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Upper Cervical Spine Fractures

Upper Cervical Spine Fractures. Originally created by Daniel Gelb, MD January 2006 Updated by Robert Morgan, MD November 2010. Upper Cervical Spine Fractures. Epidemiology Anatomy Imaging Characteristics Common Injuries Management Issues. Epidemiology.

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Upper Cervical Spine Fractures

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  1. Upper Cervical Spine Fractures Originally created by Daniel Gelb, MD January 2006 Updated by Robert Morgan, MD November 2010

  2. Upper Cervical Spine Fractures • Epidemiology • Anatomy • Imaging Characteristics • Common Injuries • Management Issues

  3. Epidemiology • 717 cervical spine fractures in 657 patients over 13 years • C1 and Hangman fractures found more in the young • Odontoid fractures evenly distributed • Younger patients have higher energy injuries • C2 fractures most common The epidemiology of fractures and fracture-dislocations of the cervical spine Ryan,M.D.; Henderson,J.J. Injury, 1992, 23, 1, 38-40

  4. Upper Cervical Anatomy

  5. Upper Cervical Anatomy • Biomechanically Specialized • Support of “large” Cranial mass • Large range of motion • Flexion/extension • Axial rotation • Unique osteological characteristics

  6. Large Cranial Mass • Keel below the SNL is thick bone Roberts, DA; Doherty, BJ; Heggeness MH. Quantitative Anatomy of the Occiput and the Biomechanics of Occipital Screw Fixation Spine 23(10), 15 May 1998, pp 1100-1107

  7. Confluence of Issues • Bicortical screws in the occiput may enter the transverse sinus • Decreased risk below the superior nuchal line Roberts, DA; Doherty, BJ; Heggeness MH. Quantitative Anatomy of the Occiput and the Biomechanics of Occipital Screw Fixation Spine 23(10), 15 May 1998, pp 1100-1107

  8. Occipital Screw Mechanics Roberts, DA; Doherty, BJ; Heggeness MH. Quantitative Anatomy of the Occiput and the Biomechanics of Occipital Screw Fixation Spine 23(10), 15 May 1998, pp 1100-1107

  9. 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

  10. Normal Vertebral Artery

  11. Tortuous Vertebral Artery

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

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

  14. Trabecular Anatomy The trabecular anatomy of the axis Authors:Heggeness,M.H. ; Doherty,B.J.Source:Spine, 1993, 18, 14, 1945-1949, UNITED STATES

  15. Trabecular Anatomy The trabecular anatomy of the axis Authors:Heggeness,M.H. ; Doherty,B.J.Source:Spine, 1993, 18, 14, 1945-1949, UNITED STATES

  16. 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

  17. Atlanto-Axial Anatomy Tectorial Membrane

  18. Atlanto-Axial Anatomy Tranverse Ligament Occiput C1 C1-C2 joint C2 Alar Ligament

  19. Atlanto-Axial Anatomy Transverse Ligament Facet for Occipital Condyle

  20. Atlanto-Axial Anatomy Vertebral Artery

  21. Radiographic Evaluation

  22. Plain Radiographic Evaluation Lateral View Prevertebral Swelling Soft Tissue Shadow <6mm at C2 Concave/Flat Pre-dental space< 3mm Atlanto-Occipital Joint Congruence Radiographic Lines* Open Mouth AP Distraction C1-2 Symmetry

  23. Radiographic Diagnosis – Screening Lines Harris’s lines Powers’s Ratio

  24. Radiographic Lines Harris’ Lines • Basion-Dental Interval (BDI) • Basion to Tip of Dens • <12 mm in 95% • >12 mm ABNORMAL • Basion-Axial Interval (BAI) • Basion to Posterior Dens • -4-12 mm in 98% • >12 mm Anterior Subluxation • >4 mm Posterior Subluxation Harris et al, Am J Radiol, 1994

  25. Radiographic Lines Powers’ Ratio • BC/OA • >1 considered abnormal • Limited Usefulness • Positive only in Anterior Translational injuries • False Negative with pure distraction Powers et al, Neurosurg, 1979

  26. Radiographic Diagnosis CT Scan • Same rules as with plain films • Better visualization of cranio-cervical junction • Subluxation • Focal hematomas • Occipital condyle fractures • Dens fractures

  27. Radiographic Diagnosis MRI Increased Signal Intensity in : • C0-C1Joint • C1-2 Joint • Spinal Cord • Cranio-cervical ligaments • Pre-vertebral soft tissues Dickman et al, J Neurosurg, 1991 Warner et al, Emerg Radiol, 1996

  28. Common Injuries Occipital Condyle Fracture Craniocervical sprain? C1 ring injuries Odontoid Fracture Hangman’s Fracture Uncommon Injuries Craniocervical Dislocation Rotatory subluxation Upper Cervical Spine Fractures

  29. Occipital Condyle Fracture Type I Impaction Fracture Type II Extension of basilar skull fracture Type III ALAR ligament Avulsion Anderson ,SPINE 1988 Tuli, NEUROSURGERY, 1997

  30. Cranio-cervical Dislocation • Antlanto-Occipital Joint • Occipito-Cervical Joint • Cranio-cervical Joint • Atlanto-Axial Joint

  31. Cranio-cervical sprain (stage 1) may be treated nonoperatively

  32. Cranio-cervical Dislocation 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

  33. Symptoms/Findings • Lower Cranial nerve deficits • Horner’s syndrome • Cerebellar ataxia • Bell’s cruciate paralysis • Contralateral loss of pain and temperature Wallenberg Syndrome

  34. Check the Cranial Nerves! www.med.yale.com www.meddean.luc.edu

  35. Cranio-cervical Dislocation • Treatment • Emergency Room • Collar/sandbag • Halo vest • Definitive • Posterior occipital cervical fusion • ALWAYS include C1 and C2

  36. Atlas Fractures - Treatment Collar • Isolated anterior arch • Isolated posterior arch • Non-displaced Jefferson fracture

  37. Atlas Fractures - Treatment Displaced <6.9 mm • Halo vest * 3 mos Displaced >6.9 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 > 5mm

  38. Transverse ligament avulsion • Bony avulsions may heal with nonoperative management • TAL rupture does not heal with nonoperative management and requires C1-C2 arthrodesis

  39. Atlas Fractures - Treatment Fusion options Gallie Post-op halo Brooks Jenkins Transarticular Screws C1 lateral mass/C2 pars-pedicle screws

  40. 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)

  41. Platzer Studies Elderly increased pseudarthrosis rate( 12% v. 8%) Elderly tolerated pseudarthosis well(1/5) Elderly tolerated halo well 10% mortality (4/41) 22% complication rate Chapman studies Elderly did not heal the odontoid fracture (4/17) Elderly tolerated halo well (7/8) 15% mortality (3/20) Harrop and Vaccaro 9/10 “union” 5/10 postop halo 1/10 perioperative death Multiple series of high mortality rates Elderly and the Odontoid Anterior screw fixation of odontoid fractures comparing younger and elderly patientsAuthors:Platzer,P.; Thalhammer,G.; Ostermann,R.; Wieland,T.; Vecsei,V.; Gaebler,C.Source:Spine, 2007, 32, 16, 1714-1720, United States Nonoperative management of odontoid fractures using a halothoracic vestAuthors:Platzer,P.; Thalhammer,G.; Sarahrudi,K.; Kovar,F.; Vekszler,G.; Vecsei,V.; Gaebler,C.Source:Neurosurgery, 2007, 61, 3, 522-9; discussion 529-30, United States Posterior atlanto-axial arthrodesis for fixation of odontoid nonunionsAuthors:Platzer,P.; Vecsei,V.; Thalhammer,G.; Oberleitner,G.; Schurz,M.; Gaebler,C.Source:Spine, 2008, 33, 6, 624-630, United States Type II odontoid fractures in the elderly: early failure of nonsurgical treatmentAuthors:Kuntz,C.,4th; Mirza,S.K. ; Jarell,A.D.; Chapman,J.R.; Shaffrey,C.I.; Newell,D.W.Source:Neurosurg.Focus., 2000, 8, 6, e7, United States Efficacy of anterior odontoid screw fixation in elderly patients with Type II odontoid fracturesAuthors:Harrop,J.S. ; Przybylski,G.J.; Vaccaro,A.R.; Yalamanchili,K.Source:Neurosurg.Focus., 2000, 8, 6, e6, United States

  42. Fracture Classification Anderson and D’Alonzo Type I 2 % (2/49) Type II 50-75 % (32/49) Type III 15-25 % (15/49) Fractures of the odontoid process of the axisAuthors:Anderson,L.D.; D'Alonzo,R.T.Source:J.Bone Joint Surg.Am., 1974, 56, 8, 1663-1674, UNITED STATES

  43. Subtypes of Type II Fractures • Type IIA and B are amenable to anterior fixation • Type IIC is not • Does not include part of facet, not a Type III Grauer,J.N et al Proposal of a modified, treatment-oriented classification of odontoid fractures.Spine J., 2005, 5, 2, 123-129

  44. Acute Management • Spinal cord injury rare (17/226) • Airway compromise • 0/8 nondisplaced • 1/21 anterior displacement • 13/32 posterior displacement (2 deaths) Epidemiolgy of spinal cord injury after acute odontoid fractures JAMES S. HARROP, M.D., ASHWINI D. SHARAN, M.D., AND GREGORY J. PRZYBYLSKI, M.D. Neurosurgical Focus 2000 Don’t do flexion reductions! Closed management of displaced Type II odontoid fractures:more frequent respiratory compromise with posteriorly displaced fractures GREGORY J. PRZYBYLSKI, M.D., JAMES S. HARROP, M.D., AND ALEXANDER R. VACCARO, M.D. Neurosurgical Focus 2000

  45. Definitive Treatment Options Type 1 C-Collar beware unrecognized CCD Type 3 C-Collar 10-15% nonunion SOMI brace Halo Vest Evidence-based analysis of odontoid fracture managementAuthors:Julien,T.D.; Frankel,B. ; Traynelis,V.C. ; Ryken,T.C. Source:Neurosurg.Focus., 2000, 8, 6, e1, United States

  46. Treatment Optionsodontoid fracture Type 2 • C-Collar • SOMI / Minerva • Halo Vest • Odontoid Screw • C1-2 posterior fusion

  47. Anterior Odontoid Screw Fixation Indications • Displaced Type II, Shallow Type III • Polytrauma patient • Unable to tolerate halo-vest • Early displacement despite halo-vest • (Reduces in extension) Contraindications • Non-reducible odontoid fracture • (Reduces in flexion) • Body habitus (Barrel chest ) • Associated TAL injury • Subacute injury (> 6 months) • Reverse oblique • (elderly) Roy-Camille Classification

  48. Anterior Screw History • Note reduced dorsal cortex

  49. Anterior Screw Technique • Skin incision at C5 • Note slight extension • Missing key element in diagram (need to atraumatically obtain open mouth fluoroscopy) • Biplanar fluoroscopy Direct anterior screw fixation for recent and remote odontoid fracturesAuthors:Apfelbaum,R.I. ; Lonser,R.R. ; Veres,R.; Casey,A.Source:J.Neurosurg., 2000, 93, 2 Suppl, 227-236, UNITED STATES

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