Transcript Upper Cervical Spine Fractures Originally created by Daniel Gelb, MD January 2006

Upper Cervical Spine
Fractures
Originally created by Daniel Gelb, MD
January 2006
Updated by Robert Morgan, MD; November 2010
Upper Cervical Spine Fractures
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Epidemiology
Anatomy
Imaging Characteristics
Common Injuries
Management Issues
Epidemiology
• Younger patients have
higher energy injuries
• C2 fractures most
common
70-79
Age
50-59
c1 ring
odontoid
hangman's
30-39
– Odontoid fractures
evenly distributed
30
25
20
Number of
15
Patients
10
5
0
<20
• 717 cervical spine
fractures in 657
patients over 13 years
• C1 and Hangman
fractures found more
in the young
Upper Cervical Spine Fracture
Demographics
The epidemiology of fractures and fracture-dislocations of
the cervical spine Ryan,M.D.; Henderson,J.J. Injury, 1992,
23, 1, 38-40
Upper Cervical Anatomy
Upper Cervical Anatomy
• Biomechanically Specialized
– Support of “large” Cranial mass
– Large range of motion
• Flexion/extension
• Axial rotation
• Unique osteological characteristics
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
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
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
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
Normal Vertebral Artery
Tortuous Vertebral Artery
C1 - Atlas
• No body
• 2 articular pillars
– Flat articular surface
– Vertebral artery
foramen
• 2 arches
– Anterior
– Posterior
• Vertebral artery groove
C2 Anatomy
• Dens
– Embriological C1 body
– Base poorly vascularized
– Osteoporotic
• Flat C1-2 joints
• Vertebral artery foramena
– Inferomedial to
superolateral
Trabecular Anatomy
The trabecular anatomy of the axis Authors:Heggeness,M.H. ; Doherty,B.J.Source:Spine, 1993, 18, 14, 1945-1949, UNITED STATES
Trabecular Anatomy
The trabecular anatomy of the axis Authors:Heggeness,M.H. ; Doherty,B.J.Source:Spine, 1993, 18, 14, 1945-1949, UNITED STATES
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
Atlanto-Axial Anatomy
Tectorial Membrane
Atlanto-Axial Anatomy
Tranverse Ligament
C1-C2 joint
Occiput
C1
C2
Alar Ligament
Atlanto-Axial Anatomy
Facet for
Occipital
Condyle
Transverse
Ligament
Vertebral
Artery
Atlanto-Axial Anatomy
Radiographic Evaluation
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
Radiographic Diagnosis – Screening Lines
Harris’s lines
Powers’s Ratio
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
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
Radiographic Diagnosis
CT Scan
• Same rules as with plain films
• Better visualization of craniocervical junction
• Subluxation
• Focal hematomas
• Occipital condyle fractures
• Dens fractures
Radiographic Diagnosis
MRI
Increased Signal Intensity in :
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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
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
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
Cranio-cervical Dislocation
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Antlanto-Occipital Joint
Occipito-Cervical Joint
Cranio-cervical Joint
Atlanto-Axial Joint
•Cranio-cervical sprain (stage 1) may
be treated nonoperatively
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
Symptoms/Findings
• Lower Cranial nerve
deficits
• Horner’s syndrome
• Cerebellar ataxia
• Bell’s cruciate paralysis
• Contralateral loss of
pain and temperature
Wallenberg
Syndrome
Check the Cranial Nerves!
www.med.yale.com
www.meddean.luc.edu
Cranio-cervical Dislocation
•Treatment
•Emergency Room
•Collar/sandbag
•Halo vest
•Definitive
•Posterior occipital
cervical fusion
•ALWAYS include C1
and C2
Atlas Fractures - Treatment
Collar
1. Isolated anterior
arch
2. Isolated posterior
arch
3. Non-displaced
Jefferson fracture
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
Transverse ligament avulsion
•Bony avulsions may heal with nonoperative
management
•TAL rupture does not heal with nonoperative
management and requires C1-C2 arthrodesis
Atlas Fractures - Treatment
Fusion options
Gallie
Post-op halo
Brooks Jenkins
Transarticular Screws
C1 lateral mass/C2 pars-pedicle screws
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)
Elderly and the Odontoid
• Platzer Studies
• Harrop and Vaccaro
– Elderly increased
– 9/10 “union”
pseudarthrosis rate( 12% v.
– 5/10 postop halo
8%)
– 1/10 perioperative death
– Elderly tolerated pseudarthosis
• Multiple series of high
well(1/5)
mortality rates
– Elderly tolerated halo well
– 10% mortality (4/41)
Anterior screw fixation of odontoid fractures comparing younger and elderly
– 22% complication rate
patientsAuthors:Platzer,P.; Thalhammer,G.; Ostermann,R.; Wieland,T.; Vecsei,V.;
Gaebler,C.Source:Spine, 2007, 32, 16, 1714-1720, United States
• Chapman studies
– Elderly did not heal the
odontoid fracture (4/17)
– Elderly tolerated halo well
(7/8)
– 15% mortality (3/20)
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
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
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
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
Definitive Treatment Options
Type 1
C-Collar
beware unrecognized
CCD
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
Type 3
C-Collar 10-15%
nonunion SOMI brace
Halo Vest
Treatment Options
odontoid fracture
Type 2
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C-Collar
SOMI / Minerva
Halo Vest
Odontoid Screw
C1-2 posterior fusion
Anterior Odontoid Screw Fixation
Indications
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Displaced Type II, Shallow Type III
Polytrauma patient
Unable to tolerate halo-vest
Early displacement despite halo-vest
(Reduces in extension)
Contraindications
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Non-reducible odontoid fracture
(Reduces in flexion)
Body habitus (Barrel chest )
Associated TAL injury
Subacute injury (> 6 months)
Reverse oblique
(elderly)
Roy-Camille
Classification
Anterior Screw History
•Note
reduced
dorsal
cortex
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
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, 227-236, UNITED STATES
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, 227-236, UNITED STATES
One or Two Screws?
• No significant difference biomechanically
– Sasso
– Graziano
• No difference clinically
– Apfelbaum
– Jenkins
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, 2383-2387, UNITED STATES
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, 1950-1953, UNITED STATES
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
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, 366-370, UNITED STATES
•Mal-reduction
•Incorrect entry point
Posterior Odontoid Stabilization
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
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
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, 464475, UNITED STATES
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
Posterior Wiring Outcomes
C1C2 Segmental Instrumentation
Posterior C1-C2 fusion with polyaxial screw and rod fixationAuthors:Harms,J.; Melcher,R.P.Source:Spine, 2001, 26, 22, 2467-2471, United States
.
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pedicle
Pars
Trans-articular
C2 pars/pedicle
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: 175-181. 2005
Harm’s Outcomes
• 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, 2467-2471, United States
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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, 222229, United States
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?
Traumatic Spondylolisthesis Axis
(Hangman’s Fracture)
Second most common fracture of axis
25% of C2 injuries
Most common mechanism of injury is
MVA
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
Where Cranio-cervical meets
Subaxial
Levine AM, Edwards CC: The management of traumatic spondylolisthesis of the axis. J Bone Joint Surg Am 1985; 67:217-226
Hangman Fracture
• Intact disk defines
Type I
• Halo treatment
difficult with torn
disk (types II and
III)
• Exercise caution
Dysphagia and
Dysphonia
Resolved
immediately with
halo adjustment
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
Atlanto-axial Rotatory Subluxation
Fuentes et al Traumatic atlantoaxial rotatory dislocation with odontoid fracture: case report and review. Spine 2001; 26(7) 830 -834
Atlanto-axial Rotatory Subluxation
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Traction/halo
Posterior fusion
Lateral facetectomy, reduction, fusion
Transoral facetectomy, reduction, fusion
Halo Immobilization
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,
1736-1739
The Basics
The halo fixator Bono,C.M. J.Am.Acad.Orthop.Surg., 2007, 15, 12, 728-737
Pin Placement
The halo fixator Bono,C.M. J.Am.Acad.Orthop.Surg., 2007, 15, 12, 728-737
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
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 e-mail to [email protected]
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 halovest 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
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 e-mail to [email protected]
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