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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

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

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 2 arches 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 Flat C1-2 joints Vertebral artery foramena
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 STATES

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

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 STATES

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
Tranverse Ligament Occiput C1 C1-C2 joint C2 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
Harris’s lines Powers’s Ratio

26 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

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

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 Dickman et al, J Neurosurg, 1991 Warner et al, Emerg Radiol, 1996

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, 1992 50% 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 Isolated anterior arch Isolated posterior arch 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 Atlas Fractures - Treatment
Fusion options Gallie Post-op halo Brooks Jenkins Transarticular Screws C1 lateral mass/C2 pars-pedicle screws

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 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 , 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, , 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

45 Fracture Classification
Anderson and D’Alonzo Type I % (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 STATES

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

47 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

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 STATES

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 STATES

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 STATES

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 450oblique 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 STATES

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 Mal-reduction Incorrect entry point 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

60 Posterior Odontoid Stabilization

61 Posterior Odontoid Stabilization
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 States

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 STATES

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 States

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 States

67 .

68 pedicle Pars Trans-articular C2 pars/pedicle

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

70 Harm’s Outcomes 102 patients 98% fusion rate 37 patients 100% fusion
Navigation Allograft/BMP 2 dissection VA injury 1 neuropathic pain (C2 root sacrifice) 4 wound infections 37 patients 100% fusion 1 wound infection Posterior C1-C2 fusion with polyaxial screw and rod fixationAuthors:Harms,J.; Melcher,R.P.Source:Spine, 2001, 26, 22, , United States 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 States

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

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

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 Halo in Elderly Tashijan J. Trauma 2006 Van Middendorp JBJS 2009
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 356-8 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 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

84 Thank You 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 OTA about Questions/Comments Return to Spine Index


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