Cervical Spine Trauma Odontoid fractures Anatomic pathology Management

Cervical Spine Trauma Odontoid fractures § Anatomic pathology § Management options § Case Illustrations Kevin Chao, MD November 8, 2010

Anatomy: Supra axial cervical spine

Anatomy: Supra axial cervical spine

Odontoid Fractures § Epidemiology § 10 -15% of c-spine fractures § 30 -40% associated fatality § Type II ~10% with deficits § Mechanism: Flexion injury § Often subsequent C 1 -C 2 subluxation § Symptoms: high cervical pain, reduced ROM, tenderness to palpation

Treatment guidelines Non operative Operative § Types I and III § Type II § Halo or SOMI brace § Follow up imaging 6 weeks § Especially in pts age > 50 (~30% non union rate) § Fracture displacement ≥ 5 mm § Neurologic deficit § Comminution § Failed alignment or malunion with external fixation

Surgical Options § Anterior fusion § Odontoid screw fixation § Posterior fusion § Wiring/fusion techniques § Gallie fusion § Brooks fusion § Locksley Tie Bar § Dickman-Sonntag § Plates/clamps § Halifax clamps § Hook plates § Transarticular screw § C 1 -C 2 articular fusion § Harm’s C 1 -C 2 construct § Occipital-cervical fusion § Combined anterior-posterior fusion

Odontoid screw § Indications: § Reducible Type II dens fx § Intact transverse ligament § Fracture < 6 months old § Contraindications: § Large fracture gap § Irreducible fracture § Pathological fracture § Oblique fracture line § Union rate 95%

Wiring/fusion techniques § Gallie § “H” graft between C 1 -C 2, C 1 and C 2 sublaminar wire § Brooks § 2 wedge bone grafts with C 1 to C 2 sublaminar wires (7585% union)

Wiring/fusion techniques § Dickman-Sonntag § 1 wedge bone graft with sublaminar wire under C 1 (97% union) § Locksley Tie bar § 3 point posterior fixation

Transarticular screw § Immediate stabilization § Wire entry needs “flat” angle § Entry point § Traverse facet joint § Target superior aspect of C 1 anterior arch § Risk for vertebral artery injury

Harms C 1 -C 2 Posterior Fusion § C 1 lateral mass - C 2 pedicle polyaxial screws and bilateral rod fixation § Anatomic advantages § Immediate stabilization § Technical Notes: § Proud C 1 screw § Superior-medial entry of C 2 § § screws Rotational reduction after screw placement Optional posterolateral fusion

Non-union § Clinical signs and symptoms § Continued high posterior cervical pain § Late myelopathy § Radiographic criteria § Contiguous sclerosis of fractured fragments § Contiguous resorption of fractured fragments § Loss of cortical continuity § Movement on dynamic films

Spine Fracture Approach Assessment Management § Mechanism of injury § Neuro exam § Imaging § § § Levels § Bone vs soft tissue § Dynamic vs static § Vessels? § Degree of instability Surgery vs no surgery Goals? Brace? Activity restrictions § Follow up § Imaging § Rehab

Case files

Case 1

Case 2

Case 3

Case 4

Case 5

Mary had a little lamb, Its fleece was white as snow Everywhere that Mary went The lamb was sure to go It followed her to school one day Which was against the rules. It made the children laugh and play To see a lamb at school And so the teacher turned it out, But still it lingered near And waited patiently about Till Mary did appear "Why does the lamb love Mary so? " The eager children cry "Why, Mary loves the lamb, you know. " The teacher did reply