DR.
SALMAN
ABBASI
Associate Prof. Orthopaedic Surgery
AL NAFEES MEDICAL COLLEGE
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SPINAL INJURIES
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CERVICAL SPINE
INJURIES
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Anatomy
The spine contains 33 vertebrae: seven cervical,
12 thoracic, 5 lumbar, 5 fused sacral and 4 fused
coccygeal vertebrae
The vertebral bodies generally increase in width
craniocaudally (exception of T1–T3)
Normal spinal curves include cervical lordosis,
thoracic kyphosis, lumbar lordosis and sacral
kyphosis
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Cancellous bone in cortical shell
Vertebral canal between body and lamina:
houses the spinal cord
Vertebrae:
› 1. Body (centrum): have articular cartilage on
superior/inferior aspects; get larger inferiorly
› 2. Arch (pedicles & lamina)
› 3. Processes: spinous, transverse, costal, mamillary
› 4. Foramina: vertebral, intervertebral, transverse
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CERVICAL VERTEBRAE
Readily identified by the foramen transversarium
perforating the transverse processes. This
foramen transmits the vertebral artery, the
vein,and sympathetic nerve fibres
Spines are small and bifid (except C1
and C7 which are single)
Articular facets are relatively horizontal
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CERVICAL VERTEBRAE
Nodding and lateral flexion movements occur at the
atlanto-occipital joint
Rotation of the skull occurs at the atlanto-axial joint
around the dens, which acts as a pivot
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CERVICAL SPINE INJURIES
Carry a double threat: damage to the vertebral
column and damage to the neural tissues
Movement may cause or aggravate the neural
lesion; hence the importance of establishing
whether the injury is stable or unstable and
treating it as unstable until proven otherwise
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STABILITY OF C-SPINE INJURIES
A Stable Injury is one in which the vertebral components
will not be displaced by normal movements
In a Stable injury, if the neural elements are undamaged
there is little risk of them becoming further damaged
An Unstable Injury is one in which there is a significant
risk of displacement and consequent damage – or
further damage – to the neural tissues
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DENIS’ 3-COLUMN CONCEPT (1983)
Three structural elements must be considered:
The Posterior Osseo-ligamentous complex (or Posterior
Column) consisting of the pedicles, facet joints, posterior
bony arch, interspinous and supraspinous ligaments
The Middle Column comprising the posterior half of the
vertebral body, the posterior part of the intervertebral
disc and the posterior longitudinal ligament
The Anterior Column composed of the anterior half of the
vertebral body, the anterior part of the intervertebral disc
and the anterior longitudinal ligament
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All fractures involving the middle column and at
least one other column should be regarded as
unstable
Only 10 per cent of spinal fractures are unstable
Less than 5 per cent are associated with cord
damage
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MECHANISM OF INJURY
Traction injury
Direct injury: Penetrating injuries to the spine, particularly from firearms
and knives, are becoming increasingly common
Indirect injury: Most common cause. A variety of forces may be applied to
the spine (often simultaneously):
› axial compression flexion
› lateral compression
› flexion-rotation
› Shear
› flexion-distraction
› Extension
Insufficiency fractures may occur with minimal force in bone which is
weakened by osteoporosis or a pathological lesion
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PRINCIPLES OF DIAGNOSIS AND
INITIAL MANAGEMENT
Diagnosis and management go hand in hand
Inappropriate movement and examination can
irretrievably change the outcome for the worse
Early management
› Airway, Breathing and Circulation
› Slightest possibility of a spinal injury in a trauma
patient, the spine must be immobilized until the
patient has been resuscitated and other life-
threatening injuries have been identified and treated.
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RADIOLOGY
› Lateral view
Top of T1 visible
Three smooth arcs maintained
Vertebral bodies of uniform height
Odontoid intact and closely applied to C1
› AP view
Spinous processes straight and spaced equally
Intervertebral spaces roughly equal
› Odontoid view
Odontoid intact
Equal spaces on either side of odontoid
Lateral margins of C1 and C2 align
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Alignment
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Key Things to Identify
Predental space – should be 3mm or less
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Disc spaces should be the equal and symmetric
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Prevertebral soft tissue swelling
› May be due to hematoma from a fracture
› Soft tissue swelling may make fracture diagnosis
difficulty
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AP View
The height of the cervical vertebral bodies should be
approximately equal
The height of each joint space should be roughly equal at all
levels
Spinous process should be in midline and in good alignment
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Odontoid View
An adequate film should include the entire odontoid and the lateral borders of C1-C2.
Occipital condyles should line up with the lateral masses and superior articular facet of C1.
The distance from the dens to the lateral masses of C1 should be equal bilaterally.
The tips of lateral mass of C1 should line up with the lateral margins of the superior articular
facet of C2.
The odontoid should have uninterrupted cortical margins blending with the body of C2.
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JEFFERSON FRACTURE
Compression fracture of the bony ring of C1, characterized
by lateral masses splitting and transverse ligament tear
Mechanism: Diving into shallow water, RTA
Best seen on Odontoid view
Signs: Displacement of the lateral masses of vertebrae C1
beyond the margins of the body of vertebra C2
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CT is required to define the extent of fracture
C/F: Pain in the neck usually without
neurological signs.
Treatment
› Stable #: (intact transverse ligament) SOFT/HARD
CERVICAL COLLAR x 3 months
› Unstable #: (broken transverse ligament)
› SKELETAL TRACTION, HALO-VEST or SURGERY (fusion
of C1-C2-C3) x 3 months
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HANGMAN’S FRACTURE
Fracture through the pedicle at pars interarticularis of C2
secondary to hyperextension
Mechanism: Hanging or hitting a dashboard
Best seen on lateral view
Signs:
› Prevertebral soft tissue swelling
› Avulsion of anterior inferior corner of C2 associated with
rupture of the anterior longitudinal ligament
› Anterior dislocation of the C2 vertebral body
› Bilateral C2 pars interarticularis fractures
After reduction, the neck is held in a halo-vest until union
occurs. Rx: PHILADELPHIA COLLAR IMMOBILIZATION
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ODONTOID FRACTURE
Fracture of the odontoid (dens) process of C2
Best seen on the lateral view
Anderson and D’Alonzo Classification(1974)
› Type I – Fracture through superior portion of dens (Stable)
› Type II – Fracture through the base of the dens (most
common, most dangerous, prone to non-union; Unstable;
requires ORIF – worse with traction!)
› Type III – Fracture that extends into the body of C2 (Stable)
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BURST FRACTURE
Fracture of C3-C7 that results from axial compression
CT is required for all patients to evaluate extent of
injury
Injury to spinal cord, secondary to displacement of
posterior fragments, is common
Rx: RIGID IMMOBILIZATION
SURGERY
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CLAY SHOVELER’S FRACTURE
Fracture of a spinous process C6-T1
Mechanism: powerful hyperflexion, usually combined with
contraction of paraspinous muscles pulling on spinous processes
(e.g. shoveling). Stable #. Stress #
Best seen on lateral view
Signs:
› Spinous process fracture on lateral view
› Ghost sign on AP view (i.e. double spinous process of C6 or C7
resulting from displaced fractured spinous process)
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C7 Clay-
Shoveller’s #
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WEDGE FRACTURE
Compression fracture resulting from flexion
Mechanism: Hyperflexion and compression
Signs:
› Buckled anterior cortex
› Loss of height of anterior vertebral body
› Anterosuperior fracture of vertebral body
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FLEXION TEARDROP
FRACTURE
Posterior ligament disruption and anterior compression fracture of
the vertebral body which results from a severe flexion injury
Mechanism: hyperflexion and compression (e.g. diving into
shallow water)
Best seen on lateral view
Signs:
› Prevertebral swelling associated with anterior longitudinal
ligament tear
› Teardrop fragment from anterior vertebral body avulsion
fracture
› Posterior vertebral body subluxation into the spinal canal
› Spinal cord compression from vertebral body displacement
› Fracture of the spinous process
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ANTERIOR SUBLUXATION
Disruption of the posterior ligamentous complex resulting from
hyperflexion
Difficult to diagnose because muscle spasm may result in similar
findings on the radiograph. May be stable initially, but it associates
with 20%-50% delayed instability
Flexion and extension views are helpful
in further evaluation.
Signs:
› Loss of normal cervical lordosis
› Anterior displacement of the vertebral body
› Fanning of the interspinous distance
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BILATERAL FACET DISLOCATION
Complete anterior dislocation of the vertebral body resulting
from extreme hyperflexion injury. It is associated with a very
high risk of cord damage
Best seen on lateral view
Signs:
› Complete anterior dislocation of affected vertebral body
by half or more of the vertebral body AP diameter
› Disruption of the posterior ligament complex and the
anterior longitudinal ligament
› Bow tie or bat wing appearance of the locked facets
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UNILATERAL FACET DISLOCATION
Facet joint dislocation and rupture of the apophyseal joint
ligaments resulting from rotatory injury of the cervical
vertebrae
Best seen on lateral or oblique views
Signs:
› Anterior dislocation of affected vertebral body by less
than half of the vertebral body AP diameter
› Discordant rotation above and below involved level
› Facet within intervertebral foramen on oblique view
› Widening of the disk space
› Bow tie or bat wing appearance of the overriding locked
facets.
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THANK
S
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