Spine

Cervical trauma - dens and facet dislocation

Odontoid and facet fracture/dislocation radiographs and bilateral facet dislocation with neurology

24 questions 4 source pages

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Q1Describe the X-ray findings in this dens fracture.▸

Inadequate exposure
Anderson and D'Alonzo type 2, Gruer A dens fracture with minimal displacement
Spinal lines intact; prevertebral soft tissue swelling
Sum of lateral mass normal; lateral ADI normal

Q2With intact neurology, how is a dens fracture managed by type?▸

Aim: stabilise the spine to promote healing, prevent neurological deficit, enhance early mobilisation
Type 1: rigid neck collar
Type 3: young - halo jacket; old - rigid neck collar (halo jacket in the elderly has higher mortality); non-union risk 7%
Type 2: depends on the risk of non-union

Q3What are the risk factors for non-union of a type 2 dens fracture?▸

Patient factors: old age (>50), smoker, delay presentation >4 days
Fracture factors: angulation >10 deg, displacement >5mm (strongest predictor), fracture gap >1mm, comminution
Non-union rate up to 20-40%

Q4How does age influence the management of a type 2 dens fracture?▸

Young + no risk factors: can try halo jacket with close monitoring; surgery if risk factors
Elderly: OT as age is already a risk factor and to avoid the jacket; OT if fit, neck collar if not
Stable fibrous union in an asymptomatic patient >65yo may be acceptable (J Neurosurg 2020 Wilson)

Q5What are the operative choices for a dens fracture?▸

Osteosynthesis of the odontoid or C1/2 fusion
Osteosynthesis retains rotation but depends on fracture configuration; may cause airway or swallowing problems
C1/2 fusion does not rely on fracture configuration and is biomechanically more secure
Osteosynthesis needs good reduction, fracture perpendicular to screw trajectory (Grauer II); C/I barrel chest, large BMI, fracture >3 weeks, poor bone quality

Q6Why is a type 2 dens fracture prone to non-union and what are the fusion rates?▸

Mechanical: fracture distal to the transverse ligament, so not stable
Biological: watershed blood supply (superior internal carotid, inferior vertebral artery); small contact surface with high cortical:cancellous ratio
C1/2 is a synovial joint - no fibrin clot; lack of cambium layer, no osteogenic potential
Fusion rate: halo 70%, wiring 80%, Magerl/Harms/transarticular >95%

Q7What history, examination and initial steps are needed in a dens fracture?▸

ATLS and rule out other injury, especially head injury
Temporary stabilisation of the C spine
AMPLE history + chronicity, smoking, dysphagia (retropharyngeal haematoma)
Assess neurology and body build

Q8What is the aim of treatment for a dens fracture?▸

Restore spinal stability and prevent late myelopathy
Stabilise the spine to promote healing, prevent neurological deficit, enhance early mobilisation

Q9What are the C1/2 fusion options for a dens fracture?▸

Harms technique: C1 lateral mass screws + C2 pedicle screws
C1/2 transarticular screws +/- wire augmentation - needs good reduction, pre-op CTA for vertebral artery anatomy
Gallie or Brooks wiring with bone block + halo - sub-optimal rotational control, Brooks better
Give neck collar x 3/12

Q10Describe the X-ray findings in this hangman's fracture.▸

C2/3 spondylolisthesis with disruption of anterior and posterior vertebral body lines
spinolaminar and spinous process lines are intact
Fracture seen at the pars, displacement and angulation (>11 deg = type 2A)
Prevertebral soft tissue swelling; look for other subaxial C spine injury
Hangman's fracture (traumatic spondylolisthesis of C2/3)

Q11How do you classify a hangman's fracture?▸

Levine/Effendi classification
Type 1: anterior translation <3mm, minimal angulation (axial load + hyperextension)
Type 2: translation >3mm, angulation <11 deg (axial load + hyperextension then hyperflexion); C2/3 disc and PLL disrupted
Type 2A: minimal translation, horizontal fracture line, angulation >11 deg (flexion distraction; ALL intact as the hinge)
Type 3: with facet dislocation (flexion distraction + hyperextension)

Q12How is a hangman's fracture managed if there is no neurological deficit?▸

Type I and II: non-op with halo/rigid collar; type IIa and III: C2/3 fusion (Li et al Eur Spine J 2006 - 50% pseudarthrosis with non-op)
Type 1: rigid neck collar 4-6 weeks (stable, disc usually intact)
Type 2: CR with halo traction then halo jacket 6-12 weeks; surgery if failed or displacement >5mm
Type 2A: traction contraindicated - halo reduce by extension + axial load, then C2/3 fusion
Type 3: more unstable, may need operation - C2/3 fusion

Q13What are the surgical options for C2/3 fixation?▸

Anterior plate and C2/3 interbody fusion
Posterior C2/3 fusion (C2 pedicle screw + C3 lateral mass screw)
Posterior C1-3 fusion; posterior C1-2-3 fusion
Posterior Judet screw
Non-union: C1-3 fusion

Q14Describe the X-ray findings in this C1 injury.▸

Increased AADI on the lateral view
Overhanging of C1 on C2 on the open mouth view (>7mm)
Likely Jefferson fracture

Q15What is a Jefferson fracture and how is it classified?▸

Burst fracture of C1
Landells: I isolated anterior or posterior arch fracture, II Jefferson burst fracture, III unilateral lateral mass fracture
Gehweiler: I isolated anterior arch; II bilateral posterior arch; III classic Jefferson (anterior and posterior arch) A TAL intact / B TAL rupture; IV lateral mass; V transverse process

Q16How is transverse ligament stability assessed in a Jefferson fracture?▸

Combined overhang >7mm (rule of Spence)
AADI >5mm (both alar and TL); if 3-5mm = TL only
PADI <14mm
Avulsion fracture of the transverse ligament
MRI showed discontinuity

Q17What is the Dickman classification and its treatment?▸

Type I: intrasubstance tear - treat with C1/2 fusion
Type II: bony avulsion - treat with halo vest

Q18What is the management of a Jefferson fracture?▸

Assess neurology - usually intact as the SAC is widened
Gehweiler I, II, IIIA, V: SOMI brace / hard collar
IIIB: halo +/- occiput to C2 or C1/2 fusion (now trend towards surgery)
IV: halo majority of the time; O-C2 stabilisation if incongruence of atlanto-occipital or atlantoaxial joint, or sagittal split of lateral mass

Q19What is the initial management principle in bilateral facet dislocation with neurology?▸

ATLS, rule out other injury, temporary stabilisation with neck collar
Minimise secondary injury, hypoxia and ischaemia at the cord injury site by ensuring adequate haemodynamics and oxygenation
Immobilise the spine
Shock can be neurogenic shock but need to r/o hypovolemic shock

Q20How do you assess the neurology in acute spinal cord injury?▸

Assess whether complete or incomplete cord injury (voluntary anal grip, deep anal sensation)
If complete, determine neurological level (most caudal level with power >3/5 and normal sensation) by ASIA classification
If incomplete, determine Frankel grading (A worst, E intact)
Rule out spinal shock (return of bulbocavernosus reflex)

Q21What is spinal shock?▸

Temporary physiological response of the cord against trauma
Complete paralysis, diaphragmatic breathing, paraesthesia, areflexia including bulbocavernosus reflex
Only when spinal shock is over can the true neurological deficit be evaluated

Q22What is neurogenic shock?▸

Temporary generalised sympathectomy due to cord injury
Triad of hypotension, bradycardia, peripheral vasodilatation
SCI above C6
Management: fluid support, vasopressor, atropine

Q23What is autonomic dysreflexia?▸

Occurs 3 weeks - 9 months (up to 12yrs); massive disordered reflex sympathetic surge to stimulation below the lesion, particularly T6 or above
Emergency - can cause seizure, retinal haemorrhage, pulmonary oedema, MI
Visceral stimuli (e.g. distended bladder); imbalanced reflex sympathetic discharge from the TL cord
Uncontrolled hypertension, bradycardia, sweating, agitation
Why above T6: below T6 there is greater vasodilatory reserve (splanchnic circulation) to offset vasoconstriction

Q24What is the timing of surgery and the postoperative care?▸

Rationale for early surgery: salvage neurology by decreasing secondary injury from swelling, ischaemia and free radicals
STASCIS 2012 (Fehlings): operate within 24hrs - safe, better neurological recovery (increase 2 ASIA grades), less complications, similar mortality
Confirmed by Fehlings 2021 Lancet meta-analysis: within 24hr for acute SCI
Postop: avoid pneumonia/UTI, bedsore, DVT, paralytic ileus, gastric ulcer
Rehab: reintegrate into community; key functions - transfer, mobility, hand skills

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Cervical trauma - dens and facet dislocation