prof. dr. neculai ianovici - "Gr.T. Popa" Iasi

“GR. T. POPA” UNIVERSITY OF MEDICINE AND PHARMACY IASI
ABSTRACT
FRACTURES OF CERVICAL SPINE
Ph.D. CANDIDATE
BOGRIS ELEFTHERIOS
SCIENTIFIC ADVISOR
PROF. DR. NECULAI IANOVICI
IASI 2010
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CONTENTS
GENERAL PART
1. INTRODUCTION
2. EPIDEMIOLOGY OF TRAUMATIC CERVICAL INJURIES
3. NOTIONS REGARDING THE ANATOMY OF THE CERVICAL
RACHIS
4. BIOMECHANICS OF THE CERVICAL SPINE
5. CLASSIFICATION OF CERVICAL VERTEBRAL
TRAUMATISMS
6. TREATMENT OF CERVICAL VERTEBRAL TRAUMATISMS
7. CURRENT DEVELOPMENTS IN THE THERAPY WITH STEM
CELLS IN CERVICAL TRAUMATIC INJURIES
PERSONAL CONTRIBUTION
1. CASE AND STATISTICAL STUDY OF PATIENTS WITH
CERVICAL VERTEBRAL TRAUMATISMS
2. ETIOLOGICAL AND EPIDEMIOLOGICAL DATA REGARDING
THE CERVICAL VERTEBRAL TRAUMATISMS BETWEEN 2005
– 2009 IN THE NEUROSURGERY CLINIC FROM IASI
3. DIAGNOSIS ELEMENTS AND ALGORITHMS IN THE
TRAUMATIC INJURIES OF THE CERVICAL RACHIS
4. ELEMENTS AND ALGORITHMS IN THE MEDICAL AND
SURGICAL TREATMENT OF THE CERVICAL RACHIS
5. CONCLUSIONS
6. BIBLIOGRAPHY
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1. INTRODUCTION
The Romanian society at the end of the 2 nd millennium is marked by deep
modifications in all aspects of life: social, economic, technical, scientific,
ideological and not in the least, medical. The explosive development of
technology, science and the increase of the population, totaling six billion
worldwide, have led to two main aspects. The first one is represented by the
high risk of trauma; the second one by the development of the medical
technique, which, aided by sophisticated means of investigation and
treatment, allows a much better evaluation of the substrate of the injuries.
In this general framework of increase in the frequency of traumatisms, the
vertebro-medullary traumas represent a special category, being among the
worst in traumatic pathology. Morbidity and mortality due to CVMT are
continuously rising making more and more innocent victims and signaling
an increase in the severity of the traumatisms. The traumatic medullar
injuries represent 2% of the deaths following traumatisms.
Cervical vertebro-medullary traumatic injuries are among the most
serious ones in traumatic pathology. There is definitely no other more
dramatic injury than tetraplegy by cervical trauma.
The concept of spinal recovery is based on the rehabilitation techniques
described in 1940 by Sir Ludwig Guttman, in the studies carried out at the
Stoke Mandeville Center in Great Britain (Collins). The mortality of 80-90%
of patients with traumatic medullar injuries, caused by the urologic sepsis or
from eschars, was greatly reduced through the use of skeletal traction, the
improvement of the care techniques and the introduction of rehabilitation
programs.
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2. EPIDEMIOLOGY
VTM represent approximately 1% of the total of traumatisms and around
43% of the pathology of the vertebral spine. The pathology is more often
met in the case of men, aged between 15 and 35. The most frequently
affected spinal segments are: the cervical spine (C6) and the thoraco-lumbar
junction (D12 and L1 vertebrae).
The epidemiology of cervical vertebro-medullary traumatisms studies
the frequency and structure of these injuries, the social and economic impact
they have in modern society.
As far as the anatomic location is concerned, the frequency of the
injuries in descending order would be as follows: C5, C6, C7, C2, C4, C3
and C1 (Arseni and Panoza).
3. NOTIONS OF ANATOMY
The vertebral spine, an organ of axial support providing resistance,
represents a post with a very complex morpho-functional structure and
junction areas of a multitude of cinematic chains. (Arseni and col.).
Inside the cervical spine there are seven vertebrae. A particular
specialization applies in the case of the first two vertebrae, the three middle
ones having specific regional characters while the last two display special
features.
The atlas – is a ring-like bone, the first cervical vertebra. It is formed of
two bony masses called lateral masses, united by two bony arches that
delimitate a large vertebral orifice.
The axis – the main component of the axis, the second cervical spine, is
the odontoid dens. Rising upwards and anteriorly it articulates in a synovial
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junction with the posterior surface of the anterior arch of the atlas. The
transverse ligament which comprises the odontoid process is the most
important support structure for the atlanto-axial articulation.
The odontoid process is a 15-18mm high pivot, overlapping by a few
millimeters the upper rim of the anterior arch of the atlas.
The typical cervical vertebrae are formed of a body, transverse
processes, posterior arches and pedicles. The relatively small vertebral
bodies have the inner surface slightly larger than the upper one, the size
rising in cranio-caudal direction.
The intervertebral discs are non-homogeneous, elastic particular
structures which distort and ensure motility and stability of the motor
segments of the rachis. The intervertebral discs are situated between the
vertebrae, except the atlanto-axial level. The adult disc is avascular and is
structurally formed of the nucleus pulposus, annulus fibrosis and the two
terminal plates of hyaline cartilage.
The spinal channel closes posteriorly through the posterior arch and the
presence of the yellow ligaments, starting with the space between the C2 and
C3 vertebrae. The elasticity of the yellow ligaments limits flexibility and
ensures cervical lordosis. The anterior plication of the yellow ligaments may
contribute to the apparition of medullar compression symptoms (Howard
and col.).
The neurovascular structures of the cervical spine include: the cervical
segment of the spine, the nerve roots, the carotid and vertebral artery, the
laryngeal nerve, the sympathetic chain, the veins and vessels of the spinal
bone marrow. The spinal bone marrow is the segment of the central nervous
system located in the rachidian channel. It has the shape of a slightly antero-
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posteriorly bent cylinder with a transversal diameter of approximately 12mm
and the sagittal one of 8-10mm (Petrovanu and col).
The spinal bone marrow is located in the rachidian channel and
communicates with it through the spinal meninges and the peridural space.
The spinal dura mater represents a fibrous cylindrical tube covering the
marrow, being attached to the circumference of the occipital foramen
magnum. The space between the wall of the vertebral channel and dura
mater is called epidural and contains: adipose tissue filled with spinal nerve
roots and the vessels destined for the marrow, the anterior, lateral and
posterior anchoring meningo vertebral ligaments, the internal vertebral
venous plexus. The epidural space communicates through the intervertebral
holes with the paravertebral spaces.
Although situated closer to the posterior wall of the spinal channel, the
marrow and spinal nerves are most frequently affected by anterior injuries –
fractures or vertebral compression, DIV herniation, tumors. On the
transversal section the spinal marrow appears to be formed of grey matter,
centrally H-shaped distributed and of white peripheral matter.
The white substance is formed of myelinated fibers, glial cells and
blood vessels. It appears under the form of longitudinal columns, forming
ventral, lateral and dorsal medullar columns.
The posterior cord is formed of homolateral fibers of the ascending
gracilis tract (Goll) and cuneatus (Burdach), which transmit conscious
epicritic, fine touch and proprioceptive sensitivity. The lateral cord is formed
of the dorsal spinocerebellar tract (direct, Flechsig) and the ventral
spinocerebellar tract (double cross Gowers) which conveys proprioceptive
sensitivity.
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The antero-lateral is formed of several tracts. The lateral and ventral
spinothalamic tract that conveys thermal, protopathic, pain and partly tactile
sensitivity. The spinotectal tract, well individualized in the cervical segments
forms one of the means of spinovisual reflexes. The descending pathways
are represented by axons of the neurons from the sensomotor areas of the
cerebral cortex or the nuclei of the brainstem. The lateral corticospinal or
cross pyramidal tract is located in the posterior side of the lateral cord. The
corticospinal ventral or direct pyramidal tract is found in the ventral
homolateral cord. The tectospinal tract ventromedially located in the ventral
cord constitutes the support of the postural reflexes triggered by visual and
auditory stimuli. The rubrospinal tract situated in the functional lateral cord
acts on the tonus of the agonist motoneurons (flexor). The vestibulospinal
tract situated in the lateral region of the ventral cord acts on the extensor
alpha neurons, playing an important role in maintaining the vertical position
of the body.
The major contribution in the vascularization of the spine and of the
cervical spinal cord belongs to the vertebral arteries originating in the
subclavian arteries. The major contribution in the medullar vascularization
belongs to the anterior and posterior spinal arteries.
Anterior microangiographic studies on the marrow described the
plexus: by overlapping the osteodiscal elements and connecting them
through ligaments and muscles an approximately 2cm opening is formed.
This tunnel contains the radicular nerve, the spinal ganglion and the ramus,
anterior of the spinal nerve.
Through the middle of the trajectory formed by the overlapping of the
transversal openings passes the vertebral artery, situated prior to the nerve
ramus and accompanied by a venous plexus and the vertebral nerve.
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4. THE BIOMECHANICS OF THE CERVICALE SPINE
The cervical spine is subject to various flexing, rotation, extension, vertical
compression or tearing forces which may cause injuries to the bony,
ligamentary, vascular and nerve elements of the spine. The understanding of
the mechanisms of the injuries at the level of the atlanto-occipital region and
that of the upper cervical spine results from the regional anatomical
particularities.
The injury in hyperextension which causes the rupture of alar,
transverse ligaments of the tectorial and cruciform membrane condition an
atlanto-occipital dislocation. Such injuries appear in the case of blows under
the chin followed by cervical hyperextension and result in a posterior
dislocation of the occiput on the CI vertebra.
The blows to the back and head may also cause fractures of the
posterior arch of the atlas or odontoid. The head or neck hyperflexion may
condition or associate a fracture of the anterior arch of the atlas. A particular
injury at this level is the cervicomedullar transaxial injury which appears as
the result of a direct blow in the vertex, without fractures of the skull or the
cervical spine. This results in an immediate cardio respiratory paralysis and
death of the patient due to petechial hemorrhages in the upper region of the
spinal marrow.
The stable and unstable spinal injuries are determined in the context of
the current vertebro-medullar traumatism. If the fractured fragment allows
the possibility of modification of position until recovery, then this fracture is
considered unstable. The fractures where the bone fragments dislocate
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causing neurological affections during the healing period are also considered
unstable.
For the cervical spine, a vertebral subluxation larger than 3.5mm and an
angulation exceeding 11° indicate a major ligamentary instability.
5. CLASSIFICATION OF CERVICAL VERTEBRAE
TRAUMATISMS
In the present literature there is no universally accepted classification of
the cervical vertebro-medullar traumatisms (cervical spine injury - in Anglo-
Saxon literature). According to Putti quoted by Arseni and col., there are two
major groups from the point of view of the injuries:
1. Rachidian injuries affecting the elements of the rachidian channel
called “myelic”;
2. Rachidian injuries without neurological symptoms or “amyelic”.
Frankel and col. Quoted by Vale and col. elaborated a classification of
the neurological deficit associated to vertebro-medullar traumatisms which
proves to be very useful in evaluating the evolution of the neurological
impairments:
Degree A – total absence of motility and sensitivity;
Degree B – absence of motility with preservation of sensitivity;
Degree C – intact motor functions but functionally useless;
Degree D – good motor power, useful;
Degree E - neurological absent deficit.
The fractures of the occipital condyles are isolated or may be
associated with injuries of the odontoid and the atlanto-occipital
complex. They are frequently associated with major neurological
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affections such as ventilation dependent tetraplegy and dysfunctions
of the cranio-caudal nerves.
The atlanto-occipital dislocation is probably caused by forces in
hyperextension or hyperflexation. This injury represents an anterior or
posterior subluxation or dislocation of the skull in relation to the upper
cervical spine.
The fractures of the atlas constitute approximately 3 – 13% of the
injuries of the cervical spine and are associated by neurological dysfunctions
in 53% of the cases. These fractures are frequently associated with the
fracture of the axis and of the occipital condyles. At this level there are four
types of fractures: fractures of the posterior arch, fractures of the lateral
masses, the Jefferson fracture and the horizontal fracture of the atlas.
6. TREATMENT OF TRAUMATIC INJURIES OF THE CERVICAL
RACHIS
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The protocol of the treatment of the acute medullar traumatic injury
systematizes the data shown above (illustration cf. Vale F. L. and col.).
The study of the complex medical and surgical treatment of CVTM
cannot be complete without the analysis of possible complications.
The gastrointestinal hemorrhages usually appear in the case of
tetraplegic patients. According to Bohlman, these complications appeared in
41% of the cases treated with steroids and only in 9% of the lot who were
not prescribed this medication.
Pulmonary embolism has a low incidence according to the same author
and requires prophylactic mechanical and pharmacological measures.
The “halo” type immobilization has a complication rate of
approximately 12-27%. The most frequent complications include:
suppurations of soft tissue around skull fixing screws, eschars at the level of
the plate, loosening of the fixture of the skull ring.
A special category is formed by patients with ankylopoetic spondylitis
and traumatisms in hyperextension. At these patients, the complications are
related to the absence of reducible major ligamentary injuries and of massive
epidural hemorrhage met, according to Bohlman, at approximately half of
the total number of patients.
The direct introduction of bacteria during the surgical intervention may
cause suppurations of the cervical spine. The perforations of the esophagus
during anterior approach may lead to esophageal and nasogastric fistulas and
long term medication with antibiotics – up to three months – may cure the
problem.
Although extremely rare, the injuries of the carotid and vertebral
arteries may be fatal. The dilacerations of the carotid artery require prompt
vascular suture.
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Another complication is the cerebral vascular stroke following arterial
thrombosis. Prophylaxis indicates the periodical suppression of traction on
the vascular wall.
The hypoglossal, upper larynx and recurrent nerve are most frequently
injured during the anterior approach. Knowledge of regional anatomy is
mandatory.
The medullar injury and dural fistulas are produced during corpectomy
due to sudden movements or due to enlargement of a partial rupture of the
LLP in view of inspecting the spinal channel for free bony or discal
fragments.
Pseudarthrosis roza is another complication of anterior cervical fusion.
Usually it is asymptomatic and does not require treatment.
Later complications include instability, persistent medullar
compression, progressive degeneration of neurological functions and
pseudarthroses or instability on different other levels.
The early identification of the cervical traumatic injuries and the
appropriate medical and surgical treatment may diminish the number of
subsequent complications.
7. ACTUALITIES IN THE THERAPY WITH STEM CELLS IN
CERVICAL VERTEBRAL TRAUMATIC INJURIES
The initial mechanic treatment is followed by a cascade of biochemical
and cellular reactions which cause the extension of the death of nerve cells,
interruption and demyelinization of nerve fibers and induce the apparition of
an inflammatory response.
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The area of medullar injury sometimes extends to several segments above
and below the initial injury, during the following days and weeks.
These secondary injuries have a cumulative effect and increase the
volume of the medullar injury; later, the glial cells start forming the glial
scar which becomes a barrier that prevents the possible recovery and axon
reconnection.
Christian A. Mueller and col. proved the important role of IL-16 in the
immediate post-injury immune response, intervening in the recruitment and
activation of immune cells, triggering the process of obstruction at the level
of microcirculation, the progression of secondary injuries. The authors used
male rats aged between 8 and 12 weeks to whom they caused medullar
injuries then divided them in groups of 5 and euthanized them 1, 3, 7, 14 or
30 weeks after the injuries.
→ the specificity of antibodies IL-16 in the spinal tissue is confirmed by the
selective inhibition of discoloration after pre-incubation for 3 hours in ice
with an excess of peptides IL-16, while the addition of an irrelevant
recombined control peptide (AIF-1) did not block discoloration.
→ immunoreactivity IL-16 is detected in most neurons;
→ only few IL-16 cells are detected in the Virchow-Robin-like spaces
adjacent to the blood vessels, while the neurons of dorsal ganglions prove a
positive reaction to IL-16
→ in comparison with the control medullar sections, after the injury of the
central system there is an accumulation of microglia and macrophage
without neurotic injuries in the close vicinity of the peri-injuries – they
represent regions where secondary injuries characterized by a morphological
structure of amoebaean microglia are developed;
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→ 3 days after the injury a new subpopulation of microglia/macrophage IL-
16 cells may be noticed, which contain multivacuolar cytoplasm and large
eccentric nuclei;
→ in the central system there is an increase in the number of IL-16 cells up
to perivascular accumulations, perivasculary located;
→ IL-16 cells coexist with the expression of ED1, OX-6 or OX-8 antigens;
→ coexpression of IL-16 and GFAP (glial fibrillary acidic protein) and
MBP (myelin basic protein) in the pannecrotic region, in the controlateral
region GFAP and MBP not being coexpressed;
→ more than 70% of perivascular IL-16 and 20% of parenchymatic are
coexpressed with antigens W3/13 and are recognized as T lymphocytes,
some OX-22 lymphocytes are observed in the perivascular spaces;
→ 3 days after the injury, a low number of microglia/macrophage IL-16
coexpress MIB-5, cells whose existence is restrained to the perilocal area.
Sabine Conrad and col. conducted a study on rats to determine the
profibrotic and agiogenic role of CTGF (connective tissue growth factor)
within the glial scar (composed of astroglioses and extracellular matrix
deposits, factors which inhibit axon regeneration). The authors used
immunohistochemistry and fluorescence tests and investigated the degree of
CTGF expression during maturation of glial scar on a period between 1 day
and 30 days after the injury. The researchers used rats to which medullar
injuries were induced, only part of them being operated after the injury, the
rest being used to observe the evolution of the injury.
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PERSONAL CONTRIBUTION
1. STATISTIC AND CASE STUDY OF PATIENTS WITH
CERVICAL VERTEBRAL TRAUMATISMS
I chose for study the time span of 5 years, 2005 – 2009, due to the fact
that, applying for a PhD degree at the Clinic of Neurology from Iasi, during
this period I had the opportunity to participate directly to the treatment of
this category of patients and to monitor their evolution.
The lot of patients under investigation comprised a large age span,
between 20 and 80 years old. The method used was mixed, retrospective and
prospective, using the observation sheets of the patients from the archive of
the Clinic of Neurosurgery from Iasi.
The paper attempts to take into consideration two aspects, to the
maximum extent possible: one that comprises the analysis of all TVMC
admitted in hospital between 2005 and 2009 and another one destined only
to the study of fractures – cervical luxations, due to the differences that exist
with regards to the clinic and therapy. In order to analyze the long-term
prognosis for patients with TVMC, I conceived a questionnaire that was sent
to the patients’ addresses. The number of replies from the patients was
nevertheless small, therefore I wasn’t able to make representative lots for a
statistical study.
Material and statistic method
The method of comparing the same phenomenon between different
categories of patients (differentiated by certain criteria, such as: age groups,
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diagnosis, risk factors, etc.) constitutes a particularly important aspect in the
understanding of the phenomena.
A series of mathematical methods were used in this study,
implemented in the software used for data management, methods that
characterize the “normal” average values of the studied phenomena, or the
dispersion and average error against these values, prognosis methods, etc.
The statistic indicators calculated in the survey allow generalization,
facilitating comparative and correlative interpretation of different subgroups
of the investigated lot, allowing thus to extrapolate the synthesis from
individual characteristics to group characteristics and later to the whole lot.
2. ETIOLOGICAL AND EPIDEMIOLOGICAL DATA REGARDING
CERVICAL VERTEBRAL TRAUMATISMS BETWEEN 2005-2009
IN THE NEUROSURGERY CLINIC FROM IASI
The horse-carriage falls (40.7%) take the first place in the etiology of
FLC, followed by the falls from heights with 28.2%, traffic accidents -
12.7%, falls from the same level, with 9.3%, water diving (5.4%) and other
causes (3.7%).
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Fig. 25. Repartition of cases on mechanisms of production of traumatisms
Fig. 26. Repartition of cases on mechanisms of production of traumatisms
and occurrence environments
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The differences in the causes of production of FLC are better outlined
in the study of these causes according to their place of occurrence.
We would like to examine as well the possible influences of the
patients’ gender on the causes of production of FLC. As can be seen in ( fig.
27) in the case of men the most frequent cause for FLC is represented by the
falls from horse-carriages, followed by the falls from heights and traffic
accidents. In the case of women, the first two causes of production of FLC
are the same, except that the traffic accidents, which come third, are equal in
frequency with the falls from the same height – specific to domestic
accidents.
The Chi-square test does not indicate significant statistic differences
between genders with regards to the production cause of FLC.
Fig. 27. Repartition of cases on mechanisms of production of traumatisms
and genders
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3. ELEMENTS AND DIAGNOSIS ALGORITHMS IN THE
TRAUMATIC INJURIES OF THE CERVICAL RACHIS
The establishment of the diagnosis was made as a rule with
observance of certain consecutive steps: traumatism anamnesis, the presence
of a facial or skull trauma mark, clinical and neurological exam and finally
paraclinical investigations.
Bilateral luxations (51.7%) represent the main type of injuries at
patients with FLC, the percentage of their identification in our study lot
confirming the data published by Alday and col. (1993), who indicate a
proportion of over 40%. Unilateral luxations represent by their frequency
(14.7%) the second type of injuries encountered in the studied series. The
cominutive and compression fractures of vertebrae with subluxations,
although more rarely encountered (9.3%), are in agreement with the
proportion of 8% published by the above mentioned author. The “tear-drop”
type fracture (6.2% of the cases) is part of a larger group of injuries through
compression in flexion encountered in a proportion of 22%. To the group of
injuries through compression in extension, in proportion of 24% published
by the same author, belong the fractures of articular apophysis with
dislocation (3.1% in our lot) as well as the vertebral fracture with dislocation
(4.0%).
In the case of unilateral dislocations, the neurological deficit most
frequently associated was represented by particular syndromes (23 cases)
and radicular (9 cases). In the bilateral dislocations, the medullar trans-
section (105 cases) was dominant as well as particular syndromes (45 cases).
The fracture of articular apophyses with dislocation (only 11 cases) was
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accompanied by radicular syndrome (4 cases) or did not determine any
neurological dysfunctions. The cominutive compressions with subluxations
were associated in most cases with particular syndromes (19 cases) or
radicular (7 cases). All the “tear-drop” like fractures provoked a syndrome
of medullar trans-section (22 cases). The “hangman’s” fracture either
evaluated without neurological deficit (10 out of 17 cases) or, in the rest of
the cases, determined a radicular syndrome (7 cases). The odontoid fracture
with dislocation in most cases (8 cases) did not determine a neurological
deficit; in the other cases it caused a neurological deficit in a varying degree,
ranging from complete deficit (in 5 cases) to the radicular syndrome (5 cases
as well). Finally, the mixed vertebral body fracture, highly neurogenic,
associates in 9 out of 14 cases a complete neurological deficit.
I have also studied a possible association between the types of
vertebral injury and the patients’ sex (fig. 49). No significant differences
were identified statistically between males and females, the situation being
similar with the repartition of the cases in the global lot.
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Fig.49. Repartition of cases on types of cervical vertebral injury and sex (%)
At very young ages (20 – 30 years) the most frequent type of injury was
represented by the compressed/cominutive fracture with subluxations (25%
of the cases). At ages over 31, the most frequent type of injury is the
bilateral dislocation, generating complete neurological deficit, followed by
the unilateral dislocation. It should also be noticed the percentage of
odontoid fractures with dislocation (10.2%) which represents the third type
of injury in frequency for ages 31-40.
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4. ELEMENTS AND ALGORITHMS IN THE MEDICAL AND
SURGICAL TREATMENT OF TRAUMATIC INJURIES OF THE
CERVICAL RACHIS
Medical treatment was used in all cases. In cases with minor
(radicular) neurological deficits or in their absence the treatment was
symptomatic. Antalgics, sedatives and sometimes decontracting medicine
were used for all patients. For all 151 patients with complete neurological
deficit the medical treatment was far more complex. Arterial hypotension
under 85 mmHg, registered in 25 cases required the administration of
hydroelectrolytic solutions (fig. 50). The solutions used were either
physiological serum (12 cases) or glucose serum 5% or 10% (8 cases). In
cases of severe hypotension (5 cases) macromolecular solutions of the type
of dextran and dopamine. The quantity of perfusions in an average of 50 to
60 ml/Kgc/day varied in proportion to the recovery of the arterial tension
and the volume of daily diuresis.
Fig. 50. Administration of hydroelectrolytic solutions: no. of cases
Corticotherapy and diuretics were also prescribed to all patients with
complete neurological defect.
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The therapy with antibiotics was a therapeutic measure used
constantly for all patients with complete neurological defect and for those
who suffered surgery.
Gypsum apparatus of “minerva” type were applied to patients from
the studied lot especially for supplementary stabilization post-surgery in 72
cases. In other 39 cases, the gypsum minerva was applied in the following
types of vertebral injuries: for 17 patients with vertebral compressions and
subluxations, for 11 odontoid fractures with moderate dislocation, for 8
“hangman’s” type fractures and for 3 patients who refused surgery.
From the lot of patients under study, 192 (54.24%) benefited only
from medical treatment while the rest (45.76%) also received surgical
treatment.
Surgical treatment
162 patients received surgical treatment, namely 45.76% of the total
patients studied. The surgical intervention was made to the purpose of
reduction, decompression and stabilization.
The most frequent surgeries were conducted to solve a bilateral
luxation, in 54.3% of cases. Unilateral dislocation take the second place,
with 13.6% of the cases, followed closely by compressed or cominutive
fractures associated with luxations (13.0%). The surgical interventions for
the other types of injuries were rarer, approximately for 3 to 5% of the cases
under study. It is therefore to be noticed that surgical treatment was
conducted more frequently for patients with neurological deficit of Degree C
(86.4% of the total cases).
I have also analyzed the extent to which the patients’ age influences
significantly surgical intervention. It is to be noticed that the number of
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surgical interventions varies significantly from one age group to another (χ 2
= 53.333, p = 0.000, SS), as we shall detail below.
It is to be noticed that if for ages between 20 and 30 only 37.5% of the
cases received surgery, for the other age groups, up to 70 years, surgery was
used in over 40% of the cases. Only for older ages, over 70, the number of
surgical interventions decreased to 24% of the admitted cases.
5. CONCLUSIONS
1. Cervical vertebro-medullar traumatisms are quite frequent and
represent 1.6% of the total of patients admitted in the Clinic of Neurosurgery
Iasi in 4 years. Among them, the cervical fractures – luxations which make
the object of this study represent 23.9%.
2. The cervical spine with its constituents shows a series of anatomical
particularities which make it more vulnerable to traumatic aggressions,
conditioning prominence within the general framework of vertebral
traumatisms.
3. The incidence of TVMC for the Moldavian region within the period of
time studied is of 4 to 100.000 people, being extremely close if not identical
to the data found in the specialty literature.
4. There are significant differences in the geographic repartition of the
number of patients with FLC, thus the Iasi County has a proportion of
30.7%.
5. The male sex is more affected than the female sex, the F/M proportion
obtained in the studied lot being of 1/6. At the same time, men aged over 60
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are even more frequently affected, the F/M relation being unfavorable for
the latter, of 1/9.
6. The age group 41-60 is the most affected by the cervical fractures –
luxations (40%), followed by the group over 60 (35.7%) and the 21-40
group (20.9%).
7. The etiology of the cervical fractures – luxations outlines as a primary
cause the falls from horse-carriages (43.4%). The falls from heights,
domestic accidents and in agricultural labor constitute 31.7%.
8. The analysis of the etiology in relation to age shows that the main
causes follow a specific distribution. Thus with children and adolescents, the
falls from heights come first, followed by water diving, with the same
frequency of 42.9%. Young adults (21-40) suffer more frequently in the case
of falls from heights (41.9%) and traffic accidents (34.9%). The falls from
carriages come first for the age groups 41-60 (52.4%) and over 60 (53.5%).
9. The variation of the etiological incidence in relation to profession
shows that public officials suffer mainly accidents following traffic incidents
(58.3%), workers are mostly affected by falls from heights (50%), farmers
and retired people by falls from horse-carriages (83.3% and 47.9%) and
pupils suffered equally from traffic accidents and falls from heights,
followed by water diving.
10. The seasonal variation in the number of patients with cervical
fractures – luxations shows that during summer and autumn, when
agricultural works is dominant in the population’s activity they cause the
most frequent traumatisms, along with traffic accidents (75.5%).
11. The neurological deficit which conditions the seriousness of
traumatisms measured using the Frankel scale shows the following
distribution: Degree A (complete deficit) – 44.9%, Degree B (incomplete) –
26

8,8%, Degree C (incomplete) – 20.5%, Degree D (incomplete) – 16.1% and
Degree E (absent deficit) – 9.7%.
12. The analysis of the neurological syndromes appeared in the case of
FLC shows on the first place the syndrome of medullar trans-section
(44.9%), followed by particular syndromes (21.5%) and radicular ones
(14.6%). The centromedullar syndrome (7.3%), acute anterior syndrome
(1.5%) and Brown-Sequard (0.5%) have a generally low incidence.
13. The vertebral level the most affected was C5 – C6, followed in order
by C6-C7 (32.7%), C4-C5 (16.6%), C1-C3 (10.8%), C3-C4 (2.4%) and C7-
T1 (1.9%).
14. Vertebral injury types within FLC with determining influence in the
seriousness of the medullar injury had the following distribution in
decreasing frequency order: bilateral dislocation – 52.2%; unilateral
dislocation – 16.1%; vertebral fracture with subluxation – 7.3%; ontoid
fracture with dislocation – 6.3%; „tear-drop” type fracture – 5.4%;
„hangman’s” fracture – 4.4%; articulation fracture with dislocation – 3.4%;
mixed vertebral fractures with dislocation – 2.9%.
15. The incidence of the neurological deficit varies in relation to the type
of vertebral injury. Thus, the FLC are extremely neurogenic injuries.
16. The type of vertebral injury determines the incidence of the
neurological syndrome as follows: unilateral dislocation associates most
frequently particular syndromes (36.4%) and radicular (30.2%); bilateral
dislocation is dominated by medullar trans-section (61,3%) and particular
syndromes (19.8%); the articulation fracture with dislocation was mostly
accompanied by radicular syndrome (57.1%) and in 28.6% of the cases no
neurological dysfunctions were present; the compressions with dislocations
in most of the cases of particular syndromes (49%) and radicular (33.3%);
27

18. The positive diagnosis was based on record data attesting the
traumatisms and the production mechanisms, the local examination, the
evidencing of skull trauma and head configuration, the objective clinical
exam and the paraclinical examinations.
19. The medical treatment was used in all cases, playing a dominant role
in the patients with complete neurological deficit or as adjuvant of surgical
therapy.
20. The medical treatment applied in the first 8 hours from the
traumatism in the case of patients with complete neurological defect may
contribute to the improvement of the functional diagnosis according to the
NASCIS 3current recommendations.
21. The initial vertebral stabilization is an important moment in the
realization of vertebral realignment which creates favorable conditions for
nerve recovery and prevents secondary radiculo-medullar injuries to a
vertebral instability.
22. The surgical treatment was used for 44.9% of the persons in this
study, aiming at reducing, decompressing and stabilizing the injury region.
The injury types for which surgery was used were: bilateral dislocation
(50%), vertebral body with dislocation (16.3%), unilateral dislocation
(15.2%), odontoid fracture and the mixed body fracture, of 5.4%, „tear-
drop” and „hangman’s” fractures of 3.3% and the articulation fracture with
dislocation (1.1%).
23. Surgical interventions were applied more frequently for patients with
incomplete neurological deficit (68.8%), to those without neurological
phenomena (65%) and only in 16,3% of the cases of complete neurological
deficit. Meanwhile, the vast majority (97.8%) of surgical interventions were
carried out 72 hours after the accident, averaging 12.5 days.
28

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