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158
10 Atlas Fractures
nondislocated (Fig. 10.8). However, if the fracture is
dislocated or burst, the traction attempt can fail to
effectively reduce the joint congruence. This can happen especially in sagittally oriented mass splits
described by Bransford et al. [3], where the craniocaudal force transmitted by the condyle does not
allow the fracture reduction. We call this “axe effect.”
Such fractures can be treated conservatively but only
with hardly achievable long-term continuous distraction in SOMI brace or halo-vest. A similar problem is
with lateral mass burst fracture. It can also be treated
conservatively; however, the functional results are
poor (Fig. 10.9).
All conservatively treated patients are radiographically checked on a regular basis at 6 weeks, 3 months,
6 months, and 1 year. The first dynamic films are
performed at 6 weeks in presumably stable injuries but
at 3 months in the others. Only CT can finally confirm
the bony fusion.
If the fracture is considered as suitable for surgical
treatment the patient and/or his family are fully informed
about the advantages and possible risks of operation and
the hard external support is offered as an alternative. We
always emphasize that, nearly, all isolated C1 fractures
can be treated conserva tively (with exception of clear AA
instability and documented TAL tear) according to literature and that there is no evidence supporting any decision
available. Surprisingly, more patients choose the more
aggressive approach believing that this allows them faster
mobilization and more active life in the future.
There is no doubt that those fractures causing
direct pressure to neural structures are indicated for
Fig. 10.8 Non sagittal fracture of C1 lateral mass healed in
Philadelphia collar, images (c, d) obtained 3 years after the initial treatment with acceptable clinical results (occasional headache). (a) Axial CT scan showing sagittal like pattern. (b)
Coronal reconstruction depicting that the fracture is not sagittally oriented. (c). axial CT scan 3 years after conservative treatment in hard collar. (d) coronal reconstruction showing healed
fracture in “acceptable” AA joint congruence
10.7 Our Treatment Algorithm
159
Fig. 10.9 Comminuted lateral mass of atlas treated 12 weeks in
halo-vest, images (c, d) obtained 4 years after the initial treatment, poor clinical result (pain in rotation, headache). (a) Axial
CT scan showing the comminution of lateral mass. (b) Initial
decompression: however, such injuries are very rare.
They can be seen as a result of direct localized blunt
violence or as open injuries related to gun shots or
sharp instrument penetration. This way the VA can
easily be involved resulting in bleeding and/or thrombosis (Fig. 10.10).
Also, the fractures with obvious AA instability
and documented TAL tear should be operated by
solid method of AA posterior fixation (Fig. 10.11).
We prefer the transarticular screw AA fixation; however, in cases where the C1 fracture-dislocation
manipulation can lead to its reduction, we prefer to
use of Harms fixator (Fig. 10.12). Mostly, we supplement the previous fixation with posterior
grafting.
coronal reformatted image. (c) Axial CT scan obtained 4 years
after the treatment showing “healed” fracture. (d) Coronal
reconstruction showing lateral mass deformity and important
joint incongruence
In fractures with TAL tubercle avulsion temporary
fixation, either with custom-made compression allowing
device (Fig. 10.5) or with the Harms technique can be
performed.
Sagittal split fracture of lateral mass can be
effectively treated with CT navigated percutaneous
direct compressive osteosynthesis (Fig. 10.13) but
open surgical approach allowing the fracture re duction and fixation is also recommendable.
In complex injuries, we favor the most important
instability as it is described in Chap. 14. Always, we
have to bear in mind that as few segments as possible
should be fused in CVJ region, especially when it
comes to the occipital bone extent of the construct that
is often unreasonable.
160
10 Atlas Fractures
Fig. 10.10 Gun shot with lateral mass destroyed but without
VA injury treated with occipitocervical fusion. (a) Axial CT
scan showing the antero-posterior pathway of the bullet through
C1 lateral mass. (b) Frontal plane reconstruction showing
Fig. 10.11 Patient from
Fig. 10.3 with coincidental
atlas fracture with TAL
incompetence and
subaxial luxation fracture.
(a) Laterogram showing the
Harms fixator stabilizing
C1– and 360 fixation of
subaxial fracture-luxation.
(b) lateral X-ray in flexion
documenting the stability of
the constructs 3 months after
surgery
lateral mass destruction. (c) CTA confirming the VA patency.
(d) Occipitocervical fusion, C2 transpedicular screw on the side
of injury, short transarticular on the other side
References
Fig. 10.12 Three part
fracture of the C1 ring with
AA dislocation manipulated
by Harms fixator to correct
joint position (because of
bilateral high riding VA the
Wright’s modification with
crosslaminar screw purchase
was used to fix C2). (a) 3D
preoperative image showing
the right AA joint posterior
displacement. (b) sagittal
reconstruction documenting
surgically achieved joint
reduction
161
Fig. 10.13 Sagittal split fracture of C1 lateral mass with intact
TAL on MRI treated with percutaneous CT guided compressive
osteosynthesis (also in Chap. 7). (a) Initial axial CT scan.
(b) Preoperative coronal reconstruction. (c) Parasagittal scan
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Odontoid Process Fractures
P. Suchomel and L. Jurák
11
The presence of odontoid fracture (OF) was first described
by Lambotte [56]; however, the first patient undergoing
treatment of the fracture by delayed posterior surgical
atlantoaxial fixation was reported by Mixter and Osgood
[61]. Interestingly, despite being the most common UCS
injury, OF has a less colorful background than the most
frequently, historically mentioned, hangman’s fracture.
Throughout the literature, the attention has always been
drawn to the fact that significant amount of odontoid fractures are detected late after the injury and they are notoriously prone to nonunion. C1-2 instability caused by loss
of restriction of translational AA movement is considered
the most dangerous consequence of this frequent injury
that can potentially result in fatal spinal cord damage.
Historically the treatment ranged from conservative
external immobilization [13, 33, 70, 74, 84] to surgical
posterior AA fusion [17, 43, 95] usually done after
failure of external immobilization, i.e., pseudoarthrosis phase. The development of anterior screw fixation
by Nakanishi [65] and independently by Magerl [39]
added another and, in fact, the most physiological
surgical treatment option.
Currently, odontoid process fractures are diagnosed
immediately after the injury and modern imaging techniques certainly facilitate the decision as to which treatment option is the most appropriate for our patients.
11.1 Classification
The earliest attempts to classify OF distinguished only
two types of fractures: those at the base and those at
P. Suchomel and L. Jurák
Department of Neurosurgery,
Neurocenter, Regional Hospital Liberec,
Husova St. 10, 46063 Liberec, Czech Republic
the neck of the process [19]. Schatzker et al. proposed
to classify OFs into two categories depending on the
location of fracture either above or below the accessory ligaments [80].
Another, more accepted classification, focused on the
fracture site stability was suggested by Roy-Camille
[72]. Fractures were divided into subtypes based on the
direction of the fracture line on plain lateral and dynamic
films. OF was considered to be unstable if displaced at
presentation or if dislocation was identified on dynamic
films. The classification comprised three fracture line
patterns (shortenings derived from French terminology):
OBAV – fracture line slopes forward anteriorly with or
without anterior displacement; OBAR – fracture line
slopes obliquely backward with or without posterior dislocation; and HTAL – horizontal fracture line with or
without displacement in any direction.
Althoff et al. [3] proposed a scheme where Type A
fracture passes through the neck of the odontoid; Type
B fracture through the rostral part of the C2 body and
Type C through the body of C2 but also the medial
aspect of one of the C2 superior articular facets. Type
D injury then involved both C2 upper articular
processes.
The classification most frequently used today is
that of Anderson and D’Alonzo [6]. It is based on the
location of the fracture line (Fig. 11.1). Type I stands
for an oblique fracture of the tip of the dens above the
transverse atlantal ligament (TAL). It is a very rare
injury commonly considered as stable [15, 36, 83].
Type II is a fracture of the base of the odontoid process. This most frequent subtype of OF is highly
unstable and very much prone to nonunion. Type III is
represented by a fracture of the dens base extending
more or less into the C2 body. Using this classification, other authors found various subtypes of the
odontoid neck injury. Hadley et al. [40] described a
Type IIA comminuted fracture of the odontoid base
P. Suchomel and O. Choutka, Reconstruction of Upper Cervical Spine and Craniovertebral Junction,
DOI: 10.1007/978-3-642-13158-5_11, © Springer-Verlag Berlin Heidelberg 2011
165
166
Fig. 11.1 A schematic
drawing of Anderson
D’Alonso classification of
odontoid fracture
11 Odontoid Process Fractures
with associated free fracture fragments. Its incidence
was estimated as 5% of all Type II fractures. Geisler
et al. [30] suggested classifying posteriorly displaced
fractures as II-P. Analyzing our series of patients, we
proposed to separate transverse odontoid process
fractures that were above the base but below the transverse ligament as Type IIT, where T means transverse
or transitional [91]. Type IIT fracture is unstable in all
directions, particularly in rotation and therefore,
requires a two-screw anterior osteosynthesis rather
than a single-screw technique popularized recently.
Gauer et al. proposed a treatment based sub-classification of Anderson Type II fractures [34]. Nondisplaced
transverse fracture with no comminution suitable for
conservative treatment was classified as Type IIA.
Type IIB was assigned to displaced transverse or
posteriorly oblique fracture that was amenable to
anterior screw fixation following fracture reduction.
Anteriorly oblique fracture line or a fracture with
significant comminution was the classified as Type
IIC. This type, according to author’s preference, is
predetermined for surgical posterior atlantoaxial
stabilization.
Vertical OF is also described in the literature [51]. It
may be considered as stable if the transverse ligament
is not involved.
Similarly to others, we have adopted the Anderson
D’Alonso classification system and therefore, their
denomination of fracture types will be used in the
remainder of the text.
11.2 Etiology and Epidemiology
The fracture of C2 odontoid process represents 50–60% of
all fractures of the axis [16, 28, 36] and 8–15% of all cervi-
cal acute spine fractures [2, 6, 16, 36, 41]. OF is the most
common cervical spine fracture in adults over the age of
70 years [64, 73] and it is the most frequent fracture of all
spine injuries in population aged over 80 years [73].
Type II is the most frequent form present in 37–83%
of all odontoid fractures with even higher incidence of
95% in the elderly [16, 36, 64, 93].
Odontoid fractures are associated with other spine
injuries in 34% of patients, of which, 85% are cervical
and 20% are associated with C1 injury [36]. Concurrent
TAL malfunction due to abruption of its attachment
has also been described [20, 36]. Similar AA instability can also result from concomitant C1 ring disintegration in combined C1-2 fractures. The association of
head injury and all C2 fracture subtypes was seen in
20.3% of cases [36].
OF can be caused by hyperflexion with possible
anterior dislocation and AA subluxation with or without transverse ligament damage or, more commonly,
by hyperextension with concomitant C1 anterior arch
fracture and/or posterior displacement of C1. As the
majority of OFs are caused by motor vehicle accidents
or simple falls [2, 6, 42, 62, 67, 91], the mechanism of
the dens fracture is usually not caused by pure sagittal
force transmission but is often modified by lateral
bending and rotational forces.
11.4 Radiology
167
11.3 Clinical Symptoms
Between 25 and 40% of patients with UCS injury die
at the scene of the accident; however, approximately
90% of surviving patients have no major neurological
deficit [11, 16, 36, 42, 96]. Fractures of the dens were
frequently missed in the past. Difficulty in obtaining
adequate lateral and transoral plain films in the acute
setting was the main reason for the delay, as hospitaladmitted trauma survivors were often uncooperative
and/or unconscious due to the associated head trauma,
multiple injuries or intoxication. In the late 1980s, we
published that 60% of acutely admitted patients with
head injury are under the influence of alcohol [90].
The diagnostic difficulty is currently eliminated by an
early and mandatory CT evaluation of all uncooperative and unconscious patients with history of trauma.
The cooperating patient usually complains only of
poorly localized pain in the posterior part of the neck
and has paravertebral muscle spasm, tenderness, and
limited movement of the neck. Neurological symptoms
and signs vary from a rather rare pentaplegia to the
more frequently seen simple occipital neuralgia with
limited neck motion.
hospitals without 24 h CT service have a standard
algorithm of radiological workup based on clinical
situation. Therefore, plain films in simple lateral and
AP projection are obtained first and if any UCS
abnormality is suspected, transoral views are added.
Dislocated fractures are, usually, easily seen and
identified (Fig. 11.2). However, hairline nondislocated
fractures can be overlooked (Fig. 11.3). Classical
tomography was historically also a good tool to confirm the presence of OF (Fig. 11.4). Only CT in bone
windows with sagittal and coronal, or even better, 3D
reconstructions, exactly delineates fracture location,
its direction and extent, as well as bone morphology
for potential surgical fixation (Fig. 11.5). Spiral CT
11.4 Radiology
As mentioned above, most major trauma victims
today are usually screened with an early, fast spiral
CT. However, there are self-presenting ambulatory
patients with minimal symptoms that harbor an
odontoid fracture. Such patients are not commonly
screened by a CT at the first instance. Also, smaller
Fig. 11.3 Non dislocated
Type II odontoid fracture.
(a) Transoral film of a hairline
Type II fracture which was
initially overlooked.
(b) Odontoid pseudoarthrosis
in the same patient 6 month
later (no treatment until then)
Fig. 11.2 Lateral radiograph of posteriorly displaced odontoid
Type II fracture