A C U TE C ER V IC A L

S P IN E IN JU R Y

Yoyos Dias Ismiarto, dr., SpOT(K),

M.Kes, FICS., CCD.

Department of Orthopedics & Trauma

Hasan Sadikin Hospital
Faculty of Medicine Universitas Padjadjaran
Introduction

Cervical spine injuries usually occur

secondary to high-energy
mechanisms.

Including motor vehicle accident

(45%) and falls from a height (20%).

Neurologic injury occurs in 40% of

patients with cervical spine fractures.
Introduction

20% of trauma patients who present

with a focal neurologic have an
associated cervical spine fracture.

Spinal cord damage is more

frequently associated with lower
rather than upper cervical spine
fractures and dislocations.
 Anatom y
Atlas
first cervical vertebra.
It has two large lateral
masses provide the only
two weight-bearing
articulations between
the skull and the
vertebral column.
About 5O% of total neck
flexion and extension
occurs between occiput
and C2,25 at occiput-
Cl, and 20 at CI-2.
Anatom y

Axis
Ones of the largest of
the cervical vertebrae.
Transverse ligament of
the atlas
(horizontalband of the
cruciform ligament)
provides primary
support for the
atlantoaxial joint.
Fifty percent of total
neck rotation occurs at
the Cl-C2 junction.
 C3-C7
 Cervical Spinal Cord
ClinicalExam ination
Airway, breathing, circulation, disability, and
exposure (ATLS).
Airway patency is the first priority with C spine.
Breathing or adequate ventilation is the next
priority
Circulation or recognition of the shock state is
the next priority.
Disability refers to doing a brief neurologic
examination.
Exposure is the final part of the initial
examination.
 Secondary survey
Physical examination
Cervical spine and neck
Head injury pt.keep in mind of cervical spine injury

Absence of neurologic deficit does not exclude

spine injury
Inspection , palpation , auscultation , cervical spine
tenderness , subcutaneous emphysema , tracheal
deviation , laryngeal fracture
Protection of C-spine injury , helmet removing
Physicalexam

Palpation
Neck pain
84% patients with a clinical exam and
fracture have midline neck pain
20% of patients with a clinically significant
cervical spine fracture with negative plain
films have a fracture on CT scan

Step off between spinous processes

Crepitus
Range of motion
Detailed neurologic exam
N eurologic Exam ination

Devlin VJ. et.al . Spine Secret Plus: Spinal Trauma. Mosby

Elsevier. 2 Ed. 2012.
Devlin VJ. et.al . Spine Secret Plus: Spinal Trauma. Mosby
Elsevier. 2 Ed. 2012.
Com plete and an incom plete SCI

Complete spinal cord injury is defined by

the total absence of sensory and motor
function below the anatomic level of injury
in the absence of spinal shock.

Incomplete spinal cord injury is present

when residual spinal cord and/or nerve root
function exists below. It can beclassified by
pattern of neurologic deficit into several
syndromes, which is helpful in determining
prognosis
Instability

Clinical instability is defined as the

loss of the spines ability under
physiologic loads to maintain its
patterns of displacement, so as to
avoid initial or additional neurologic
deficits, incapacitating deformity and
intractable pain.

White and Panjabi 1987

 Stability
Evaluation of stability should include
anatomic components (bony and
ligamentous)
static radiographic evaluation of
displacement
dynamic evaluation of displacement
(controversial)
neurologic status (unstable if neurologic
injury)
future anticipated loads
Radiographic Exam
Spine Stability
D iagnostic Im aging

Lateral cervical spine radiograph: This will

detect 85% of cervical spine injuries.

Prevertebral soft tissue depends on the level,

or an normal contour of the tissues:
At Cl < 10 mm
At C3, C4 < 7 mm
At C5, C6, C7 < 20 mm

The atlantodens interval (ADI) should be <3

mm in adults and <5 mm in children.
Plain Radiographic Evaluation
Lateral View
Prevertebral Swelling
Soft Tissue Shadow
<6mm at C2
Concave/Flat
Pre-dental space < 3mm
Atlanto-Occipital Joint Congruence
Radiographic Lines*

Open Mouth AP
Distraction
C1-2 Symmetry
Radiographic D iagnosis

CT Scan

Same rules as with plain films

Better visualization of cranio-cervical
junction
Subluxation
Focal hematomas
Occipital condyle fractures
Dens fractures
 Radiographic Diagnosis
MRI

Increased Signal Intensity in :

C0-C1Joint
C1-2 Joint
Spinal Cord
Cranio-cervical
ligaments
Pre-vertebral soft
tissues
M anagem ent
Prehospital Care
Immobilization of the head and neck should be
maintained until a hard cervical collar can be
applied
Airway security and hemodynamic
resuscitation

In-Hospital Resuscitation
Initial assessment of the ABCs
Immobilized by manual in-line stabilization
during transfers
Maintaining a patent airway and hemodynamic
stability

 D eterm ine nonoperative or operative
treatm ent

*Total score = 3 nonoperative treatment is recommended,

a score = 4 either surgery or nonoperative treatment is indicated,
a score = 5 surgery is recommended.
N onoperative M anagem ent

Cervical Orthoses
Cervicothoracic Orthoses
Skull-Based Traction and Closed
Reduction
Halo Vest
SurgicalM anagem ent

Surgical Timing
A number of clinical series have
demonstrated that, in the least, surgery
performed as soon as 8 hours does not
appear to increase the rate of
complications or lead to neurological
decline.
 Surgical Techniques

Anterior Surgery
Anterior Approaches to Upper Cervical Spine
Transoral Approach
High Anterior Retropharyngeal Approach
Anterior Approach to the Lower Cervical Spine

Posterior Surgery
Reduction Maneuvers for the Upper Cervical
Spine
Reduction Maneuvers for the Lower Cervical
Spine
Postoperative Care

Rigid cervical collar is prescribed for

awake, alert patients who will be
ambulatory following surgery for 6 weeks.

Antiembolic chemoprophylaxis can be

started on postoperative day 4 or 5 so as
to avoid an epidural hematoma.

Prophylactic antibiotics are continued for

48 hours.
CO M PLICATIO N S O F SU RG ERY

Complications Specific to the

Anterior Approach
dysphagia, which may occur in up to
50% of cases
Recurrent laryngeal nerve palsy
Horner's syndrome
Hypoglossal, facial, and
glossopharyngeal nerve injuries
 General Perioperative Complications

Early Postoperative Complications

wound infections
Late Postoperative Complications
Pseudarthrosis and hardware failure
Take H om e M essage

Successful treatment based on knowledge of

anatomy, mechanism of injury and
compromise of bone and/or soft tissue
Stabilization of the spine
Decompression of neurological deficit
Restore alignment
Restore function
Thank You