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upper cervical trauma.pptx
- 1. Case conference Presenter : Dr. 黃獻漳
- 2. Case description Age • 62 / Male, healthy status Chief complaint • Severe posterior neck pain for one week Present illness • The patient was involved in falling down trauma from ladder with height of 1.5 meters. • Occipital region and posterior neck were contused • Ever visited our OPD on post-injury day 5 for treatment but the neck pain was persistent Physical examination • Four limbs freely movable • Local tenderness over posterior neck without shoulder, upper arm and forearm. • Pain aggravated while performing neck ROM
- 3. Brief history 2022/06/06 : • First visit to our outpatient department • Severe neck pain for 5 days • Arranged x-ray
- 4. 2022/06/06
- 5. 2022/06/06
- 6. Brief history 2022/06/06 • First visit to our outpatient department • Severe neck pain for 5 days • Arranged x-ray 2022/06/08 • Come to my outpatient department • Neck pain persistent and poor reaction to pain-killer • Tx : Trigger point injection over posterior neck • Ever suggest wearing collar but patient denied
- 7. Brief history 2022/06/06 • First visit to our outpatient department • Severe neck pain for 5 days • Arranged x-ray 2022/06/08 • Come to my outpatient department • Neck pain persistent and poor reaction to pain-killer • Tx : Trigger point injection over posterior neck • Ever suggest wearing collar but patient denied 2022/06/13 • No resolution of pain after treatment even more severe • Suspected hematoma accumulation or infection after injection • Arrange MRI
- 10. C4 2022/06/13
- 11. C5 2022/06/13
- 12. C6 2022/06/13
- 13. Brief history 2022/06/27 • Admit to our hospital due to liver abscess with left intraocular infection and blurred vision, • Ophthalmologist suggest arrange ocular CT
- 14. 2022/06/28
- 15. 2022/06/13 C1
- 16. Final Diagnosis • Left side lateral mass fracture of Atlas, minimally displaced (~1.0mm) , intact TAL • Left side posterior arch linear fracture of Atlas
- 17. DISCUSSIONS
- 19. Introduction • Occipital – C1 – C2 • Complex, heterogenous pattern with significant morbidity • Bimodal age • High - energy mechanism in young age (16-25 years) • Low - energy in geriatric patients • Junctional relationship from O-C1/2 • Restraint : ligament > bony structure
- 20. Anatomy • Craniocervical jxn = occipitoatlantal + atlantoaxial articulation • Upper cervical stability : gravity and ligamentous effect • Alar ligament • Hold occipital condyle downward • Cruciate ligament • Restraint atlantoaxial anterior subluxation
- 21. Mnemonic : NSAID Neurological deficit, Spinal tenderness, Altered mental status, Intoxication, Distraction injury NEXUS Criteria for C-spine injury
- 22. Patient classification Schoenfeld AJ, J Am Acad Orthop Surg 2019;27(17):633-641.
- 23. • Low-risk patient • Lateral, AP and open-mouth view • Dynamic view to compare the alignment • high-risk patient • CT recommended initially • Neurologic deficit, suspicion of cervical instability MRI • Blunt cerebrovascular injuries (BCVIs) • Denver screening criteria CT angiography • Reported incidence of BCVI (37%) • Fracture extension into transverse foramen • Facet subluxation • Dislocation of upper cervical spine Image arrangement
- 24. Upper cervical trauma Occipital condyle fractures (OCFs) Craniocervical dissociations (CCDs) Atlas fractures Atlantoaxial instability Axis fractures Odontoid fractures
- 25. Upper cervical trauma Occipital condyle fractures (OCFs) Craniocervical dissociations (CCDs) Atlas fractures Atlantoaxial instability Axis fractures Odontoid fractures
- 26. Occipital condyle fractures (OCFs) • Reported incidence : 1~3% in blunt craniocervical trauma • Typically identified by CT, rarely by MRI • Clinical exam limited to detect injury, one specific is cranial nerve injury (40% in patient with OCF) Collet-Sicard syndrome • CN IX • Loss taste in post. 1/3 of togue • CN X • Vocal cord paralysis and dysphagia • CN XI • Weakness in SCM / trapezius • CN XII • Tongue muscle atrophy
- 27. Fracture / injury classification - Type I : comminuted without displacement - Type II : associated skull base injuries (+/- displacement ) - Type III : avulsion fractures from the alar ligaments. • Retrospective review (2018) • 60% of patient with associated c-spine injury • 40% showed biomechanical instability Bransford RJ,. J Am Acad Orthop Surg 2014;22(11):718-729.. West JL. World Neurosurg 2018;115:e238-e243.
- 28. Treatment • Based on the stability and displacement • Stable OCFs cervical collar • Unstable OCFs • Less severe halo vest • Severe occipital cervical fusion
- 29. Upper cervical trauma Occipital condyle fractures (OCFs) Craniocervical dissociations (CCDs) Atlas fractures Atlantoaxial instability Axis fractures Odontoid fractures
- 30. Craniocervical dissociations (CCDs) • Atlanto-occipital dislocations • Atlantoaxial diastasis • Structure restrained by alar ligament, tectorial membrane and atlanto-occipital joint capsules • Very rare in blunt trauma (0.6%) but with high mortality and usually missed in 25% of CCDs patient • Associated injury is common • >50% with traumatic brain injury and cranial nerve deficit • 10-50% with carotid and vertebral arterial injury • 20% with stroke • CT angiography is recommended for all patients with CCD
- 31. Diagnosis and classification • Most identified by CT • Classified by skull displacement direction Powers ratio(BC/AO) • ratio = 1 , normal • Ratio > 1, anterior translation • Ratio < 1, posterior translation Harris rule of 12 • Basion-dens interval, BDI <12mm • Basion-axial internal, BAI <12mm Condylar-C1 gap • Normal value < 2mm
- 32. Treatment of CCDs Initial treatment • Immediate temporary stabilization • Collar fits well and not impose distractive force to avoid traction • During transportation, keep upright position of 30~40 degrees Definitive treatment • Displaced craniocervical dissociation injuries craniocervical fusion
- 33. Upper cervical trauma Occipital condyle fractures (OCFs) Craniocervical dissociations (CCDs) Atlas fractures Atlantoaxial instability Axis fractures Odontoid fractures
- 34. Atlas fractures • 20% of patients in combination of axis fractures Classification Landells classification • Type I , Isolated anterior or posterior arch, stable pattern
- 35. • Type II, combined anterior and posterior arch (Jefferson frx) • IIA, intact transverse ligament • IIB, disrupted transverse ligament • Type III, lateral mass frx w/ or w/o TAL injury
- 36. Dickman classification • Type I, TAL avulsion injury • Type II, midsubstance TAL injury, poor prognosis
- 39. Upper cervical trauma Occipital condyle fractures (OCFs) Craniocervical dissociations (CCDs) Atlas fractures Atlantoaxial instability Axis fractures Odontoid fractures
- 40. Atlantoaxial instability • Displaced C1-C2 articulation in any direction • Most commonly in odontoid, atlas, OCFs and isolated TAL injuries • Isolated transverse ligament injury • Atlantoaxial fusion • C1-2 TP screw vs C1-lateral mass-C2 pedicle screw : similar excellent result • If combined CCD injury Occipitocervical fusion Rotatory subluxation of C1-2 • Rare in adult atlantoaxial fusion • More common in children conservative treatment
- 41. Upper cervical trauma Occipital condyle fractures (OCFs) Craniocervical dissociations (CCDs) Atlas fractures Atlantoaxial instability Axis fractures Odontoid fractures
- 42. Traumatic spondylolisthesis of the Axis • Hangman’s fracture • Pars interarticularis fracture traumatic separation of ant/post element of C2 • Rarely associated with neurologic injuries (except for type III) Classification Levine / Edward classification
- 43. Treatment • Type I : stable, 10~12 weeks of collar or orthosis • Type II & III: no consensus currently • Anterior plate and interbody graft is preferred
- 44. Type I with mild angulation Type III , anterolisthesis of C2
- 45. Upper cervical trauma Occipital condyle fractures (OCFs) Craniocervical dissociation (CCDs) Atlas fractures Atlantoaxial instability Axis fractures Odontoid fractures
- 46. Odontoid fractures • Anderson & Alonzo system • Type I – dens tip fracture • Type II – waist fracture • IIA : transverse • IIB : oblique from AP • IIC : comminuted • Type III – body fracture • Extension into atlantoaxial articulations
- 47. Treatment of odontoid fractures Type I & III • Conservative for non-displaced pattern • If any signs of CCDs fusion procedure is needed
- 48. Type II • High rates of nonunion if without surgery (25~50%) • Risk factor of nonunion : displacement >5mm, angulation > 11 degrees, comminuted, old age Odontoid screw • Pros : allow healing without loss of atlantoaxial motion • Poor outcome especially in geriatric patient • SR(2014), 10% of nonunion rate, 10% of revision surgery and 10% of persistent dysphagia • Biomechanical study : 1 vs 2 screw no difference
- 49. Posterior atlantoaxial fusion • Pros : stronger fixation than odontoid screw • Cons : lose 50% of head rotation • CT angiography study to identify the vascular anomalies
- 50. Conclusions • Cervical spine injuries are common in patients sustaining blunt trauma, occurring in 3% to 5% of these patients. • Treatment decisions based on neurologic deficits and fracture stability, and the goals of treatment are to protect the neural elements from further injury, stabilize fractures and dislocations, and provide long-term spinal stability. • Most axis injuries able to be successfully managed without surgery, demonstrating fusion rates near 90% • Injury characteristics such as comminution, initial displacement, and time to treatment have been associated with higher rates of failure in conservative management
- 51. Thanks for your listening
Editor's Notes
- on the first time of OPD, we arrange x-ray for the patient
- C spine ap view showed no specific finding and normal alignment
- From the lateral dynamic view, there is no step-off over anterior and posterior vertebral line, spinolaminar line and posterior spinous line showed smooth curve There is no translation or spinal instability in this dynamic series anterior vertebral line: anterior margin of the vertebral bodies posterior vertebral line: posterior margin of the vertebral bodies (also known as George's line) spinolaminar line: posterior margin of the spinal canal posterior spinous line: tips of the spinous processes
- 2 days later, the patient came to my clinic due to persistent neck pain so i apply the trigger point injection for the patient and also suggest patient wear collar but patient denied
- After 5 days, patient came to clinic again and mentioned that there was no improvement after injection and even got worse initially I thought is there any possibility of hematoma or infection after injection so i arrange the MRI
- And fortunately , the c spine MRI was done on the same day On the C1 level , there is no fluid accumulation or abascess in posterior neck region
- And i go through the C1 to C6 level , there is no protrusion or rupture disc Spinal cord quality is good and no soft tissue abnormality over posterior neck region
- And i go through the C1 to C6 level , there is no protrusion or rupture disc Spinal cord quality is good and no soft tissue abnormality over posterior neck region
- And i go through the C1 to C6 level , there is no protrusion or rupture disc Spinal cord quality is good and no soft tissue abnormality over posterior neck region
- And i go through the C1 to C6 level , there is no protrusion or rupture disc Spinal cord quality is good and no soft tissue abnormality in posterior neck region
- however, after 2 weeks , the patient admit to hospital owing to …. Eye doctor was consulted and arrange ocular CT and then the NP call me for abnormal finding from ocular CT
- From the axial view , we can see fracture site over left side lateral mass of atlas and linear fracture over left side posterior arch
- So i trace the previous MRI we can see some increased signal over lateral mass but fortunately the transverse ligament seems normal and intact
- The patient feel much better than previous condition but there still mild tenderness I insist the patient wearing hard collar for at least 2 months
- About the discussion, the topic i went to talk is upper cervical trauma
- The upper cervical region ranges from occipital to C2 level and often, the injury pattern is complex and heterogenous , some time cause morbidity It usually occur in bimodal age with high energy in young age and low energy in elderly The major restraint force around this area is ligament effect which is stronger than bony structure
- In terms of the anatomy, the craniocervical junction is composed with occipitoatlantal and atlantoaxial articulation The stability of upper c spine is based on gravity and ligament, For example The alar lig can hold the occipital condyle downward The cruciate lig including transverse and longitudinal part can resist the anterior subluxation between C1/C2
- And when we face the suspected c-spine trauma cases, we can use NEXUS criteria for initial evaluation If there is any positive finding on the above items we should arrange medical image to diagnose
- Patient can be further classified into 4 categories and to arrange proper image studies
- For low risk patient, at least, we should arrange lateral ,ap and open month view, and the dynamic view can be consider if patient can tolerate For high risk patient, ct is the first choice In the whole scenario of upper cervical trauma, CV injuries in not uncommon , reported incidence is about 37% If there are following injury patterns, we had to consider CT angiography
- ervical spine alignment, look for four parallel lines connecting structures in the cervical spine: anterior vertebral line: anterior margin of the vertebral bodies posterior vertebral line: posterior margin of the vertebral bodies (also known as George's line) spinolaminar line: posterior margin of the spinal canal posterior spinous line: tips of the spinous processes
- Here, i will introduce some upper c spine trauma , classification, diagnosis and treatment
- OCF is about 1~3% in blunt craniocervical trauma and usually identified by CT rarely by MRI However, the ability of clinical exam is limited , what we should keep in mind is cranial nerve injury about 40% in condyle fractures Such as collet-Sicard syndrome which involve cranial nerve from no.9 to no.12 We can see the hypoglossal canal and jugular foramen is just lateral to the occipital condyle
- one retrospective review in 2018 reported that 60% of condyle fracture patient had combined c spine injury and 40% of instability
- Treatment depend on the stability and displacement If fractures pattern is stable enough just like this case, this picture showed type II condyle fracture without significant displacement, we can consider collar protection But for unstable cases, halo vest and fusion can be considered
- However, using TpBA is not popular in current treatment so i can not find the article about the removal of TpBA So i turn to find some article about the cage removal
- CCDs include both atlanlto-occipital dislocation and atlantoaxial diastasis All these structure are mainly supported by alar lig, tectorial membrance and joint capsules Although it is very rare in blunt trauma but there is high mortality rate and usually missed in 25% patients The combined injury is common, such as traumatic brain injury, carotid or vertebral artery injury and stroke so it is reasonable for this kind of to receive CT angiography exam
- Diagnosis is done by ct and classified by skull displacement direction There are three parameters we have to know Powers ratio , normal value is 1 Harris rule of 12, both BDI and BAI are less than 12mm Condylar-c1 gap is less than 2 mm
- Sometimes combined with axis fractures And we use landells classification
- The retropulsion is cage movement inot the spinal canal It is very rare and usually cause neural structure compression
- In this table , we can see most atlas fracture can be treated with collar except for the landell type IIB of which the transverse ligament is disrupted
- This picture show type IIA atlas fractures, we can see after 3 months of collar protection, the distance between basion and den is preserved and the while arrow showed the atlanto-dens interval which is normal Open mouth view showed no widening between C1 lateral mass
- Which means displaced C1/2 in any direction and mostly occur in odontoid, atlas and OCFs and isolated TAL injuries Isolated transverse ligament injury is bested treated with atlantoaxial fusion, we can either choose C1-2 TPS SCREW or c1 lateral mass screw with C2 pedicle screw, both procedure showed similar good result But if combined CCD we should consider occipitocervical fusion Another pattern is rotatory subluxation between c1/c2 level, it is rare in adult and usually need fusion but more common in children, the conservative treatment is adequate
- The most common is traumatic spondylolithethsis of axis or so-called hangman fracture Actually it is rarely with associated neurologic injuries except for the type III fracture we use levine/Edward classification Type is non-displaced fracture Type ii is fracture with angulation more than 11 degrees and translation more than 3 mm Type iia Type iii
- Paper 47 Bx type i is stable, 10~12 weeks of collar is usually adequate but for the type II and IIi fractures, there is no current consensus and we have many choices, including …… Anterior plate and interbody graft is preferred due to low morbidity but it is contraindicated in irreducible facet joint But for patient with neurological injury, posterior approach is better for decompression
- Upper picture show type i with mild angulation , after 3 months of collar protection, we can see the bony union Lower picture is a case of type III fracture , due to anterior translation, Occipitocervical fusion is performed and C2 level is reduced FIGURE 10 FIGURE 11
- However, using TpBA is not popular in current treatment so i can not find the article about the removal of TpBA So i turn to find some article about the cage removal
- We use Anderson Alonzo system to classifiy
- Type ii has high nonunion rate if without surgery , the risk factor include displacement > 5mm, angulation >11 degrees, comminuted and old age One of procedures is odontoid screw of which the pros is allowing healing and without loss of atlantoaxial motion But one sr report 10%... One or two screws there is no difference on biomechanical study
- The other procedure is posterior atlantoaxial fusion which can provide stronger fixation than screw alone But loss of 50% rotation And ct angiography should be arrange before surgery