Operative Treatment For Cervical Spine Fractures

Dr. T. G. Hogan

Occipito-cervical Dissociation

Occipitocervical Instability Basion

BDI < 12

Basion Axis Int <12

Basion-Dens-Interval <12 mm.

>12 mm. Suggests Vertical Instability

Basion-Axial-Interval < 12mm

>12mm. Suggests Anterior Instability

<0mm. Suggests Posterior Instability

Occipitocervical Dislocation

• Mechanism Unclear– Rotation & Distraction

• Neurological Deficits Confusing– High Tetraplegia– Cruciate Paralysis– Wallenberg’s Syndrome

• Ligamentous Injuries = Unstable

• Avoid Traction

Atlas Fractures: Extension• Anterior Arch

– Hyper-extension– Avulsion of Longus

Colli– R/O Other Injuries– 65% (Landells)

• Stewart G, Radiology 1977

Atlas Fractures: Extension• Posterior Arch Fractures

• Occipital Pain & Numbness

• Stable• R/O Other Injuries

(Odontoid #)

Jefferson Fractures

• Four Part Burst

• Axial Load

• 6.9 mm Overhang– Spence KF, JBJS, 1970

• 8.1 mm Overhang – Heller JG, J Spinal

Disord, 1993

Lateral Mass Fractures of C-1

• Free-Floating Lateral Mass of C-1

• Often Comminuted

– Segal & Stauffer, JBJS, 1987

Treatment & Results C-1 #’s

• Good Results Reported with– Halo Traction + Vest– Rigid or Simple Orthoses

• Late Pain:– Ant/Post Arch 50%– Jefferson 70%– Lateral Mass 33%

• Landells, VanPeteghem, Spine 1987

Anderson & D’Alonzo Classification (JBJS, 1974)

• Type I

• Type II

• Type III

Odontoid fractures

Type 1

Type 2

Type 3

Type II Odontoid

• Halo-Thoracic Brace

• Non-union Rate 14-32-75%

• Risk Factors:– Failure to Treat– 5mm Displacement– >10 deg. Angulation– Posterior Displacement– Elderly

Type II Odontoid

• Direct Screw Fixation

• Preserves C1-2 Motion

• No Bone Graft Required

• Avoid Non-Unions

• Avoid Reverse Oblique #

– Aebi, Spine 1989

Type II Odontoid

• Posterior Fusion– Primary– for Non or Delayed Union

• Trans-articular Facet Screws

• 96% Fusion Rate

• Restricted Rotation

C2 Magerl screw fixation• Good stability • Does not need

– odontoid– C1 arch– C2 arch

• Challenging

Odontoid stabilisation

Arthrodesis: Magerl screw fixation - challenging

– Good stability – Does not need odontoid, C1 arch or

C2 arch

Osteosynthesis: odontoid screw fixation

Traumatic Spondylolisthesis C-2(Levine & Edwards, JBJS, 1985)

Traumatic Spondylolisthesis C-2

(Levine & Edwards, JBJS, 1985)

Traumatic Spondylolisthesis C-2(Levine & Edwards, JBJS, 1985)

Traumatic Spondylolisthesis C-2(Levine & Edwards, JBJS, 1985)

Dislocated

Subaxial C-Spine

Flexion-compression...

1

3

2 4

5

Checklist Approach

• Applies to trauma and degenerative disease

• The more points the more unstable• 5 points does not mean surgery

occasionally <5 need Sx>5 don’t need Sx

• Currently investigated by CSRS• Different considerations for different levels• 2-column VS 3-column

Sensitivity Settings

C2-T1

• Usually for trauma, but applies to all• Ant./post. Element failure• Stretch test (1.7mm, >7.5 degrees)• X-Ray (>3.5mm, 11 degrees)• Flex/ext x-ray (>3.5mm, 20 degrees)• Pavlov’s ratio (<0.8) sagittal diameter <13• Narrow disc• Cord damage• Root damage• Dangerous loading anticipated

Cervical Measurements

Mr. Roeth. C-4 Fracture

Mr. Roeth. C-4 Fracture

CSLP Ant. & Post Instability

Mr. R. Co. C5 & 6 Fractures

Mr. R. Co. C5 & 6 Fractures

Mr G H C4-5 Facet Dislocation

Mr G H C4-5 Facet Dislocation

Cervical trauma

Case presentations

Cervical trauma

Case 1

Patient JM, 16yrs

C6

C6

• Fell boarding 2/52 ago – “winded”– continued 2/7– hemoptysis 4/7– saw GP– neck xrayed

• Full ROM• Not tender

Patient JM, 16yrs

C6

C7Spot lateral

Patient JM, 16yrs

C6

CC77

Extension

C6

CC77

Flexion

Patient JM, 16yrs

CC77

CC66

CT reformatsCT reformats

• New or old injury?–Snowboarding 2wks ago?–Dirtbike 2yrs ago?

• Observe only?–Advice and precautions–Risks

• Stabilise?–Anterior or posterior–Risks

Patient EC, 72f Initial Xray Initial Xray

C5

Patient EC, 72f

CTCTLeftLeft RightRight

CC55

Patient EC, 72f

PostreductionPostreduction

CC55

T2 MRIT2 MRI

CC55

EC

PostopPostop

CC55

Cervical trauma

Case 3

Patient M, 65yrs Initial CT Initial CT

Patient M, 65yrs Initial CT Initial CT

Left Right

Patient M, 65yrs Intraoperative Intraoperative

PostopPostop

Patient M, 65yrs Initial CT Initial CT

Patient BB, 32yrs

25lbs + 1 day

25lbs

20lbs

15lbs

BB

10lbs

BB

BB

6 months

3 months