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126
10 Cervical Spine Traum a
b. Treatment.
(1) If instability is 3 to 5 mm , halo or rigid orthosis is used for 2 to 3
months.
(2) If instability is > 5 mm, then fuse C1–C2.
2. Atlantoaxial rotatory xation.
a. The head is tilted toward the side of xation and the chin and C2 spinous
process are pointed toward the opposite direction.
E. Fra c t u re o f a t la s (C1 ) (Fig. 10.4).
1. Axial loading disrupts the atlantal ring.
2. Neurological injury is rare because of the wide spinal canal.
a. Cranial nerve injuries may be observed.
a
c
b
d
e f
Fi g . 1 0 . 4 Le v i n e a n d E d w a r d s c l a s s i c a t i o n o f a t l a s f r a c t u r e s . (a) Norm al anat o m y. (b) Posterior arch
fract ure. (c) Classic Je erson’s or burst fracture. (d) Avulsion fracture of the anterior arch. (e) Lateral
mass fracture. (f) Unilateral ring fracture.
10 Cervical Spine Trauma 127
3. An anteroposterior open-mouth odontoid view to assess the lateral masses
of C1 relative to the lateral mass of C2:
a. Greater than 6.9 mm widening of the lateral mass indicates a transverse
ligam entou s ru pture.
(1) Allow atlas fractures to heal rst with halo imm obilization for 2 to 3
months.
(2) C1–C2 fusion may be done if instability is > 5 mm .
4. Treatment:
a. Cervical orthosis for 3 months if nondisplaced.
b. Halo vest for 3 months if displaced or delayed union.
c. Posterior C1–C2 fusion for nonunion.
F. Fr a c t u r e s o f t h e o d o n t o i d (Fig. 10.5).
1. Type I.
a. Rare avulsion fractures of the tip.
(1) Stable and treatm ent is with a cervical collar.
2. Type II.
a. Fractures at the base of the odontoid:
(1) Anterior displacement ( exion injury).
(a) More comm on than posterior displacement (extension injury).
a
c d
b
Fi g . 1 0 . 5 An d e r s o n a n d D ’Alo n z o c la s s i c a t i o n o f o d o n t o i d fr a c t u r e s . (a) Odontoid tip avulsion.
(b) Fracture at the base of the dens. (c) Fracture within the body of C2. (d) Lateral view of a fracture
at the base of the dens.
128
10 Cervical Spine Traum a
b. The nonunion rate is 20 to 80%.
(1) Risk factors for nonunion.
(a) Age over 50 years.
(b) More than 4 m m displacem ent.
(c) Posterior angulation.
c. Treatment:
(1) Halo traction for reduction of fracture.
(a) If acceptable reduction is achieved, then a halo jacket is applied
for 1 2 w e e ks a n d a ce r vica l colla r for 6 w e eks.
(b) Indication s for C1–C2 fusion :
i. Delayed union or nonun ion.
ii. Redisplacem ent follow ing halo placem en t .
iii. Fract ures at high risk for nonunion (> 4 mm displacem en t,
older patient).
(c) Treatm ent options for odontoid fractures associated with C1 ring
fract u re:
i. Consider posterior C1–C2 screw xation or an terior odontoid
screw xation.
ii. Halo initially to let C1 heal, then C1–C2 fusion if C2 nonunion
develops.
3. Type III.
a. Fracture through the body.
(1) Nondisplaced.
(a) Treat with a cervical orthosis or halo.
(2) Displaced.
(a) Halo jacket for 3 months.
G. Tr a u m at ic sp on dylolist h esis of t h e a xis—h an gm a n ’s fract u re (Fig. 10.6).
1. Mechanism.
a. Acute hyperextension injury.
2. Types (Ta b l e 1 0 . 1 ) .
3. Treatment.
a. Type I.
(1) Halo jacket for 12 weeks.
b. Type II.
(1) Cervical traction to reduce displacem ent and allow callus form ation.
(2) Halo jacket for 10 to 12 weeks.
c. Type IIA.
(1) Reduction in extension followed by halo vest im mobilization.
d. Type III or late instability/nonunion.
(1) Anterior C2–C3 fusion.
(2) Posterior screw xation (C2–C3 plating).
H. Subaxial cervical traum a.
1. Allen–Ferguson classi cation of subaxial trauma.
a. Classi cation is based on the mechanism of injury.
b. Provides a biomechanical understanding of the injury pattern.
c. Classi cation (Allen) (Fig. 10.4, Fig. 10.5, Fig. 10.6, Fig. 10.7, and Fi g. 1 0 .8 )
(Table 10.2).
10 Cervical Spine Trauma 129
a
b
c d
Fi g . 1 0 . 6 E e n d in c l a s s i c a t i o n o f h a n g m a n ’s f ra c t u r e . (a) Norm al anat o m y. (b) Type I no n d isplace d
(< 3 m m of displacement). (c) Type IIa—no translation, signi cant angulation, anterior longitudinal
liga m e nt in t ac t , post e rior longit u d in al liga m e n t a n d C2–C3 d isk sp a ce d isrupte d . (d) Typ e III—a n t e rior
C2– C3 d isp lace m e n t , ang u lat ion , an d fa ce t d islo c at io n .
2. Subaxial cervical spine injury classi cation (SLIC) system for cervical spine
injuries (Table 10.3).
a. Classi cation is based on the morphology of the fracture, the stability of
the posterior ligamentous complex, and the patient’s neurological status.
b. A score < 4 can be treated nonoperatively, whereas a score > 4 requires
surgical intervention. A score of 4 is surgeon’s choice.
IV. Treat m e n t of sp e ci c in ju r ies.
A. Un ilat e r a l or b ila t e ra l fa ce t d is lo c a t io n s .
1. Cervical traction to reduce dislocation as soon as possible followed by
cervical arthrodesis.
a. In an awake, cooperative patient, MRI can be performed after attempted
reduction.
(1) If the patient is obtunded/intoxicated, obtain a prereduction MRI to
rule out an associated disk herniation.
130
10 Cervical Spine Traum a
Ta b l e 1 0 . 1 Le v i n e c l a s s i c a t i o n o f t r a u m a t i c s p o n d y l o l i s t h e s i s o f t h e a x i s ( h a n g m a n ’ s
fract ure)
Ty p e D i s p l a c e m e n t a n d a n g u l a t i o n O t h e r c h a r a c t e r i s t i c s
IMinimal displacement < 3 mm
without angulation
IA Min im a l d isp la ce m e n t wit h lit t le
or no angulation
II Sig n i c a nt d isp la ce m en t > 3 m m
and angulation > 11°
IIA Min im a l d is p la ce m e n t ( < 3 m m )
and angulation > 11°
– Bilateral pars fracture
– C2–C3 ligamentous structures are intact
– Fracture lines extend through foramen
transversarum on computed tomography
(possible vertebral artery injury)
– Most common fracture subtype
– Posterior longitudinal ligament is
disrupted
– Anterior longitudinal ligament is usually
int act
– Additional widening of posterior part of
C2 – C3 d isk sp a ce
III As s o c ia t e d C2 – C3 fa ce t d is lo ca t io n – Un ila t e ra l o r b ila t e ra l fa ce t d is lo ca t io n
St eve n C. Kirsh blu m , St e p h e n P. Burn s, Fin Bie rin g -So re n s e n , e t a l. In t e rn a t io na l st a n dards for neurological classi cation of spinal cord injury (Revised 2011). The Journal of
Spin a l Co rd Me d icin e , 20 1 1; 34 (6 ): 53 5 -54 6 . Use d wit h p e rm issio n.
B. Face t d is lo ca t io n s w it h h e r n ia t e d d is k .
1. Closed reduction may be dangerous, producing further neurological de cits.
a. Anterior diskectomy and fusion may be performed rst.
(1) Cervical fusion and stabilization may be accom plished by either anterior
grafting and plate xation or anterior grafting and posterior xation.
(2) If radiculopathy is present with an associated facet fracture, rem oval
of the fracture fragment is recommended during posterior fusion.
C. Fr a c t u r e s o f C3 – C7 ve r te b ra l b o d ie s.
1. Wedge compression fractures.
a. Cervical collar for 6 weeks if posterior elements are intact.
b. Halo jacket immobilization if there is signi cant compression or posterior
elements are disrupted.
c. Posterior fusion may be necessary in cases with severe kyphotic
angulation or in cases of late instability (Fig. 10.7 and Fig. 10.8).
2. Teardrop fractures.
a. Always unstable due to signi cant bony comminution and associated
disruption of the anterior ligamentous complex.
b. Posterior ligaments are frequently injured as well.
c. Treatment: posterior fusion.
3. Fractures of the spinous process (clay-shoveler’s fracture).
a. Stable exion injury with avulsion fracture.
b. Treatment.
(1) Cervical collar.
10 Cervical Spine Trauma 131
Fig . 1 0 . 7 An t e r o p o s t e r io r ce r vic a l s p in e
radiograph demonstrat ing a unilateral C5–
C6 face t dislo c at io n w it h t h e sp in o us p ro cess of C5 rotated toward the right.
Fig . 1 0 . 8 Mag n e tic re so n a n ce
im a g in g of a 3 2 -year-old m an wh o
sustained a bilateral C5–C6 facet
dislocation with signi cant cord
compromise.
132
10 Cervical Spine Traum a
Ta b l e 1 0 . 2 Me ch an ist ic cla ssi c a t io n (Alle n – Fe rg u so n )
Ca t e g o r y Fi n d i n g s
Co m p re ss io n - e xio n Fa i l u r e o f t h e a n t e r i o r c o l u m n v i a c o m p r e s s i o n
Post e rior co lu m n d ist ra ct ion
Ve r t i c a l c o m p r e s s i o n Bu r s t fr a c t u r e s
Dist ract ion - e xion Fa c e t d i s l o c a t i o n s
Co m p re ss io n -e xt e nsio n Po st e rio r c o lu m n co m pre ssio n
An t e r io r c o lu m n d is t r a c t io n
La t e r a l - e x i o n Un co m m o n
Dist ract ion -e xt e nsion As so cia t e d w it h d isk sp a ce w id e n in g a n d / o r re t r o lis t h e sis
Ta b l e 1 0 . 3 Th e su ba xia l c e rvic a l sp in e in ju ry classi c at io n syst e m (SLIC)
for ce rvical spin e in ju rie s
Mo rp h o lo g y
No ab n o rm a lit y 0
Co m p re ssio n 1
Bu r s t + 1 = 2
Distract ion (e.g ., fa ce t d islo cat ion , unst able t ea rd ro p
4
or advanced-stage exion compression injury)
Diskoliga ment ous com plex
In t a c t 0
In de t e r m in at e (e . g. , iso la t e d in t er sp in ou s w id e nin g,
1
magnetic resonance imaging signal change only)
Disrupte d (e.g., wide ning o f d isk sp a ce, facet pe rch
2
or dislocation)
Neu ro lo gica l s t a tu s
In t a c t 0
Ro o t in j u r y 1
Co m p le t e c o rd in ju ry 2
In co m p le t e co rd in ju ry 3
Co nt in uo us co rd c o m pr e ss io n in s et t in g o f n eu ro lo gica l
de cit (neuro modi er)
+1
4. Soft tissue injury.
a. Extension-acceleration “whiplash”.
(1) Involves anterior longitudinal ligam ent, anterior musculature, and
intervertebral disk.
(2) Symptom s.
(a) Pain in the neck; referred pain to the head, shoulder, and
arm; dysphagia; ocular symptoms; dizziness; and temporal
mandibular problems.
(b) Treatm ent.
i. Brace acutely and m ay need surgery later if cer vical
spondylosis is problem atic.
10 Cervical Spine Trauma 133
b. Flexion-deceleration injury.
(1) Muscle strain and greater auricular nerve stretch, interspinous
ligam ent, capsular tear, posterior longit u dinal ligam ent, an d posterior
aspect of the disk.
(2) Treatm ent.
(a) Conservative rst and if unstable by White’s criteria and
symptomatic, then posterior wiring and fusion.
Sugg este d Reading
Bo ld in C, Ra it h J, Fa n kh a u s e r F, Ha u n s ch m i d C, Sc h w a n t ze r G, Sch w e ig h o fe r F. Pr e d ic t -
ing neurologic recovery in cervical spinal cord injury w ith postoperat ive MR im aging.
Spine 20 06;31(5):554–5 59
Bo n o CM, Va cc a r o AR, Fe h l i n gs M , e t a l. Me as u re m e n t t e c h n iq u e s fo r low e r ce r v ic a l
spine injuries: consensus statem ent of the Spine Traum a Study Group. Spine 2006;
31(5):603–660
Co e JD, Vacc a r o AR, Da ile y AT, e t a l . La t e r a l m a ss sc r e w x at io n in t h e ce r vic a l s p i n e : a
syste m at ic lite rat u re review . J Bon e Join t Surg Am 2 013;95 (23):2136–2 143
Moore TA, Vaccaro AR, Anderson PA. Classi cation of lower cervical spine injuries. Spine
2006;31(11, Su ppl):S37– S43, discu ssion S61
Plat zer P, Jain dl M, Thalh am m er G, et al. Clear in g t h e ce r vica l sp in e in cr it ically in ju red
patients: a comprehensive C-spine protocol to avoid unnecessary delays in diagnosis.
Eu r Spin e J 2006;15(12):1801–1810
11 Thoracolumbar Spine Fractures
11.1 General Considerations
I. In t r o d u ct ion .
A. Th e t h or a co lu m ba r sp in e is t he m ost co m m on s it e o f s p in al in ju r ie s.
1. Transition from less mobile spine segments in the thorax to relatively
hypermobile spinal segments in the lumbar spine.
B. Mo st in ju r ie s o c c u r in m a le s (a g e 1 5– 29 ) a n d a r e m o s t co m m o n ly t h e r e su lt o f a
motor vehicle accident (50%) or a fall from > 6 feet (25%).
C. M o st in ju rie s o cc u r b et w ee n T1 1 a n d L1 (5 2 %).
1. L1–L5 (32%).
2. T1–T10 (16%).
D. Associated inju r ies are com m on and m ay occur in up to 50% of pat ien t s, usu ally
the result of a distractive force.
1. Intra-abdominal bleeding from liver and splenic injuries.
2. Arterial or venous vessel disruption.
3. Pulmonary injuries.
a. Hemothorax.
b. Pulmonary contusion.
4. Noncontiguous spine injuries (5%).
II. Pat ie n t e va lu at io n .
A. Ge n e r al a sse s sm e n t .
1. Respiratory, cardiothoracic, abdominal, urological evaluation.
2. Head/cervical spine status.
B. Ne u r o l o gic al a ss es s m e n t .
1. Frankel scale and American Spinal Injury Association (ASIA) motor index.
2. Spinal cord, conus, cauda equina, root injuries.
C. Ra d io lo g i c a l e va lu at io n .
1. All patients who have injuries suspicious for spinal trauma should undergo
plain radiographic imaging (anteroposterior or lateral) of all vertebral levels.
2. Plain X-ray is the initial screening modality:
a. Computed tomography.
(1) Best imaging modality for evaluation of the middle colum n, especially
with sagittal reconstructions.
134
b. Magnetic resonance imaging.
(1) Most useful in evaluating the spinal cord and soft tissue disruption
(disk/ligam entous injury).
III. Cla ssi cat io n m et h o ds.
A. Sp in e st a b ilit y (De n is cla ssi cat io n ) (Fig. 11.1).
1. Three columns:
a. Anterior column.
11 Thoracolumbar Spine Fractures 135
a
Fi g . 1 1 . 1 ( a , b ) Th e t h re e co lu m n s o f t h e sp in e a s d e s c r ib ed b y De nis .
b
(1) Anterior longitudinal ligam ent, anterior annulus brosus, and
anterior half of the vertebral body.
b. Middle column.
(1) Posterior longitudinal ligam ent, posterior annulus brosis, posterior
half of the vertebral body.
c. Posterior colum n.
(1) Pedicles, facet joints, lam ina, spinous processes, and interspinous and
supraspinous ligam ents.
2. Clinical application:
a. Instability is de ned as a disruption of two or more of the three spinal
colum ns.
b. If the middle colum n is disrupted, then the spine is unstable except in the
follow in g:
(1) Thoracic vertebrae above T8 (stability provided by the ribs).
(2) L4–L5 where the posterior column is intact (signi cant weight
bearing through the posterior column because of lordosis).
(3) Distraction injuries where fractures occur through the cancellous bone.
3. Stability is not “black and white”; it is a gray zone (Denis).
a. Stable fractures.
(1) Transverse process.
(2) Spinous process.
(3) Articular process.
(4) Pars interarticularis.
(5) Com pression fractures.
B. Th o r a co lu m b a r i n ju r y cla ss i c a t io n a n d s e ve r it y ( TLICS) s c o re .
1. Operative treatment is based on three factors (Table 11.1).
a. Morphology of the fracture.
(1) Com pression.
(2) Burst.
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