Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_6052_Библиотеки_им_академика_М_И_Перельмана.pdf
98 II Trauma
a. Rare avulsion fractures of the tip
(1) Stable and treatment is with a cervical collar.
2. Type II
a. Fractures at the base of the odontoid
(1) Anterior displacement (flexion injury)
(a) More common than posterior displacement (extension in-
jury)
b. Nonunion rate is 20 to 80%.
(1) Risk factors for nonunion
(a) Age over 50 years
(b) More than 4-mm displacement
(c) Posterior angulation
c. Treatment
(1) Halo traction for reduction of fracture
(a) If acceptable reduction, then halo jacket for 12 weeks and
cervical collar for 6 weeks
(b) Indications for C1–C2 fusion
(1) Delayed union or nonunion
(2) Redisplacement in halo
(3) High risk for nonunion (4-mm displacement, older
patient)
Figure 8–2 Anderson and D’Alonzo classification of odontoid fractures. (A) Odontoid tip avul-
sion. (B) Fracture at the base of the dens. (C) Fracture within the body of C2. (From An HS. Prin-
ciples and Techniques of Spine Surgery. Baltimore: Williams and Wilkins, 1998. Reprinted with
permission.)
Chapter 8 Cervical Spine Trauma 99
(c) Treatment options for odontoid fractures associated with
C1-ring fracture
(1) Consider posterior C1–C2 screw fixation or anterior
odontoid screw fixation.
(2) 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 cervical orthosis or halo.
(2) Displaced
(a) Halo jacket for 3 months
G. Traumatic spondylolisthesis of the axis—Hangman’s fracture (Fig. 8–3)
Figure 8–3 Effending classification of Hangman’s fracture. (A) Normal anatomy. (B) Type I nondis-
placed (3 mm of displacement). (C) Type IIa—no translation, significant angulation, anterior longi-
tudinal ligamanet intact, posterior longitudinal ligament and C2–C3 disk space disrupted. (D) Type
III—anterior C2–C3 displacement, angulation, and facet dislocation. (From An HS. Principles and
Techniques of Spine Surgery. Baltimore: Williams and Wilkins, 1998. Reprinted with permission.)
100 II Trauma
1. Mechanism
a. Acute hyperextension injury
2. Types
a. Type I
(1) Minimal displacement 3 mm
b. Type II
(1) Significant displacement 3 mm and angulation 11 degrees
c. Type IIA
(1) Minimal displacement (3 mm) and angulation 11 degrees
d. Type III
(1) Associated C2–C3 facet dislocation
3. Treatment
a. Type I
(1) Halo jacket for 12 weeks
b. Type II
(1) Cervical traction to reduce displacement and allow callus for-
mation
(2) Halo jacket for 10 to 12 weeks
c. Type IIA
(1) Reduction in extension followed by halo vest immobilization
d. Type III or late instability/nonunion
(1) Anterior C2–C3 fusion
(4) Posterior screw fixation (C2–C3 plating)
H. Subaxial cervical trauma
1. Allen—Ferguson classification of subaxial trauma
2. Classification is based upon the mechanism of injury
a. Provides a biomechanical understanding of the injury pattern
3. Classification (Allen) (Figs. 8–1 to 8–5; Table 8–1)
IV. Treatment of specific injuries
A. Unilateral or bilateral facet dislocations
1. Cervical traction to reduce dislocation as soon as possible followed by
cervical arthrodesis.
Table 8–1 Classification (Allen)
Category Findings
Compression-flexion • Failure of the anterior column via compression
• Posterior column distraction
Vertical compression • Burst fractures
Distraction-flexion • Facet dislocations
Compression-extension • Posterior column compression
• Anterior column distraction
Lateral-flexion • Uncommon
Distraction-extension • Associated with disk space widening and/or retrolisthesis
Chapter 8 Cervical Spine Trauma 101
a. In an awake, cooperative patient, magnetic resonance imaging
(MRI) can be performed after attempted reduction.
(1) If patient is obtunded/intoxicated, obtain a prereduction MRI to
rule out associated disk herniation.
B. Facet dislocations with herniated disk
1. Closed reduction may be dangerous, producing further neurological
deficits.
a. Anterior discectomy and fusion may be performed first.
(1) Cervical fusion and stabilization may be accomplished by either
anterior grafting and plate fixation or anterior grafting and pos-
terior fixation.
(2) If radiculopathy is present with an associated facet fracture,
removal of the fracture fragment is recommended during pos-
terior fusion.
Figure 8–4 Anteroposterior cervical spine radiograph demonstrating a unilateral C5–C6 facet
dislocation with the spinous process of C5 rotated toward the right.
102 II Trauma
Figure 8–5 An MRI of a 32-year-old man who sustained a bilateral C5–C6 facet dislocation with
significant cord compromise.
C. Fractures of C3–C7 vertebral bodies
1. Wedge compression fractures
a. Cervical collar for 6 weeks if posterior elements are intact
b. Halo jacket immobilization if there is significant compression or
posterior elements are disrupted
c. Posterior fusion may be necessary in cases with severe kyphotic an-
gulation or in cases of late instability (Figs. 8–4, 8–5).
2. Tear drop fractures
a. Always unstable due to significant 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 flexion injury with avulsion fracture
b. Treatment
(1) Cervical collar
Chapter 8 Cervical Spine Trauma 103
4. Soft tissue injury
a. Extension-acceleration “whiplash”
(1) Involves anterior longitudinal ligament, anterior musculature,
and intervertebral disk
(2) Symptoms
(a) Pain in the neck, referred pain to the head, shoulder and
arm, dysphagia, ocular symptoms, dizziness, and temporal
mandibular problems
(b) Treatment
(1) Brace acutely and may need surgery later if cervical
spondylosis is problematic
b. Flexion-deceleration injury
(1) Muscle strain and greater auricular nerve stretch, interspinous
ligament, capsular tear, posterior longitudinal ligament, and
posterior aspect of the disk
(2) Treatment
(a) Conservative first and if unstable by White’s criteria and
symptomatic, then posterior wiring and fusion
Suggested Reading
Boldin C, Raith J, Fankhauser F, et al. Predicting neurologic recovery in cervical spinal cord injury with
postoperative MR imaging. Spine 2006;31:554–559
Bono CM, Vaccaro AR, Fehlings M, et al. Measurement techniques for lower cervical spine injuries: con-
sensus statement of the Spine Trauma Study Group. Spine 2006;31:603–609
Moore TA, Vaccaro AR, Anderson PA. Classification of lower cervical spine injuries. Spine 2006;31:
S37–S43
Platzer P, Jaindl M, Thalhammer G, et al. Clearing the cervical spine in critically injured patients: a com-
prehensive C-spine protocol to avoid unnecessary delays in diagnosis. Eur Spine J 2006;15(12):1801–1810
104
9
Thoracolumbar Spine Fractures
I. General considerations
A. Thoracolumbular spine is the most common site of spinal injuries
B. Most injuries occur in males (age 15 to 29), usually a result of a motor ve-
hicle accident
C. Most injuries occur between T11 and L1 (52%)
1. L1–L5 (32%)
2. T1–T10 (16%)
D. Associated injuries are common and may occur in up to 50% of patients,
usually 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
II. Patient evaluation
A. General assessment
1. Respiratory, cardiothoracic, abdominal, urologic evaluation
2. Head/cervical spine status
B. Neurological assessment
1. Frankel scale and American Spinal Injury Association (ASIA) motor
index
2. Spinal cord, conus, cauda equina, root injuries
C. Radiological evaluation
1. All patients who have injuries suspicious for spinal trauma should un-
dergo 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 column es-
pecially with sagittal reconstructions
Chapter 9 Thoracolumbar Spine Fractures 105
b. Magnetic resonance imaging (MRI)
(1) Most useful in evaluating the spinal cord and soft tissue disrup-
tion (disk/ligamentous injury)
III. Classification methods
A. Spine stability (Denis classification) (Fig. 9–1)
1. Three columns
a. Anterior column
(1) Anterior longitudinal ligament, anterior anulus fibrosus, and
anterior half of the vertebral body
b. Middle column
(1) Posterior longitudinal ligament, posterior anulus fibrosis, pos-
terior half of the vertebral body
c. Posterior column
(1) Pedicles, facet joints, lamina, spinous processes, and interspinous
and supraspinous ligaments
2. Clinical application
a. Instability is defined as a disruption of two or more of the three
spinal columns.
b. If the middle column is disrupted, then the spine is unstable except
(1) Thoracic vertebrae above T8 (stability provided by the ribs)
(2) L4–L5 where the posterior column is intact (significant weight
bearing through the posterior column because of lordosis)
(3) Distraction injuries where fractures occur through the cancel-
lous bone
Figure 9–1 A schematic drawing of the three columns of the spine as described by Denis. (From An
HS. Principles and Techniques of Spine Surgery. Baltimore: Williams and Wilkins; 1998. Reprinted
with permission.)
106 II Trauma
3. Stability is not “black and white” but gray zone (Denis)
a. Stable fractures
(1) Transverse process
(2) Spinous process
(3) Articular process
(4) Pars interarticularis
(5) Compression fractures
B. Thoracolumbar injury classification and severity score
1. Operative treatment is based upon three factors (each subcategory has
been listed with increasing severity).
a. Morphology of the fracture
(1) Compression
(2) Burst
(3) Translational/rotational
(4) Distraction
b. Posterior ligamentous complex
(1) Intact
(2) Indeterminate/suspected
(3) Injured
c. Neurological status
(1) Intact
(2) Root injury
(3) Cord
(a) Incomplete
(b) Complete
(4) Cauda equina syndrome
IV. Treatment
A. General considerations
1. Multifactorial
a. Neurological status of the patient
(1) An anterior approach is preferred in patients who are neurolog-
ically compromised.
b. Posterior ligamentous complex integrity
(1) If disrupted, requires reconstruction of the posterior tension band
c. Fracture morphology
2. Timing of surgery
a. Immediate operative intervention most likely gives the best chance
for reduction and neural recovery but not clinically proven.
b. Indications for acute surgical intervention
(1) Progressive neurological deficit
(2) Irreducible dislocations
(3) Open or contaminated injuries
c. Early surgery (2 to 3 days)
(1) Easier reduction and decompression via ligamentotaxis
(2) Earlier mobilization of the patient
Chapter 9 Thoracolumbar Spine Fractures 107
(3) Potential operative complications
(a) Transportation issues regarding patients with severe spinal
instability
d. Late surgery (7 to 10 days)
(1) Arguments for delayed intervention include providing a chance
for the spinal cord to recover from trauma and edema
(a) Skeletal traction and closed reduction and Stryker motorized
rotating bed for patients with deformity or dislocations that
cannot be operated on soon
3. External immobilization
a. Above T5: cervico-thoracic-lumbosacral orthosis
b. T6–L4: Jewet hyperextension or thoracolumbar-sacral orthosis
(TLSO) braces
c. L5–S1: Pantaloon cast
B. Neurological status and stability
1. Neurologically intact with a stable spine
a. Common in compression fractures, seat belt–type injuries and burst
fractures of the lower lumbar spine
b. Orthosis or body cast
2. Neurologically intact with an unstable spine
a. Common in burst fractures and severe compression fractures
b. Operative stabilization to prevent neurological loss
c. Early rehabilitation is preferred.
3. Neurologically compromised and spine unstable
a. Burst fractures or fracture dislocations of the lower thoracic spine
and lumbar spine (Fig. 9–2)
b. Anterior decompression with or without posterior stabilization
C. Specific fracture treatment
1. Compression-flexion injuries
a. Anterior column injury alone usually does not cause neurological
deficits.
(1) Factors suggestive of instability and disruption of the posterior
ligamentous complex
(a) Greater than 50% collapse
(b) Thirty-degree angulation
(c) Thirty-degree kyphosis
b. Treatment
(1) Conservative if anterior column failure alone
(a) Hyperextension orthosis
(2) Middle column failure
(a) Operative intervention
2. Distraction flexion injuries (seat belt injury) (Fig. 9–3)
a. Chance fracture without subluxation or dislocation
(1) Hyperextension body cast
b. Ligamentous flexion-distraction injury
(1) Posteriorly instrumented arthrodesis