Cervical Injury
Management
SAPANA SHAH
SUGAM ADHIKARI
SUGOV BUDHATHOKI
Objective
● General Anatomy and Principles
● Mechanism of Injury
● Special Named injury
● Clinical Features
● Complications
● Managements
General Anatomy
Structure of Vertebra
Denis 3 column Concept
● One column disrupted → Stable
Eg: Wedge compression Fracture
● Two column disrupted → Unstable
Eg: Burst Fracture of vertebral body
● Three column disrupted → Always Unstable
Eg: Vertebral dislocation
Mode of injury
● The patient will usually give a history of a fall from height,
a diving accident or a vehicle accident in which the neck is
forcibly moved
Stable vs Unstable injury
● Stable Injury: Normal Physiological loads do not
displace vertebrae so the neural tissues are not at risk
● Unstable Injury: High risk of displacement so the neural
tissue injury is possible
AO/ASIF CLASSIFICATION
● Type A injuries: Anterior column compression fractures which tend to be
stable
● Type B injuries: Involve anterior and posterior columns with distraction;
these are unstable
● Type C injuries: Double-column injuries with rotation or sheer; these are
unstable.
Mechanism of Injury
1. Traction (Avulsion)
○ Muscle pull avulses the bone.
○ Lumbar: transverse process avulsion.
○ Cervical: C7 spinous avulsion = Clay-shoveller’s fracture.
2. Direct Injury
○ From firearms, knives, blunt trauma.
○ Rarely causes instability, but → direct neurological damage.
3. Indirect Injury (Most common)
○ Seen in falls from height or violent trunk/neck movements.
○ Spine collapses on vertical axis.
○ Forces: axial compression, flexion, lateral compression,
rotation (often combined).
Classification of Spinal injuries
● Flexion Injury
● Flexion-rotation injury
● Vertical Compression injury
● Extension injury
● Flexion-distraction injury
● Direct Injury
● Indirect injury due to violent muscle contraction
Flexion Injury
● Most common spinal injury
● Eg: 1) Heavy blow across the shoulder
2) Fall from height on heels/buttocks
● Results:
1. Sprain of ligaments and m/s of back of
the neck
2. Compression fracture of vertebral body
3. Dislocation of one vertebra over another
(C5 over C6)
Flexion-rotation injury
Flexion-rotation injury
● Worst type → Because it leaves a highly unstable spine and is
associated with high incidence of neurological damage.
● Mechanism / Examples:
○ Heavy blow to one shoulder → trunk flexion + opposite rotation.
○ Fall or blow to postero-lateral head.
● Results:
1. Cervical: Facet dislocation, fracture-dislocation.
2. Dorso-lumbar: Vertebra twisted off, neural arch + posterior ligament
damage.
3. Stability: Highly unstable
Vertebral Compression Injury
Vertebral Compression Injury
● Frequency: Common spinal injury.
● Mechanism /Examples:
○ Blow to the top of the head (falling object).
○ Fall from height in erect position.
● Cervical Spine Effects:
○ Burst fracture: vertebral body crushed vertically.
○ Bone or disc fragments may enter spinal canal causing cord
compression.
● Dorso-lumbar Spine Effects:
○ Similar fracture pattern.
○ Wide spinal canal → neurological deficit is rare.
● Stability: Unstable injury
Extension Injury
Extension Injury
● This injury is commonly seen in the cervical spine.
● Examples: (i) motor vehicle accident – the forehead striking
against the windscreen forcing the neck into hyperextension; (ii)
shallow water diving – the head hitting the ground, extending the
neck
● Results: This injury results in a chip fracture of the anterior rim
of a vertebra. Sometimes this injuries may be unstable
Flexion-distraction/Chance injury
Flexion-distraction/Chance injury
● This is a recently describe spinal injury, being recognized in western
countries where use of seatbelt is compulsory while driving a car
● Mechanism: Sudden car stop → upper body moves forward, lower
body restrained by seat belt → flexion + distraction force.
● Results: Horizontal fracture through posterior elements with or without
vertebral body
● Stability: Unstable
● Basically Distraction force opens the posterior column disrupting
vertebral integrity
General Anatomy
Clinical Features
● Pain in the back
● Neurological deficit → inability to move the limbs
and loss of sensation
Treatment
Phase-I
Emergency care at the scene of accident or in emergency
department
Phase-II
Definitive care in emergency department, or in the ward
Phase-III
Rehabilitation
Diagnosis
History Examination Imaging
• History of • General • X-ray (AP and
RTA/fall from examination – lateral view)
height shock • CT
(hypovolemic,
• Unconscious and neurogenic, spinal) • MRI
polytraumatized
patients need to be • Neurological
considered as having examination
an unstable spinal • Spine Examination
injury until proven
otherwise
Wedge Compression Fracture
Results from a flexion force
● Posterior elements are usually intact – injury is stable
● Treatment
● Reduction is not required
● Neck – kept immobilized – skull traction/ sling traction
● Once pain and muscle spasm subside, the neck is supported in a
cervical collar, PoP cast or a brace
● Exercises of the neck are started after 8-12 weeks.
Features Noted in Plain X-Ray
● Change in general alignment (kyphosis, scoliosis)
● Reduction in height of vertebra AP or sideways
displacement of one vertebra over other
● Fracture of vertebral body, posterior elements(pedicle,
lamina, transverse process)
Features suggestive of unstable injury
● Wedging of body with anterior height reduced more than half
of posterior height
● Fracture-dislocation on X-ray
● Rotational displacement of spine
● Injury to the facet joints, pedicle or lamina
● Increase in space between the adjacent spinous as seen on
lateral x-ray
Burst fracture of the vertebral body
Results from a vertical compression force
• Posterior elements are usually intact but because of the
severity of crushing of the vertebra, fracture is considered
unstable
• May be associated with a neurological deficit
• T/t: No neurological deficit –same as wedge compression fracture
Definitive Care
Objectives
• To avoid any deterioration of neurological status
• To minimize a perceived threat of neurological compression
• To stabilize the spine
• To rehabilitate the paralyzed patient
Indications for urgent surgical stabilization
• Unstable fracture with incomplete neurological deficit or progressive
neurological deficit with imaging confirming neural compression
• Unstable fracture in a polytraumatized patient (relative indication)
● Aim of treatment is to achieve proper alignment of vertebrae and
maintain in that position till vertebra stabilizes.
● Non-operative method and operation
● Operative stabilization of fracture of spine has become the treatment of
choice
● Operation is particularly required for
■ Irreducible subluxation because of ‘locking’ of the articular
processes
■ Persistent instability
Subluxation and dislocation of Cervical Spine
● A flexion rotation force or a severe flexion force may result in the
forward displacement of one vertebra over the other (commonly C5
over C6).
● The displacement may be partial or complete.
● Treatment
1. Surgical stabilization is treatment of choice
2. Some cases can be treated conservatively.
Non Operative Method
● Reduction by skull traction applied
through skull calipers – Crutchfield
tongs
● A weight of up to 10 kg is applied and
check X-rays taken every 12 hours
● Close watch is kept on the patient’s
neurological status
● This is followed by immobilization –
PoP cast or a plastic collar (3-4
months)
Treatment Methods
Collar Tongs Halo ring Fixation
Subluxation and dislocation of Cervical Spine
● A flexion rotation force or a severe flexion force may result in the
forward displacement of one vertebra over the other (commonly C5
over C6).
● The displacement may be partial or complete.
● Treatment
1. Surgical stabilization is treatment of choice
2. Some cases can be treated conservatively.
Fracture of Atlas
• A ‘burst’ fracture
• Both, ant. & post. arches of the atlas are
fractured by a vertical force acting
through the skull is a common atlas
fracture (Jefferson’s fracture)
• T/t:
• Traction, followed by immobilisation in
a) Minerva jacket
b) Halopelvic
support
Atlanto-Axial Fracture-Dislocation
Atlanto-Axial Fracture-Dislocation
• A fracture dislocation is more common than pure
dislocation
• A pure dislocation is more often associated with a
neurological deficit
• The displacement is commonly anterior
• T/t – Skull traction, followed by immobilization
in a Minerva jacket
● Clay shoveller’s fracture
■ This is a fracture of the spinous process of D1 vertebra
■ It is caused by muscular action as occurs in shovelling by
laborer's
● Displacement of intervertebral disc
■ A violent flexion-compression force can sometimes result
in sudden prolapse of the nucleus pulposus of a
cervical disc into the vertebral canal resulting in
quadriplegia
■ Early decompression may give good results
References
Apley's Solomon`s System of Orthopaedics and Fractures, 10th
edition
Essential Orthopaedics, 5th Edition – Maheshwari
Thank You
