1. Operative Treatment For Cervical Spine Fractures
Dr. T. G. Hogan

2. Occipito-cervical Dissociation

3. Occipitocervical Instability
Basion-Dens-Interval <12 mm.
>12 mm. Suggests Vertical Instability
Basion-Axial-Interval < 12mm
>12mm. Suggests Anterior Instability
<0mm. Suggests Posterior Instability
Occipitocervical Instability
Basion
Basion Axis Int <12
BDI < 12

4. Occipitocervical Dislocation
Mechanism Unclear
Rotation & Distraction
Neurological Deficits Confusing
High Tetraplegia
Cruciate Paralysis
Wallenberg’s Syndrome
Ligamentous Injuries = Unstable
Avoid Traction

5. Atlas Fractures: Extension
Anterior Arch
Hyper-extension
Avulsion of Longus Colli
R/O Other Injuries
65% (Landells)
Stewart G, Radiology 1977

6. Atlas Fractures: Extension
Posterior Arch Fractures
Occipital Pain & Numbness
Stable
R/O Other Injuries
(Odontoid #)

7. Jefferson Fractures Four Part Burst Axial Load 6.9 mm Overhang
Spence KF, JBJS, 1970
8.1 mm Overhang
Heller JG, J Spinal Disord, 1993

8. Lateral Mass Fractures of C-1
Free-Floating Lateral Mass of C-1
Often Comminuted
Segal & Stauffer, JBJS, 1987

9. Treatment & Results C-1 #’s
Good Results Reported with
Halo Traction + Vest
Rigid or Simple Orthoses
Late Pain:
Ant/Post Arch 50%
Jefferson 70%
Lateral Mass 33%
Landells, VanPeteghem, Spine 1987

10. Anderson & D’Alonzo Classification (JBJS, 1974)
Type I
Type II
Type III

11. Odontoid fractures Type 1 Type 2 Type 3
From Anderson and D’Alonzo JBJS (1974) 56A cited in Chapman and Anderson, Cervical Spine Trauma chapter in Frymoyer JW ed The Adult Spine Second Edition 1997 Lippincott-Raven, Philadelphia

12. Type II Odontoid Halo-Thoracic Brace Non-union Rate 14-32-75%
Risk Factors:
Failure to Treat
5mm Displacement
>10 deg. Angulation
Posterior Displacement
Elderly

13. Type II Odontoid Direct Screw Fixation Preserves C1-2 Motion
No Bone Graft Required
Avoid Non-Unions
Avoid Reverse Oblique #
Aebi, Spine 1989

14. Type II Odontoid Posterior Fusion Trans-articular Facet Screws
Primary
for Non or Delayed Union
Trans-articular Facet Screws
96% Fusion Rate
Restricted Rotation

15. C2 Magerl screw fixation
Good stability
Does not need
odontoid
C1 arch
C2 arch
Challenging

16. Odontoid stabilisation
Osteosynthesis: odontoid screw fixation
Arthrodesis: Magerl screw fixation - challenging
Good stability
Does not need odontoid, C1 arch or C2 arch

17. Traumatic Spondylolisthesis C-2 (Levine & Edwards, JBJS, 1985)

18. Traumatic Spondylolisthesis C-2 (Levine & Edwards, JBJS, 1985)

19. Traumatic Spondylolisthesis C-2 (Levine & Edwards, JBJS, 1985)

20. Traumatic Spondylolisthesis C-2 (Levine & Edwards, JBJS, 1985)
Dislocated

21. Subaxial C-Spine

22. Flexion-compression...
Allen B, The Cervical Spine (Chapter 6) ed Sherk et al, Lippincott, Philadelphia, 1989
Stages of compressive flexion
When to refer…….most GPs would likely refer from stage 3 on, when the anterior column compression is becoming a burst fracture, and when we would begin to add a CT for evaluation and determination of the type of brace or other treatment. 3 4 2 5 1

23. Checklist Approach Applies to trauma and degenerative disease
The more points the more unstable
5 points does not mean surgery occasionally <5 need Sx >5 don’t need Sx
Currently investigated by CSRS
Different considerations for different levels
2-column VS 3-column

24. Sensitivity Settings

25. C2-T1 Usually for trauma, but applies to all
Ant./post. Element failure
Stretch test (1.7mm, >7.5 degrees)
X-Ray (>3.5mm, 11 degrees)
Flex/ext x-ray (>3.5mm, 20 degrees)
Pavlov’s ratio (<0.8) sagittal diameter <13
Narrow disc
Cord damage
Root damage
Dangerous loading anticipated

26. Cervical Measurements

27. Mr. Roeth. C-4 Fracture

28. Mr. Roeth. C-4 Fracture

29. CSLP Ant. & Post Instability

30. Mr. R. Co. C5 & 6 Fractures

31. Mr. R. Co. C5 & 6 Fractures

32. Mr G H C4-5 Facet Dislocation

33. Mr G H C4-5 Facet Dislocation

38. Cervical trauma
Case presentations

39. Cervical trauma
Case 1

40. Patient JM, 16yrs C6 C6 Fell boarding 2/52 ago Full ROM Not tender
“winded”
continued 2/7
hemoptysis 4/7
saw GP
neck xrayed
Full ROM
Not tender C6 C6

41. Patient JM, 16yrs C6 C7
Spot lateral

42. Patient JM, 16yrs C6 C6 C7 C7
Extension
Flexion

43. Patient JM, 16yrs C6 C7
CT reformats

44. New or old injury? Observe only? Stabilise? Snowboarding 2wks ago?
Dirtbike 2yrs ago?
Observe only?
Advice and precautions
Risks
Stabilise?
Anterior or posterior

45. Patient EC, 72f
Initial Xray C5

46. Patient EC, 72f C5
Left CT
Right

47. Patient EC, 72f
T2 MRI C5 C5
Postreduction

48. EC C5 Postop Findings: Interspinous lig torn facet capsules torn
Lig flavum peeled off upper lamina
Postop

49. Cervical trauma
Case 3

50. Patient M, 65yrs
Initial CT

51. Patient M, 65yrs
Initial CT
Left
Right

52. Patient M, 65yrs
Intraoperative
Postop

53. Patient M, 65yrs
Initial CT

54. Patient BB, 32yrs

55. 15lbs
20lbs
10lbs
25lbs
25lbs + 1 day BB

56. BB

57. 3 months
6 months BB