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Upper Cervical Spine Fractures

Upper Cervical Spine Fractures. EpidemiologyAnatomyRadiologyCommon InjuriesManagement Issues. Upper Cervical Spine Fractures. EpidemiologyCauseMVC42

Samuel
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Upper Cervical Spine Fractures

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    1. Upper Cervical Spine Fractures Daniel Gelb, MD Created January 2006

    2. Upper Cervical Spine Fractures Epidemiology Anatomy Radiology Common Injuries Management Issues

    3. Upper Cervical Spine Fractures Epidemiology Cause MVC 42% Fall 20% GSW 16% Gender Male 81% Female 19%

    5. Upper Cervical Spine Fractures Epidemiology Level of Education To 8th Grade: 10% 9th to 11th: 26% High School: 48% College: 16%

    8. Upper Cervical Anatomy

    9. Upper Cervical Anatomy Biomechanically Specialized Support of “large” Cranial mass Large range of motion Flexion/extension Axial rotation Unique osteological characteristics

    10. C1 - Atlas No body 2 articular pillars Flat articular surface Vertebral artery foramen 2 arches Anterior Posterior Vertebral artery groove

    11. 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 vertebral artery is a common fracture site

    12. C2 Anatomy Dens Embriological C1 body Base poorly vascularized Osteoporotic Flat C1-2 joints Vertebral artery foramena Inferomedial to superolateral

    13. Anatomy – The Axis Important transition point for forces within the c-spine Important anatomical points Superior and inferior 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

    14. 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 ligaments External Anterior and posterior atlanto-occipital membranes Anterior and posterior atlanto-axial membranes Articular capsules and ligamentum nuchae

    15. AtlantoAxial Anatomy

    16. AtlantoAxial Anatomy

    17. AtlantoAxial Anatomy

    19. AtlantoAxial Anatomy

    20. Radiographic Evaluation

    21. Plain Radiographic Evaluation

    23. Radiographic Lines Harris’ Lines

    24. Radiographic Lines BC/OA >1 considered abnormal Limited Usefulness Positive only in Anterior Translational injuries False Negative with pure distraction

    25. Radiographic Diagnosis

    27. Upper Cervical Spine Fractures Common Injuries Occipital Condyle Fracture Occipital Cervical Dislocation C1 ring injuries Odontoid Fracture Hangman’s Fracture

    28. Occipital Condyle Fracture Type I Impaction Fx Type II Extension of basilar skull fx Type III ALAR LIG AVULSION

    33. Transverse ligament avulsion

    34. Atlas Fractures - Treatment

    35. Atlas Fractures - Treatment

    36. Atlas Fractures - Treatment

    37. Odontoid Fractures Most common fracture of Axis (nearly 2/3 of all C2 Fxs) 10 – 20 % of all cervical fractures Etiology Bimodal distribution Young - high energy, multi-trauma Elderly - low energy, isolated injury (most common C-spine Fx elderly)

    39. Treatment Options odontoid fractures Type 1 C-Collar beware unrecognized AOD

    40. Treatment Options odontoid fracture Type 3 C-Collar SOMI brace Halo Vest 10-15% nonunion rate

    41. Treatment Options odontoid fracture Type 2 C-Collar SOMI brace Halo Vest Odontoid Screw C1-2 posterior fusion

    42. Type II Fracture Nonunion Risk Factors Nonunion 10-70% Initial displacement > 6mm Age > 60 yr old Delay Diagnosis > 3 wk Angulation > 10° Posterior displacement

    43. Anterior Odontoid Screw Fixation Indications Displaced Type II, Shallow Type III Polytrauma patient Unable to tolerate halo-vest Early displacement despite halo-vest Contraindications Non-reducible odontoid fracture Body habitus (Barrel chest ) Associated TAL injury Subacute injury (> 6 months) Reverse oblique

    44. Posterior Odontoid Fixation Options Posterior wiring Up to 25% pseudoarthrosis Halo vest necessary (?) Dickman JNS 1996, Grob Spine 1992 Transarticular screw fixation Magerl and Steeman Cerv Spine 1987 Reilly et al, JSD 2003 C1 lateral mass - C2 pars/pedicle screw

    45. The 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

    46. Harms J, Melcher RP. Posterior C1–C2 fusion with polyaxial screw and rod fixation. Spine 2001;26:2467–71.

    49. Traumatic Spondylolisthesis Axis (Hangman’s Fracture) Second most common fracture of axis 25% of C2 injuries Most common mechanism of injury is MVA

    50. Hangman’s Fracture Younger age group (Avg 38 yrs) Usually due to hyperextension-axial compression forces (windshield strike) Neurologic injury seen in only 5-10 % (acutely decompresses canal) Traditional treatment has been Halo-vest Collar adequate if < 6 mm displaced Coric et al JNS 1996

    51. Hangman’s Fracture Treatment Type III Treatment Options Posterior Open reduction and C1-C3 fusion Direct pars repair and C2-C3 fusion Anterior C2/C3 ACDF with instrumentation

    52. Halo Immobilization

    53. In-hospital mortality rates in Pts > 70 yr age Rx’d Halo-vest 20 – 36% Elderly and Halo-vest Treatment

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