Trauma of the upper cervical spine

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Trauma of the upper cervical spine

• Dr. J. VAN LERBEIRGHE
• AZ ST LUCAS GENT

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Upper cervical spine

• Atlantooccipital junction
• C1-C2 trauma

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Upper cervical spine

• 1/3 of all injuries of the cervical spine
• High-energy trauma, polytrauma
• Often demanding diagnostic work out

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Indication fot surgery ?

• Understanding of the mechanism
• Stability

classification
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Upper cervical spine

• ½ of the flexion- extension between C0-C1
• ½ of the rotation between C1-C2
• High kinematic demands

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OBJECTIVES OF TREATMENT

• Prevent or reverse neurologic deficit
• Restore spinal stability
• Prevent deformity or restore normal alignment
• Allow early mobilisation

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Upper cervical spine

• Atlantooccipital dislocation
• Fractures of the occipital condyles
• Fractures of the ATLAS, Jefferson
• Atlantoaxial instability, fixed rotatory
  subluxation
• Traumatic spondylolisthesis of the AXIS,
  Hangmans
• Odontoïd fractures.

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Upper cervical spine

• Atlantooccipital dislocation
• Fractures of the occipital condyles
• Fractures of the ATLAS, Jefferson
• Atlantoaxial instability, fixed rotatory
  subluxation
• Traumatic spondylolisthesis of the AXIS,
  Hangmans
• Odontoïd fractures.

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Atlantooccipital dislocations

• TYPE I
• Anterior dislocation is the most common form
• TYPE II
• Longitudinal dislocation without anterior or
  posterior shifting
• TYPE III
• Posterior dislocation ( very rare)
• TYPE IV
• Lateral dislocation

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Atlantooccipital dislocations
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Learning points C0-C1 dislocation
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Upper cervical spine

• Atlantooccipital dislocation
• Fractures of the occipital condyles
• Fractures of the ATLAS, Jefferson
• Atlantoaxial instability, fixed rotatory
  subluxation
• Traumatic spondylolisthesis of the AXIS,
  Hangmans
• Odontoïd fractures.

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Fractures of the occipital condyles
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Fractures of the occipital condylesLearning
points
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Upper cervical spine

• Atlantooccipital dislocation
• Fractures of the occipital condyles
• Fractures of the ATLAS, Jefferson
• Atlantoaxial instability, fixed rotatory
  subluxation
• Traumatic spondylolisthesis of the AXIS,
  Hangmans
• Odontoïd fractures.

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Fractures of the atlas
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Atlas Fractures
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Atlas fracture

• Type I
• Isolated fracture of the anterior ring
• Type II
• Isolated fracture of the posterior ring
• Type III
• Combined fracture of the anterior and posterior
  arch (Jefferson fracture)
• Type IV
• Isolated fracture of the lateral mass
• Type V
• Fracture of the transverse process

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Fractures of the atlas
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Atlas fractureNon-operative treatment

• Minimal dislocation of only one lateral mass
• No Instability on flexion extension X-Ray
• 12 weeks orthosis followed by physical therapy

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Jefferson fractureslearning points
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Jefferson fractureOperative treatment
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Jefferson fractureOperative treatment
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Upper cervical spine

• Atlantooccipital dislocation
• Fractures of the occipital condyles
• Fractures of the ATLAS, Jefferson
• Atlantoaxial instability, fixed rotatory
  subluxation
• Traumatic spondylolisthesis of the AXIS,
  Hangmans
• Odontoïd fractures.

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Atlanto-axial instability

• Type A Anterior atlantoaxial instability
• Type B Posterior atlantoaxial instability
• Type C Rotatory atlantoaxial instability

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Atlanto-axial instability

• Type A Anterior antlantoaxial instability
• Flexion injury
• Adults gt 3.5 mm atlantodental distance
• Children gt 5 mm atlantodental distance
• Due to rupture or bony avulsion of the transverse
  ligament

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Atlanto-axial instability

• Type A Anterior antlantoaxial instability

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Atlanto-axial instability

• Type B Posterior atlantoaxial instability
• Probably hyperextension
• The tectorial as well as the alar ligaments must
  be torn

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Atlanto-axial instability

• Type B Posterior atlantoaxial instability
• Probably hyperextension
• The tectorial as well as the alar ligaments must
  be torn

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Atlanto-axial instability

• Type C Rotatory atlantoaxial instability
• Type I
• Without anterior gliding
• Type II
• Atlantodental interval up to 5 mm
• Type III
• Atlantodental interval of gt 5 mm

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Atlanto-axial instability

• Type C Rotatory atlantoaxial instability
• Type I
• Without anterior gliding

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Atlanto-axial instability

• Type C Rotatory atlantoaxial instability
• Type II
• Atlantodental interval up to 5 mm

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Atlanto-axial instability

• Type C Rotatory atlantoaxial instability
• Type III
• Atlantodental interval of gt 5 mm

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Atlantoaxial sagittal instabilitylearning points
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Atlanto-axial instability

• Possibility of tetraplegia after another accident
  gt prevention surgery
• Possibility of slow onset myelopathy due to
  repeated trauma to the cord.

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Type C Rotatory atlantoaxial instability

• Skull traction
• Stiff collar or Halo vest for 6-8 weeks
• Manipulation under anesthesia?
• Anterior transoral release and rotation under
  traction gt C1-C2 fusion

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Type C Rotatory atlantoaxial instabilitylearnin
g points
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Upper cervical spine

• Atlantooccipital dislocation
• Fractures of the occipital condyles
• Fractures of the ATLAS, Jefferson
• Atlantoaxial instability, fixed rotatory
  subluxation
• Traumatic spondylolisthesis of the AXIS,
  Hangmans
• Odontoïd fractures.

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Traumatic SpondylolisthesisHangmans Fracture

• Type I
• Stable undislocated. C2-C3 disc is intact and
  C2-C3 is stable ( 65)
• Type II
• Unstable. The C2-C3 disc is torn and anteriorly
  displaced.
• Type III
• Type II injury with additional unilateral
  dislocation.

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Traumatic SpondylolisthesisHangmans Fracture
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Traumatic SpondylolisthesisHangmans Fracture
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Traumatic SpondylolisthesisHangmans
Fracturelearning points
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Traumatic SpondylolisthesisHangmans
Fracturesurgical treatment rationale
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Traumatic SpondylolisthesisHangmans
Fracturesurgical treatment rationale
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Atypical hangmans fracture

• Spinal stenosis
• Trough the posteror body of C2 !
• Surgical treatment after reduction to maintain
  stability

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Upper cervical spine

• Atlantooccipital dislocation
• Fractures of the occipital condyles
• Fractures of the ATLAS, Jefferson
• Atlantoaxial instability, fixed rotatory
  subluxation
• Traumatic spondylolisthesis of the AXIS,
  Hangmans
• Odontoïd fractures.

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Odontoïd fracturesAnderson and DAlonzo

• Type I
• Tip of the dens
• Type II
• Fracture of the dens itself
• Type III
• Fracture of the dens with extension into the
  vertebral body

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Odontoïd fractures
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Roy Camilletype II

• HORIZONTAL
• OBAV
• OBAR

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Odontoïd fracturessurgical treatmentodontoïd
fixation ( 2 screws)
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Anterior screw fixationType II fractures

• 2 C-arms
• No arthrodesis but slight advantage in mobility !
• Not in osteoporotic patiënts
• Horizontal or OBAR

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All other type II fractures

• C1-C2 fusion
• Transarticular fusion ( Gallie procedure )
• Aspecially in the older patiënt.
• Occipito-cervical fusion.

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Entry points
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Gallie procedure
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Gallie
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Transarticular fixation
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Transarticular fixation
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Even simple procedures need expertise
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Thank YOU !
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