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Lower Cervical Burst Fractures

- See:
       - Cervical Compression Frx:
       - Burst Frx of Spine
       - Flexion Tear Drop Frx
       - Extension Teardrop Frx of C2

- Discussion:
    - may be clinically & radiographically similar to flexion teardrop frx;
         - its important to distinguish these two, since, neurologic deficits assoc w/ burst frx may be transient & therefore have better prognosis 
              than deficits resulting from a flexion injury;
    - features of burst frx include disruption & vertical frx thru body, posterior element frx, anterior wedge deformity, & retropulsed 
           fragments w/ verying degrees of narrowing of canal as a result of fragments;
    - highest in-hospital mortality from cervical spinal cord injury is related to C4-C5-level spinal cord disruption;
    - comminuted burst fractures are usually caused by axial loading plus flexion moment and often results from diving injuries;
    - vertebral body is comminuted, & bony fragments are retropulsed into spinal canal, injuring the cord;
    - these frx are unstable and are frequentlly complicated by disastrous neurologic injury as a result of damage to both the anterior and 
           posterior columns of the cervical spine;
    - mechanism:
           - associated w/ axial loading with neck in neutral position will cause comminuted burst fracture;
           - typically w/ burst frx, neck is in neutral position, body frx is verticle, & there is no disruption of posterior soft tissues, which are 
                  features not seen w/ flexion teardrop frx;
                  - axial load force w/ neck in flexion causes tearing of posterior ligaments & dislocation seen in flexion teardrop;

- Treatment:
    - frx is reduced by skeletal traction as soon as possible;
    - after pts condition has stabilized, a decision should be made as to whether spinal cord should be decompressed surgically;
    - anterior column failure w/ posterior ligamentous deficit;
            - failure of the anterior vertebral body should always suggest potential disruption of the posterior ligamentous complex;
            - if posterior ligamentous instability is present, posterior wiring & fusion is performed to stabilize posterior structures;
            - then an anterior decompression may be carried out;
    - anterior column failure w/ posterior ligaments intact;
          - if posterior ligaments are intact, then isolated anterior column failure may be treated non operatively w/ hard collar;
          - if decompression is indicated & posterior interspinous ligaments are intact, then anterior vertebral body excision and grafting 
                with an iliac bone strut are indicated;
    - middle column failure:
          - isolated failure of posterior vertebral wall (middle column) w/o posterior ligament failure is an unusual lesion;
          - treatment of middle column collapse w/o neurologic injury entails restoring anatomic alingment with traction, and re-assessment 
                of frx anatomy:
                - following traction, if a bony spike remains within the spinal canal (which correlates w/ an incomplete lesion) then these patients 
                       will require anterior vertebrectomy and strut fusion;
                - if bony alignment is acceptable and no neurologic deficit is present, then consider immobilizing the patient in halo
                        orthosis for 10-12 wks to prevent deformity;
    - w/ incomplete neurologic loss & spinal cord compression, decompression of vertebral fragments is recommended, followed by placement 
          of strut grafts;

- The Edwin Smith Papyrus: Instructions concerning a crushed vertebra of his neck -

    - EXAMINATION: If thou examinest a man having a crushed vertebra in his neck, (and) thou findest that one vertebra
          has fallen into the next one, while he is voiceless and cannot speak ; his falling head downward has caused
          that one vertebra crush into the next one ; (and) shouldst thou find that he in unconscious of his two arms
          and his two legs because of it.

    - DIAGNOSIS : Thou shouldst say concerning him : "One having a crushed vertebra in his neck ; he is unconscious of
          his two arms (and) his two legs (and) he is speechless. An ailment not to be treated".

Subaxial injuries.

Spinal injury at the level of the third and fourth cervical vertebrae from football.

Sagittal measurements of the cervical spine in subaxial fractures and dislocations. An analysis of two hundred and eighty-eight patients with and without neurological deficits.

Arthrodesis of the cervical spine for fractures and dislocations in children and adolescents. A long-term follow-up study.