neurological recovery

THE INJURIES

C1 and C2: by anatomic location

C3 to T1: by mechanism of injury

(Modified from the classification of John Harris, et al.)

ATLANTOOCCIPITO DISSOCIATION

Often fatal but in children survivable complete disruption of all ligamentous relationships between the occiput

and the atlas

Death usually occurs immediately from stretching of the brainstem, which can result in respiratory arresttation & Distraction

ICA & vertebral injuries are common Fatal cases often show contusions in pons, medulla ,spinal cord Neurological Deficits Confusing

High Tetraplegia Cruciate Paralysis Wallenberg’s Syndrome

Avoid Traction Always severe retropharyngeal swelling Distance from basion to odontoid < 12mm

The Power ratio is calculated by dividing the distance between the basion and the posterior C1 arch by the distance between the opisthion and the anterior C1 arch.

A ratio greater than 1 is suggestive of an atlanto-occipital dislocation.

Harris measurements, also known as the “rule of twelve,” include the BAI (basion-axis interval) and the BDI (basion-dens interval). The BAI is the measured distance between the basion and a perpendicular line drawn in relation to the posterior vertebral body tangent line of C2. The BDI is the measured distance between the basion and the tip of dens. Both distances should normally be less than 12 mL.

CLASSIFICATION

TREATMENT

Non operative; Halovest Operative stabilization with a plate-screw-rod

construct and fusion with iliac crest bone graft.

THE ATLAS AND THE AXIS

C1 and C2 injuries differ from the rest of the cervical spine and are considered separately.

Although controversial, best to consider ALL C1 and C2 injuries as UNSTABLE in the acute trauma setting.

THE ATLAS: C1

Anterior arch fracture: extension, uncommon.

Posterior arch fracture: extension, more common.

JEFFERSON fracture: axial load, common

C1: ISOLATED ARCH FRACTURES

Anterior arch Posterior arch CAUTION: You may be

dealing with a Jefferson fracture with occult components:

Best to CT all C1 fractures.

Non operative if no instability

JEFFERSON FRACTURE: C1

Axial loading/burst #

Lateral view: anterior and posterior arch fractures

OMO view: lateral displacement of C1 lateral masses

The lateral masses of C1 and C2 must be aligned on the OMO view.

1-2mm of lateral displacement on one side and an EQUAL medial displacement on the other is head rotation.

ANY other pattern: lateral displacement on both sides or lateral on one side, and none on the other is abnormal.

cord injury in 15% cases

JEFFERSON FRACTURE CT

Classical Jefferson: 4 fractures, 2 ant./2 post.

Jefferson variants: 2 or 3 fractures, but at least 1 ant. & 1 post.

The distinction between stable and unstable Jefferson or burst fractures is the integrity of the transverse ligaments. The transverse ligament is disrupted in tension with lateral displacement of the fragment fragments, which can lead to C1-C2 instability

TREATMENT

Stable Jefferson or burst fractures can be treated nonoperatively in a rigid cervical collar for 8 to 12 weeks.

Unstable fractures can be reduced in halo traction, followed by placement in a halo vest

Surgery Posterior atlantoaxial stabilization and fusion is an effective treatment of residual C1-C2 instability

THE AXIS: C2

Odontoid fractures

Pars fractures Extension

teardrop fractures

ODONTOID#

Complex mechanism of injury

Generally unstable

ANDERSON & D’ALONZO CLASSIFICATION (JBJS, 1974)

Type I 1 fracture through the tip

rare

Rigid cervical collar for 8 wks

Type II Type 2 fracture through the base

Most common

Type III Type 3 fracture through the base and body of axis

Best prognosis

TREATMENT

type I-hard cervical collar for eight weeks Most nondisplaced type II fractures in young

patients are treated in halo vest most nondisplaced type III fractures are

treated a hard cervical collar. Displaced type II and III fractures in young

patients are first reduced using halo traction. posterior C1-C2 stabilization and fusion in

those with neurological deficits

C2: PARS FRACTURE/HANGMANS#

Called Hangman’s or pedicle fracture, both wrong.

Extension injury. Cord injury in 15%. Non-displaced,

displaced, subluxed.

LEVINE & EDWARDS CLASSIFIACTION type I is a minimally or nondisplaced with no evidence of translation or angulation and thus no substantial injury to the C2-C3 disc space.

Type II both angulation and translation and presumably occur from an extensions mechanism. They incur substantial injury to the C2-C3 interspace. In contrast,

type IIa fractures occur via a flexion mechanism and are characterized by marked angulation with minimal translational deformity.

Type III fractures include any C2 pars fracture associated with a dislocation of the C2-C3 facet joint

TREATMENT

Type 1 rigid cervical orthosis

Type 2 closed reduction with traction and position opposite direction

instability halo vest immobilization follow for loss of reduction

Type 3 reduction of facet dislocation with traction early posterior open reduction and fixation using lateral mass

screw fixation of C2 and C3 C2 -C3 fusion after pre-op MRI

C2: EXTENSION TEARDROP FRACTURE

Avulsion by the anterior longitudinal ligament of the anterior-inferior corner of the body.

Extension mechanism.

Cord injury is low. Unstable.

LOWER CERVICAL SPINE C3-C7CLASSIFICATIONFERGUSON 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

1.COMPRESSION FLEXIONCF Stage 1: Blunting of the anterosuperior vertebral body margin

CF Stage 2: Beak-appearance of the anterosuperior vertebral body margin, a sagittal vertebral body split may also be present

CF Stage 3: Oblique primary fracture line that extends from the anterior vertebral body to the inferior endplate.

CF Stage 4: In addition to stage 3 features, posterior translation of the upper vertebra measuring less than 3 mm

CF Stage 5: Posterior translation of the upper vertebral measuring 3 mm or greater, facet gapping, indicating anterior and posterior ligamentous injury

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

VERTICAL COMPRESSION

VC Stage 1: Central superior or inferior endplate fracture

VC Stage 2: Superior and inferior endplate fractures, sometimes with vertebral body fracture lines that give the appearance of a quadrangular fracture fragment

VC Stage 3: Vertebral body comminution, with or without retropulsion of fragments

(This has been by others as a burst-type cervical fracture), with or without kyphotic (late flexion type) or translational (late extension type) deformity

2.VERTICAL COMPRESSION

C6-7 most common shortening of ant and post columns stage 1 -

cupping of end plate with partial failure anteriorly and normal 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

VERTICAL COMPRESSION

“Burst” fractures explode the body.

All are very unstable and cause cord injury in 2/3 (except C1).

There is usually an element of flexion also.

BURST FRACTURES

On lateral, body is compressed anteriorly, inferior end plate often fractured, posterior body contour is convex. On AP, body fracture is vertical or oblique and pedicles spread.

BURST FRACTURES

CT more accurately displays the fracture pattern and the very important degree of narrowing of the spinal canal.

3.DISTRACTIVE FLEXION

DF Stage 1: Facet subluxation, gapping of the spinous process ligaments, indicating failure of the PLC, with or without some blunting of anterosuperior vertebral body (like CF stage 1)

DF Stage 2: Unilateral facet dislocation, usually PLC is intact, rotational

deformity

DF Stage 3: Bilateral facet dislocations, 50% translation of upper vertebral body on lower one

DF Stage 4: Close to 100% translation of upper vertebral body on lower one, apperance of a so-called floating vertebra

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

FLEXION DISTRACTION

50-80% assoc acute disk herniation at level of injury

awake closed reduction has not shown worsening of 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

TREATMENT

Closed reduction initially max weight controversial

successful non-operative treatment 64% late

instability fusion recommended

unsuccessful open reduction and fusion

UNILATERAL INTERFACETAL DISLOCATION

UID is not stable, as the contralateral capsule ligaments are torn.

Cord injury is uncommon, but root injury is common,

Findings can be subtle: less than 50% subluxation, malalignment of spinous processes.

CT: THIS IS A NORMAL FACET JOINT, NORMAL “HAMBURGER SIGN”

UID

CT: UID has “reversed hamburger sign” of facet joint.

CT is also more sensitive for associated lateral mass fractures.

UID

Oblique view

CT Sagittal Reformat

REDUCTION MANOUVRE

BILATERAL INTERFACETAL DISLOCATION

BID, also called “locked facets” is anything but locked. It is a severe 3 column injury that is completely unstable.

Cord is injured in 2/3. Body is subluxed

anteriorly at least 50%. Marked posterior

distraction.

4.COMPRESSIVE EXTENSION

CE Stage 1: Posterior arch fracture that may be facet, pedicle, or lamina fracture, with or without rotation that can result in mild anterior translation. (These are more commonly referred to as lateral mass fractures.)CE Stage 2: Bilateral lamina fractures, can be multiple levels

CE Stage 3: Bilateral lamina, facet, pedicle fractures without vertebral body displacement. Although admittedly “hypothetical… having not been encountered” in their review, the injury may be described as a floating lateral mass fracture

CE Stage 4: As for CF stage 3, with partial anterior vertebral body displacement

CE Stage 5: As for CF stage 3, with 100% anterior vertebral body displacement

POSTERIOR ARCH FRACTURES

Plain films are insensitive, CT is outstanding.

Isolated: pedicle, lateral mass, lamina or spinous process.

Multiple fractures are common. Pedicle/lamina fractures cause free-floating lateral mass.

May be additional element of lateral bending.

Stability depends on what is fractured.

5.DISTRACTIVE EXTENSION

DE Stage 1: Abnormal widening of the disc space, may or may not be avulsion fractures of the anterior vertebral body margin, no posterior translation

DE Stage 2: DF stage 1 plus posterior translation

CHILDREN

Cervical spine fractures are uncommon in children. The overall incidence of spinal fractures in pediatric trauma patients is <1%

In addition, the injury patterns are different, with cranio-cervical junction injuries being more prevalent in this group

CSI IS RARE IN CHILDREN: 1% OF ALL PEDS FRACTURES AND 2% OF ALL SPINE FRACTURES

BY AGE 8-10, NO ANATOMICAL OR BIOMECHANICAL DIFFERENCES

PEDS < 10 Y.O. ARE FUNDAMENTALLY DIFFERENT DUE TO ANATOMICAL VARIATIONS OF THE DEVELOPING SPINE, AND TO A LESSER EXTENT, THE DIFFERENCES IN MECHANISMS OF INJURY

INHERENTLY MORE MOBILE:

GENERALIZED LAXITY OF INTERSPINOUS LIGAMENTS AND JOINT CAPSULES

THICK CARTILAGINOUS ENDPLATES

INCOMPLETE VERTEBRAL OSSIFICATION (WEDGE-SHAPED VERTEBRAL BODIES)

SHALLOW ANGLED FACET JOINTS, ESPECIALLY B/W OCCIPUT AND C4

HEAD DISPROPORTIONATELY LARGE

PSEUDOSUBLUXATIONPERSISTENT SYNCHONDROSESANTERIOR ANGULATION OF DENSFOCAL KYPHOSIS OF MID-CERVICAL SPINEDIFFERENT SOFT TISSUE MEASUREMENTS

PEAD ANATOMIC VARIANTS -NON TRAUMATIC INJURY

SCIWORA

DEFINED BY PANG AND WILBERGER, 1982: “Objective Signs Of Myelopathy As A Result Of Trauma With No Evidence Of Fracture Or Ligamentous Instability On Plain Xray And

Tomography”

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

SPECIAL CONSIDERATION

SCIWORA = Spinal Cord Injury Without Radiographic Abnormalities Children have vertebrae that can dislocate

and quickly relocate. Cord gets damaged but shows an aligned vertebral column.

Cord can be transected or compressed.

STABILITY OF SPINE

THREE COLUMN THEORY OF DENIS

Spinal column divided into 3 columns; Anterior column; The anterior longitudinal ligament,

anterior 2/3 of the body and disc. Middle column; Posterior longitudinal ligament and

posterior 1/3 of body and disc. posteriorcolumn; The posterior osseous arch and

ligaments.

Injury to one column is stable, two or three are unstable.

DOES IT WORK?

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.

PANJABI AND WHITE: CLINICAL INSTABILITY IN THE LOWER CERVICAL SPINE

Anterior elements Destroyed or Unable to Function 2 Posterior Elements Destroyed of Unable to Function2 Relative Sagittal Plane Translation > 3.5mm 2 Relative Sagittal Plane Rotation > 11deg 2 Positive Stretch Test 2 Medullary (Cord) Damage 2 Root Damage 1 Abnormal Disc Narrowing 1 Dangerous Loading Anticipated 1

TOTAL OF 5 OR MORE = UNSTABLE

PLAIN RADIOGRAPHY & CT - INSTABILITY

Anterior translation of the vertebral body a distance >3.5 mm relative to the subjacent vertebra

▪ Vertebral body shows > 20 degrees of angulation relative to the adjacent vertebra

▪ Vertebral body shows >11 degrees of angulation relative to the adjacent vertebral body pairs

▪ Increase in atlantoaxial distance (>3 mm) ▪ Hangman fracture with >3 mm of fragment

displacement or >a 15-degree angle at the fracture site ▪ Hangman fracture with abnormal C2-3 disc space or

with C2-3 dislocation ▪ Anterior or posterior displacement of the C2

spinolaminar line of >2 mm relative to a line drawn between the spinolaminar lines of C1 and C3

Basion-dental interval (BDI) >12 mm ▪ Basion-axial line interval (BAI) >12 mm ▪ Unilateral facet dislocation ▪ Bilateral facet dislocation Widening of the uncovertebral joints Sum of C1 lateral mass offset in excess of 7

mm (adding the amount of lateral displacement of each C1 lateral mass)

▪ Odontoid fracture type I or II ▪ Occipital condyle fracture type III

INITIAL TREATMENT

Immobilization rigid cervical orthosis- Philadelphia collar unstable injury this is inadequate often

and cervical 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

CLOSED REDUCTION Injuries demonstrating angulation, rotation or

shortening 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

STABILIZATION

Traction Skin Skeletal

Halo traction Crutchfield tongs

STABILIZATION (1)

In incomplete lesion, early stabilization prevent repetitive injury of the spinal cord and improve neurological outcome. Delayed neurological deterioration--- 5%.

Improper immobilization. Early mobilization and rehabilitation.

Stabilization had benefit in all spinal injury patients.

STABILIZATION (2)

Immediate correction with external orthotic device or operative fixation

External orthoses vs surgical intervention Surgical stabilization better than external

orthoses only Early stabilization better than late

stabilization in post-surgical neurological deterioration

CERVICAL TRACTION

CRUTCH FIELD TONGS

HALO TRACTION

PHARMACOLOGICAL MANAGEMENT

NASCIS I,II,III---randomized, prospective, double-blinded---Methylprednisolone sodium succinate (MPSS) Within 3 hours, MPSS 30mg/kg bolus +

5.4mg/kg/hr infusion for 24 hours. During 3~8 hours, MPSS 30mg/kg bolus +

5.4mg/kg/hr infusion for 48 hours. Effect of neurogenic improvement:

suppress inflammatory response and vasogenic edema.

SURGICAL DECOMPRESSION (1)

Cervical spinal cord injury---- During complete injury, no neurological

improvement in early or later decompression.

During incomplete injury, controversial in surgical decompression.

Laminectomy may result in neurological deterioration.

Anterior cervical decompression may improve function in incomplete quadriplegics.


Experimental models-- rapid decompression better than later intervention.

Human model— early reduction within 8 hours brings significant recovery in one study; however, some others against it.

Increased risk such as pulmonary morbidity associates early surgery.


Anterior approach is favored; posterior laminectomy has no benefit and worse cord compression.

As a consensus, the only accepted indication for emergent surgical treatment is progressive neurological deterioration--- such as fracture displacement, epidural hematoma, spinal cord edema or infarction.

TAKE HOME MESSAGE

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

KNOW YOUR PEDIATRIC ANATOMICAL VARIATIONS DO NOT FORGET NONSKELETAL INJURIES: LIGAMENTOUS INSTABILITY, AND SCIW0RA If a spinal fracture is identified at any level, the

entire spine should be examined with anteroposterior and lateral views to document the presence or absence of spinal fractures at other levels

DON’T BE IN A HURRY TO CLEAR THE CERVICAL SPINE - 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

cervical spine injuries initial evaluation

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