[Surgical procedures to stabilize the upper cervical spine]

Development and first application testing of a new protocol for CT-based stability evaluation of the injured upper cervical spine

PURPOSE

For trauma surgeons, the evaluation of the stability of the upper cervical spine may be demanding. The aim of this study was to develop a protocol for decision-making on upper cervical spine stability in trauma patients based on established parameters obtained by CT imaging as well as testing the protocol by having it applied by trauma surgeons.

METHODS

A structured literature search on upper cervical spine stability was performed. The best evaluated instability criteria in CT imaging were determined. Based on these parameters a protocol for stability evaluation of the injured upper cervical spine was developed. A first application testing was performed. In addition to the assessment of instability, the time required for the assessment was analyzed.

RESULTS

A protocol for CT-based stability evaluation of the injured upper cervical spine based on the current literature was developed and displayed in a flow chart. Testing of the protocol found the stability of the cervical spine was correctly assessed in 55 of 56 evaluations (98.2%). In one test run, a stable upper cervical spine was judged to be unstable. Further analysis showed that this case was based on a measurement error. The assessment time of CT-images decreased significantly during repeat application of the protocol (p < 0.0001), from 336 ± 108 s (first case) to 180 ± 30 s (fourth case).

CONCLUSION

The protocol can be applied quickly and safely by non-specialized trauma surgeons. Thus, the protocol can support the decision-making process in CT-based evaluation of the stability of the injured upper cervical spine.

Maxillofacial trauma - Underestimation of cervical spine injury

Undiagnosed cervical spine injury can have devastating results. The aim of this study was to analyse patients with primary maxillofacial trauma and a concomitant cervical spine injury. It is hypothetised that cervical spine injury is predictable in maxillofacial surgery. A monocentric clinical study was conducted over a 10-year period to analyse patients with primary maxillofacial and associated cervical spine injuries. Demographic data, mechanism of injury, specific trauma and treatments provided were reviewed. Additionally a search of relevant international literature was conducted in PubMed by terms "maxillofacial" AND "cervical spine" AND "injury". Of 3956 patients, n = 3732 (94.3%) suffered from craniomaxillofacial injuries only, n = 174 (4.4%) from cervical spine injuries only, and n = 50 (1.3%) from both craniomaxillofacial and cervical spine injuries. In this study cohort the most prevalent craniofacial injuries were: n = 41 (44%) midfacial and n = 21 (22.6%) skull base fractures. Cervical spine injuries primarily affected the upper cervical spine column: n = 39 (58.2%) vs. n = 28 (41.8%). Only in 3 of 50 cases (6%), the cervical spine injury was diagnosed coincidentally, and the cervical spine column was under immobilised. The operative treatment rate for maxillofacial injuries was 36% (n = 18), and for cervical spine injuries 20% (n = 10). The overall mortality rate was 8% (n = 4). The literature search yielded only 12 papers (11 retrospective and monocentric cohort studies) and is discussed before our own results. In cases of apparently isolated maxillofacial trauma, maxillofacial surgeons should be aware of a low but serious risk of underestimating an unstable cervical spine injury.

[Injuries to the upper cervical spine. Part 2: osseous injuries]

This article for continuing education describes osseous injuries of the upper cervical spine and their treatment. Fractures of the occipital condyles are very rare and mostly result from high-speed traumas. These are usually managed conservatively. Atlas fractures can also usually be treated with immobilization of the cervical spine; in cases of unstable or dislocated injuries, various surgical procedures are employed. Three types of axis fractures can be distinguished: odontoid fractures, traumatic spondylolistheses, which also affect the isthmic region, and atypical fractures in the corpus region. The incidence, classification, diagnostic workup, standard treatment, and characteristics of the fractures mentioned are presented in detail.

[Injuries to the upper cervical spine. Part 1: ligamentous injuries]

This article for continuing education describes ligamentous injuries of the upper cervical spine. Functional radiological imaging studies are particularly important in the diagnostic workup. Computed tomography can serve to visualize additional osseous traumas and magnetic resonance imaging can demonstrate discoligamentous, neuronal, and vascular structures. Traumatic ligamentous instabilities of the upper cervical spine can be categorized into four main groups: occipitocervical dislocation and translational, axial, and rotational atlantoaxial instabilities. The incidence, classification, diagnostic workup, standard treatment, and characteristics of the individual ligamentous injuries are presented. In addition, the topic of combined injuries of the upper cervical spine is addressed.