Download - Upper C Spine Fracture
Upper Cervical Spine Fractures
Daniel Gelb, MD
Created January 2006
Upper Cervical Spine Fractures
• Epidemiology
• Anatomy
• Radiology
• Common Injuries
• Management Issues
Upper Cervical Spine Fractures
• Epidemiology– Cause
• MVC 42%• Fall 20%• GSW 16%
– Gender• Male 81%• Female 19%
Etiology of Spinal Cord Injury by Age
Source: National Spinal Cord Injury Statistical Center, University of Alabama at Birmingham, 2004 Annual Statistical Report, June, 2004
Upper Cervical Spine Fractures
• Epidemiology– Level of Education
• To 8th Grade: 10%• 9th to 11th: 26%• High School: 48%• College: 16%
Source: National Spinal Cord Injury Statistical Center, University of Alabama at Birmingham, 2004 Annual Statistical Report, June, 2004
Employment Status
Source: National Spinal Cord Injury Statistical Center, University of Alabama at Birmingham, 2004 Annual Statistical Report, June, 2004
Percent Employed
Upper Cervical Anatomy
Upper Cervical Anatomy
• Biomechanically Specialized– Support of “large” Cranial mass– Large range of motion
• Flexion/extension
• Axial rotation
• Unique osteological characteristics
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
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
AtlantoAxial Anatomy
Tectorial Membrane
AtlantoAxial Anatomy
occiput
C1
C2
Tranverse Ligament
C1-C2 joint
Alar Ligament
AtlantoAxial Anatomy
TransverseLigament
Facet forOccipitalCondyle
AtlantoAxial Anatomy
Vertebral Artery
Radiographic Evaluation
Plain Radiographic EvaluationPlain Radiographic EvaluationLateral View
Prevertebral SwellingSoft Tissue Shadow
<6mm at C2Concave/Flat
Predental space < 3mm Atlanto-Occipital Joint CongruenceRadiographic Lines*
Open Mouth APDistractionC1-2 Symmetry
Radiographic Diagnosis – Screening Lines
Powers’s RatioHarris’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 DiagnosisCT Scan
• Same rules as with plain films• Better visualization of
craniocervical junction• Subluxation• Focal hematomas• Occ condyle fx• Dens fx
Radiographic DiagnosisMRI
Increased Signal Intensity in :
• Occ-C1Joint• C1-2 Joint• Spinal Cord• Craniocervical
ligaments• Prevertebral
soft tissues
Warner et al, Emerg Radiol, 1996
Dickman et al, J Neurosurg, 1991
Upper Cervical Spine Fractures
• Common Injuries– Occipital Condyle Fracture– Occipital Cervical Dislocation– C1 ring injuries– Odontoid Fracture– Hangman’s Fracture
Occipital Condyle FractureOccipital Condyle Fracture
Type I
Impaction Fx
Type II
Extension of basilar skull fx
Type IIIALAR LIG AVULSION
Anderson ,SPINE 1988Tuli, NEUROSURGERY, 1997
OccipitoAtlantal Dissociation (OAD)
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
OccipitoAtlantal Dissociation (OAD)
• Symptoms/Findings– Wallenberg Syndrome
• Lower Cranial nerve deficits
• Horner’s syndrome
• Cerebellar ataxia
• Cruciate paralysis
• Contralateral loss of pain and temperature
Occipital Cervical Dissociation
•Treatment•Emergency Room
•Collar/sandbag•Halo vest
•Definitive•Posterior occipital cervical fusion
Transverse ligament avulsion
Atlas Fractures - Treatment
Collar
Isolated anterior arch
Isolated posterior arch
Nondisplaced Jefferson fx
Atlas Fractures - TreatmentDisplaced <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
Fusion options
Gallie
Post-op halo
Brooks Jenkins
Transarticular Screws
C1 lateral mass/C2 pars-pedicle screws
Atlas Fractures - Treatment
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)
Odontoid Fractures
Anderson and D’Alonzo
Type I 2 %
Type II 50-75 %
Type III 15-25 %
Treatment Optionsodontoid fractures
Type 1• C-Collar• beware unrecognized AOD
Treatment Optionsodontoid fracture
Type 3• C-Collar• SOMI brace• Halo Vest
10-15% nonunion rate
Treatment Optionsodontoid fracture
Type 2• C-Collar• SOMI brace• Halo Vest• Odontoid Screw• C1-2 posterior fusion
Type II Fracture Nonunion Risk Factors
Nonunion 10-70%Initial displacement > 6mm
Age > 60 yr old
Delay Diagnosis > 3 wk
Angulation > 10°
Posterior displacement
Schatzker 1971Anderson 1974Apuzzo 1978Ekong 1981Hadley 1985Clark 1985Dunn 1986Hanssen 1987Schweigel 1987Hadley 1989Hanigan 1993Ryan 1993Seybold 1997
Anterior Odontoid Screw FixationIndications
• Displaced Type II, Shallow Type III• Polytrauma patient• Unable to tolerate halo-vest• Early displacement despite halo-vest
Contraindications• Non-reducible odontoid fracture• Body habitus (Barrel chest )• Associated TAL injury• Subacute injury (> 6 months)• Reverse oblique
Posterior Odontoid Fixation
• 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 screw
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
Harms J, Melcher RP. Posterior C1–C2 fusion with polyaxial screw and rod fixation. Spine 2001;26:2467–71.
C1 lateral mass screws
..
pedicle
Pars
transarticular
C2 pars/pedicle
Traumatic Spondylolisthesis Axis(Hangman’s Fracture)
Second most common fracture of axis25% 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 displacedCoric et al JNS 1996
Hangman’s Fracture Treatment
Type III Treatment OptionsPosterior
– Open reduction and C1-C3 fusion– Direct pars repair and C2-C3 fusion
Anterior– C2/C3 ACDF with instrumentation
Halo Immobilization
In-hospital mortality rates in Pts > 70 yr age Rx’d Halo-vest 20 – 36%
Elderly and Halo-vest Treatment
E-mail OTA about
Questions/Comments
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]
Return to SpineIndex