1. Cervical Spine Trauma Odontoid fractures Anatomic pathology
Management options
Case Illustrations
Kevin Chao, MD
November 8, 2010

2. Anatomy: Supra axial cervical spine

3. Anatomy: Supra axial cervical spine
ALL -> anterior atlanto-occipital membrane
PLL -> tectorial membrane (16)
7 - > apical ligament
8 -> vertical cruciform ligament15 -> transverse ligament

4. Odontoid Fractures Epidemiology Mechanism: Flexion injury
10-15% of c-spine fractures
30-40% associated fatality
Type II ~10% with deficits
Mechanism: Flexion injury
Often subsequent C1-C2 subluxation
Symptoms: high cervical pain, reduced ROM, tenderness to palpation
Transverse ligament injury  instability

5. Treatment guidelines Non operative Operative Types I and III
Halo or SOMI brace
Follow up imaging 6 weeks
Operative
Type II
Especially in pts age > 50 (~30% non union rate)
Fracture displacement ≥ 5 mm
Neurologic deficit
Comminution
Failed alignment or malunion with external fixation

6. Surgical Options Anterior fusion Posterior fusion
Odontoid screw fixation
Posterior fusion
Wiring/fusion techniques
Gallie fusion
Brooks fusion
Locksley Tie Bar
Dickman-Sonntag
Plates/clamps
Halifax clamps
Hook plates
Transarticular screw
C1-C2 articular fusion
Harm’s C1-C2 construct
Occipital-cervical fusion
Combined anterior-posterior fusion

7. Odontoid screw Indications: Contraindications: Union rate 95%
Reducible Type II dens fx
Intact transverse ligament
Fracture < 6 months old
Contraindications:
Large fracture gap
Irreducible fracture
Pathological fracture
Oblique fracture line
Union rate 95%

8. Wiring/fusion techniques
Gallie
“H” graft between C1-C2, C1 and C2 sublaminar wire
Brooks
2 wedge bone grafts with C1 to C2 sublaminar wires (75-85% union)

9. Wiring/fusion techniques
Dickman-Sonntag
1 wedge bone graft with sublaminar wire under C1 (97% union)
Locksley Tie bar
3 point posterior fixation

10. Transarticular screw Immediate stabilization
Wire entry needs “flat” angle
Entry point
Traverse facet joint
Target superior aspect of C1 anterior arch
Risk for vertebral artery injury

13. Harms C1-C2 Posterior Fusion
C1 lateral mass - C2 pedicle polyaxial screws and bilateral rod fixation
Anatomic advantages
Immediate stabilization
Technical Notes:
Proud C1 screw
Superior-medial entry of C2 screws
Rotational reduction after screw placement
Optional posterolateral fusion

14. Non-union Clinical signs and symptoms
Continued high posterior cervical pain
Late myelopathy
Radiographic criteria
Contiguous sclerosis of fractured fragments
Contiguous resorption of fractured fragments
Loss of cortical continuity
Movement on dynamic films

15. Spine Fracture Approach
Assessment
Mechanism of injury
Neuro exam
Imaging
Levels
Bone vs soft tissue
Dynamic vs static
Vessels?
Degree of instability
Management
Surgery vs no surgery
Goals?
Brace?
Activity restrictions
Follow up
Imaging
Rehab

16. Case files

17. Case 1

20. Case 2

24. Left vert out

27. Case 3

29. Case 4

33. Case 5

34. Small pedicles

37. Mary had a little lamb, Its fleece was white as snow
Everywhere that Mary went The lamb was sure to go
It followed her to school one day Which was against the rules.
It made the children laugh and play To see a lamb at school
And so the teacher turned it out, But still it lingered near
And waited patiently about Till Mary did appear
"Why does the lamb love Mary so?" The eager children cry
"Why, Mary loves the lamb, you know." The teacher did reply