Upper Cervical Spine Fractures

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 1100-1107
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 1100-1107
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 1100-1107
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
AuthorsHeggeness,M.H. Doherty,B.J.SourceSpine,
1993, 18, 14, 1945-1949, UNITED STATES
16
Trabecular Anatomy
The trabecular anatomy of the axis
AuthorsHeggeness,M.H. Doherty,B.J.SourceSpine,
1993, 18, 14, 1945-1949, 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
AuthorsHeggeness,M.H. Doherty,B.J.SourceSpine,
1993, 18, 14, 1945-1949, 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 lt6mm at C2 Concave/Flat Pre-dental space lt
3mm Atlanto-Occipital Joint Congruence Radiograph
ic Lines Open Mouth AP Distraction C1-2 Symmetry
25
Radiographic Diagnosis Screening Lines
Harriss lines
Powerss Ratio
26
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
27
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
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
• Hangmans 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

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36
Symptoms/Findings

• Lower Cranial nerve deficits
• Horners syndrome
• Cerebellar ataxia
• Bells cruciate paralysis
• Contralateral loss of pain and temperature

Wallenberg Syndrome
37
Check the Cranial Nerves!
www.med.yale.com
www.meddean.luc.edu
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 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

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 patientsAuthorsPlat
zer,P. Thalhammer,G. Ostermann,R. Wieland,T.
Vecsei,V. Gaebler,C.SourceSpine, 2007, 32, 16,
1714-1720, United States
Nonoperative management of odontoid fractures
using a halothoracic vestAuthorsPlatzer,P.
Thalhammer,G. Sarahrudi,K. Kovar,F.
Vekszler,G. Vecsei,V. Gaebler,C.SourceNeurosurg
ery, 2007, 61, 3, 522-9 discussion 529-30,
United States
Posterior atlanto-axial arthrodesis for fixation
of odontoid nonunionsAuthorsPlatzer,P.
Vecsei,V. Thalhammer,G. Oberleitner,G.
Schurz,M. Gaebler,C.SourceSpine, 2008, 33, 6,
624-630, United States
Type II odontoid fractures in the elderly early
failure of nonsurgical treatmentAuthorsKuntz,C.,4
th Mirza,S.K. Jarell,A.D. Chapman,J.R.
Shaffrey,C.I. Newell,D.W.SourceNeurosurg.Focus.,
2000, 8, 6, e7, United States
Efficacy of anterior odontoid screw fixation in
elderly patients with Type II odontoid
fracturesAuthorsHarrop,J.S. Przybylski,G.J.
Vaccaro,A.R. Yalamanchili,K.SourceNeurosurg.Focu
s., 2000, 8, 6, e6, United States
45
Fracture Classification
Anderson and DAlonzo
Type I 2 (2/49)
Type II 50-75 (32/49)
Type III 15-25 (15/49)
Fractures of the odontoid process of the
axisAuthorsAnderson,L.D. D'Alonzo,R.T.SourceJ.B
one Joint Surg.Am., 1974, 56, 8, 1663-1674,
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, 123-129
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
Dont do flexion reductions!
Closed management of displaced Type II odontoid
fracturesmore 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
managementAuthorsJulien,T.D. Frankel,B.
Traynelis,V.C. Ryken,T.C. SourceNeurosurg.Focus
., 2000, 8, 6, e1, United States
49
Treatment Optionsodontoid 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 (gt 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 fracturesAuthorsApfelbaum,R.I.
Lonser,R.R. Veres,R. Casey,A.SourceJ.Neurosurg
., 2000, 93, 2 Suppl, 227-236, 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 fracturesAuthorsApfelbaum,R.I.
Lonser,R.R. Veres,R. Casey,A.SourceJ.Neurosurg
., 2000, 93, 2 Suppl, 227-236, 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 fracturesAuthorsApfelbaum,R.I.
Lonser,R.R. Veres,R. Casey,A.SourceJ.Neurosurg
., 2000, 93, 2 Suppl, 227-236, 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
processAuthorsGraziano,G. Jaggers,C. Lee,M.
Lynch,W.SourceSpine, 1993, 18, 16, 2383-2387,
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
techniqueAuthorsSasso,R. Doherty,B.J.
Crawford,M.J. Heggeness,M.H. SourceSpine, 1993,
18, 14, 1950-1953, UNITED STATES
58
Apfelbaum Clinical Outcomes

• 147 patients
• 129 (117) lt6 months
• 18 gt 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 fixationAuthorsJenkins,J.D. Coric,D.
Branch,C.L.,Jr SourceJ.Neurosurg., 1998, 89, 3,
366-370, 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 techniquesAuthorsPapagelopoulos,P.J.
Currier,B.L. Hokari,Y. Neale,P.G. Zhao,C.
Berglund,L.J. Larson,D.R. An,K.N. SourceSpine,
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 AuthorsJeanneret,B.
Magerl,F.SourceJ.Spinal Disord., 1992, 5, 4,
464-475, UNITED STATES
64
Wiring Mechanics
Biomechanical comparison of C1-C2 posterior
arthrodesis techniquesAuthorsPapagelopoulos,P.J.
Currier,B.L. Hokari,Y. Neale,P.G. Zhao,C.
Berglund,L.J. Larson,D.R. An,K.N. SourceSpine,
2007, 32, 13, E363-70, United States
65
Posterior Wiring Outcomes
66
C1C2 Segmental Instrumentation
Posterior C1-C2 fusion with polyaxial screw and
rod fixationAuthorsHarms,J. Melcher,R.P.SourceS
pine, 2001, 26, 22, 2467-2471, United States
67
(No Transcript)
68
pedicle
Pars
Trans-articular
C2 pars/pedicle
69
Harms 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
70
Harms Outcomes

• 102 patients
• 98 fusion rate
• 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 fixationAuthorsHarms,J. Melcher,R.P.SourceS
pine, 2001, 26, 22, 2467-2471, 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
techniquesAuthorsAryan,H.E. Newman,C.B.
Nottmeier,E.W. Acosta,F.L.,Jr Wang,V.Y.
Ames,C.P.SourceJ.Neurosurg.Spine, 2008, 8, 3,
222-229, 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
• Harms technique is most flexible
• Think about hooks?

72
Traumatic Spondylolisthesis Axis(Hangmans
Fracture)

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

73
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

74
Where Cranio-cervical meets Subaxial
Levine AM, Edwards CC The management of
traumatic spondylolisthesis of the axis. J Bone
Joint Surg Am 1985 67217-226
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
Hangmans 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) 830 -834
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, 1736-1739
81
The Basics
The halo fixator Bono,C.M. J.Am.Acad.Orthop.Surg.,
2007, 15, 12, 728-737
82
Pin Placement
The halo fixator Bono,C.M. J.Am.Acad.Orthop.Surg.,
2007, 15, 12, 728-737
83
Halo in Elderly

• Tashijan J. Trauma 2006
• 78 patients, age gt 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 gt65 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
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