Occult posttraumatic cervical ligamentous instability

Posttraumatic progressive cervical ligamentous instability and spinal deformity may occur in spite of initially apparently normal spine radiographs. Patients at risk for the development of this problem are generally under 25 years of age and have greater than 1.5 mm of horizontal displacement and greater than 5 degrees of angular displacement on initial cervical roentgenograms. Recent experience with this entity at our institution has led to a reevaluation of the currently existing radiographic criteria for determining ligamentous stability.     

Rupture of the cervical esophagus and trachea associated with cervical spine fracture

Rupture of the cervical esophagus and trachea secondary to cervical spine fracture-dislocation occurs rarely. Herein we describe a case and propose a mechanism to account for these associated injuries. Awareness of this complication of cervical spine fracture is crucial for prompt recognition and management.     

Occult fracture-dislocation of the cervical spine

Summary Occult injuries of the cervical spine in certain patients may lead to misdiagnosis or delayed diagnosis and treatment. The authors present a patient with an occult cervical spinal fracture-dislocation and review the literature. A 37 year-old male was involved in a motor vehicle accident. At his admission, the patient was alert and denied any pain in the cervical region, as well as neurologic symptoms. Physical examination revealed painless range of motion of his neck and no sensory or motor deficits. Plain radiographs of the cervical spine showed unilateral dislocation of C₄ on C₅ vertebra with fracture of the left facet of C₅ vertebra. Computed tomography scanning showed no neural compression. Operative reduction, stabilization and arthrodesis of the spine were advised, but the patient refused operative treatment. One year after his initial injury, the patient presented with torticollis and no neurologic symptoms.     

Esophageal injury associated with anterior cervical spine surgery

BACKGROUND: Anterior cervical spinal surgery has been used to treat a variety of conditions including spondylosis, fracture, tumor, infection, trauma, and instability. Esophageal perforation, a rare and unusual complication of anterior cervical procedures, has been largely relegated to only incidental case reports with few large retrospective studies performed to determine true incidence, treatment, etiology, and outcome. METHODS: More than 3000 anterior cervical spine surgeries conducted over a 30-year period by 5 active practicing surgeons were reviewed. There were 3 cases of esophageal injury identified with subsequent critical evaluation to determine presentation, diagnosis, risk factors, management, and outcomes. In addition, incidence rates were calculated based on overall occurrence and antecedent risk factors. RESULTS: Two of the patients with esophageal injury had predisposing risk factors, including diverticula or cervical spine trauma. The third patient had no antecedent risk factors. Symptoms included axial spine pain, odynophagia, dysphagia, purulent spondylitis, and sepsis. Treatment consisted of one or more of the following: reoperation with exploration and repair, esophageal diversion, esophageal rest, antibiotic administration, and wound drainage. Functional outcomes were achieved in all cases with no deaths. CONCLUSIONS: Esophageal injury incidence based on overall occurrence in this study was 0.1%. Patients with no antecedent risk factors had an incidence of 0.03%. Our results compare favorably with those of the Cervical Spine Research Society survey from 1989, which predicted an incidence of 0.25% based on questionnaires filed by surgeons, representing 1 of only 2 reports that included more than 1000 patients.     

Severity of cervical spine ligamentous injury correlates with mechanism of injury,not with severity of blunt head trauma

Clearance of the cervical spine (CS) in obtunded trauma patients in an intensive care unit is problematic. Patients with no osseous injuries have potential unstable extradural supportive soft tissue injury. Evaluation of the supporting structures involves dynamic fluoroscopy or MRI both of which have inherent risks and convenience issues. Defining which of these patients are at highest risk for severe supportive structure injury may improve resource utilization for CS clearance. The purpose of this study was to evaluate clinical factors that may predict the probability of CS supportive soft tissue injury in patients with traumatic brain injury. Patients who sustained traumatic brain injury with intracranial pathology, absence of CS osseous injury, and a limited cervical spine MRI within 72 hours of injury were included. Potential clinical predictors included the severity of the traumatic brain injury defined by the Abbreviated Injury Severity Score for the cerebrum and initial Glasgow Coma Scale, the Injury Severity Score (ISS), mechanism of injury, and high versus low-velocity mechanism. Severity of soft tissue/ligament injury was graded by MRI findings. One hundred twenty-five patients met the study criteria; 81 had negative MRI findings and in 44 the MRI study was positive for potentially unstable injuries. High-velocity mechanisms of injury and ISS--not the severity of the traumatic brain injury or initial Glasgow Coma Scale score--were statistically significant predictors of severe CS supportive soft tissue injuries. Obtunded blunt trauma patients who have been involved in high-velocity-mechanism incidents and have high ISS are at greatest risk for extradural supportive soft tissue CS injuries. These patients should either remain in CS immobilization until clinical evaluation can be completed or undergo further evaluation of their supportive soft tissue structures by MRI or fluoroscopic flexion/extension.     

Traumatic ligamentous instability of the cervical spine in children

Sixteen cases of dislocation and ligamentous disruptions of the cervical spine in children are reported. In five cases resulting from injury to the upper cervical spine, the roentgenographical features of the instability at the C1-C2 level are documented and their therapeutic orientation is defined. Eleven injuries were of the lower cervical spine: three dislocations, two of which were old cases, and eight serious ligamentous disruptions. Diagnosis of serious ligamentous disruptions was based on precise radiographic criteria: increase of the interspinous distance, loss of parallelism between the articular processes, and posterior widening of the disc space. The indications for surgical fixations in serious ligamentous disruptions depend on persistence of the clinical and radiological signs after a long orthopedic immobilization.     

Canal geometry changes associated with axial compressive cervical spine fracture

STUDY DESIGN: A laboratory study using isolated ligamentous human cadaveric cervical spines to investigate canal occlusion during (transient) and after (steady-state) axial compressive fracture. OBJECTIVES: To determine whether differences exist between transient and postinjury canal occlusion under axial compressive loading, and to examine the effect of loading rate on canal occlusion. SUMMARY OF BACKGROUND DATA: Prior studies have shown no correlation between neurologic deficit and canal occlusion measurements made on radiographs and computed tomography scans. The authors hypothesized that postinjury radiographic assessment does not provide an appreciation for the transient occlusion that occurs during the traumatic fracture event, which may significantly affect the neurologic outcome. METHODS: Twelve human cervical spines were instrumented with a specially designed canal occlusion transducer, which dynamically monitored canal occlusion during axial compressive impact. Six specimens were subjected to a fast-loading rate (time to peak load, approximately 20 msec), and the other six were subjected to a slow-loading rate (time to peak load, approximately 250 msec). After impact, two different postinjury canal occlusion measurements were performed. RESULTS: Each of the six specimens subjected to the fast-loading rate incurred burst fractures, whereas the slow-loading rate produced six wedge-compression fractures. For the fast-rate group, the postinjury occlusion-measurements were significantly smaller than the transient occlusion. In contrast, transient occlusion was not found to be significantly different from postinjury occlusion in the slow-rate group. All of the comparisons between loading rate groups showed significant differences, with the fast-rate fractures producing larger amounts of canal occlusion in every category. CONCLUSIONS: The findings indicate that even if canal occlusion could be measured immediately after axial compressive trauma, the measurement would underestimate the maximal amount of transient canal occlusion. Therefore, postinjury measurement of canal occlusion may indicate a smaller degree of neurologic deficit than what might be expected if the transient occlusion could be measured.     

颈椎骨折脱位并发的椎动脉损伤

目的：分析颈椎骨折脱位并发的推动脉损伤的发生率及易发因素,方法：11例颈椎骨折脱位患者均接受颈椎MRI及颈部磁共振血管成像（MRA）检查。结果：3例合并有椎动脉损伤（均为单侧）,由屈曲暴力致伤及存在小关节脱位。嵴髓损伤均为A级（ASIA标准）。结论：颈椎骨折脱位可能并发椎动脉损伤、脊髓完全性损伤及颈椎小关节脱位患者,应常规进行MRA检查,以明确是否合并椎动脉损伤。     

颈椎骨折脱位合并椎动脉损伤

目的　探讨颈椎骨折脱位与椎动脉损伤的相关性。方法　 2 0例闭合性颈椎创伤患者 ,同时接受颈椎MRI和椎动脉磁共振血管成像 (MRA)检查。结果　 2 0例闭合性颈椎损伤中 ,5例无椎动脉血流成像 ,均为单侧 ,左侧 2例 ,右侧 3例。其中颈椎骨折 3例 ,单侧小关节脱位 1例 ,无放射影像的异常脊髓损伤 1例。 4例椎动脉损伤患者无任何症状 ,1例有轻度头昏、嗜睡。结论　颈椎骨折脱位可并发椎动脉损伤 ,由于缺乏特异性症状 ,前瞻性MRA检查是最重要的方法。     

后路内固定复位治疗上颈椎骨折脱位发生椎动脉损伤的临床分析

目的:分析后路内固定复位治疗上颈椎骨折脱位发生椎动脉损伤的原因、外科治疗策略及其预防措施。方法:2013年1月~2017年12月,我院采用后路复位内固定术治疗上颈椎骨折脱位患者96例,其中6例术后出现椎动脉损伤,男4例,女2例,年龄32~57岁(39.8±8.3岁),病程18~26d(22.0±2.5d)。2例术前行磁共振血管成像(MRA)检查未见椎动脉损伤,4例术前未行MRA检查。术后3~42h出现脑缺血症状,其中4例切口渗血或周围血肿形成,行颈后路探查止血后行CT血管造影(CTA)和数字减影血管造影(DSA)检查,2例直接行CTA和DSA检查,明确椎动脉损伤后行血管腔内介入治疗,随访观察患者脑缺血症状改善情况。结果:1例寰枢椎复合型骨折和1例混合型骨折患者复位内固定难度较大,其余4例患者手术均顺利。4例椎动脉V3段血管壁损伤(双侧1例,单侧3例),行覆膜支架置入;2例单侧椎动脉V3段假性动脉瘤形成,行椎动脉闭塞术。6例患者行介入治疗后椎动脉损伤出血均有效止血,出院后均获随访,随访6~12个月(10.0±2.2个月),1例双侧血管壁损伤患者术后1年随访仍诉头晕、头痛,面部麻木;3例单侧血管壁损伤患者脑缺血症状明显缓解,术后1年随访时未诉特殊不适;2例单侧假性动脉瘤形成患者行椎动脉闭塞术后6个月及9个月随访时诉脑缺血症状逐渐缓解。2例患者椎动脉损伤为内固定手术术中所致,4例患者因术前未行MRA或CTA检查,无法明确椎动脉损伤原因。结论:上颈椎骨折脱位及手术复位内固定可能造成椎动脉损伤,根据影像学检查结果行介入治疗可取得较好效果;对上颈椎骨折患者术前需进行详细的影像学检查及评估,术中需谨慎操作,避免椎动脉的损伤。     

合并椎体爆裂型骨折的颈椎过伸性损伤及其外科治疗

目的 探讨合并椎体爆裂型骨折的颈椎过伸性损伤的临床表现及治疗方法。方法 对1996～2004年间收治的17例合并椎体爆裂型骨折的颈椎过伸性损伤患者损伤原因、机制，合并脊髓神经损伤的类型、程度以及手术治疗疗效进行分析。结果 合并椎体爆裂型骨折的颈椎过伸性损伤常因高速撞击伤所致，损伤过程中发生了过伸性损伤转变为屈曲损伤，脊髓损伤严重。积极地行椎体切除减压、植骨融合重建颈椎稳定性的手术治疗效果满意。结论 合并椎体爆裂型骨折的颈椎过伸性损伤是由于过伸应力转变为屈曲应力。及早解除机械性压迫因素，重建和保持颈椎稳定性是手术治疗的原则。     

Dens fracture with concurrent subaxial cervical spine injury in patients with ankylosing spondylitis

Odontoid process fractures in patients with ankylosing spondylitis (AS) are rare and their finding together with subaxial cervical spine injury is a great exception. Neither the mechanism of such a combined cervical spine injury nor its surgical treatment has so far been reported in the relevant literature (MEDLINE). The authors present two such cases, one in a 30- and the other in a 74-year-old man. Both AS patients showed a common mechanism of injury sustained in a car accident, which involved hitting a solid barrier at 60 to 70 kilometres per hour, resulting in hyperextension of the cervical spine. In both patients the fractures were stabilised from the anterior approach: the dens fractures with one or two screws by the Magerl-B?hler method and the subaxial fractures with long-plate and screw fixation. At 2 post-operative years complete bone union of the subaxial spine was recorded in both patients; complete healing of the dens fracture was achieved in one patient while in the other partial fibrous union of the dens fracture occurred.     

Isolated ligamentous cervical spinal injury in the polytrauma patient with a head injury

The evaluation of the cervical spine in the unconscious trauma patient is a difficult and controversial topic in trauma management. Conventional cervical clearance protocols consisting of plain radiology and computed tomography may not adequately detect unstable cervical ligament and disc injuries, even though a high-risk mechanism of injury has occurred. We present two cases where cervical clearance protocols, utilising plain X-rays and multi-slice computed tomography, failed to identify significant ligamentous spinal injuries. A delay in diagnosis or a missed spinal injury can lead to delays in treatment, thereby increasing the risk of neurological deterioration with the potential devastating sequela of quadriplegia. Therefore, in the unconscious trauma patient who, by definition, has sustained a high-risk mechanism injury, we routinely recommend the use of magnetic resonance imaging in addition to plain X-rays and computed tomography, to evaluate further discoligamentous status.     

颈椎骨折合并急性颈髓损伤的手术时机探讨

目的：探讨颈椎骨折合并急性颈髓损伤的手术时机。 方法：回顾性分析2000年1月~2011年1月我科治疗的颈髓损伤患者42例,其中急诊手术组（≤24h）18例,延期手术组（>24h）24例,对比分析手术前后神经功能变化、术后并发症和住院时间等临床资料,并进行统计学分析。 结果：急诊手术组感觉和运动功能改善明显,并发症发生率、重症监护时间和住院时间均低于延期手术组。 结论：颈椎骨折合并急性颈髓损伤的急诊手术减压是可行的,对神经功能的恢复有积极作用,并减少围手术期并发症。