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    C1, C2 Injuries

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    Vishad Naidoo
    This document provides an overview of cervical spine trauma management principles and classifications of various cervical injuries including occipitocervical dissociation, atlantoaxial injuries, atlas fractures, odontoid fractures, and Hangman's fractures. Treatment options including immobilization, halo vest, cervical collar, and various fusion procedures are discussed. Outcomes of conservative versus operative management are also summarized.

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    C1, C2 Injuries

    Uploaded by

    Vishad Naidoo
    86 views58 pages
    This document provides an overview of cervical spine trauma management principles and classifications of various cervical injuries including occipitocervical dissociation, atlantoaxial injuries, atlas fractures, odontoid fractures, and Hangman's fractures. Treatment options including immobilization, halo vest, cervical collar, and various fusion procedures are discussed. Outcomes of conservative versus operative management are also summarized.

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    Upper C spine fractures.

    Original Title

    C1, C2 injuries

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    This document provides an overview of cervical spine trauma management principles and classifications of various cervical injuries including occipitocervical dissociation, atlantoaxial injuries, atlas fractures, odontoid fractures, and Hangman's fractures. Treatment options including immobilization, halo vest, cervical collar, and various fusion procedures are discussed. Outcomes of conservative versus operative management are also summarized.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    86 views58 pages

    C1, C2 Injuries

    Uploaded by

    Vishad Naidoo
    This document provides an overview of cervical spine trauma management principles and classifications of various cervical injuries including occipitocervical dissociation, atlantoaxial injuries, atlas fractures, odontoid fractures, and Hangman's fractures. Treatment options including immobilization, halo vest, cervical collar, and various fusion procedures are discussed. Outcomes of conservative versus operative management are also summarized.

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    C1, C2 trauma management

    Part 2
    Vishad Naidoo
    Emergency management principles overview
    • C-spine always assumed to be injured
    • Immobilise C-spine during resuscitation, transport and
    transfer

    • ATLS
    • ABCDE

    • Initial evaluation
    • Assess skeletal injury
    • Assess neurological injury
    • Assess associated injuries
    • Identify instability
    • “loss of ability of spine to maintain structure under
    physiological load and not cause pain, deformity or
    neurology”
    • Immobilise appropriately

    • Classify and define injury

    • Management planning.
    Clinical assessment
    • Clearance of C spine
    • Remove collar/head blocks

    • Examine face/scalp/neck for direct trauma

    • Identify any abnormality of angle/rotation of head


    holding position
    • Log-roll (protecting C spine)
    • Inspect entire spine for deformities, scars, bruises,
    wounds
    • Palpate for gaps, steps, tenderness, crepitus
    • Assess motion if no positive findings

    • NEXUS and Canadian C-spine rules


    • Appropriate radiology
    • CT – better for assessing fractures
    • MRI – better for assessing soft tissue structures
    Sensitivity Specificity
    • NEXUS study 99.6% 12.6%
    • CCR Study 99.4% 45.1%
    Atlas fractures

    Atlanto-axial Ligamentous Occipito-cervical


    injuries instability
    instability

    Odontoid fractures

    Sub-axial
    Hangman’s fractures instability
    Occipito-cervical dissociation
    • Caused by ligamentous injury

    • Paired alar ligaments


    • Apical ligament
    • Transverse ligament
    • Tectorial membrane
    • O-C joint capsule
    • Cruciate ligament
    • Traynelis classification (descriptive)
    • Dislocation orientation
    • Harbourview classification of stability
    • Unstable – operate

    Stage I Minimal or non-displaced, unilateral Stable


    injury to craniocervical ligaments

    Stage II Minimally displaced, but MRI Stable or


    demonstrates significant soft-tissue Unstable
    injuries. Stability may be based on
    traction test

    Stage III Gross craniocervical misaligment (BAI Unstable


    or BDI > 2mm beyond normal limits)
    • Harris rule of 12

    • Basion-dens interval or
    Basion- axial interval
    • >12mm suggest
    Occipito-cervical
    dissociation
    • Power’s ratio
    Condylar-C1 interval
    Treatment
    •Stable
    • Halovest
    • Cones – with minimal traction

    •Unstable
    • Occipitocervical fusion
    • C1 – may be skipped, or unilateral lateral mass screw
    for rotational stability
    • C2 – lateral mass screws
    • C3 – lateral mass screws
    Halovest
    Cones callipers (Crutchfield/Gardner Wells)
    • 2kg for head + 0.5kg for every vertebra above injury
    Occipitocervical fusion
    Outcomes

    •Favourable rates of fusion and clinical


    function post OC-fusion with strict rehab
    protocols

    • (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7008657/)
    Atlanto-axial rotational dislocation
    Fielding and Hawkin’s classification
    Atlanto-dens interval
    Treatment options

    •Non-operative indications
    •Subluxation present <1 week
    • Collar
    •Subluxation present >1 week
    • Head halter traction
    •Subluxation present >1 month
    • Head halter traction > Halovest, 12 weeks
    Treatment options

    •Operative indications
    •Subluxation present >1 month
    •Neurological fallout
    •Failed Halo
    •Recurrent subluxation
    • Posterior C1-C2 fusion
    Atlas fractures
    • Caused by high energy mechanisms
    • Falls in elderly with osteopaenic bone
    • Often by axially loading
    • Usually no neurological deficit due
    to relatively larger SAC at C1 level
    • Jefferson classification
    Dickman’s classification

    Intrasubstance tear.
    Type 1 Treat with C1-2 fusion.

    Bony avulsion at tubercle on C1 lateral


    Type 2 mass. Treat with halo vest (successful in 75%)
    • Landells atlas classification (combo of above)
    • Recommends management based on Jefferson and Dickman findings
    Treatment options
    • Stable
    • Cervical collar
    • Unstable
    • Non-operative: Halo Vest
    • Operative: posterior fusion
    • OC fusion
    • Posterior pedicle screws
    • Harms
    • C1 ORIF
    Hard collar
    Lateral mass screws
    Harm’s procedure
    C1 ORIF
    Outcomes
    •Common complaints after conservative
    management:
    •Mostly: activity limitation: 34%
    •8-20% complaints of neck stiffness and
    pain
    •Contact athletes may not return to play
    •Prognostic variables
    • degree of injury and healing potential of
    transverse ligament
    Odontoid fractures
    • Fracture of axis peg
    • Watershed blood-supply
    • High ratio of cortical to
    cancellous bone
    • Anderson & D’Alonzo classification
    • Grauer modification
    •Risk factors for non union

    •Fracture
    • Displacement/translation >3mm
    • Comminution
    • Angulation >10o

    •Patient and surgery


    • Age >50 yrs
    • Treatment delay >4 days
    • Smoking
    •Treatment Overview Table

    •Type I •Collar

    •Type II (age < 40) •Halo Vest

    •Type II (40-80) •Surgery

    •Type II (> 80 years) •Collar

    •Type III •Collar


    •Stable
    •Non operative
    • Type 1 & type 3
    • Cervical collar
    •Unstable
    •Non-operative
    •Halo Vest
    •Operative:
    •Type 2A & 2B
    • Anterior odontoid screw
    •Type 2C
    • Posterior approaches
    • Brooks
    • Harms
    • Magerl
    • Gallie
    Anterior odontoid screw
    Gallie technique
    Brook’s procedure
    Magerl procedure
    Outcomes

    •Collar had a good functional outcome in


    the majority of cases,
    • Minimal change in ADLs in 89% of patients.
    •Overall, patients > 80 yo, do poorly with
    operative or nonoperative treatment
    • especially with halo orthosis

    https://pubmed.ncbi.nlm.nih.gov/30610342/
    Hangman’s fractures
    • Traumatic C2 spondylisthesis
    • Hyperextension
    • leads to fracture of bilateral pars
    • Secondary flexion
    • tears PLL and disc thus causing
    subluxation
    • Levine and Edwards classification
    • Comprehensive mechanism, anatomical and management
    Mechanism

    Type I Axial compression and hyperextension

    Hyperextension and axial load followed by


    Type II rebound flexion

    Type IIA Flexion-distraction

    Type III Flexion-distraction followed by hyperextension


    Treatment options
    • L&E
    •I
    • collar
    • II
    • <5mm Reduction and halo

    • >5mm surgery or prolonged cones


    • IIA
    • Gentle reduction and cones
    • Halovest
    • III
    • Surgical reduction and stabilisation
    • Posterior
    • C1-C3 fusion
    • B/L C2 pars screws
    C2 pars screws
    Anterior cervical discectomy and
    fusion
    Outcomes
    •Hangman's fractures respond well
    to conservative treatment
    •Potential disadvantages with
    conservative treatment:
    •recurrent axial pain,
    •anterior dislocation,
    •pseudarthrosis
    •angulation of C2 over C3.
    • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5763593/#:~:text=Most%20cases%20of%20Hangman's%20fracture,angulation%20of%20C2%20over
    %20C3.
    Combinations
    •Multiple concomitant upper C-spine
    fractures are relatively common: 26%
    •Dens fracture with posterior arch C1
    fracture
    •Dens fracture and C2 articular pillar
    fracture
    •Associated lower C spine fractures
    https://link.springer.com/article/10.1007/s005860000153
    Note
    • Choose treatment options that allow for early
    mobilisation
    • In absence of neurology If injury is not stable
    enough with correct bracing within 24-48hrs, then
    consider surgical options
    • With neurology – reacclimatise to gravity within 48
    hrs by tilting bed toward upright position, after
    surgery
    References
    • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2899718/
    • https://pubmed.ncbi.nlm.nih.gov/25892721/
    • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4958388/
    • https://www.researchgate.net/publication/348076955_Fractures_of_C2_Axis_Vertebra_
    Clinical_Presentation_and_Management
    • https://www.ncbi.nlm.nih.gov/books/NBK519563/#:~:text=Trauma%20as%20the%20sol
    e%20cause,traumatic%20causes%20of%20atlantoaxial%20instability.
    • https://www.sciencedirect.com/science/article/abs/pii/S1529943015000108
    • https://www.sciencedirect.com/science/article/pii/S1878875022003461
    • https://www.orthobullets.com/spine/2014/occipitocervical-instability
    • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4958379/#:~:text=The%20occipitocervi
    cal%20junction%20(OCJ)%20consists,integrity%20of%20the%20occipitocervical%20junct
    ion.

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