Spine Fractures

Cervical Spine Fractures

Anatomy

spinal cord occupies ~ 35% of canal at the level of the Atlas and ~ 50% of the canal in the lower cervical region (C2-7) and the thoracolumbar spine

History

nature of incident
any neurological symptoms, any change in neurol status
LOC
head/ pectoral girdle injury

Examination


observe

head control
head injuries, pectoral girdle injuries: contusion
voluntary movement of all 4 limbs
Priapism
any limitation of movement of the pts head to either side

Palpate

tenderness over head + back off neck
step in spines
local haematoma

Neurological exam


Sensory
C2 back of head
C3 front of neck
C4 lat and inf over clavicles down to 2nd interspace
C5 - T1 upper limb
T2 below nipple
T10 unbilicus
L1 groin
L2- S2 lower limb
S3- S5 + coccygeal roots perianal/ saddle

-once the sensory level is determined, examine distally for any evidence of sparing.
Sacral sparing indicates preservation of the lateral columns and recovery of lost muscle function is quite likely

Motor

after the sensory exam the diagnosis of a root lesion or cord lesion can be made and the completeness determined
Examine sequential nerve roots
C4 pt breaths diapragmatically
C5/6 biceps
C5 deltoid
C6 ECRL/ECRB
C7/8 triceps
C7 EDC
C8 FDP/FDP
T1 intrinsics
L1/2 adductors
L3/4 knee extension
L5/1 knee flexion
L4 tib ant
L5 EHL/ peronei
S1/2 ankle plantar flexion

Rectal inability of the pt to feel the finger in the rectum confirms a complete sensory lesion

If sphincter doesn't contract voluntarily about the finger + there are no other signs of voluntary motor power,complete motor paralysis is confirmed

Bulbocavernosus reflex: a squeeze on the glans, a tap on the mons or a tug on the catheter stimulating the trigone of the bladder causes reflex contraction of the anal sphincter about the gloved finger

If spinal shock is present a complete lesion cannot be diagnosed with certainty- if the bulbocavernosus has not returned in 24 hrs its absence is due to complete lesion as spinal shock resolves within 24 hrs

Spinal Cord Lesions

Spinal Shock

Wrt spinal cord injury = a spinal cord nervous tissue dysfunction based on physiologic dysfunction rather than structural disruption.
Spinal shock has resolved when the reflex arcs below the level of the injury begin to function again

Root injuries

are essentially peripheral nerve injuries , partial recovery is expected
root avulsion is rare except in plexus injury

Incomplete spinal cord lesions

any sparing distal to the injury = incomplete lesion= possible recovery
the greater the sparing the greater the prognosis

Brown- Sequard

an injury to either side of the cord (hemisection)
ipsilateral: muscle paralysis and jt position/ vibration loss
contralateral: pain and temperature loss
- good prognosis, 90% regain bladder / bowel function + walk

Central cord syndrome

most common incomplete cord injury, assoc with extension injury to Cx spine in middle aged pt

Impact direct to the central grey matter®severe flaccid LMN paralysis of the upper limbs

Damage to the central portion of the corticospinal and spinothalamic long tracts in the white matter®UMN spastic paralysis of the lower limbs and trunk
The sacral tracts are peripheral and are usually spared and the pt has sacral sparing

Prognosis
50-60% have progressive return of motor and sensory function to lower limbs- but poor recovery of hand function due to irreversible damage to the central grey matter

Anterior cord syndrome

complete motor and sensory loss apart from dorsal column sparing with deep pressure/ proprioception/ vibration as only remaining modality
prognosis
good if recovery progressive within 24 hrs
after 24 hrs prognosis poor
10-15% have recovery

Posterior cord syndrome

loss of deep pressure/ proprioception/ vibration only

Complete Cord Injuries

Frankel classification of Neurological Deficits in pts with Cord injuries

ref: Frankel etal "The value of postural reduction in the initial management of closed injuries of the spine with paraplegia and tetraplegia: Part 1."
Paraplegia 7: 179-192, 1969
Types
  1. absent motor and sensory function
  2. sensation present, motor function absent
  3. sensation present, motor function present but not useful (gd 2-3/5)
  4. sensation present motor function active and useful ( gd 4-5/5)
  5. normal motor and sensory function

Assessment of Cx cord injuries

Plain XR

direct XR evidence of instability
  1. Increased angulation bw spinous processes more than 11 deg than in adjacent segments
  2. Ant or post translation of the vertebral bodies more than 3.5 mm
  3. segmental disc space widening on lat XR
  4. facet jt widening
  5. malalignment of spinous processes of ant view
  6. Rotation of the facets on lat XR
  7. at tilt of vertebral body on ant XR
XR findings suggestive of unstable injuries
  1. Increased retro pharyngeal space - ant to C3 normal not more than 3 mm
    C4 + below- normal varies 8-10 mm
  2. minimal compression fracture of ant vertebral bodies
  3. Avulsion fracture at or near insertion of spinal ligs
  4. nondisplaced fracture lines

Tomography

good for posterior elements, dens fracture

CT

assess bony encroachment on canal , best method for accurate bone definition

MRI

evaluate neural elements
disc disruption
ligamentous disruption

Stress XR's

flexion/ extension contraindicated in altered state of consciousness

The 3-column Cervical spine

Denis first described the 3 column spine in relation to thoracolumbar fractures
This 3 column concept has been extended to the Cx spine by Allen
ref: Allen, BL; "Recognition of injuries to the lower cervical spine." In cervical spine research committee: The Cervical Spine : 286-298. Philadelphia, JB Lippincott,1989
Each cervical motion segment can be divided into :

Anterior

resist compression: vertebral body centrum, ant disc
resist tension: ant annulus, ant longitudinal lig

Middle

resist compression: post vertebral body + the 2 uncovertebral jts
-there is no significant disc material in the middle column
resist tension: posterior annulus, post longitudinal lig

Posterior

resist compression: R+L facet jts and lat masses
resist tension: facet jt capsules, interspinous ligs

Stability

stable injuries compression fracture of ant body of less than 25% of body ht
anteroinferior avulsion fracture where frag width less than 20% of body width
unstable injuries compression fracture more than 25% of body ht- indicative of PLL rupture
fractures through the vertebra
In the 3 column spine, the middle column is critical to stability-
failure of middle column bony structures indicated by-
  1. wide pedicles
  2. more than 25% loss of post body ht
  3. presence of fracture lines through post body cortex
failure of middle column ligamentous structures indicated by-
  1. interspinous or intervertebral angulation 11 deg more than than adjacent segment
    ( N= 2-4 deg)
  2. horiz translation more than 3.5 mm
  3. intervertebral disc space separation more than 1.7 mm

Direction of stability

3 directions
  1. flexion -either with-
    distraction eg bilat facet dislocation
    Treatment: posterior wiring
    or
    compression eg: -tear -drop fracture with failure of post column in tension and failure of ant column by fracture of anterosup vertebral body and middle column remaining intact
    - burst fracture- failure of all 3 columns
    Treatment anterior stabilisation
  2. extension
    Treatment SOMI - fuse if late instability
  3. rotational- rotational ligament injuries ® assymetric disruption of the facet complexes- if combined with lateral compression , a fracture may accompany the ligamentous injury eg lat mass fracture
    Treatment unilat facet disloc- reloc, SOMI
    unilat facet disloc with fracture of either facet or lat mass- with loss of bony stabilisation there is a tendency for cont displacement \wire facet or lat mass plating

Atlanto- Occipital Dislocation

due to hyperextension and distraction
The basion to post arch of C1 distance less than opisthion to anterior arch C1- if this is reversed then dislocation has occurrred

treatment

often fatal -if not fatal avoid traction, definitive fusion occiput to C1

Transverse ligament ruptures

may occur alone or with fracture atlas or atlanto- axial subluxation- due to flexion
the transverse lig is the main restraint to ant motion of C1
Normal distance bw ant ring of atlas and dens less than 3mm

Treatment

if bony avulsion - immob in SOMI until healed, then check flexion extension views to assess transverse lig competency
if midsubstance tear- primary atlanto axial fusion

Atlanto axial rotatory subluxation

due to trauma or spontaneously occur
pts c/o neck pain, occipital neuralgia, occas symptoms of vertebrobasilar insufficiency
Odontoid view- shows rotation
AP view shows C2 spine rotated off midline
CT - in R+L rotation - if C1 fails to reposition = fixed deformity
- shows the dens separates from the ant arch of C1 with increased rotation

Classification

  1. atlantodental interval less than 3mm= intact transverse lig
  2. 3-5 mm= failed transverse lig
    but intact alar ligs
  3. more than 5mm= failed transverse lig and alar ligs
  4. complete post disloc of atlas

Treatment

all symptomatic subluxations should be reduced- through light weight skeletal traction and physio.
After reduction, if transverse lig insufficient-fuse C1+2 (types 2,3,4)

Atlas Fracture

Ref: Levine and Edwards "Fractures of the Atlas" JBJS 73A: 680-691, 1991
due to axial compression ® forced widening of ring
hyperextension®post arch fracture
Odontoid view if combined overlap more than 7mm, the transverse lig = insufficient

Treatment

stable fracture- hard collar for 8 wks eg simple arch fracture, undisplaced lat mass fracture, fracture TP
Unstable fracture- immob in SOMI/ halo 8/52

Odontoid Fracture

Anderson and D'Alonzo JBJS 56A:1663-1674
Type
  1. fracture of tip= avulsion fracture of alar lig
  2. fracture at junction of dens with body of axis
  3. fracture extends into body of axis

Treatment

Type
  1. stable
  2. if more than 5mm displacement or 10 deg angulation high risk nonunion
    - SOMI 8/52
  3. high risk nonunion if treat with hard collar alone-SOMI 8/52

Traumatic spondylolisthesis of C2

Levine and Edwards " management of traumatic spondylolisthesis of the axis"
JBJS 67A: 217-226, 1985
Type
  1. No angulation, upto 3 mm of ant translation - are stable
  2. angulation more than 10 deg and ant translation more than 3mm
  3. severe angulation and displacement because of dislocation of one or both C2-3 facets

Treatment

type
  1. hard collarr 8/52
  2. SOMI 8/52
  3. very unstable- CR of disloc facets may not be possible- may need ORIF with fusion

Treatment of Cervical Fractures

General

assess for assoc injury
BP decrases in quadriplegia= neurogenic shock, due to disruptionof sympathetic outflow and unopposed vagal tone- do not fluid overload
bradycardia/ arrhythmias may be present
respiratory- if vital capacity less than 20% predicted or less than 1000cc may need tracheostomy

Initial

Steroid:
give within 8 hrs
30 mg /kg bolus
5.4 mg /kg every hr for 23 hrs
ref: Bracken etal NEJM 322: 1405-1411, 1990

If pt has loss spine should be reduced as soon as possible
Traction it takes 10 lbs of traction to overcome the wght of the head and approx 5 lbs for each interspace with a max of 35 -45 lbs for dislocations at the C6-7 space
Operative gentle CR
OR

Definitive

3 options
1. nonoperative treatment
- continued traction supine until healing
in general the greater the neuro deficit the greater the effort to move the pt into the upright posture early as they tolerate recumbency poorly
complications include: resp- atelactasis, pneumonia
skin- pressure sores
G-I- bleeding - gastritis/ PU
retention/ UTI
osteoporosis
jt contracture, muscle atrophy
psych withdrawal
2. immobilisation in SOMI/ halo
3. ORIF indications
progressive loss
partial loss with persistence of cont pressure on neural elements
unstable dislocations that have been reduced
aims removal of persistent impingement on neural elements
stability- to alow immed mobilisation of the pt with minimal external support
avoid unnecessary disruption of intact structures

Direction of stability

3 directions
1. flexion -either with-
distraction eg bilat facet dislocation
Treatment: posterior wiring
or
compression eg -tear -drop fracture with failure of post column in tension and failure of ant column by fracture of anterosup vertebral body and middle column remaining intact
- burst fracture- failure of all 3 columns
Treatment: anterior stabilisation
2. Extension
Treatment: SOMI - fuse if late instability
3. rotational-
rotational ligament injuries ® assymetric disruption of the facet complexes- if combined with lateral compression , a fracture may accompany the ligamentous injury eg lat mass fracture
Treatment: unilat facet disloc- reloc, SOMI
unilat facet disloc with fracture of either facet or lat mass- with loss of bony stabilisation there is a tendency for cont displacement \wire facet or lat mass plating

Thoracolumbar Fractures

Classification

The 3 column spine

Denis F "The 3 column spine and its significance in the classification of acute thoracolumbar spinal injuries" Spine 8: 817-831, 1983
Anterior
ALL, ant vertebral body, anterior annulus
Middle
PLL, post aspect of vertebral body, post annulus
Posterior
pedicles, facet jt and facet capsules, lig flavum,osseous neural arch and interspinous and supraspinous ligs
The columns can fail indivually or in combination by 4 basic mechanisms of injury:
  1. compression
  2. distraction
  3. rotation
  4. shear
resulting in 4 major types of injury

1. Compression fracture

injure the ant column due to ant or lat flexion; middle column remains intact; post column usually intact but may fail in tension
XR - decreased ht ant vert body, post body ht normal
amount of ant compression less than 40% of post body ht
clinically - stable, neuro loss rare

Columns

anterior compression middle none
posterior none or distraction (severe)
4 types
  1. involvement of both endplates
  2. superior endplate only
  3. inferior endplate only
  4. buckling of ant cortex with both endplates intact

Treatment

symptomatically- usually stable
hyperextension exercises
avoid compression loads for 3/12
if loss of vertebral ht more than 50%, angulation more than 20deg, or multiple adjacent compressionfractures- is potentially instable.
thus mobilise as above and monitor for progression of deformity
- if progresses ORIF

a vertebral compression fracture wedged more than 40% of normal ht usually needs a post stabilisation procedure as these fracturea may compress even more - even after 3 mths

2. Burst

essential feature is disruption of the middle column with varying degrees of retropulsion into the neural canal
XR- spreading of post elements
clinically- if post elements involved- 50% have neuro injury

Columns

anterior: compression
middle: compression
posterior: none
5 types
    fracture of both end plates seen in low lumbar region
    does not lead to kyphosis
    due to pure axial load
  1. fracture of the superior endplate seen at the thoraco lumbar jn
    due to axial load + flexion
  2. fracture of inferior endplate rare- due to axial load and flexion
  3. burst rotation due to axial load and rotation
  4. burst lateral flexion due to axial load and lat flexion

Treatment

options
nonoperative- pts with no neurol involvement do well in long term with no neuro deterioration and little residual back pain
operative- indications-
  1. in thoracic spine Kyphosis more than 40 deg assoc with progression of deformity
  2. where neurol injury present- loss of vertebral ht of more than 50%
    angulation more than 20 deg
    canal compromise more than 40%
in 75% adequate canal decompression can be obtained by post instrumentation alone- thus do post op CT - in the situation that residual canal compromise is more than 25% with an incomplete lesion, consider an anterior decompression

3. Seatbelt type: ( = flexion distraction)

may be purely bony ( ie Chance fracture) , purely ligamentous or mixed
XR widening of interspinous distance
clinically- neuro deficit rare

Columns

anterior: none or compression
middle: distraction
posterior: distraction

Treatment

posterior stabilisation with compression

4. fracture-dislocation


all 3 columns fail under compression, tension, rotation or shear leading to subluxation or dislocation

Columns

anterior: compression/ rotation/ shear
middle: distraction/ rotation/ shear
posterior: distraction/ rotation/ shear
Types
  1. Flexion rotation post + middle columns fail under tension and rotation; the ant column fails under compression and rotation
  2. Shear may be PA shear - with the vertebra above shearing forward on the one below
    or be AP shear - with vertebra above shearing back on the one below
  3. Flexion distraction resembles the seatbelt type of injury- in addition to this the entire annulus is torn, allowing the vertebra above to sublux or dislocate on the one below

Treatment

assoc with severe neuro damage
Goals: realign the spinal column, stabilise spine to allow early mobilisation
Early mobilisation reduces morbidity and mortality and allows earlier return to the community

Timing of surgery

emergency if cauda equina syndrome
progression of deficit
for all others - ORIF when medical and surgical conditions optimal
no evidence that early decompression enhances results or that delay compromises results

Trauma

Methylprednisolone has been found to be beneficial in limiting neurological deficit following spinal cord injury (Bracken et al, 1990)
Some doubt exists about the validity of these results and currently further research is under way to assess the efficacy of lower doses
30mg/Kg body weight over 15 minutes followed by 5.4mg/kg/hr for 23 hours starting 45 mins after the initial bolus

Unstable Cervical Injuries

Atlanto-occipital joint translation more than 1mm
Apex of dens to basion more than 5mm
Anterior translation of vertebrae more than 3.5mm
Flexion at any one level of more than 11o Facet joints subluxation of more than 50%
Traumatic rupture of transverse (cruciate) ligament indicated if the atlanto-dens interval is more than 3mm in an adult and more than 5mm in children
Jefferson fracture with lateral shift of the lateral masses of C1 on C2 of more than 7mm implies division of the transverse ligament allowing the two halves to separate ® indicates an unstable injury

Unilateral facet dislocation classically leads to anterior subluxation of up to 25% whereas bilateral dislocation results in anterior subluxation of at least 50%
Retro-pharyngeal soft tissue should not exceed 3mm at C3 and should not be greater than the width of the vertebral bodies below the level of C4/5

Neurological Injuries: (Incomplete)

Only absolute indication for decompression is a patient with an incomplete neurological lesion and a documented progression of loss
The more sparing and the more rapid the recovery the greater the expected recovery

Brown Sequard Syndrome

Injury to lateral half of the cord ® ipsilateral paralysis and contra lateral hypo-aesthesia to pain and temperature
Good prognosis for partial recovery and most regain bladder and bowel control and ability to walk

Central Cord Syndrome

Most common incomplete lesion usually associated with extension injury in osteo-arthritic cervical spine and results in a flaccid LMN paralysis of the upper limbs and spastic UMN paralysis of the lower limbs usually with sacral sparing indicated by big toe flexion, voluntary anal tone, peri-anal sensation and normal bulbo-cavernous reflex
Usually good recovery of lower limb function but poor recovery of hand function
Likely to regain bowel and bladder control and walk with a spastic gait

Anterior cord Syndrome

Complete paralysis and anaesthesia with exception of the dorsal column modalities of deep pressure, vibration and proprioception
Prognosis good if recovery evident and progressive during the first 24 hours (usually anterior longitudinal artery)

Posterior Cord Syndrome

Rare with loss of deep pressure, vibration and proprioception with normal power and slapping gait

Conus Lesion

Involves long tract and anterior horn cell damage of varying degree with a mixed LMN and UMN paralysis in the lower limbs
If complete ® loss of bladder contraction, bladder reflex, bulbo-cavernous reflex and anal wink, loss of voluntary anal tone and absent sensation
Often incomplete however with normal peri-anal sensation and variable bladder tone

Neurological Injuries: (Complete)

Persistent loss of all motor and sensory function below the level of the lesion after recovered from spinal shock (as indicated by return of bulbo-cavernous reflex)
May be some recovery of cervical nerve root function
Temporary generalised sympathectomy after quadriplegia leads to a BP of 90/50 but the pulse does not become elevated
Must not fluid over-load
Priapism implies severe cervical cord injury (primitive spinal reflex)

Spinal Shock

Complete cessation of all voluntary and reflex activity below the level of the lesion immediately following the injury
Within 24 hours - 3 months all reflex activity will return below the lesion and be hyperactive due to loss of central inhibitory pathways
The return of the bubo-cavernous reflex heralds the end of spinal shock

Odontoid Fracture

Classification: (Anderson & Alonzo)

Types
  1. Avulsion of the tip
  2. Waist fracture ® 50% heal with immobilisation but series reported with 20 - 80% going on to non-union
    Increased risk if initial displacement more than 4mm, posterior vs anterior displacement, age greater than 50 years and treatment with prolonged traction, no halo
  3. Fracture into body of C2 95% heal in a brace

Lumbar and Thoraco-lumbar Fractures

Denis Classification

Anterior column
Consists of the anterior vertebral body, the anterior longitudinal ligament, and annulus fibrosus
Middle column
Consists of posterior longitudinal ligament, the posterior annulus and posterior wall of the vertebral bodies
Posterior column
Consists of the posterior ligamentous and articular complex
Stable fracture without neurological deficit ® extensor muscle exercises then ambulation once comfortable
External spinal support probably of no value and should not be used
Long term results ® 25% no residual symptoms
55% mild discomfort but no disability
20% sever symptoms leading to disability
If loss of vertebral height more than 50% a case can be made for distraction

Complications

Respiratory system ® ARDS, trauma may ® rib fractures etc
Intercostal paralysis
Partial phrenic nerve palsy
Impaired ability to expectorate
Ventilation / perfusion mismatch
DVT incidence up to 25% and PE in up to 5% of cases
Spinal deformity either scoliosis due to paralysis or kyphosis / Kyphus
If kyphus more than 30o should fix
Bowel and bladder complications
Urinary infections etc
Flaccid bladder with catheter ® decreased volume

Prognosis

C4 Quad
Totally dependent
C5 Quad
Electric wheelchair needed for functional mobility and is unable to transfer
Can assist in ADL
C6 Quad
Can propel wheel chair in gentle slopes and assist in ADL as well as drive a car with hand controls
C7 Quad
Can be totally independent
C8/T1
Totally independent wheel chair life
Techniques of electrical stimulation and computer-based neuroprosthetics will clearly become increasingly available and there is good prospects for improved independence of these patients with the development of new technology.