Upper Cervical Spine Fractures

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Upper Cervical Spine Fractures

• Daniel Gelb, MD
• Created January 2006

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Upper Cervical Spine Fractures

• Epidemiology
• Anatomy
• Radiology
• Common Injuries
• Management Issues

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Upper Cervical Spine Fractures

• Epidemiology
• Cause
• MVC 42
• Fall 20
• GSW 16
• Gender
• Male 81
• Female 19

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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
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Upper Cervical Spine Fractures

• Epidemiology
• Level of Education
• To 8th Grade 10
• 9th to 11th 26
• High School 48
• College 16

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Employment Status
Source National Spinal Cord Injury Statistical
Center, University of Alabama at Birmingham, 2004
Annual Statistical Report, June, 2004
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Percent Employed
Source National Spinal Cord Injury Statistical
Center, University of Alabama at Birmingham, 2004
Annual Statistical Report, June, 2004
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Upper Cervical Anatomy
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Upper Cervical Anatomy

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

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C1 - Atlas

• No body
• 2 articular pillars
• Flat articular surface
• Vertebral artery foramen
• 2 arches
• Anterior
• Posterior
• Vertebral artery groove

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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

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C2 Anatomy

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

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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

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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

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AtlantoAxial Anatomy
Tectorial Membrane
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AtlantoAxial Anatomy
Tranverse Ligament
occiput
C1
C1-C2 joint
C2
Alar Ligament
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AtlantoAxial Anatomy
Transverse Ligament
Facet for Occipital Condyle
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AtlantoAxial Anatomy
Vertebral Artery
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Radiographic Evaluation
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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
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Radiographic Diagnosis Screening Lines
Harriss lines
Powerss Ratio
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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
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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
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Radiographic Diagnosis
CT Scan

• Same rules as with plain films
• Better visualization of craniocervical junction
• Subluxation
• Focal hematomas
• Occ condyle fx
• Dens fx

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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
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Upper Cervical Spine Fractures

• Common Injuries
• Occipital Condyle Fracture
• Occipital Cervical Dislocation
• C1 ring injuries
• Odontoid Fracture
• Hangmans Fracture

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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
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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

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OccipitoAtlantal Dissociation (OAD)

• Symptoms/Findings
• Wallenberg Syndrome
• Lower Cranial nerve deficits
• Horners syndrome
• Cerebellar ataxia
• Cruciate paralysis
• Contralateral loss of pain and temperature

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Occipital Cervical Dissociation

• Treatment
• Emergency Room
• Collar/sandbag
• Halo vest
• Definitive
• Posterior occipital cervical fusion

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Transverse ligament avulsion
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Atlas Fractures - Treatment
Collar Isolated anterior arch Isolated posterior
arch Nondisplaced Jefferson fx
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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

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

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Odontoid Fractures
Anderson and DAlonzo
Type I 2
Type II 50-75
Type III 15-25
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Treatment Optionsodontoid fractures

• Type 1
• C-Collar
• beware unrecognized AOD

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Treatment Optionsodontoid fracture

• Type 3
• C-Collar
• SOMI brace
• Halo Vest
• 10-15 nonunion rate

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Treatment Optionsodontoid fracture

• Type 2
• C-Collar
• SOMI brace
• Halo Vest
• Odontoid Screw
• C1-2 posterior fusion

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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
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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

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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

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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

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Harms J, Melcher RP. Posterior C1C2 fusion with
polyaxial screw and rod fixation. Spine
200126246771.
C1 lateral mass screws
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pedicle
Pars
transarticular
C2 pars/pedicle
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Traumatic Spondylolisthesis Axis(Hangmans
Fracture)

• Second most common fracture of axis
• 25 of C2 injuries
• Most common mechanism of injury is MVA

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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

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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

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Halo Immobilization
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Elderly and Halo-vest Treatment

• In-hospital mortality rates in Pts gt 70 yr age
  Rxd Halo-vest 20 36

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