ODONTOID AND HANGMANS FRACTURES Avelino Parajn Servicio de

ODONTOID AND HANGMAN´S FRACTURES Avelino Parajón Servicio de Neurocirugía Hospital Universitario Puerta de Hierro, Majadahonda- MADRID

ACUTE AXIS (C 2) FRACTURES 20% OF CERVICAL SPINE FRACTURES NEUROLOGICAL INJURY UNCOMMON (< 10 % ) LOW MORTALITY ( 2. 4 % ) MOST CAN BE TREATED WITH RIGID INMOBILIZATION

ACUTE AXIS (C 2) FRACTURES • ODONTOID FRACTURES • HANGMAN´S FRACTURES • MISCELANEOUS C 2 FRACTURES

ODONTOID FRACTURES MOST COMMON FRACTURES OF C 2 59 % IN THE GREEN ET AL. SERIES 10 -15 % OF ALL CERVICAL SPINE FRACTURES Green KA, Dickman CA, Marciano FF et al. : Spine 1997, 22

ODONTOID FRACTURES FLEXION Anterior displacement of C 1 on C 2

ODONTOID FRACTURES SIGNS SYMPTOMS • PARASPINAL MUSCLES SPASM • HIGH POSTERIOR CERVICAL PAIN • REDUCED RANGE OF MOTION • OCCIPITAL NEURALGIA • TENDERNESS • 10 % SIGNIFICANT NEURO DEFICIT

ODONTOID FRACTURES

ODONTOID FRACTURES ESTIMATED FRECUENCY OF FATALITIES AT THE TIME OF ACCIDENT FROM ODONTOID FRACTURES: 25 - 40 % Crokard et al. , J Neurosurg 1993, 78

ODONTOID FRACTURES CLASSIFICATIONS • ANDERSON AND D´ALONZO • ROY CAMILLE • GRAUER

Anderson L L, D´Alonzo R T: Fractures of the odontoid process of the axis. J Bone Joint Surg 1974, 56 A

Hadley et al. Neurosurgery 1988, 22

Grauer J N et al: Spine J 2005, 5

ODONTOID FRACTURES • TYPE OF FRACTURES • C 1 -C 2 DISPLACEMENT • ANGLE FRACTURE LINE- BODY OF C 2 • TRANSVERSE LIGAMENT INTEGRITY • AGE

ODONTOID FRACTURES NO TREATMENT OF ODONTOID FRACTURES IS AN UNACCEPTABLE OPTION 1985 Cervical Spine Research Society multicenter study J Bone Joint Surg Am 1985, 67

ODONTOID FRACTURES Guidelines: ISOLATED TYPE II ODONTOID FX IN ADULTS > 50 YEARS AGE SHOULD BE CONSIDERED FOR SURGICAL STABILIZATION AND FUSION

ODONTOID FRACTURES Option: TYPE I, II AND III ODONTOID FX MAY BE MANAGED INITIALLY WITH EXTERNAL CERVICAL INMMOBILIZATION Option: TYPE II AND III ODONTOID FX CONSIDER SURGICAL FIXATION FOR FX DISPLACEMENT > 5 mm TYPE II A INHABILITY TO MANTAIN ALIGNMENT WITH EXT. INMOB.

ODONTOID FRACTURES CERVICAL COLLAR IMMOBILIZATION FOR TYPE I ODONTOID FX THIS TREATMENT ALONE SEEMS SUFFICIENT 100 % FUSION CERVICAL COLLAR IMMOB ILIZATION FOR TYPE III ODONTOID FX 10 % NONUNION 40 % MALUNION

ODONTOID FRACTURES HALO- DEVICE IMMOBILIZATION FOR TYPE I ODONTOID FX 100 % FUSION HALO- DEVICE IMMOB ILIZATION FOR TYPE III ODONTOID FX 98. 6 – 100 % FUSION HALO- DEVICE IMMOBILIZATION FOR TYPE II ODONTOID FX 26. 3 – 29. 7% FUSION FAILED

ODONTOID FRACTURES PREDICTORS OF NON UNION • DISPLACEMENT 4 - 6 mm • AGE 40 – 65 years

ODONTOID FRACTURES FUSION IS THE STANDARD OF EVALUATION FOR TREATMENTS

ODONTOID FRACTURES LATE MYELOPATHY IN 77 % OF MOBILE NONUNIONS

ODONTOID FRACTURES NON UNION RX CRITERIA • SCLEROSIS • RESORPTION • CORTICAL DISCONTINUITY • MOVEMENT OF FRAGMENTS

ODONTOID FRACTURES • PAIN • MYELOPATHY

ODONTOID FRACTURES ANTERIOR APPROACHES • ANTERIOR ODONTOID SCREW POSTERIOR APPROACHES • POST. TRANSARTICULAR SCREWS • ANT. TRANSARTICULAR SCREWS • WIRE/ CABLE TECHNIQUES • ANT. C 1 C 2 PLATE • LAMINAR CLAMPS • POST SEGMENTAL SCREW FIXATION

Bohler J: Anterior stabilization for acute fractures and non-union of the dens. J Bone Joint Surg 1982, 64

ODONTOID FRACTURES odontoid screw ADVANTAGES CONTRAINDICATIONS • PRESERVES MOTION C 1 C 2 • TRANSVERSE LIG RUPTURE • DONT NEED POSTOP HALO • EXTENSE C 2 BODY FX • DONT NEED BONE GRAFT • IRREDUCTIBLE FRACTURE • ANTERIOR OBLICUE FX

ODONTOID FRACTURES • RIGID COLLAR 10 -12 WEEKS • ONE SCREW • BEST RESULTS DURING FIRST 6 MONTHS AFTER FX Jenkins et al. J Neurosurg 1988, 89 Apfelbaum et al. J Neurosurg 2002, 93

ODONTOID FRACTURES odontoid screw • 90% FUSION TYPE II • 95% FUSION TYPE II < 6 MONTHS EVOL. • 100% FUSION TYPE III

ODONTOID FRACTURES transarticular screws Anterior, Lateral, POSTERIOR (Magerl) 90 -99 % FUSION VERTEBRAL ARTERY LESION RISK 3. 7 - 8. 2% CONTRAINDICATIONS • ANATOMICAL VARIATIONSSCREW TRAYECTORY • GREAT HIGH THORACIC KYPHOSIS • SEVERE OSTEOPOROSIS NEEDS PREOP CT C 0 -C 3 (20% VA ANATOMICAL VARIATIONS))

ODONTOID FRACTURES c 1 lat mass c 2 pedicle screws • LOWER RISK OF V. ARTERY LESION • 100% FUSION • DIFFERENT TECHNIQUES – Goel and Laeheri – Harms and Melcher – Resnick and Benzel

ODONTOID FRACTURES cable-wire techniques GALLIE 70% FUSION BROOKS 85 % FUSION SONNTAG 100% FUSION POSTOP COLLAR 12 WEEKS

SONNTAG GALLIE BROOKS N. CABLES 1 1 2 CABLE SUBLAMINAR C 1 + + + CABLE SUBLAMINAR C 2 NO NO + GRAFT BIOMECH TRICORT SEMIRIG UNICORT FLEXIBLE DOBLE SEMIRIG

HANGMAN´S FRACTURES • HIPEREXTENSION + DISTRACTION • HIPEREXTENSION + AXIAL LOAD • ANTERIOR SUBLUXATION OF C 2 ON C 3

HANGMAN´S FRACTURES • 95% NO NEURO DEFICIT • EFFENDI / FRANCIS I

HANGMAN´S FRACTURES classification • Pepin and Hawkins – Tipo II • Francis • Effendi- Levine

HANGMAN´S FRACTURES Francis classification • GRADE I angulation < 11º • GRADE II angulation > 11º displacement < 3. 5 mm displacement > 3. 5 mm • GRADE III angulation < 11º • GRADE IV angulation > 11º displacement > 3. 5 mm • GRADO V C 2 C 3 disc disruption Francis et al. , J Bone Joint Surg 1981, 63 B

HANGMAN´S FRACTURES Effendi classification • TYPE I • TIPO IA < 3 mm subluxation C 2 C 3 fx lines on each side not parallel • TIPO IIA > 3 mm subluaxion and/or angulation little subluxation (< 3), more angulation (>15º) • TIPO III C 2 C 3 facets locked Effendi et al, J Bone Joint Surg 1981, 63 B Levine et al, J Bone Joint Surg, 1985, 67 A

Effendi IIA Effendi III

HANGMAN´S FRACTURES OPTION: MAY INITIALLY BE MANAGED WITH EXTERNAL IMMOBILIZATION IN MOST CASES (HALO/ COLLAR)

HANGMAN´S FRACTURES SURGICAL STABILIZATION MUST BE CONSIDERED IN • SEVERE ANGULATION C 2 ON C 3 • Effendi II, II A (>15º) • Francis II y IV (>11º) • C 2 C 3 DISC DISRUPTION • Effendi III • Francis V • INHABILITY TO MANTAIN ALIGNMENT WITH EXTERNAL IMMOBILIZATION

HANGMAN´S FRACTURES non surgical treatment • 90 -100 % FUSION WIHT EXTERNAL IMMOBILIZATION • BEST RESULTS WITH HALO • PHILADELPHIA COLLAR MAY BE USED • 8 – 12 WEEKS

HANGMAN´S FRACTURES surgical treatment C 2 C 3 DISC DISRUPTION INHABILITY TO MANTAIN ALIGNMENT NON UNION POSTERIOR FUSION C 1 C 3 ANTERIOR DISCECTOMY + FUSION C 2 C 3 POSTERIOR C 2 PEDICLE SCREWS

HANGMAN´S FRACTURES INSTABILITY: ANTERIOR DISPLACEMENT C 2 C 3 > 50%

Francis grade V

SUMMARY C 2 FRACTURES • ODONTOID FRACTURES – FLEXION – ANTERIOR DISPLACEMENT C 1 ON C 2 • HANGMAN´S FRACTURES – HYPEREXTENSION – ANTERIOR DISPLACEMENT C 2 ON C 3

SUMMARY C 2 FRACTURES non surgical management • ODONTOID FRACTURES: – TYPE I, TYPE III, 12 WEEKS HALO – TYPE I, RIGID COLLAR • HANGMAN´S FRACTURES: – EFFENDI I, FRANCIS I, PHILADELPHIA COLLAR 12 WEEKS

SUMMARY C 2 FRACTURES surgical indication • ODONTOID FRACTURES – TYPE II > 50 – TYPE II > 5 mm displacement – TYPE II A • HANGMAN´S FRACTURES – ANGULATION • EFFENDI IIA, FRANCIS II, FRANCIS IV – DISC DISRUPTION: • EFFENDI III, FRANCIS V

OBRIGADO, THANK YOU, GRACIAS