Cervical spine injuries - Upper nd Lower

Cervical spine injuries

1. CERVICAL SPINE INJURIES PRESENTER : Dr.Himaja Padavala MODERATOR-Dr. Vamsi Krishna sir CHAIRPERSON-Dr. V.Sarath sir

2. Introduction to Cervical Spine Fractures And Dislocations In the upper cervical region [ occiput (C0) to the axis (C2)], O ccipitocervical dislocations O ccipital condyle fractures A tlas (C1) fractures (e.g., Jefferson-type burst fractures ) A tlantoaxial instability or rotatory dislocations C2 fractures (e.g., odontoid or bilateral pars interarticularis fractures,lateral mass ) Subaxial injuries of the cervical spine (C3–C7) frequently include B urst fractures F acet dislocations T eardrop (flexion–compression) fractures I solated facet S imple spinous process fractures.

3. Pathoanatomy and Applied Anatomy of the Cervical Spine The upper cervical spine consists of the atlas (C1), axis (C2),and the skull base (C0) including the occiput . The anatomy at each level is unique and differs from the subaxial cervical region. The subaxial cervical spine includes the C3 to C7 vertebral segments, which maintain a relatively uniform anatomical configuration analogous to the thoracic and lumbar spine. During exposure of the posterior C1 arch, dissection should not extend beyond 1.5 cm in the posterior midline, or 1 cm along the superior border, in order to avoid injury to the vertebral artery. Diagram of a side view of the cervical spine. The transverse process forms a half-pipe configuration that cradles the exiting spinal nerve, while the overall alignment is normally lordotic .

4. Diagram of the subaxial cervical spine viewed from the front. The bilateral uprisings, known as the uncinate processes,create a cup-in-saucer formation of the intervertebral disc space. The transverse process is made of two components. The anterior portion is actually the remnant of a costal process ( i.e.,rudimentary rib). The posterior portion is the true developmental transverse process. Together, they form the transverse foramen , the conduit for the vertebral artery.

5. Epidemiology of Cervical Injuries The upper cervical region is thought to be the most frequent site of fracture. However , associated spinal cord injury is less common as compared with subaxial injuries, presumably due to increased spinal canal diameter. Within the subaxial region , approximately 40% of all injuries are localized to C6 or C7 . This area is also commonly involved in extension-type injuries seen in hyperostosis [ankylosing spondylitis (AS) or diffuse idiopathic skeletal hyperostosis (DISH)].

6. Mechanism of Injury for Cervical Spine Fractures and Dislocations B imodal distribution. In young, active patients, the mechanism of injury is most commonly high-energy trauma, such as a motor-vehicle accident or fall from height, although penetrating injuries are of increasing concern M otorcycle accident was the cause in more than half of all cases. In the elderly, low-velocity falls are the most frequent cause of cervical spine fracture. However, especially in those elderly patients with hyperostotic conditions of the spine, the resulting damage may be as severe as that encountered in high-energy

7. Pre-hospital ca re for Cervical Spine Fractures and Dislocations ATLS protocols maintain that the cervical spine should be immobilized during the initial vital assessments, including evaluation of a patient’s airway, breathing, and circulatory status. Initially, manual immobilization should be undertaken until a hard cervical collar can be applied. If not available, secured to a stretcher using sandbags and tape. Most cervical collars intended for use in the trauma setting will have an anterior window that enables access to tracheostomy or emergent cricothyroidotomy sites . Motorcycle helmets, as well as those used in sporting activities,should be maintained in position during the initial evaluation and en route care . Ideally, the helmet should be left in place until radiographic evaluation of the cervical spine is performed. This is facilitated by the fact that most modern motorcycle and football or hockey helmets allow for independent removal of the facemask or visor to facilitate access to the face and mouth while the helmet itself remains in place.

8. Hospital Care for Cervical Spine Fractures and Dislocations ATLS guidelines During initial evaluation, the patient’s cervical spine must remain immobilized in a cervical collar with manual in-line stabilization performed during transfers and at any time the collar is removed. Spinal precautions and log roll maneuvers should also be utilized. Research has demonstrated an association between neurologic deterioration after spinal injury and excessive manipulation . The systolic pressure should be kept above 100 mm Hg and the mean arterial pressure above 85 mm Hg. The hypotension of neurogenic shock should be treated by maintaining the patient in the Trendelenburg position and by the administration of vasopressors together with careful use of intravenous fluids

9. History and Physical Examination of Cervical Spine Fractures and Dislocations P atient is alert and able to participate : he or she should be questioned regarding previous injuries , significant spinal surgical history, the events surrounding the present injury, the location of pain, and any perceived sensory or motor deficits. P atient is obtunded or has sustained other serious injuries such as a long-bone fracture or an abdominal injury, he or she may be unable to completely answer questions or identify other sites of injury. W itnesses or first responders should be interviewed . The mechanism of injury (e.g., fall from height, low-velocity fall with hyperextension of the cervical spine), direction of impact, and associated injuries (e.g., facial fractures, blunt head trauma, calcaneal fractures) or symptoms can assist in raising the level of suspicion concerning spinal trauma

10. A standardized, systematic spinal evaluation should be performed. Ideally, the examination should begin in the cervical region and proceed distally Alternatively, if a spinal zone is already known to be injured, this region should be examined last. The orientation of the head should be examined , as fixed rotation may indicate a unilateral facet dislocation. Areas of ecchymosis or open injury should be noted. Finally, the spinous processes and paraspinal musculature should be palpated and areas of pain, crepitation, or deformity recorded . A thorough neurologic examination follows palpation of the spine. If the patient is obtunded , this evaluation may be limited to observation of spontaneous motor function, withdrawal from noxious stimuli, determination of rectal tone, and assessment of the bulbocavernosus reflex.

11. In an alert patient, the examination can be more complete and consists of cranial nerve examination as well as motor, sensory, and reflex examination in all dermatomal and myotomal distributions . Cranial nerve impairment, particularly in the lower cranial nerves, can occur in occipital condylar fractures and other upper cervical spine injuries Sensation is assessed on a 3-point scale (normal, decreased, or absent) and motor function is graded from 0 to 5 . Sensory and motor deficits are conventionally combined to give a grade and motor score . The presence of a complete (no sensory or motor function below the level of injury) or incomplete (some sensory or motor preservation below the level of injury) spinal cord injury and spinal shock (absence of bulbocavernosus reflex) is determined .

12. Imaging and Other Diagnostic Studies for Cervical Spine Fractures and Dislocations Radiographs may be used for screening patients A lateral radiograph can be used in polytrauma patients presenting in extremis which provides sufficient information on the status of the osseoarticular structures of the cervical spine to facilitate a decision regarding emergent transport to the operating room. CT scans as screening modality - more cost-effective as well as more sensitive when compared with plain radiographs in polytrauma MRI d etects discoligamentous injuries missed by CT scanning alone “Rule of three” with respect to evaluation of the cervical spine : requiring that two out of three components present to definitively declare a patient free of injury . R eliable physical examination in a cooperative patient N egative computed tomography N egative MRI

13. The atlanto -dens interval is measured from the posterior surface of the anterior CI ring to the anterior surface of the odontoid process (dens). The posterior atlanto -dens interval is measured from the posterior surface of the odontoid process to the anterior portion of the posterior CI ring. The normal ADI is less than 3 mm in adult patient and widening indicates disruption of the transverse ligament. A PADI measuring less than 13 mm .

14. Radiographic lines, landmarks and measurements using a lateral cervical spine radiograph. The spinolaminar line (A), posterior vertebral body line (B) the anterior vertebral body line (C) On a perfect lateral view the facet joints should appear as stacked parallelograms (D). The prevertebral soft tissue shadow is measured at the level of C2 (E) and C6 (F) vertebral bodies. Greater than 6 mm of soft tissue shadow at C2 and 22 mm at C6 are strongly suggestive of an underlying spinal injury.

15. Imaging of Cervical Spine Fractures and Dislocations Radiographs- In the subacute trauma setting, a complete radiographic series of the cervical spine should include a minimum of AP, lateral,and open-mouth odontoid views, with oblique images obtained as necessary. Injuries identified on initial screening studies can be investigated further by radiographs, and some parameters are useful in predicting stability and informing treatment. An example is the evaluation of C1 Jefferson burst fractures , where stability, as indicated by the integrity of the transverse ligament,is determined by displacement of the lateral masses of C1 on an open-mouth odontoid view. If the combined lateral overhang of the C1 lateral masses relative to those of C2 exceeds 6.9 mm (rule of Spence ), a disrupted transverse ligament is inferred. As the 6.9-mm value was derived from direct anatomic measurements,it has been suggested that one magnification taking into account a measurement of 8.1 mm may be more appropriate.

16. A: Recommended measuremen technique of odontoid displacement. B : Recommended measurement technique of odontoid angulation.

17. Cobbs Endplate method of measuring C2–C3 angulation . Posterior vertebral body tangent line method for C2–C3 angulation measurement

18. The Cobb method of measuring cervical kyphosis . A line is drawn along the superior endplate of the superior adjacent uninjured vertebrae; a second line is drawn along the inferior endplate of the inferior adjacent uninjured vertebrae. The angle subtended between the two is then measured. Kyphosis exceeding 11 degrees using the endplate method may indicate compromise of the posterior ligamentous complex (PLC) and instability.

19. The posterior vertebral body tangent method of measuring cervical kyphosis . A line is drawn along the posterior aspect of the adjacent vertebral bodies. The angle subtended between the two is then measured. Sagittal translation is measured at the level of the inferior aspect of the superior vertebral body.

20. Vertebral body height loss can be expressed as a percentage. This is best assessed by measuring both anterior and posterior height of the injured and adjacent uninjured vertebral bodies.

21. CT SCAN : CT scans are more sensitive than plain radiographs in identifying fractures and subtle osseoarticular abnormalities. Helical multidetector CT technology produces images with good anatomic detail and is now the screening modality of choice for cervical trauma at most level I centers. It is highly advantageous to link axial and sagittal images . Vertebral bodies should be inspected to determine the presence of fracture lines, especially on the axial image that has a higher sensitivity for detecting sagittal split fractures than on the plain radiographs. If a fracture is present, the degree of comminution and retropulsion into the spinal canal will also be apparent. Facet, lamina, pedicle fractures and spinous process fractures will also be easily visualized

22. Vertebral body translation and frank dislocation are also demonstrable on axial CT scans. If a substantial amount of translation is present, as in bilateral facet dislocations, a “double-lumen” sign may be present on a single axial image. In a normal cervical spine, the inferior articular process from the level above lies dorsal to the superior articular process of the level below. The absence of opposed articular surfaces may result in an “empty facet sign.” In facet dislocations, the inferior articular process of the level above will be visualized anterior to the superior articular process of the caudal vertebrae . Both coronal and sagittal reconstructions can be used to evaluate widening across the occipitoatlantal joint and fractures of the occipital condyles. Paramedian sagittal cuts through the facet joints may help appreciate dislocations, subluxations, and estimations of fracture fragment size. Retropulsion of fracture fragments into the canal, and resultant compromise,can best be estimated on a midsagittal CT scan.

23. Magnetic Resonance Imaging: S uperior to computed tomography in terms of visualizing cervical soft-tissue structures, including the spinal cord, cervical nerve roots, intervertebral discs, and posterior ligamentous complex (PLC). U seful in detecting subtle compressive injuries, undisplaced fractures of the vertebral bodies(via the presence of osseous edema), epidural hematomas, and vertebral artery injury. MRI scan is obtained in cases of cervical spine trauma when any of the following criteria are met: (1) the patient presents with a neurologic deficit, (2) the integrity of the PLC is unclear and injury to this structure would have a direct influence on treatment, such as determining the need for surgery (3) the patient presents with a facet dislocation where there is concern regarding disc herniation into the spinal canal that may prevent safe reduction and cause difficulty in deciding on the correct approach for surgical intervention.

24. In this sagittal T2-weighted image of a patient with a C6 vertebral body fracture, the small arrows are pointing to the posterior longitudinal ligament, which is disrupted along the posteroinferior aspect of the fractured level ( lower small arrow). The large black arrow indicates the ligamentum flavum at an uninjured level. The large white arrow indicates an area of the ligamentum flavum that has been disrupted.

25. Axial T2-weighted magnetic resonance image through the C1 ring, showing an intact transverse ligament ( arrowheads) spanning the C1 lateral masses over the posterior surface of the odontoid process ( O).

26. Spinal canal compromise in the cervical spine most commonly occurs from translational deformity, as depicted in the sagittal computed tomographic reconstruction of a patient with a unilateral facet dislocation. The normal anteroposterior dimension of the canal is noted above ( A) and below (C) the injury. At the level of the translational deformity, the spinal canal is smaller ( B).

27. GOALS OF TREATMENT OF C-SPINE INJURIES To realign the spine To prevent loss of function of undamaged nuerological tissue To improve nuerological recovery To obtain and maintain spinal stability To obtain early functional recovery

28. Pharmacological Management Methylprednisolone sodium succinate (MPSS) Within 3 hours  30mg/kg bolus + 5.4mg/kg/hr infusion for 24 hours. During 3 to 8 hours  30mg/kg bolus + 5.4mg/kg/hr infusion for 48 hours. suppress inflammatory response and vasogenic edema

29. Nonoperative Management of Cervical Spine Fractures and Dislocations Cervical Orthoses Many cervical spine fractures can be managed nonoperatively . D ecrease rather than eliminate motion. U se three-point pressure to restrict motion, generally making contact with the mandible and the occiput proximally, the clavicle and the sternal notch anteroinferiorly , and the T3 spinous process and scapular spines posteriorly . A variety of rigid cervical collars are currently available and provide differing degrees of immobilization depending on their design and material composition. Some of the more commonly encountered cervical collars in a clinical setting are the Miami-J, Philadelphia, and Aspen devices.

30. The foam composition of the Philadelphia collar facilitates personal hygiene, whereas the Miami-J contains removable pads that, although washable, must be changed frequently. NecLoc device restricted flexion–extension, axial rotation, and lateral bending moments to a greater degree than the Miami-J, Philadelphia, Aspen, or Stiffneck orthoses. Complications of cervical orthoses- Pressure ulcers in the areas of contact, particularly the occiput, angle of the mandible and sternum Swallowing difficulty, Increase the risk of aspiration Increase intracranial pressure in patients with head injury

31. Cervicothoracic Orthoses CTOs consist of a cervical immobilization apparatus with a thoracic extension that immobilizes the cervicothoracic junction and distally to T5. M ore effective in immobilizing the cervical spine than stand-alone cervical orthoses in all planes because they achieve better control of the head. Commonly available CTOs include the sterno-occipitomandibular immobilizer, the Yale brace, Minerva brace, Lerman noninvasive halo (NIH), and pinless NIH. Minerva as a viable alternative to conventional halo fixation in compliant patients who would not take off, or tamper with, the device. Advantages over traditional halo-thoracic vests include the elimination of pin fixation with a consequent reduction in infection rates and reduced pressure ulcer formation.

32. Halothoracic Vest for Cervical Spine Fractures and Dislocations Halo vest immobilization was used extensively in the past as a definitive means of treatment of many cervical spine injuries E mployed as a means of facilitating reduction and providing temporary stabilization prior to surgical intervention. The fact that a halo ring can be connected to most Mayfield head rest adapters enhances its versatility, particularly in polytrauma patients who must undergo numerous diagnostic and non–spine-related. Most effective nonoperative means of resisting rotational and translational movements. Intersegmental motion can still occur, especially with attempted flexion and extension of the neck. This results in translation of the subaxial vertebrae relative to each other, a phenomenon that has been referred to as “snaking.” The device has also been associated with increased mortality rates among the elderly and advanced patient age may be a contraindication

33. Application and Technique The patient remains supine for the entire procedure. The posterior part of the thoracic vest can be placed first by logrolling the patient from side to side and maintaining in-line cervical traction at all times. The anterior part of the vest is then applied and secured using the shoulder straps and side buckles. An appropriately fitted vest should extend down to the level of the xiphoid process , keeping the abdomen free, and be secure enough to maintain its position while still allowing access to the underlying skin. Next , a small roll of towels is placed behind the occiput. Proposed pin sites should be plotted by provisionally stabilizing the ring to the patient’s head using removable suction devices. These sites should be marked with a pen. The hair should be shaved from the posterior pin sites prior to sterile preparation. The proposed pin sites are then prepped in sterile fashion. The optimal position of the anterior pins is 1 cm above the lateral third of the orbital rim to avoid injury to the supraorbital nerve, whereas the posterior pins should be placed 1 cm above the helix of the ear . Optimal pin fixation is achieved when the pins are placed perpendicular to the bone.

34. The lock nuts are then tightened to prevent pin loosening. Pins should be retightened 24 to 48 hours after halo application. If a pin becomes loose with time, it can be retightened as long as resistance is met. Once the ring has been applied, the longitudinal struts are attached and secured. Cervical radiographs, or fluoroscopic images, are then used to determine cervical alignment, and reduction and careful adjustments can be made to optimize the final position . Complications Pin site loosening and infection are the most common Swallowing difficulty, which can be associated with the head and neck being overextended, even in young individuals. Pressure sores. Loss of reduction or alignment can also occur with halo vest immobilization. Risk of fracture displacement in a halo with facet joint involvement or dislocation. Cardiopulmonary events and death,

35. Skull-Based Traction and Closed Reduction for Cervical Spine Fractures and Dislocations Traction can be used to temporarily immobilize unstable cervical injuries at the place of injury or in the emergency room. This may be advantageous when transferring patients between institutions or for individuals awaiting surgical intervention. E mployed as a means to realign or reduce cervical spine fractures or dislocations . the progressive application of weight to the upper cervical region, through the skull, results in distraction forces at the site of injury, realigning fracture fragments through ligamentotaxis , or distracting jumped facets if there is a dislocation. Contraindications : Occipitocervical dislocation Type IIA traumatic spondylolisthesis

36. Two of the more common devices used to apply traction to the cervical spine are Gardner–Wells (G–W) tongs and the halo ring . G–W tongs are applied more quickly and easily than a halo ring. However, G–W tongs are temporary devices that cannot be used as an adjunct to, or substitute for, spinal stabilization. Traction is applied with a halo device if the planned definitive treatment includes halo-thoracic immobilization, or there is a requirement for an MRI compatible traction ring that can support large reduction forces. Following the application of cervical traction, ligamentotaxis can potentially reduce these fragments and produce a degree of indirect canal decompression. However, the success of indirect decompression relies on contiguity of the ligamentous structures and injury severity. Traumatic segmental kyphotic angulation may also be improved by the application of traction.

37. Application Technique G–W tongs are applied to the skull through two, slightly cranially angulated, fixation pins. The optimal site of insertion is approximately 1 cm, or a finger’s breadth, above the helix of the ear. Neutral pin position is aligned with the external auditory meatus, which best facilitates longitudinal traction.

38. The skin over the proposed pin site should be marked and sterilized with povidone–iodine or Betadine solution. It is not necessary to shave the site, as it is routinely performed when inserting halo pins. The skin and the underlying periosteum are then anesthetized with a local infiltration of Lidocaine . The tongs are then held in position and the pins are advanced through the skin until they engage the outer cortex of the cranium. Most tongs have an indicator on one pin end that signals when appropriate force has been applied. It is important not to overtighten the pins, as they can penetrate the inner table of the skull, which may result in intracranial injury. However pins that are insufficiently secured can loosen and pullout from the skull, leading to soft-tissue injury, scalp laceration, or temporal artery injury. Brain abscess has also been described as a rare complication associated with the use of G–W tongs.

39. Reduction Technique for Odontoid Fractures With most acute fractures, longitudinal, in-line traction, with a weight of 5 to 30 lb, is usually effective at correcting an angulation deformity. Translational displacement may be more difficult to correct. Rushton et al. described the use of “ bivector ” traction, in which a second traction line is used to deliver an anterior moment, to achieve reduction of posteriorly displaced odontoid fractures. Conversely, the thorax can be elevated using bolsters or rolls to facilitate reduction of anteriorly translated odontoid fractures. An initial weight of 5 to 10 lb is applied. This is followed by a lateral radiograph to rule out occult occipitocervical instability or overdistraction across the fracture site, both of which should prompt slow and careful release of traction. Weight is added in 5- to 10-lb increments , with sufficient time allowed between applications to enable stress relaxation of the soft-tissue structures. During this time a lateral radiograph can be obtained and the neurologic status checked. A thorough neurologic examination should be performed between each incremental increase in weight. A change in a patient’s neurologic status warrants immediate attention, including a decrease in the amount of traction weight and further imaging studies.

40. Reduction Technique for Bilateral Facet Dislocation Prior to the application of G–W tongs or a halo ring, a towel roll can be placed between the patient’s scapulae to raise the head slightly off the bed. Because facet reduction requires some flexion in addition to distraction, the pins should be placed about 1 cm posteriorly . The location of the skull equator should be noted. If pins are located above, or cranial to, the equator, they can slide along the slope of the cranium and dislodge. By positioning the pulley anterior to the patient, the traction vector can be used to apply a flexion moment to the cervical spine. Rolled towels can also aid in producing neck flexion, which can help unlock the articular processes . It is important that this traction setup permits subsequent adjustments, as the force vector should be changed to a neutral or slightly extended position once the facets have been reduced A n initial weight of 5 to 10 lb should be applied, followed by a lateral radiograph to rule out overdistraction through the injured site or a more proximal location

41. Serial neurologic examinations should be performed by the same surgeon in between incremental increases in traction weight , until and even after reduction is achieved. Traction weight is added in 10-lb increments every 10 to 15 minutes, followed by a lateral cervical radiograph, until reduction occurs. While some have advocated that traction weights be limited to 55 or 60 lb,weights as high as 140 lb have been safely used to achieve cervical reductions. It is recommended that attempts at reduction using heavy weights be abandoned if the weight applied exceeds two-thirds of patient body weight, distraction across the site of injury exceeds 10 mm, or there is a progression of neurologic deficit. After reduction is radiographically confirmed, the weight is incrementally reduced to 10 to 15 lb and the traction vector adjusted to produce slight neck extension.

42. Reduction Technique for Unilateral Facet Dislocations Unilateral facet dislocations generally result from lower energy mechanisms than bilateral dislocations. Because of this, they are often stable in the dislocated position and can require comparatively greater amounts of weight to achieve reduction . Reduction maneuver for a unilateral right-sided facet dislocation. With the tongs in place and weight applied, distractive force is applied to the dislocated side, while compressive force is applied to the nondislocated side. The head is then rotated toward the dislocated side. A satisfying “ clunk” signifies that the dislocation has been reduced

43. Surgical Management of Cervical Spine Fractures and Dislocations Anterior Approaches : Transoral Approach High Anterior Retropharyngeal Approach : C1 -C3 Anterior Approach to the Subaxial Cervical Spine: C3 - C7 Anterior Reduction of Dislocated Facets Reconstruction Anterior Instrumentation Posterior approaches : Decompression Reduction Maneuvers for the Upper Cervical Spine Reduction Maneuvers for the Subaxial Cervical Spine

44. Transoral Approach Direct exposure of the anterior atlantoaxial region can be achieved Successful fusion and instrumentation procedures have been reported, but the transoral approach is probably best reserved for excisional procedures , such as the excision of a displaced odontoid nonunion, because there is a higher risk of infection if bone graft or implants are inserted. A specially designed,rectangular -shaped self-retaining retractor is used to access the oropharyngeal mucosa. Four fascial layers are crossed to access the spine: the pharyngeal mucosa, the pharyngeal constrictor muscles, the buccopharyngeal fascia, and the prevertebral fascia. A scalpel is used to incise through the ALL down to vertebral bone. The entire soft-tissue layer is then stripped subperiosteally using a periosteal elevator. Electrocautery should be avoided as it damages the tissue edges and can make closure difficult. After a transoral approach, extubation must be delayed until laryngeal and pharyngeal edema sufficiently resolve. Failure to do so can lead to acute respiratory compromise, necessitating emergent reintubation through swollen tissues.

45. High Anterior Retropharyngeal Approach The prevascular retropharyngeal approach can be used to access the skull base down to C3. Procedures that can be performed via this approach include anterior cervical discectomy and fusion of C2–C3, odontoidectomy , and osteosynthesis of the anterior C1 ring. It is readily extended distally into an expansile anterior cervical approach.

46. Anterior Approach to the Subaxial Cervical Spine The standard Smith–Robinson approach can be utilized to access most of the subaxial cervical spine anteriorly. Depending on the size of the patients and their stature, as well as the length of their neck, a standard anterior approach to the cervical spine can safely access the subaxial region from C3 to T1 vertebral bodies. The superficial interval is between the sternocleidomastoid muscle (lateral) and strap muscles (medial). Deep dissection is between the carotid sheath (lateral, which contains the carotid artery, internal jugular, and recurrent laryngeal nerve) and the trachea/esophagus . The alar and prevertebral fascia (deepest) are swept away to access the anterior longitudinal ligament, vertebral bodies, and disc spaces.

47. Anterior Decompression Anterior decompression of the cervical spine can be achieved via discectomy or vertebral body corpectomy Based on the extent of vertebral body fracture, the presence of comminution, and the location of compressive pathology within the spinal canal. Vertebral body fractures that involve sizable portions of the endplate, or that are substantially comminuted, cannot be used as viable docking points for strut grafts or fixation points for screws A discectomy can be performed if a herniated disc is the only structure compressing the neural elements

48. Anterior Reduction of Dislocated Facets If a herniated cervical disc was identified by MRI to be associated with a facet dislocation, an anterior discectomy may need to be performed prior to an attempt at reduction. A lamina spreader may be placed between the vertebral endplates to distract the injured segments, unlock the dislocated joints, and facilitate reduction. If this technique is used, care must be taken to avoid overdistraction , as this can result in spinal cord injury. Another method relies on Caspar pins that are placed into the vertebral bodies. The pins are then used to manipulate the vertebral segments, and the cephalad vertebra is levered over the caudal body without substantial distraction. Once reduction has been achieved, intraoperative fluoroscopic image or lateral plain film is used for confirmation. Irreducible dislocations may require additional posterior surgery to allow reduction.

49. Reconstruction Following a complete decompression, the superior and inferior endplates of the adjacent vertebral bodies are denuded of cartilage and lightly burred until punctate bleeding is present . If overhanging osteophytes are located at the vertebral margins, these should be rongeured such that a flat surface is available to accept plate placement. The corpectomy or discectomy site is measured to determine the appropriate size of the interbody graft or strut . Implants include titanium mesh cages, expandable cages, and polyethyleneether-ketone (PEEK) cages. Structural autograft is obtained from the iliac crest. The graft or cage should be fashioned to match the length, width, and height of the post decompression defect.

50. Anterior instrumentation Anterior stabilization is performed after the graft is inserted. Anterior plating is used to stabilize discectomy and corpectomy defects. The positioning of the screws and cortical purchase are critically important in ensuring stabilization and to encourage fusion. Initially , the plate is centered over the anterior vertebral bodies and is held in place with provisional pins. Pilot holes can be drilled, or self-tapping, self-drilling screws may be inserted if they are available. Pilot holes should be angled away from the endplate and 10 to 15 degrees toward the midline, to avoid inadvertent penetration of the vertebral artery.

51. Posterior Approach to the Cervical Spine M idline , extensile approach that can be extended from the occipitocervical junction to the lumbosacral articulation. The dissection can be relatively bloodless if maintained within the avascular plane of the ligamentum nuchae , which separates the right and left paraspinal musculature. Intramuscular hemorrhage and posterior interspinous and supraspinous process ligament damage are often apparent at the level of injury. It is important to maintain the integrity of any uninjured ligaments, until the correct surgical level is identified, to avoid unnecessary destabilization of adjacent segments. Subperiosteal dissection is started on either side of the bifid spinous process, continued down to the spinolaminar junction, and extended laterally over the laminae . Further dissection onto the lateral masses and facet joints should occur only at the levels to be fused . Classically, it is recommended that lateral dissection along the posterior C1 ring be restricted to within 1.5 cm from the posterior midline to avoid injury to the vertebral artery.

52. The artery is located along the superior aspect of the C1 ring approximately 1 cm from the midline. More lateral exposure of the ring can be safely performed along the inferior aspect of C1. Exposure of this region is often necessary to facilitate the insertion of lateral mass screws into C1. Surgeons should note the presence of a ponticulus posticus , or osseous enclosure of the vertebral artery at C1, which may be present in as many as 16% of patients. The presence of a ponticulus posticus may be appreciated on axial or sagittal CT scans. While the osseous enclosure around the vertebral artery can offer some protection during exposure, it should not be erroneously interpreted as a starting point for C1 screw insertion . Similarly, exposure of the superior aspect of the C2 ring should proceed with caution to avoid inadvertent entry into the spinal canal, which is not protected by the ligamentum flavum at this level. Bipolar cautery is recommended for exposure of the C2 pedicle to allow cauterization of the leash of veins in this location and limit bleeding. The C2 nerve root can be visualized,as it lies along the posterior surface of the C1–C2 joint. It usually needs to be retracted superiorly or inferiorly to expose the posterior aspect of the C1 lateral mass. Alternatively, it can be ligated, although this will result in anesthesia in a portion of the posterior scalp.

53. Decompression In most cases of acute traumatic cervical injury, posterior decompression via laminectomy is not necessary. Canal compromise is most often caused by dislocation, translation, or retropulsed vertebral body fragments. In case of anteriorly displaced posterior arch fragments, a laminectomy is indicated to directly remove the offending compressive elements. In c ases of acute spinal cord injury associated with multilevel spondylotic stenosis, or ossification of the PLL, in which a posterior decompressive procedure can be considered the procedure of choice if cervical lordosis has been maintained.

54. If a posterior cervical decompression is to be performed, the appropriate levels are identified during exposure and dissection is carried out over the spinous process, laminae , and facet joints. The decompression should start centrally involving the spinous processes and laminae to the junction with the lateral masses. If loose fracture fragments are already present, they can be removed with a rongeur or delivered using a small curette and excised with pituitary forceps. Alternatively, the spinous processes may be resected with a rongeur and the laminae burred down to a thin cortical layer. The decompression is completed by removing the cortical bone and ligamentum flavum with Kerrison rongeurs . Another approach is to resect the osseous junction between the lamina and the lateral mass over the entire area that is to be decompressed and then to remove the piece, en bloc, with the assistance of bone clamps. In general, this technique is more applicable to degenerative conditions and is less useful in spinal trauma.

55. After posterior exposure has been performed, anterior displacement of the C1 ring can be reduced by delivering a posterior force via towel clips. Reduction Maneuvers for the Upper Cervical Spine

56. In challenging cases that do not reduce by conventional closed or open methods , a Penfield elevator can be carefully inserted posterolaterally into the odontoid fracture site (A). It should be advanced just beyond the anterior aspect of the proximal fragment under lateral fluoroscopy (B). The instrument is then levered superiorly to unlock the fracture fragments and restore alignment (C).

57. Reduction Maneuvers for the Subaxial Cervical Spine A Kerrison rongeur can be used to resect the superior aspect of the articular process if open reduction maneuvers are not successful. Open reduction of dislocated facets using a posterior approach. A Penfield 4 elevator (or other small, smooth, elevator) is inserted over the superior articular process. It is walked inferiorly to hook the inferior (dislocated) articular process. The elevator is then levered caudally to reduce the joint.

58. Posterior stabilization and fusion Lateral mass screw fixation is considered standard method of posterior fixation of subaxial spine. The Roy- Camille technique orients the screws perpendicularly to the long axis of spine making fixed-angle screw fixation to a rod easier at the expense of shorter screw lengths, reduced pullout strength, and greater risk of injury to the vertebral artery . The Magerl method of screw insertion maintains the advantages of greater screw length and enhanced biomechanical properties. With the screw tip directed toward the level of the disc space, the exiting nerve root may be at greater risk, whereas there is reduced risk of vertebral artery injury

59. Side view (A) and posterior view (B) of a diagram depicting a variable angle posterior screw–rod construct for stabilization of lower cervical spine injuries

60. Complications Associated with the Anterior Approach Dysphagia Recurrent laryngeal nerve palsy (dysphonia, vocal cord paralysis) Superior laryngeal nerve injury (loss of high phonation) Horner's syndrome Durotomy Airway obstruction from soft tissue swelling or hematoma Vascular injury: vertebral artery, carotid artery Complications a ssociated with the Posterior Approach Wound complications Pulmonary complications Venous thromboembolic events Durotomy C5 palsy Vertebral artery injury

61. Specific Injuries for Cervical Spine Fractures and Dislocations

62. C-SPINE VERTEBRAL FRACTURES 1.Occipital Condyle Fractures 2.Atlanto Occipital Dislocation 3.Atlas Fractures 4.Axis Fractures Odontoid f rac t ures Lateral Mass fractures P ars fracture 5.Atlanto Axial Combined fracture s 6.Subaxial fractures And Dislocations

63. OCCIPITAL CONDYLE CLASSIFICATION Rare And f requently m issed May p resent a s Lower Cranial Nerves Palsy Delayed Hypoglosal Nerve Palsy Alone Usually Results From ‘Axial Loading’ And ‘Lateral Bending’ Classification : ANDERSON Impaction fracture Comminuted fracture Stable Basillar fracture Stable Avulsion fracture of alar ligament Unstable

64. TREATMENT: Type I and type II fractures are stable - rigid cervical orthrosis -halo vest Type III # is unstable  immobilization for 12wks in halo vest, instability on flx & ext. films --> OCCIPITAL-C2 FUSION

65. Occipital condyle fracture treatment algorithm. MRI, magnetic resonance imaging

66. ATLANTO OCCIPITAL DISLOCATION Usually fatal, many patients die immediately a s a result of complete resp iratory arrest caused by brain stem compression TRAYNALIS & CO WORKERS CLASSIFICATION: Type I : A nterior displacement of occiput Type II : L ongitudinal distraction Type III: P osterior displacement

67. TREATMENT C onsist s of reduction and stabilization of atlantooccipita l joint Cervical Traction i s c ontraindicated b ecause of se vere i nstability “Immediate application of halo vest is recomm e nded ” Instability is ev i denced by bradycardia or episodes of brady cardi a followed by asystole Early surgical stabilization of atlantooccipital dislocation is advi s ed because ligamentous hea l ing in a halovest is unpredictable

68. Posterior Cervical Arthrodesis - using large c orticocancellous grafts with stabilization by dual plates screwed to posterior occiput and attached to lateral mass screws

69. Careful inspection of a paramedian image through C2 reveals the bony corridor through which a screw can be placed ( black arrow with dashed line). The vertebral artery in this patient is more high riding in its lateral course ( right), while the artery is more inferior medially (left). This highlights the importance of preoperative imaging evaluation, as the screw trajectory should be medialized . The starting point ( black dot) and trajectory (dashed arrow) for a C2 isthmus screw. The starting point lies just superior and lateral to the medial aspect of the C2–C3 joint.

70. Wertheim And Bohlman Occipitocervical Fusion Wires passed through the outer table of occiput , under the arch of atlas and spinous process of the axis Unicortical cancellous graft placed on wires tightened to secure graft in place

71. Magnetic resonance images of a patient with an occipitoatlantal dissociation (A) showing a frankly disrupted tectorial membrane ( black lines) and resultant spinal cord compression. There was an increased interval noted between the basion ( B) and odontoid (O). The patient had previously undergone an anterior corpectomy and fusion in the subaxial region. A posterior occipitocervical fusion was performed (B, C).

72. ATLAS FRACTURES Axial loading Associated with other spinal fractures (53%) -type 1 traumatic spondylilisthesis of axis posteriorly displaced type II & type I I I dens # LANDELL’S AND VON PETEGHAM CLASSIFICATION: Type I : P osterior arch fracture ( usually stable ) Type II : J efferson fracture (anterior and posterior arch # ) Type III : L ateral atlantal mass fracture

73. TYPE I : Stable injury Usually occur at the junction of the posterior arch and the lateral mass Unrecognised Posterior arch # may associated with C2 # may cause clinical instability after surgery  in this case external immobilization of c-spine until healing of C1 ring # should be done before proceeding with C2# stabilization (because occiput C2 stabilization results severe restriction of c- spine motion )

74. TYPE II (JEFFERSON’S) Burst fracture Characterized by four fracture –two in the anterior arch ,two in the posterior arch Stable # :transverse ligament is intact Unstable # :transverse liament is ruptured

75. TYPE III ( LATERAL MASS) U sually occur on one side only with the fracture line passing either through the articular surface or just anterior and posterior to the lateral mass on one side

76. C1 fracture treatment algorithm

77. RUPTURE OF TRANSVERSE LIGAMENT Results from a fall with blow from the back of the head For ligamentous injury nonoperative treatment is ineffective DICKMAN GREENE AND SONNTAG Classification : Type I : D i sruption of substance of ligament Type II : Avulsion from lateral mass of C1

78. Anterior subluxation of the ring of C1 can be detected on flexion films,instability is reduced in extesion on lateral film check for retropharyngeal hematoma. Primary indication for surgery is instability at C1-2 on flexion,extension views An anterior widening of the atlanto-dens inderval of more than 5mm on flexion suggests that the transverse ligament is incompetent

79. TREATMENT Initial treatment consists of immobilization through skull traction Type I injuries incapable of healing wirthout internal fixation T ype II injuries intially treated with rigid cervical o rthosis for 3-4 months In patients with n onunion and persistant instability-> posterior stabilization of C1-2 complex with - G allie type of posterior C1-2 arthrodesis - B rooks and J ennings fusion by bone block technique

80. Gallie ’s fusion : Wire loop under the arch of atlas . P ass the free end of wire through the loop grasping the arch of C1 Place the corticocancellous graft against the lamina of C2 and arch od C1 beneath the wires

81. Broock And Jennings Type Fusion (Bone Block Technique) Insertion of wires under the atlas and axis Full thickness rectangular iliac bone graft placed between arch of atlas and each lamina of axis Graft is secured in place by wire tightening over them

82. Patients present with torticolis and restricted neck motion An open mouth odontoid radiograph may reveal the ‘wink sign’ caused overriding of the C1-2 joint on one side and normal configuration on other side FIELDING AND HAWKINS CLASSIFICATION : Type 1 - simple rotary subluxation without anterior shift odontoid acts as pivot Type 2 - rotary displacement with anterior displacement of 3-5mm lateral articular process act as pivot type 3 - rotary displacement with anterior displacement of >5mm Type 4 - rotary displacement with posterior displacement ROTARY SUBLUXATION OF C1 ON C2

83. TREATMENT Acute rotary subluxation if C1-2 can be reduced by closed reduction  immobilization in halo vest for 8-12 wks If Closed reduction is not obtained  open reduction by posterior approach  Stabilization of C1-2 complex by posterior cervical arthrodesis using autogenous iliac bone grafting and oblique wiring. Halo v e st is recommonded for 8-12 wks C1-2 TRANSARTICULAR SCREW FIXATION (MAGERL AND SEEMANN TECHNIQUE ) Provides excellent rotational stability Halovest is unnecessary Cervical collar may be worn for 8-12wks

84. ODONTOID FRACTURES ANDERSON D’ALANZO CLASSIFICATION: Type I : avulsion of dist al odontoid process Type II : Fracture through the base of the odontoid process Type III: Fracture extending int o the body of C2

85. TYPE I FRACTURES: Uncommon Usually seen above the transvers ligament No instability even after nonunion occurs

86. TYPE II FRACTURES: Most common Nonunion rate 36% Significant displacement >5mm may have n onunion Posteriorly displaced dens #s are more likely to have f racture o f t he r ing Of C1

87. ANTERIOR SCREW FIXATION OF DENS # CONTRAINDICATIONS: Oblique fracture configuration Associated unstable atlas fracture Pathological fracture s Nonunion of dens fractures

88. TYPE III FRACTURES: Have large cancellous base Heals without surgery (90%)

89. T r e a tme n t : Goal of treatment in displaced dens # is to correct the angulation in a halo vest Non displaced # are stable that heals with 8- 12 wks of immobilisation in halovest or cervical collor

90. 2.Lateral Mass Fracture Axial compression and lateral bending Presented with neck pain ,limited motion no nuerological injury A depression fracture of the C2articular surface is common TREATMENT R anges from coll ar immobilisation to late fusion for chronic pain

91. Traumatic spondylolesthesis of the axis (hangman fracture) M.c.c is motor vehicle accident with hyperextension of the head on the neck Occiput forced down against the posterior a rch of the atlas which is forced against the pedicle of C2 LEVINE & EDWARD CLASSIFICATION: Type I : pars # <2mm dislocation Type II : pars # disrupted PLL c2-3 disc disruption Possible ALL disruption or avulsion from C3 Type IIA : same as type II but Less displacement and more angulation Type III : initial disruption of C2,C3 facet capsules then pars # after dislocation 3.PARS FRACTURE

92. TYPE I Caused by hyperextension and axial loading With failure of nueral arch in tension Because of ligamentous injury is minimal these fractures are stable TREATMENT immobilization in rigid cervical arthosis for 12wks and usually heal

93. TYPE II >3mm of anterior translation and significant angulation Results from hyperextension and axial loading that cause the nueral arch to fail with vertical fracture line Followed by significant flexion results stretching o f posterior annulus of the disc and the significant anterior translation and angulation C2-3 disc may disrupted by acute flexion component TREATMENT Skull traction through tong / Halo ring in slight extension of the neck over a rolled-up towel for 3-6 wks  Immobilization in a halovest for 3-6 months usually unites

94. Type IIA n Flexion distraction injury Variant of type II fracture Shows severe angulation betweenC2-3 with minimal translation Usually more horizontal # line than vetrical through C2 arch It is imp. To identify this # that traction can cause marked widening of C2-3 disc space and displacement TREATMENT: Halo vest immobilization with slight compression under image intensificatio to achieve and maintain the reduction  if reduction btained contiue halovest for 12 wks

95. Type III It is c o mbined bipedicular fracture with posterior facet injuries Severe angulation and translation of nueral arch Associated U/L or B/L facet dislocation at C2-3 Frequently associated with nuerological deficit TREATMENT: Type 3 is the only hangmann # commonly require surgical stabilization Open reduction and internal fixation and b/l obli q ue wiring Posterior cervical fusion and halo vest immobilization for 3months

96. Hangman’s fracture treatment algorithm. ACDF, anterior cervical discectomy and fusion.

97. ATLATO AXIAL COMBINED FRACTURES Neurological injury is common DICKMAN AND COLLEAGUE CLASSIFICATION ATLAS fracture AXIS fracture P osterior arch fracture T ype 2, T ype 3 odontoid fracture Jefferson fracture + H ang man fracture Lateral mass fracture O ther C2 fractures

98. THANK YOU