1. Upper Cervical Trauma Sohail Bajammal, MBChB, MSc November 14, 2006
St. Joseph’s Healthcare, Hamilton
Weekly Orthopaedic Teaching Rounds

2. Upper Cervical Trauma a.k.a. Cranio-cervical Trauma
Occipito-cervical Trauma
Occipito-atlanto-axial Trauma

3. Outline
The Problem
Anatomy
X-rays
Fractures of O, C1, C2

4. The Problem Better recognition Improved cars safety:
Better pre-hospital care (ATLS, Orthopod)
Radiographic finding
Improved cars safety:
Less mortality at scene, more of OC injury

5. Evaluation History: mechanism of injury Physical: ATLS Radiology:
2° survey: thorough neurological exam
Radiology:
3-views C-spine, CT, MRI

6. Anatomy

7. Anatomy Unique anatomy of O-C1-C2 Ligaments: Vertebral artery
C1: no body, 2 articular pillars connected by 2 arches
C2: dens, flat C1-2
Ligaments:
Intrinsic (within spinal canal):
Odontoid: alar, apical
Cruciate: transverse lig, vertical bands
Tectorial membrane: thickening of PLL
Extrinsic:
Ligamentum nuchae
Anterior and posterior atlanto-occipital membrane
Anterior and posterior atlanto-axial membrane
Joint capsules
Vertebral artery

8. Courtesy of AnatomyTV

15. Ponticulus Posticus Latin, little posterior bridge
Young et al., 2005 JBJS(A)
15.5% prevalence of arcuate foramen in 464 lateral c-spine x-rays

16. Ponticulus Posticus

17. Ponticulus Posticus

18. X-rays

19. Cervical X-rays ABCDEs
A: adequacy, alignment
B: bones
C: cartilage
D: disc space
E: else (skull, clavicle)
S: soft tissue

20. Lateral C-spine

21. Harris Lines
SAC: > 13 mm

22. Powers’ Ratio BC/OA Limited Usefulness
>1 considered abnormal
Limited Usefulness
Positive only in Anterior Translational injuries
False Negative with pure distraction

23. Open-mouth View

24. Occipital Condyle Fractures
CT, R/O OC dissociation
I: comminuted, axial impaction
Stable  Collar 6-8 weeks
II: extension of basilar skull fracture into 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

25. Occipito-cervical Dissociation
Rare and usually fatal
Often assoc. with facial injuries, chest trauma
Deceleration
AVOID traction!!
Halo until surgery
1º treatment:
Oc-C2 fusion if good screw purchase
Oc-C3 fusion otherwise
Biomechanically: plate & screw > screws > wires

26. Traynelis Classification of Occipito-cervical Dissociation

27. Harborview Classification of Occipitocervical Injury
MRI: hemorrhage or edema at OC junction
Normal Harris lines
No distraction on traction test with 25 lb of traction
II:
< 25 lb traction: sufficient distraction to meet OC dissociation thresholds of Harris
III:
Static imaging: distraction beyond thresholds of Harris

28. Atlas (C1) Fractures 10% of all cervical fractures
Rare neurological deficits; if any, R/O dissociation
50% concomitant fractures
Morphological classification
Posterior arch: hyperextension
Lateral mass: rotation or lateral flexion forces
Anterior arch fractures (blowout or plow fractures) : hyperextension,
Bursting-type fractures (Jefferson): symmetrical axial load
Transverse process
Anterior tubercle

29. Atlas Fractures
The extent of lateral mass separation is more relevant than the number of fracture fragments

30. Stable Atlas Fractures
Posterior arch fracture: collar weeks
Anterior arch avulsion fracture: collar
C1 ring fracture with <7 mm of overall lateral mass displacement: collar or halo

31. Unstable Atlas Fractures
C1 ring fracture with ≥7 mm of overall C1 lateral mass displacement: prolonged halo or fusion (C1-C2, or Occiput-C2)
Plough fracture: reduction with halo in slight flexion or C1-C2 fusion or occiput-C2

32. Plough Fracture

33. Rupture of Transverse Ligament
Flexion force
Dickman Classification:
Mid-substance tear
Avulsion of lateral mass of C1
As force increases, alar and apical lig tear (ADI > 7mm)
Treatment:
If ADI ≤5mm  collar
If ADI >5mm and type I  C1-C2 fusion
If ADI >5mm and type II  halo

34. Atlanto-Axial Instability
A: Rotational
Around the dens
Treated with closed reduction and immobilization.
Beware of associated fractures
B: Translational
Translation between C1–C2, where transverse lig is disrupted
Mid-substance transverse ligament tears (type I) are treated with C1–C2 arthrodesis
C: Distraction:
Indicating craniocervical dissociation
Bony avulsions (type II) may be treated with halo or C1–C2 arthrodesis

35. Rotatory Atlanto-Axial Instability
C1-C2 Fusion
Collar or Halo

36. Axis (C2) Fractures Odontoid fractures
Traumatic spondylolisthesis of the axis (hangman's fracture)

37. 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

39. Type I Odontoid Occurs at tip, cephalad to the transverse Least common
Represent an avulsion of the alar ligament
Treated with collar or halo 6-8 weeks
Surgery (occiput-C2 fusion) if associated with occipitocervical dissociation

40. Type III Odontoid Extends into the body of the axis
More stable than type II fractures
Higher union rate with non-surgical
Treated with a halo or brace 8-12 weeks after reduction if displaced

41. Type II Odontoid
At the junction of the base of the odontoid and body of the axis
The most common fracture type
The least likely to heal with non-surgical (10-77% non-union)
IIA: new addition, comminution at base
Treatment: controversial

42. Type II Odontoid Higher risk of non-union:
Initial displacement > 5mm
Posterior displacement
Angulation > 100
Age > 50
Smoking
Delay in diagnosis > 3 weeks
Inability to achieve or maintain reduction

43. Options for High Risk type II
Collar: very high risk of non-union
Reduction and Halo: risk of complications in elderly
Anterior Odontoid Screw(s)
Pros: High union rate, preserves atlanto-axial motion
Cons: Poor fixation in osteoporotic, difficult in large chest or posteriorly displaced
C/I: reverse obliquity
Posterior C1-C2 arthrodesis:
C1-2 transarticular screw > segmental C1-2 fixation > wires techniques

44. Anterior Odontoid Screw

45. Traumatic spondylolisthesis of the Axis (Hangman's fracture)
2nd most common fracture of C2
15% of all cervical spine fractures
Higher energy injury, associated spinal #: 30%
Younger age group, MVC
MOI: hyperextension + axial compression; additional flexion moment leads to very unstable injury
Rare neurological involvement

46. Hangman's Fracture Effendi  Levine & Edwards Classification

47. Type I Hangman’s Most common
Bilateral pars fractures with translation <3 mm and no angulation
Treated with collar, occasionally halo

48. Type IA Hangman’s Atypical fracture, recently recognized
Minimal translation and little or no angulation
Elongation of the C2 body
CT: extension of fracture line into the body and often through the foramen transversarium (vertebral artery injury may occur)
May have canal compromise
Usually halo, surgery if neuro deficits
Surgical options: anterior C2–C3 arthrodesis, posterior C1–C3 vs C2–C3 arthrodesis, or combined approach

49. Type IA Hangman’s

50. Type II Hangman’s
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

51. Type IIA Hangman’s Less common; MOI: hyperext, axial then flex
Fracture line is more oblique than vertical (vs II)
Little or no translation, but significant angulation.
Avoid traction
Halo, and if markedly displaced, possibly direct fixation of fractured arch through a posterior approach C1-C3, or by C2–C3 anterior discectomy and arthrodesis

52. Type III Hangman’s
A combination of pars fracture with dislocation of the C2-3 facet joints
Very unstable, with free-floating inferior articular processes
The most common injury to be associated with neurological deficit
Requires surgery; it is irreducible by closed means
Options: Anterior C2-3 discectomy and fusion, or posterior open reduction and C1-3 fusion

53. Posterior C1-2 Fusion Gallie Technique

54. Posterior C1-2 Fusion Brooks-Jenkins technique

55. C1–C2 Transarticular Screw Fixation Magerl technique

56. Finally.. It’s over!

57. Halo Crown first then the vest Prep areas in infiltrate with local
Normally put scoop under head (unless contraindicated)
Put halo crown around head
Landmarks: for the anterolateral pins, 1cm above the lateral 1/3 of the eyebrow and the same distance above the top of the ear
Place the anterior pins in bare skin NOT in the hairline

58. Halo Have patient close eyes before insertion of ant pins
Place 4 pins in and tighten all 4 to engage skin and bone
Tighten to 8 in-lb with the torque wrench
Place the vest on
X-ray!

59. Halo Care Routinely retighten after 24-48 hours
If a pin is to be replaced, a new pin should be inserted satisfactorily before the loose pin is removed
Pin sites should be cleaned daily
Most commonly injured nerves are the supraorbital and supratrochlear

60. Halo Care
Inserting anterolateral pins behind the hairline in hopes of obtaining a more cosmetically acceptable scar should be avoided - this location places the pin within the temporal fossa where the skull is the thinnest
Pins located in the temporal fossa also pierce the temporalis muscle and often lead to painful mastication