upper cervical injuries

8/13/2019 Upper Cervical Injuries

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UPPER CERVICALINJURIES

Dr. Mohamed Musheer HussainModerators: Prof. Mahabala Rai

Dr. Atmananda Hegde


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Incidence10,000 per year

80% male

< 40 years

Introduction


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RTA, diving accidentsmost common cause

Suspicion in head or highenergy trauma orneurological deficit

? MISSED

16% people will havenon-contiguous spinefractures

50% will have otherskeletal or visceralinjuries


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Anatomy


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EvaluationATLSABCD

Evidence of Trauma?

Neurological Examination

Immobilize the entire spine on a

backboard with a rigid collar.


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AwakeNo

neurologicalDeficit

PlainRadiograph

Tender

Limited MRI

NegativeSTOP

PositiveCT & Flex/Ext

Xray

Non TenderSTOP


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Radiographs

Lateral X- Rays


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Radiographs

Lateral X- Rays

Harris Lines


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Radiographs

Powers Ratio


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Radiographs

OPEN MOUTH VIEW


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Upper Cervical Injury

Occiput-cervical InjuriesOcciputal

Condyle Fracture

Occiputal-Cervical ligamentous InjuryC1Injuries

Posterior ring fractures

Lateral mass fracturesJefferson fracture

Avulsions of anterior ring


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C1-C2 Injuries

Rotational instabilityTransverse ligament injury

C2 Injuries

Dens fractureTraumatic Spondylolisthesis

Extension Tear Drop fracture


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Occipital CondyleFractures

CT, R/O OC dissociation

I: comminuted, axial impaction Stable Collar 6-8 weeks

II: extension of basilar skull fractureinto 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

AVOID traction!!

Halo until surgery1treatment:

Oc-C2 fusion if good

screw purchase

Oc-C3 fusion otherwise


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TraynelisClassification of Occipito-cervical Dissociation


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Stable Atlas Fractures

Posterior arch fracture: collar 10-12weeks

Anterior arch avulsion fracture:collar

C1 ring fracture with


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Unstable Atlas Fractures

C1 ring fracture with 7 mm ofoverall C1 lateral mass

displacement: prolonged halo orfusion (C1-C2, or Occiput-C2)

Plough fracture: reduction with haloin slight flexion or C1-C2 fusion orocciput-C2


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Plough Fracture
http://www.ajronline.org/content/vol181/issue3/images/large/09_AD0200_01A.jpeg


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Rupture of Transverse Ligament

Flexion force

Dickman Classification:I. Mid-substance tearII. Avulsion of lateral mass of C1

As force increases, alar and apical ligtear (ADI > 7mm)

Treatment: If ADI 5mm collar If ADI >5mm and type I C1-C2 fusion If ADI >5mm and type II halo


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Rotatory Atlanto-Axial

Instability

Collar or HaloC1-C2

Fusion


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Axis (C2) Fractures

1. Odontoid fractures

2. Traumaticspondylolisthesis of the

axis (hangman'sfracture)


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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

oblique fracture through the upper part of

the odontoid process

Least common

Represent an avulsion of the alar ligament

Treated with collar or halo 6-8 weeks

Occiput-C2 fusion if associated with

occipitocervical dissociation


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Type II Odontoid

At the junction of the base of the odontoid

and body of the axis

most common

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 OdontoidHigher risk of non-union:

Initial displacement > 5mm

Posterior displacementAngulation > 100

Age > 50

SmokingDelay in diagnosis > 3 weeks

Inability to achieve or maintain

reduction


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Traumatic spondylolisthesis of the

Axis (Hangman's fracture)2nd most common fracture of C2

15% of all cervical spine fractures

Younger age group, RTAMOI: hyperextension + axial

compression; additional flexion

moment leads to very unstable injuryRare neurological involvement


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Hangman's FractureEffendiLevine & Edwards

Classification


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Type I Hangmans

Most common

Bilateral pars fractures with

translation


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Type IA HangmansAtypical fracture, recently recognized

Minimal translation and little or no angulation

Elongation of the C2 body

CT: extension of fracture line into the body andoften through the foramen transversarium (vertebralartery injury may occur)

May have canal compromise

Usually halo, surgery if neuro deficits

Surgical options: anterior C2C3 arthrodesis,posterior C1C3 vs C2C3 arthrodesis, or combinedapproach


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Type IA Hangmans


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Type II Hangmans

C2-3 disc and PLL are disrupted,

resulting in translation >3 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, axialthen flex

Fracture line is more oblique thanvertical (vs II)

Little or no translation, but significantangulation.

Avoid traction

Halo, and if markedly displaced,possibly direct fixation of fracturedarch through a posterior approachC1-C3, or by C2C3 anteriordiscectomy and arthrodesis


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Type III Hangmans

A combination of pars fracture withdislocation of the C2-3 facet joints

Very unstable, with free-floating inferiorarticular processes

The most common injury to be associatedwith neurological deficit

Requires surgery; it is irreducible by closedmeans

Options: Anterior C2-3 discectomy andfusion, or posterior open reduction and C1-3 fusion


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Treatment Goals(1) to realign the spine,

(2) to prevent loss of function of

undamaged neurological tissue,

(3) to improve neurological recovery,(4) to obtain and maintain spinal

stability,

(5) to obtain early functional recovery


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EMERGENT IMMOBILIZATION OF THE

UPPER CERVICAL SPINE

Gardner-Wells tongs

site directly superior to

the external auditory

meatus and onefingerbreadth above

the pinna.

A vertical line throughtthe tips of mastoid

process at right angles

to second line

bisecting skull ant-post.


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EMERGENT IMMOBILIZATION OF THE

UPPER CERVICAL SPINE

5 lb (2.3 kg) percervical levelabove thefracture

Initial 10 (4.6 kg)to 15 lb (6.8 kg)to overcomethe friction of

the head on thebed


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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 Fixation

Magerl technique


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Halo Splint

Anteriorly -1 cm superiorto the orbital ridge,

below the equator of

the skull, and over the

lateral two-thirds of theorbit

Posteriorly - placed at

180 on the contralateralside. Any area 2 to 3 cm

posterior to the edge of

the pinna of the


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ReferencesChapman's Orthopaedic Surgery, 3rd

Edition

Canale & Beaty: Campbell's OperativeOrthopaedics, 11th ed.

Spine Surgery- Techniques, ComplicationAvoidance and Management , Benzel ,3rd Edition

Rockwood and Green's Fractures inAdults, 7thedition

upper cervical injuries

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