Comprehensive presentation of the cervical spine injuries

1. Cervical spine injuries
Dr. Sairamakrishnan S

2. • Upper cervical injuries – C1,C2
• Lower cervical injuries – C3 to C7

3. Upper Cervical Injuries

4. Demographics
• Common in children and in people >60 years
• Paediatric
• MVA in 38% of cases
• 1 to 9% of all spine injuries.
• 56 to 73% of cervical spine injuries.
• 53% with head injuries (41% mortality)

5. • Age >60 years
• Occurs from minor trauma
• osteoporosis/osteopenia
• spondylosis of the lower cervical spine
• 69.8% of all cervical spine trauma
• 57% are odontoid fractures
• Lower rate of neurologic injury (26% to 28% mortality)

6. Anatomy of the Upper Cervical Spine
• Three-unit joint - bones of the occiput, atlas, and axis, their synovial
articulations, and the associated ligamentous structures.
• Six synovial joints – 2 x occipitoatlantal joints, anterior and posterior
median atlantoodontoid joints, 2 x atlantoaxial joints
• Occiput-C1 articulation supplies approximately 50% of total cervical
flexion and extension.
• C1-C2 articulations supply 50% of total cervical rotation.

7. • The ligamentous restraints provide the necessary stability to prevent
injury to the enclosed brainstem and spinal cord
• Anterior longitudinal ligament
• Cruciform ligament
• Tectorial membrane (extension of the posterior longitudinal
ligament)
• Nuchal ligament
• Atlanto-odontoid ligament
• Apical ligament
• Alar ligaments

10. Clinical Evaluation
• Cervical spine injury has been closely linked to
• severe head injury
• high-energy mechanism
• focal neurologic deficit
• Adequate airway and ventilation must be established - Nasotracheal
intubation or cricothyroidotomy is safest.
• initial stabilization – rigid cervical collar, spine board, sandbags.
• noncontiguous spinal injuries - 6%
• 24% overall incidence of vertebral artery injury - fatal ischemic
damage

11. • Neurologic evaluation – difficult
• occipitocervical junction – incomplete cord injury –
compression/injury of the pyramidal decussation – mimics central
cord syndrome
• Lower cranial nerves – CN IX, X, XI, XII

12. Imaging
• Plain radiography
• Anteroposterior
• Lateral
• Open-mouth view
• Flexion and extension views – 33% voluntary gaurding

16. • Computed tomography (CT)
• Most sensitive modality
• Sensitivity of 84%
• Cost effective as a primary screening tool

18. • Magnetic resonance imaging (MRI)
• Poor sensitivity for detecting fractures
• Gold standard for detecting neurological injuries and to detect
hematomas.

20. Occipital Condyle Fractures
• High energy trauma to the head and neck
• Complaints of
• High cervical pain
• Torticollis
• Headaches
• Impaired mobility
• Extremely difficult to detect with conventional radiography.
• CT with reconstruction is the imaging modality of choice.

21. • Anderson and Montesano classification
• Type 1
• impaction fractures of the condyle from axial loading
• If unilateral – stable
• Type 2
• part of a more extensive basioccipital fracture that
involves one or both occipital condyles.
• Usually stable
• Type 3
• avulsion fractures near the alar ligament insertion that
result in medial displacement of the condylar fracture
fragment
• Usually unstable

22. • Management
• Patients with occipitocervical misalignment only should be treated in a
halo vest or with a posterior fusion.
• Rest all patients can be treated with rigid cervical collar.
Maserati MB, Stephens B, Zohny Z, et al: Occipital condyle fractures: clinical decision rule and
surgical management. J Neurosurg Spine 11:388-395, 2009.

23. Atlanto-Occipital Injuries
• Children younger than 12 years of age are uniquely predisposed to
this injury because their occipitoatlantal joints are flatter and because
their head weight–to–body weight ratio is significantly greater than in
adults.
• Account for 19% to 35% of all deaths from cervical spine trauma.
• Significant retropharyngeal soft tissue swelling at C3 will be seen.
• Flexion-extension views are not recommended.

24. • Powers’ ratio, the ratio of the
distance from the basion to the
posterior arch of the atlas divided
by the distance from the
opisthion to the anterior arch of
the atlas, should be 1.0 or less in
the absence of anterior
occipitoatlantal dislocation

25. • The distance between the basion
and the posterior axial line (the
basion-axial interval) is greater
than 12 mm then occipitocervical
instability is present.

26. • Traynelis classification

27. • All occipitocervical dislocations should be treated initially by
immediate application of a halo vest.
• Because the majority of these injuries are unstable, posterior
occipitocervical fusion is the procedure of choice
Eismont FJ, Bohlman HH: Posterior atlanto-occipital dislocation with fractures of the atlas and
odontoid process. J Bone Joint Surg Am 60:397-399, 1978.
Montane I, Eismont FJ, Green BA: Traumatic occipitoatlantal dislocation. Spine 16:112-116, 1991.

28. Fractures of the Atlas
• First described by Jefferson in 1921.
• 2% to 13% of all cervical spine fractures.
• 25% of all injuries to the atlantoaxial complex.
• Seen in the younger age groups (mean age, 30 years).
• Caused by axial loading.
• Fractures usually occur in the anterior and posterior arches.
• Neurologic injury is uncommon in the case of isolated fractures of the
atlas.

29. • Jefferson classification
• Type 1 – Posterior arch fracture
• Type 2 – Anterior arch fracture
• Type 3 – Burst fracture
• Type 4 – Lateral mass fracture

30. • Stable fractures that can be treated in a cervical collar
• Lateral mass nondisplaced injuries can be treated with a cervical
collar.
• Lateral mass injuries that are displaced more than 5 mm can be
treated with immediate halo vest application.
• Burst fractures < 7mm displacement are treated with cervical collar
• Burst fractures > 7mm displacement are treated with a halo vest for 3
months. Post removal if significant C1-C2 instability then C1-C2
fusion.

31. • Traction reduction followed by early C1-C2 fusion using C1-C2
transarticular screws has also been described.
• Intraoperative difficulty may be found owing to gross instability of the
C1 lateral masses and the loose C1 posterior arch.
McGuire RA Jr, Harkey HL: Primary treatment of unstable Jefferson’s fractures. J Spinal Disord 8:233-
236, 1995.

33. Atlantoaxial Subluxation and Dislocation
• Patients present with a “cock robin” appearance with the head tilted
toward and rotated away from the side of the dislocation.
• Radiographs will show asymmetry of the lateral masses on the open-
mouth view.
• Dynamic CT with head rotations is ideal.

34. Fielding and hawkins classification
• Type 1 – Rotatory subluxation without anterior shift
• Type 2 – Rotatory displacement with anterior displacement 3-5 mm
• Type 3 – Rotatory displacement with anterior displacement >5 mm
• Type 4 – Rotatory displacement with posterior displacement

35. • Closed reduction with skull thongs and cervical collar application is
done.
• If reduction was difficult to achieve then halo application is done.
• If closed reduction fails then open reduction with C1 C2 fusion is
done.

36. Fractures of the Odontoid
• Fractures of the dens constitute 7% to 13% of all cervical spine
injuries.
• Hyperflexion results in anterior displacement of the dens fracture,
and hyperextension results in posterior displacement of the dens
fracture.
• The fracture can usually be seen on open-mouth and lateral
radiographs of the cervical spine, although nondisplaced fractures can
easily be missed.

37. • Anderson classification
• Type 1 - avulsion injuries at the tip of the dens.
• Type 2 - through the base of the dens.
• Type 3 - extend into the body of the axis.

38. • Type 1 injuries can be treated nonoperatively with a rigid cervical
collar. After 3 months of immobilization, flexion and extension
radiographs are taken.
• Type II odontoid fracture is the most problematic type of odontoid
fracture. High chance of non-union (33%).
• There is an increased nonunion rate associated with fractures with
greater than 5 mm of displacement, angulation greater than 10
degrees, age older than 40 years, and posterior displacement.

39. • Halo vest treatment may be a good option for a patient with an
undisplaced type II odontoid fracture or an undisplaced/minimally
displaced type III odontoid fracture.
• In patients with high risk for non union (old age, smoking) primary
C1C2 fusion can be done which increases the union rate to 96%.
• Primary fixation of Dens is ideal in transverse, noncomminuted, and
reducible fractures and preserves cervical rotation.

40. • Primary fixation of dens is associated with higher complications and
non-union in elderly (13-17%)
• Jeanneret et al in their study said that improvement in rotational
movements with primary fixation of dens is insignificant.
Jeanneret B, Vernet O, Frei S, Magerl F: Atlantoaxial mobility after screw fixation of the odontoid: A
computed tomographic study. J Spinal Disord 4:203-211, 1991.

41. Traumatic Spondylolisthesis of the Axis
(Hangman’s franture)
• The fracture line passes through the neural arch of the axis.
• Combinations of extension, flexion, distraction, and axial loading of
the cervical spine.

42. • Modified effendi classification
• Type 1 - occur through the pars interarticularis bilaterally with less than
3 mm translation and no angulation.
• Type 2 - bipedicular fractures with greater than 3 mm of displacement.
• Type 2A - angulation >11* but has minimal translation.
• Type 3 - associated with unilateral or bilateral facet dislocations.

43. • In type 1 fractures the disc and ligaments are intact.
• In type 2 fractures there is disruption of the C2C3 disc with
compression fracture of the anterosuperior corner of C3 or the
posteroinferior body of C2.
• In type 2a fractures there is significant disruption of the disc and
posterior longitudinal ligament. Associated with a 33% incidence of
neurologic deficit.
• Type 3 has disruption of the posterior longitudinal ligament and the
C2-C3 intervertebral disc occurs in these injuries. These injuries are
commonly associated with neurologic injuries.

44. • Type III injuries occur in three basic patterns:
• bilateral neural arch fractures anterior to the facet joints with bilateral
facet dislocations posterior to it
• a rotational injury with fracture of the neural arch on one side
anterior to the facet joint and on the second side in the area of the
facet joint causing a unilateral facet dislocation
• a bilateral facet dislocation with fractures of the neural arch just
posterior to the facet joints.

45. • Isolated type I fractures can be treated in a rigid cervical collar for 8 to
12 weeks.
• Type II fractures are treated with initial traction in extension followed
by immobilization in a halo vest.
• Type IIa fractures are treated with immediate application of a halo
vest. Traction is avoided in patients with type IIa injuries because
even minimal traction can cause severe overdistraction.
• All type III fractures should be treated with surgical reduction and
posterior C2-C3 fusion.

46. Injuries of the Lower Cervical
Spine

47. Anatomy
• The subaxial cervical spine is highly mobile but protective of its soft
tissue contents, namely the spinal cord, nerve roots, and vertebral
arteries.
• Each vertebra from C3 to 7 is progressively larger and is connected
both above and below by three articulations, the disc complex and
the paired lateral pillars.
• These form three columns that are essential for the weight-bearing
function of the spine.
• The anterior column is connected to each lateral pillar by pedicles,
and the lateral pillars are connected by the lamina.

48. • The large spinous processes are levers for attachment of the
paraspinal muscles and ligaments.
• Posterior ligamentous complex is essential to maintaining stability
against flexion and anterior shear forces.

49. Bony anatomy
• Vertebral bodies are relatively large weight-bearing cuboid structures
that are connected to each other by the intervertebral disc.
• The uncus is responsible for resistance to lateral bending, lateral
listhesis, and rotation.
• Short transverse processes extend lateral from the body about
midlevel in anteroposterior direction and are confluent with vestigial
ribs forming the foramen transversarium.
• Within this structure lies the vertebral artery and venous plexus
except at C7, which is void.

50. • Pedicles extend posteriorly and outward from the cranial aspect of
the posterior wall of the body to the lateral masses.
• Because of the close proximity of the vertebral arteries, pedicle screw
is often considered dangerous and supplanted by the use of the
lateral masses as screw anchorage.
• The lateral masses or pillars when viewed laterally are parallelogram
in shape and appear square when viewed ventrally or dorsally.
• Superior and inferior articular facets have cartilage surfaces that form
the facet articulations.

51. • The superior facet is located behind the neuroforamen and, when
fractured, may cause root injury.
• The laminae are thin plates of bone that extend from the lateral mass
obliquely posterior and meet each other at the base of the spinous
process.
• The spinous processes project posteriorly, angling downward, and are
progressively larger from cranial to caudal direction.
• The spinous process of C3 to C5 is always bifid, whereas C6 may be
and C7 is never bifid.

55. Ligamentous Anatomy
• The ligaments of the cervical spine are essential to maintain both
stability and range of motion.
• The anterior and posterior longitudinal ligaments lie on the respective
surfaces of the vertebral body.
• The annulus joins the corresponding vertebral bodies and is the
primary restraint to all directions of movements.
• The posterior ligamentous complex consists of the nuchal ligaments,
ligamentum flava, facet joint capsules, and all bony attachments.

56. • The nuchal ligaments include the ligamentum nuchae, which is a thick
band strongly attached to the spinous processes of C2 and C7.
• The ligamentum nuchae blends with the supraspinous ligament,
which bands together each spinous process at their tips.
• Between the spinous processes are the interspinous ligaments.
• The ligamentum flava attaches to the underside of the cranial lamina
and top-most aspect of the caudal vertebrae.
• Each facet articulation has relatively redundant facet capsules that
offer only a small amount of stability

58. Neurovascular Anatomy
• The spinal cord is an elastic structure that lies inside the spinal canal.
• In adults its anteroposterior diameter measures about 8 mm and
cross-section is slightly oval.
• At each disc level ventral and dorsal roots sprout and join laterally,
forming the spinal nerve in the neuroforamina.
• Neuroforamina are bordered anteriorly by the posterior lateral corner
of the disc and uncus, above and below by pedicles and posteriorly by
the superior articular facet and lateral mass.

59. • The vertebral artery ascends from the subclavian artery to pass within
the foramen transversarium at C6, although in 1% of cases this can
occur aberrantly at C7 or higher levels.
• It exits the foramen transversarium of C2 turning anteriorly and
medially in C2 and then again laterally into C1.

61. Kinematics
• Kinematically each segment of the subaxial spine normally has
approximately 11, 5, and 5 degrees of movement in flexion-extension,
lateral bending, and rotation.
• Small amounts (1 to 2 mm) of translation occur in both anterior-
posterior and lateral directions.

62. Classification
• Cervical Spine Injury Severity Score
• The Cervical Spine Injury Severity Score (CSISS) is based on
independent analysis of four columns
• The anterior column includes the body, disc including the annulus,
anterior and posterior longitudinal ligaments, and transverse
processes.
• Each lateral column is scored separately and includes the facet
projections, lateral mass, pedicles, and facet joint capsules.
• The posterior column includes the lamina, spinous process,
ligamentum flavum, and nuchal ligaments.

63. • Each column is scored using a 0-5 analog scale.
• Fractional scores can be used.
• Scores increase proportional to either displacement of fracture
fragments or separation as a result of soft tissue injury.
• For example, a nondisplaced fracture is scored 1 while the worst
injury possible for that column is a 5.
• Each column is scored independently and summed, giving the CSISS
ranging 0-20.

66. • Subaxial Cervical Spine Injury Classification
• Evaluates fracture morphology, the discoligamentous complex, and
neurologic function, creating a comprehensive system to aid
treatment decision making.
• The system assigns points for each domain and if the score
exceeds a threshold, surgery would be indicated.

67. • Morphology
• Compression injuries are assigned one point, with an additional
point being assigned for burst fractures or when greater than 10
degrees of scoliosis is created by lateral compression injuries.
• Distraction injuries have a poor prognosis, and are therefore
assigned three points.
• Rotation and translational injuries such as from facet dislocations
are given four points.

68. • Discoligamentous Complex
• Anteriorly these include the disc annulus complex and the
anterior/posterior longitudinal ligaments.
• Posteriorly these include the nuchal ligaments as well as the
ligamentum flavum and facet capsules.
• The discoligamentous complex is scored 0 for intact, 1 for
indeterminate, and 2 for disrupted.

69. • Neurologic Function
• Root injuries have a good prognosis and are scored 1.
• Complete cord injuries are given 2 points.
• Three points are assigned for incomplete, which is a higher score
than for complete because incomplete injuries are more likely to
benefit from surgery.
• Finally, an additional point is added when residual neural tissue
compression is present in patients with neurologic deficits.

70. • A patient with an SLIC score equal to 3 is treated nonoperatively,
whereas surgery is recommended in a patient with a score equal to 5.
• Scores of 4 can be treated either operatively or nonoperatively.

75. Anterior Compression Fractures
• Anterior compression fractures, like burst fractures, occur from
hyperflexion and/or axial loading forces.
• During this loading, the disc is pressurized, resulting in failure of the
endplate and creating wedging of the vertebral body.
• . This usually occurs along the superior endplate.
• During hyperflexion the posterior ligaments may be strained beyond
physiologic limits, causing disruption. This injury pattern has been
termed “hidden flexion injury” and often fails nonoperative
treatment.

76. Burst Fractures
• Caused by rapid increase in intradiscal pressure resulting in failure of
the superior endplate, which is driven along with the disc into the
vertebral body.
• The rapid increased intravertebral pressure creates hoop stresses and
eventual failure of the body with radial displacement of bone
fragments.
• In addition, the pedicles are pushed outward causing posterior
fractures.
• Often flexion is present, causing posterior ligamentous complex
disruption and/or facet subluxation, fracture, or dislocation.

78. Flexion Axial Loading Injury
• Also called tear drop fractures, are devastating injuries due to the
propensity for neurologic injury and often are the result of diving or
other sports-related activities.
• The injury occurs from a compression force obliquely applied in a
downward and posterior direction.
• Forces are concentrated in the anterior inferior corner of the
vertebral body, which is sheared off, giving the injury its name.
• The remaining part of the vertebral body shears through the disc
space and rotates posteriorly into the spinal canal, crushing the spinal
cord.

80. Transverse Process Fractures
• Transverse process fractures are quite common, occurring in isolation
or in association with other more severe injuries.
• These fractures are not involved with spinal stability and therefore are
not significant in treatment decision making for the spine.
• However, transverse process fractures at C6 and above may warn of
possible vertebral artery injury.

81. Disc-Distraction Injury
• Impacting the head or face in a fall or forward striking a windshield
creates hyperextension, compression, and posterior shear.
• The anterior longitudinal ligament and disc annulus can fail from
tension.
• Excessive compressive loading of the lateral masses and impaction of
the spinous process may cause fracture.
• The disc distraction injury occurs often in spondylotic spines.
• The forced hyperextension with compression can transiently narrow
the spinal canal, causing spinal cord injury, typical of the central cord
type.

82. Treatment of Anterior Column Injuries
• Anterior column injuries with low SLIC or CSISS scores can be treated
non-operatively.
• Less significant injuries can be treated with a cervical collar, while
burst fractures and flexion/axial loading injuries can be treated with a
cervical thoracic orthosis (CTO) or halo vest.
• Surgical indications for anterior column injuries are those with
evidence of disruption of the posterior ligamentous complex as
demonstrated by high CSISS and SLIC scores.

83. • Although both anterior and posterior approaches may be used, it is
recommend addressing pathology at its major location (anteriorly).
• After strut grafting or insertion of a cage, an anterior plate is applied.
• Surgical indications for disc distraction injuries are cases with any
significant displacement, ongoing neurologic symptoms, or chronic
pain.
• Anterior discectomy and fusion are indicated in neurologically intact
patients and those with radiculopathy or those with cord injury
limited to injured level.

84. • If multilevel stenosis options available are single-level anterior
cervical discectomy and fusion combined with posterior
decompression or posterior decompression with posterior fusion.

88. Spinous Process and Lamina Fractures
• Occur from impaction forces as a result of compression during forced
hyperextension.
• Paraspinal muscle contractions can also result in spinous process
fractures termed clay shoveler’s fracture.

89. Posterior Ligamentous Injury without
Subluxation
• Posterior ligamentous disruptions occur from hyperflexion and are
worsened with any rotation.
• Posterior ligamentous injuries without subluxation are suspected
when interspinous process spreading is present but without vertebral
or facet subluxation.

90. Treatment of Posterior Column Injuries
• Management of isolated spinous process and lamina fractures is with
simple collar immobilization.
• Because they may be associated with complete posterior ligamentous
complex disruption, kyphosis or progressive subluxation may occur.
• Spinous process fractures may not heal due to the displacement from
muscle contractions, although this rarely leads to chronic pain or
further surgical treatment.

91. • Isolated posterior ligamentous injuries without subluxation have a
worse prognosis.
• Initial management of these injuries unless there is MRI evidence of
complete disruption is nonoperative in a collar or CTO. The latter is
preferred at the lower cervical spine (C5-C7).
• If upright radiographs demonstrate increasing deformity or excessive
motion after 8 to 10 weeks of immobilization, surgery is
recommended.
• Patients with complete ligamentous disruption can be taken for
posterior surgery.

92. Isolated Facet Fractures
• Isolated facet fractures occur from forced impaction against the
neighboring facet, usually with a component of anterior shear.
• Should always be evaluated with the suspicion that greater instability
is present.
• Plain radiographs may miss these injuries unless subluxation is
present.
• CT is sensitive for these injuries, and they are best evaluated on
sagittal reconstructions.

93. Lateral Mass Fractures
• Lateral mass fractures most commonly result from lateral
compression or hyperextension where facets impact each other.
• Transiently this may narrow the neuroforamina with resultant root
injury.

94. • Kotani classification
• Type I is a fracture separation.
There is an ipsilateral pedicle
and lamina fracture.
• . Type II lateral mass fractures
are highly comminuted.
• Type III is a vertical fracture in
the coronal plane with
invagination of the superior
facet into the cranial lateral
mass.
• Type IV fractures are traumatic
spondylolisthesis, which usually
occurs at C7 or T1.

95. Unilateral Facet Dislocations
• Head rotation or rotation associated with flexion cause forward and
upward translation of the opposite facet, which when severe causes
unilateral facet dislocation and in many cases facet fracture as well.
• There is associated injury to the intervertebral disc and ligamentum
flava.
• CT will show that the inferior facet of the rostral vertebra is anterior
to the superior facet of the caudal vertebra.

96. Bilateral Facet Dislocation
• Bilateral facet dislocations are devastating injuries frequently
resulting in quadriplegia.
• Bilateral facet dislocations occur from hyperflexion with or without
rotation.
• There will always be associated disruption of the posterior
ligamentous complex.
• Fractures of the facets, lamina, and spinous processes are common.
• Posterior interspinous widening is usually present.
• The disc may be inappropriately narrowed, suggesting posterior
herniation.
• The spinal canal is significantly narrowed

97. Treatment of Lateral Column Injuries
• Isolated facet fractures can be treated nonoperatively with a collar or
CTO – should look for increasing kyphosis.
• Type I lateral mass fractures with minimal anterior translation can be
treated nonoperatively with a CTO or preferably a halo vest.
• Those having subluxation should be treated surgically.
• An important surgical consideration is that lateral mass separations
involve two motion segments.
• Fusion at only one of these levels may be associated with late
subluxation at the other level.

98. • The preferred treatment is posterior lateral mass fixation at two
motion segments.
• Anterior fusion at both segments is an alternative option.
• Type II comminuted lateral mass fractures are treated similarly
• Type III can be treated with an orthosis unless significant
displacement is present.
• Type IV traumatic spondylolisthesis is difficult to reduce and often
comminuted.
• Open reduction is usually required and is best performed posteriorly.

101. Special Injury Types
• ankylosed spines
• central cord syndrome
• vertical distraction injuries
• fractures in the elderly

102. Ankylosed Spines
• Ankylosing spondylitis, diffuse idiopathic spinal hyperostosis
• Increased risk of spinal column and cord injury.
• The loss of intervertebral disc decreases elastic deformation following
trauma further amplified by long lever arms.
• Spine may be may be osteoporotic and have potential for epidural
bleeding.
• The anterior column fails in tension and compressive forces are then
created posteriorly, resulting in fractures of the spinous processes and
lamina.

103. • The treatment of subaxial fractures in patients with ankylosing
spondylitis is surgical unless medically contraindicated.
• The aggressive approach is warranted by the high incidence of
displacement and resultant neurologic injury or kyphosis that can
occur with nonoperative treatment.
• The surgical treatment is best performed with posterior
instrumentation over many segments because there is no concern
over fusing many segments.
• Bone graft is not necessary, although local bone graft can be added at
the fracture site.

104. Central Cord Syndrome
• Occurs from a hyperextension injury in patients with narrow spinal
canals, usually from spondylosis.
• This causes infolding of the ligamentum flavum and bulging of the
disc creating a pincer to the spinal cord.
• Radiographically no significant injuries are noted.
• Neurologic examination is a picture of greater involvement of the
upper extremities than the lower extremity and sacral roots.
• Neurologic manifestations reflect injury to the central gray matter and
surrounding white matter in the central spinal cord.

105. • The axonal tracts to the upper extremities are located more centrally
than the lower extremity and sacral regions and therefore are injured
to a greater degree leading to the classic pattern of neurologic
findings.
• The overall prognosis for this injury is good, although hand function
may remain poor.
• Aggressive surgical approach is advocated with the goals to speed
recovery, shorten hospitalization, and reduce morbidity

106. Vertical Distraction Injury
• This is a rare devastating injury where there is vertical separation
between the vertebral segments through the disc space and facet
articulations.
• Complete spinal cord injury is always present and vascular
abnormities should be anticipated.
• Occur from rapid head deceleration or from hanging.
• Excessive tensile forces result in disruption of all ligamentous
constraints and are only limited by elasticity of the neurovascular
elements.

107. • Traction is contraindicated and reduction is best achieved either
surgically or by halo vest.
• Definitive treatment by combined anteroposterior fixation is
recommended.

108. Fractures in Geriatric Patients
• Elderly patients are more prone to injury due to osteoporosis,
generalized sensory imbalance with aging, developmental stenosis
with increased risk of spinal cord injury, and a higher rate of vehicular
accidents per mile driven.
• Mortality of geriatric patients with cervical fractures ranges 30% to
50%.
• Treatment by traction, prolonged bed rest, and the halo vest are
associated with increased mortality and should be avoided.
• Geriatric patients are particularly prone to aspiration pneumonia due
to retropharyngeal soft tissue swelling and dysphagia.

109. • If medical conditions allow, rigid stabilization should be considered for
any marginal or unstable injury.
• Posterior fusions are preffered in order to avoid anterior approaches
and the consequent risk of airway or swallowing complications.