upper cervical spine fractures

Upper Cervical Spine Fractures

Originally created by Daniel Gelb, MDJanuary 2006

Updated by Robert Morgan, MD; November 2010


• Epidemiology• Anatomy• Imaging Characteristics• Common Injuries• Management Issues

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

<20

30-3

9

50-5

9

70-7

9

05

1015202530

Number of Patients

Age

Upper Cervical Spine Fracture Demographics

c1 ringodontoidhangman's

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

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

•Keel below the SNL is thick bone

Confluence of Issues


•Bicortical screws in the occiput may enter the transverse sinus

•Decreased risk below the superior nuchal line

Occipital Screw Mechanics


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

http://www.refworks.com.floyd.lib.umn.edu/Refworks/~0~



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


Occiput

C1

C2

Tranverse Ligament

C1-C2 joint

Alar Ligament


TransverseLigamentFacet for

OccipitalCondyle

Atlanto-Axial AnatomyVertebral Artery

Radiographic Evaluation

Plain Radiographic EvaluationPlain Radiographic Evaluation

Lateral ViewPrevertebral Swelling

Soft Tissue Shadow<6mm at C2Concave/Flat

Pre-dental space < 3mm Atlanto-Occipital Joint CongruenceRadiographic Lines*

Open Mouth APDistractionC1-2 Symmetry

Radiographic Diagnosis – Screening Lines

Powers’s Ratio

Harris’s linesHarris’s lines

Radiographic LinesRadiographic Lines

Harris et al, Am J Radiol, 1994

• 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’ Lines

Radiographic Lines

• BC/OA– >1 considered abnormal

• Limited Usefulness• Positive only in Anterior

Translational injuries• False Negative with pure

distraction

Powers et al, Neurosurg, 1979

Powers’ Ratio

Radiographic DiagnosisRadiographic Diagnosis

CT Scan

• Same rules as with plain films• Better visualization of cranio-

cervical junction• Subluxation• Focal hematomas• Occipital condyle fractures• Dens fractures

Radiographic DiagnosisMRI

Increased Signal Intensity in :

• C0-C1Joint• C1-2 Joint• Spinal Cord• Cranio-cervical

ligaments• Pre-vertebral

soft tissues

Warner et al, Emerg Radiol, 1996

Dickman et al, J Neurosurg, 1991


• Common Injuries– Occipital Condyle

Fracture– Craniocervical sprain?– C1 ring injuries– Odontoid Fracture– Hangman’s Fracture

• Uncommon Injuries– Craniocervical

Dislocation– Rotatory subluxation

Occipital Condyle FractureOccipital Condyle Fracture

Type IImpaction Fracture

Type IIExtension of basilar skull

fracture

Type IIIALAR ligament Avulsion

Anderson ,SPINE 1988Tuli, NEUROSURGERY, 1997

Cranio-cervical Dislocation

• 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 FatalPresent 6-20% of post

mortem studies– Alker et al, 1978– Bucholz & Burkhead,1979– Adams et al, 1992

50% missed injury rate1/3 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 temperatureWallenberg Syndrome

www.med.yale.comwww.meddean.luc.edu

Check the Cranial Nerves!

Cranio-cervical Dislocation•Treatment

•Emergency Room•Collar/sandbag•Halo vest

•Definitive•Posterior occipital cervical fusion•ALWAYS include C1 and C2

Atlas Fractures - Treatment

Collar1. Isolated anterior

arch2. Isolated posterior

arch3.Non-displaced

Jefferson fracture


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 filmsC1-2 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

Fusion optionsGallie

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 fracturesEtiology Bimodal distribution

Young - high energy, multi-traumaElderly - low energy, isolated injury

(most common C-spine Fx elderly)

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 patientsAuthors:Platzer,P.; Thalhammer,G.; Ostermann,R.; Wieland,T.; Vecsei,V.; Gaebler,C.Source:Spine, 2007, 32, 16, 1714-1720, United States

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 ClassificationAnderson 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)

Don’t do flexion reductions!Closed management of displaced Type II odontoid fractures:more frequent respiratory compromise with posteriorlydisplaced fractures GREGORY J. PRZYBYLSKI, M.D., JAMES S. HARROP, M.D., AND ALEXANDER R. VACCARO, M.D. Neurosurgical Focus 2000

Epidemiolgy of spinal cord injury after acute odontoid fracturesJAMES S. HARROP, M.D., ASHWINI D. SHARAN, M.D., AND GREGORY J. PRZYBYLSKI, M.D. Neurosurgical Focus 2000

Definitive Treatment Options

Type 1C-Collarbeware unrecognized CCD

Type 3C-Collar 10-15% nonunion SOMI braceHalo VestEvidence-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

Treatment Optionsodontoid fracture

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

Anterior Odontoid Screw FixationIndications

• 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 (> 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







• Need to enter body caudal portion of promontory

• Midline for single screw placement








• Critical to cross rostral cortex

• Critical to use lag screw technique

• Limited support for second screw







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

mortalityA 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, 464-475, 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




pedicle

Pars

Trans-articular

C2 pars/pedicle

Harm’s Mechanics

Hott et al: Biomechanical comparison of C1-2 posterior fixation techniques. J Neurosurg Spine 2: 175-181. 2005

•LC1-PC2 performs similar to transarticular screws•Transarticular screws with graft stiffest construct•Interspinous graft behaves as intact specimen regarding lateral bending

Harm’s Outcomes

• 37 patients• 100% fusion• 1 wound infection

• 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, 222-229, United States

Posterior C1-C2 fusion with polyaxial screw and rod fixationAuthors:Harms,J.; Melcher,R.P.Source:Spine, 2001, 26, 22, 2467-2471, 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 axis25% of C2 injuries

Most common mechanism of injury is MVA

Hangman’s FractureYounger 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 displacedCoric 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

Dysphagia and Dysphonia

Resolved immediately with halo adjustment

• Intact disk defines Type I

• Halo treatment difficult with torn disk (types II and III)

• Exercise caution

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

• 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

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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 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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upper cervical spine fractures

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cervical spine ryan

fixation of fractures

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