Cervical Trauma

การแบง่ชนิดของการบาดเจบ็ของกระดกูสว่นคอ

Upper Cervical spine injury :: skull base -> Axis C2Occipital condyle FractureAtlanto occipital dislocationJefferson fractureOdontoid fractureHangman’s fracture

Sub-axial cervical spine injury :: C3 -> C7

Traumatic Spondylolithesis of Axis (Hangman's Fracture)

• Introduction • Traumatic anterior spondylolithesis of the axis due

to bilateral fracture of pars interarticularis– MVA is most common cause

• Mechanism is– hyperextension

• leads to fracture of pars– secondary flexion

• tears PLL and disc allowing subluxation

• Associated injuries– 30% have concomitant c-spine fx

Presentation

• Symptoms– neck pain

• Physical Exam– patients are usually neurologically intact

Imaging

• Radiographs– flexion and extension radiographs show

subluxation • CT– study of choice to delineate fracture pattern

Classification & Treatment

Treatment• Nonoperative

– rigid cervical collar 4-6 weeks• indications

– Type I fractures (< 3mm horizontal displacement)

– closed reduction followed by halo immobilization for 8-12 weeks• indications

– Type II with 3-5 mm displacement– Type IIA

• reduction technique– Type II

» cervical axial traction combined with extension– Type IIA

» hyperextension (avoid axial traction in Type IIA)

Treatment

• Operative– reduction with surgical stabilization• indications

– Type II with > 5 mm displacement and severe angulation– Type III (facet dislocations)

• technique– anterior C2-3 interbody fusion– posterior C1-3 fusion– bilateral C2 pars screw osteosynthesis

Closed Cervical Traction

• Indications– subaxial cervical fractures with malalignment– unilateral and bilateral facet dislocations– displaced odontoid fractures– select hangman's fractures– C1-2 rotatory subluxation

• Contraindications– patient who is not awake, alert, and cooperative– presence of a skull fracture may be a contraindication

Patient position • Preferred setting

– emergency room, operating room, ICU for close observation and frequent flouroscopy/radiographs

• Patient position– supine with reverse trendelenburg or use of arm and leg

weights and can help prevent patient migration to the top of the bed with addition of weights.

• Sedation– small doses of diazepam can be administered to aid in muscle

relaxation– however patient must remain awake and able to converse

Pin Placement • Pin placement (Garner-Wells pins)

– pin placement is 1 cm above pinna in line with external auditory meatus and below the equator of the skull.

• Pin tightness– On Gardner-Wells tons pins are tightened until spring loaded

indicator protrudes 1 mm above surface– over tightening of the pins can result in penetration fo the inner

table of the calvarium• Pin strength

– stainless steel pins have higher failure loads than titanium and MRI-compatible graphite and should be used with traction of > 50lbs.

Reduction with Serial Traction • Serial traction

– an intital 10lbs is added. – weights are increased at 10lb increments every 20 minutes– serial exams and radiographs are taken after each weight is placed– maximal weight is controversial

• some authors recommend weight limits of 70 lbs• recent studies report up to 140 lbs is safe

• Reduction maneuvers– reduction of a unilateral facet dislocation

• reduction maneuver performed after facet is distracted to a perched position• maintain axial load and rotate head 30-40 degree past midline in the direction of the

dislocation• stop once resistance is felt and confirm with radiographs

– reduction of bilateral facet dislocation• reduction maneuver performed after facet is distracted to a perched position• palpate the stepoff in the spinal process posteriorly and apply an anterior directed force

caudal to the level of the dislocation• rotate the head 40 degree beyond midline in one direction, and then rotate 40 degreee in

the other direction while axial traction is maintained.

Complications

• Failure to reduce• Change in neurologic exam

Halo Orthosis Immobilization• Fixes skull relative to torso – provides most rigid form of cervical spine external

immobilization– ideal for upper C-spine injury

• Allows intercalated paradoxical motion in the subaxial cervical spine– therefore not ideal for lower cervical spine injuries (lateral

bending least controlled) • "snaking phenomenon"

– recumbent lateral radiograph shows focal kyphosis in midcervical spine – yet, upright lateral radiograph shows maintained lordosis in midcervical spine

Indications• Indications

• definitive treatment of cervical spine trauma including– occipital condyle fx– occiptiocervical dislocation– stable Type II Atlas fx (stable Jefferson fx)– type II odontoid fractures in young patients – type II and IIA hangman’s fractures

• adjunctive postoperative stabilization following cervical spine surgery

• Contraindications– absolute

• cranial fractures• infection• severe soft-tissue injury

– relative• polytrauma• severe chest trauma• barrel-shaped chest• obesity• advanced age

• CT scan prior to halo application– indications

• clinical suspicion for cranial fracture• children younger than 10 to determine thickness of bone

Complications

• Loosening (36%)• Infection (20%)• Discomfort (18%)• Dural puncture (1%)• Abducens nerve palsy • Supraorbital nerve palsy • Supratrochlear nerve palsy • Medical complications