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

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