1. UPPER CERVICAL SPINE INJURIES
Joseph Donnelly, M.D.
SFORP

2. Overview Introduction Anatomy Evaluation & early management
Cervicocranial injuries
Occipitocervical dissociation
Occipital condyle fractures
Atlas fractures
Atlantoaxial instability
Axis fractures

3. Introduction 40% risk of neuro deficits with cervical spine injuries
Cost per injured pt= incredibly high
Etiology: MVA 45%, falls 20%, sports 15%, violence 15%

4. Anatomy -atlanto-odontoid joint= synovial
-tectorial membrane= cephalad continuation of PLL

5. Anatomy -extrinsic ligaments (nuchae, joint capsules)= weaker
-apical ligament= weak
-alar ligaments= 5-6mm in diameter and strong
-extrinsic ligaments (nuchae, joint capsules)= weaker
-intrinsic ligaments= within spinal canal, majority of ligamentous stability
3 layers: 1)tectorial membrane 2)cruciate ligament
3)odontoid ligaments

6. Anatomy

7. Range of Motion Occiput-atlas Atlantoaxial Flexion/extension: 25deg
Lateral bending: 5deg each side
Rotation: 5deg each side
Atlantoaxial
Flexion/extension: 20deg
Lateral bending: 5deg
Rotation: 40 deg

8. Range of Motion
Alar ligaments and tectorial membrane limit distraction to >2mm
Translation (limited by facet joints and alar/tectorial ligaments) should not exceed 1mm

9. Cervical Spine Evaluation
Primary survey
ABCDE
Physical exam 1st, detailed history later
Neuro exam
Initial x-ray- lateral c-spine film, must include C7-T1 junction
Maintain airway with jaw thrust, not head tilt method

10. Neuro Exam -cranial nerves: VI, VII, IX, XI, XII
-reflexes: DTR’s, cremasteric (T12,L1), anal wink (S2,3,4), BC (S3,4)

11. Radiographs
Complete C-spine= x-table lateral, swimmers if needed, AP, Odontoid
Nearly 100% sensitive if all these views obtained
CT: for atlantoaxial/cervicothoracic junctions, equivocal C1-2 x-rays
MRI: disc pathology, ligament injury, spinal cord injury

12. Lateral C-spine Film Anterior vertebral line Posterior vertebral line
Spinolaminar line
ADI (nl= mm)
Retropharyngeal soft tissue >5mm is abnormal

13. AP C-spine film Least infomative Vertebrae height
Spinous process alignment & spacing
Uniform disc and uncovertebral spacing

14. Open Mouth Odontoid Lateral mass overlap should be less than 7mm total
Look for odontoid tilt

15. Early Management Goal=prevent further damage Methylprednisolone
30 mg/kg bolus
5.4 mg/kg/hr for 23 hrs
Only effective under 8 hours
1-3 hrs: continue 24 hrs
3-8 hrs: continue 48 hrs

16. Early Management
-Gardner Wells tongs: for unstable or malaligned injuries needing traction
pre-op or reduction
-below temporal ridges 2cm above external auditory meatus
-start with 10 lbs, add 5 lb increments, PATIENT AWAKE

17. General Treatment Goals
1)Protect neural structures
2)Reduce and stabilize injured segment
3)Provide long term stability

18. Occipitocervical Dissociation
Extremely rare ligamentous injury with high mortality rate
5-12% of cervical injuries in autopsy studies
Mechanism: peds vs. auto (hyperext/distraction)
Anterior (most common), posterior, longitudinal
Kids predisposed
Ligament laxity
Immature OC joints
Larger head to body size ratio

19. Power’s Ratio BC/OA ratio less than 1=normal
If more than 1, anterior dislocation exists
Can be misleading with posterior dislocaton, odontoid fx, congen. anomalies

20. Harris Rule of 12 Better measurement Adults and kids >13yo
Odontoid
tip
Basion
Better measurement
Adults and kids >13yo
Three landmarks
Basion
Odontoid tip
Posterior axial line
1) Basion-axial interval
2) Basion-dental interval
Both should be <12mm
Posterior axial
line

21. Occipitocervical Dissociation
Clinical findings range from mild to catastrophic
Death by medulla oblongata transection and respiratory failure
Cranial nerve injuries
Abducens (VI) most often
Vertebral artery injuries
ALC, nystagmus, ataxia, diplopia, dysarthria
Treatment:
Respiratory support
Early halo vs. traction stabilization
PSF vs. prolonged halo
Non-op tx rarely results in stability

22. Occipital Condyle Fractures
Often in conjunction with other c-spine fx’s
Usually found on CT, hard to find on x-ray
Usually axial compression
Dx: look for prevertebral swelling, torticollis, CN XI-XII (acute or delayed)

23. Occipital Condyle Fractures: Classification
Anderson and Montesano, based on CT findings
Type I: impaction of condyle, stable
Type II: associated basilar skull fracture
Stable unless entire condyle separated
Type III: avulsion fx via alar ligaments
Can be bilateral
In 30-50% of atlanto-occipital dislocations

24. Occipital Condyle Fractures
Treatment:
Types I & II: halo vest 6-12 weeks depending on stability
Type III: potentially unstable, require at least 12 weeks halo vest

25. Occipital Condyle Fractures
-MVA, neck pain, C5-6 translation on lateral film
-dysarthria due to XII (hypoglossal) palsy from type I OCF noted on CT

26. Atlas Fractures 10% of cervical spine injuries
Neurologic injury is rare
Ring tends to expand with injury allowing more room for the cord
High incidence of associated injury
Up to seven types
Each has a predictable mechanism

27. Atlas Fractures Burst fracture (33%) “Jefferson Fx”
Symmetric axial load
3 or 4 parts
Least likely to cause neuro injury

28. Atlas Fractures
Transverse ligament can fail (tension from lateral masses), defining unstable fracture
Apical and alar ligaments spared

29. Atlas Fractures Burst fx treatment
Stable: non or minimally displaced lateral masses (<5mm)
Collar or halo 3 mos
High union rate
Unstable: >5mm displacement due to transverse ligament disruption
Reduction by traction, then halo or surgery
Need 4-6 weeks traction prior to halo to hold reduction
Surgery= C1-2 fusion

30. Atlas Fractures Posterior arch fracture (28%)
Hyperextension with axial load injury
Stable:
Lateral masses and anterior arch intact

31. Atlas Fracture Posterior arch fracture Treatment:
Collar for weeks until union
High union rate

32. Atlas Fractures Comminuted/lateral mass fracture (22%)
Axial compression with lateral flexion
Usually with transvere ligament avulsion fx
Most likely to result in nonunion and poor functional outcome
Tx: same as burst fractures (depends on lateral mass displacement)

33. Atlas Fractures Anterior arch fractures “blow out” fx
may see odontoid fx
Reduction requires flexion
Halo vest in flexion vs. PSF

34. Atlas Fractures Transverse process fractures Unilateral or bilateral
Avulsion or lateral bending
Along with other avulsion fx’s, treat symptomatically with soft collar 4-6 weeks

35. Transverse Ligament Spence JBJS 1970 Hyperflexion injury
Burst fx with intact ligament: less than 5.7 mm atlantoaxial offset
Burst fx with ruptured ligament: greater than 6.9 mm offset
Hyperflexion injury
Different than burst, alar/apical ligaments can be affected, more unstable
Translation <5mm, transverse ligament only disrupted
Translation >7mm, loss of alar ligament and tectorial membrane

36. Transverse Ligament ADI: Normal
Adults <3mm
Children <5mm
>3mm on flex/ext x-rays= transverse ligament ruptured
>5mm, accessory ligaments ruptured

37. Odontoid Fractures 8-12% cervical fx’s 10-20% have neuro deficits
Odontoid with transverse ligament prevent anterior/posterior dislocation
Fx mechanism unclear
Flex/ext/rotation combo
Usually MVA

38. Odontoid Fractures Type I Type II Type III Least common
Stable, avulsion?
Type II
Most common
Least likely to heal nonoperatively
Type III
More stable than type II with higher union rate

39. Odontoid Fractures Type I treatment
If not part of a more serious injury, immobilize in cervical orthosis 6-8 weeks
May represent OC dislocation with alar ligament disruption
This requires occiput-C2 fusion

40. Odontoid Fractures Type III treatment
Usually seen in kids <7yo= epiphyseal separations
May require traction to reduce fracture if displaced >5mm or angulated >10deg
Halo vest for 8-12 weeks
Union rates exceed 95%

41. Odontoid Fractures Type II treatment Nonunion rates 10-77%
Risk factors: initial displacement >5mm, posterior displacement, comminution, inability to reduce, age >50yo
Non-displaced: halo vest 12 weeks with frequent x-rays
With displaced then anatomically reduced fractures, union %

42. Odontoid Fractures
Vascular insult theories for high Type II non-union rate
Damage to ascending artery as it pases base
But angio and autopsy in non-unions have shown rich blood supply and no AVN
Interposed soft tissue? Intraarticular?

43. Odontoid Fractures Type II treatment High risk fractures
Collar= bad, high nonunion
Halo= not tolerated well in elderly
Odontoid screw= high union rate (79-100%), preserves AA motion, bad with osteopenia/big chests/ posterior displacement
C1-2 PSF= high union rate (87-100%), sacrifices AA motion

44. Odontoid Fractures
-posterior displaced type II treated with bone block construct and
Sublaminar/subarch wires

45. Odontoid Fractures

46. Odontoid Fractures

47. Traumatic Spondylolisthesis of the Axis
“Hangman’s Fracture”
Radiology similar, mechanism different
Hanging= violent hyperextension/distraction with complete disruption of disc & ligaments between C2 and C3, spinal cord severed
MVA= combo of ext/axial compress/ flexion with varying disc injury
Neurologic injury uncommon, spinal canal decompressed
Axis vulnerable as transition vertebrae between mobile elements above and fixed elements below
Transition of articulations from front to back
Fracture through pars intraarticularis

48. Traumatic Spondylolisthesis of the Axis
Classification:
Type I= fracture through neural arch, no angulation, up to 3mm displacement
Type IA= atypical, recently recognized, elongation of C2 body, extension into transverse foramen can injure vertebral A.
Type II= significant angulation and displacement
Type IIA= minimal displacement, severe angulation
Type III= combined bilateral facet dislocation C2-3 with axis neural arch fx

49. Traumatic Spondylolisthesis of the Axis
Type II
Type I
Type IIA
Type III

50. Traumatic Spondylolisthesis of the Axis
Type I
Bilateral pars fx’s
C2-3 disc/ligaments intact, major injury to bone
Treat with collar immobilization
Treat IA the same

51. Traumatic Spondylolisthesis of the Axis
Type II
C2-3 disc & PLL disrupted allowing translation >3mm
ALL intact but stripped from bone
Gentle traction reduction
Add extension with bolster behind shoulders
Halo vest 6-8 weeks

52. Traumatic Spondylolisthesis of the Axis
Type II
If displaced >5mm or angled >10deg
Traction to reduce
Recumbant bedrest 4-6 weeks
Halo vest 6-8 weeks
Surgical stabilization an option, but spontaneous anterior fusion=common (favors non-op)

53. Traumatic Spondylolisthesis of the Axis
-transpedicular lag screw fixation of a type II hangman’s fracture

54. Traumatic Spondylolisthesis of the Axis
Type IIA
Less common than type II
Fx more oblique
Avoid traction, will diplace fx
Reduction: extension and gentle axial load
Halo vest 6-8 weeks

55. Traumatic Spondylolisthesis of the Axis
Type III
Very unstable
Most common with assoc neuro injury
Irreducible closed
Inferior facets of C2 floating free
Tx: ORIF with wiring or plating based on facet & lamina integrity

56. Traumatic Spondylolisthesis of the Axis
Results:
No long term studies
Levine 4.5 year f/u
Type I: 90% healed, 10% with degenerative changes
Type II: 70% developed spontaneous anterior fusion
Type III: overall poor prognosis due to neurologic deficits

57. THE END