Fracture Servical

Puji Tri Hastuti, S.Kep.,Ns

A. Introduction

Figure 1. Lateral view of the vertebra column, illustrating the spinal curvatures
The vertebral column is composed of alternating vertebrae and intervertebral (IV)
discs supported by robust spinal ligaments and muscles. All of these elements, bony,
cartilaginous, ligamentous, and muscular, are essential to the structural integrity of the
spine. The spine serves three vital functions: protecting the spinal cord and spinal nerves,
transmitting the weight of the body, and providing a flexible axis for movements of the
head and the torso. The vertebral column is capable of extension, flexion, lateral flexion
(side to side), and rotation. However, the degree to which the spine is capable of these
movements varies by region. These regions, including the cervical, the thoracic, the
lumbar, and the sacrococcygeal spine, form four curvatures. The thoracic and the
sacrococcygeal curvatures are established in fetal development, while the cervical and
the thoracic curvatures develop during infancy. The cervical curvature arises in response
to holding the head upright, while the lumbar curvature develops as an infant begins to
sit upright and walk. Congenital defects and degenerative diseases can result in
exaggerated, abnormal curvatures. The most common of these include a thoracic

kyphosis (or hunchback deformity), a lumbar lordosis (or swayback deformity), and
scoliosis. Scoliosis involves a lateral curvature of greater than 10, often accompanied by
a rotational defect. To appreciate the potential underlying causes of scoliosis, we need to
understand the cellular and genetic basis of vertebral column and skeletal muscle
development from somites. In this chapter, we will review the embryonic development of
the spine and associated muscles and link them to the functional anatomy of these
structures in the adult.
The Anatomy and Development of the Vertebrae and IV Discs
A typical vertebra consists of two parts: the body and the vertebral (or neural) arch.
The vertebral body is located anteriorly and articulates with the adjacent IV discs.
Together, the vertebral body and the arch form a central, vertebral foramen, and,
collectively, the foramina create a vertebral canal, protecting the spinal cord. In this
section, the functional anatomy of the vertebrae and IV discs in the adult and the genetic
basis for their development in the embryo will be discussed.

Figure 2. Features of a typical human vertebra. (a) Superior and; (b) lateral view
The Anatomy and Development of Spinal Muscles
The spinal muscles function to stabilize and achieve movements of the vertebral
column. A number of muscle groups act on the spine. Those located anterior to the
vertebral bodies act as flexors. These include longus capitis and colli, psoas major, and
rectus abdominis. Lateral flexion is achieved by the scalenes in the cervical region and
quadratus lumborum, transversus abdominis, and the abdominal obliques in the lumbar
region. The flexors and lateral flexors of the spine are innervated by the ventral rami of
spinal nerves. In contrast, the extensors of the spine are located posterior to the vertebral
bodies and are innervated by the dorsal rami of spinal nerves. The term spinal muscles

typically refers to the extensors of the spine. In this section, the functional anatomy of
the spinal muscles and the genetic basis for their development in the embryo will be
Classification and Etiology of CSI
While several classification systems for CSI co-exist, none of them has gained
uniform acceptance among researchers or clinicians. CSI can be classified according to
injury level, trauma mechanism, morphology, or instability of the fracture. As the exact
trauma mechanism in a CSI often remains uncertain, even classifications based on
trauma mechanism rely, to some extent, on morphologic patterns of the injury; the
trauma mechanism is indirectly determined from radiological findings. The complexity
of some CSIs indicates the presence of several different injury mechanisms in a single
trauma. Assessment of spinal stability and instability are essential in conjunction with all
classification systems, as choice of treatment in each specific type of CSI is based on
whether the injury is considered biomechanically and clinically stable or not.
Classification by injury level to upper (C02) and lower (C37) CSI is well established,
because the anatomical and biomechanical propertiesand thus also the type and
significance of injuriesof the two uppermost cervical vertebra significantly differ from
those in the third to seventh vertebra. In most studies and also clinically, a combination
of several classification methods is used concurrently. For example, the injury is
described by both level and trauma mechanism followed by morphological description of
the injury and finally an assessment of stability.

Figure 3 Classification of some CSIs by level, trauma mechanism, and morphology, and
resultant clinical stability. In clinical practice, great care is required to assess the
stability of each injury individually.
B. Fracture Servical
The most common causes of cervical spine injury are automobile accidents,
followed by diving into shallow water, firearm injuries, and sports activities. There is a
bimodal age distribution among patients with spinal cord injuries: the first peak occurs in
patients between 15 and 24 years, and the second in patients over 55 years of age.

Functional Anatomy

Figure 3. Surface anatomy of cervical spine

Figure 3 illustrates the surface anatomy of the cervical spine (C-spine). The C-spine
consists of seven vertebrae (C1C7) and supports the weight of the head (approximately
14 pounds). The first two vertebrae are called the axis and atlas, respectively, and do not
have a disc between them, but are closely bound together by a complex of ligaments. The
C1 (axis) ring rotates around the odontoid or peg of C2 (atlas), allowing for almost
50% of total cervical rotation. The spinal canal is housed within the cervical vertebrae
and is widest between the C1 and C3 levels (A-P diameter 1630 mm) and narrows as it
progresses caudally (14 23 mm). When the neck is fully extended, this canal can narrow
an additional 23 mm. Cervical spine vertebrae differ from lumbosacral vertebrae in
several ways. First, there are foramina on each side which allow passage of the vertebral
arteries. Additionally, the facet joints in the C-spine have steeper angles which allow for
more rotation between vertebrae without subluxation. The most important difference,
however, is the nonsynovial joint, known as the uncovertebral joint or joint of
Luschka. During midlife, this joint prevents a disc rupture from directly pressing onto

the nerve root. This means that most disc herniations in the neck occur posteriorly
(unlike the LS spine, in which most herniations occur laterally). As we age, these joints
can form osteophytes that can impinge upon the nerve root or compress the cervical cord
directly causing cervical myelopathy.
Red Flags
Some serious conditions can present as neck pain, and the following are considered
red flag conditions which should spur further evaluation.
1. Trauma: Neck pain in the setting of trauma should receive emergent evaluation and
is best managed in an emergency department. If there is any fear of spine instability,
9-1-1 should be summoned.
2. History of neck surgery: New neck pain in a patient who has had prior neck surgical
intervention must be approached with caution. Strong consideration to immediate
referral should be given in all but the most clear-cut cases.
3. Rapidly progressing neurological deficit: Patients who present with rapid,
progressive neurologic deficits should be suspected of having CNS involvement and
should be urgently referred.
Lower Cervical Spine Fractures
Previously, the most commonly used classifications of cervical fractures were those
of Allen-Ferguson

and the AO. More recently, the SLIC classification has added

neurological status as another factor to consider. The Allen-Ferguson classification was

one of the first classifications to be used, but its importance today is only historical. It
divides injuries into six types: compressionflexion, vertical compression, distractionflexion, compression- extension, distraction-extension, and lateral flexion. Still widely
used by various centers, the classification of lower cervical fractures recommended by
the AO group consists of three types (A, B and C), which are extended into groups and
subgroups. The types describe the trauma mechanism (A: compression; B: distraction; C:
rotation), while the groups and subgroups define the morphological parameters. This
classification represents a ranking that follows aprognostic hierarchy, i.e., as one
progresses through the classification, the severity becomes theoretically higher and the
prognosisworsens. The AO classification of fractures of the lower cervical spine (C3C7). The Subaxial Injury Classification (SLIC) Scale was created to remedy the lack of
consensus among classification groups. To create the scale, a systematic review of the

surgical treatment of lower cervical spine trauma was conducted, and a treatment
algorithm was created with the evidence-based consensus of a group of specialists. This
classification of lower cervical spine injuries takes into account the following
characteristics: morphology, status of the disco-ligamentous complex and neurogical
assessment.
Approach to the Patient with Cervical Spine Pathology
Approach to the Patient with Cervical Spine Pathology Neck pain is extremely
common; almost 70% of the population experiences neck pain at some time. Neck pain
accounts for almost 1% of all visits to primary care physicians in the United States.
History is quite helpful in sorting out different types of C-spine pathologies. Important
questions include the nature, duration, and location of the pain, associated numbness or
tingling in either or both upper extremities, duration of the pain, other musculoskeletal
symptoms, and inquiring about any history of trauma. In patients presenting with neck
pain, the physical exam must include a neurologic evaluation. The necessary exam will
differ with different types of patient presentations (evaluation is described in detail
below). Most patients with neck pain in the absence of neurologic findings will have
benign neck pain which requires no further workup. Two different sets of rules have been
created to assist health care providers in determining when imaging is appropriate (the
Canadian Task Force (CTF) X-ray Rules and the Nexus Rules). It has been suggested
that the CTF rules are more relevant in the primary care setting. These rules are shown in
tabel 1
Tabel 1 Canadian C-spine task force rules
Condition 1: Perform radiography in patients with any of the following
Age 65 years or older
Dangerous mechanism of injury
Fall from 3 feet (1 m) or 5 stairs
Axial load to the head, such as diving accident
Motor vehicle crash at high speed (>62 mph)
Motorized recreational vehicle accident
Ejection from a vehicle
Bicycle collision with an immovable object
Parasthesias in the extremities
Condition 2: In patients with none of the above characteristics, assess for any low-

risk factor that allows safe assessment of neck range of motion. Perform
radiographs to assess patients WITHOUT any of the low-risk factors listed here.
Perform the range of motion examination described in Condition 3 to assess
patients WITH any of the low-risk factors listed.
Simple rear-end motor vehicle accident
Sitting position in emergency department
Ambulatory at any time Delayed onset of neck pain
Absence of midline cervical spine tenderness
Condition 3: Test active range of motion in patients with ANY of the low-risk
factors listed in Condition 2 Perform radiography in patients who are unable to
actively rotate the neck 45 both left and right. Patients able to rotate their neck,
regardless of pain, do not require imagin
Treatment
The correct way to transport a patient with a suspected cervical fracture is in the
dorsal decubitus position on a rigid surface with a person hands or pads placed beside the
patient to secure the head and prevent rotation. Ideally, a collar should be fitted
immediately (28). The patient should be examined while still in the dorsal decubitus
position with an inspection of the ear canals to rule out the possibility of fluid fistula or
otorrhagia behind the tympanic membrane, which would indicate a skull fracture. The
head and spinous processes should be palpated. If there are signs of spinal cord injuries
or factors potentially leading to such injuries, treatment measures should be commenced
immediately. Recent studies support the idea that the sooner the spine is stabilized with
decompression of the injured spinal cord, the greater the chances of recovery.
Radiographic exams should be performed that include profile, anteroposterior, oblique,
and transoral views of the cervical spine. CT may be used to clarify any unclear findings
in the simple radiographs, reveal an occult injury, and assess an identified fracture or
fracture-dislocation in greater depth.
Orthopedic treatment to reduce the fracture or dislocation will re-conduct the
vertebral canal to its normal form and dimension and lead to spinal cord decompression.
Reduction through traction with a cranial halo is a method commonly used in some
emergency services and is efficient and well tolerated by the patient. Reduction by
manipulation under general anesthesia is contraindicated because it is an extremely
dangerous method; even with gradual traction, care must be taken and small weights
should be utilized first. Because of the instability associated with dislocations, most
recent guidelines indicate that surgery is required to achieve adequate reduction and

stabilization,

ensure

spinal

cord

decompression,

and

prevent

uncomfortable

immobilization. Surgery may be performed via the anterior, posterior, or double routes.
More recent anatomical and biomechanical studies support the use of instrumentation
with the most modern synthesis materials, such as cages and anterior plates, or posterior
lateral mass screws. Posterior fixation of the cervical spine by means of implants
anchored in the lateral vertebral masses has been extensively used due to its mechanical
advantage over fixations that use the interspinous cerclage technique. In addition, this
procedure has other technical advantages, such as the possibility to be used in cases
where the posterior elements are absent or fractured. The most recent guidelines for
surgical treatment are described in Table 2.
Tabel 2
Guidelines for the surgical treatment of cervical fractures.

Situation

Findings

Approach and Comment

Sagittal lordotic alignment or Laminoplasty

or
compression at multiple
laminectomy
and
levels
arthrodesis
Sagittal cyphotic alignment or Previous
compression at one or two
vertebrectomy(ies) or
Central spinal cord
levels
multiple discectomies
injuries
frequently
requiring
posterior
arthrodesis
with
or
without
associated
laminectomies
Vertical burst fracture
Anterior
cervical
(compression trauma)
vertebrectomy, cage or
structured
graft
(allogeneic
or
autologous)
with
anterior cervical plate
The isolated anterior route
is usually capable of
creating
satisfactory
decompression
It is safe only when the
disco-ligamentous

Injuries resulting
from
hyperextension or
avulsion
(distraction trauma)

Generally occur in elderly

individuals

Single or bifaceted Magnetic resonance imaging

subluxation
shows disc herniation
(distraction trauma) Magnetic resonance imaging
shows
disc-ligament
rupture without herniation

elements are intact

Anterior discectomy and
arthrodesis
Very
stiff
spines
(ankylosing spondylitis,
severe
spondylitis)
require surgery using
the posterior approach
(long lever arms)
Anterior
route,
with
discectomy,
sagittal
realignment,
and
fixation with a plate
(risk of inadequate
reduction and need for
posterior route)
Posterior
route,
with
resection
of
the
ligamentum flavum and
fixation of the lateral
masses with arthrodesis
(risk of progressive disc
collapse
and
development
of
segmental kyphosis)
The anterior route is
indicated only where
there is perfect facet
congruence; even so,
there is a risk of failure
Bifaceted
dislocation
requires the posterior
route due to the risk of
kyphosis after the use of
the isolated anterior
route
Isolated
posterior
ligamentary injury can
be treated by the
posterior approach with
complementary
decompression
when
necessary
There is still no absolute

consensus, and the

possible complications
should be considered
Associated
compression Posterior route
fracture of the vertebral Anterior and posterior
routes
body
Isolated anterior route if
Plateau compression
Single or bifaceted Explosion fracture
there
is
adequate
Without associated fracture of
dislocation or
reduction; if there is
fracture (distraction
the vertebral body
inadequate
reduction,
Without intracanal disc
trauma
anterior and posterior
routes combined
Posterior
route
with
fixation
of
lateral
masses and arthrodesis
Complications
In addition to the commonly known complications involved in the treatment of
fractures of the cervical spine with spinal cord or nerve injury (for example,
pseudarthrosis, or defective consolidation, and postoperative infection), less common
complications should also be considered, such as lead poisoning in cases of fractures
caused by firearm injuries. In conclusion, fractures of the cervical spine are potentially
serious and can lead to devastating consequences if not properly treated. Correct
diagnosis and classification of the injury is the first step toward determination of the
most appropriate treatment, which can be either surgical or conservative.

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