Fracture and Dislocation of the Spine
I. Introduction
long period in treatment
associated spinal cord injury is common
Residual deformity and dysfunction may be permanent and serious
Causes : traffic accident, fall-down, slip-down, sports injury
Age : 20-40 decade, male is more common
Associated injuries : fracture of extremity or pelvis, brain injury, chest, abdomen, U.T. injury
in 10-25 % ; cord injury
II. Fracture of Cervical spine
1. Anatomy
1. Atlas
no vertebral body , ring structure with 2 lateral mass
bearing skull weight
2. Axis
Largest body in the cervical spine
odontoid process is placed posterior to the ring of atlas, stabilized by transverse, apical and alar ligaments
3. C3 - C7 vertebrae
similar structure in each other
C5-6 : motion is free than other level , degeneration & dislocation are common
uncinate process : superior projection on lateral aspect of vertebral body, when disc degenerated & disc space narrowed --> uncovertebral joint --> root compression
4. Steel's rule of third
at C1 level (Atlas) : spinal cord : 1/3
odontoid process : 1/3
free space : 1/3
at other level : 50 % of canal is dural content (spinal cord)
5. Normal motion of the cervical spine
# atlanto-occipital junction : only flexion & extension -- 20-30 degrees
# atlanto-axial junction : rotation 40 on either side ( 50 % of 160 rotation in neck motion )
# C2- C7 : no single motion at one interspace
4 types of principal motion ; flexion, extension, lateral bending & rotation
2. Mechanism of injury
1. Three column theory by Denis
: anterior, middle & posterior column
anterior column : ALL, ant. 1/2 of body & annulus
middle column : PLL, post. 1/2 of body & annulus
posterior column : 2 pedicles, 2 liminae, supraspinous & inerspinous
ligament, ligamentum flavum, facet joint capsules
2. 3 principal direction of force : flexion, extension & rotation
body & disc : resist to compression
annulus & ligaments : resist to distraction
3. Mechanism of Injury
# Compression Flexion injury
ant. compression injury of upper vertebra -> ligament injury of middle &
post column -> post displacement of post-inf margin of vert.
A-P view : saggital separation of body
Lat. view : triangular fragment on anteroinf. of body
most common in C4-5 & C5-6
# Vertical Compression injury
simultaneous compression injury on ant. & middle column
1 side end plate is involved, compressed -> upper & lower end plate are
involved -> burst around body -> cord compression by retropulsed
fragments
early anterior decompression is necessary
# Distractive Flexion injury
rupture of PLL -> tear of ant & middle ligaments -> anterior displacement of
body
degree of displacement ; minimal, unilateral facet dislocation, bilateral facet
dislocation, full vertebral body width displacement
more common in injury of root
# Compressive Extension injury
unilateral vert. arch fracture (facet joint, pedicle or lamina) -> bilateral arch fracture -> anterior displacement of ant & middle column
pillar view in diagnosis of unilat arch fracture
# Distractive Extension injury
anterior, middle & posterior ligament tear -> post displacement of upper body
radiologically : avulsion fracture of ant body on annular insertion is comon
# Lateral Flexion injury
rare
asymmetric compression on AP view
body compression with fracture of ipsilateral arch
occured in lower cervical level, associate with brachial plexus injury or complete cord paralysis is often
3. Diagnosis
Delay in diagnosis of cervical lesion occur in 1/3 of cases due to head injury, decreased level of consciousness, alcoholic intoxication and multiple injury
# History taking
neck pain after trauma
any unconscious trauma patients should be regarded as having cervical spine injury until diagnosis is confirmed
# Physical sign
* inability of neck motion
* weakness, numbness
* paralysis of upper exremity or lower exremity
* tenderness over head and/or back of neck
# Physical exam : motor, sensory, respiration
step-off, local hematoma, interspinous widening on neck
DTR, Babinski sign
cremasteric reflex
anal wink : anal sphincter contraction with stroking anal skin
bulvocavernous reflex : squeezing of glans penis or clitoris
--> contraction of anal sphincter
# Neurologic examination
a. functioning level
- above C4 level : constantly on a ventilator
- C4 level : complete upper extremity paralysis
- C5 level : no muscle power available below the elbow flexor
- C6 level : no elbow extensor and no hand function
- C7 level : still absent finger or muscle power
b. Major reflex : biceps(C5-6), brachioradialis reflex(C6), triceps(C7),
c. spinal shock
complete absence of reflex below the level of cord injury
traumatic disruption of sympathetic otuflow(T1-L2) and unopposed vagal
reflex
hypotension(normal pulse rate-- ddx point for hypovolemic shock)
bulbocavernous reflex is absent & flaccid anal sphincter tone in spinal shock
usually end within 24 hours
recovery sign : return of bulbocarvenous reflex or anal wink
* Complete spinal cord injury
- After recovery from spinal shock, anal reflex, bulbocavernous reflex,
plantar reflex are positive without recovery of sensation & motor
function
- complete anesthesia & absence of voluntary motor power distal to level
of injury
- immediate paralysis & no sign of sacral sparing
- after spinal shock, definite diagnosis of complete cord injury can be made
* Incomplete spinal cord injury : partial loss of cord function
the greater motor & sensory sparing, and the more rapid the recovery,
the better prognosis for full recovery
a. central cord syndrome
b. anterior cord syndrome
c. posterior cord syndrome
d. Brown-Sequard syndrome
(1) Brown-Sequard syndrome :
- injury limited to either side of spinal cord
- ipsilateral motor paralysis & contralateral hypesthesia to pain and
temperature
- good prognosis ; 90% regain bladder & bowel control and ability to walk
(2) Central cord syndrome : most common
- extension injury to an osteoarthritic spine
- damage to central gray matter produced by osteophyte anteriorly and
enfolded ligamentum flavum posteriorly
- flaccid lower motor neuron paralysis of U/E.
spastic upper motor neuron paralysis of trunk & L/E.
- sacral sparing (+)
- 50-60% return of motor & sensory to trunk and L/E
(3) Anterior cord syndrome :
- hyperflexion injury, post. displacement of bony fragment or disc
- complete motor paralysis & sensory (except dorsal column) anesthesia
- poor prognosis
(4) Posterior cord syndrome : rare
- hyperextension injury
- loss of deep pressure, deep pain, proprioception
(5) Conus medullaris syndrome
- injury of sacral cord(conus) and lumbar nerve roots within sp.canal
- results in areflexic bladder, bowel and L/E
- flaccid paralysis in the perineum and loss of all bladder and perianal
muscle
- absence of bulbocarvernous reflex and perianal wink
- motor function in the L/E between L1 and L4 may be present if nerve
root sparing(+)
(6) Cauda equina syndrome
- injury between the conus medullaris and the L-S nerve roots within
spinal canal
- areflexic bladder, bowel and lower limbs
- all peripheral nerves to the bowel, bladder, perianal area, and lower
extremity are lost, and the B-C reflex, anal wink and all reflexic
activity in the L/E are absent
d. Sacral sparing : incomplete spinal cord injury
- perianal sensation,
- voluntary control of anal sphincter,
- voluntary control of toe flexor
e. Autonomous zone of sensation : C2 - posterior scalp, C3 - anterior neck,
C4 - inferior clavicle, C5 - lateral arm, C6 - 1st & 2nd fingers, C7 -
3rd & 4th fingers, C8 - ulnar side of forearm, T1 - medial arm
f. Muscle grading :
C5 - biceps, C6 - FCRL, C7 - triceps, C8 - FDP, T1 - intrinsic muscles of
fingers L2 - iliopsoas, L3 - quadriceps, L4 - TA, L5 - EHL, S1 - soleus
important in prognosis
# Radiologic evaluation
AP & Lateral view are fundamental
Open mouth view for C1 & C2 fracture
Swimmer's view for C7-T1
pillar view for lateral mass
stress view for instability (flexion & extension view)
special study : tomogram, myelogram, CT, MRI
* CT is the best method assessing the degree of bony encroachment into the
canal
* MRI : helpful in disk herniation of cervical spine fracture & ligamentous
disruption
- aid in examination of the condition of the spinal cord & predicting
neurologic recovery following acute spinal cord injury
local increase of lordosis : suspicious hyperextension injury
local kyphosis : flexion injury
fracture & dislocation : malalignment of post vertebral line or disruption
irregular interspinous space : ant dislocation d/t flexion injury
displaced spinous process on AP view : unilateral facet dislocation or rotational deformity due to fracture
* Signs of cervical injury on x-ray
widened retropharygeal space
widened retrotracheal space
tracheal & laryngeal deviation
widened interspinous space
rotation of vertebral body
widening or narrowing intervertebral disc space
widening of apophyseal joint
4. Treatment
1) Prehospital care (5 phases)
Evaluation
Resuscitation
Immobilization
Extrication
Transport
2) Initial patient assessment
A : Airway maintenance & control of C-spine
B : Breathing
C : Circulation with hemorrhage control
D : Disability (neurologic disability & consciousness)
E : Exposure (undressed)
<Resuscitation>
Supplementary oxygen
Airway
Intubation : nasotracheal
Circulatory support : hemorrhage control, IV line keep
3) General consideration
@ DDx spinal shock & hypovolemic shock
@ Associated injury (intrathoracic, abdominal)
@ Immobilization of neck with sandbag, orthosis
@ Prevention of pressure ulcer, GI bleeding & urinary retention
4) Medical treatment
: decrease an edema of spinal cord in cord injured patient
: steroid, naloxone
5) Treatment for cervical spine injuries
< 4 major treatment >
(1) external immobilization in an orthosis
(2) prolonged traction, with the use of orthosis
(3) surgical decompression of the spinal cord or roots
(4) surgical spinal realignment and stabilization
* goals of treatment : to achieve a stable, anatomically aligned spinal
column and maximal neurologic function
< Nonoperative treatment >
(1) skeletal traction : the most widely accepted method of initial treatment
- Type : Crutchfield tong, Gardner-Wells tong, Halo
- if, mechanical bony block (+) : traction with different direction
usually flexion and rotation to unlock the locked facet
- maintenance of reduction when closed reduction with skeletal traction is
achieved
i) continue traction until bone and ligament have healed
ii) immobilization with Halo and plaster or plastic body jacket
iii) operative stabilization
(2) halo body cast
(3) cervical orthosis
< Operative treatment >
(1) foremost indication of surgery :
a. progressive neurologic deficit of persistent dislocation
b. neural compression is not corrected by closed method
c. persistent paresis by compression
* less urgent indication :
reduced unstable cervical dislocation
disrupted ligament for stable healing
complete spinal cord injury
unstable spinal fracture or dislocation
failure of conservative treatment
* Methods of operation
Anterior approach
Posterior approach
Ant. & post. combined approach
Decompression, fusion & internal fixation
(2) anterior versus posterior fusion
posterior fusion for posterior instability
anterior fusion for anterior instability
both anterior and posterior fusion for complex injuries with anterior and
posterior instability
(3) posterior fixation type
i) interspinous wiring
ii) laminar clamp or hook devices
iii) plating
< Reduction of Fracture & dislocation >
skeletal traction is the widely accepted method
Urgency of reduction is dictated by neurologic loss
Open reduction : if fail the closed reduction
< Maintenance of reduction >
Continuous traction until bone and lig. have healed
Brace : cervical collar, Philadelphia brace or four poster brace
Immobilization with halo & plaster or body jacket
< Operative treatment >
# Goals & methods of operative treatment
(1) Decompression of fractured fragments, disc, hematoma
(2) Reduction of dislocation
(3) Stabilization
# Approach : Anterior -, posterior -, or combined approach
# decompression, fusion & int. fixation
5. Complications
Muscle atrophy
Pulm Cx. (Pneumonia, aterectasis)
Joint stiffness
Vacation loss
Bed sore
GIT bleeding
GUT infection
Psychiatric trauma
Death
6. Cervical sprain
most common injury on neck
Partial injury of cervical ligament structure but still maintained of contiuity of ligament structure
Sx. : neck pain, LOM, rad. pain to U/E
Tx : immobilization with brace for 3-6 wks
7. Whiplash injury
1) Injury mechanism ; sudden extension of cervical spine by foreward acceleration force
2) ant. cervical muscle, ALL, and ant. fiber of annulus are injured
3) Sx. : neck pain with or without radiation to shoulder or U/E, dysphagia, blurring of vision, tinnitus, dizziness
4) Tx. : soft collar for 4-6 wks
8. Jefferson's Fracture.
1) Definition : bursting fracture of C1 by axial loading
2) neurologic deficit is uncommon because of wideningn of spinal canal
3) Stable type of atlas fracture : simple arch fracture, nondisplaced lateral mass
fracture & transverse process fracture
4) Unstable fracture. : 7 mm > overlapping of C1 & C2 facet in open mouth view
4 mm > atlantodental interval
5) Treatmentof atlas fracture
Simple arch fracture : cervical collar or brace
Jefferson's fracture : undisplaced fracture -> cervical brace for 8-10 wks
displaced fracture -> skeletal traction for 6-8 wks and then
halo vest 2-3 mo.
In case of fracture with transverse ligament rupture : C1-2 fusion is neccesary
9. Odontoid process Fracture.
1) Type 1 : oblique fracture on upper portion, stable,
treated with collar or brace
2) Type 2 : fracture between process & body, unstable, high rate of nonunion,
treated with halo vest or operative (C1-2 fusion or ant screw fixation)
3) Type 3 : fracture involving body, good union rate,
traction ->halo vest for 6-12 weeks
10. Traumatic spondylolisthesis of axis (Hangman's fracture)
pedicle fracture by hyperextension & vertical compression -> C2-3 disc rupture & ant. displacement of body by 2ndary flexion
11. Unilateral facet dislocation
Distractive flexion , post & middle column injury
common in C5-6, usually associated with nerve root or cord injury
25 % anterior displacement of body on lateral view
reduced by skeletal traction and then halo vest for 3 mo.
Operation : if fail of closed reduction, unstable case, associated facet fracture, associated root injury -> OR/IF with fusion
12. Bilat. facet dislocation
Distractive flexion, post & middle &/or ant. column injury
50 % displacement of body on lat view
unstable, cord injury is common
reduced by skeletal traction and then int. fixation & fusion
13. Vertebral body Fracture.
< Compressive flexion >
possibility of instability -> flexion & extension view should be checked
only anterior compression fracture : stable, treated with brace for 8-12 weeks
anterior fracture & post ligament injury : unstable, but uncommon of neurologic deficit, skeletal reduction & int fixation with fusion
<Tear drop fracture >
a. mechanism of injury : compressive flexion
b. 3 column are injured
c. anteroinf. triangular fracture fragment and retropulsion of posteroinf. portion of body -> cord compression
d. unstable, high rate of neurologic deficit
e. Tx. : ant. corpectomy & strut bone graft, internal fixation on anterior or ant & post. combined fixation
¡¡
III. Fracture of Thoracic & Lumbar spine
1. Anatomical characteristics
50 % of canal (lower cervical & TL junction) is cord
others ; CSF, dura, epidural fat
conus medullaris : spinal cord terminates at L1-2 level of intervertebral space
cauda equina : below level of conus medullaris
peripheral nerve ; more resilient to trauma than central n. fiber
< Neurologic deficit by injury >
above T10 : cord damage
T10 to L1 : both cord and root damage
below L1 : root damage
Critical zone of spinal cord : T4 - T9
Artery of Adamkiewicz : Lt T10-11
2. Mechanism of injury by McAfee
Wedge compression fracture.
Stable bursting fracture.
Unstable bursting fracture.
Chance fracture.
Flexion-distraction injury
Translational injury
< 3 column theory by Denis >
Ant. Column : ALL, ant. 1/2 of body & annulus
Middle Column : PLL, post. 1/2 of body & annulus
Post. Column : 2 pedicles, 2 liminae, supra- & inerspinous lig., ligamentum flavum, facet joint capsules
1) Wedge compression fracture.
ant. compression force
fracture on ant. column only
uncommon in neurologic damage
wedge shaped fracture
2) Stable bursting fracture.
injured by compression load
ant. & middle column injury, no loss of integrity the posterior elements
3) Unstable bursting fracture.
ant. & middle column injury by compression and post. column injury by
compression, lateral bending or rotation
unstable
tendency for post traumatic kyphosis or progressive neurologic damage
4) Chance fracture
Rotational axis : anterior to ALL
horizontal avulsion fracture. from ant. body to spinous process
5) Flexion-distraction injury
Rotational axis : post. to ALL
flexion injury of ant. column and distraction injury of middle & post. column
-> subluxation, dislocation or fracture of facet joint
unstable due to rupture of posterior ligament complex
6) Translational injury
Shearing force
all three column are failed
coronally displaced
disruption of alignment of neural canal
3. Dx. of T-L spine fracture.
1) History : trauma Mx., sensation of extrem.
2) P.E. : tender on TL area, widening of interspinous space, step off
3) Neurologic examination
Sensation & muscle power
Exam. for spinal shock
: Anal wink (S2-4)
Bulbocarvenous reflex (S3-4)
plantar reflex
1st recovery from spinal shock : contraction of toe flexor
4) Radiologic examination
AP & lat. view
CT scan : bony protrusion into canal, pedicle, facet joint, lamina fracture
myelogram
MRI : lig. & soft tissue injury, cord edema, extent of cord injury
4. Treatment of TL spine fracture.
1) Two important factors : stability of fracture
neurologic damage
2) Goals of tx : prevention of progression of n. injury
recovery from damaged nerve
prevention of deformity by stabilization
prevention of complication by early rehabilitation
3) Nonoperative methods
Pharmaceutical Tx. : decrease the cord edema in cord injured patient
Conservative Tx : bed rest for 3-4 wks --> brace (TLSO) for 6-8 wks
# Indications of nonop. Tx.
a. No injury of middle osteolig. complex & post. ligament
b. less than 50 % of compression of body
c. less than 20 degree of kyphotic angle
4) Operative methods of TL spine fracture
Controversy
Post. fusion with fixation
Ant. decompression with fusion & fixation
# Benefits of Op.
a. Correction of displacement & deformity -> reduction of protruded
fragment into canal
b. Prevention of recurrence of deformity by stabilization
c. Decrease the complication by early ambulation
(1) Posterior fusion
# Indications : Unstable bursting fracture.
Chance fracture.
flexion-distraction injury
dislocation of facet joint
translational injury
Open reduction & internal fixation with bone graft
(2) Anterior fusion
# Benefits :
- Direct approach to protruded fragment & able to complete decompression
- Short term of external support
- Further operation is not necessary
# Indication of anterior fusion
- Neurologic deficit with retropulsed bony fragment on canal
- Progression of neurologic deficit in bursting fracture
- Post-traumatic kyphosis with severe back pain
(3) Spinal instrumentation
# Post. implant :
Harrington distraction / compression rod
Luque segmental sublaminar wiring
Cotrell-Dubousset hook system
Pedicle screw with rod or plate
# Ant. implant :
Ant. screw & plate
Zielke instrument
Kaneda instrument
5. Complications of TL spine fracture.
Paralytic ileus
UT infection
Bed sore
Pneumonia
Paraplegia or paresis due to nerve damage
respiratory insufficiency
joint stiffness & muscle atrophy
death