Cervical spine fractures, especially those involving C1 and C2, were discussed. Key points included that 10% of cervical fractures involve C1, with 56% being isolated fractures and 44% combined fractures. 20% involve C2. Types of C1 fractures described were Type 1 stable fractures at the posterior arch-lateral mass junction, Type 2 burst fractures, and Type 3 lateral mass fractures. Types of C2 fractures included odontoid fractures classified using Anderson and D'Alonzo's system, Hangman's fractures classified using Levine or Francis systems, and other miscellaneous fractures. Management depended on fracture type but often involved external immobilization though surgery may be indicated for unstable fractures or those with displacement,

1. Cervical Spine Fracture
C1 – C2
Mohamed Elsayed Elsebaey
Neurosurgery Registrar
Egypt, Ismailia
Ministry of Health
Seba3y700025@gmail.com
Mohamed E Elsebaey

2. Spine fracture
• Atlanto- occipital injuries
• Atlanto- axial subluxation
• Atlas fractures
• C2 fractures
• Subaxial Fracture
• thoracic fractures
• thoracolumabar fractures
• Sacral fractures

3. 10 % of the Cervical #s resembles C1 #
56% of those C1 are pure ( Isolated )
44% of those C1 # are Combination
20% of the cervical #s resembles C2 #

7. Atlas C1

8. Axis C2

11. Radiographic Signs of Trauma
Alignment
disrupted cervical arcs
Focal kyphosis/scoliosis/loss of lordosis
Spinous process rotation
Vertebral listhesis
Cartilage (joint/disc) space
facet widening
Interspinous widening (“fanning”)
Widened predental space
Widened/narrowed disc space

12. Bone Integrity
fracture/cortical buckling
Disrupted posterior vertebral body line
Anterior wedging
Disrupted C2 ring (“fat” C2 sign)
Soft Tissue
widened prevertebral space
Displaced prevertebral “fat” strip
Vacuum disc phenomenon
Deviated airway

18. Cervical ligamentous structure

19. Ligaments
Internal
• Tectorial membrane
• Cruciate membrane
• Alar & Apical ligaments
External
• Ant. & Post. Atlanto
occipital membrane
• Ant. & Post. Atlanto
axial membrane
• Articular capsules

23. Pathophysiology of injury
• Flexion
• Flexion rotation
• Extension
• Extension rotation
• Vertical compression
• Lateral flexion

24. So what will happen ???
No thing or Injury

25. Mechanism of injury
• Primary
• Compression that can be
occurred by bony
fragments
• Acute spinal cord
distraction
• Acceleration-
Deceleration with
shearing
• Laceration from
penetrating injuries
• Secondary
• hypoxia and ischemia
• Intracelular & extracellular
ionic shift
• Lipid peroxidation
• Free radical production
• Excitotoxicity
• Neutral protease activation
• Prostaglandin production
• Apoptosis

26. Complain
• Neck pain
• Loss of function ( moving the head )
• Numbness and weakness
• Bowel and bladder dysfunction

27. Management
• Primary: A,B, C
• Secondary:
• Local signs: brusing, increased interspinous
gap
• Search for another spine injury
• Priapism & diaphramitic breathing
• Warm & well perfused peripharies

28. Neurological assessment
• Examine
• Detect the level
• Reflexes
• The first reflex to return is the bulbocavernous
reflex in over 90% of cases
•ASIA

30. Neurological Assessment
• ASIA level can only be determined with
accurate three repeated physical exams in 72
hours.
• No reliable way of determining the real and
exact neurologic injury level at admission.
• Great difference in prognosis between
complete ( ASIA-A) & Incomplete ( ASIA-B,C,D)
• Always give the patient the benefit of doubt.

34. Spinal cord injury
Complete
Another session
Incomplete
Anterior
Posterior
Central
Brown sequard

35. Radiological Assessment
• Cervical –X- Ray
Lateral
A-P especially (( Odontoid # type 2 ))
Open mouth
• CT thin cuts with reconstruction ( sagittal, Coronal )
• MRI

36. C1
Reported # C1 in boy 6 year old FFH into his
vertex, complained with Neck pain, Muscle
Spasm, Head tilt
Judd DB1, Liem LK, Petermann G, Neurosurgery.2000 Apr,46 (4):991-4

37. • Reported congenital deficiency of the
posterior arch in 16 year old girl that was
falling from bicycle
Schrodel M H, Braun V, Stolpe E, Emerg Med J 2005;22:526-8
• So there is classification
of the defects of the Post.
Atlas that we must not forget

38. Classification of defects of Post. Arch of
C1
Von Torklus and Gehle (1975) reported:
Failure of the posterior midline fusion of the two
hemiarches
Type A
Unilateral cleftType B
Bilateral cleftsType C
Total absence of the post. Arch + Persistent Post. tubercleType D
Total absence of the post. Arch + Absent Post. tubercleType E

39. C1 fracture
• Type 1
Stable
Usually occur in the junction of the posterior
arch and the lateral mass

40. C1 fracture
• Type 2
Burst
Named Jefferson #, has many variations
( 4 , 3 or 2 ) points of fracture in the ring

41. C1 fracture
Jefferson # , is classified into
Stable unstable
Intact Transverse Lig. Ruptured
Transverse Lig.

42. Dickman greene & sonttag (1996)
classified the TL injury into
Type 1
Disruption of substance of
the ligament
Type 2
Avulsion from the lateral
mass

43. C1 fracture
• Type 3
Lateral mass #
Usually occur in one side with line passing
through the articular surface, just Anterior or
posterior to the lateral mass on one side

44. Different Subtypes types of C1 fracture

45. Management
• Immobilization

46. Since 1950
Price now is about 1000 $

47. Fracture Line
• Union
• Same
• Diastasis

48. C2 fracture

49. C2 fracture
Types:
Odontoid #
Hangman #
Miscellnanous #s

50. Odontoid #
Anderson and D Alonzo classification 1974

51. Be aware
• Odontoid tip # itself is stable fracture but
it means Alar ligament Avulsion -
Atlanto Occipital Instability
It highly suggest Transverse ligament disruption -
 Atlanto Axial Instability
So, it is very annoying Unstable fracture

52. Management of Odontoid #
Type 1:
If there is Atlanto Axial instability  surgical
intervention for fusion is necessary
But
If the stability is preserved  Ext. Immobilization

53. Management of Odontoid #
Type 2:
The main is conservative Except in:
• Age > / = 7 year old with
• Displacement > 5 mm
• Instability at #site in the Halovest
• Nonunion including fibrous union especially if
accompanied with myelopathy
• Disruption of the transverse ligament

55. Odontoid #
Type 3
Heal with External mobilizaion as
it contains large cancellous surface for fusion
Aim here is to correct the Angulation of displaced
Dens #
Halovest : Fusion rate reach 100%
Rigid collar : fusion rate reach 50 – 70%
for 8 – 14 weeks
Monitoring the pt. with frequent C spine X ray

56. Hangman #
Described by Schneider et al in 1965
Bilateral # at the Pars interarticularis of C2 +
Traumatic subluxation of C2 on C3

57. Levine classification 1973
• type I: fracture with <3 mm antero-posterior deviation
• no angular deviation
• type II: fracture with >3 mm antero-posterior deviation
• significant angular deviation
• disruption of posterior longitudinal ligament
• type IIa: the fracture line is horizontal/oblique (instead
of vertical)
• significant angular deviation without anterior translation
• type III: type I with bilateral facet joint dislocation

59. Anterior displacement

61. William R. Francis / Bassam El-Effendi
Both graduated in 1973, different universities.
They were also both unaware they studied the
same topic
Their paths crossed in the same edition of a journal
where their studies were published in the same
year
One classification scheme is well-known while the
other is almost completely unheard of for no
apparent reason other than chance for one and
misfortune for the other.
A coinsidence, a chance or a misfortune? Hangman's fracture.
Dalbayrak S1, Yaman O2. Neurol Neurochir Pol. 2014;48(4):305-7.

62. DisplacementAngulationGrade
d < 3.5 mm< 11I
d < 3.5 mm> 11II
d >3.5 mm and d/b < 0.5< 11III
d >3.5 mm and d/b < 0.5> 11IV
Disc disruption-V
d is displacement
b is C3 body width
Francis grading
system for hangman
fracture

63. Management
 Managed with External Mobilization in Most
cases.
 Surgical stabilization should be considered:
Severe angulation ( Levaine II, Francis II, IV )
Disc C2, C3 disruption ( Levaine II, Francis V )
Inability to maintain alignment with Ext.
Mobilization.

64. Miscellaneous fractures
Present 20% of the fractures
Include:
Spinous process
Lamina
Facets
Lateral mass
Vertebral body
Ext. Immobilization

65. Combined C1 & C2 #s
• Common
• Accompanying C2 injuries
• ttt is based on the nature of the C2 fracture
• External immobilization is recommended
%Injury
40%Type 2 dens fracture
20%Type 3 dens fracture
12%Hangman’s fracture
28%other

66. Surgical stabilization
• C1 – type II odontoid combination # with d >
5mm.
• C1 – hangman combination # C2-3 angulation
> 11 degree

67. Be so familial with the Enemy

73. Take home massage
• The ossification centres of dens that mimic
the fracture lines
• Transverse lig. & Alar lig.s are the most
stabilizing ligaments.
• A ( C ) , B , C , D, …
• Do not wait for neurological deficit if u suspect
C1, C2 injury
• Do not neglect the pediatric traumatized pts.
• The more cancellous surface meet each other,
the more fusion done

74. Surrounding talks
• Embryology of the Craniovertebral
junction.
• Types of Spinal Cord Injury.
• Vertebral Artery Anatomy and Dissection.
• Surgical Approaches in management of
C1 and C2 fractures.