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INTRODUCTION

• The cervical spinal column is extremely vulnerable to injury.
• The seven cervical vertebrae, whose specific facet joint articulations allow movement in the planes of flexion, extension, lateral bending, and rotation, have attached at the cephalic aspect the skull and its contents.
• Injury occurs when forces applied to the head and neck result in loads that exceed the ability of the supporting structures to dissipate energy.

Compressive Flexion (CF)—Five Stages

• CF Stage 1: blunting of the anterosuperior vertebral margin to a rounded contour, with no evidence of failure of the posterior ligamentous complex.
• CF Stage 2: obliquity of the anterior vertebral body with loss of some anterior height of the centrum, inaddition to the changes seen in Stage 1. The anteroinferior vertebral body has a "beak" appearance, concavity of the inferior end plate may be increased, and the vertebral body may have a vertical fracture.
• CF Stage 3: fracture line passing obliquely from the anterior surface of the vertebra through the centrum and extending through the inferior subchondral plate, and a fracture of the beak, in addition to the characteristics of a Stage 2 injury.
• CF Stage 4: deformation of the centrum and fracture of the beak with mild (less than 3 mm) displacement of the inferoposterior vertebral margin into the spinal canal.
• CF Stage 5: bony injuries as in Stage 3 but with more than 3 mm of displacement of the posterior portion of the vertebral body posteriorly into the spinal canal.
• The vertebral arch remains intact, the articular facets are separated, and the interspinous process space is increased at the level of injury, suggesting a posterior ligamentous disruption in a tension mode.

Vertical Compression (VC)—Three Stages

• VC Stage 1: fracture of the superior or inferior end plate with a "cupping" deformity. Failure of the end plate is central rather than anterior, and posterior ligamentous failure is not evident.
• VC Stage 2: fracture of both vertebral end plates with cupping deformities. Fracture lines through the centrum may be present, but displacement is minimal.
• VC Stage 3: progression of the vertebral body damage described in Stage 2. The centrum is fragmented, and the displacement is peripheral in multiple directions. The posterior aspect of the vertebral body is fractured and may be displaced into the spinal canal. The vertebral arch may be intact with no evidence of ligamentous failure, or it may be comminuted with significant failure of the posterior ligamentous complex; the ligamentous disruption is between the fractured vertebra and the one below it.

Distractive Flexion (DF)—Four Stages

• DF Stage 1: failure of the posterior ligamentous complex, as evidenced by facet subluxation in flexion, with abnormal divergence of the spinous process.
• DF Stage 2: unilateral facet dislocation (the degree of posterior ligamentous failure ranges from partial failure sufficient only to permit the abnormal displacement to complete failure of both the anterior and posterior ligamentous complexes, which is uncommon).
• Subluxation of the facet on the side opposite the dislocation suggests severe ligamentous injury. In addition, a small fleck of bone may be displaced from the posterior surface of the articular process, which is displaced anteriorly.
• On serially dividing the posterior interspinous ligaments, facet capsule, posterior longitudinal ligament, annulus fibrosus, and anterior longitudinal    ligament and found that unilateral facet dislocation can occur with rupture of only the posterior interspinous ligament and the facet capsule.
• DF Stage 3: bilateral facet dislocations, with approximately 50% anterior subluxation of the vertebral body. Blunting of the anterosuperior margin of the inferior vertebra to a rounded corner may or may not be present. Beatson demonstrated that rupture of the interspinous ligament, the capsules of both facet   joints, the posterior longitudinal ligament, and the annulus fibrosus of the intervertebral disc was    necessary to create this lesion.
• Widening of the uncovertebral joint on the side of the dislocation and displacement of the tip of the spinous process toward the side of the dislocation may be seen.
• DF Stage 4: full vertebral body width displacement anteriorly or a grossly unstable motion segment,giving the appearance of a "floating" vertebra.

Compression Extension (CE)—Five Stages

• CE Stage 1: unilateral vertebral arch fracture with or without anterorotatory vertebral displacement.
• Posterior element failure may consist of a linear fracture through the articular process, impaction of the articular process, and ipsilateral pedicle and lamina fractures, resulting in the "transverse facet"appearance on anteroposterior roentgenograms, or a combination of ipsilateral pedicle and articular process fractures.
• CE Stage 2: bilaminar fractures without evidence of other tissue failure. Typically the laminar fractures occur at multiple contiguous levels.
• CE Stage 3: bilateral vertebral arch fractures with fracture of the articular processes, pedicles, lamina, or some bilateral combination, without vertebral body displacement.
• CE Stage 4: bilateral vertebral arch fractures with partial vertebral body width displacement anteriorly.
• CE Stage 5: bilateral vertebral arch fracture with full vertebral body width displacement anteriorly. The posterior portion of the vertebral arch of the fractured vertebra does not displace, and the anterior portion of the arch remains with the centrum.
• Ligament failure occurs at two levels: posteriorly between the fractured vertebra and the one above it and anteriorly between the fractured vertebra and the one below it. Characteristically, the anterosuperior portion of the vertebra below is sheared off by the anteriorly displaced centrum.

Distractive Extension (DE)—Two Stages

• DE Stage 1: either failure of the anterior ligamentous complex or a transverse fracture of the centrum.
• The injury usually is ligamentous, and there may be a fracture of the adjacent anterior vertebral margin.
• The roentgenographic clue to this injury is abnormal widening of the disc space.
• DE Stage 2: evidence of failure of the posterior ligamentous complex, with displacement of the upper vertebral body posteriorly into the spinal canal, in addition to the changes seen in Stage 1 injuries.
• Because displacement of this type tends to reduce spontaneously when the head is placed in a neutral position, roentgenographic evidence of the displacement may be minimal, rarely greater than 3 mm on initial films with the patient supine.

Lateral Flexion (LF)—Two Stages

• LF Stage 1: asymmetrical compression fracture of the centrum and ipsilateral vertebral arch fracture, without displacement of the arch on the anteroposterior view. Compression of the articular process or comminution of the corner of the vertebral arch may be present.
• LF Stage 2: lateral asymmetrical compression of the centrum and either ipsilateral displaced vertebral     arch fracture or ligamentous failure on the contralateral side with separation of the articular processes.
• Both ipsilateral and compressive and contralateral disruptive vertebral arch injuries may be present.

INSTABILITY

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

TREATMENT
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.

Nonoperative Treatment
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

Operative Treatment
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,

Atlas Fractures.
(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

• This injury is a purely ligamentous injury and is different from other injuries involving the C1-2 complex.
• It most commonly results from a fall with a blow to the back of the head.
• The transverse ligament may be avulsed with a bony fragment from the lateral mass on either side, or it may rupture in its mid substance.
• type I, disruptions of the substance of the ligament; and type II, fractures and avulsions involving the tubercle insertion of the transverse ligament on the lateral masses of C1 type I injuries are incapable of healing without internal fixation, and they should be treated with early surgery.
• Type II injuries, which render the transverse ligament physiologically incompetent even if the ligament substance is not torn, should be treated initially with a rigid cervical orthosis

Dens Fracture

• Type I fractures are uncommon, and even if nonunion occurs after inadequate immobilization, no instability results.
• Type II fractures are the most common and in the study of Anderson and D'Alonzo had a 36% nonunion rate for both displaced and nondisplaced fractures.
  Type III fractures have a large cancellous base and heal without surgery in 90% of patients.
• In type II fractures of the dens, it is important to determine if the displacement is anterior or posterior.
• Patients with posteriorly displaced dens fractures are more likely to have fractures of the ring of C1.
•  If a fracture in the posterior arch of C1 is not recognized, reduction may be lost after surgery or the fusion may have to be extended to include the occipitocervical joint
• Type III fractures through the body of the axis may be nondisplaced or displaced. Nondisplaced fractures are stable injuries that heal with 8 to 12 weeks of immobilization in either a halo vest or cervical collar.

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