Upper Cervical Trauma

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Upper Cervical Trauma

• Sohail Bajammal, MBChB, MSc
• November 14, 2006
• St. Josephs Healthcare, Hamilton
• Weekly Orthopaedic Teaching Rounds

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Upper Cervical Trauma

• a.k.a.
• Cranio-cervical Trauma
• Occipito-cervical Trauma
• Occipito-atlanto-axial Trauma

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Outline

• The Problem
• Anatomy
• X-rays
• Fractures of O, C1, C2

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The Problem

• Better recognition
• Better pre-hospital care (ATLS, Orthopod)
• Radiographic finding
• Improved cars safety
• Less mortality at scene, more of OC injury

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Evaluation

• History mechanism of injury
• Physical ATLS
• 2 survey thorough neurological exam
• Radiology
• 3-views C-spine, CT, MRI

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Anatomy
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Anatomy

• Unique anatomy of O-C1-C2
• C1 no body, 2 articular pillars connected by 2
  arches
• C2 dens, flat C1-2
• Ligaments
• Intrinsic (within spinal canal)
• Odontoid alar, apical
• Cruciate transverse lig, vertical bands
• Tectorial membrane thickening of PLL
• Extrinsic
• Ligamentum nuchae
• Anterior and posterior atlanto-occipital membrane
• Anterior and posterior atlanto-axial membrane
• Joint capsules
• Vertebral artery

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Courtesy of AnatomyTV
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Ponticulus PosticusLatin, little posterior bridge

• Young et al., 2005 JBJS(A)
• 15.5 prevalence of arcuate foramen in 464
  lateral c-spine x-rays

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Ponticulus Posticus
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Ponticulus Posticus
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X-rays
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Cervical X-rays ABCDEs

• A adequacy, alignment
• B bones
• C cartilage
• D disc space
• E else (skull, clavicle)
• S soft tissue

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Lateral C-spine
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Harris Lines
SAC gt 13 mm
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Powers Ratio

• BC/OA
• gt1 considered abnormal
• Limited Usefulness
• Positive only in Anterior Translational injuries
• False Negative with pure distraction

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Open-mouth View
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Occipital Condyle Fractures

• CT, R/O OC dissociation
• I comminuted, axial impaction
• Stable ? Collar 6-8 weeks
• II extension of basilar skull fracture into
  condyle
• Potentially unstable ? Collar 6-8 weeks
• III avulsion of alar lig
• Minimal displaced ? Halo vest, 8-12 weeks
• Displaced ? O-C2 fusion
• Consider surgery if OC dissociation

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Occipito-cervical Dissociation

• Rare and usually fatal
• Often assoc. with facial injuries, chest trauma
• Deceleration
• AVOID traction!!
• Halo until surgery
• 1º treatment
• Oc-C2 fusion if good screw purchase
• Oc-C3 fusion otherwise
• Biomechanically plate screw gt screws gt wires

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Traynelis Classification of Occipito-cervical
Dissociation
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Harborview Classification of Occipitocervical
Injury

• I
• MRI hemorrhage or edema at OC junction
• Normal Harris lines
• No distraction on traction test with 25 lb of
  traction
• II
• MRI hemorrhage or edema at OC junction
• Normal Harris lines
• lt 25 lb traction sufficient distraction to meet
  OC dissociation thresholds of Harris
• III
• Static imaging distraction beyond thresholds of
  Harris

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Atlas (C1) Fractures

• 10 of all cervical fractures
• Rare neurological deficits if any, R/O
  dissociation
• 50 concomitant fractures
• Morphological classification
• Posterior arch hyperextension
• Lateral mass rotation or lateral flexion forces
• Anterior arch fractures (blowout or plow
  fractures) hyperextension,
• Bursting-type fractures (Jefferson) symmetrical
  axial load
• Transverse process
• Anterior tubercle

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Atlas Fractures

• The extent of lateral mass separation is more
  relevant than the number of fracture fragments

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Stable Atlas Fractures

• Posterior arch fracture collar 10-12 weeks
• Anterior arch avulsion fracture collar
• C1 ring fracture with lt7 mm of overall lateral
  mass displacement collar or halo

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Unstable Atlas Fractures

• C1 ring fracture with 7 mm of overall C1 lateral
  mass displacement prolonged halo or fusion
  (C1-C2, or Occiput-C2)
• Plough fracture reduction with halo in slight
  flexion or C1-C2 fusion or occiput-C2

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Plough Fracture
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Rupture of Transverse Ligament

• Flexion force
• Dickman Classification
• Mid-substance tear
• Avulsion of lateral mass of C1
• As force increases, alar and apical lig tear (ADI
  gt 7mm)
• Treatment
• If ADI 5mm ? collar
• If ADI gt5mm and type I ? C1-C2 fusion
• If ADI gt5mm and type II ? halo

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Atlanto-Axial Instability

• A Rotational
• Around the dens
• Treated with closed reduction and immobilization.
  
• Beware of associated fractures
• B Translational
• Translation between C1C2, where transverse lig
  is disrupted
• Mid-substance transverse ligament tears (type I)
  are treated with C1C2 arthrodesis
• C Distraction
• Indicating craniocervical dissociation
• Bony avulsions (type II) may be treated with halo
  or C1C2 arthrodesis

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Rotatory Atlanto-Axial Instability
C1-C2 Fusion
Collar or Halo
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Axis (C2) Fractures

• Odontoid fractures
• Traumatic spondylolisthesis of the axis
  (hangman's fracture)

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Odontoid Fractures

• 60 of C2 fractures
• 10-20 of all c-spine fractures
• Neurological deficits in 10-20
• Bimodal
• young (high energy), elderly (falls)
• Anderson and D'Alonzo Classification

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Type I Odontoid

• Occurs at tip, cephalad to the transverse
• Least common
• Represent an avulsion of the alar ligament
• Treated with collar or halo 6-8 weeks
• Surgery (occiput-C2 fusion) if associated with
  occipitocervical dissociation

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Type III Odontoid

• Extends into the body of the axis
• More stable than type II fractures
• Higher union rate with non-surgical
• Treated with a halo or brace 8-12 weeks after
  reduction if displaced

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Type II Odontoid

• At the junction of the base of the odontoid and
  body of the axis
• The most common fracture type
• The least likely to heal with non-surgical
  (10-77 non-union)
• IIA new addition, comminution at base
• Treatment controversial

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Type II Odontoid

• Higher risk of non-union
• Initial displacement gt 5mm
• Posterior displacement
• Angulation gt 100
• Age gt 50
• Smoking
• Delay in diagnosis gt 3 weeks
• Inability to achieve or maintain reduction

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Options for High Risk type II

• Collar very high risk of non-union
• Reduction and Halo risk of complications in
  elderly
• Anterior Odontoid Screw(s)
• Pros High union rate, preserves atlanto-axial
  motion
• Cons Poor fixation in osteoporotic, difficult in
  large chest or posteriorly displaced
• C/I reverse obliquity
• Posterior C1-C2 arthrodesis
• C1-2 transarticular screw gt segmental C1-2
  fixation gt wires techniques

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Anterior Odontoid Screw
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Traumatic spondylolisthesis of the Axis
(Hangman's fracture)

• 2nd most common fracture of C2
• 15 of all cervical spine fractures
• Higher energy injury, associated spinal 30
• Younger age group, MVC
• MOI hyperextension axial compression
  additional flexion moment leads to very unstable
  injury
• Rare neurological involvement

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Hangman's Fracture Effendi ? Levine Edwards
Classification
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Type I Hangmans

• Most common
• Bilateral pars fractures with translation lt3 mm
  and no angulation
• Treated with collar, occasionally halo

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Type IA Hangmans

• Atypical fracture, recently recognized
• Minimal translation and little or no angulation
• Elongation of the C2 body
• CT extension of fracture line into the body and
  often through the foramen transversarium
  (vertebral artery injury may occur)
• May have canal compromise
• Usually halo, surgery if neuro deficits
• Surgical options anterior C2C3 arthrodesis,
  posterior C1C3 vs C2C3 arthrodesis, or combined
  approach

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Type IA Hangmans
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Type II Hangmans

• C2-3 disc and PLL are disrupted, resulting in
  translation gt3 mm and marked angulation
• ALL generally remains intact but is stripped
  from its bony attachment
• Halo after reduction in slight extension

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Type IIA Hangmans

• Less common MOI hyperext, axial then flex
• Fracture line is more oblique than vertical (vs
  II)
• Little or no translation, but significant
  angulation.
• Avoid traction
• Halo, and if markedly displaced, possibly direct
  fixation of fractured arch through a posterior
  approach C1-C3, or by C2C3 anterior discectomy
  and arthrodesis

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Type III Hangmans

• A combination of pars fracture with dislocation
  of the C2-3 facet joints
• Very unstable, with free-floating inferior
  articular processes
• The most common injury to be associated with
  neurological deficit
• Requires surgery it is irreducible by closed
  means
• Options Anterior C2-3 discectomy and fusion, or
  posterior open reduction and C1-3 fusion

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Posterior C1-2 FusionGallie Technique
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Posterior C1-2 FusionBrooks-Jenkins technique
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C1C2 Transarticular Screw FixationMagerl
technique
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Finally..Its over!
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Halo

• Crown first then the vest
• Prep areas in infiltrate with local
• Normally put scoop under head (unless
  contraindicated)
• Put halo crown around head
• Landmarks for the anterolateral pins, 1cm above
  the lateral 1/3 of the eyebrow and the same
  distance above the top of the ear
• Place the anterior pins in bare skin NOT in the
  hairline

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Halo

• Have patient close eyes before insertion of ant
  pins
• Place 4 pins in and tighten all 4 to engage skin
  and bone
• Tighten to 8 in-lb with the torque wrench
• Place the vest on
• X-ray!

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Halo Care

• Routinely retighten after 24-48 hours
• If a pin is to be replaced, a new pin should be
  inserted satisfactorily before the loose pin is
  removed
• Pin sites should be cleaned daily
• Most commonly injured nerves are the supraorbital
  and supratrochlear

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Halo Care

• Inserting anterolateral pins behind the hairline
  in hopes of obtaining a more cosmetically
  acceptable scar should be avoided - this location
  places the pin within the temporal fossa where
  the skull is the thinnest
• Pins located in the temporal fossa also pierce
  the temporalis muscle and often lead to painful
  mastication

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