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Understand the complexities and treatment of upper cervical spine trauma, including fractures, dislocations, and stability classifications. Explore surgical indications and operative treatments for various injuries.
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Trauma of the upper cervical spine Dr. J. VAN LERBEIRGHE AZ ST LUCAS GENT Orthopedica Belgica Antwerpen
Upper cervical spine • Atlantooccipital junction • C1-C2 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 Orthopedica Belgica Antwerpen
Indication fot surgery ? • Understanding of the mechanism • Stability classification Orthopedica Belgica Antwerpen
Upper cervical spine • ½ of the flexion- extension between C0-C1 • ½ of the rotation between C1-C2 • = High kinematic demands Orthopedica Belgica Antwerpen
OBJECTIVES OF TREATMENT • Prevent or reverse neurologic deficit • Restore spinal stability • Prevent deformity or restore normal alignment • Allow early mobilisation 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. 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. 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 Orthopedica Belgica Antwerpen
Atlantooccipital dislocations Orthopedica Belgica Antwerpen
Learning points C0-C1 dislocation 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. Orthopedica Belgica Antwerpen
Fractures of the occipital condyles Orthopedica Belgica Antwerpen
Fractures of the occipital condylesLearning points 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. Orthopedica Belgica Antwerpen
Fractures of the atlas Orthopedica Belgica Antwerpen
Atlas Fractures 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 Orthopedica Belgica Antwerpen
Fractures of the atlas Orthopedica Belgica Antwerpen
Atlas fractureNon-operative treatment • Minimal dislocation of only one lateral mass • No Instability on flexion extension X-Ray • 12 weeks orthosis followed by physical therapy Orthopedica Belgica Antwerpen
“Jefferson” fractureslearning points Orthopedica Belgica Antwerpen
“Jefferson” fractureOperative treatment Orthopedica Belgica Antwerpen
“Jefferson” fractureOperative treatment 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. Orthopedica Belgica Antwerpen
Atlanto-axial instability • Type A: Anterior atlantoaxial instability • Type B: Posterior atlantoaxial instability • Type C: Rotatory atlantoaxial instability 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 Orthopedica Belgica Antwerpen
Atlanto-axial instability • Type A: Anterior antlantoaxial instability Orthopedica Belgica Antwerpen
Atlanto-axial instability • Type B : Posterior atlantoaxial instability • Probably hyperextension • The tectorial as well as the alar ligaments must be torn Orthopedica Belgica Antwerpen
Atlanto-axial instability • Type B : Posterior atlantoaxial instability • Probably hyperextension • The tectorial as well as the alar ligaments must be torn 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 Orthopedica Belgica Antwerpen
Atlanto-axial instability • Type C : Rotatory atlantoaxial instability • Type I • Without anterior gliding Orthopedica Belgica Antwerpen
Atlanto-axial instability • Type C : Rotatory atlantoaxial instability • Type II • Atlantodental interval up to 5 mm Orthopedica Belgica Antwerpen
Atlanto-axial instability • Type C : Rotatory atlantoaxial instability • Type III • Atlantodental interval of > 5 mm Orthopedica Belgica Antwerpen
Atlantoaxial sagittal instabilitylearning points 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. 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 > C1-C2 fusion Orthopedica Belgica Antwerpen
Type C : Rotatory atlantoaxial instabilitylearning points 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. Orthopedica Belgica Antwerpen
Traumatic SpondylolisthesisHangman’s Fracture • Type I • Stable undislocated. C2-C3 disc is intact and C2-C3 is stable ( 65%) • Type II • Unstable. The C2-C3 disc is torn and anteriorly displaced. • Type III • Type II injury with additional unilateral dislocation. Orthopedica Belgica Antwerpen
Traumatic SpondylolisthesisHangman’s Fracture Orthopedica Belgica Antwerpen
Traumatic SpondylolisthesisHangman’s Fracture Orthopedica Belgica Antwerpen
Traumatic SpondylolisthesisHangman’s Fracturelearning points Orthopedica Belgica Antwerpen
Traumatic SpondylolisthesisHangman’s Fracturesurgical treatment rationale Orthopedica Belgica Antwerpen
Traumatic SpondylolisthesisHangman’s Fracturesurgical treatment rationale Orthopedica Belgica Antwerpen
Atypical hangman’s fracture • Spinal stenosis • Trough the posteror body of C2 ! • Surgical treatment after reduction to maintain stability 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. Orthopedica Belgica Antwerpen
Odontoïd fracturesAnderson 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 Orthopedica Belgica Antwerpen
Odontoïd fractures Orthopedica Belgica Antwerpen
Roy Camilletype II • HORIZONTAL • OBAV • OBAR Orthopedica Belgica Antwerpen
Odontoïd fracturessurgical treatmentodontoïd fixation ( 2 screws) Orthopedica Belgica Antwerpen