< Back Dr. Ozcan KAYA Subaxial Cervical Spine Fractures Subaxial cervical spine injuries (C3–C7) are common consequences of high- to moderate-energy trauma, though even low-energy mechanisms can cause significant damage in elderly or ankylosed spines. They result from flexion, extension, compression, or burst mechanisms, most frequently between C5 and C7. Diagnosis begins with ATLS evaluation and cervical immobilization, followed by neurologic assessment and imaging. Standard radiographs (AP, lateral, odontoid) are complemented by CT for fracture detail and MRI for disco-ligamentous complex (DLC) and cord evaluation. Classification systems such as AOSpine, SLIC, and Allen–Ferguson guide management. Stable compression fractures without posterior ligamentous involvement may be managed conservatively using a rigid orthosis, whereas unstable or displaced injuries—especially burst and flexion teardrop fractures—require surgical decompression and fixation. Prognosis depends on the initial neurological deficit, fragment displacement, and timing of surgery; patients with ankylosing spondylitis are at higher risk of neurological deterioration and often need long-segment stabilization. Overview Injury to bony and ligamentous anatomy of C3 to C7 levels Wide range of motion makes this region vulnerable to injury High energy -moderate energy injury mechanism; in elderly low energy trauma Anklylosis Spondylitis very low energy trauma may cause injury Compression,burst, flexion teardrop, extention tear drop mechanisms etc. Cervical spine injury 3% due to blunt trauma ;50% between C5 and C7 Clinical Presentation Focal neurologic deficit, neck pain, torticollis, Reporting diving as the mechanism of injury 1st evaluation is ATLS and suspicion of cervical spine injury requires spinal immobilization Posterior midline tenderness and step off Patient transport with spine board log roll technique *Cervical alignment: In children head size is larger so Alignment of the external auditory meatus with the shoulders, even if this involves a relative extension of the neck, will align the cervical spine in neutral and avoid forward flexion in young children *Standard sensory and motor exam, with reflexes of the upper and lower extremities, should be documented. *Findings of upper motor neuron signs ( muscle weakness, spasticity, hyperreflexia, and clonus) may indicate cord compression *Compromised root may indicate injury level; In cervical spine roots exit above corresponding vertebral body (Figure ROOT MUSCLE TABLOSU) Imaging * An anteroposterior, lateral, and open-mouth odontoid xray views are standard *Normal cervical spine should be 15 to 30 degrees of lordosis from C1 through C7 *NEXUS criterias for radiologic evaluation of cervical spine injury *Multiplanar CT scans *Suspicion of neurologic injury and age over 60, polytrauma patients, cervical spondylosi, and a patient that cannot undergo evaluation due to a low GCS or other altered mental status needs MRI Classification 1-AOSpine Subaxial Cervical Spine Injury Classification (LINK) fracture type, facet injury, neurological status, and the presence of specific modifiers 2-Subaxial Injury Classification System (SLIC) (LINK+ FIGURE) the type of fracture, the competency of the DLC, and the patient’s neurologic status 3-Allen and Ferguson Classification (FIGURE) *Subaxial cervical spine injuries are the result of compression or distraction forces that cause flexion or extension moments. Treatment Conservative treatment: *Rigid cervical/cervicothoracic orthosis for 6 to 12 weeks and follow-up with interval radiographs to evaluate alignment ( compression fractures; no posterior ligamentous or capsular involvement-stable fracture pattern) *High risk of posttraumatic kyphosis with conservative treatment if the fracture is a C7 Surgery: *Unstable fracture w/wo neurologic compromise needs decompression and fixation *Burst fractures mostly unstable w/wo neurologic deficits and usually require surgical decompression and fixation( displacement to the canal, flexion-type teardrop fractures often treated anterior approach (effected number of levels/intact DLC+ posterior fixation support) * Awake and alert patient; facet dislocations may be reduced with controlled cervical traction (Unilateral dislocations may be locked and inappropriate for closed reduction) *Unconscious and incoorperate patient evaluate with MRI before reduction attempt *Ankylosing spondylitis patient check neuro with intervals; may require long instrumentation Prognosis *Larger fragments compressing cord and advanced injury classification scores are related with poor prognosis also increased time to surgery from injury may cause poor prognosis *60% limits neurologic deficit and 30% improves somewhat *A flexion moment injury and known AS may be associated with late onset neurologic deterioration *AS pts tend to have higher incidence of neurologic complications. References Fehlings MG, Tetreault LA, Riew KD, Middleton JW. Cervical Spine Trauma: Principles of Evaluation and Management. In: Orthopaedic Knowledge Update: Spine 6. AAOS; 2018. Vaccaro AR, Hulbert RJ, Patel AA, et al. The Subaxial Cervical Spine Injury Classification System and Case Examples. Spine (Phila Pa 1976). 2007;32(21):2365–2374. Joaquim AF, Patel AA. Subaxial Cervical Spine Trauma: Evaluation and Surgical Decision-Making. Global Spine J. 2014;4(1):63–70. AOSpine Knowledge Forum Trauma. AOSpine Subaxial Cervical Spine Injury Classification. Eur Spine J. 2015;24(10):2244–2257. Allen BL, Ferguson RL, Lehmann TR, O'Brien RP. A Mechanistic Classification of Closed, Indirect Fractures and Dislocations of the Lower Cervical Spine. Spine (Phila Pa 1976). 1982;7(1):1–27. Mendenhall SK, Mroz TE, Benzel EC. Subaxial Cervical Spine Trauma. Neurosurgery. 2017;80(3S):S139–S145. Previous Next

Spine General Principles Anatomy & Biomechanics Stability Principles Neurologic Assessment Spine Trauma Classifications Imaging Cervical Spine Occipital-Cervical Injuries Atlantoaxial Injuries (C1-C2) Odontoid Fractures Hangman’s Fracture Subaxial Cervical Spine Fractures Facet Dislocations Cervical Myelopathy Cervical Radiculopathy Thoracolumbar Spine Thoracic Spine Fractures Lumbar Spine Fractures Chance Fractures Burst Fractures Compression Fractures Flexion-Distraction Injuries Sacral Fractures Lumbar Disc Herniation Lumbar Spinal Stenosis Degenerative Spondylolisthesis Thoracolumbar Burst Fractures Adult Isthmic Spondylolisthesis Special Considerations Ankylosing Spondylitis & DISH Fractures Osteoporotic Spine Fractures Pediatric Spine Trauma Spinal Cord Injury Management Timing of Surgery Adult Spinal Deformity Adolescent Idiopathic Scoliosis Pediatric Spondylolysis & Spondylolisthesis Congenital Scoliosis Spinal Cord Monitoring Adult Pyogenic Vertebral Osteomyelitis

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< Back Dr. Alper DUNKI University of Health Sciences, Istanbul, Umraniye Research and Education Hospital Dr. Alper Dünki completed his medical education at Yeditepe University Faculty of Medicine and residency training in Orthopaedics and Traumatology at Tekirdağ Namık Kemal University. His primary fields of interest include orthopaedic oncology and trauma. He currently serves as an orthopaedic surgeon at SBÜ Ümraniye Training and Research Hospital. Dr. Dünki is a member of TOTBİD, the Foot and Ankle Surgery Society, and the Young Orthopaedic Surgeons Group (AGUH). Oncologic Orthopaedics alperdunki@gmail.com Previous Next

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< Back Mirels' Score for Upper Limb Metastatic Lesions: Do We Need a Different Cutoff for Recommending Prophylactic Fixation? Conclusions: This study demonstrates moderate to substantial agreement between and within raters using Mirels’ score on upper limb radiographs. However, Mirels’ score had a poor ensitivity and specifity in predicting upper extremity fractures. Until a more valid scoring system has been developed, based on our study, we recommend a Mirels’ threshold of 7/12 for considering prophylactic fixation of impending upper limb pathologic fractures. This contrasts with the current 9/12 cutoff, which is recommended for lower limb pathologic fractures. 🧠 Key Points: Mirels score was originally proposed for metastatic lesions in the lower extremities; its applicability to the upper extremity has been questioned. A score of ≥7 may be sufficient to consider prophylactic fixation in upper extremity metastases. This was a retrospective study analyzing 138 cases. JSES International (2022), Vol 6(4): 675–681 DOI:10.1016/j.jseint.2022.03.006 Previous Next

< Back Dr. Ali Erkan Yenigul Principles of Surgical Resection & Margins Tumour resection aims to achieve oncologic control while preserving function; margin status is critical for local recurrence risk. Historical Background Pre-1940s → Amputation was standard treatment. 1940s sonrası → Tumour resection 1970s → Chemotherapy + Radiotherapy + Limb-sparing surgery standard of care. Basic Principles Wide surgical margin = most important factor for local control. All imaging must be completed before surgery. Surgical planning should be based on imaging close to surgery date . Enneking’s Margin Classification Intralesional Curettage / piecemeal debulking / Macroscopic disease remains Marginal Shelling out via pseudocapsule- reactive zone / May leave satellite or skip lesions Wide En bloc with cuff of normal tissue / Adequate, but skip lesions possible Radical En bloc removal of whole compartment / No residual local disease Natural Barriers Bone: Cortical bone, articular cartilage Joint: Articular cartilage, capsule Soft tissue: Fascial septa, tendon origins/insertions Barrier effect : Fascia, tendon sheath, vascular sheath, cartilage act as protective margins Critical Points in Limb-Sparing Surgery Poor biopsy incision Major vascular involvement Motor nerve sacrifice Preoperative infection Expected poor motor function after resection ➡️ These complicate but do not always contraindicate limb-sparing surgery. Advanced Techniques Microsurgical reconstruction Tendon transfers, nerve/vessel grafts Flap coverage after large resections Role of Adjunctive Therapies Neoadjuvant chemotherapy/radiotherapy → may shrink tumour, improve margin status. Wide margins still required even after neoadjuvant treatment. Practical Margin Rules Bone tumours: ≥ 3 cm bone marrow margin on T1 MRI. Soft tissue tumours: Aim for ≥ 2 cm margin. References Enneking WF. Musculoskeletal Tumor Surgery. New York: Churchill Livingstone; 1983. Simon MA, Springfield DS. Surgery for Bone and Soft-Tissue Tumors. Philadelphia: Lippincott-Raven; 1998. Healey JH, Lane JM. Operative Techniques in Orthopaedic Surgical Oncology. Philadelphia: Lippincott Williams & Wilkins; 1996. (For the figures and the margin classification) Mankin HJ, Hornicek FJ. Diagnosis, classification, and management of soft tissue sarcomas. Cancer Control. 2005;12(1):5–21. O’Donnell RJ, Springfield DS, Motwani HK, et al. Recurrence of giant-cell tumors of the long bones after curettage and packing with cement. J Bone Joint Surg Am. 1994;76(12):1827–33. Previous Next

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