Operative Treatment For Cervical Spine Fractures Dr T

Basion-Dens-Interval <12 mm. >12 mm. Suggests Vertical Instability Basion Occipitocervical Basion Instability Axis Basion-Axial-Interval

Occipitocervical Dislocation • Mechanism Unclear – Rotation & Distraction • Neurological Deficits Confusing –

Atlas Fractures: Extension • Anterior Arch – Hyper-extension – Avulsion of Longus Colli –

Atlas Fractures: Extension • Posterior Arch Fractures • Occipital Pain & Numbness • Stable

Jefferson Fractures • Four Part Burst • Axial Load • 6. 9 mm Overhang

Lateral Mass Fractures of C-1 • Free-Floating Lateral Mass of C-1 • Often Comminuted

Treatment & Results C-1 #’s • Good Results Reported with – Halo Traction +

Anderson & D’Alonzo Classification (JBJS, 1974) • Type III

$Odontoid fractures Type 1 Type 2 Type 3$

Type II Odontoid • Halo-Thoracic Brace • Non-union Rate 14 -32 -75% • Risk

Type II Odontoid • Direct Screw Fixation • • Preserves C 1 -2 Motion

Type II Odontoid • Posterior Fusion – Primary – for Non or Delayed Union

C 2 Magerl screw fixation • Good stability • • Does not need –

Odontoid stabilisation Osteosynthesis: odontoid screw fixation Arthrodesis: Magerl screw fixation - challenging – Good

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

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

Checklist Approach • Applies to trauma and degenerative disease • The more points the

C 2 -T 1 • • • Usually for trauma, but applies to all

Patient JM, 16 yrs • Fell boarding 2/52 ago – – – C 6

Patient JM, 16 yrs C 6 C 7 Extension C 6 C 7 Flexion

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

Patient EC, 72 f C 5 Postreduction T 2 MRI

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Operative Treatment For Cervical Spine Fractures Dr. T. G. Hogan

Occipito-cervical Dissociation

Basion-Dens-Interval <12 mm. >12 mm. Suggests Vertical Instability Basion Occipitocervical Basion Instability Axis Basion-Axial-Interval < 12 mm >12 mm. Suggests Anterior Instability <0 mm. Suggests Posterior Instability Int <12 BDI < 12

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 – Jefferson – Lateral Mass 50% 70% 33% • Landells, Van. Peteghem, Spine 1987

Anderson & D’Alonzo Classification (JBJS, 1974) • Type III

$Odontoid fractures Type 1 Type 2 Type 3$

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 – 5 mm Displacement – >10 deg. Angulation – Posterior Displacement – Elderly

Type II Odontoid • Direct Screw Fixation • • Preserves C 1 -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

C 2 Magerl screw fixation • Good stability • • Does not need – odontoid – C 1 arch – C 2 arch Challenging

Odontoid stabilisation Osteosynthesis: odontoid screw fixation Arthrodesis: Magerl screw fixation - challenging – Good stability – Does not need odontoid, C 1 arch or C 2 arch

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

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

Subaxial C-Spine

Flexion-compression. . . 3 2 1 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

C 2 -T 1 • • • Usually for trauma, but applies to all Ant. /post. Element failure Stretch test (1. 7 mm, >7. 5 degrees) X-Ray (>3. 5 mm, 11 degrees) Flex/ext x-ray (>3. 5 mm, 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

CSLP Ant. & Post Instability

Mr. R. Co. C 5 & 6 Fractures

Mr G H C 4 -5 Facet Dislocation

Cervical trauma Case presentations

Cervical trauma Case 1

Patient JM, 16 yrs • Fell boarding 2/52 ago – – – C 6 “winded” continued 2/7 hemoptysis 4/7 saw GP neck xrayed • Full ROM • Not tender C 6

Patient JM, 16 yrs C 6 Spot lateral C 7

Patient JM, 16 yrs C 6 C 7 Extension C 6 C 7 Flexion

Patient JM, 16 yrs C 6 C 7 CT reformats

• New or old injury? –Snowboarding 2 wks ago? –Dirtbike 2 yrs ago? • Observe only? –Advice and precautions –Risks • Stabilise? –Anterior or posterior –Risks

Patient EC, 72 f Initial Xray C 5

Patient EC, 72 f C 5 Left CT Right

Patient EC, 72 f C 5 Postreduction T 2 MRI

EC C 5 Postop

Cervical trauma Case 3

Patient M, 65 yrs Initial CT

Patient M, 65 yrs Initial CT Left Right

Patient M, 65 yrs Intraoperative Postop

Initial CT Patient M, 65 yrs

Patient BB, 32 yrs

10 lbs 15 lbs 20 lbs BB 25 lbs + 1 day

3 months 6 months BB