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whichstabilization and transfer methods are safest for patients with suspected
cervicalspineinjuries(15).Alift-and-slidemaneuveroralogrollmaneuverwith
inlinemanualcervicalstabilizationisrecommended(14,15).
A complete neurological assessment should be performed to gain an
understandingof the extentofneurological injury,ifany.Keyelementsof the
examination with regard to injuries of the cervical spine include motor and
sensory examination of upper and lower extremities as well as an anorectal
examinationtoassess forsacral sparing(14,16).Incasesofpenetratinginjury,
anyobviousretainedobjectswithintheneck,whichmaybeinjuringthecervical
spinevertebralcolumnand/orneuralelements,shouldbe leftinplaceuntilthe
trajectory,depth,andneurovascularstructuralinvolvementmaybeassessedwith
imaging(17,18).
Radiography
X-ray (XR), computed tomography (CT), and magnetic resonance imaging
(MRI)arethemainstayforprimaryevaluationoftheinjurytothecervicalspine
in cases of SCI, although guidelines exist for determining which patient
presentationsmaybe safely assessed with XR alone. One such presentation is
thatofwhiplashwithoutneurologicaldeficits.Whiplashisaninjurythatoccurs
secondary to trauma to the soft tissue structures of the cervical spine such as
muscles, ligaments, intervertebral discs and joints, and the clinical grading of
whiplash-associateddisorders(WADs)includesfourgradeswithvariousdegrees
ofpain,weakness,orsensorydeficits(19).SeeTable14.1.
TABLE14.1ClinicalGradingofWhiplash-AssociatedDisorders(WADs)
GRADE PAIN,WEAKNESS,SENSORYDEFICITS
Grade0 Nocomplaintsabouttheneck.Nophysicalsign(s)
Grade1 Neckcomplaintofpain,stiffness,ortendernessonly.Nophysicalsign(s)
Grade2 NeckcomplaintANDmusculoskeletalsign(s).Musculoskeletalsignsincludedecreasedrangeof
motionandpointtenderness
Grade3 NeckcomplaintANDneurologicalsign(s).Neurologicalsignsincludedecreasedrangeofmotion
andpointtenderness
Grade4 NeckcomplaintANDfractureordislocation
Source:FromHaidukP,BenzT,LehmannetS,etal.Interdisciplinaryrehabilitationafterwhiplashinjury:
anobservationalprospective5yearsoutcomestudy.Medicine.2017;96(9):e6113.
doi:10.1097/MD.0000000000006113
Imaging is not recommended for grade one patients, while grade two and
threepatientsshouldobtaincervicalspinex-rays,butmoreextensiveimaging
modalities such as CT or MRI should be reserved for patients with clinical
presentation of SCI (e.g., neurological deficits), if deemed appropriate. The
fourthgradeincludeswhiplashandfractureordislocation.
Studies have shown that in the aging population, it is not uncommon for
those with cervical spine fractures to present without neck pain, and thus an
older patient presenting after a significant mechanism of trauma should be
imagedmoreaggressively(20).Additionally,thosewithankylosingspondylosis
shouldhaveimmediatecervicalspineimmobilizationandfullimagingwithboth
CTandMRIregardlessoftheclinicalpresentation(21,22).
CT angiography (CTA) may be indicated for evaluation of vascular
structuresoftheneck(e.g.,vertebralarteriesandcarotidarteries)andhead.The
DenverScreeningCriteria(DSC)orthemodifiedMemphiscriteriamaybeused
to guide providers when to obtain a CTA in cases where there may be blunt
cerebrovascular injury (BCVI) (23) (see Tables 14.2a and 14.2b). The DSC
focusonsignsandsymptomsaswellasriskfactors.
In cases of gunshot wounds (GSWs), artifact may limit complete bony
fractureanalysis.Additionalevaluationofthediscoligamentouscomplex(DLC)
throughMRImaybecontraindicated,andthesafetyofMRIisdeterminedbythe
radiologistwhomustconsiderthelocationoffragmentsastheyrelatetoveins,
arteries,andneural elements (24). Arecent prospective study found that there
was no migration of retained fragments in patients with cervical GSWs, thus
providingsomebasisforselectingpatientswhomaybenefitfromevaluationvia
MRI(25).
XR, CT,and MRI provide different information that is helpful during the
decision-makingprocessinSCI.Forexample,incasesofassessingtheintegrity
of the transverse ligament, which is essential for determining surgical
management, an MRI may show STIR signal suggesting ligamentous injury,
while an XR may be used to calculate the rule of Spence. This rule is a
radiographic calculation stating that a transverse ligament integrity is
compromisedifthecombinedmeasurementoftherightandleftlateralmassesof
C1hangoverthelateralmassesofC2by7mmormore.Ingeneral,theuseof
the MRI is vital to fully understand the scope of the injury to the neural
structures and DLC, including increased T2 signal within the spinal cord or
STIRsignal withinthedisc or ligaments(17). There does exist a “spinal cord
injury without radiographic abnormality” (SCIWORA), and these patients
should be assessed with flexion-extension films in the acute and late setting
despite negative MRI (26). SCIWORA, typically a pediatric presentation,
patientsneedtoavoidhigh-riskactivitiesforatleast6monthswhilethey are
observedconservativelywithserialflexion-extensionfilms(26).
TABLE14.2aDenverScreeningCriteria(DSC)
SIGNSANDSYMPTOMS
• Focalneurologicdeficit
• Arterialhemorrhage
• Cervicalbruitorthrill(<50years)
• InfarctonheadCT
• Expandingneckhematoma
• NeurologicalexaminationinconsistentwithheadCT
RISKFACTORS
• Midfacefractures
• Basilarskullfracture
• GlascowComaScalescore<8
• Hangingwithanoxicbraininjury
• Seatbeltabrasionorothersofttissueinjuryoftheanteriorneckwithswellingand/oralteredmentalstatus
MedicalManagement
Controversyexistsregardingvariousmedicaltreatmentsincludinghypothermia
andsteroidadministrationinthesettingofacuteSCI.Manystudieshavebeen
done to assess the risks and benefits of both modalities. This is described in
greaterdetailinChapter12.
Infection is an inherent risk in cases of penetrating injuries from either
externalsources of contamination or internal sources (e.g., traversing mucosal
surfaces)(27,28).Tetanusprophylaxisshouldbe administeredaccordingtothe
currenttraumaguidelinesforthosewithpenetratinginjuries(29).Additionally,it
isimportanttorememberthattheforeignobjectmaybeprovidingsomeelement
oftamponadeanditshouldnotberemovedeitherwithoutimaginationoroutside
ofanoperatingroomtopreventdevastatinghemorrhage(30).
TABLE14.2bTheModifiedMemphisCriteria
• Baseofskullfracturewithinvolvementofthecarotidcanal
• Baseofskullfracturewithinvolvementofthepetroustemporalbone
• Cervicalspinefracture
• Neurologicalexaminationfindingsnotexplainedbyneuroimaging
• Hornersyndrome
• LeFortIIorIIIfracturepattern
• Necksofttissueinjury(e.g.,seatbeltsign,hanging,andhematoma)
Cervical motion can be limited by hard collars by about 54% and even
further with a halo (15). In situations of penetrating SCI without DLC or
neurological deficits, cervical orthoses do not improvethe natural outcome of
these cases by preventing kyphosis or neurological decline (31). Therefore,
carefulselectionofoperativecandidatesisjustasimportantasconsideringwho
isagoodnonoperativecandidate.
SurgicalManagement
Clinical evidence suggests that early surgical decompression (<24 hours after
injury) leads to improved outcomes and decreased complications (14,16,32).
(Forgreaterdiscussion,pleaseseeChapter13)Forpersonswithanincomplete
neurological injury and continued canal compromise, either open or closed
reductionoffracture/dislocationsincludingfacetdislocationshouldbeattempted
early after evaluation. This may occur prior to obtaining an MRI in order to
decompressneuralelements,withsomerecommendingthatbestoutcomesoccur
early with a recent study suggesting that the best outcomes occur within less
than6hoursafterthedislocation(21,33).Limitationsincludethosewhocannot
beexaminedsecondarytoheadinjuryorintoxication;thus an MRI should be
completedpriortoreductioninthosecases(21).
SPECIFICSURGICALCONSIDERATIONS
C1-2
AcuteC1oratlasfracturesoccurinisolationorinconjunctionwithaC2fracture
(>50%versus<45%,respectively).Guidelinesregardingisolatedfracturesofthe
atlas and axis depend on location of fracture and presence or absence of
ligamentousdisruption (i.e., odontoid,hangman,and axis body) (21,26,34,35).
Jeffersonfractureisdescribedasafour-pointfractureoftheC1ringbutcanalso
include three-point or two-point fractures, which is due to axial load (36).
Traditionally,isolatedC1fractureismanagedwithrigidcervicalcollaroraHalo
vestforadurationof10to14weeks.However,ifruleofSpenceispositiveit
would warrant a Halo vest immobilization and if there is an associated C2
fractureitneedstobemanagedwithsurgicalstabilizationwithposteriorC1–C2
fusionorOcciput–C2fusion.
OdontoidfracturesareclassifiedastypeIwhenthefractureisthroughthetip
of the odontoid process; type II when the fracture line is through the base of
dens,whichisalsomostcommon;typeIIIwhenthefractureisthroughthebody
ofC2(12).TypeIOdontoidfractureismostlyconsideredstableandrareandis
managedbyahardcervicalcollar.Insomecases,thiscouldbeassociatedwith
atlanto-occipital dislocation. Type II odontoid fractures can be managed with
rigidcervicalcollaroraHalovestorsurgicalfusion,asdescribedfurther.Type
III odontoid fractures are considered stable and managed with a hard cervical
collarfor10to14weeks.However,recentliteratureisfullofcasesandstudies
showing that fusion is used more frequently at these cervical levels with
excellentoutcomes(13,37,38).Stabilityoftheatlatoaxialjointandgoodfusion
rates are reported with a posterior atlantoaxial fusion using a screw-plate and
screw-rod system (10). In cases where a C2 pedicle screw cannot be safely
placed,either secondaryto bony anatomyor aberrantvertebralartery location,
onemayplaceshorterC2parsscrews(10).
Surgeryforodontoidfracturesisgenerallyrecommendedinpatientsoverthe
age of 50 secondary to the risk of nonunion. Additionally, surgery is
recommended in patients with displacement greater than 5 mm that does not
maintainreductionincervicalorthosis.Controversyexistsbetweenselectionof
anterior versus posterior approach for fixation of odontoid fractures (39). In
general,theanteriorfixationispreferredwhenthereisminimalcomminutionof
fractureandinthosewithoutsevereosteoarthritis.Withregardtoage,arecent
study by Dhall et al. found that surgery of traumatic C2 fractures in
octogenarians tends to lead to longer hospitalization with increased risk for
medical complications including pneumonia, respiratory distress, and pressure
injuries (40). However, a study of surgery for C2 fractures in the Medicare
population found that those treated surgically had a lower 30-day and 1-year
mortality rate (38). Thus, the general health of an elderly patient must be
considered when determining appropriateness of surgical management of
odontoid fractures. For those with odontoid fractures initially treated
nonsurgically,imaging2weekslatershouldshowlessthan5degreesofchange
inangulation,otherwisesurgicalfixationisindicated.
Hangman fractures are classified into type I if there is ≤3 mm C2-3
subluxation; type II when there is C2-3 disc disruption, posterior longitudinal
ligamentinjuryleadingtoC2-3subluxationof≥4mmorangulationof11°and
Type IIA when there is less displacement and more angulation than Type II;
TypeIIIifthereisC2-3facetcapsulesdisruptedwithlockedfacetsatC2-3and
possible anterior longitudinal ligament injury (41). Types I and II hangman’s
fractureareconsideredstableandnotassociatedwithanyneurologicalinjury,so
they managed with hard cervical collar for 10 to 14 weeks. If there is any
concernfornoncomplianceinmaintainingahardcervicalcollar,thenHalovest
canbeconsidered.TypesIIAandIIIhangman’sfracturerequiresurgicalfixation
whenthereissignificantdisplacement(>3.5mm)and/orangulationofC2onC3
(>11°)ordisruptionoftheC2/3discspace(34,35,42).
SubaxialSpine
Surgical fixation may be performed through an anterior approach, a posterior
approach, or a combined approach, also refered to as a 360° approach or
circumferential approach (43). The decision-making process needs to involve
understandingcomorbidities,riskofsurgicalapproach,andgeneralsurgicalrisks
asmorethanoneapproachmayaccomplishthesamegoals(7).Essentialgoals
shouldincludedecompressionofneuralelements,restorationofalignment,and
mechanicalstability(7,44).Burstfractures,oftenreferredtoasteardropinjuries
andmostcommonlyoccurringatC2,usuallyinvolvesignificantDLCinjuryand
neurologicdeficitsrequiringananteriorcorpectomywithgraftwithaplateand
possiblyaposteriorapproachwhenposteriorelementsaredisrupted(13).
Criticsofananteriorapproachforasubaxialspineflexion-distractioninjury
may cite the increased risk of swallowing or speech dysfunction or that the
posterior tension band is not addressed in the anterior-only approch (45).
However,Jacketal.foundthatananterioraloneapproachincasesofsubaxial
flexion-distractioninjurieswasareasonableapproachwithfewexceptionssuch
as bilateral facet disruption (45). Furthermore, they felt that those requiring a
circumferential approach revealed themselves through asymptomatic yet
radiographically progressive postoperative translation or kyphosis. Disc
herniationiscommonwithunilateralorbilateralfacetinjuries,yetinmanycases
afterclosedreduction,aposteriororanteriorapproachmaybeacceptable(13).
Patients with ankylosing spondylosis or diffuse idiopathic skeletal
hyperostosis(DISH)orsevereosteoarthritispresentuniquechallenges,andthese
cases should be discussed with experienced surgeons. The stiffness of these
spines tends to require long posterior fixation constructs in addition to an
anteriorapproach(13,46).
UseofTractioninSubaxialSpineFractures
Closed reduction of facet dislocation by manipulation was first described by
Walton in 1893. In 1933, Crutchfield introduced tongs for inline traction
reduction (47). The primary goal of applying the traction in cervical spine
fracturedislocationsistorealignthespineand,inturn,relievethespinalcord
compression and preserve and assist in recovery of neurological function.
Tractionalsoservestostabilizetheunstablespineuntiladefinitivetreamentin
the form of rigid brace (Halo) or surgery (anterior,posterior, or combined) is
performed.
Craniocervicaltraction is initiatedwithGardner-Wells or Crutchfieldtongs
or a Halo ring appliedto head under sterile conditions usinglocal anesthesia.
Gardner-Wellstongs arepreferred duetoease ofapplication andmaintainence
and in the cases needing a definitive surgery following closed reduction of
fracturedislocation.HaloringisMRIcompatibleandhasfour-pointfixationof
cranium,whichisconsideredmorestable,andispreferredinchildrensinceuse
offourpinsisknowntoreducepulloutforce,increasestiffness,andallowfora
lowertorqueappliedtothepins(48).Haloringgivesbettercontrolofheadand
neck,especiallyifpositioninganddirectionaltractionareneededtoreducethe
fracturedislocation.Haloringisalsousedincaseswhere,afterclosedreduction
isaccomplished,cervicalspinecanbestabilizedwithvestastreatmentmodality.
Placementofpinsinthecaseoftongsareapproximately1cmabovethepinnain
line with external auditory canal. Pins are placed slightly posterior to cause
flexionmovementtoreducedislocatedfacet.InthecaseofHaloring,itisheld
in place temporarily with three positioning pins containing plastic caps. After
administering local anesthesia, four halo pins are applied. Anterior pins are
placed1cmabovetheorbitalrim,belowtheequatoroftheskull,andabovethe
lateraltwo-thirdsoftheorbit.Theposteriorpinsareplaceddiagonallyopposite
totheanteriorpins.Weightisselectedwith3lbspersuperiorinjurylevel,butin
generalstart with 15–20 lbs and increase 5lbsevery 15 to 20 min with close
monitoring of neurological, hemodynamic functions and radiographic
assessment. Upper limitof the weight has varied from 50 to 150 lbs (49,50).
However,thepulloutstrengthofthemorecommonlyusedGardner-Wellstongs
isgreaterthanthatoftheHaloring(51).Countertractionintheformofshoulder
straps and weights at the foot end of bed will prevent upward sliding of the
patient. Alow dose of a benzodiazepine can be used to relieve anxiety in an
awakepatient.
Forconsideringclosed reductionof cervicalspinefracturedislocation,it is
recommended that patient be awake, alert and able to follow commands for
thorough neurological exam without any intoxication or associated traumatic
brain injury. If the patient is intubated for airway protection or due to altered
mentalstatus,whichprecludesneurologicalexamination,itisprudenttoobtain
an MRI of the cervical spine to evaluate for any disc herniation or epidural
hematomacompromisingthespinalcanal,whichcouldbeoneofthecausesfor
neurologicaldeteriorationfollowingclosedreductionwithtraction(52).Ifthere
isanyworseningofneurologicalfunctionfollowingapplicationoftraction,itis
recommendedtoimmediatelyreversethetractionprocessandallowthepatient
to recover. A prospective pilot study of 11 consecutive patients at Thomas
Jefferson University compared the rates of disc herniations before and after
manualreductionofclosed-facetdislocations.Theprevalenceofdischerniations
before and after reduction was 18% and 56%, thereby suggesting that the
process of closed reduction with traction may cause disc disruption and soft
tissueinjury(53).Inthepresenceof anacutedischerniation,surgicaldecision
can be made to approach anteriorly first to decompress the spinal cord and
stabilize,followedbyposteriorstabilizationifnecessary.Incaseswhereclosed
reductioniscontraindicatedsecondarytodischerniation,thethree-stagesurgery
maybeused,intialanteriorapproachtodecompressthespinalcordfollowedby
posterioropenreduction,andstabilizationfollowedbyanteriorstabilization.
In a combined series of 1,200 patients who were treated with closed
reduction, the reported rate of permanent neurological complication was less
than 1%. The causes of neurological deterioration associated with closed
reductionincludedoverdistraction,failuretorecognize arostral noncontiguous
lesion,discherniation,epiduralhematoma,andspinalcordedema(54).
AdditionalSurgicalConsiderations
In general, intraoperative neuromonitoring should be utilized. Anterior
approachesmaybeperformedeitheronadonutheadrestorwiththehorseshoe
headrest. It is recommended that an inflatable bag be placed beneath the
shoulder to allow for extension in cases where this is safe. Additionally,
Gardner-Wellstongsmaybeusedfortractionduringthe case.Insuch cases,a
horseshoeheadrestishelpful.PosteriorapproachesinvolveuseoftheMayfield
clampwiththepatientproneonchestrolls.
Perioperative care includes deep vein thrombosis prevention with both
mechanicalandchemicalprophylaxis.Additionally,perioperativeantibioticsfor
24 hours is alsoappropriate. Generally, patients wear ahard collar for 4to 6
weeksfollowinginstrumentedfusion.
Incasesofpenetratinginjurytothecervicalspine,generalconsensusisthat
neurologicallyintactpatientspresentingwithoutlargeretainedfragmentsfroma
penetratinginjurytothecervicalspinedonotrequiresurgicaldecompression,
fusion,orimmobilization(24,55,56).
Cervical spine decompressive laminectomy may be reserved for cases in
which blood, infection, bone, or other foreign body are felt to be creating
progressiveneurologicaldeteriorationorasinthecaseofaretainedpenetrating
object,suchastheknifehandleandblade,essentialtoberemovedinorderfor
thepatienttorecover(18).Anothersituationisintheeventofconcernforlead
orcopperfragmentsandassociatedconcernfortoxicity(27,57).
RepairofaCSFfistula,incasesofanymechanismofpenetratinginjuryto
thecervicalspine,maybeperformedthroughconservativeskinclosure,witha
lumbardrainmaybeattemptedpriortoopensurgeryandprimaryduralclosure
orpatchwithsubsequentCSFdiversion(e.g.,lumbardrain)(55,56).
Asinmostcasesofpenetratingcervicalspine injury, ligamentousinjury is
infrequent,thusobviatingtheneedforspinalinstrumentation.However,whenit
is indicated based on findings of instability or secondary to destabilization
following decompressive laminectomy, the anterior versus posterior versus
combined approach may be decided according to routine evaluation of the
fracturesandinstabilityathand(27,31,58–62).
Somecircumstancesofvertebralarteryorcarotidarteryinjurymayrequire
openversusendovascularrepair(18,56).Combat-relatedvertebralarteryinjuries
havebeenstudied.Aswithcivilianstudies,theyarerelativelyuncommonand,
when they occur, it is with concurrent cervical spine fractures (63). PseudoaneurysmsoftheV2region,from the C2 to C6 transverse foramen, are more
commonthan occlusionand othervertebralartery injuries,and maybetreated
withcoilingorstent-assistedcoilingaloneorinconjunctionwithanticoagulation
(63–65).
Anterior approaches may include a transnasal and/or transoral approach.
With all anterior approaches, the patient’s nutrition status and neurological
examination may guide preoperative planning for a gastric tube and a
preoperativetracheostomy(66).Considertracheotomywithvagal,hypoglossal,
and/orglossopharyngealnervedysfunction(67).APEGandtracheostomymay
beplanned incases ofextendedtransnasal and/ortransoral exposuregiventhe
increased risk of infection and velopharyngeal incompetence or nasal
regurgitation(68).
CONCLUSION
Acute cervical SCI management and surgical decision making involves
considerationofseveralkeyfactors,includingthepatient’sage,levelorlocation
ofinjury,mechanismofinjury,injurytypeincludingbone ordiscoligamentous
involvement, and neurological function. Cervical SCI is most common either
among younger males injuring the subaxial spine secondary to accidents or
amongthoseofadultsover65sustaininginjurytoC2secondarytoground-level
falls. The decision for operative versus nonoperative management depends on
thestabilityofthespineaswellasthepresenceorabsenceofdislocatedfracture
or discoligamentous injury. When planning management through traction or
when planning an operative approach, the patient’s existing medical
comorbidities, preoperative neurological deficits, and potential risk of
neurological and possibly systemic deterioration must be considered and
discussedinordertomanagepatientandteamexpectations.
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