State University of Medicine and Pharmacy [600571]

State University of Medicine and Pharmacy
"Nicolae Testemițanu"

Thesis

State University of Medicine and Pharmacy
"Nicolae Testemițanu"
FACULTY OF MEDICINE
Department of Orthopedics and traumatology

License Thesis
Results of surgical treatment of cervical
Fracture and Dislocation

Presented by :

Mahamid Mohamed , Group 1637

Direction and guidance:

Ph.D , Dr. Oleg Pulbere

2015

© Copyright by Mahamid Mohamed
All Rights Reserved

CONTENT

STATMENTS I
DEDICATION II
CERTIFICATION III
ABBREVIATIONS IV
INTRODUCTION …………………………………….………..……. 1
MAIN OBJECTIVES OF THESIS ………………….………………. 3
REVIEW OF LITERATURE ……………………………….……….. 5
I. Anatomy of the cervical spine ………………..…… ………………..… 5
The cervical vertebrae…………………………………………………… 6
The cervical joints ………………………………………………………. 8
The cervical ligaments………………………………………………..… 9
The cervical spinal cord………………………………………………… 11
II. Neck injuries …… ….…………………………………………………. 14
Cervical vertebral fracture ……………………………………………. 16
Cervical vertebral dislocation …………………………………………. 20
III. Diagnosis of cervical fracture ……………………………………….. 22
X-ray of cervical fracture ………………………… …………………… 23
CT-scanning of cervical fracture ……………………………………… 25
MRI of cervical fracture ………………………………………….……. 27

IV. Treatment of cervical fracture / dislocation ……………………….. 29
Cervical collar …………………………………….………………….. 29
Rigid braces …………………………………………………………… 30
Cervical – thoracic braces ………………….…………………………. 31
Surgery of cervical fracture / dislocation …………………………….. 32
Cervicothoracic junction / Lower cervical spine surgery…………..… 33
Posterior internal stabilization ………………………………………… 34
Types of cervical spine surgery ………………………………………. 36
Surgical technique …………………………………………………… 38
COMPLICATIONS ………………………………….……………….. 41

Cervical fusion complication ………………………………………….. 41

Recovery ……………………………………………………………… 43
AIMS OF STUDY …….…………………………….…………………. 44
MATERIALS AND METHOD ……….………….…………………… 45
Statistical analysis ……………………………………………………… 46
Statistics ……………………………………………………………….. 48
DISCUSSION …….……………………………….…………………… 53
Evolutions of fusional block …………………………………………… 57
RECOMMENDATION ………………………………………….…… 61
CONCLUSION ……………..…………………………………….…… 63
ACKNOWLEDGEMENTS . ………… ………………………………. 64
REFERENCESS ………………………………………………….…… 65

Statement

I hereby declare that the license thesis “cervical trauma – vertebral fracture ” is written
by me and has never been submitted to another university or institution of higher
education in the country or abroad . all sources used, are given in the paper with the rules
for avoiding plagiarism .
All the clinical cases and x -ray’s of patients in this thesis was token from
MD ,PhD DR. Pulbere Oleg association professor of USMF “ Nicolae Testemițanu „
Chisinau ‚ Republic of moldova .

…… ……………… ……………………………….
Date Mahamid Mohamed

I

DEDICATION

This Thesis is dedicated to my parents …

My father Asaad Mahamid and my Mother Lmia …

All I have and will accomplished are only possible due their love ,
support , encouragement and sacrifices .

II

CERTIFICATION

The undersigned certifies that he has read and hereby recommends for
acceptance of the dissertation entitled “ Cervical trauma – vertebral
fracture “ , in fulfillment of the requirements for Thesis of Medicine in the
department of “Orthopedics and Traumato logy “ of the State University
of Medicine and Pharmacy “ Nicolae Testemițanu „ .

______________________
Dr. Nicolae Caproș

______________________
Date

______________________
Dr. Oleg Pulbere

______________________
Date

III

ABBREVIATIONS

ALL …… …… …. Anterior longitudinal ligament
AS …… ……… … Ankylosing spondylitis
ACIF ………… … Anterior cervical interbody fusion
CSI …… ……… …Cervical spine injury
CL ……………… Capsular ligament
CT …… ………. .. Computed tomography
GCS …………… Glasgow Coma Scale
HTV …… ……… . Halo -thoracic vest
ISL …………… .. Interspinous ligament
LCS ……….…… The cervical spine from vertebra three to seven
MRT …………… Magnetic Resonance Tomography
MDCT …………… Multi -detector co mputed tomography; multi -slice CT
MPR …………….. . Multiplanar reformation
MRI …… ……… Magnetic resonance imaging
MVA …… …….. Motor vehicle accident
PLL ….………… Posterior longitudinal ligament
ROM …… ……… Range of motion
SCI …… ..….….. Spinal cord injury
SEH …… ….….. . Spinal epidural hematoma
VBS …… ….….. . Vertebral body sagittal distance

IV

Introduction

Neck injuries are very severe types of injuries, since there is a high risk of fatality or
paraplegia. Any neck injury can have devastating if not life threatening consequences.
Highspeed transportation as well as leisure -time adventures have increased the number
of serious neck injuries and made us increasingly aware of the consequences.
Many protective devises have been developed to shield the human neck when we
practice motor vehicle sports, skiing , mountain climbing and in other dangerous
situations. Unfortunately there is a lack of biomechanical data and understanding of
injury mechanisms, and therefore these safety devises are not optimal.
The cervical spine is a complex me chanism from a mechanical and structural point of
view. The vertebral column has two major functions, to stabilize the head and to protect
the spinal cord. Therefore, cervical spinal injuries are a potential threat to the spinal cord
and must be treated wi th respect and caution. The effects of spinal cord injuries are
serious, as mentioned above, ranging from death to quadriplegia, loss of sensory
functions, and a range of deficits.
A superior location of the spinal cord injury causes more severe effects th an an inferior
injury. It is therefore of uttermost importance to protect patients with neck injuries from
further damage of the spinal cord. Head and facial trauma is often coupled to serious
spinal trauma, In order to account for the interaction between the head and the spine, it is
a necessary to analyze the head, brain, and cervical spine as one complex. Cervical
spinal injuries are caused by impacts going beyond the tolerance threshold of ligaments
and b one in the area. The medical personnel would benefit from knowledge of the forces
or the kinetic energy causing a
fractured cervical spine to find secondary injuries, predict late symptoms and to chose
the appropriate treatment.

Today, advanced imaging te chniques, such as computer tomography(CT) and

magnetic resonance tomography (MRT), are good diagnostic tools and can give
information on location and type of injury. Medically, it is not always possible to
evaluate the stability of the injured cervical spine. There is a need for better knowledge
about how fractures and soft tissue injuries influence the spinal kinematics, as well as
injury mechanics.
Researchers today explore the area of spinal injuries with different approaches.
Statistical surveys are important tools to define the populations at risk, the external
causes of injury, and to evaluate preventive measures. Clinical studies of fractures and
follow -up of patients give valuable insight into fracture mechanics and severity of the
injury, but lac k detailed information of the load situation. Experimentally induced
fractures are ideal for studies of injury mechanics and initialization, as the loads applied
can be controlled. Unfortunately, there are difficulties in applying realistic load
conditions and experimental injuries may not be representative of real life injuries.
Numerical analysis is another method with potential to simulate real life accidents better
than experimental set -ups. This approach has the advantage
of highly detailed models, whe re stresses and strains can be studied through out the
simulation for all the different tissues. One of the drawbacks with numerical analysis is
the uncertainty of material properties of biological tissues. All these different
approaches are important and when interacting they offer a great opportunity to increase
the knowledge of neck injury mechanics.

Main objectives of the T hesis

In this thesis I will focus on the techniques and method that used in this type of trauma’s
because the cervical trauma is sensitive and it can lead to severe complication . In my
work will spot a light on the ways that we can accept this cases ether it’s a normal
trauma or some accident.
First help in the site of the accident and in the location of the trauma, because each
trauma is different from other but it all sharing the same principles and choice having
dislocation or ether fractures in the vertebral bone is quite high, so the techniques and
evaluation of the patient from the site of the accident is important .

In this work will explain about the dissection of the doctor which techniques is the best
ending with the best result of operation , in some patient we have to perform a
techniques with several kinds of instruments . but in other patient ’s we don’t need to
perform a plate or other application methods .
This thesis will reflect the true about 33 patient that has an accident or some types of
trauma end with ether dislocation of the vertebral bone or fracture of the cervical
vertebra bone .

The main aim of this research is to analyzed result from different method that we can
use in this patient that had the cervical trauma dislocation or fracture .
To complete the perfect work and to get a good result in treatment with this patient we
need a e xamination method that will help us and I’ll show a several examination
methods like x -ray , CT , of the patient in real life before and after operation to
understand the maximum perfect result that we can get from this methods, the CT and

the x -ray is hel pful in this kinds of operation and trauma , also in this work I focused in
the using the x -ray in main time of the surgery to get best dimension to choose exactly
where to insert screw or where to a apply a plate .

At the end of the historical data after the surgery I will continue to follow up the patient
to make sure of the result that they get after the surgery and to know the mobility its
improved over the time, finally I will insert my Statistics that I collect from 33 patient to
reflex all the data , that complete the picture of the general cervical trauma of the neck .

I . Anatomy of cervical spine

The spinal column is a complex structure, whose main functions are to hold us upright,
support the head, and protect the spinal cord and blood vessels. The spine is divided into
five regions :

– The cervical spine,
– The thoracic spine connecting to the ribs,
– The lumbar spine,
– The sacrum, and
– The coccyx.

Figure 1: The human spine with the cervical spine extending from C1 to C7, the
thoracic spine from T1 to T12, the lumbar spine from L1 to L5, the sacrum and the
coccyx .

In the neck, the spinal region is called the cervical spine. It contains the top seven
vertebrae The cervical spine supports the head and allows a wide range of head motion.
It can be divided into the upper and lower cervical spine. This report focuses mainly on
the upper cervical spine, which has a different anatomy than the rest of the vertebral
column and is the most flexible part of the cervical spine.
There are several different systems of naming th e vertebrae. In this report the following
is used: the top vertebra is C1, the second C2 and so on until the last cervical vertebra,
C7. The occiput, or h ead, is called C0, even though it is not part of the spine. The first
two vertebrae are called the atlas and axis. C1 is named atlas after the giant who carried
the earth on his shoulders; similarly the atlas holds up the head. C2 is named axis,
probably b ecause it provides the axis for axial rotation in the upper cervical spines. Two
consecutive vertebrae,the connecting joints and intermediate ligaments make up a
motion segment. Hence, the cervical spine contains eight motion segments. These are
named afte r the two vertebrae: C0/C1, C1/C2, etc. The last motion segment is C7/T1,
where T1 is the first thoracic vertebra.

1.The Vertebrae
The vertebral bone is of a sandwich structure. It has a stiff outer shell, the cortical bone,
and aporous inner marrow, the trabecular bone. The geometry of the vertebrae in the
upper cervical spine, C1 and C2, is significantly different from the lower cervical spine,
C3 to C7,

1.1 The Upper Cervical Spinal Vertebrae
The upper cervical spine is made up of two vertebrae, the atlas (C1) and the axis (C2).
The atlas is composed of a bony ring and lacks a vertebral body. It is divided into the
anterior and posterior arch. On the lateral masses of the atlas there are facet joint

surfaces . The superior facets connect with the occipital condyles (two bony
protuberances on the base of the skull) and make up the occipitoatlantal joint. The lower
facet joint surfaces match the superior facets of the axis. The axis is composed of a
vertebral body and posterior arch, just like the lower cervical vertebrae. In addition, the
axis also contains the dens or odontoid process that projects superiorly between the
lateral masses of the atlas, Figure 2. Two small joint surfaces on either side of the dens
are in contact with th e anterior arch of the axis and the transverse
Ligament.

Figure 2 : the c1 and c2 axis , atlas of the upper cervical vertebrae

1.2 The Lower Cervical Spinal Vertebrae
A typical vertebra in the lower cervical spine has an elliptical vertebral body and a bony
posterior arch, Figure 2. The posterior arch can be divided into the pedicles, the lamina,

th spinous process, the transverse process, and the superior and inferior facet joint
surfaces. The spinal cord is protected and surrounded by the posterior e lements.

figure 3 : the lower cervical vertebrae c4 , c7 .

2.The Joints
In the upper cervical spine there are two joints, the occipitoatlantal joint and the
atlantoaxial joint. These joints differ from the joints in the lower cervical spine since
they do not have a disc. The different structures give distinct characteristics. The
occipitoatlantal joint is most flexible in flexion -extension, the so -called ‘yes -motion’ of
the head. The main function of the atlantoaxial joint is to allow rotation, a ‘no -motion’
of the head. Lateral bending is distributed evenly between the spinal joints.

2.1 The Occipitoatlantal Joint
The occipitoatlantal joint is formed by the occipital condyles on the skull base and the
superior facet surfaces of the atlas. The lack of vertebral body on C1 and the shape of
the joint surfaces enables considerable mobility in flexion -extension of this joint.

2.2 The Atlantoaxial Joint
The atlantoaxial joint is composed of three synovial joints between the atlas and the
axis. The superior facet surfaces of the axis and the inferior facet surfaces of the atlas
form two facet joints, the third joint is between the anterior arch of the atlas and the
dens. This joint enables considerable axial rotati on, as the atlas rotates around the dens
on the axis.

2.3 The Lower Cervical Spine Joints
The joint between C2 and C3 is of the same structure as the joints in the lower cervical
spine, that is, two posterior facet joints and an inter vertebral disc. The disc is a fibro
cartilaginous joint. It has a fluid like central portion (nucleus pulposus) and a n outer
fibrous, solid structur e (annulus fibroses ). The annulus fibroses is a composite, where
the annulus fiber are embedded in a matrix of annulus ground substance.

3. The Ligaments
Ligaments stabilize the joints in the spine and restrict motion. The lower cervical spinal
ligaments are the anterior longitudinal ligament (ALL), the posterior longitudinal
ligament (PLL), the capsular ligaments (CL), the liga mentum flavum (LF), the inter
spinous ligaments (ISL), and the super spinous ligaments (SSL) as shown in Figure 3.
The upper parts of these ligaments also belong to the upper cervical spine. Ligaments
specific to the upper cervical spine are the apical lig ament, the alar ligament, the
transverse ligament (TL), the tectorial membrane (TM), the anterior atlantooccipital

membrane (AAOM), and the posterior atlantooccipital membrane (PAOM) . The TM is
the continuation of the PLL from C2 to the occiput, the AAOM t he continuation of the
ALL from C1 to the occiput. The PAOM is the continuation betw een C1 and the head
for the LF , Several authors have treated t he subject of spinal ligaments.

Figure 4 : ligaments of the cervical vertebral .

3.1 The Apical Ligament
The apical ligament attaches posteriorly at the superior surface of the dens and on the
occipital foramen. It is thin and slightly V -shaped, with the majority of the fibers
concentrated in the middle , The purpose of the apical ligament is to restrain flexion.

3.2 the alar ligament
The alar ligaments restrain axial rotation of the occipitoatlantal joint, Its origin is the
lateral margins on the upper third of the dens and the insertion is mainly on the occiput,

but also on the lateral mas ses of C1 , The main fiber constituent is collagen, thus giving
an inelastic ligament with a large stiffnes developed a model describing how the alar
ligaments work. They claimed that both the left and the right alar ligaments limit axial
rotation in both directions.

3.3 The Transverse Ligament and Vertical Cruciate
The transverse ligament originates on one side of the lateral masses of the atlas and
inserts on the other, passing on the posterior side of the dens (middle and upper thirds),.
It works as a restraining band on the dens, holding it against the anterior ring of the
atlas, thus preventing movement of the dens toward the spinal cord . The transverse
ligament has two vertical extensions: an upward prolongation to the occiput and a
downward extensio n to the vertebral body of the axis. These vertical fibers are called the
vertical cruciate and restrain flexion of the head . The transverse ligament fibers are
mainly of collagen as the alar ligaments .

3.4 The Anterior Longitudinal Ligament and the Ante rior Atlantooccipital
Membran e
The ALL tightly adheres to the anterior surface of the vertebral bodies and the discs
between them . It is a broad ligament that narrows at the C1/C2 level. The ALL is
replaced by the anterior atlantooccipital membrane at the C0/C1 level. The superficial
fiber layers span several motion segments while the deeper fibers stretch between
two adjacent vertebrae .

4.The Cervical spinal cord
In addition to the seven cervical vertebrae, cervical anatomy features eight cervical nerves (C1 –
C8) that branch off of the spinal cord and control different types of bodily and sensory

activities.Each cervical nerve is named based on the lower cervical ve rtebra that it runs
between. As an example, the nerve root that runs between the second cervical vertebra and the
third cervical vertebra in the ne ck is described .

Figure 5 : the spinal cord of the cervical vertebral section

Cervical Nerve Functions
Branching off from the nerves in the spinal cord, the cervical nerves are responsible for
relaying messages and ensuring functioning to different body parts.
The spinal cord comes off the base of the brain, runs throughout the cervical and thoracic
spine, and ends at the lower part of the thoracic spine. Therefore, spinal cord injury or damage
may accompany trauma or diseases of the cervical spine or thoracic spine.
The spinal cord does not run through the lumbar spine (lower back). After the spinal cord s tops
in the lower thoracic spine, the nerve roots from the lumbar and sacral levels come off the
bottom of the cord like a "horse's tail" (cauda equina) and exit the spine

Therefore, because the lumbar spine has no spinal cord and comprises a large amount of space
for the nerve roots, even serious conditions (such as a large disc herniation) are unlikely to
cause paraplegia (loss of motor function in the legs).
More specifically:
 C1 and C2 (the first two cervical nerves) control the head.
 C3 and C4 help control the diaphragm (the sheet of muscle that stretches to the bottom
of the rib cage and plays an important role in breathing and respiration).
 C5 controls upper body muscles like the Deltoids (which form the rounded contours of
the shoulders) and the B iceps (which allow flexion of the elbow and rotation of the
forearm).
 C6 controls the wrist extensors (muscles like the extensor carpi radialis longus, extensor
carpi radialis brevis, and extensor carpi ulnaris that control wrist extension and
hyperextensi on) and also provides some innervation to the biceps.
 C7 controls the Triceps (the large muscle on the back of the arm that allows for
straightening of the elbow).
 C8 controls the hands.

Figure 6: The Cervical Spine containts 8 Nerves, each innervating specific areas of the upper bod

II. Neck Injuries

Epidemiology
The incidence of traumatic cervical spine fractures (CS -fx) in the general population is
largely unknown. Several reports describe the incidence of CS -fx in differ ent
subpopulations, such as trauma center patients, specific age groups, head injury patients,
military populations and osteoporotic patients, Our literature search identified only one
article describing the incidence of spine fractures in a general population. In 1996,.
reported the incidence of spine fractures, all sites, to be 64/100,000 However,
subgrouping into cervical, thoracic or lumbar frac tures was performed for only 45% of
the patients. The assumed incidence of CS -fx can be estimated to be 12/100,000 based
on this study, which was performed on a population just in Canada.

Figure 7 : Number of CSI in each age group enrolled in the NEXUS study.

Background

It has been shown that, cervical spine injuries are more often connected with spinal cord
injuries than the lower spinal regions There is also a strong association between head
and face trauma and neck injuries, In the cervica l spine, the cranio cervical junction
(Occiput –C2) and the C5 -C6 motion segment are the primary locations of cervical
injury . The cranium cervical junction is vulnerable due to the flexibility of the upper
cervi cal spine. The most inferior motion segments have a higher incidence because of
the stiffness change between the flexible cervical spine and the stiffer thoracic spine. In
Papers A and B it was found that the elderly population had a higher incidence for u pper
cervical injuries rather than lower cervical injuries.

Figure 8: Local motions of lower cervical spine segments, due to different loading modes.

Neck injuries can be divided into two major classes, vertebral fractures and soft tissue
injuries( International Classification of Diagnosis version 10). Neck injury
classifications usually refers to the global loading mode, which is the motion of the head
relative to the torso. This is not always appropriate since the local loading mode between
two co nsecutive vertebrae may differ from the global motion. For example, a
compression loading of the head may cause local compression, flexion, and extension
loading in different motion segments. Figure 5 defines the terminology for global

motions, while illus trates the corresponding local loading modes. Another way of
characterizing injuries is by use of the Abbreviated Injury Scaling (AIS), where AIS 0 is
non-injury and AIS 6 describes a fatal injury. Clinically, spinal trauma is evaluated in
terms of spinal stability. An unstable cervical spine is a threat to the spinal cord and
medical treatment is necessary to reduce the risk of spinal cord injury. A stable spine can
protect the spinal cord under normal physiologic loads and more conservative
treatments can be suitable.
It is important to distinguish between the medical interpretation of spinal stability and
the mechanical meaning of the word stability. There are two major types of spinal
instability, acute and chronic instability.
For injuries with acute instability there are immediate risks of spinal cord injury even
for small spinal movements. An injury with chronic instability is considered stable from
the beginning and develops instability over time, therefore the spinal cord injury may
occur many year s after the original injury occasion.
This chapter gives a brief overview of some of the more common neck injuries and their
injury mechanisms., the injuries are grouped according to their classifications in the
Hospital Discharge Register. This presentati on does not claim to b e complete, since it is
not possible to cover all neck injury research in just one chapter.

Cervical vertebral fractures

Hangman’s fracture
Hangman’s fracture, or traumatic spondylo listhesis of the axis, is a fracture of the
pedicles or between the facet surfaces (pars interarticularis) in the posterior arch of C2

This injury is thought to be the result of either tension or tension -extension loading, such
as blows to the face or, as the name suggests, result of a judicial hanging. It can also be
caused by a flexion -compression loading, for example in diving accidents. Most patients
surviving this injury are successfully treated with external immobilization .

Figure 9: Hangman’s fracture, superior and posterior view of C2 with fractured pedicles.

Burst Fracture
In burst fractures the vertebral body disintegrates into several smaller fragments,
This injury is frequently combined with fractures to the endplates and injury of the
Inter vertebral disk. Burst fractures are often associated with neurological injuries, since
the bony fragments can protrude into the spinal canal .
Critical loading for this fracture is thought to be severe axial compressive forces on the
vertebral body. A numerical study concluded that the fracture would begin in the central
trabecular bone of the vertebral body.
The most common fractures sites are C4 -C5, C5 -C6, and C6 -C7. Burst fractures without
neurologica l deficits can be treated with traction and external fixation, as the halo vest.
For the cases where bone segments have injured the spinal cord surgical treatment, such
as grafting, is necessary to enable recover y of the spinal cord fun ctions .

Teardrop Fr acture
The teardrop fracture is characterized by a triangular shaped bone segment that fractures
from the inferior part of the vertebral body (on the anterior side), Figure 9. The injury is
considered highly unstable in extension because the ALL is rupture d. The injury is
stable in flexion since all the posterior ligaments are intact.
This injury is caused by flexion -compression loading, but can also be the result of local
tensile loading of the ALL due to a global extension.
External fixation is preferable for this inju ry if there are no neurological abnormalities
found in the A B C categories .

Figure 10: Lower vertebral fractures. A) Burst fracture. B) Teardrop fracture. C) Wedge
fracture.

Wedge Fracture
The wedge fracture is a failure of the anterior vertebral body, Figure 9C. This injury is
thought to be the result of a flexion bending moment and a compression forces on the

vertebral motion segment. According to McElhaney and Myers [1993] the most
common site are C4, C5, and C6. conclu ded that slow compressive loading produced
wedge fractures, while fast loading produced burst fractures. This fracture type is
considered stable if the ligaments are intact.

Posterior Element Fracture
Fracture of the posterior elements of the cervical spine occur throughout the upper and
lower cervical spine. This fracture can be isolated, but multiple fractures are frequent
,These fractures include fractures of the laminae, the pedicles, the spinous processes, and
the pars interarticularis. The bony st ructures that protect the spinal cord are injured. If
this injury is associated with vertebral body displacement it is very unstable and requires
internal fixation of several motion segments. The type of appropriate
fixation depends on the fracture site a nd the patient’s spinal cord status.
The posterior element fracture is the result of bony contact between consecutive
posterior elements, caused by extreme local extension. It is important to remember that
local extension may appear in global extension, flexion, or compression of the
neck. A B C D .
A b c d

Figure 1 1: Posterior element fracture. Fracture of spinous process, superior view (A) and
posterior view(B). Fracture of the lamina, superior view (C) and posterior view (D).

Cervical vertebral dislocation :

Facet Dislocation
In facet dislocations the superior vertebra is displaced anteriorly compared to the inferior
vertebra, thus lockin g the facet joints . A dislocation can be either unilateral or bilateral,
that is injury to only one or both of the facet joints. The bilateral facet dislocation causes
a significant reduction of neural canal diameter, and is therefore often associated with
spinal cord injuries. Neurological deficits are less
common for the unilateral dislocations. The initial t reatment is traction to reduce the
dislocation, followed by a surgical treatment to stabilize the spine in axial rotation It is
common that facet dislocations are combined with facet fractures, thus complicating the
injury and its treatment. According to A the loading mode producing this injury is local
tension -flexion, that compression -flexion with tensile strains in the posterior ligaments
is a more frequent failure mode. The same authors believe that unilateral dislocations are
produced under the same lo ading conditions as the bilateral dislocations with the
addition o local lateral bending or rotation.

Figure 1 2: Facet dislocation between two vertebrae in the lower cervical spine.

Occipitoatlantal Dislocation
Dislocation at this level is the result of local tension in combination with other loading
modes.This is a severe ligamentous injury often resulting in instantaneous death The
distraction of the spinal cord during the injury event is often associated with a lethal
rupture of the spinal cord close to the brainstem. An agree that occipitoatlantal
dislocations are rare, but that the true incidence is underestimated since most injuries are
fatal. Those patients surviving usually have significant neurological de ficits, showing
symptoms such as quadriplegia. This injury requires immediate surgical treatment with
internal fixation, to ensure spinal stability and to reduce spinal cord injury.

Atlantoaxial Subluxation
Atlantoaxial subluxation refers to injuries where one or both facet surfaces on C1 are
displaced anterior or posterior to the facet surfaces on C2. Depending on the severity of
displacement the alar, transverse, and capsular ligaments can be ruptured ,
that these injuries should be treated with traction until normal vertebral alignment is
resumed. Then, either external or internal fixation is needed to stabilize the spine, for
most patients. Atlantoaxial .

III .CERVICAL FRACTURE DIAGNOSIS

In diagnosis the Radiological evaluation of the cervical spine is indicated for all patients
who do not meet the criteria for clinical clearance. Imaging studies should be technically
adequate and interpreted by experienced clinicians.
Clinical cervical spine clearance
The clinical decision rules studied by the NEXUS group are highly accurate for the task
for which they were designed: In some patients they can rule out virtually any unstable
CSI. The NEXUS criteria for clinical exclusion of CSI are the following: no evidenc e of
intoxication, no posterior midline neck tenderness, no painful distracting injuries,
normal level of alertness, and no focal neurologic deficit. Patients who meet all five
criteria have a low risk for CSI (99.8% negative predictive value). The sensiti vity of the
decision rule is high (99.0%), but due to its low specificity (12.9%), its positive
predictive value is low (2.7%). Use of the NEXUS criteria could, in theory, reduce the
number of radiographic examinations of the cervical spine by approximatel y 20%

Radiography
The standard 3 view plain film series is the lateral, antero -posterior and open -mouth
view. The lateral cervical spine film must include the base of the occiput and the top of
the first thoracic vertebra. The lateral view alone is inadequate and will miss up to 15%
of cervical spine injuries. The lower cervical spine may be difficult to examine and
caudal traction on the arms should be used to improve visualizati on. Repeated attempts
at plain radiography are usually unsuccessful and waste time. If the lower cervical spine
is not visualized a CT scan of the region is indicated.

The antero -posterior view must include the spinous processes of all the cervical
vertebr ae from C2 to T1.The open -mouth view should visualise the lateral masses of C1
and the entire odontoid peg. Bite blocks may improve the open -mouth view. In the
unconscious, intubated patient the open mouth view is inadequate and should be
replaced by a CT scan from the occiput to C2.
The addition of two oblique views to the standard 3 -view series does not increase the
sensitivity of plain film evaluation. Some centres use two supine or trauma -oblique
views to replace the antero -posterior view. These views can provide excellent
visualisation of the posterior elements of the cervical spine and provide significantly
more information than the antero -posterior view.

X-ray imaging
The normal cross -table lateral cervical spine X -ray must visualise the entire cervical
spine, from the skull base to the cervico -thoracic junction. A film that does not show the
upper border of T1 is inadequate and should be repeated or supplem ented with a
swimmer's view (flying angel). Caudad traction on the arms will improve the view
obtained – someone else should stabilise the patient's head and pelvis during the X -Ray.

figure 13 : x -ray of the cervical vertebrae

Next, examine the alignment of the columns of the cervical spine. The anterior vertebral
line, posterior vertebral line and spinolaminar line should have a smooth curve with no
steps or discontinuities. Note tha t malalignment of the posterior vertebral bodies is more
significant than that anteriorly, which may be due to rotation. A translation of > 3.5mm
is significant anywhere. Spinal canal diameter (between posterior cortex of vertebral
bodies and spinolaminar line) should be 18mm or greater. Narowing of the canal is
definitely present if this is reduced to 14mm or less .

Figure 14 : x -ray shows the lines of middle ,anterior and posterior line of vertebra
Anterior subluxation of one vertebra on another indicates facet dislocation. Less than
50% of the width of a vertebral body and this is a unifacet dislocation. More than 50% is
a bilateral facet dislocation. This is usually accompanied by widening of the interspinous
and inte rlaminar spaces.

Figure 15 : x -ray show the dislocation of cervical vertebra

Examination of the vertebral bodies and the intervertebral disc space will reveal
compression and burst type injuries. Bodies should be regular cuboids similar in size and
shape to the vertebrae immediately above and below (not C1/C2). Compression fractures
may present as anterior wedging of the vertebral body or teardrop fractures of the
antero -inferior portion of the body (compression in flexion).
The presence of a compression type injury as shown, with malalignment of the anterior
or posterior cortices or anterior compression of greater than 40% of normal body height
indicates a burst fracture, with retropulsion of fragments of the vertebral body into the
spinal canal.
Loss of height of an intervertebral disc space, when compared to adjacent spaces may
indicate disc herniation – usually posteriorly into the cana l. Analysis of the prevertebral
soft tissues may allow the diagnosis of cervical injuries from very subtle changes on the
lateral film. The soft tissue shadow is created by the pharyngeal and prevertebral tissues,
with the posterior larynx and oesophagus t hickening the shadow below C4. Above C4
the width of the shadow should be less than 50% of the width of a vertebral body, while
below C4 the limit is one full vertebral body width.

CT Scanning
Thin -cut (2mm) axial CT scanning on specific bone windows, with sagittal and coronal
reconstruction should be used to evaluate abnormal, suspicious or poorly visualized
areas on plain radiology. With technically adequate studies and experienced
interpretat ion, the combination of plain radiology and directed CT scanning provides a
false negative rate of less than 0.1%. The scan should include the entire vertebral body

above and below the region of interest, as these must be undamaged for subsequent
internal fixation
Despite advances in computed tomography (CT) plain that concentrate on the
radiography is still the fundamental primary imaging method for CSI. In plain
radiographic clearance of the cervical spine, three views including lateral,
anteroposterior, and open -mouth odontoid are the minimum requirements
Utilization of supine oblique views in addition to these three views does not
significantly improve detection of CSI however, improve diagnostic confidence and
more specifically the confidence of exclu ding fractures The use of five views may be
cost-efficient by reducing the need for CT after non -visualization of the cervicothoracic
junction Supplementary CT is cost -effective in radiographic nonvisualization of the
cervicothoracic junction While radiogr aphy is only 83 to 93% sensitive in detecting
cervical spine fractures it is 92 to 96% sensitive and 85 to 98% specific in detection of
clinically relevant fractures Interestingly, in the study radiography missed only 0.4% of
clinically relevant CSI .
which may be a result of verification bias. The use of supplementary flexionextension
lateral view radiographs is controversial .

Figure 16 : CT o f the cervical verteb rae .

MRI
Magnetic resonance imaging now has an established role in the assessment of spinal
injuries, because there is often associated spinal cord and nerve root compromise and a
relatively common association of unsuspected disc herniation with vertebral fractures .
The craniocervical junction is seen well on MRI. The anterior aspect of the foramen
magnum is delineated, but the posterior margin is less constant in appearance.
Compression and distortion of the medulla and upper cervical cord by bony and
extramedullar y lesions are seen easily. Vertebral artery injury associated with
craniocervical junction trauma can be detected by MR angiography.
Unstable ligamentous injury has traditionally been evaluated by flexion -extension views.
MR is less dangerous and more sensitive for soft tissue injury than conventional
radiography. MRI is useful in differentiating between pathologic vertebral fractures
related to metastatic malignancy and benign osteopenic insufficiency fractures.
Vaccaro et al determined that MRI is neither useful nor cost -effective in patients
presenting with a fracture of the upper cervical spine without neurologic deficit. They
conducted a prospective an alysis of patients admitted with isolated upper cervical spine
fractures who had MRI performed within 48 hours after the traumatic event. In patients
with an identified neurologic deficit, MR findings changed the treatment of 25% of the
patients, whereas M R findings did not change the treatment of patients without a
neurologic deficit.
MRI is particularly useful in the following situations:
 Trauma at the craniocervical junction
 Evaluation of spinal cord injuries associated with cervical spine fractures
 Follow-up of SCIWORA
 Neurologic deficit with negative radiography

 When neurologic deficit does not correlate with the level of trauma
 Prior to surgical decompression or stabilization
 Evaluation of patients with persistent pain and negative radiographs
 Imaging long-term sequelae of spinal trauma, particularly when new deficit develops in
patients with past history of trauma
MRI scanning is being increasingly used as an adjunct to plain films, but the lack of
wide availability and the relatively prolonged scannin g time required limits its
usefulness in the acute setting. Another major drawback is limitation regarding the
resuscitation equipment and stabilizing devices that can be used near MRI scanners.
MRI is considerably weaker than plain films or CT for posteri or element fractures, but
some fractures are better detected with MRI, such as intramedullary fractures and
fractures in the axial plane (eg, Chance fracture).
Another disadvantage with MRI for acute trauma is motion artifact, because MRI is
particularly s ensitive to patient motion. However, this may not be such an issue with
modern scanners.

Figure 17 : MRI shows cervical fracture and spinal cord compression .

IV. Treatment cervical fracture

Complete immobilization of the head and neck should be done as early as possible and
before moving the patient. Immobilization should remain in place until movement of the
head and neck is proven safe. In the presence of severe head trauma, cervical fracture
must be presumed until ruled out. Immobilization is impe rative to minimize or prevent
further spinal cord injury. The only exceptions are when there is imminent danger from
an external cause, such as becoming trapped in a burning building.
Non-steroidal anti -inflammatory medications ( NSAIDs ), such as aspirin or ibuprofen ,
are useful in decreasing swelling and pain.
In the long term, physical therapy will be given to build strength in the muscles of the
neck to increase stability and better protect the cervical spine.
Collars, traction and surgery can be used to immobilize and stabilize the neck after a
cervical fracture.

Cervical collar
Minor fractures can be immobilized with a cervical collar without need for traction or
surgery. A soft collar is fairly flexible and is the least limiting but can carry a high risk
of further neck damage in patients with osteoporosis. It ca n be used for minor injuries or
after healing has allowed the neck to become more stable.
A range of manufactured rigid collars are also used, usually comprising a firm plastic bi –
valved shell secured with Velcro straps and removable padded liners. The most
frequently prescribed are the Aspen, Malibu, Miami J, and Philadelphia collars. All
these can b e used with additional chest a head extension pieces to increase stability .

Rigid braces
Rigid braces that support the head and chest are also prescribed.[3] Examples include
the Sterno -Occipital Mandibular Immobilization Device (SOMI) , Lerman Minerva and
Yale types. Special patients, such as very young children or non -cooperative a dults, are
sometimes still immobilized in medical plaster of paris casts, such as the Minerva cast.

Soft cervical collar
There are two types of neck braces: soft and rigid. A soft cervical collar is made from
thick foam rubber covered in cotton. It is used to support your neck and control pain
after an injury (e.g., whiplash). Rigid braces are made from molded plastic with a
removable padded liner in two pieces —a front and back piece —fastened with Velcro.
This brace is used to restrict neck movement dur ing recovery from a fracture or surgery
(e.g., fusion). Common rigid braces are the Philadelphia collar and the Miami J collar.

Miamijcollar
Know how to apply your brace before leaving the hospital. Wear your brace all the
time—even during sleep —unless otherwise instructed by the surgeon. You will wear the
brace until your spine has healed or fused, which may be as short as 4 weeks or as long
as 4 to 6 months.

Cervical -thoracic braces
Neck (cervical) and upper back (thoracic) injuries require a special cervical -thoracic
brace to restrict neck and upper back movement after an injury or neck fusion surgery.
This rigid brace has a plastic padded chest jacket in two pieces —a front and back
piece —fastened with Velcro straps. Supports for the chin and back of the head arise
from the chest jacket .

Figure : Minerva brac e Figure : halo brace

Traction
Traction can be applied by free weights on a pulley or a Halo type brace. The Halo
brace is the most rigid cervical brace, used when limiting motion to the minimum that is
essential, especially with unstable cervical fractures. It can provide stability and support
during the time (typically 8 –12 weeks) needed for the cerv ical bones to heal.

Surgery
Surgery may be needed to stabilize the neck and relieve pressure on the spinal cord. A
variety of surgeries are available depending on the injury. Surgery to remove a damage
of vertebral disc may be done to relieve pressure on the spinal cord. The discs are
cushions between the vertebrae. After the disc is removed, the vertebrae may be fused
together to provide stability. Metal plates, screws, or wires may be needed to hold
vertebrae or pieces in place.

Stabilization operation

Posterior stabilization of cervical spine fractures and subluxations with metal plates and
screws is commonly used in Europe, but has rarely been employed by neurosurgeons in
North America, where stabilization has usually been achieved with wires supplemented
by bone grafts or acrylic. The limitations of the more commonly used stabilization
techniques include the failure to achieve rotational stability, the necessity for intact
laminae, and the requirement for bone grafting. We therefore examined the efficacy of
posterior cervical plating in 19 patients who had posttraumati c instability of the cervical
spine between C3 and C7 without residual spinal cord compression and 1 patient who
had a subluxation as a result of osteomyelitis. Two patients had no neurological deficit,
4 had partial deficits, and 14 had no neurological fu nction below the level of injury.
Operation was performed after patients were medically stable and maximal reduction of
fractures was achieved (usually within 48 hours). The plates are made of vitallium and
contain two or three holes 13 mm apart through wh ich 16 -mm screws are placed
bilaterally into the center of the articular masses of two or three adjacent vertebrae to
stabilize one or two motion segments. Bone grafting is not performed. Patients are
mobilized on the day after operation in a Philadelphia collar, which is worn for 3

months. Fourteen patients had stabilization of one motion segment and 6 had
stabilization over two motion segments. The mean follow -up is 9.2 months. In a single
patient with ankylosing spondylitis, plate fixation failed when sc rews pulled out. No
patient experienced neurological deterioration as a result of the operative procedure.

Figure 18 : Stabilization posterior view of plate .

Lower cervical spine
A relatively safe and efficient way of reducing cervical spine displacements in awake
patients is skull traction with progressively increasing weights —without general
anesthesia. The repositioning of fractures and dislocations by skull traction relies on the
tensile force applied to PLL to re -align the posterior verte bral body margins HTV has
been successfully used, in addition to unstable upper cervical spine injuries, in both
compressive flexion and distractive flexion injuries of the lower cervical spine Late
symptoms, however, such as mild or moderate neck discomfo rt and reduced ROM may
persist for years after such a treatment .
Concluded that patients with unilateral facet dislocations should be initially treated with
initial halo traction in an attempt to obtain ,They also recommended HTV in
neurologically intact patients in whom closed reduction was successful. In contrast,

concluded that facet dislocations without apparent fracture do not respond well to
conservative treatment. Surgical treatment of cervical spine dislocations allows earlier
mobilization of the patient and shortens the primary hospital stay .

Posterior internal stabilization
In posterior internal stabilization numerous fixation methods have been used
successfully: interspinous or interlaminar fixation such as Rogers interspinous wiring
Bohlmann’s modification of the Rogers wiring with addition of bone
grafting and triple -wires , the interspinous Daab plate and interspinous or sublaminar
wiring with multistrand cables , Other methods are direct fixation of lateral masses with
plates and s crews and various instrumentation utilizing rods and screws .
Triple -wire fixation and direct fixation of lateral masses with plates are biomechanically
equally stable but lateral mass fixation with screws and rods may be even more efficient
in preventing P osterior fixation can stabilize one – and two -column posterior injuries, but
without additional anterior stabilization these are insufficient for three -column injuries
.The area of anterior instrumentation began when Bohler reported the use of anterior
plate fixation in cervical spine fractures. Further evolution of anterior instrumentation
includ ed the AO cloverleaf or H -plate and the Caspar plate requiring bicortical screw
positioning .As use of hollow screws locking to the anterior plate eliminates the
requirement for posterior cortex purchase a variety of anterior instrumentation sets
followed Screw loosening in such instrumentation occurs in approximately 5% of cases.
Anterior plates can stabilize not only compressive flexion and extension injuries, but
also distractive flexion injuries (dislocations and fracture dislo cations), by either non –
locking or locking cervical spine plates Although stabilization of distractive flexion
injuries by anterior non -locking plates does not biomechanically provide a comp letely
rigid construct , in vivo they have been successful .

Figure 19 : Anterior decompression and stabilization with a locking plate.

As complete removal of mechanical axial loading from the healing bone results in
negative bone remodeling and net bon loss . concerns have arisen about locking plates
being too rigid. Dynamic plates, allowing minimal axial load to the anterior bone graft,
are under experimental and clinical evaluation , yet biomechanical testing has revealed
only minor differences bet ween axial loading capabilities of locking and dynamic plates
. After anterior inter body fusion, 92% of cases develop degeneration of adjacent
interspaces, due to altered biomechanics or natural progression of pre -existing
degenerative disk disease. The Anterior, posterior, or a combination of both anterior and
Posterior internal stabilization methods has been successful. Both conservative and
surgical treatments are associated with low complication rates.

Types of Cervical Spine Surgery

Neck injuries can cause damage to the part of the spine that runs through the neck —the
cervical spine —by pushing spinal discs out of place. If the discs bulge out far enough to
touch the nearby nerve roots, patients can experience pain and numbness in the parts of
the b ody connected to those nerves, such as the arms and shoulders. While physical
therapy and medications can sometimes be enough to treat mild cervical spine injuries,
explains the American Academy of Orthopaedic Surgeons, in more severe cases, surgery
is nec essary to relieve pressure and get the spinal cord back in proper alignment.

Anterior Cervical Diskectomy and Fusion
Surgeons often operate through the front (anterior) of patients’ necks to remove the
bulging spinal discs, according to the American Academy of Orthopaedic Surgeons,
because such an approach allows them to directly remove all the damaged discs while
also f using two or more vertebrae together with a bone graft to fill the space the discs
had previously filled, and to stabilize the spine. The anterior approach also usually
relieves neck pain more than the posterior approach does.

Anterior Cervical Corpectomy and Fusion
Doctors remove damaged discs during this type of surgery, as well, but rather than
fusing vertebrae together, they remove vertebrae from the injured area and replace it
with bone graft material that fuses to the spine, explains the American Aca demy of
Orthopaedic Surgeons. Patients can choose between three different types of bone graft
material for either a diskectomy or a corpectomy: autograft material (their own bone,
taken from their hips), allograft material (cadaver bone from a bone bank) o r artificial

bone material. According to the American Academy of Orthopaedic Surgeons, the best
choice is to use a patient's own bone, since it is most likely to lead to a successful fusion
after the surgery.
Posterior Cervical Laminoforaminotomy
Operating on the injured area from the back of the neck (a posterior approach) often
reduces the amount of spinal motion that patients lose from the surgery, states the
American Academy of Orthopaedic Surgeons, but it also frequently results in less pain
relief tha n the anterior approach does. When surgeons perform a posterior cervical
laminoforaminotomy, they can remove discs without fusing vertebrae together, which
can help patients recover more quickly than if they’d had spinal fusion.
Posterior Cervical Laminectomy
In a posterior cervical laminectomy, doctors remove the bony arch (lamina) and any
bone spurs and ligaments that are pressing on the spinal cord. Surgeons often also
perform spinal fusion with this surgery, according to the American Academy of
Orthopaedic Surgeons.
Posterior Cervical Laminoplasty
This type of surgery is an alternative to posterior cervical laminectomy, because it
involves hinging the lamina open without completely removing it, according to the
American Academy of Orthopaedic Sur geons. Spinal fusion often accompanies this
surgery.

Surgical technique

There are five steps to the procedure, which generally takes 1 hour for each vertebra
treated:
Step 1: prepare the patient
You will lie on the operative table and be given conscious sedation. Once sedated, you
will be positioned on your stomach with your chest and sides supported by pillows.
Depending on the section of the spine (cervical, thoracic, or lumbar) where the
compresse d vertebra is located, your back or neck will be cleansed and prepped.

Step 2: insert the needle
A local anesthetic is injected in the area where a small, half -inch skin incision will be
made over the fractured bone. With the aid of a fluoroscope (a special X -ray machine),
two large diameter needles are inserted into the vertebral body through the pedi cles (Fig
2). The fluoroscopy monitor allows the surgeon to see exactly where the needles are
positioned and how far they are inserted. The needles are advanced through the bone
using either a twisting motion or a tapping mallet. The needles are angled to avoid the
spinal cord. Depending on the vertebral level, a single needle may be used. As shown in
the figure 20 -21.
Step 3: restore vertebra height (kyphoplasty only)
If the vertebra is significantly wedge -shaped, the surgeon will insert inflatable ballo ons
through the needles into the vertebra. To insert the balloon tamps, the surgeon first uses
a drill to create a working channel. The surgeon carefully inflates the balloons, raising

the vertebra back to its normal height (Fig. 3). The amount of height r estored depends on
the age of the fracture. The balloons are deflated and withdrawn, leaving a space in the
middle of the vertebra. This procedure is called kyphoplasty because it reduces
unwanted kyphosis, or forward curvature, before the bone is stabiliz ed.

Figure 21: The balloon is inserted into the working channel inside the vertebra, then inflated to
raise the vertebra to the appropriate height.
Step 4: inject bone cement
Bone cement is slowly injected under pressure, filling the deepest area first, th en with
drawing the needle slightly to fill top areas (Fig 4). The pressure and amount of cement
injected are closely monitored to avoid leakage into unwanted areas. While complete
filling of the vertebral body is ideal, it is not always possible or necessary for pain relief.

Figure 22 : The balloon is removed and bone cement is injected into the cavity. Fluoroscopic x –
ray shows cement in upper vertebra (red arrow) and needle inserted in lower vertebra.

Step 5: closure
The needles are withdrawn promptly before the cement hardens. The small skin incision
is closed with steri -strips. You will not be moved from the operating table until the
remaining cement in the mixing bowl hardens.
Spinal fusion
is a surgical procedure in which one or more of the bony vertebrae of the spine are
permanently joined together to provide stability to the spine. Spinal fusion can be
performed at any level of the spine but is most common in the lumbar and cervical
regions where it is most moveable. At each level of the spine, there is a disc space in the
front and paired facet joints in the back. Working together, these structures define a
motion segment and permit range of motion. Two vertebral segments need to be fused to
stop the motion at one segment .

Figure 23: Spinal fusion restores the normal height of the disc space and prevents abnormal
movement.

Cervical fusion complication

The cervical spine is composed of seven small bones, called vertebra, which stack atop
one another along the neck. Patients who develop persistent neck pain may experience
symptom relief after undergoing cervical spinal cord fusion. During this surgical
procedure, a surgeon attaches, or fuses, t wo or more vertebra within the neck using a
bone graft, which helps alleviate pressure on the nerves that run along the spinal column.
Before choosing this form of treatment, patients should talk with their doctors about
potential cervical spinal cord fusi on complications.
All surgeries and procedures are associated with complications. Complications can
include bleeding, infection, blood clots, and nerve damage according to the AAOS
Comprehensive Orthopedic Review. Some patients develop pain at the site wh ere the
bone graft is harvested . The surgery has varying levels of success in regards to
preventing recurrence of symptoms. Some patients have complete resolution of
symptoms, while others have recurrence of symptoms. If the spine does not fuse
correctly, there can be a condition that occurs known as a pseudoarthrosis. A
pseudoarthrosis is a "false joint" where there is movement of bones.
cervical spine fractures are fairly common and, together with cervical spine dislocations,
account for around half of a ll spinal injuries. Cervical spine fracture complications vary,
depending on the degree of damage. They can cause symptoms ranging from minor
discomfort to life -threatening complications.
Nerve Damage
A surgeon can inadvertently damage the nerves within the cervical spine during this
procedure, eSpine reports. If this occurs, patients can experience complications of

numbness, tingling or paralysis that localize to regions of the body beneath the site of
nerve injury. Paralysis occurs when a patient is unable to voluntarily move certain
regions of the body such as the legs or arms. Mild nerve damage or inflammation
typically resolves as the nerves heal after surgery. More extensive nerve damage, such
as severing a cervical spine nerve, can result in permanent paralysis complications in
affected patients.
Difficulty Swallowing or Hoarseness
Injury to the recurrent laryngeal nerve, which connects with the vocal cords in the throat,
can cause vocal hoarseness or difficulty swallowing in certain patients. Though this
complication is typically temporary, it can take several months for side effects to resolve
after surgery. Persistent vocal hoarseness or d ifficulty swallowing is rare . Swallowing
or vocal complic ations that do not resolve may require patients to undergo additional
medical evaluation or treatment.
Movement of the Bone Graft
In approximately 1 to 2 percent of patients, the implanted bone graft moves or migrates
out of its proper position between the fused cervical vertebrae, the Mayfield Clinic
reports. This complication of cervical spinal cord fusion typically requires patients to
undergo additional surgery to replace the bone graft.
Chronic Pain
Cervical spinal cord fusion does not guarantee that p atients will experience relief of
painful neck symptoms. Chronic pain complications following cervical spinal cord
fusion surgery may even be more severe than symptoms experienced prior to surgery,
the University of Maryland Medical Center warns.

Hardware or Fusion Problems
Typically, metal plates or screws, called hardware, are attached to the cervical vertebrae
to help stabilize the fused spinal bones. In certain cases, these pieces of hardware can
become damaged or may crack or break before the attached cervical vertebrae fully fuse,
the Mayfield Clinic explains. Hardware complications following cervical spinal cord
fusion typically necessitate additional surgery to repair or replace the damaged
hardware. Additionally, the connected cervical vertebrae may fail to fuse together,
which can contribute to chronic neck pain symptoms. Fusion complications after surgery
occur more commonly among patients who are obese, smoke cigarettes or have
osteoporosis, a degenerative bone disease.
Muscle Weakness
A severe ce rvical spine fracture can cause nerve irritation or damage. If the nerves that
control the muscles are disrupted in any way, muscles may feel weaker. In some cases,
they may even become partially or completely paralyzed. If the cervical spine fracture
affects the nerves leaving the spinal cord, the arms or hands may feel weaker. However,
if the fracture affects the nerves in the spinal cord itself, weakness or paralysis may be
present anywhere below the level of injury.
Recovery

Rehabilitation and recovery from spinal fusion can take months for the bones to heal
appropriately. Usually during the early recovery period, patients begin to have an
improvement in symptoms. Patients usually do physical therapy to help improve posture
and keep the fused bones in p roper alignment to augment healing. Patients usually have
multiple follow -up appointments with a surgeon to monitor the healing process and
assess for any complications.

AIMS OF THE STUDY

The aims of the study classified to several categories :

1. To analysis results from different methods of surgery that will help to
compares between the patients and the severity of the health situation that
they get after the cervical trauma .

2. To focus on the diagnosis method that used in the fracture and dislocation of
the cervical vertebrae .

3. To collect all the data of 33 patient that have been in the hospital for cervical
trauma and to compare with each other for the perfect results .

4. Follow up the patients before the operation and save the data , CT , x-ray
and other examination to compare after the final result of the surgery , also
the x -ray is taking during the surgery for the dimensions of the vertebral size
and location before app lying the plate or screw to make sure that we get the
best postoperation results .

5. To explain the postoperation status of patients for any complication after
surgery .

6. The most efficiency techniques that use to perform such an operation that is
very sensitive and complicated .

MATERIALS AND METHODS

This chapter of the thesis will reflect the materials and methods that been use in my
study of the orthopedic and traumatology department in the USMF .
The different types of surgery than been done to a lot of patients that came to the
hospital with severe or medium cases of the cervical trauma “ fractures and dislocation “
of the cervical vertebrae .

From the previous year was performed a lot of operation for patient that was suffering
from cervical trauma ether it was dislocation or fracture die to car accident or other type
of trauma that end with cervical trauma .
Traumatology and orthopedic department in Chisinau was successfully able to accep t
and perform operation for those patient that were need to surgical intervention and was
done with almost no complication .

In this chapter I will explain and introduce all this patients that done an operation of the
cervical trauma in the hospital and r eview the statistical analyses of them .
A several method was made form each kind of surgery to end with best result the doctor
can get and minimum risk damage of the spinal cord and best mobility can we get , in
different types of surgery were done a use ful and international techniques of the cervical
fracture and dislocation is the , the plate is specific piece of metal or titanium that design
for connect and hold the vertebral in same position than was

before the surgery it replace the longitudinal l igament that hold and covered the
vertebral surface .

The plate is very usefully in this kind of operation because it can hold the vertebral in
position and prevent and damage of the disc that cause from the pressure of the
dislocation or fracture ver tebra .

It also used a wire to hold the posterior spine of the vertebral to minimized the mobility
of the vertebral to end with good specific diminution that the operation requires .

Statistical analysis

patients

The collection data was from the 1991 tell the end of 2013 for patients that have done
the operation in traumatology and orthopedic department in chisnau .

33 patient was applied to the hospital due to cervical trauma ether it was a result of
accident or o ther types of trauma , in the hospital was done all the necessary medical
diagnosis and examination to put a patient in the best category .
The ages of the patients was from 15 years old up to 64 years old , all of the patients has
surgical intervention to improve and requires their life quality specially after getting
trauma in sensitive location .

The patient where ether rural or urban that came to the hospital to get this type of
surgery . and improve their quality of life . in my statistical analysis I will show all al the
information of the patients , types of surgery ether it as with plate or without plate .

Statistical analysis of patients

1. Number of patient s admitted to the hospital for cervical surgery : 33 patient
.

2. Ages of patients : 15 years old – 64 years old .

3. Sex of patient with cervical trauma : 26 male / 7 female .

4. Type of surgery monosegmet or polisegment : 26 monosegment and 7
polisegmets .

5. Techniques of the operation : 25 with plate / 8 without plate .

6. Years of hospitalization : from 1991 – 2013 .

7. Types of cervical trauma : Dislocation 14 / Fracture 6 / F-D 13 .

8. The community of the patients : URBAN 7 / RURAL 26 .

9. The level of the cervical fracture or dislocation.

Figure 1 : SEX of cervical trauma patients .

Figure 3 : Number of patients with cervical fusion .
79 % 21 % SEX
MALE
FEMALE
0 5 10 15 20 25
monosegmental fusion polisegmental fusion 24
9 Cervical fusion
monosegmental fusion
polisegmental fusion

Figure 4 : cervical fusion patient’s Age .

Figure 5 : Cervical plate implant .

0 2 4 6 8 10 12
<20 years 20-30 years 30-40 years >40 years 5 12
5 11 Patient's Age
<20 years
20-30 years
30-40 years
>40 years
0 5 10 15 20 25
with plate without plate 25
8 Plate Implant
with plate
without plate

Figure 6 : T ypes of cervical trauma .

Figure 7 : Dem ographic patient that have done cervical operation .
43%
18% 39% Type of Trauma
Dislocation
Fracture
dislocation / Fracture
79% 21% Dem ographic
Rural
Urban

Figure 7 : Duration of the cervical fracture/dislocation operation .

Figure 8 : Blood loss during operation of the cervical trauma .

0 50 100 150 200 250 300 350 400
0 1 2 3 4 5 6 7 8 OPERATION TIME ( MIN )
NUMBER OF PATIENTS PATIENTS
31%
27% 18% 6% 3% 12% 3% Blood Loss
300 ml
200 ml
100 ml
150 ml
250 ml
400 ml
800 ml

Figure 9 : Level of cervical fracture or dislocation .

0 2 4 6 8 10 12 14 16
C2 C3 C4 C5 C6 C7 1 8
7
1 15
1 Level of cervical trauma

DISCUSSION

In CSI of the lower cervical spine, both anterior and posterior surgical stabilization have
certain benefits. An anterior approach allows removal of bone and disk material from the
spinal canal and a rigid stabilization targeted to the anterior column, while spinal cord
injury, or iatrogenic anterior SEH are potential, but rare complications.
Reduction of facet joints can be difficult or impossible from this approach and anterior
plating is insufficient in the most severe distractive flexion injuries .

In contrast, posterior approaches allow relatively safe open reduction of facet joints and
reconstruction of posterior column stability, but also require reasonably intact posterior
bony structures for fixation. Removal of herniated disk material, which may have
herniated into the spinal canal during the open reduction, is impossible from a poster ior
approach, and spinal canal decompression by laminectomy would increase undesirable
instability.

Whether anterior or posterior stabilization should be favored in cases without herniated
disk material necessitating anterior surgery is controversial.
Timing of cervical spine surgery may play a critical role in treatment of SCI patients.
While the safety of surgery within the first days after trauma has been questioned, an
increasing amount of evidence supports the safety of early surgery and —most
importa ntly—supports the hypothesis of early surgical decompression and stabilization
as aiding recovery from SCI .

Fracture dislocations is a heterogeneous group of flexion, flexion -distraction, and
flexionrotation injuries causing both ligamentous and osseous injury are often
complicated by spinal cord and root injuries. Fracture dislocations have been
treated successfully by a number of methods. As the biomechanical instability in these
injuries is mainly caused by disruption of posterior column structures, t he most
logical therapeutic intervention is restoration of posterior column integrity. However,
compared to many of the newer stabilization methods, the interspinous wiring carries
definite disadvantages: It is ineffective in injuries with multiple, conti guous spinous
process or laminar fractures. Similarly, the tendency of wires to cut through the spinous
processes imposes requirements on bone quality which may be less of a problem in the
Bohlman triple -wire modification of the technique, with bone grafts and a tension band
construct. Biomechanically, the stability of posterior triple -wire fixation is comparable
with that of lateral mass plating .
Interspinous cervical fusion is generally safer than posterior sublaminar techniques and
is technically less d emanding than anterior approaches or posterior lateral mass plating;
the posterior approach allows, when necessary, a relatively safe open reduction of facet
joints.
In addition to biomechanical considerations, the choice of either anterior or posterior
surgery is also influenced by spinal canal compromise with bone fragments, epidural
hematoma, or herniated disk material. Traumatic disk herniation and hematoma
is relatively common in these injuries and is a probable confounding factor in a
retrospective st udy setting of this kind, since most of the cases were treated before the
MRI. Medullary impingement by herniated disk material manifesting at the moment of
vertebral reduction is a rare but much feared complication. MRI can identify herniated
disk materi al, and this complication can, to at least to some extent, be avoided by the
choice of anterior surgery. However, imaging takes time and, especially in cord
compression, time can be a critical factor .

Whether MRI is necessary before repositioning or whet her immediate repositioning is
safest is controversial . MRI either prior to or after repositioning can disclose not only
complicating herniated disk material and hematoma , but can also provide fundamental
information as to SCI severity , vital forchoice of treatment.

Results of Study show correlation between the degree of reduction of displacements
and neurological recovery. Anatomical results after surgery were better than those after
conservative treatment, but were inconsistent in that surgery did no t per se guarantee
neurological recovery; neurological recovery occurred also in a number of
conservatively treated patients with less than perfect anatomical results. Conversely,
some patients, despite perfect surgical restoration of the spinal canal dime nsions, failed
to improve.
Theoretically, the force of the initial impact may be the main determinant of the
outcome in fracture dislocation. Here, however, the association between initial
displacement, i.e., the displacement seen on arrival, and neurological outcome was
weak. Correlation of post -injury radiological deformity in cervical spine fracture
dislocations with occlusion of the spinal canal during impact has not been established.

The number and profile of complications were similar in bot h treatment methods
studied, although c onservatively treated patients had a longer average stay in hospital.
They also suffered more often from late deformities, instability, and chronic neck pain.
Finally, almost a third of the conservatively treated inju ries required late surgery
because of an unacceptable anatomical result with residual instability or progression of
neurological symptoms. That deep venous thrombosis was uncommon in surgically
treated patients, could be related either to the shorter immob ilization required after
surgical treatment or to improved antithrombotic prophylaxis.

In the figures will show the different and comparison between the pre and post operation
of the patients with cervical dislocation / fractures , in the height , horizont al of the
fusion block and the NDI score that shows the results after the surgery in improving the
quality life of the patients , also the angulations by COBB . all of this result will and
measurement reflex the best surgical result that the surgeon can g et after the surgery .

0 10 20 30 40 50 60 70 80 90 100
Monosegmet
of fusion with
plate Monosegmet
of fusion
without plate Polisegment
of fusion with
plate polisegment
of fusion
without plate
preoperation 93.38 82.07 87.3 89.3
operation 100 100 100 100
postoperation 96.8 91.8 92.2 92.3 93.38
82.07 87.3 89.3 100 100 100 100 96.8 91.8 92.2 92.3 Percent % 2. Evolution (in Percent %) of height in fusioned block

0 20 40 60 80 76.43 68.5 74.6 59.4
40.14 43.07 75 34.7
52.88 45.5 58 50
Percent % postoperation 52.88 45.5 58 50
operation 40.14 43.07 75 34.7
preoperation 76.43 68.5 74.6 59.4 1. Evolution (in Percent %) of horizontal displacment of
vertebral after ACIF

0 2 4 6 8 10 12 14 16 18 20
Monosegmet
al fusion
without plate Monosegmet
al fusion with
plate polisegmental
fusion
without plate Polisegmental
fusion with
plate
operationn 19.4 18.1 13.3 19.5
posoperation 6.2 7.6 9 9.2 19.4
18.1
13.3 19.5
6.2 7.6 9 9.2 POINTS 4. NDI (Neck disability index) Score

-30 -25 -20 -15 -10 -5 0 5
Monosegmet of
fusion without
plate Monosegmet of
fusion with
plate polisegment of
fusion without
plate Polisegment of
fusion with
plate
preoperation -25.57 -15 -25 -17.7
operation -7.86 2.2 -11 -0.7
postoperation -11.86 -0.5 -19.3 -7.4 -25.57 -15
-25 -17.7 -7.86 2.2
-11 -0.7
-11.86 -0.5
-19.3 -7.4 Degree ° 3. Evolution of Angulation (in degree °) by COBB in fusional
block

Cervical fusion post -operation Recommendation

Your cervical spine includes the seven vertebrae that connect your head to your spine
and extend down to your shoulders. Cervi cal spine fusion surgery may be recommended
when the disc material begins to seep out of your cervical vertebrae and place pressure
on your spinal nerves. This causes pain in your neck, along with tingling and pressure in
your neck and arms. Rehabilitation will improve your daily function after this surgery.
Follow the specific instructions given to you by your doctor or physical therapist to
ensure proper recovery.

Post-Surgery
Immediately following surgery, your physician will likely encourage you to move and
position yourself as comfortably as possible. Your rehabilitation may begin with
walking, which typically takes place several hours after surgery. Walking and moving
around can help you feel better and helps you recover from the anesthesia used during
surgery. With each successive day following surgery, you may walk a little more to
increase your overall movement. Discuss initial limitations with your physician as far as
movement immediately following surgery.

Up to Two Months Following Surgery
Your physician may ask that you refrain from vigorously bending and twisting your
neck up to several months following surgery. This is to allow for sufficient time for your
vertebrae to heal and fuse together without pressure. The process typically takes at least
six weeks. This does not mean that you will refrain from movement entirely. Your

physical therapist may recommend gentle stretching exercises, such as moving slightly
to the l eft and right and tucking your chin in toward your neck to stretch the back of
your neck. Deep breathing exercises may also help to relax your neck muscles. You may
need to wear a special neck brace during this time to immobilize your neck.

Three to Six Months Following Surgery
When your physician has determined the bones of your cervical fusion have sufficiently
healed, you may begin more extensive physical therapy exercises. Your physician will
likely recommend stabilization exercises to strengthen the n eck muscles. These may
include the chin tuck, shoulder shrugs or shoulder rolls. Another exercise that may be
included is scapular retraction, in which you hold your elbows in toward your body and
bring your shoulder blades together.

Cardiovascular Fitnes s
In addition to specific exercises to stretch the neck and spine, cardiovascular
conditioning is important. Exercise strengthens your muscles and improves oxygen flow
to your muscles. Better oxygen flow means more nutrients are delivered to your muscles
and blood vessels. While vigorous exercise, such as sprinting or playing football, soccer
or basketball, may be too much for your spine, low impact exercises like walking,
bicycling, swimming or using an elliptical machine may improve your cardiovascular
function. Talk to your doctor before beginning any exercise after neck fusion surgery.

CONCLUSION

We concludes in this work of cervical fractures and dislocation that the surgical
intervention was performed correctly each in independent case to give the best results
and quality life. The Post surgical status of the patient that transfer to hospital with
neck fracture and dislocation has shown that the monosegmental stabilization with plate
give the best results , with high quality of life .
The techniques and methods that used in the surgery of the fracture and dislocation ends
with good results .The plate implantation reduce any movement of the vertebral and
fixed in place .

We compare results of surgery treatment by IBFCS by different methods of
stabilization and correlated them with clin ical results by NDI ( quality of life ) .
We observed ; the best result of stabilization was in the monosegmental stabilization
with plate , its give us the best surgical results in the cervical dislocation

Acknowledgements

This work was carried out during the years 2014 -2015 at the department of
Orthopedics and Traumatology , in University of Medicine and Pharmacy
"Nicolae Testemițanu" .

I owe my deepest gratitude to my supervisor M.D, Ph.D. Dr. Pulbere Oleg
Without his continuous optimism ,encouragement and support this thesis
would hardly have been completed .

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