' 1.4.

2013

Osteology The cervical spine contains 7 vertebral bodies

C1 (atlas) C2 (axis) C1 to C7 C2 to C6

have a transverse foramen vertebral artery travels through transverse foramen of C1 to C6 have bifid spinous process despite having a transverse foramen, the vertebral artery does NOT travel

C7

through it in the majority of individuals there is no C8 vertebral body although there is a C8 nerve root

Alignment Normal sagittal lordosis (measured from C2 to C7) Spinal Canal

normal diameter is 17mm

<13 mm indicates possible cord compression

Subaxial Cervical Spine (C3 to C7)

have a transverse foramen vertebral artery travels through transverse foramen of C1 to C6 have bifid spinous process contains palpable carotid tubercle which is a valuable landmark for anterior approach to cervical spine nonbifid spinous process despite having a transverse foramen, the vertebral artery does NOT travel through it in the majority of patients there is no C8 vertebral body although there is a C8 nerve root

C2 to C6 C6

C7

The superior articular facets of the subaxial cervical spine (C3-C7) are oriented in a posteromedial direction at C3 and posterolateral direction at C7, with a variable transition between these levels

KINEMATICS
Rotation decreases caudally due to greater inclination of facet joints

DEFINITION Loss of the ability of the spine under physiological loads to maintain relationships between vertebrae in such a way that the spinal cord or nerve roots are not damaged or irritated, and deformity or pain does not develop (White and Panjabi - clinical instability) The supporting structures of the lower cervical spine can be divided into two groups anterior and posterior A motion segment is made up of two adjacent vertebrae and the intervening soft tissues. If a motion segment has all the anterior elements and one posterior element intact, or all the posterior elements and one anterior element intact, it can remain stable under physiological loads (White and Panjabi)

Radiographically, cervical spine instability is indicated by the horizontal translation of one vertebra relative to an adjacent vertebra greater than 3.5 mm on the lateral flexionextension view Instability also is indicated by more than 11 degrees of angulation of one vertebra relative to another

Checklist for the diagnosis of clinical instability of the lower cervical spine

a score of 5 or more indicates instability.

Represent spectrum of Osteoligamentous pathology that includes

Unilateral facet dislocation

most frequently missed cervical spine injury on plain x-rays leads to ~25% subluxation on x-ray associated with monoradiculopathy that improves with traction

Bilateral facet dislocation

leads to ~50% subluxation on x-ray often associated with significant spinal cord injury

Facet fractures
more frequently involves superior facet may be unilateral or bilateral

Epidemiology

Location
~75% of all facet dislocations occur within the subaxial spine (C3 to C7) 17% of all injuries are fractures of C7 or dislocation at the C7-T1 junction this reinforces the need to obtain radiographic visualization of the cervico-thoracic junction

Mechanism

flexion and distraction forces +/- an element of rotation

Physical exam

Monoradiculopathy
seen in patients with unilateral dislocations C5/6 unilateral dislocation usually presents with a C6 radiculopathy
weakness to wrist extension numbness an tingling in the thumb

C6/7 unilateral dislocation usually presents with a C7 radiculopathy

weakness to triceps and wrist flexion numbness in index and middle finger

Spinal cord injury symptoms

seen with bilateral dislocations symptoms worsen with increasing subluxation

5 Classification developed through the years

1. 2. 3. 4. 5. Holdsworth's classification 1970 Allen's classification 1982 Harris' classification 1986 The Subaxial Cervical Spine Injury Classification System (SLIC) 2007 Cervical Spine Injury Severity Score (CSISS) 2006

Sir Frank Holdsworth published his classification in 1970. The classification was for spinal trauma in general and therefore also included cervical spinal injuries.

Pure flexion injuries : Pure flexion injuries and results in a crushing of the anterior part of the vertebra (a wedge fracture). This fracture remains stable because the posterior ligament complex is intact
Flexion-rotation injuries : The flexion of the spine causes With the additional rotation of the spine and the rupture of the posterior ligament complex flexion-rotation injury results in a dislocation of the articular processes and the rupture of the intervertebral disc. This injury is unstable Extension injuries : Rupture of the anterior longitudinal ligament and intervertebral disc. The posterior ligament complex is not injured and the injury is stable as long as the cervical spine is not extended. Extension of the cervical spine may cause an extension injury

Compression injuries : Occur when force is applied longitudinally to the cervical spine and one or the other vertebral end plate fractures and the nucleus of the disc is forced into the vertebral body which explodes(a burst fracture). The ligaments are intact and the injury is stable. Shearing injuries : When a powerful force is applied to the posterior part of the neck, the violence may cause a shearing injury, whereby the upper vertebra is forced anteriorly relative to the lower vertebra, the articular processesf racture and all ligaments rupture. When this injury occurs in the cervical spine, it is unstable

In 1982, Ben Allen et al published the classification of Closed, Indirect Fractures and Dislocations of the Lower Cervical Spine. They hypothesise that the mechanism that causes an injury can be deduced from the radiographical findings, that similar injuries are caused by similar mechanisms and that within each injury class there is a spectrum of injury which ranges from trivial to severe Compressive flexion (5 stages) Vertical compression (3 stages) Distractive flexion (4 stages) 1. Facet subluxation 2. Unilateral facet dislocation 3. Bilateral face dislocation 50% displacement 4. Complete dislocation Compressive extension (5 stages) Distractive extension (2 stages) Lateral flexion (2 stages)

D-F injuries are characterized by a failure of the posterior ligamentous complex, evidenced by an increased spacing of the spinous processes and a Facet subluxation or dislocation. There may be a blunting of the anterior-superior margin. With increasing stage, there is also an increasing anterior motion of the superior vertebral body. The injury mechanism was known in 6 cases and in each the impact came to the back of the head when the neck was in flexion Stage 1: Facet subluxation, gapping of the spinous process ligaments, indicating failure of the posterior ligamentous complex, with or without some blunting of anterosuperior vertebral body Stage 2: Unilateral facet dislocation, usually posterior ligamentous complex is intact, rotational deformity. Stage 3: Bilateral facet dislocations, 50% translation of upper vertebral body on lower one. Stage 4: Close to 100% translation of upper vertebral body on lower one, appearance of a so-called floating vertebra.

In 1986, Harris et al published A Practical Classification of Acute Cervical Spine Injuries The classification has 7 main categories with subgroups. Flexion (5 subgroups) - Bilateral interfacetal dislocation : Dislocation of facet joints bilaterally with rupture of all ligamentous structures Flexion rotation - unilateral interfacetal dislocation, resulting in rupture of the posterior ligament complex. The anterior ligament complex may also be ruptured Extension-rotation Vertical compression (2 subgroups) Hyperextension (7 subgroups) Lateral flexion Diverse or imprecisely understood mechanisms (2 subgroups)

Vaccaro et al published the Subaxial Cervical Spine Injury Classification System in2007 Its a comprehensive classification system, incorporating pertinent characteristics for generating prognosis and courses of management Three major injury characteristics were identified as critical to clinical decision 1. morphology as determined by the pattern of spinal column disruption on available imaging studies 2. Integrity of the disco-ligamentous complex represented by both anterior and posterior ligamentous structures as well as the intervertebral disk 3. neurological status of the patient

These three injury characteristics were recognized as largely independent predictors of clinical outcome. Within each of the three categories, subgroups were identified and graded from least to most severe

The sum of the 3 classes in the SLIC scale is then computed and confounders are noted. If the score is between 1-3, the patient does not receive surgery, while for a score 5 surgery is recommended

Published by Moore et al in 2006. They propose a scoring system where 0-5 points are given based on the severity of the fracture and ligamentous injury in 4 spinal columns (anterior, posterior, right pillar, left pillar), with 0 being no injury and 5 being the worst possible injury in the affected column. The 4 spinal columns where defined to include the following structures: Anterior: vertebral body, vertebral disc, anterior and posterior longitudinal ligaments, uncinate processes and transverse processes Posterior: the spinous process, the laminae, the posterior ligamentous complex and the ligamentum flavum Lateral pillars: lateral masses, pedicle, transverse processes, superior and inferior articular processes and the facet capsules.

The scores are then summed to a final injury severity score.

Radiographs

CT scan

Lateral shows subluxation of vertebral bodies Unilateral dislocations lead to ~ 25% subluxation Bilateral facet dislocation leads to ~ 50% subluxation on xray Valuable in demonstrating

Bony anatomy of the injury Malalignment or subtle subluxation of facet Facet fracture Fracture of the pedicle or lamina on axial images

MRI

Indications are controversial but include

Timing

Acute facet dislocation in patient with altered mental status Failed closed reduction and before open reduction to look for disc herniation Any neurologic deterioration is seen during closed reduction Timing of MRI depends on severity and progression of neurologic injury MRI should always be performed prior to open reduction or surgical stabilization

Valuable in demonstrating

Disc herniations Extent of posterior ligamentous injury

Nonoperative

cervical orthosis or external immobilization (6-12 weeks)

indications facet fractures without significant subluxation, dislocation, or kyphosis

Operative

Closed reduction followed by surgical stabilization

Indications awake and cooperative patient with unilateral facet dislocation awake and cooperative patient with bilateral facet dislocation Outcomes 26% of patients will fail closed reduction and require open reduction unilateral dislocations are more difficult to reduce but more stable after reduction bilateral dislocation are easier to reduce (PLL torn) but less stable following reduction

Open reduction and surgical stabilization

Indications patient with mental status changes and facet dislocations patients who fail closed reduction unilateral facet fracture with significant subluxation, kyphosis, or radiculopathy bilateral facet fractures lateral mass dissociations

Closed reduction

gradually increase axial traction with the addition of weights perform serial neurologic exams and plain radiographs after addition of each weight abort if neurologic exam worsens and obtain immediate MRI

Anterior open reduction & ACDF

indications

facet dislocations reduced through closed methods with an anterior disc herniation unilateral facet dislocations that fail closed reduction with an anterior disc herniation reduction technique involves distracting vertebral bodies with caspar pins and then rotating the proximal pin towards the side of the dislocation not effective for reducing bilateral facet dislocations

anterior open reduction techniques

Posterior reduction & instrumented stabilization

indications

when unable to reduce by closed or anterior approach no anterior compression (no disc herniation) performed with lateral mass screws usually have to fuse two levels due to inadequate lateral mass purchase at level of dislocation

technique

Combined anterior decompression and posterior reduction / stabilization

indications

when anterior disc herniation present that requires decompression in patient that can not be reduced through closed or open anterior technique go anterior first, perform discectomy, position plate but only fix plate to superior vertebral body this way the plate will prevent graft kick-out but still allows rotation during the posterior reduction this technique eliminates the need for a second anterior procedure

technique

Denis' Three-Column Theory Three-column concept divides a spinal segment into three parts: anterior ALL,anterior annulus fibrosus, and the ant. part of the vertebral body middle - PLL, post. annulus fibrosus, and the post. wall of the vertebral body posterior post. bony complex (post. arch) with the post. lig complex: supraspinous , interspinous, capsule, and lig flavum

According to Denis' system, spinal traumas are classified to minor and major injury based on their potential risks to cause instability Each type of fracture also may be divided some subclasses based on severity of the damage.

In terms of their instability risk as follows (from the most stable to the most instable): wedge fracture < burst fracture < seat-belt-type fracture < fracture dislocation

A failure under compression of the anterior column. The middle column is intact and acts as a hinge. There may be a partial failure of the posterior column, indicating the tension forces at that level. Competent middle column prevents the fracture from subluxation or compression of the neural elements by retropulsion of the fragments of the posterior wall into the canal.

Four subtypes of compression fractures can be identified:

Type A - involvement of both end plates Type B - involvement of superior end plate Type C - inferior end plate Type D - buckling of anterior cortex w/ both end plates intact.

Results from failure under axial load of both the anterior and the middle columns originating at the level of one or both endplates of the same vertebra. Five different types of burst fractures can be described A: Fracture of both end-plates. The bone is retropulsed into the canal. B: Fracture of the superior end-plate. a combination of axial load with flexion. C: Fracture of the inferior end-plate. D: Burst rotation. Could be misdiagnosed as a fracture-dislocation. The mechanism is a combination of axial load and rotation. E: Burst lateral flexion. differs from the lateral compression fracture in that it presents an increase of the interpediculate distance on anteroposterior roentgenogram.

Both posterior and middle columns fail due to hyper-flexion and subsequent tension forces. The anterior part of the anterior column may partially damaged under compression, but still functions like a hinge. There is no subluxation, and spine is mainly unstable in flexion.

Seat-belt injuries may be divided to two subtypes One-level injury: It present as a simple fracture going through bone, or as a ligamentous disruption passing through posterior ligamentous complex and the intervertebral disc. Two-level injury: The middle column is ruptured either through the bone or the disc

Presents with failure of all three columns under compression, tension, rotation, or shear. It is similar to seat-belt-type injury. However, the anterior hinge is also disrupted and some degree of dislocation is present. There are three subtypes of fracture-dislocations based on mechanism of injury: flexion rotation flexion distraction Shear

Flexion-rotation type fracture-dislocation. There is a complete disruption of the posterior and middle columns under tension and rotation. The anterior column may fail in rotation or compression and rotation. The failure at the level of the middle and anterior columns may occur through the vertebral body or purely through the disc.

Flexion-distraction type fracture-dislocation. This injury resembles the seat-belt type of injury with disruption of both the posterior and middle columns under tension. However, in addition, it presents tear of the anterior annulus fibrosus, and subsequent stripping of the anterior longitudinal ligament during subluxation or dislocation.

Shear type fracture-dislocation. This injury results from an extension type of mechanism in which the anterior longitudinal ligament is disrupted. The disc is first torn anteriorly to posteriorly until the continued shearing force translates the upper segment on top of the inferior segment, or vice versa.

It has 2 subtype: (1) In the posteroanterior shear subtype, the segment above is sheared off forward on top of the segment below. The posterior arch of the last one or two vertebrae of the upper segment is usually fractured in the translation, leaving a floating posterior arch behind. The frequency of dural tear and complete paraplegia is very high in this type of fracture. (2) In the anteroposterior shear, the segment above shears off on the segment below in a posterior direction. Its posterior arch has nothing to clear during its posterior displacement; therefore, no free-floating laminae exist.

Fracture patterns include: Compression fracture

compressive failure of anterior vertebral body without disruption of posterior body cortex and without retropulsion into canal fracture extension through posterior cortex with retropulsion into the spinal canal often associated with complete and incomplete spinal cord injury characterized by fracture of anterior inferior portion of vertebra posterior-inferior corner of body breaks off and is retropulsed posteriorly often associated with posterior ligamentous injury associated with SCI unstable and usually requires surgery must differentiate from a true teardrop fracture caused by mild extension injury small fleck of bone is avulsed of anterior endplate

Burst fracture

Flexion teardrop fracture

Extension teardrop avulsion fracture

Nonoperative

Collar immobilization for 6 to 12 weeks

Indications
stable mild compression fractures (intact posterior ligaments & no significant kyphosis) anterior teardrop avulsion fracture

Cxternal halo immobilization

Indications

only if stable fracture pattern (intact posterior ligaments & no significant kyphosis)

Operative

Anterior decompression, corpectomy, strut graft, & fusion with instrumentation

Indications
compression fracture with 11 degrees of angulation or 25% loss of vertebral body height unstable burst fracture with cord compression unstable tear-drop fracture with cord compression minimal injury to posterior elements

Posterior decompression, & fusion with instrumentation

Indications
significant injury to posterior elements anterior decompression not required