Bajammal 2006 Upper Cervical Trauma

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Upper cervical (craniocervical) trauma: diagnosis & management. The presentation was done in 2006.

Bajammal 2006 Upper Cervical Trauma

  1. 1. Upper Cervical Trauma Sohail Bajammal, MBChB, MSc November 14, 2006 St. Joseph’s Healthcare, Hamilton Weekly Orthopaedic Teaching Rounds
  2. 2. Upper Cervical Trauma a.k.a. Cranio-cervical Trauma Occipito-cervical Trauma Occipito-atlanto-axial Trauma
  3. 3. Outline <ul><li>The Problem </li></ul><ul><li>Anatomy </li></ul><ul><li>X-rays </li></ul><ul><li>Fractures of O, C1, C2 </li></ul>
  4. 4. The Problem <ul><li>Better recognition </li></ul><ul><ul><li>Better pre-hospital care (ATLS, Orthopod) </li></ul></ul><ul><ul><li>Radiographic finding </li></ul></ul><ul><li>Improved cars safety: </li></ul><ul><ul><li>Less mortality at scene, more of OC injury </li></ul></ul>
  5. 5. Evaluation <ul><li>History: mechanism of injury </li></ul><ul><li>Physical: ATLS </li></ul><ul><ul><li>2° survey: thorough neurological exam </li></ul></ul><ul><li>Radiology: </li></ul><ul><ul><li>3-views C-spine, CT, MRI </li></ul></ul>
  6. 6. Anatomy
  7. 7. Anatomy <ul><li>Unique anatomy of O-C1-C2 </li></ul><ul><ul><li>C1: no body, 2 articular pillars connected by 2 arches </li></ul></ul><ul><ul><li>C2: dens, flat C1-2 </li></ul></ul><ul><li>Ligaments: </li></ul><ul><ul><li>Intrinsic (within spinal canal): </li></ul></ul><ul><ul><ul><li>Odontoid: alar, apical </li></ul></ul></ul><ul><ul><ul><li>Cruciate: transverse lig, vertical bands </li></ul></ul></ul><ul><ul><ul><li>Tectorial membrane: thickening of PLL </li></ul></ul></ul><ul><ul><li>Extrinsic: </li></ul></ul><ul><ul><ul><li>Ligamentum nuchae </li></ul></ul></ul><ul><ul><ul><li>Anterior and posterior atlanto-occipital membrane </li></ul></ul></ul><ul><ul><ul><li>Anterior and posterior atlanto-axial membrane </li></ul></ul></ul><ul><ul><ul><li>Joint capsules </li></ul></ul></ul><ul><li>Vertebral artery </li></ul>
  8. 8. Courtesy of AnatomyTV
  9. 15. Ponticulus Posticus Latin , little posterior bridge <ul><li>Young et al., 2005 JBJS(A) </li></ul><ul><li>15.5% prevalence of arcuate foramen in 464 lateral c-spine x-rays </li></ul>
  10. 16. Ponticulus Posticus
  11. 17. Ponticulus Posticus
  12. 18. X-rays
  13. 19. Cervical X-rays ABCDEs <ul><li>A: adequacy, alignment </li></ul><ul><li>B: bones </li></ul><ul><li>C: cartilage </li></ul><ul><li>D: disc space </li></ul><ul><li>E: else (skull, clavicle) </li></ul><ul><li>S: soft tissue </li></ul>
  14. 20. Lateral C-spine
  15. 21. Harris Lines SAC: > 13 mm
  16. 22. <ul><li>BC/OA </li></ul><ul><ul><li>>1 considered abnormal </li></ul></ul><ul><li>Limited Usefulness </li></ul><ul><li>Positive only in Anterior Translational injuries </li></ul><ul><li>False Negative with pure distraction </li></ul>Powers’ Ratio
  17. 23. Open-mouth View
  18. 24. Occipital Condyle Fractures <ul><li>CT, R/O OC dissociation </li></ul><ul><li>I: comminuted, axial impaction </li></ul><ul><ul><li>Stable  Collar 6-8 weeks </li></ul></ul><ul><li>II: extension of basilar skull fracture into condyle </li></ul><ul><ul><li>Potentially unstable  Collar 6-8 weeks </li></ul></ul><ul><li>III: avulsion of alar lig </li></ul><ul><ul><li>Minimal displaced  Halo vest, 8-12 weeks </li></ul></ul><ul><ul><li>Displaced  O-C2 fusion </li></ul></ul><ul><li>Consider surgery if OC dissociation </li></ul>
  19. 25. Occipito-cervical Dissociation <ul><li>Rare and usually fatal </li></ul><ul><li>Often assoc. with facial injuries, chest trauma </li></ul><ul><li>Deceleration </li></ul><ul><li>AVOID traction!! </li></ul><ul><li>Halo until surgery </li></ul><ul><li>1 º treatment: </li></ul><ul><ul><li>Oc-C2 fusion if good screw purchase </li></ul></ul><ul><ul><li>Oc-C3 fusion otherwise </li></ul></ul><ul><ul><li>Biomechanically: plate & screw > screws > wires </li></ul></ul>
  20. 26. Traynelis Classification of Occipito-cervical Dissociation
  21. 27. Harborview Classification of Occipitocervical Injury <ul><li>I: </li></ul><ul><ul><li>MRI: hemorrhage or edema at OC junction </li></ul></ul><ul><ul><li>Normal Harris lines </li></ul></ul><ul><ul><li>No distraction on traction test with 25 lb of traction </li></ul></ul><ul><li>II: </li></ul><ul><ul><li>MRI: hemorrhage or edema at OC junction </li></ul></ul><ul><ul><li>Normal Harris lines </li></ul></ul><ul><ul><li>< 25 lb traction: sufficient distraction to meet OC dissociation thresholds of Harris </li></ul></ul><ul><li>III: </li></ul><ul><ul><li>Static imaging: distraction beyond thresholds of Harris </li></ul></ul>
  22. 28. Atlas (C1) Fractures <ul><li>10% of all cervical fractures </li></ul><ul><li>Rare neurological deficits; if any, R/O dissociation </li></ul><ul><li>50% concomitant fractures </li></ul><ul><li>Morphological classification </li></ul><ul><ul><li>Posterior arch: hyperextension </li></ul></ul><ul><ul><li>Lateral mass: rotation or lateral flexion forces </li></ul></ul><ul><ul><li>Anterior arch fractures (blowout or plow fractures) : hyperextension, </li></ul></ul><ul><ul><li>Bursting-type fractures (Jefferson): symmetrical axial load </li></ul></ul><ul><ul><li>Transverse process </li></ul></ul><ul><ul><li>Anterior tubercle </li></ul></ul>
  23. 29. Atlas Fractures <ul><li>The extent of lateral mass separation is more relevant than the number of fracture fragments </li></ul>
  24. 30. Stable Atlas Fractures <ul><li>Posterior arch fracture: collar 10-12 weeks </li></ul><ul><li>Anterior arch avulsion fracture: collar </li></ul><ul><li>C1 ring fracture with <7 mm of overall lateral mass displacement: collar or halo </li></ul>
  25. 31. Unstable Atlas Fractures <ul><li>C1 ring fracture with ≥7 mm of overall C1 lateral mass displacement: prolonged halo or fusion (C1-C2, or Occiput-C2) </li></ul><ul><li>Plough fracture: reduction with halo in slight flexion or C1-C2 fusion or occiput-C2 </li></ul>
  26. 32. Plough Fracture
  27. 33. Rupture of Transverse Ligament <ul><li>Flexion force </li></ul><ul><li>Dickman Classification: </li></ul><ul><ul><ul><li>Mid-substance tear </li></ul></ul></ul><ul><ul><ul><li>Avulsion of lateral mass of C1 </li></ul></ul></ul><ul><li>As force increases, alar and apical lig tear (ADI > 7mm) </li></ul><ul><li>Treatment: </li></ul><ul><ul><li>If ADI ≤5mm  collar </li></ul></ul><ul><ul><li>If ADI >5mm and type I  C1-C2 fusion </li></ul></ul><ul><ul><li>If ADI >5mm and type II  halo </li></ul></ul>
  28. 34. Atlanto-Axial Instability <ul><li>A: Rotational </li></ul><ul><ul><li>Around the dens </li></ul></ul><ul><ul><li>Treated with closed reduction and immobilization. </li></ul></ul><ul><ul><li>Beware of associated fractures </li></ul></ul><ul><li>B: Translational </li></ul><ul><ul><li>Translation between C1–C2, where transverse lig is disrupted </li></ul></ul><ul><ul><li>Mid-substance transverse ligament tears (type I) are treated with C1–C2 arthrodesis </li></ul></ul><ul><li>C: Distraction: </li></ul><ul><ul><li>Indicating craniocervical dissociation </li></ul></ul><ul><ul><li>Bony avulsions (type II) may be treated with halo or C1–C2 arthrodesis </li></ul></ul>
  29. 35. Rotatory Atlanto-Axial Instability Collar or Halo C1-C2 Fusion
  30. 36. Axis (C2) Fractures <ul><li>Odontoid fractures </li></ul><ul><li>Traumatic spondylolisthesis of the axis (hangman's fracture) </li></ul>
  31. 37. Odontoid Fractures <ul><li>60% of C2 fractures </li></ul><ul><li>10-20% of all c-spine fractures </li></ul><ul><li>Neurological deficits in 10-20% </li></ul><ul><li>Bimodal: </li></ul><ul><ul><li>young (high energy), elderly (falls) </li></ul></ul><ul><li>Anderson and D'Alonzo Classification </li></ul>
  32. 39. Type I Odontoid <ul><li>Occurs at tip, cephalad to the transverse </li></ul><ul><li>Least common </li></ul><ul><li>Represent an avulsion of the alar ligament </li></ul><ul><li>Treated with collar or halo 6-8 weeks </li></ul><ul><li>Surgery (occiput-C2 fusion) if associated with occipitocervical dissociation </li></ul>
  33. 40. Type III Odontoid <ul><li>Extends into the body of the axis </li></ul><ul><li>More stable than type II fractures </li></ul><ul><li>Higher union rate with non-surgical </li></ul><ul><li>Treated with a halo or brace 8-12 weeks after reduction if displaced </li></ul>
  34. 41. Type II Odontoid <ul><li>At the junction of the base of the odontoid and body of the axis </li></ul><ul><li>The most common fracture type </li></ul><ul><li>The least likely to heal with non-surgical (10-77% non-union) </li></ul><ul><li>IIA: new addition, comminution at base </li></ul><ul><li>Treatment: controversial </li></ul>
  35. 42. Type II Odontoid <ul><li>Higher risk of non-union: </li></ul><ul><ul><li>Initial displacement > 5mm </li></ul></ul><ul><ul><li>Posterior displacement </li></ul></ul><ul><ul><li>Angulation > 10 0 </li></ul></ul><ul><ul><li>Age > 50 </li></ul></ul><ul><ul><li>Smoking </li></ul></ul><ul><ul><li>Delay in diagnosis > 3 weeks </li></ul></ul><ul><ul><li>Inability to achieve or maintain reduction </li></ul></ul>
  36. 43. Options for High Risk type II <ul><li>Collar: very high risk of non-union </li></ul><ul><li>Reduction and Halo: risk of complications in elderly </li></ul><ul><li>Anterior Odontoid Screw(s) </li></ul><ul><ul><li>Pros: High union rate, preserves atlanto-axial motion </li></ul></ul><ul><ul><li>Cons: Poor fixation in osteoporotic, difficult in large chest or posteriorly displaced </li></ul></ul><ul><ul><li>C/I: reverse obliquity </li></ul></ul><ul><li>Posterior C1-C2 arthrodesis: </li></ul><ul><ul><li>C1-2 transarticular screw > segmental C1-2 fixation > wires techniques </li></ul></ul>
  37. 44. Anterior Odontoid Screw
  38. 45. Traumatic spondylolisthesis of the Axis (Hangman's fracture) <ul><li>2 nd most common fracture of C2 </li></ul><ul><li>15% of all cervical spine fractures </li></ul><ul><li>Higher energy injury, associated spinal #: 30% </li></ul><ul><li>Younger age group, MVC </li></ul><ul><li>MOI: hyperextension + axial compression; additional flexion moment leads to very unstable injury </li></ul><ul><li>Rare neurological involvement </li></ul>
  39. 46. Hangman's Fracture Effendi  Levine & Edwards Classification
  40. 47. Type I Hangman’s <ul><li>Most common </li></ul><ul><li>Bilateral pars fractures with translation <3 mm and no angulation </li></ul><ul><li>Treated with collar, occasionally halo </li></ul>
  41. 48. Type IA Hangman’s <ul><li>Atypical fracture, recently recognized </li></ul><ul><li>Minimal translation and little or no angulation </li></ul><ul><li>Elongation of the C2 body </li></ul><ul><li>CT: extension of fracture line into the body and often through the foramen transversarium (vertebral artery injury may occur) </li></ul><ul><li>May have canal compromise </li></ul><ul><li>Usually halo, surgery if neuro deficits </li></ul><ul><li>Surgical options: anterior C2–C3 arthrodesis, posterior C1–C3 vs C2–C3 arthrodesis, or combined approach </li></ul>
  42. 49. Type IA Hangman’s
  43. 50. Type II Hangman’s <ul><li>C2-3 disc and PLL are disrupted, resulting in translation >3 mm and marked angulation </li></ul><ul><li>ALL generally remains intact but is stripped from its bony attachment </li></ul><ul><li>Halo: after reduction in slight extension </li></ul>
  44. 51. Type IIA Hangman’s <ul><li>Less common; MOI: hyperext, axial then flex </li></ul><ul><li>Fracture line is more oblique than vertical (vs II) </li></ul><ul><li>Little or no translation, but significant angulation. </li></ul><ul><li>Avoid traction </li></ul><ul><li>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 </li></ul>
  45. 52. Type III Hangman’s <ul><li>A combination of pars fracture with dislocation of the C2-3 facet joints </li></ul><ul><li>Very unstable, with free-floating inferior articular processes </li></ul><ul><li>The most common injury to be associated with neurological deficit </li></ul><ul><li>Requires surgery; it is irreducible by closed means </li></ul><ul><li>Options: Anterior C2-3 discectomy and fusion, or posterior open reduction and C1-3 fusion </li></ul>
  46. 53. Posterior C1-2 Fusion Gallie Technique
  47. 54. Posterior C1-2 Fusion Brooks-Jenkins technique
  48. 55. C1–C2 Transarticular Screw Fixation Magerl technique
  49. 56. Finally.. It’s over!
  50. 57. Halo <ul><li>Crown first then the vest </li></ul><ul><li>Prep areas in infiltrate with local </li></ul><ul><li>Normally put scoop under head (unless contraindicated) </li></ul><ul><li>Put halo crown around head </li></ul><ul><li>Landmarks: for the anterolateral pins, 1cm above the lateral 1/3 of the eyebrow and the same distance above the top of the ear </li></ul><ul><li>Place the anterior pins in bare skin NOT in the hairline </li></ul>
  51. 58. Halo <ul><li>Have patient close eyes before insertion of ant pins </li></ul><ul><li>Place 4 pins in and tighten all 4 to engage skin and bone </li></ul><ul><li>Tighten to 8 in-lb with the torque wrench </li></ul><ul><li>Place the vest on </li></ul><ul><li>X-ray! </li></ul>
  52. 59. Halo Care <ul><li>Routinely retighten after 24-48 hours </li></ul><ul><li>If a pin is to be replaced, a new pin should be inserted satisfactorily before the loose pin is removed </li></ul><ul><li>Pin sites should be cleaned daily </li></ul><ul><li>Most commonly injured nerves are the supraorbital and supratrochlear </li></ul>
  53. 60. Halo Care <ul><li>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 </li></ul><ul><li>Pins located in the temporal fossa also pierce the temporalis muscle and often lead to painful mastication </li></ul>

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