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Upper Cervical Spine Fractures

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Title: Upper Cervical Spine Fractures


1
Upper Cervical Spine Fractures
  • Daniel Gelb, MD
  • Created January 2006

2
Upper Cervical Spine Fractures
  • Epidemiology
  • Anatomy
  • Radiology
  • Common Injuries
  • Management Issues

3
Upper Cervical Spine Fractures
  • Epidemiology
  • Cause
  • MVC 42
  • Fall 20
  • GSW 16
  • Gender
  • Male 81
  • Female 19

4
Etiology of Spinal Cord Injury by Age
Source National Spinal Cord Injury Statistical
Center, University of Alabama at Birmingham, 2004
Annual Statistical Report, June, 2004
5
Upper Cervical Spine Fractures
  • Epidemiology
  • Level of Education
  • To 8th Grade 10
  • 9th to 11th 26
  • High School 48
  • College 16

6
Employment Status
Source National Spinal Cord Injury Statistical
Center, University of Alabama at Birmingham, 2004
Annual Statistical Report, June, 2004
7
Percent Employed
Source National Spinal Cord Injury Statistical
Center, University of Alabama at Birmingham, 2004
Annual Statistical Report, June, 2004
8
Upper Cervical Anatomy
9
Upper Cervical Anatomy
  • Biomechanically Specialized
  • Support of large Cranial mass
  • Large range of motion
  • Flexion/extension
  • Axial rotation
  • Unique osteological characteristics

10
C1 - Atlas
  • No body
  • 2 articular pillars
  • Flat articular surface
  • Vertebral artery foramen
  • 2 arches
  • Anterior
  • Posterior
  • Vertebral artery groove

11
Anatomy The Atlas
  • Transition zone between head and c-spine
  • Important anatomical points
  • Superior articular processes allow flex/ext
  • Inferior articular processes are important for
    rotation
  • Notch for vertebral artery is a common fracture
    site

12
C2 Anatomy
  • Dens
  • Embriological C1 body
  • Base poorly vascularized
  • Osteoporotic
  • Flat C1-2 joints
  • Vertebral artery foramena
  • Inferomedial to superolateral

13
Anatomy The Axis
  • Important transition point for forces within the
    c-spine
  • Important anatomical points
  • Superior and inferior articular processes are
    offset in the AP direction- due to different
    functions at each articulation
  • Pars interarticularis- due to this transition is
    a frequent fracture site
  • Odontoid process- the pivot for rotation

14
Anatomy The Ligaments
  • Allow for the wide ROM of upper C-spine while
    maintaining stability
  • Classified according to location with respect to
    vertebral canal
  • Internal
  • Tectorial membrane
  • Cruciate ligament including transverse ligament
  • Alar and apical ligaments
  • External
  • Anterior and posterior atlanto-occipital
    membranes
  • Anterior and posterior atlanto-axial membranes
  • Articular capsules and ligamentum nuchae

15
AtlantoAxial Anatomy
Tectorial Membrane
16
AtlantoAxial Anatomy
Tranverse Ligament
occiput
C1
C1-C2 joint
C2
Alar Ligament
17
AtlantoAxial Anatomy
Transverse Ligament
Facet for Occipital Condyle
18
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19
AtlantoAxial Anatomy
Vertebral Artery
20
Radiographic Evaluation
21
Plain Radiographic Evaluation
Lateral View Prevertebral Swelling Soft Tissue
Shadow lt6mm at C2 Concave/Flat Predental space lt
3mm Atlanto-Occipital Joint Congruence Radiograph
ic Lines Open Mouth AP Distraction C1-2 Symmetry
22
Radiographic Diagnosis Screening Lines
Harriss lines
Powerss Ratio
23
Radiographic Lines
  • Harris Lines
  • Basion-Dental Interval (BDI)
  • Basion to Tip of Dens
  • lt12 mm in 95
  • gt12 mm ABNORMAL
  • Basion-Axial Interval (BAI)
  • Basion to Posterior Dens
  • -4-12 mm in 98
  • gt12 mm Anterior Subluxation
  • gt4 mm Posterior Subluxation

Harris et al, Am J Radiol, 1994
24
Radiographic Lines
Powers Ratio
  • BC/OA
  • gt1 considered abnormal
  • Limited Usefulness
  • Positive only in Anterior Translational injuries
  • False Negative with pure distraction

Powers et al, Neurosurg, 1979
25
Radiographic Diagnosis
CT Scan
  • Same rules as with plain films
  • Better visualization of craniocervical junction
  • Subluxation
  • Focal hematomas
  • Occ condyle fx
  • Dens fx

26
Radiographic Diagnosis
MRI
Increased Signal Intensity in
  • Occ-C1Joint
  • C1-2 Joint
  • Spinal Cord
  • Craniocervical ligaments
  • Prevertebral soft tissues

Warner et al, Emerg Radiol, 1996
Dickman et al, J Neurosurg, 1991
27
Upper Cervical Spine Fractures
  • Common Injuries
  • Occipital Condyle Fracture
  • Occipital Cervical Dislocation
  • C1 ring injuries
  • Odontoid Fracture
  • Hangmans Fracture

28
Occipital Condyle Fracture
  • Type I
  • Impaction Fx
  • Type II
  • Extension of basilar skull fx
  • Type III
  • ALAR LIG AVULSION

Anderson ,SPINE 1988 Tuli, NEUROSURGERY, 1997
29
OccipitoAtlantal Dissociation (OAD)
  • Commonly Fatal
  • Present 6-20 of post mortem studies
  • Alker et al, 1978
  • Bucholz Burkhead,1979
  • Adams et al, 1992
  • 50 missed injury rate
  • 1/3 Neurological Worsening
  • Davis et al, 1993

30
OccipitoAtlantal Dissociation (OAD)
  • Symptoms/Findings
  • Wallenberg Syndrome
  • Lower Cranial nerve deficits
  • Horners syndrome
  • Cerebellar ataxia
  • Cruciate paralysis
  • Contralateral loss of pain and temperature

31
Occipital Cervical Dissociation
  • Treatment
  • Emergency Room
  • Collar/sandbag
  • Halo vest
  • Definitive
  • Posterior occipital cervical fusion

32
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33
Transverse ligament avulsion
34
Atlas Fractures - Treatment
Collar Isolated anterior arch Isolated posterior
arch Nondisplaced Jefferson fx
35
Atlas Fractures - Treatment
  • Displaced lt6.9 mm
  • Halo vest 3 mos
  • Displaced gt6.9 mm
  • Halo traction (reduction) several weeks
    followed by halo vest
  • Immediate halo vest
  • Posterior C1-2 fusion (unable to tolerate halo)
  • After brace treatment complete confirm C1-2
    stability
  • Flexion/extension films
  • C1-2 fusion for ADI gt 5mm

36
Atlas Fractures - Treatment
Fusion options Gallie Post-op halo Brooks
Jenkins Transarticular Screws C1 lateral mass/C2
pars-pedicle screws
37
Odontoid Fractures
  • Most common fracture of Axis
  • (nearly 2/3 of all C2 Fxs)
  • 10 20 of all cervical fractures
  • Etiology Bimodal distribution
  • Young - high energy, multi-trauma
  • Elderly - low energy, isolated injury
  • (most common C-spine Fx elderly)

38
Odontoid Fractures
Anderson and DAlonzo
Type I 2
Type II 50-75
Type III 15-25
39
Treatment Optionsodontoid fractures
  • Type 1
  • C-Collar
  • beware unrecognized AOD

40
Treatment Optionsodontoid fracture
  • Type 3
  • C-Collar
  • SOMI brace
  • Halo Vest
  • 10-15 nonunion rate

41
Treatment Optionsodontoid fracture
  • Type 2
  • C-Collar
  • SOMI brace
  • Halo Vest
  • Odontoid Screw
  • C1-2 posterior fusion

42
Type II Fracture Nonunion Risk Factors
  • Nonunion 10-70
  • Initial displacement gt 6mm
  • Age gt 60 yr old
  • Delay Diagnosis gt 3 wk
  • Angulation gt 10
  • Posterior displacement

Schatzker 1971Anderson 1974Apuzzo
1978 Ekong 1981Hadley 1985Clark 1985Dunn
1986Hanssen 1987Schweigel 1987 Hadley
1989Hanigan 1993Ryan 1993Seybold 1997
43
Anterior Odontoid Screw Fixation
  • Indications
  • Displaced Type II, Shallow Type III
  • Polytrauma patient
  • Unable to tolerate halo-vest
  • Early displacement despite halo-vest
  • Contraindications
  • Non-reducible odontoid fracture
  • Body habitus (Barrel chest )
  • Associated TAL injury
  • Subacute injury (gt 6 months)
  • Reverse oblique

44
Posterior Odontoid Fixation
  • Options
  • Posterior wiring
  • Up to 25 pseudoarthrosis
  • Halo vest necessary (?) Dickman JNS 1996, Grob
    Spine 1992
  • Transarticular screw fixation
  • Magerl and Steeman Cerv Spine 1987
  • Reilly et al, JSD 2003
  • C1 lateral mass - C2 pars/pedicle screw

45
The course of the vertebral artery through C1 and
C2 determines the possibility of placing screws
for fixation of fractures and dislocations
  • C1 lateral mass screws
  • C1-2 transarticular screws
  • C2 pedicle/pars screws

46
Harms J, Melcher RP. Posterior C1C2 fusion with
polyaxial screw and rod fixation. Spine
200126246771.
C1 lateral mass screws
47
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48
pedicle
Pars
transarticular
C2 pars/pedicle
49
Traumatic Spondylolisthesis Axis(Hangmans
Fracture)
  • Second most common fracture of axis
  • 25 of C2 injuries
  • Most common mechanism of injury is MVA

50
Hangmans Fracture
  • Younger age group (Avg 38 yrs)
  • Usually due to hyperextension-axial compression
    forces (windshield strike)
  • Neurologic injury seen in only 5-10 (acutely
    decompresses canal)
  • Traditional treatment has been Halo-vest
  • Collar adequate if lt 6 mm displaced
  • Coric et al JNS 1996

51
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52
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53
Hangmans Fracture Treatment
  • Type III Treatment Options
  • Posterior
  • Open reduction and C1-C3 fusion
  • Direct pars repair and C2-C3 fusion
  • Anterior
  • C2/C3 ACDF with instrumentation

54
Halo Immobilization
55
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56
Elderly and Halo-vest Treatment
  • In-hospital mortality rates in Pts gt 70 yr age
    Rxd Halo-vest 20 36

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