Trauma of the upper cervical spine Dr J

Trauma of the upper cervical spine Dr. J. VAN LERBEIRGHE AZ ST LUCAS GENT 9/18/2020 Orthopedica Belgica Antwerpen

Upper cervical spine • • 9/18/2020 Atlantooccipital junction C 1 -C 2 trauma Orthopedica Belgica Antwerpen

Upper cervical spine • 1/3 of all injuries of the cervical spine • High-energy trauma, polytrauma • Often demanding diagnostic work out 9/18/2020 Orthopedica Belgica Antwerpen

Indication fot surgery ? • Understanding of the mechanism • Stability classification 9/18/2020 Orthopedica Belgica Antwerpen

Upper cervical spine • ½ of the flexion- extension between C 0 -C 1 • ½ of the rotation between C 1 -C 2 • = High kinematic demands 9/18/2020 Orthopedica Belgica Antwerpen

OBJECTIVES OF TREATMENT • Prevent or reverse neurologic deficit • Restore spinal stability • Prevent deformity or restore normal alignment • Allow early mobilisation 9/18/2020 Orthopedica Belgica Antwerpen

Upper cervical spine • • • Atlantooccipital dislocation Fractures of the occipital condyles Fractures of the ATLAS, Jefferson # Atlantoaxial instability, fixed rotatory subluxation Traumatic spondylolisthesis of the AXIS, Hangman’s # • Odontoïd fractures. 9/18/2020 Orthopedica Belgica Antwerpen

Upper cervical spine • • • Atlantooccipital dislocation Fractures of the occipital condyles Fractures of the ATLAS, Jefferson # Atlantoaxial instability, fixed rotatory subluxation Traumatic spondylolisthesis of the AXIS, Hangman’s # • Odontoïd fractures. 9/18/2020 Orthopedica Belgica Antwerpen

Atlantooccipital dislocations • TYPE I – Anterior dislocation is the most common form • TYPE II – Longitudinal dislocation without anterior or posterior shifting • TYPE III – Posterior dislocation ( very rare) • TYPE IV – Lateral dislocation 9/18/2020 Orthopedica Belgica Antwerpen

Atlantooccipital dislocations 9/18/2020 Orthopedica Belgica Antwerpen

Learning points C 0 -C 1 dislocation Most C 0 -C 1 dislocation end in death; often children; if survival significant neurological deficit. They need stable occipitocervical fixation Plate fixation to occiput and C 1 -C 2 transarticular fixation ( 100 % surgical indication) 9/18/2020 Orthopedica Belgica Antwerpen

Upper cervical spine • • • Atlantooccipital dislocation Fractures of the occipital condyles Fractures of the ATLAS, Jefferson # Atlantoaxial instability, fixed rotatory subluxation Traumatic spondylolisthesis of the AXIS, Hangman’s # • Odontoïd fractures. 9/18/2020 Orthopedica Belgica Antwerpen

Fractures of the occipital condyles 9/18/2020 Orthopedica Belgica Antwerpen

Fractures of the occipital condyles Learning points Compression fractures or extensions of fractures of the skull. They are generally stable. Avulsion fractures, however, may suggest significant ligamentous disruption and instability Traction under c-arm can help to asses stability 9/18/2020 Orthopedica Belgica Antwerpen

Upper cervical spine • • • Atlantooccipital dislocation Fractures of the occipital condyles Fractures of the ATLAS, Jefferson # Atlantoaxial instability, fixed rotatory subluxation Traumatic spondylolisthesis of the AXIS, Hangman’s # • Odontoïd fractures. 9/18/2020 Orthopedica Belgica Antwerpen

Fractures of the atlas 9/18/2020 Orthopedica Belgica Antwerpen

Atlas Fractures 9/18/2020 Orthopedica Belgica Antwerpen

Atlas fracture • Type I – Isolated fracture of the anterior ring • Type II – Isolated fracture of the posterior ring • Type III – Combined fracture of the anterior and posterior arch (Jefferson fracture) • Type IV – Isolated fracture of the lateral mass • Type V – Fracture of the transverse process 9/18/2020 Orthopedica Belgica Antwerpen

Fractures of the atlas 9/18/2020 Orthopedica Belgica Antwerpen

Atlas fracture Non-operative treatment • Minimal dislocation of only one lateral mass • No Instability on flexion extension X-Ray • 12 weeks orthosis followed by physical therapy 9/18/2020 Orthopedica Belgica Antwerpen

“Jefferson” fractures learning points May be treated nonoperatively if there is no atlantoaxial instability on the lateral view Lateral flexion/extension x-rays must be performed once the fracture has healed to rule out late instability Halo traction usually does not reduce lateral mass dislocation 9/18/2020 Orthopedica Belgica Antwerpen

“Jefferson” fracture Operative treatment Unstable two-part Jefferson fracture with osseous avulsion of the transverse ligament Patient’s preference Definitive treatment 9/18/2020 Orthopedica Belgica Antwerpen

“Jefferson” fracture Operative treatment C 1 -C 2 transarticular fixation and bone grafting after reduction ( special clamp) or Direct osteosynthesis of the C 1 arch with lateral mass screws or C 1 -C 2 rod construction without fusion and removal of the implants after healing 9/18/2020 Orthopedica Belgica Antwerpen

Upper cervical spine • • • Atlantooccipital dislocation Fractures of the occipital condyles Fractures of the ATLAS, Jefferson # Atlantoaxial instability, fixed rotatory subluxation Traumatic spondylolisthesis of the AXIS, Hangman’s # • Odontoïd fractures. 9/18/2020 Orthopedica Belgica Antwerpen

Atlanto-axial instability • Type A: Anterior atlantoaxial instability • Type B: Posterior atlantoaxial instability • Type C: Rotatory atlantoaxial instability 9/18/2020 Orthopedica Belgica Antwerpen

Atlanto-axial instability • Type A: Anterior antlantoaxial instability – Flexion injury – Adults > 3. 5 mm atlantodental distance – Children > 5 mm atlantodental distance – Due to rupture or bony avulsion of the transverse ligament 9/18/2020 Orthopedica Belgica Antwerpen

Atlanto-axial instability • Type A: Anterior antlantoaxial instability 9/18/2020 Orthopedica Belgica Antwerpen

Atlanto-axial instability • Type B : Posterior atlantoaxial instability – Probably hyperextension – The tectorial as well as the alar ligaments must be torn 9/18/2020 Orthopedica Belgica Antwerpen

Atlanto-axial instability • Type B : Posterior atlantoaxial instability – Probably hyperextension – The tectorial as well as the alar ligaments must be torn 9/18/2020 Orthopedica Belgica Antwerpen

Atlanto-axial instability • Type C : Rotatory atlantoaxial instability – Type I • Without anterior gliding – Type II • Atlantodental interval up to 5 mm – Type III • Atlantodental interval of > 5 mm 9/18/2020 Orthopedica Belgica Antwerpen

Atlanto-axial instability • Type C : Rotatory atlantoaxial instability – Type I • Without anterior gliding 9/18/2020 Orthopedica Belgica Antwerpen

Atlanto-axial instability • Type C : Rotatory atlantoaxial instability – Type II • Atlantodental interval up to 5 mm 9/18/2020 Orthopedica Belgica Antwerpen

Atlanto-axial instability • Type C : Rotatory atlantoaxial instability – Type III • Atlantodental interval of > 5 mm 9/18/2020 Orthopedica Belgica Antwerpen

Atlantoaxial sagittal instability learning points Preexisting or acute trauma of the transverse ligament CT scan and TC 99 scan for bony avulsion MRI for the direct visualisation of the rupture Transarticular fusion !!! Position and anomalies of the arteria vertebralis. 9/18/2020 Orthopedica Belgica Antwerpen

Atlanto-axial instability • Possibility of tetraplegia after another accident > prevention surgery • Possibility of slow onset myelopathy due to repeated trauma to the cord. 9/18/2020 Orthopedica Belgica Antwerpen

Type C : Rotatory atlantoaxial instability – Skull traction – Stiff collar or Halo vest for 6 -8 weeks – Manipulation under anesthesia? – Anterior transoral release and rotation under traction > C 1 -C 2 fusion 9/18/2020 Orthopedica Belgica Antwerpen

Type C : Rotatory atlantoaxial instability learning points Closed reduction and immobilization if diagnosis is made early For late deformities : C 1 -C 2 fusion Persistent RAAI is to be avoided in children because torticollis induce facial asymmetries during growth 9/18/2020 Orthopedica Belgica Antwerpen

Upper cervical spine • • • Atlantooccipital dislocation Fractures of the occipital condyles Fractures of the ATLAS, Jefferson # Atlantoaxial instability, fixed rotatory subluxation Traumatic spondylolisthesis of the AXIS, Hangman’s # • Odontoïd fractures. 9/18/2020 Orthopedica Belgica Antwerpen

Traumatic Spondylolisthesis Hangman’s Fracture • Type I – Stable undislocated. C 2 -C 3 disc is intact and C 2 -C 3 is stable ( 65%) • Type II – Unstable. The C 2 -C 3 disc is torn and anteriorly displaced. • Type III – Type II injury with additional unilateral dislocation. 9/18/2020 Orthopedica Belgica Antwerpen

Traumatic Spondylolisthesis Hangman’s Fracture 9/18/2020 Orthopedica Belgica Antwerpen

Traumatic Spondylolisthesis Hangman’s Fracture 9/18/2020 Orthopedica Belgica Antwerpen

Traumatic Spondylolisthesis Hangman’s Fracture learning points A hangman’s fracture will lead to enlargement of the spinal canal and is unlikely to cause a neurological injury In many cases, a hangman’s fracture will eventually lead to ankylosis or spontanneous fusion across the anterior part of the C 2 -C 3 disc space 9/18/2020 Orthopedica Belgica Antwerpen

Traumatic Spondylolisthesis Hangman’s Fracture surgical treatment rationale Type II lesions not willing to undergo halo vest or minerva cast Progressive subluxation of C 2 on C 3 9/18/2020 Orthopedica Belgica Antwerpen

Traumatic Spondylolisthesis Hangman’s Fracture surgical treatment rationale Type III lesions can not be reduced closed because of the destroyed structures of C 2 -C 3 and manipulation of the head does not have effect on C 2 -C 3 Posterior open reduction of the facets is mandatory with posterior fusion using the anchorage screws as a direct repair 9/18/2020 Orthopedica Belgica Antwerpen

Atypical hangman’s fracture • Spinal stenosis • Trough the posteror body of C 2 ! • Surgical treatment after reduction to maintain stability 9/18/2020 Orthopedica Belgica Antwerpen

Upper cervical spine • • • Atlantooccipital dislocation Fractures of the occipital condyles Fractures of the ATLAS, Jefferson # Atlantoaxial instability, fixed rotatory subluxation Traumatic spondylolisthesis of the AXIS, Hangman’s # • Odontoïd fractures. 9/18/2020 Orthopedica Belgica Antwerpen

Odontoïd fractures Anderson and D’Alonzo • Type I – Tip of the dens • Type II – Fracture of the dens itself • Type III – Fracture of the dens with extension into the vertebral body 9/18/2020 Orthopedica Belgica Antwerpen

Odontoïd fractures 9/18/2020 Orthopedica Belgica Antwerpen

Roy Camille type II • HORIZONTAL • OBAV • OBAR 9/18/2020 Orthopedica Belgica Antwerpen

Odontoïd fractures surgical treatment odontoïd fixation ( 2 screws) Unstable type II fractures OBAR fractures C 2 H 5 OH Difficult Halo or Minerva treatment 9/18/2020 Orthopedica Belgica Antwerpen

Anterior screw fixation Type II fractures • 2 C-arms • No arthrodesis but slight advantage in mobility ! • Not in osteoporotic patiënts • Horizontal or OBAR 9/18/2020 Orthopedica Belgica Antwerpen

All other type II fractures • • C 1 -C 2 fusion Transarticular fusion ( + Gallie procedure ) Aspecially in the older patiënt. Occipito-cervical fusion. 9/18/2020 Orthopedica Belgica Antwerpen

Entry points 9/18/2020 Orthopedica Belgica Antwerpen

Gallie procedure 9/18/2020 Orthopedica Belgica Antwerpen

Gallie 9/18/2020 Orthopedica Belgica Antwerpen

Transarticular fixation 9/18/2020 Orthopedica Belgica Antwerpen

Transarticular fixation 9/18/2020 Orthopedica Belgica Antwerpen

Even simple procedures need expertise 9/18/2020 Orthopedica Belgica Antwerpen

Thank YOU ! Thank 9/18/2020 You Orthopedica Belgica Antwerpen