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

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Presentation on theme: "Upper Cervical Spine Fractures Originally created by Daniel Gelb, MD January 2006 Updated by Robert Morgan, MD; November 2010."— Presentation transcript:

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 Biomechanically Specialized –Support of “large” Cranial mass –Large range of motion Flexion/extension Axial rotation Unique osteological characteristics

6 Large Cranial Mass 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 Keel below the SNL is thick bone

7 Confluence of Issues 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 Bicortical screws in the occiput may enter the transverse sinus Decreased risk below the superior nuchal line

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

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 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

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

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

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

17 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 The trabecular anatomy of the axis Authors:Heggeness,M.H. ; Doherty,B.J.Source:Spine, 1993, 18, 14, , UNITED STATESHeggeness,M.H.Doherty,B.J.Spine

18 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

19 Atlanto-Axial Anatomy Tectorial Membrane

20 Atlanto-Axial Anatomy Occiput C1 C2 Tranverse Ligament C1-C2 joint Alar Ligament

21 Atlanto-Axial Anatomy Transverse Ligament Facet for Occipital Condyle

22 Atlanto-Axial Anatomy Vertebral Artery

23 Radiographic Evaluation

24 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

25 Radiographic Diagnosis – Screening Lines Powers’s Ratio Harris’s lines

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

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

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

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

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

31 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

32 Cranio-cervical Dislocation Antlanto-Occipital Joint Occipito-Cervical Joint Cranio-cervical Joint Atlanto-Axial Joint

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

34 Cranio-cervical Dislocation Commonly Fatal Present 6-20% of post mortem studies –Alker et al, 1978 –Bucholz & Burkhead,1979 –Adams et al, % missed injury rate 1/3 Neurological Worsening –Davis et al, 1993

35

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

37 Check the Cranial Nerves!

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

39 Atlas Fractures - Treatment Collar 1.Isolated anterior arch 2.Isolated posterior arch 3.Non-displaced Jefferson fracture

40 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

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

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

43 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)

44 Elderly and the Odontoid 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 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, , United StatesPlatzer,P.Thalhammer,G.Ostermann,R.Wieland,T.Vecsei,V. Gaebler,C.Spine 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 , United StatesPlatzer,P.Thalhammer,G.Sarahrudi,K.Kovar,F.Vekszler,G. Vecsei,V.Gaebler,C.Neurosurgery 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, , United StatesPlatzer,P.Vecsei,V.Thalhammer,G.Oberleitner,G.Schurz,M. Gaebler,C.Spine 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 StatesKuntz,C.,4thMirza,S.K.Jarell,A.D.Chapman,J.R. Shaffrey,C.I.Newell,D.W.Neurosurg.Focus. 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 StatesHarrop,J.S.Przybylski,G.J.Vaccaro,A.R. Yalamanchili,K.Neurosurg.Focus.

45 Fracture Classification Anderson and D’Alonzo Type I 2 % (2/49) Type II % (32/49) Type III % (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, , UNITED STATESAnderson,L.D.D'Alonzo,R.T.J.Bone Joint Surg.Am.

46 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.NGrauer,J.N et al Proposal of a modified, treatment-oriented classification of odontoid fractures. Spine J., 2005, 5, 2, Spine J.

47 Acute Management Spinal cord injury rare (17/226) Airway compromise –0/8 nondisplaced –1/21 anterior displacement –13/32 posterior displacement (2 deaths) 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 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

48 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

49 Treatment Options odontoid fracture Type 2 C-Collar SOMI / Minerva Halo Vest Odontoid Screw C1-2 posterior fusion

50 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

51 Anterior Screw History Note reduced dorsal cortex

52 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, , UNITED STATESApfelbaum,R.I. Lonser,R.R.Veres,R.Casey,A.J.Neurosurg.

53 Anterior Screw Technique Need to enter body caudal portion of promontory Midline for single screw placement 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, , UNITED STATESApfelbaum,R.I. Lonser,R.R.Veres,R.Casey,A.J.Neurosurg.

54 Anterior Screw Technique Critical to cross rostral cortex Critical to use lag screw technique Limited support for second screw 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, , UNITED STATESApfelbaum,R.I. Lonser,R.R.Veres,R.Casey,A.J.Neurosurg.

55 One or Two Screws? No significant difference biomechanically –Sasso –Graziano No difference clinically –Apfelbaum –Jenkins

56 Screw Mechanics A comparative study of fixation techniques for type II fractures of the odontoid processAuthors:Graziano,G.; Jaggers,C.; Lee,M.; Lynch,W.Source:Spine, 1993, 18, 16, , UNITED STATES

57 Screw Mechanics 13 cadavers Load to failure –Extension-deflection –45 0 oblique No difference between one and two screws Failure mode is screw pullout from body Anatomic reduction without comminution Biomechanics of odontoid fracture fixation. Comparison of the one- and two-screw techniqueAuthors:Sasso,R.; Doherty,B.J.; Crawford,M.J.; Heggeness,M.H. Source:Spine, 1993, 18, 14, , UNITED STATESSasso,R.Doherty,B.J.Crawford,M.J.Heggeness,M.H.Spine

58 Apfelbaum Clinical Outcomes 147 patients –129 (117) <6 months –18 > 6 months 88% fusion rate –Recent fractures –Horizontal and posterior oblique –No difference between one or two screws 25% fusion rate in remote fractures 10% implant complication –Screw pullout of C2 body 1% perioperative mortality –6% within 30 days

59 Jenkins Clinical Outcomes 42 patients 8.5 month followup 15% nonunion rate (plain radiographs) 5% perioperative mortality 10% 3 month mortality A clinical comparison of one- and two-screw odontoid fixationAuthors:Jenkins,J.D.; Coric,D.; Branch,C.L.,Jr Source:J.Neurosurg., 1998, 89, 3, , UNITED STATES Mal-reduction Incorrect entry point

60 Posterior Odontoid Stabilization

61 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/lamina screw

62 Wiring Techniques Biomechanical comparison of C1-C2 posterior arthrodesis techniquesAuthors:Papagelopoulos,P.J.; Currier,B.L. ; Hokari,Y.; Neale,P.G.; Zhao,C.; Berglund,L.J.; Larson,D.R.; An,K.N. Source:Spine, 2007, 32, 13, E363-70, United StatesPapagelopoulos,P.J. Currier,B.L.Hokari,Y.Neale,P.G.Zhao,C.Berglund,L.J.Larson,D.R.An,K.N.Spine

63 Trans-articular Screw Technique Primary posterior fusion C1/2 in odontoid fractures: indications, technique, and results of transarticular screw fixation Authors:Jeanneret,B.; Magerl,F.Source:J.Spinal Disord., 1992, 5, 4, , UNITED STATESJeanneret,B. Magerl,F.J.Spinal Disord.

64 Wiring Mechanics Biomechanical comparison of C1-C2 posterior arthrodesis techniquesAuthors:Papagelopoulos,P.J.; Currier,B.L. ; Hokari,Y.; Neale,P.G.; Zhao,C.; Berglund,L.J.; Larson,D.R.; An,K.N. Source:Spine, 2007, 32, 13, E363-70, United StatesPapagelopoulos,P.J. Currier,B.L.Hokari,Y.Neale,P.G.Zhao,C.Berglund,L.J.Larson,D.R.An,K.N.Spine

65 Posterior Wiring Outcomes

66 C1C2 Segmental Instrumentation Posterior C1-C2 fusion with polyaxial screw and rod fixationAuthors:Harms,J.; Melcher,R.P.Source:Spine, 2001, 26, 22, , United StatesHarms,J.Melcher,R.P.Spine

67 ..

68 pedicle Pars Trans-articular C2 pars/pedicle

69 Harm’s Mechanics Hott et al: Biomechanical comparison of C1-2 posterior fixation techniques. J Neurosurg Spine 2: LC1-PC2 performs similar to transarticular screws Transarticular screws with graft stiffest construct Interspinous graft behaves as intact specimen regarding lateral bending

70 Harm’s Outcomes 37 patients 100% fusion 1 wound infection 102 patients 98% fusion rate Navigation Allograft/BMP 2 dissection VA injury 1 neuropathic pain (C2 root sacrifice) 4 wound infections Stabilization of the atlantoaxial complex via C-1 lateral mass and C-2 pedicle screw fixation in a multicenter clinical experience in 102 patients: modification of the Harms and Goel techniquesAuthors:Aryan,H.E.; Newman,C.B.; Nottmeier,E.W.; Acosta,F.L.,Jr; Wang,V.Y.; Ames,C.P.Source:J.Neurosurg.Spine, 2008, 8, 3, , United StatesAryan,H.E.Newman,C.B.Nottmeier,E.W. Acosta,F.L.,JrWang,V.Y.Ames,C.P.J.Neurosurg.Spine Posterior C1-C2 fusion with polyaxial screw and rod fixationAuthors:Harms,J.; Melcher,R.P.Source:Spine, 2001, 26, 22, , United StatesHarms,J.Melcher,R.P.Spine

71 Posterior Fusion Takehome Catastrophic failures reported for trans-articular screws alone Trans-articular screws with wired bone graft is stiffest construct –Requires intact C1 lamina –Requires reducible C1-2 facets –Requires favorable anatomy Gallie wiring is inadequate without two supplemental screws No advantage of either wiring construct with two transarticular screws Harm’s technique is most flexible Think about hooks?

72 Traumatic Spondylolisthesis Axis (Hangman’s Fracture) Second most common fracture of axis 25% of C2 injuries Most common mechanism of injury is MVA

73 Hangman’s 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 < 6 mm displaced Coric et al JNS 1996

74 Where Cranio-cervical meets Subaxial Levine AM, Edwards CC: The management of traumatic spondylolisthesis of the axis. J Bone Joint Surg Am 1985; 67:

75 Hangman Fracture Dysphagia and Dysphonia Resolved immediately with halo adjustment Intact disk defines Type I Halo treatment difficult with torn disk (types II and III) Exercise caution

76 Hangman’s Fracture Treatment Types II and III Treatment Posterior –Open reduction and C1-C3 fusion –Direct pars repair and C2-C3 fusion Anterior –C2/C3 ACDF with instrumentation

77 Atlanto-axial Rotatory Subluxation Fuentes et al Traumatic atlantoaxial rotatory dislocation with odontoid fracture: case report and review. Spine 2001; 26(7)

78 Atlanto-axial Rotatory Subluxation Traction/halo Posterior fusion Lateral facetectomy, reduction, fusion Transoral facetectomy, reduction, fusion

79 Halo Immobilization

80 Halo Frank Bloom –Apparatus for stabilization of facial fractures –“Maxillofacial surgeon” (actually a Navy orthopaedic surgeon) –World War II: treated pilots with inwardly displaced facial fractures –Similar design Incomplete ring with 3 pin tiara The history of the halo skeletal fixator O'Donnell,P.W.; Anavian,J.; Switzer,J.A.; Morgan,R.A. Spine, 2009, 34, 16,

81 The Basics The halo fixator Bono,C.M. J.Am.Acad.Orthop.Surg., 2007, 15, 12,

82 Pin Placement The halo fixator Bono,C.M. J.Am.Acad.Orthop.Surg., 2007, 15, 12,

83 If you would like to volunteer as an author for the Resident Slide Project or recommend updates to any of the following slides, please send an to Halo in Elderly Tashijan J. Trauma 2006 –78 patients, age > 65yo –Type II or III odontoid fractures –Increased early morbidity and mortality Compared with treatment using operative fixation or rigid collar Van Middendorp JBJS 2009 –239 patients –All ages in halo –No increased risk of pneumonia or death in patients >65 years old Halo vest immobilization in the elderly: a death sentence? Majercik,S.; Tashjian,R.Z.; Biffl,W.L.; Harrington,D.T.; Cioffi,W.G. J.Trauma, 2005, 59, 2, 350-6; discussion 356-8Majercik,S. Tashjian,R.Z.Biffl,W.L.Harrington,D.T.Cioffi,W.G.J.Trauma Incidence of and risk factors for complications associated with halo- vest immobilization: a prospective, descriptive cohort study of 239 patients van Middendorp,J.J.; Slooff,W.B.; Nellestein,W.R.; Oner,F.C. J.Bone Joint Surg.Am., 2009, 91, 1, 71-79

84 OTA about Questions/Comments If you would like to volunteer as an author for the Resident Slide Project or recommend updates to any of the following slides, please send an to Thank You Return to Spine Index


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