Cervical spine injury antomy and management.pptx

Cervical spine

1. Cervical Spine Injuries Capt Aung Khaing Myo PG 2 nd Year 1

2. Introduction functionally the most important region complex anatomy, spinal biomechanics - difficult to assess careful evaluation of each region is necessary 2

3. Osseous Anatomy 3

4. Ligamentous Anatomy 4

5. lower cervical vertebrae (C3-7) are connected by two longitudinal ligaments and the intervertebral discs 5

6. Spinal Canal triangular and greater in medial-to-lateral dimension than in anterior-to-posterior dimension c rosssectional area of spinal canal is largest at C2 smallest at C7 6

7. Vascular Anatomy major blood supply of the cervical cord and the cervical spine is vertebral artery 7

8. Neuroanatomy cervical cord emerges from foramen magnum as a continuation of medulla oblongata enlarges from C3 and becomes maximal at C6 o ccupies 50% of canal 8

9. Mechanism of injury t raction (avulsion) direct injury indirect injury 9

10. Common Mechanism of Injury Hyperflexion Axial Compression Hyperextension 10

11. Hyperflexion Distraction creates tensile forces in posterior column Can result in compression of body (anterior column) Most commonly results from MVA and falls 11

12. Compression Result from axial loading Commonly from diving, football, MVA Injury pattern depends on initial head position May create burst, wedge or compression fracture 12

13. Hyperextension Impaction of posterior arches and facet compression causing many types of fracture lamina spinous processes pedicles With distraction get disruption of ALL 13

14. Principles of initial management At the scene of accident Resuscitation protocol Airway Breathing Circulation 14

15. Essential principle spine must be immobilized until patient has been resuscitated and other life-threatening injuries have been identified and treated 15

16. Methods of temporary immobilization In-line immobilization 16

17. Quadruple immobilization backboard, sandbags, forehead tape and semi-rigid collar 17

18. Diagnosis History high index of suspicion is essential symptoms and signs – minimal history is crucial h ead injury or loss of consciousness - cervical spine injury until proven otherwise 18

19. Examination bruises in head and face could indicate indirect trauma to cervical spine b ones and soft tissues of neck - tenderness and areas of ‘bogginess’, or increased space between spinous processes throughout the entire examination cervical spine must not be moved 19

20. Neurological examination To determine the type and level of injury. Full & may have to be repeated during the first few days. Assess cord longitudinal column function & Sacral sparing Perianal sensation – complete or incomplete In the state of spinal shock, difficult to determine the type of injury. 20

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23. Investigations Imaging Plain x-rays must be of high quality AP - lateral outlines should be intact - spinous processes and tracheal shadow in midline Open mouth view - C1 and C2 fracture Swimmer view - C7-T1 junction 23

24. Lateral view 24

25. Prevertebral soft tissue space 25

26. CT scan - to assess bone morphology and - canal compromise MRI - to assess cord and nerve root injury - to assess ligaments injury 26

27. 27 AO/OTA Classification

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29. Principle of Definitive Management to preserve neurological function to minimize neurological compression to stabilize the spine to rehabilitate the patient 29

30. Instability “ Clinical instability is defined as the loss of the spine’s ability under physiologic loads to maintain its patterns of displacement, so as to avoid initial or additional neurologic deficits, incapacitating deformity and intractable pain.” 30

31. Denis three-column theory of spinal stability All fractures involving the middle column and at least one other column should be regarded as unstable fracture. 31

32. Indications for urgent surgical stabilization (a) unstable fracture with progressive neurological deficit (b) unstable fracture in a patient with multiple injuries 32

33. Non-operative Treatment 33

34. Collars Skull traction Halo vest - at least 4 pins are inserted to outer table - ring is applied - distraction rods are applied to ring and vest 34

35. Operative treatment Indications - unstable spinal injuries with or without neurological deficit and potentially unstable spine Advantages - preserve neurological function. - facilitate nursing care and early physiotherapy. - prevent late deformity, neurological injury and painful instability. 35

36. Type of surgical procedures Decompression - anterior or posterior Stabilization and fusion - with bone graft (strut) or cage Instrumentations - wiring - plating - lateral mass screw fixation - pedicle screw fixation (short or long segment ) 36

37. Decompression and stabilization Retropulsed bone or disc fragments should be decompressed and anterior fusion. For posterior ligamentous or bony instability, posterior stabilization and bone graft 37

38. Instrumentations Wiring of spinous process Posterior cervical plating system Anterior plating system 38

39. Pedicle screw fixation Screws were placed within the pedicles or lateral masses and joined with plate or rods. Achieve stable construct High percentage of fusion rate and low hardware failure 39

40. Combine fixation devices Obtain stable fixation and provide considerable flexibility Consist of pedicle, transverse process and sublaminal hooks and segmental fixation Complex and technically difficult High incidence of nerve injury 40

41. Specific types of injury Occipito-atlantal dislocation Usually fatal Occasionally pt may survive without neurological deficit Halo ring & vest immobilization without traction F/B posterior fusion of occiput to upper cervical spine 41

42. C1 fracture Posterior arch# - Cervical collar if stable Lateral mass # - Collar - Halo vest traction when lateral displacement > 7cm Burst # with rupture ligament - unstable injury - halo vest for several weeks - posterior C1-C2 fusion if instability present 42

43. Odontoid fracture Usually without neurological injury Type 1 - avulsion fracture rigid cervical collar Type 2 - usually unstable >5cm displacement need reduction - halo vest immobilization - screw fixation Type 3 - if displace – halo vest for 8-12 weeks 43

44. Hangman # ( traumatic spondylolisthesis ) The pedicle of axis are fracture and C1-2 disc is rupture Extension and distraction injury neurological injury is unusual If undisplaced - rigid cervical collar If displaced - need reduction 44

45. Unilateral Facet Dislocation Flexion/rotation injury Painful neck Easy to miss - supine position can reduce injury “Bow tie” sign: both facets visualized, not overlapping 45

46. Reduce to minimize late pain, instability 50 % successful reduction Halo vest – 6-8 weeks 46

47. Bilateral Facet Dislocation Injury to cord is common 10-40% herniated disc into canal Vertebral body displaced at least 50% 47

48. Timing for reduction Spinal cord injury may be reversible at 1-3 hours Need for MRI If significant cord deficits If paresthesias or declining status If neurologically stable, perform MRI prior to operative treatment 48

49. Approach Guidelines Anterior Approach Burst fx w/SCI Disc involvement Significant compression of anterior column Posterior Approach Ligamentous injuries Lateral mass Fx Dislocations 49

50. Anterior Surgery Advantages Anterior decompression Atraumatic approach Supine position Disadvantages Limited as to number of motion segments included Potential for increased morbidity Poor access to CT transition zone 50

51. Posterior Surgery Advantages Rigid fixation Foraminal decompression Deformity correction May extend to occiput and CT transition zones Implant choices Disadvantages Minimal anterior cord decompression Prone positioning 51

52. Summary Successful treatment based on knowledge of anatomy, mechanism of injury and compromise of bone and/or soft tissue Stabilization of the spine Decompression of neurological deficit Restore alignment Restore function 52

53. Thank You! 53