TREATMENT: GENERAL CERVICAL SPINE

Initial Treatment

• Immobilization with a cervical orthosis (for stable fractures) or skull traction (for unstable injuries) should be maintained in the emergency setting before CT for evaluation of spinal and other system injuries. Skull or skeletal traction may be applied using Gardner-Wells tongs or preferably by application of a halo-crown, which can be used for traction and subsequently attached to a vest assembly (halovest).

• Vasopressor support is indicated for suspected neurogenic shock and emergency assessment for potential intracranial trauma.

• Use of intravenous methylprednisolone per the NASCIS II and III protocol (30 mg/kg loading dose and then 5.4 mg/kg for 24 hours if started within 3 hours, for 48 hours if started within 8 hours. Steroids have no benefit if they are started more than 8 hours after injury) is controversial and is no longer considered the “standard of care” (see Chapter 8).

• The majority of cervical spine fractures can be treated nonoperatively. The most common method of nonoperative treatment is immobilization in a cervical orthosis. In reality, orthoses decrease motion rather than effect true immobilization. Motion at the occipital–cervical junction is slightly increased by most cervical collars.

  • Soft cervical orthosis: This produces no significant immobilization and is a supportive treatment for minor injuries.

  • Rigid cervical orthosis (Philadelphia collar): This is effective in controlling flexion and

    extension; however, it provides little rotational or lateral bending stability.

  • Poster braces: These are effective in controlling midcervical flexion, with fair control in other planes of motion.

  • Cervicothoracic orthoses: These are effective in flexion and extension and rotational control,

    with limited control of lateral bending.

  • Halo device: This provides the most rigid immobilization (of external devices) in all planes.

  • For traction, Gardner-Wells tongs are applied one finger’s width above the pinna of the ear in

    line with the external auditory canal. Slight anterior displacement will apply an extension force, whereas posterior displacement will apply a flexion force, useful when reducing facet dislocations (Fig. 9.16).

  • Numerous complications are associated with the use of cervical collars. Skin breakdown at bony prominences, in particular, the occiput, mandible, and sternum, can occur. Up to 38% of patients with severe closed head injuries can develop skin complications with prolonged use.

     

     

     

• Patients with neural deficits from burst-type injuries: Traction is used to stabilize and indirectly decompress the canal via ligamentotaxis.

• Patients with unilateral or bilateral facet dislocations and complete neural deficits: Gardner-Wells tong traction and reduction by sequentially increasing the amount of traction are indicated. Radiographs must be performed after the first 10 lb of weight is applied to rule out occult occipital–cervical dislocation. The weight is increased in 5-lb increments with radiographs obtained after each increase.

• Traction is contraindicated in distractive cervical spine injuries and type IIA spondylolisthesis injuries of C2.

• Patients with incomplete neural deficits or who are neurologically intact with unilateral and bilateral facet dislocations require MRI before reduction via traction to evaluate for a herniated disc, especially if a patient is not awake and alert and able to cooperate with serial examinations during reduction maneuvers. Although controversial, some authors recommend immediate traction reduction in the awake patient with an incomplete spinal cord injury if the patient can cooperate with serial exams so that no time is lost getting an MRI.

• A halo has been recommended for patients with isolated occipital condyle fractures, unstable atlas ring fractures, odontoid fractures, and displaced neural arch fractures of the axis.

• The halo vest relies on a firm fit of the vest around the torso and is poorly tolerated by elderly patients and patients with pulmonary compromise or thoracic deformities, such as those with

  ankylosing spondylitis.

• The halo ring should be applied 1 cm above the ears. Anterior pin sites should be placed below the equator of the skull above the supraorbital ridge, anterior to the temporalis muscle, and over the lateral two-thirds of the orbit. Posterior sites are variable and are placed to maintain horizontal orientation of the halo. Pin pressure should be 6 to 8 lb in the adult and should be retightened at 24 hours. Pin care is optional.

• Prolonged recumbence carries an increased morbidity and mortality risk, and consideration should be given to the use of a RotoRest bed and mechanical as well as pharmacologic thromboprophylaxis.

• Because of the normally wide spinal canal diameter, decompression of neural elements in upper cervical spine fractures is not commonly required for traumatic conditions.

• The optimal time to perform surgery, particularly in patients with neurologic deficits, remains unclear. The two most commonly proposed benefits of earlier versus later surgery are improved rates of neurologic recovery and improved ability to mobilize the patient without concern of spinal displacement. To date, little human clinical evidence supports the view that early surgical decompression and stabilization improve neurologic recovery rates. However, clinical series have demonstrated that surgery performed as soon as 8 hours after injury does not appear to increase the rate of complications or lead to neurologic decline.

  Stabilization of the Upper Cervical Spine (Occiput–C2)

• The mainstay of operative treatment of upper cervical fractures and dislocations remains fusion with instrumentation, most commonly performed from the posterior approach. In order of frequency, the most common upper cervical fusion procedures are atlantoaxial fusion, occipitocervical fusion, and, least commonly, C1–C3 fusion.

• Fusion of the occiput–C2 limits 50% of flexion and extension.

• Fusion of C1–C2 limits 50% of rotation.

Anterior Approach

There are three main indications for anterior upper cervical spine exposure in trauma.

1. Screw fixation of a type II odontoid fracture

2. Anterior interbody fusion and plating of the C2–C3 interspace for a type IIA or III hangman’s fracture

3. Anterior arthrodesis of the atlantoaxial articulations as a rare salvage procedure for failed posterior atlantoaxial fusion attempts

   Posterior Approach

   Most upper cervical fractures are treated through a posterior approach.

   • Modified Brooks or Gallie arthrodesis uses sublaminar wires and a bone graft between the arches of C1 and C2.

     • Flexion control is obtained via the wires, extension via the bone blocks, and rotation via friction

       between the bone blocks and the posterior arches.

   • Transarticular screws (Magerl) are effective, especially if the posterior elements of C1 and C2 are fractured.

   • Lateral mass screw fixation of C1 and (pedicle) screw fixation of C2 with rods between C1 and C2 (Harms fixation) also provides effective posterior fixation.

     Osteosynthesis

   • The two indications for direct fracture repair in the upper cervical spine involve the treatment of type II odontoid fractures or type II traumatic spondylolistheses of C2 with interfragmentary screw fixation.

   • This is not indicated for fixation of anteriorly displaced odontoid fractures.

     Stabilization of the Lower Cervical Spine (C3–C7)

   • Fifty percent of flexion/extension and 50% of rotation are evenly divided between each of the facet articulations.

   • Fusion of each level reduces motion by a proportionate amount.

   • Posterior decompression and fusion:

     • The posterior approach to the cervical spine is a midline, extensile approach that can be used to access as many spinal levels as necessary, with a variety of instrumentation techniques in use.

     • In the majority of acute, traumatic, subaxial spinal injuries, posterior decompression via

       laminectomy is not necessary. Canal compromise is most frequently caused by dislocation, translation, or retropulsed vertebral body fragments. In rare cases of anteriorly displaced posterior arch fragments, laminectomy would be indicated to directly remove the offending compressive elements. This is not true, however, in cases of acute spinal cord injury associated with multilevel spondylotic stenosis or ossification of the posterior longitudinal ligament, in which a posterior decompressive procedure may be considered the procedure of choice if cervical lordosis has been maintained.

     • Open reduction of dislocated facet joints is typically performed using a posterior approach.

   • Posterior cervical fusion and instrumentation with lateral mass fixation

     • This can be utilized for a variety of fractures including facet fractures, facet dislocations, and “teardrop” (compressive flexion stage V) fractures.

     • Single-level fusions are sufficient for dislocations, although multilevel fusions may be required

       for more unstable patterns.

     • This can stop fusion at levels with fractured spinous processes or laminae, thus avoiding the fusion of extra levels with consequent loss of motion.

   • Anterior decompression and fusion

     • These are used for vertebral body burst fractures with spinal cord injury and persistent anterior cord compression.

     • The anterior approach to the subaxial spine utilizes the interval plane between the

       sternocleidomastoid (lateral) and anterior strap (medial) muscles. Deeper, the interval of

       dissection is between the carotid sheath laterally and the trachea/esophagus medially.

     • MRI, myelography, and CT scans are valuable in preoperative assessment of bony and soft tissue impingement on the spinal cord.

     • A simple discectomy or corpectomy in which osseous fragments are removed from the canal and

       a tricortical iliac or fibular graft placed between the vertebral bodies by a variety of techniques can be performed.

     • In the presence of a herniated cervical disc associated with dislocated facet joints, one may elect to perform an anterior discectomy and decompression with or without corpectomy before facet reduction.

     • Anterior plating or halo vest immobilization adds stability during healing.