1、Upper Cervical Spine Fractures,Originally created by Daniel Gelb, MD January 2006Updated by Robert Morgan, MD; November 2010,Upper Cervical Spine Fractures,Epidemiology Anatomy Imaging Characteristics Common Injuries Management Issues,Epidemiology,717 cervical spine fractures in 657 patients over 13
2、 years C1 and Hangman fractures found more in the young Odontoid fractures evenly distributed Younger patients have higher energy injuries C2 fractures most common,The epidemiology of fractures and fracture-dislocations of the cervical spine Ryan,M.D.; Henderson,J.J. Injury, 1992, 23, 1, 38-40,Upper
3、 Cervical Anatomy,Upper Cervical Anatomy,Biomechanically Specialized Support of “large” Cranial mass Large range of motion Flexion/extension Axial rotation Unique osteological characteristics,Large Cranial Mass,Roberts, DA; Doherty, BJ; Heggeness MH. Quantitative Anatomy of the Occiput and the Biome
4、chanics of Occipital Screw Fixation Spine 23(10), 15 May 1998, pp 1100-1107,Keel below the SNL is thick bone,Confluence of Issues,Roberts, DA; Doherty, BJ; Heggeness MH. Quantitative Anatomy of the Occiput and the Biomechanics of Occipital Screw Fixation Spine 23(10), 15 May 1998, pp 1100-1107,Bicor
5、tical screws in the occiput may enter the transverse sinus Decreased risk below the superior nuchal line,Occipital Screw Mechanics,Roberts, DA; Doherty, BJ; Heggeness MH. Quantitative Anatomy of the Occiput and the Biomechanics of Occipital Screw Fixation Spine 23(10), 15 May 1998, pp 1100-1107,The
6、course of the vertebral artery through C1 and C2 determines the possibility of placing screws for fixation of fractures and dislocations,C1 lateral mass screws C1-2 transarticular screws C2 pedicle/pars screws,Normal Vertebral Artery,Tortuous Vertebral Artery,C1 - Atlas,No body 2 articular pillars F
7、lat articular surface Vertebral artery foramen 2 arches Anterior Posterior Vertebral artery groove,Anatomy The Atlas,Transition zone between head and c-spine Important anatomical points Superior articular processes allow flex/ext Inferior articular processes are important for rotation Notch for vert
8、ebral artery is a common fracture site,C2 Anatomy,Dens Embriological C1 body Base poorly vascularized Osteoporotic Flat C1-2 joints Vertebral artery foramena Inferomedial to superolateral,Trabecular Anatomy,The trabecular anatomy of the axis Authors:Heggeness,M.H. ; Doherty,B.J.Source:Spine, 1993, 1
9、8, 14, 1945-1949, UNITED STATES,Trabecular Anatomy,The trabecular anatomy of the axis Authors:Heggeness,M.H. ; Doherty,B.J.Source:Spine, 1993, 18, 14, 1945-1949, UNITED STATES,Anatomy The Axis,Important transition point for forces within the c-spine Important anatomical points Superior and inferior
10、articular processes are “offset” in the AP direction- due to different functions at each articulation Pars interarticularis- due to this transition is a frequent fracture site Odontoid process- the “pivot” for rotation,The trabecular anatomy of the axis Authors:Heggeness,M.H. ; Doherty,B.J.Source:Sp
11、ine, 1993, 18, 14, 1945-1949, UNITED STATES,Anatomy The Ligaments,Allow for the wide ROM of upper C-spine while maintaining stability Classified according to location with respect to vertebral canal Internal: Tectorial membrane Cruciate ligament including transverse ligament Alar and apical ligament
12、s External Anterior and posterior atlanto-occipital membranes Anterior and posterior atlanto-axial membranes Articular capsules and ligamentum nuchae,Atlanto-Axial Anatomy,Tectorial Membrane,Atlanto-Axial Anatomy,Occiput,C1,C2,Tranverse Ligament,C1-C2 joint,Alar Ligament,Atlanto-Axial Anatomy,Transv
13、erse Ligament,Facet for Occipital Condyle,Atlanto-Axial Anatomy,Vertebral Artery,Radiographic Evaluation,Plain Radiographic Evaluation,Lateral View Prevertebral Swelling Soft Tissue Shadow 6mm at C2 Concave/Flat Pre-dental space 3mm Atlanto-Occipital Joint Congruence Radiographic Lines*Open Mouth AP
14、 Distraction C1-2 Symmetry,Radiographic Diagnosis Screening Lines,Powerss Ratio,Harriss lines,Radiographic Lines,Harris et al, Am J Radiol, 1994,Basion-Dental Interval (BDI) Basion to Tip of Dens 12 mm ABNORMAL Basion-Axial Interval (BAI) Basion to Posterior Dens -4-12 mm in 98% 12 mm Anterior Sublu
15、xation 4 mm Posterior Subluxation,Harris Lines,Radiographic Lines,BC/OA 1 considered abnormal Limited Usefulness Positive only in Anterior Translational injuries False Negative with pure distraction,Powers et al, Neurosurg, 1979,Powers Ratio,Radiographic Diagnosis,CT Scan,Same rules as with plain fi
16、lms Better visualization of cranio-cervical junction Subluxation Focal hematomas Occipital condyle fractures Dens fractures,Radiographic Diagnosis,MRI,Increased Signal Intensity in :,C0-C1Joint C1-2 Joint Spinal Cord Cranio-cervical ligaments Pre-vertebral soft tissues,Warner et al, Emerg Radiol, 19
17、96,Dickman et al, J Neurosurg, 1991,Upper Cervical Spine Fractures,Common Injuries Occipital Condyle Fracture Craniocervical sprain? C1 ring injuries Odontoid Fracture Hangmans Fracture,Uncommon Injuries Craniocervical Dislocation Rotatory subluxation,Occipital Condyle Fracture,Type I Impaction Frac
18、ture Type II Extension of basilar skull fracture Type III ALAR ligament Avulsion,Anderson ,SPINE 1988 Tuli, NEUROSURGERY, 1997,Cranio-cervical Dislocation,Antlanto-Occipital Joint Occipito-Cervical Joint Cranio-cervical Joint Atlanto-Axial Joint,Cranio-cervical sprain (stage 1) may be treated nonope
19、ratively,Cranio-cervical Dislocation,Commonly Fatal Present 6-20% of post mortem studies Alker et al, 1978 Bucholz & Burkhead,1979 Adams et al, 1992 50% missed injury rate 1/3 Neurological Worsening Davis et al, 1993,Symptoms/Findings,Lower Cranial nerve deficits Horners syndrome Cerebellar ataxia B
20、ells cruciate paralysis Contralateral loss of pain and temperature,Wallenberg Syndrome,,www.meddean.luc.edu,Check the Cranial Nerves!,Cranio-cervical Dislocation,Treatment Emergency Room Collar/sandbag Halo vest Definitive Posterior occipital cervical fusion ALWAYS include C1 and C2,Atlas Fractures
21、- Treatment,Collar Isolated anterior arch Isolated posterior arch Non-displaced Jefferson fracture,Atlas Fractures - Treatment,Displaced 6.9 mm Halo traction (reduction) * several weeks followed by halo vest Immediate halo vest Posterior C1-2 fusion (unable to tolerate halo) After brace treatment co
22、mplete confirm C1-2 stability Flexion/extension films C1-2 fusion for ADI 5mm,Transverse ligament avulsion,Bony avulsions may heal with nonoperative management TAL rupture does not heal with nonoperative management and requires C1-C2 arthrodesis,Fusion options Gallie Post-op halo Brooks Jenkins Tran
23、sarticular Screws C1 lateral mass/C2 pars-pedicle screws,Atlas Fractures - Treatment,Odontoid Fractures,Most common fracture of Axis (nearly 2/3 of all C2 Fxs) 10 20 % of all cervical fractures Etiology Bimodal distributionYoung - high energy, multi-traumaElderly - low energy, isolated injury (most
24、common C-spine Fx elderly),Elderly and the Odontoid,Platzer Studies Elderly increased pseudarthrosis rate( 12% v. 8%) Elderly tolerated pseudarthosis well(1/5) Elderly tolerated halo well 10% mortality (4/41) 22% complication rateChapman studies Elderly did not heal the odontoid fracture (4/17) Elde
25、rly tolerated halo well (7/8) 15% mortality (3/20),Harrop and Vaccaro 9/10 “union” 5/10 postop halo 1/10 perioperative death Multiple series of high mortality rates,Anterior screw fixation of odontoid fractures comparing younger and elderly patientsAuthors:Platzer,P.; Thalhammer,G.; Ostermann,R.; Wi
26、eland,T.; Vecsei,V.; Gaebler,C.Source:Spine, 2007, 32, 16, 1714-1720, United States,Nonoperative management of odontoid fractures using a halothoracic vestAuthors:Platzer,P.; Thalhammer,G.; Sarahrudi,K.; Kovar,F.; Vekszler,G.; Vecsei,V.; Gaebler,C.Source:Neurosurgery, 2007, 61, 3, 522-9; discussion
27、529-30, United States,Posterior atlanto-axial arthrodesis for fixation of odontoid nonunionsAuthors:Platzer,P.; Vecsei,V.; Thalhammer,G.; Oberleitner,G.; Schurz,M.; Gaebler,C.Source:Spine, 2008, 33, 6, 624-630, United States,Type II odontoid fractures in the elderly: early failure of nonsurgical tre
28、atmentAuthors:Kuntz,C.,4th; Mirza,S.K. ; Jarell,A.D.; Chapman,J.R.; Shaffrey,C.I.; Newell,D.W.Source:Neurosurg.Focus., 2000, 8, 6, e7, United States,Efficacy of anterior odontoid screw fixation in elderly patients with Type II odontoid fracturesAuthors:Harrop,J.S. ; Przybylski,G.J.; Vaccaro,A.R.; Ya
29、lamanchili,K.Source:Neurosurg.Focus., 2000, 8, 6, e6, United States,Fracture Classification,Anderson and DAlonzo,Type I 2 % (2/49),Type II 50-75 % (32/49),Type III 15-25 %(15/49),Fractures of the odontoid process of the axisAuthors:Anderson,L.D.; DAlonzo,R.T.Source:J.Bone Joint Surg.Am., 1974, 56, 8
30、, 1663-1674, UNITED STATES,Subtypes of Type II Fractures,Type IIA and B are amenable to anterior fixation Type IIC is not Does not include part of facet, not a Type III,Grauer,J.N et al Proposal of a modified, treatment-oriented classification of odontoid fractures. Spine J., 2005, 5, 2, 123-129,Acu
31、te Management,Spinal cord injury rare (17/226) Airway compromise 0/8 nondisplaced 1/21 anterior displacement 13/32 posterior displacement (2 deaths),Dont do flexion reductions!,Closed management of displaced Type II odontoid fractures:more frequent respiratory compromise with posteriorly displaced f
32、ractures GREGORY J. PRZYBYLSKI, M.D., JAMES S. HARROP, M.D., AND ALEXANDER R. VACCARO, M.D. Neurosurgical Focus 2000,Epidemiolgy of spinal cord injury after acute odontoid fractures JAMES S. HARROP, M.D., ASHWINI D. SHARAN, M.D., AND GREGORY J. PRZYBYLSKI, M.D. Neurosurgical Focus 2000,Definitive Tr
33、eatment Options,Type 1 C-Collar beware unrecognized CCD,Type 3 C-Collar 10-15% nonunion SOMI brace Halo Vest,Evidence-based analysis of odontoid fracture managementAuthors:Julien,T.D.; Frankel,B. ; Traynelis,V.C. ; Ryken,T.C. Source:Neurosurg.Focus., 2000, 8, 6, e1, United States,Treatment Options o
34、dontoid fracture,Type 2 C-Collar SOMI / Minerva Halo Vest Odontoid Screw C1-2 posterior fusion,Anterior Odontoid Screw Fixation,Indications Displaced Type II, Shallow Type III Polytrauma patient Unable to tolerate halo-vest Early displacement despite halo-vest (Reduces in extension) Contraindication
35、s Non-reducible odontoid fracture (Reduces in flexion) Body habitus (Barrel chest ) Associated TAL injury Subacute injury ( 6 months) Reverse oblique (elderly),Roy-Camille Classification,Anterior Screw History,Note reduced dorsal cortex,Anterior Screw Technique,Skin incision at C5 Note slight extens
36、ion Missing key element in diagram (need to atraumatically obtain open mouth fluoroscopy) Biplanar fluoroscopy,Direct anterior screw fixation for recent and remote odontoid fracturesAuthors:Apfelbaum,R.I. ; Lonser,R.R. ; Veres,R.; Casey,A.Source:J.Neurosurg., 2000, 93, 2 Suppl, 227-236, UNITED STATE
37、S,Anterior Screw Technique,Need to enter body caudal portion of promontory Midline for single screw placement,Direct anterior screw fixation for recent and remote odontoid fracturesAuthors:Apfelbaum,R.I. ; Lonser,R.R. ; Veres,R.; Casey,A.Source:J.Neurosurg., 2000, 93, 2 Suppl, 227-236, UNITED STATES
38、,Anterior Screw Technique,Critical to cross rostral cortex Critical to use lag screw technique Limited support for second screw,Direct anterior screw fixation for recent and remote odontoid fracturesAuthors:Apfelbaum,R.I. ; Lonser,R.R. ; Veres,R.; Casey,A.Source:J.Neurosurg., 2000, 93, 2 Suppl, 227-
39、236, UNITED STATES,One or Two Screws?,No significant difference biomechanically Sasso Graziano No difference clinically Apfelbaum Jenkins,Screw Mechanics,A comparative study of fixation techniques for type II fractures of the odontoid processAuthors:Graziano,G.; Jaggers,C.; Lee,M.; Lynch,W.Source:Sp
40、ine, 1993, 18, 16, 2383-2387, UNITED STATES,Screw Mechanics,13 cadavers Load to failure Extension-deflection 450oblique No difference between one and two screws Failure mode is screw pullout from body Anatomic reduction without comminution,Biomechanics of odontoid fracture fixation. Comparison of th
41、e one- and two-screw techniqueAuthors:Sasso,R.; Doherty,B.J.; Crawford,M.J.; Heggeness,M.H. Source:Spine, 1993, 18, 14, 1950-1953, UNITED STATES,Apfelbaum Clinical Outcomes,147 patients 129 (117) 6 months 88% fusion rate Recent fractures Horizontal and posterior oblique No difference between one or
42、two screws 25% fusion rate in remote fractures 10% implant complication Screw pullout of C2 body 1% perioperative mortality 6% within 30 days,Jenkins Clinical Outcomes,42 patients 8.5 month followup 15% nonunion rate (plain radiographs) 5% perioperative mortality 10% 3 month mortality,A clinical com
43、parison of one- and two-screw odontoid fixationAuthors:Jenkins,J.D.; Coric,D.; Branch,C.L.,Jr Source:J.Neurosurg., 1998, 89, 3, 366-370, UNITED STATES,Mal-reduction Incorrect entry point,Posterior Odontoid Stabilization,Posterior Odontoid Stabilization,Options Posterior wiring Up to 25% pseudoarthro
44、sis Halo vest necessary (?) Dickman JNS 1996, Grob Spine 1992 Transarticular screw fixation Magerl and Steeman Cerv Spine 1987 Reilly et al, JSD 2003C1 lateral mass - C2 pars/pedicle/lamina screw,Wiring Techniques,Biomechanical comparison of C1-C2 posterior arthrodesis techniquesAuthors:Papagelopoul
45、os,P.J.; Currier,B.L. ; Hokari,Y.; Neale,P.G.; Zhao,C.; Berglund,L.J.; Larson,D.R.; An,K.N. Source:Spine, 2007, 32, 13, E363-70, United States,Trans-articular Screw Technique,Primary posterior fusion C1/2 in odontoid fractures: indications, technique, and results of transarticular screw fixation Aut
46、hors:Jeanneret,B.; Magerl,F.Source:J.Spinal Disord., 1992, 5, 4, 464-475, UNITED STATES,Wiring Mechanics,Biomechanical comparison of C1-C2 posterior arthrodesis techniquesAuthors:Papagelopoulos,P.J.; Currier,B.L. ; Hokari,Y.; Neale,P.G.; Zhao,C.; Berglund,L.J.; Larson,D.R.; An,K.N. Source:Spine, 200
47、7, 32, 13, E363-70, United States,Posterior Wiring Outcomes,C1C2 Segmental Instrumentation,Posterior C1-C2 fusion with polyaxial screw and rod fixationAuthors:Harms,J.; Melcher,R.P.Source:Spine, 2001, 26, 22, 2467-2471, United States,pedicle,Pars,Trans-articular,C2 pars/pedicle,Harms Mechanics,Hott
48、et al: Biomechanical comparison of C1-2 posterior fixation techniques. J Neurosurg Spine 2: 175-181. 2005,LC1-PC2 performs similar to transarticular screws Transarticular screws with graft stiffest construct Interspinous graft behaves as intact specimen regarding lateral bending,Harms Outcomes,37 pa
49、tients 100% fusion 1 wound infection,102 patients 98% fusion rate Navigation Allograft/BMP 2 dissection VA injury 1 neuropathic pain (C2 root sacrifice) 4 wound infections,Stabilization of the atlantoaxial complex via C-1 lateral mass and C-2 pedicle screw fixation in a multicenter clinical experience in 102 patients: modification of the Harms and Goel techniquesAuthors:Aryan,H.E.; Newman,C.B.; Nottmeier,E.W.; Acosta,F.L.,Jr; Wang,V.Y.; Ames,C.P.Source:J.Neurosurg.Spine, 2008, 8, 3, 222-229, United States,
