The document discusses upper cervical trauma, highlighting the anatomy, types of fractures, and their associated treatment protocols. It emphasizes the importance of early recognition, appropriate pre-hospital care, and specific radiographic evaluations for better management of cervical injuries. Various classifications and treatment options for different types of cervical fractures, including odontoid and hangman's fractures, are also outlined.

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 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 2° survey: thorough neurological exam Radiology: 3-views C-spine, CT, MRI

6. Anatomy

7. Anatomy Unique anatomy of O-C1-C2 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. BC/OA >1 considered abnormal Limited Usefulness Positive only in Anterior Translational injuries False Negative with pure distraction Powers’ Ratio

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 1 º 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 I: MRI: hemorrhage or edema at OC junction Normal Harris lines No distraction on traction test with 25 lb of traction II: MRI: hemorrhage or edema at OC junction Normal Harris lines < 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 10-12 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 Collar or Halo C1-C2 Fusion

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 > 10 0 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) 2 nd 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