Common fracture & dislocation of the cervical spine. Theerachai Apivatthakakul Department of Orthopaedic Chiangmai University

Transcription

1 Common fracture & dislocation of the cervical spine Theerachai Apivatthakakul Department of Orthopaedic Chiangmai University

2 Objective Anatomy Mechanism and type of injury PE.and radiographic evaluation Common C spine injuries

3 Anatomy Osseous elements Articulations,ligaments,disc Neural elements Vascular structures

4 Cervical spine Upper c-spine C1-2 atlas, axis Lower c-spine C3-7

5 Vertebral artery

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7 Neural elements

8 SPINAL CORD PART OF THE CNS WHICH IS LODGED IN THE VERTEBRAL CANAL.

9 Spinal cord Medulla oblongata to conus medullaris C 5-T1 brachail plexus L 2-S4 lumbosacral plexus

10 Conus medullaris lower L1 Cauda equina root injury

11 History taking What? When? Where? How?

12 Physical examination vital sign life threatening conditions look,feel,move neurological exam motor,sensory,reflex

13 Physical examination

14 Sensory evaluation Dermatome C3-S4

15 Motor Evaluation

16 Bulbocarvernosus reflex S 2,3,4

17 Sacral sparing

18 Evaluation of Spinal Cord Injury(SCI) Spinal shock Anatomical classification Functional classification

19 Evaluation of Spinal cord injury Anatomical classification Complete cord injury no voluntary motor, sensory below lesion Incomplete cord injury

20 Incomplete SCI Anterior cord syndrome Posterior cord syndrome Brown sequard syndrome Central cord syndrome Mixed lesion

21 INCOMPLETE CORD LESIONS ANTERIOR BROWN SEQUARD POSTERIOR CENTRAL

22 Radiology Lateral view C-spine 76% Dx of injury Plus AP view and open mouth -85% No evidence of Fx,dislocation % X ray include C1-C7 Short neck -Swimmers view Lateral skull film-detect upper C-spine Fx

23 C-spine lateral view

24 C-spine AP

25 Open mouth view

26 CT scan

27 Magnetic resonance image(mri) Detect soft tissue disc herniation cord damage

28 Easily missed fracture

29 Treatment Medical treatment Non operative treatment Operative treatment

30 Principle of treatment Structural instability > 2 column injury = unstable Neurological instability spinal cord or nerve root damage

31 Aim of treatment Without neuro. deficit -Stable spine Neuro.deficit -complete cord stable spine -incomplete cord stable spine - neuro. recovery

32 Stable fracture Conservative treatment Pain medication Bed rest Cast or brace for 6-12 weeks

33 Conservative treatment Halo cast SOMI brace

34 Unstable fracture Without neurological deficit -Surgical stabilization With neurological deficit -Surgical stabilization with or without decompression

35 Goals of Internal Fixation 1. Stable internal fixation 2. Preservation of blood supply 3. Anatomical alignment 4. Early active painfree movement

36 Surgical approach Anterior approach more difficult Posterior approach simple,unable to direct decompression of anterior Fx

37 Supine,anterior approach C5 C6

38 Posterior approach C spine

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40 Anterior fusion Posterior fusion

41 Occipito-Cervical Dislocation

42 Occipito-Cervical Dislocation up to 35% of MVA fatalities Survivors: 40% quadriplegic/paretic 40% hemiplegic/paretic 20% neurologically normal

43 Treatment Closed reduction Halo vest Beware of Traction Posterior occipital cervical fusion

44 Atlas (C1) Fractures Axial loading 10% of all cervical fractures 50% associated with other Fx Odontoid fracture Hangman fracture

45 C1 FRACTURES

46 Burst Fractures C1 Jefferson fx Fracture of both arches A+B >7mm: unstable C1-2 transarticular screws Occipital-cervical fusion

47 Odontoid Fracture Anderson & D Alonzo classification Type I Type II Type III

48 TYPE I Apex avulsion fracture Symptomatic treatment with collar

49 TYPE II Base of odontoid (most common) Reduction/halo Surgery if reduction poor or unstable

50 C1-2 Fusion for Odontoid Fractures

51 TYPE III Fx extends downward through body C2 Halo vest (8-12 weeks) Nonunions (13%) > 5mm displacement > 10 degrees angulation

52 Spondylolisthesis Of C2 Hangman s Fx Three types Usually neuro intact Canal expanding fx

53 Closed reduction skull traction

54 Displaced Fx ORIF fusion

55 Lower Cervical Injuries C3-C7

56 Flexion injury

57 Compression Fx Injury 3 Mos

58 Extension injury Central cord syndrome

59 Burst Fractures Anterior + middle column Spinal canal retropulsion Moderate to high SCI rate Rx: corpectomy, strut graft, plate

60 Axial compression

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64 Pre op Post op

65 Translation without fracture

66 Facet dislocation

67 Unilateral facet lock Most common at C5-6 Mechanism Flexion-Rotation X-rays AP : rotation of spinous process lateral : anterior subluxation < 50% Closed reduction with skull traction successful rate 50-71%

68 Unilateral Facet Dislocation Torticollis 25% subluxation 70% radiculopathy 10% SCI Closed reduction, fusion

69 Unilateral facet dislocation

70 Unilateral facet lock

71 Bilateral Facet Dislocation

72 Bilateral Facet lock Subluxation of body > 50% Frequently associated neurological deficit Associated disc herniation ---> neurological deterioration after traction

73 Bilateral Facet Dislocation 50% subluxation SCI common 9% herniated disc

74 Translation of upper vertebral body

75 Closed reduction by skull traction 5 kgs 8 kgs 13 kgs

76 Surgical Treatment Operative positioning for posterior approach Dislocated facets

77 Surgical Treatment Operative reduction of the dislocated facets Instrumented fusion with bone-graft & wiring

78 Postoperative X-rays

79 Thank you for your attention