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Cervical fx Flashcards

Atlas fx - C1 Axis fx- odontoid peg traumatic spondylolithesis C2-hangman fx cervical facet dislocations/fx cervical spine fx

1
Q

What is the epidemiolgy of atlas fx?

A
  • 7% of all cervical fx
  • risk of Neurologic injury= LOW
  • commonly missed due to inadequate imaging of occiptocervical junction
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2
Q

What is the pathophysiology of atlas Fx?

A
  • Hyperextension
  • lateral compression
  • axial compression
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3
Q

Name any associated conditions with atlas fx?

A
  • Spine fractures
    • 50% associated spinal injury
    • 40% assoc AXIS fracture
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4
Q

What is the prognosis of atlas fx?

A
  • Stabilty dependent on degree of injury and healing potential of TRANSVERSE ligament
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5
Q

Describe the anatomy of Atlas bone?

A
  • C1 is a ring containing 2 articular lateral masses
  • lacks vertebral body or spinous process
  • forms form 3 ossification centres
  • incomplete formation of post arch is relatively common anatomic variant- doesn’t represent traumatic injury
  • occipital-cervical junction & atlantoaxial junction are coupled
  • intrinsic ligaments provide most stability
    • transverse ligament
    • paired alar ligaments
    • apical ligament
    • tectorial membrane- connects posterior bocy of axis to anterior foramen magnum and is the cephalad continuation of PLL
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6
Q

What is the classification of atlas fractures?

A
  • Type 1
    • Isolated ANT or POST ARCH Fx
  • Type 2
    • Jefferson Burst Fx
    • Bilateral ANT & POST Arch FX
    • Stability determined by transverse ligament
  • ​Type 3
    • ​Unilateral Lateral Mass Fx
    • stability determined by integrity of transverse ligament
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7
Q

What is the classification of transverse ligament injuries?

A
  • Type 1 - Intrasubstance tear
  • Type 2 - Bony avulsion
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8
Q

What imaging aids dx of atlas fx?

A
  • Lateral xray
    • Atlanto-dens interval
      • <3mm normal adult ( <5mm child)
      • 3-5mm= injury transverse ligament
      • >5mm = injury to transverse lig, alar and tectorium membrane
  • Open mouth odontoid view
    • to identify atlas fracture
    • sum of lateral mass displacement
    • if >7mm = transverse lig rupture assured- unstable

CT

  • delinate fracture pattern & assoc injuries

MRI

  • More sensitive at detecting injury to transverse lig
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9
Q

What are the tx for atlas fx?

A

Non operative

  • Hard cervical orthosis vs halo immobilisation 6-12 wks
    • for Stable Type 1- intact TL
    • Stable Jefferson fx- intact TL
    • Stable type 3- intact TL

Operative

  • Posterior C1-2 Fusion vs Occipitocervical Fusion
    • ​for Unstable Type 2
    • unstable Type 3
  • posterior C1-2 fusion preserves motion cf occiptocervical fusion
  • C1-2 transarticular screw placement or *C1 lateral mass to C2 pedicle screw- *see pic
  • Occiptocervical fusion used when unable to get adequate puchase of C1
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10
Q

What are the complications of atlas fx?

A
  • Delayed c spine clearance
    • higher rates of complications in pts with delayed c spine clearance so important to clear expeditiously
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11
Q

Define an odontoid fracture?

A
  • a fracture of the dens of the AXIS C2
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12
Q

What is the epidemiology of Odontoid fracture?

A
  • Incidence
    • most common fracture of the axis
    • accounts for 10-15% of all cervical fx
    • occurs bimodal distribution
      • elderly
        • missed, caused by simple falls
        • assoc increased morbidity/mortality
      • Young pts
        • blunt trauma to head-> cervical hyperextension/flexion
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13
Q

What is the pathophysiology of odontoid fractures?

A
  • Displacement maybe Anterior ( hyperflexion) or Posterior (hyperext)
  • Anterior displacement=
    • TL failure
    • Atlanto-axial instability
  • Posterior displacement
    • direct impact from ant arch during hypextension
  • *A fx thru the base of the odontoid process severly compromises the stability of the upper cervical spine*
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14
Q

Name any associated conditions with odontoid fx?

A
  • Os odontoideum
    • Appears like a type 2 odontoid fx on xray
    • previously thought to be due to failure of fusion at the base of the odontoid
    • may represent the residules of old traumatic process
    • tx is obervation
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15
Q

Describe the anatomy of axis?

A
  • axis has odontoid process
    • develops from 5 ossification centres
    • subdental synchondrosis is an intial cartilaginous junction between dens & vertebral body that does not fuse until 6 years of age
    • secondary ossification centres appear 3ys fuses to dens at 12
  • Axis Kinematics
    • C1-C2 atlantoaxial articulation
      • Diathrodal joint which provides
      • 50 degrees of cervical rotation
      • 10 degrees of flexion/extension
      • 0 lateral bend
    • C2-3 joint
      • 50 degrees of rotation
      • 50 degrees of flex/ext
      • 60 degrees lat bend
  • Ligamentous stability
    • transverse ligament
    • Apical ligament
    • alar ligament
  • Blood supply
    • Wateshed exists between apex and base of odontoid
    • apex supplied branches internal carotid A
    • base supplied branches vertebral A
    • limited blood supply affect healing type 2 odontoid fx
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16
Q

Describe the classification of axix fractures?

A
  • Anderson and D’Alonzo
  • Type 1 = Oblique Avulsion fx, tip odontoid
    • avulsion by alar ligament
  • Type 2= Fx thru WAIST
    • ​high non union rate- watershed blood supply
  • ​Type 3 = fx extends into cancellous body C2
    • involves variable portion of C2/3 joint
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17
Q

What are the symptoms and sign of axis fracture?

A

Symptoms

  • Neck pain worse with motion
  • dysphagia maybe present when assoc large retropharyngeal haematoma

Signs

  • Myelopathy
  • v rare as large x ssection of c spine here
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18
Q

What imaging is important in axis fx?

A

Xrays

  • Ap, Lateral. open mouth odontoid peg view
  • flexion-extension: c spine instability in type 1
    • ADI ( atlantodens- interval) >10mm
    • <13mm Space Available for the cord

CT

  • delinate fractures and assess stability

MRI

  • If neurology present

Ct angio

  • To determine locality of vertebral artery prior to post instrumentation
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19
Q

What is the tx of axis fx?

A
  • OS Odontoideum = Observe
  • Type 1 avulsion = Hard Cervical Orthosis
  • Type 2 Young pt
    • Halo vest immobilisation 6-12 wks if no risk factors for non union
    • Surgery if risk of Non union
  • Type 2 Elderly
    • Hard Cervical orthosis 6-12wks- if not surgical fit
    • Surgery if surgically fit
  • Type 3
    • Hard Cervical Orthosis 6-12 wks
    • no evidence to support halo over orthosis!!
    • elderly pt poorly tolerate halo-> aspiration, penumonia, death
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20
Q

Describe the techniques of surgery to Axis fx?

A
  • Posterior C1-2 fusion
    • for Type 2 fx w risk fx of nonunion
    • type 2/3 fx non unions
    • posterior c1-2 transarticular screw - see pic- avoid in pt w aberrant vertebral artery
    • or post C1 lateral mass and c2 pedicle
    • loss of 50% neck motion
  • Anterior Odontoid osteosynthesis
    • iin type 2 fx with risk nu &
    • acceptable alignment/minimal displacement
    • obliq fx pattern perpendicular to screw trajection
    • pt body habitus allows screw trajection
    • assoc higher failure rates than post fusion
  • transoral odontoidectomy
    • in severe post displacment & cord compression/neurological deficits
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21
Q

Decribe the technique for anterior odontoid screw osteosynthesis?

A
  • anterior apporach cervical spine
  • single screw adequate
  • assoc with higher failure rate cf post fusion
  • preserves atlanto axial motion
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22
Q

What are the complcaitions of axis fx?

A
  • Non union
    • increased in type 2
    • risk factors include
      • >5mm posterior displacement
      • >1mm fracture displacement
      • fx comminution
      • angulation >10o
      • age >50 years
      • delay in tx > 4 days
      • posterior redisplacement >2mm
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23
Q

What is a hangman’s fx?

A
  • Traumatic anterior spondylolitheis if AXIS due to BILATERAL fx of PARS INTERARTICULARIS
24
Q

What is the mechanism of a hangman’s fx?

A
  • Hyperextension
    • leads to fx of pars interarticularis
  • Secondary Flexion
    • Tears PLL and disc
    • leads to Subluxation
  • 30% have concomitant c spine fx
25
Q

What are the symptoms and signs of trumatic spondylothiesis of axis

A

Symptoms

  • Neck Pain

Signs

  • Pts are Neurologically Intact
26
Q

What imaging is helpful in dx of traumatic cervical spondylolithesis of axis?

A
  • xrays
    • flexion/extension shows subluxation
  • CT
    • delinate Fracture pattern
  • MRI
    • suspicious of vascular injru to vertebral artery
27
Q

What is the classification system for traumatic cervical spondylolithesis of axis?

A
  • Levine and Edwards
28
Q

Can you describe and the tx for type I traumatic cervical spondylolithesis of axis?

A
    • no angulation
  • C2/3 remains intact
  • stable fx pattern

tx

  • Rigid cervical collar 4-6 wks
29
Q

Can you describe and the tx for type 2 traumatic cervical spondylolithesis of axis?

A
  • >3mm horizontal displacement
  • Significant angulation
  • vertical fracture line
  • C/3 disc& PLL interupted
  • Unstable fx pattern

Tx

  • If <5mm displacment then reduce with traction then HALO immobilisation for 6-12 wks
  • if >5mm displacement ?surgery/ prolonged traction
  • normally autofuse depsite displacement
30
Q

Can you describe and the tx for type 2a traumatic cervical spondylolithesis of axis?

A
  • No horizontal displacment
  • horizontal fracture line
  • sig angulation

TX

  • Avoid TRACTION
  • Reduction with hyperextension then halo immobilisaiton 6-12 weeks
31
Q

Can you describe and the tx for type 3 traumatic cervical spondylolithesis of axis?

A
  • Type 1 with assoc bilateral C2/3 facet disslocation
  • rare injury

tx

  • Surgical reduction of facet dislocation
  • then Stabilisation
    • anterior C2-3 interbody fusion
    • posterior c1-3 fusion
    • Bilateral C2 pars screw osteosynthesis
32
Q

What is a cervical disc dislocation/fx?

A
  • Spectrum of osteoligamentous pathology includes
  • Unilateral facet dislocation
    • most freq missed c spine injury
    • ->25% subluxation on xray
    • assoc w monoradiculopathy- improves w traction
  • Bilateral Facet dislocation
    • ->50% subluxation on xray
    • assoc sig spinal cord injury
  • Facet fractures
    • more freq involves superior facet
    • maybe unilateral/ bilateral
33
Q

What is the epidemiology of cervical facet dislocations/fx?

A
  • 75% of all facet dislocations occur within the subaxial spine C3-C7
  • 17% of all injuries are fx of C7 or dislocations of C7-T1 junction
34
Q

What is the mechanism of cervical facet dislocations?

A
  • Flexion & distraction +/- element of rotation
  • so in a facet dislocation the posterior structures (interspinous ligament, facet capsule, liagmentum flavum, posterior annulus) are likely disrupted,
35
Q

What is the signs of cervical facet dislocation?

A

Signs

  • Monoradiculopathy
    • pt w unilateral dislocation
    • C5/6 unilater
      • C6 radiculopathy
      • Weakness wrist extension
      • numbness in thumb
    • C6/7 unilat
      • C7 radiculopathy
      • weakness in triceps/wrist flexion
      • numbness to index/middle finger
  • Spinal cord injury
    • Seen in bilateral facet dislocations
    • symptoms worsen with increasing subluxation
36
Q

What imaging is useful in dx of cervical facet dislocation/fx?

A
  • Xrays
    • lateral
    • unilateral facet dislocation- 25% subluxation(pic)
    • bilateral facet dislocation- 50% subluxation
    • loss of disc height ? retropulsed disc in canal
  • CT
    • essential for more detailed bony anatomy
  • MRI
    • when acute facet dislocation in pt w altered mental state
    • failed closed reduction before open reduction to look for disc herniation
      • if find ant disc herniation need to open anterior first
    • any neurological deterioration
37
Q

what is the tx for cervical facet dislocation/fx?

A

Non operative

  • Cervical Orthosis/ external immobilisation 6-12 wks
  • for facet fractures wout sig subluxation/dislocation/kyphosis

Surgery

  1. Immediate closed reduction , then MRI then surgical stabilisation
  • for bilat facet disclocation w deficits in awake & cop pt
  • unilat facet dislocation w deficits in awke & coop pt
  • never closed reducition on pt w altered mental state
  • Always do MRI b4 surgery so check no disc
    • PSF/ ACDF in absence of disc
    • ACDF if disc herniation
  • 26% pts will fail closed reduction & require open

2.MRI then open reduction + surgical stabilisation

  • for facet dislocations when pt changed mental state
  • or failed closed reductions
  • if anterior disc need to go in anteriorly
38
Q

Can you how you do a closed reduction of cervical facet dislocation?

A
  • Adequate aneathesia
  • sedation
  • supervision of respiratory function
  • serial cross table laterals- do in theatre
  • gradually increase axial traction with addition of weight ( can give >50lbs)
  • a compotnet of cervical flexion can aid reduction
  • perform serial neuro exams and xray after each weight
  • abort if neurological exam worsens & obtain urgent MRI
39
Q

Describe the type of cervical vertebral body fractures?

A

By fracture Pattern

  • Compression
  • Burst fracture
  • flexion teardrop fx
  • extension teardrop fx

Allen and ferguson classification

of subaxial spinal injuries by mechanism used only for research

40
Q

What compression cervical fractures characterised by?

A
  • Compressive failure of Anterior vertebral body without disruption of posterior body cortex and without retropulsion into canal
  • often assoc with posterior ligamentous injury
41
Q

What Burst cervical fx characterised by?

What are they associated with?

A
  • fracture extension thru posterior cortex with retropulsion into spinal canal
  • often assoc with posterior ligamentous injury
  • often assoc with complete/incomplete spinal injury
  • frequently unstable
  • usually requires Surgery
42
Q

What flexion teardrop cervical fractures characterised by?

A
  • fx of anterior inferior portion of vertebra
  • post portion of vertebra RETROPULSED POST
  • often assoc w post ligament injury
  • assoc with SPINAL cord injury
  • normally unstable
  • Requires Surgery
43
Q

What extension teradrop avulsion cervical fractures characterised by?

A
  • small fleck of bone avulsed of anterior endplate
  • usually at c2
  • must differentiate from true tear drop fx
  • mechanism= extension
  • stable injury pattern
  • Not assoc with Spinal cord injury
  • TX= cervical collar 6-12 wks
44
Q

What are the tx options for cervical spine fractures?

A

Non operative

  • collar immobilisation 6-12 wks
  • stable mild compression fx
  • ant teardrop avulsion fx
  • ext halo immobilisation
  • only if stable fx pattern

Surgery

  • Anterior decompression, corpectomy, strut graft and fusion with instrumentation
    • burst fx w cord compression
    • unstable tear drop
    • compression fx with angulation 110 or25% loss in height
  • Posterior decompression, fusion w instrumentation
    • sig injury to post elements
    • ant decomp not required
45
Q

Describe the 2 types of occiptiocervical dislocation?

A
  • Traumatic occipitocervical dislocation
    • severe injury, pt rarely survives
    • most pt die of brainstem destruction
    • 19% of fatal cervical injuries
    • os those survive high neurological injury
    • mechanism- translation/distraction
  • ​Acquired occipitocervical instability
    • ​in Down’s syndrome
46
Q

Can you describe the classification of occiptiocervical instability?

A
  • type 1 - anterior
  • type 2- longitudinal dislocation
  • type 3 - posterior
47
Q

What do the radiographs show of occipitocervical instability?

A
  • Low sensitivity in detecting injury
  • Powers ratio
    • used to detect occipitocervical instability
    • Powers ratio = C-D/A-B
    • C-D = distance from basion to post arch
    • B-A= distance from ant arch to opisthion
    • ratio normal =1
    • if >1 = anterior dislocation
    • if <1
      • post ​atlanto-occipital dislocation
      • odontoid fx
      • ring of atlas fx
48
Q

What is th tx of occiptiocervical instability?

A
  • Non op- don’t use traction= 10% risk of neurological deterioration
  • Operative
    • Occipitocervical fusion
      • mot cases require stabilisation
      • modular occiptial plates
      • position 8mm unicortical screw 2cm lateral and 2cm inferior of external occiptal protruberance-5cm lateral is the thickest portion of occiput- see pic
      • don’t put screw just below external occiptal protuberance as major dural venous sinuses here and risk of penetration
49
Q

What is the epidemiology of occipital condyle fx?

A
  • Involve the craniocervical junction
  • approx 1-3% population
  • often missed due to low sensitivity of plain xrays
  • dx on CT
50
Q

What is the mechanism of occiptial condyle fx?

Name any assoc injuries?

A
  • High energy- non pentrating to head/neck
  • fx patterns dependent on directional forces

assoc injuries

  • c spine fx
  • polytrauma
  • intrcranial bleeding
  • brainstem and vascular lesion
  • elevated ICP
51
Q

What is the prognosis of occiptial condyle fx?

A
  • High mortality rate 11% - associated injuries
52
Q

Describe the anatomy of occipital condyles?

A
  • Paired prominences of occipital bone
  • form lateral aspects of foramen magnum
  • forms the occiptioatlantoaxial complex
  • 6 main synovial articulations
  • ligamentus structure
    • Transverse L
    • apical ligament
    • paired alar ligaments
    • tectorial membrane
  • Proximity to
    • Medulla oblongata
    • vertebral arteries
    • Lower cranial nerves CN IX-XII
53
Q

Describe the classification of occipital condyle fractures?

A
  • Anderson and Montesano
  • Type 1
    • impaction type due to compression between atlanto-odontoid joint
    • stable as minimal fragment displacment into foramen magnum
  • Type 2
    • basilar skull fx extends into 1/2 occipit condyles
    • direct blow ot skull
    • stable as alar lig and tentorium membrane intact
  • Type 3
    • avulsion fx of condyle in region of alar lig
    • due to forced rotation and lat bending
    • unstable due to craniocervical disruption
54
Q

What are the signs and symptom of occiptial condyle fracture?

A

Symptoms

  • high cervical pain
  • reduced head rom
  • torticollis
  • lower cranial n deficit
  • motor paresis

signs

  • CN IX, X, XI affected
55
Q

what imaging useful in occipital condyle fx?

A
  • Xrays
    • Ap, lateral ope mouth ap view
  • CT
    • method of choice
  • MRI
    • soft tissue craniocervical trauma
56
Q

What is the tx of occiptial condyle fx?

A

Non op

  • Analgesia, cervical orthosis( semi-rigid/rigid)
    • type 1 & 2
    • type 3 without instability

Operative

  • Type 3 with overt instability
  • neural compression from displaced fx
  • assoc occipital- atlanto-axial injuries
  • C0-C2/3 occipitocervical arthrodesis using semi rigid segmental fixation or post decompression and instrumented fusion
  • may need bone graft/removal of bony fragments

Trauma (16 decks)

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