Severe Cervical Spine Research Articles

Hangmanʼs Fracture Resulting From Improper Seat Belt Use

Diagonal seat belt application without accompanying lap belt closure may produce severe cervical spine injuries, including hangman's fracture and decapitation. Seat belts are effective in reducing injury, but they must be worn properly to do so. Passive restraint systems involving a diagonal seat belt may be hazardous if the motorist does not use the accompanying lap belt. We have presented a case in which the driver in a motor vehicle accident sustained a hangman's fracture (bilateral fracture of the pedicles of C-2) caused by use of a diagonal seat belt without accompanying lap belt closure. The mechanism of injury, as classically described in judicial hanging, is hyperextension and distraction, which occurred when the victim "submarined" under the diagonal seat belt and was caught at the neck.

Pitfalls of Spinal Deformities Associated With Neurofibromatosis in Children

A study of 116 patients younger than 12 years of age conclusively diagnosed as having neurofibromatosis was undertaken to determine the incidence of significant orthopedic problems. Deformities of the spine comprised the most common skeletal problem. Seventy-four patients (64%) had spinal deformities. Forty-six patients were treated by posterior spinal fusion. Ten required exploration for pseudarthrosis; six were found to have pseudarthrotic defects in the fusion mass. Eight patients had more kyphosis than scoliosis. Only three patients with kyphoscoliosis obtained a solid posterior spinal fusion after multiple surgical procedures. Anteroposterior and lateral roentgenograms of the cervical spine are recommended at the time of initial evaluation of all spinal deformities. Four patients had severe cervical spine deformities, only one of whom was initially identified as having a cervical spine disorder while under treatment for scoliosis. Three of these patients were seen by other surgical services for neck masses. Following removal of posterior elements, the osseous structures were unstable. Only one patient developed spondylolisthesis. Because of the exceedingly high incidence of pseudarthrosis and spinal instability following attempts at spinal fusion, certain guidelines have evolved for the management of these deformities. High-volume computed tomographic myelography in the prone, lateral, and supine positions or magnetic resonance imaging should be performed on all patients prior to surgical treatment. Anterior disc excision and bone graft followed by posterior arthrodesis with instrumentation are indicated if the kyphotic angle is greater than 50 degrees or if scoliosis is greater than 80 degrees. Even combined anterior and posterior arthrodesis operations did not guarantee successful permanent spinal stability in young patients with neurofibromatosis.

Factors affecting the prognosis of multiply injured patients: an analysis of 1169 consecutive cases

When analysing 1169 multiply injured patients treated in the intensive care unit between 1966 and 1984 we noticed a dramatic fall in mortality from a level of about 14.6 per cent to 4.8 per cent since 1981. The patient populations and accident patterns were surprisingly identical, though since 1981 the severity of thoracic injuries has increased and the brain injuries decreased. The fall in mortality was great for all causes of death but most significant for patients with severe thoracic, brain and cervical spine injuries. The trend is to treat more and more fractures operatively and immediately after the injury. There has been a better diagnosis of all injuries according to autopsy findings. An attitude of prophylactic treatment on a respirator which leads to better oxygenation, together with a wellorganized, co-ordinated injury care system with systematized diagnostic, laboratory and therapeutic procedures, are among the most important factors in the lowering of the mortality.

Traumatic rotatory displacement of the lower cervical spine.

Traumatic rotatory displacement (TRD) are defined as all slight anterior corporeal displacements (less than 1/3 of the vertebral body) secondary to different vectors, but with a constant and dominant rotatory component. The authors report on 47 cases of TRD (35% of all severe lower cervical spine injuries) (follow-up: 6 months to 7 years). TRD occurs only when two lesions are present: an anterior lesion in the disk and ligaments, and a posterior lesion of the articular process, as the authors confirmed earlier in an experimental study on monkeys and specimens. Depending on the nature of the posterior lesions, three anatomoclinical types occur: 1) posterior capsular lesions cause unilateral facet dislocation (UFD): ten cases; 2) bony lesions of the articular process cause unilateral facet fracture (UFF): 28 cases; 3) double bony lesions, which can set free the articular facets, are called fracture separation of the articular pillar (FSAP): nine cases. The common radiographic characteristic of these three lesions is slight anterior displacement (or antero-listhesis), which is well seen on the lateral film; only tomograms or CT scans can show the posterior lesions. Instability, as defined by Roy-Camille, Denis and our experiments, was obvious on X-rays: soon after the injury, for UFD, and some time later, for 18 UFF and three FSAP. Statistically, 25% of all cases of TRD are associated with another traumatic lesion of the lower or upper cervical spine. Clinically, there is a 30% rate of radicular complications in TRD: this figure is higher than that of other injury types.(ABSTRACT TRUNCATED AT 250 WORDS)

The relationship between pelvic, spinal and hip involvement in ankylosing spondylitis--one disease process or several?

One hundred and one consecutive patients with ankylosing spondylitis (males 85%) were reviewed by radiographic evaluation after a mean disease duration of 21.2 years (mean age at onset 22.9 years). Osteitis pubis occurred in seven cases of varied duration and severity of disease. Hip involvement (grade 2-4) occurred in 19%. Their mean age of onset (19.6 years) was younger than for those with normal hips (25.1 years; p = 0.003). Lone sacroiliitis (grade 3 and 4) without ascending spinal disease occurred in 11 patients. The mean age at onset for those with lone sacroiliitis and marked spinal disease was similar (23.3 and 24.9 years respectively; NS). By contrast, disease duration was 13.3 and 28.4 years respectively (p = 0.0007). Five patients (three women) had severe pelvic and cervical spine disease with normal lumbar spine. 1. Osteitis pubis occurs as an unusual, random event. 2. Hip involvement is an expression of young age at onset. 3. Lone sacroiliitis is uncommon and progression to ascending spinal disease is primarily a function of disease duration. 4. Skip lesions occur rarely and particularly in women. 5. Sacroiliitis and ascending spinal disease are part of the same spectrum.

Axis fractures resulting from motor vehicle accidents. The need for occupant restraints.

A total of 625 patients who sustained acute cervical spine fractures were evaluated by the Spinal Cord Injury Service at Barrow Neurological Institute, Phoenix, Arizona, between January 1976 and January 1984. Of them, 107 had fractures of the second cervical vertebra. In a retrospective review, motor vehicle accidents were found to be the most common mechanism of injury, resulting in 73 (68%) of the 107 axis fractures. All axis fracture types were encountered in this subgroup: hangman's (27%), Odontoid Type II (39%), Odontoid Type III (15%), and miscellaneous fractures (19%). Only one of the 30 patients with complete medical records and detailed information about the accident was wearing a seat belt. Equally remarkable is that 15 of the 30 accidents were single car mishaps, where occupant restraints might theoretically provide the most protection. Sixteen of the 30 patients were thrown from their vehicles, another five were found in the backseat, which leads to the conclusion that a significant of the driving population does not wear seat belts or shoulder restraints. Patients with axis fractures from an automobile accident had a high rate of associated severe head injuries or other cervical spine fractures, three times that of patients with C-2 fractures from other causes. Motorists who are thrown from their vehicles suffer the most severe trauma and have the highest rates of morbidity and mortality. As many as 25% to 40% of individuals who sustain high cervical fractures in motor vehicle accidents die as a result of their injuries.

Epidemiology, pathomechanics, and prevention of athletic injuries to the cervical spine

Athletic injuries to the cervical spine associated with quadriplegia most commonly occur as a result of axial loading. Whether it be a football player striking an opponent with the top or crown of his helmet, a poorly executed dive into a shallow body of water where the subject strikes his head on the bottom, or a hockey player pushed into the boards head first, the fragile cervical spine is compressed between the rapidly decelerated head and the continued momentum of the body. Appropriate rule changes recognizing this mechanism have resulted in a reduction of football quadriplegia by two-thirds. Presumably, educational efforts designed to inform the public of the dangers of diving would have a similar effect. The predominance of the axial loading mechanism is not as clearly defined in trampoline and minitrampoline injuries. However, both of these devices are dangerous when used in the best of circumstances, and their use has no place in recreational, educational, or competitive gymnastics. The emergence of severe cervical spine injuries resulting from ice hockey is recognized. Methods, based on sound scientific evidence, to modify the games so as to prevent these injuries are lacking.

Accuracy of standard radiographic views in detecting cervical spine fractures

Recent studies have challenged the accuracy of standard radiographs for detecting cervical spine injuries. We used thin-section tomography to determine the accuracy of the cross-table lateral view (CTLV) alone, and the three standard emergency department views (CTLV, anteroposterior, and open-mouth) together, for detecting acute cervical spine fractures. Seventy-one patients with blunt cervical spine injuries had thin-section tomography performed for the following indications: fracture, dislocation, or suspicious findings on standard radiographs; or persistent severe pain or neurologic deficit. Tomography detected acute fractures in 44 of the 71 patients. The CTLV had a sensitivity of 82%, specificity of 70%, and accuracy of 77% for detecting patients with fractures. The three standard views had a corresponding sensitivity, specificity, and accuracy of 93%, 71%, and 84%, respectively. Eight patients with fractures had the CTLV interpreted as normal, and three patients with fractures had all three standard views interpreted as normal. The use of thin-section tomography is recommended when there are suspicious radiographic or clinical findings suggesting a severe cervical spine injury.

Internal metal plate fixation combined with anterior interbody fusion in cases of cervical spine injury.

The authors report their experience with the use of a modified method of internal metal plate fixation combined with anterior interbody fusion in six patients with an unstable lower cervical spine. All of the patients had sustained severe cervical spine injuries in accidents. In most of the cases, the operation was carried out at 1 to 4 weeks after injury. The insertion of the metal plate was very simple and maintained the block bone graft in satisfactory position. This alternative method of internal fixation of the cervical spine was not associated with morbidity, allowed very early mobilization, and shortened the hospital stay.

Treatment of severe cervical spine injuries by anterior interbody fusion with early mobilization.

A follow up study of 24 patients treated for severe injury of the cervical spine is presented. The dislocation was initially reduced by skull traction, which was later replaced by anterior fusion using a tibial graft. Solid fusion occurred in all patients. The neurological improvement was unaffected by the operation. Our conclusion is that anterior fusion as opposed to conservative treatment leads to earlier mobilization, shorter hospitalization, and less costly rehabilitation.

Multiple Dislocations of the Cervical Spine in a Patient with Juvenile Rheumatoid Arthritis and Down??s Syndrome

Both Down's syndrome and juvenile rheumatoid arthritis can cause instability of the cervical spine. Patients with Down's syndrome usually have instability of the atlantoaxial joint. With juvenile rheumatoid arthritis, cervical instability is a manifestation of a more generalized process involving ligamentous laxity, posterior facet ankylosis, and growth disturbances of the vertebral bodies. When the two syndromes occur in the same patient, the potential exists for serious cervical instability. In the 14-year-old girl reported here, the two conditions coexisted, and more severe cervical spine involvement occurred than was originally anticipated. Prior awareness of the combined effects of Down's syndrome and juvenile rheumatoid arthritis on the stability of the cervical spine should be useful in the management of future cases.

The prognosis of patients sustaining severe cervical spine injury (C2-C7 inclusive).

In a study of 145 patients with severe cervical spine injury, it was found that 79 had serious neurological disturbance. A policy of the earliest possible referral to a spinal paralysis service is recommended. Associated injuries and in particular a head injury can make early precise neurological diagnosis difficult, and may affect management of the spinal injury. The use of Gardner Wells Skull Tongs and the Edinburgh Simpson Bed is recommended. Early spinal operation does not influence outcome of neurological function. Anatomical re-alignment of the spine is not essential for neurological recovery. Myelography is very rarely of benefit in assisting diagnosis and treatment. Glucocorticosteroids and Mannitol do not appear to influence neurological recovery. The prognosis in relation to clinical neurological syndromes is discussed.