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|Posted On : 18 Jan 2010 (Total Views : 3244)|
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Compressive Flexion (CF)—Five Stages
Vertical Compression (VC)—Three Stages
Distractive Flexion (DF)—Four Stages
Compression Extension (CE)—Five Stages
Distractive Extension (DE)—Two Stages
Lateral Flexion (LF)—Two Stages
White and Panjabi defined clinical instability as the loss of the ability of the spine under physiological loads to maintain relationships between vertebrae in such a way that the spinal cord or nerve roots are not damaged or irritated and deformity or pain does not develop.
Clinical instability may be caused by trauma, neoplastic or infectious disorders, or iatrogenic causes. Instability may be acute or chronic. Acute instability is caused by bone or ligament disruption that places the neural elements in danger of injury with any subsequent loading or deformity. Chronic instability is the result of progressive deformity that may cause neurological deterioration,prevent recovery of injured neural tissue, or cause increasing pain or decreasing function.
The supporting structures of the lower cervical spine can be divided into two groups: anterior and posterior
A motion segment is made up of two adjacent vertebrae and the intervening soft tissues. If a motion segment has all the anterior elements and one posterior element intact, or all the posterior elements and one anterior element intact, it will remain stable under physiological loads.
Roentgenographically, cervical spine instability is indicated by the horizontal translation of one vertebra relative to an adjacent vertebra in excess of 3.5 mm on the lateral flexion-extension view Instability also is indicated by more than 11 degrees of angulation of one vertebra relative to another
The goals of treatment of cervical spine injuries are
(1) to realign the spine,
(2) to prevent loss of function of undamaged neurological tissue,
(3) to improve neurological recovery,
(4) to obtain and maintain spinal stability,
(5) to obtain early functional recovery.
After initial medical stabilization and documentation of neurological function, spinal alignment can be obtained by skeletal traction through spring-loaded Gardner-Wells tongs or a halo ring.
Continuous monitoring during reduction is essential to prevent iatrogenic injury from verdistraction of an unstable motion segment
If spinal realignment cannot be obtained by traction, open reduction and stabilization, usually through a posterior approach, are indicated.
If spinal realignment is obtained with traction and is documented roentgenographically, weight is reduced by 50% to maintain alignment and the course of treatment is determined.
Usually tomograms, CT scanning, and MRI provide additional information about ligamentous, intervertebral disc, and osseous injuries.
Many cervical spine injuries can be treated without surgery. Immobilization in a rigid cervical orthosis for 8 to 12 weeks may be sufficient. For a stable cervical spine injury with no compression of the neural elements, a rigid cervical brace or halo for 8 to 12 weeks usually produces a stable, painless spine without residual deformity.
Stable compression fractures of the vertebral bodies and undisplaced fractures of the laminae, lateral masses, or spinous processes also can be treated with immobilization in a cervical orthosis.
Unilateral facet dislocations that are reduced in traction may be immobilized in a halo vest for 8 to 12 weeks. Patients with spinal fractures that are treated nonoperatively must be observed closely
Unstable injuries of the cervical spine, with or without neurological deficit, generally require operative treatment.
In most patients early open reduction and internal fixation are indicated to obtain stability and allow early functional rehabilitation.
Cervical spine fractures may be stabilized through an anterior, posterior, or combined approach.
This allows rapid mobilization of the patient in a cervical orthosis, and healing usually occurs within 8 to 12 weeks. If the spinal cord or nerve roots have been compressed by retropulsed bone fragments or disc material, anterior decompression, with or without internal fixation, may be indicated to improve neurological recovery.
When decompression or stabilization is indicated, several basic principles should be followed:
1.The injury must be clearly defined before surgery by plain roentgenograms, high-resolution CT scanning with sagittal and coronal reconstruction, or MRI.
2.Laminectomy has a limited role in the treatment of cervical fractures or dislocations and may contribute to clinical instability and neurological deficit. It occasionally may be indicated if posterior bone fragments from the neural arch are compressing the neural elements.
3.Compression of the cervical cord or roots by retropulsed bone fragments or disc material usually isanterior; therefore anterior decompression and fusion, with or without internal fixation, are indicated.
4.For posterior ligamentous or bony instability, posterior stabilization with internal fixation and bone grafting are indicated.
Distraction flexion lesion at C6-7
Anterior decompression and fusion, with or without internal fixation, are most often indicated for burst fractures of the cervical spine with documented compression of the neural elements by retropulsed bone or disc fragments and an incomplete neurological deficit
Combined anterior decompression and posterior fusion are indicated for patients who have severe instability and a significant neurocompressive pathological condition
Dislocations of Atlantooccipital Joint
Dislocations of the atlantooccipital joint are uncommon
The injury may be either anterior or posterior and usually is fatal. Davis et al., in an extensive study of fatal cranial spinal injuries, demonstrated that many spinal injuries occurred between the occiput and C3.
For this injury to occur, the alar and apical ligaments, the tectorial membrane, and the posterior atlantooccipital ligaments must be disrupted.
Fractures of the atlantooccipital joint may accompany the dislocation.
Although many patients die immediately of complete respiratory arrest caused by brainstem compression, there are reports in the literature of patients who survived this injury.
Treatment consists of reduction of the dislocation and stabilization of the atlantooccipital joint.
Cervical traction is contraindicated because of severe instability. Immediate application of a halo vest is recommended to stabilize the joint. The patient's respiratory and neurological status must be carefully monitored.
We recommend early surgical stabilization of the atlantooccipital joint because ligamentous healing in a halo vest is not predictable, and many of these injuries are so unstable that displacement may occur even in the halo vest.
Stabilization is obtained by posterior cervical arthrodesis using large cortical cancellous bone grafts wired in place,
(1) posterior arch fracture, whichusually occurs at the junction of the posterior arch and the lateral mass;
(2) lateral mass fracture, which usually occurs on one side only with the fracture line passing either through the articular surface or just anterior and posterior to the lateral mass on one side; a fracture through the posterior arch on the opposite side sometimes occurs; and
(3) burst fracture (Jefferson fracture), which is characterized by four fractures, two in the posterior arch and two in the anterior arch.
Most fractures of the atlas can be treated with immobilization in a rigid cervical orthosis or a halo vest.
Isolated posterior arch fractures are stable injuries that can be treated in a cervical collar for 8 to 12 weeks.
Rupture of Transverse Ligament
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