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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_31_библиотеки_им_акад_М_И_Перельмана
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Upper Cervical Spine Injuries
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SanderP.J.Muijs andF.CumhurÖner
5.1 Occipital Condyle andCranio-Cervical Junction Injury
The cranio-cervical junction is the most mobile part of the spine, formed by the
condyles of the occiput and the rst two cervical vertebrae; its stability is largely
dependent on ligamentous structures. Of all cervical spine injuries, approximately
one-third involves the cranio-cervical junction. Due to the great improvement of
onsite management (pre-hospital care) of trauma patients, cranio-cervical injuries,
which in the past were often fatal on-site, are becoming increasingly common inhospital trauma care.
5.1.1 Physical Examination
5
Symptoms may include altered consciousness, high cervical or occipital pain, loss
of cervical spine motion, torticollis, and cranial nerve dysfunction (most frequently
the 12th cranial nerve). Directly lateral to the condyles, the jugular foramina are
located and contain the jugular vein and the 4th, 5th, and 6th cranial nerves, which
provide innervation to the throat and to sternocleidomastoid and trapezius muscles.
Acute traumatic palsy of cranial nerves rarely shows complete recovery while
delayed onset palsy tends to have a more favorable outcome.
In Type B and C injuries neurologic decit is frequent: only 20% of the patients
have no neurological compromise while 38% of patients have quadriparesis or
Supplementary Information The online version contains supplementary material available at
(https://doi.org/10.1007/978- 3- 030- 80356- 8_5).
S. P. J. Muijs · F. C. Öner (*)
Department of Orthopaedics, University Medical Center Utrecht, Utrecht, Netherlands
e-mail: S.P.J.Muijs@umcutrecht.nl; F.C.Oner@umcutrecht.nl
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2022
A. Şenköylü, F. Canavese (eds.), Essentials of Spine Surgery,
https://doi.org/10.1007/978-3-030-80356-8_5
31
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quadriplegia, 34% hemiparesis or hemiplegia, and 10% lower cranial nerve palsies
(n. hypoglossus, n. vagus) (Videos 5.3 and 5.4).
S. P. J. Muijs and F. C. Öner
5.1.2 Imaging
Multiple radiologic measurements have been proposed for the assessment of the
atlanto-occipital region (Appendix A). The cranial tip of the odontoid, the caudal tip
of the basion (clivus), the midpoint of the posterior arch of C1, the opisthion (the
midpoint on the posterior margin of the foramen magnum), and the spinous processes are the commonly used landmarks.
Most commonly used are computed tomography (CT) scan–based measurements such as the Pang’s occipital Condyle-C1-Interval (CCI) [1], the Harris’
Basion-Axial Interval (BAI) [2] combined with the Wholey’s dens-basion interval
(DBI) [3], the Powers ratio, and the Sun’s C1–C2/C2–C3 interspinous ratio [4, 5].
Magnetic resonance imaging (MRI) should be performed to visualize compression, myelopathy, and hemorrhage and to rule out ligamentous injury in case of any
signs of neurologic involvement. MRI is also indicated to rule out SCIWORA
(Chap. 4).
Atlanto-occipital dislocation can reduce spontaneously and therefore radiologic
measurements as described above may underestimate the injury.
On MRI, extensive ligamentous injury of the cranio-cervical junction can be
found even in the presence of a (almost) normal CT scan. Information concerning
the mechanism of trauma and the kinetics of the injury is of paramount importance
in the workup of all trauma patients with suspected cervical spine injury.
5.2 Occipital Condyle andCranio-Cervical Junction Injury
5.2.1 Occipital Condyle Fractures (AO Type A)
High-energy blunt compression trauma is the most common trauma mechanism for
occipital condyle fractures. The occipital condyles form the lateral border of the
foramen magnum.
5.2.1.1 Treatment Options
The majority of condyle fractures are without any signs of ligament injury and
hence are calssied as Type A injuries.
5.2.2 Atlanto-Occipital Injury (AO Type B andC)
Atlanto-occipital injuries are often fatal as a result of neurogenic shock and respiratory arrest and are hence rare although nowadays more patients tend to survive and
reach the emergency department due to the improvement in pre-hospital (on site).
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The normal relation between C0 (occiput) and C1 is (potentially) unstable.
Atlanto-occipital dislocation (AO Type C) results from extreme high forces, in which
the cranial extension of the posterior longitudinal ligament ruptures due to a combination of axial distraction and extreme hyperextension. The injury is more frequently
seen in children after a high-energy trauma (Chap. 1), which results in a combination
of axial, translation, and rotational forces. In some cases where there is no dislocation, ligamentous injury can only be detected on MRI (AO Type B injuries).
5.2.2.1 Treatment Options
Atlanto-occipital injuries are highly unstable. In case of manipulation, respiratory
arrest and neurologic deterioration can occur. Traction should be avoided at all times.
Operative Treatment
AO Type C injuries require an occipital-cervical fusion (Fig.5.1) (Videos 5.2 and
5.7). Immobilization in a halo-jacket (Videos 5.1 and 5.2) is a safe option for transport, intubation, and positioning of the patient on the operation table.
Conservative Treatment
Atlanto-occipital dislocations are highly unstable. Halo-vest immobilization for
6–8weeks (Video 5.1), with a weekly radiologic follow-up, is an option only for AO
Type B injuries without displacement.
5.2.2.2 Expected Outcomes
The expected outcomes are largely dependent on neurological symptoms and the
presence of concomitant (e.g., vascular) injuries. A C0–C2 xation will lead to a
a
Fig. 5.1 (a) 3-D CT reconstruction of an evident C0–C1 dislocation. (b) Imaging after reduction
in halo and surgical C0–C4 xation
b
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decrease of exion-extension of at least 25°, and loss of approximately 50% of cervical rotation.
S. P. J. Muijs and F. C. Öner
5.3 C1 Ring andC1–C2 Joint Injuries
5.3.1 Definition
C1 is a closed ring formed by the lateral masses and the anterior and posterior arch.
The odontoid process of C2 articulates with C1 and ensures most of the rotation of
the cervical spine (all other segments combined together contribute signicantly
less to the rotational range of motion of the cervical spine).
Fractures of C1 account for 25% of atlanto-axial injuries, and for 10% of all
cervical spine injuries. If a C1 fracture is diagnosed, a second fracture of the spine
is seen in approximately 50% of the cases (Appendix A).
Preservation of a range of motion of the atlanto-axial segment should be considered when treating atlanto-occipital or C1–C2 injuries.
The isolated C1 lateral mass or posterior arch fracture is in most cases stable (AO
Type A). The most classical form is the Jefferson fracture which is a burst fracture
of the Atlas and is seen in axial compression trauma. The fracture typically has
bilateral fractures at the junction of the lateral masses and the posterior and anterior
arches of C1 [6].
The assessment of the integrity of the transverse ligament is essential in the evaluation of isolated C1 fractures [7]. Injury to the transverse ligament makes the C1–
C2 complex potentially unstable (AO Type B). Although most patients with isolated
C1 fractures do not have any neurological decit, secondary displacement with neurologic deterioration can occur.
Frank dislocations of the C1–C2 complex (AO Type C) are rare injuries and are
commonly seen in children and young patients (Chap. 1).
5.3.2 Treatment Options
All injuries without any sign of transverse ligament disruption are considered to be
stable and external immobilization for 6–8weeks is generally sufcient although
there is no consensus on the type of immobilization (halo-jacket vs. collar) due to
the lack of good scientic evidence.
In injuries in which a bony avulsion of the transverse ligament is present, a good
clinical outcome with non-surgical treatment can be obtained. These injuries can be
treated with halo-immobilization for 12weeks (Video 5.1). In case of MRI evidence
of a mid-substance tear of the transverse ligament, the prognosis is less favorable
when non-surgical treatment is chosen.
Surgical treatment options in order to fuse C1 and C2 include C1–C2 transarticular screw xation and the technique described by Harms (C1 lateral mass and the C2
pedicle, pars interarticularis or translaminar screw xation using polyaxial screws)
(Videos 5.2 and 5.7).
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5.3.3 Expected Outcomes
Conservative treatment can preserve some of the C1–C2 rotational range of motion
although there is a higher risk of long-term pain due to osteoarthritis and/or pseudoarthrosis. If non-surgical management is chosen, and radiologic follow-up shows signs
of instability after a period of 8weeks, surgical treatment should be re-considered.
5.4 C2 andC2–C3 Injuries
C2 fractures represent approximately 20% of all cervical fractures and are common in
the elderly population. The most common fracture types (Appendix A) are odontoid
fracture (dens fracture) and the hangman fractures (traumatic bi-lateral spondylolisthesis of C2). The incidence of neurologic decit is less than 10% due to the wide
diameter of the spinal canal at this level. C2–C3 injuries show a higher incidence of
neurologic involvement (up to 25%), especially in (bi-lateral) facet dislocation.
Associated injury is seen in the form of paravertebral soft tissue injury, injury of the
pharynx, trachea and esophagus, and Horner’s syndrome; injury of the vertebral artery
is described in fractures passing through the transverse foramen (Chap. 4) [2, 6–8].
5.4.1 Imaging
CT scan imaging is routinely performed when any cervical fracture is suspected. An
MRI should be considered in case of a suspected combined injury or ligamentous injury.
5.4.2 Odontoid Fractures
Odontoid fractures are the most common fractures of the axis and are also the most
common osteoporotic fractures of the cervical spine. Historically three types are
recognized (Fig.5.2) [8] (Appendix A).
In Type I odontoid fractures atlanto-occipital dislocation (AO occiput-to- cervical
junction fracture Type C) should be ruled out. If there are no signs of an atlantooccipital dislocation (AO C2 Type A), treatment with a stiff collar for 6weeks is
appropriate.
Type II odontoid fractures are the most common type and have a signicantly
higher non-union risk [9]; non-union rates for conservative management can be as
high as 75% in elderly patients with displacement of more than 6mm. The symptomatic non-union rate is much lower but still approximately 20%.
There is an ongoing discussion among spine surgeons concerning the need for
early surgical xation of Type II fractures, especially in the elderly. Surgeons supporting early xation (with anterior odontoid screw) argue that halo treatment has a
high morbidity and even mortality in the elderly population. On the other hand,
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Fig. 5.2 Type I, II, and III odontoid fractures
S. P. J. Muijs and F. C. Öner
surgeons supporting treatment by halo-jacket (Video 5.1) argue the bone quality is
often sub-optimal, and the risk of non-union and secondary dislocation of the screw
is also high. If surgery is chosen, primary C1–C2 xation is preferable especially in
the elderly. C1–C2 fusion for Type II odontoid fractures should be considered in
case of secondary dislocation or symptomatic non-union.
Type III odontoid fractures are usually stable and may be treated with cervical
immobilization with a union rate above 80%. Although Type II and III odontoid
fractures have historically been treated with halo vest immobilization, evidence that
cervical collars give a higher non-union rate compared to halo-jackets is lacking
[10]. Considering the high rate of complications in the elderly population following
surgery or aggressive conservative treatment with a halo-jacket (Video 5.1), and the
benign nature of many of the non-union, supportive treatment with a collar and a
“benign neglect” policy can also be considered.
Surgical options for odontoid fractures include posterior fusion or anterior odontoid screw in some cases (Video 5.7). In some rare cases, a dislocation through a
fractured odontoid may lead to AO Type C injury.
5.5 Traumatic Spondylolisthesis oftheAxis (Hangman’s
Fracture)
The classical hangman fracture describes a fracture of the pedicles or pars interarticularis of C2 (Appendix A). The term is partially misleading due to the fact that the
most common trauma mechanism leading to traumatic spondylolisthesis of C2 is
caused by compression and hyperextension, and not by distraction and hyperextension as occurs in hanging. The most frequent mechanisms of injury are diving in
shallow water, motor vehicle accidents, and falls.
5.5.1 Other C2 Fractures
Not all C2 fractures can be classied with the systems described above. Especially
more comminuted C2 vertebral body fractures that are neither odontoid nor
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hangman type fractures. These fractures (often exion type injuries) can be difcult to reduce with halo-traction. The extension needed to reduce the fracture
anatomically makes it impossible for the patient to see the horizon when xed in
the halo (Video 5.1). In our experience, a horizontal bar between the two posterior-vertical bars of the halo- jacket, with a pad in the neck to stabilize the caudal
cervical vertebral column, gives a lever to reduce and maintain reduction. Surgery
is reserved for cases with neurologic decit or painful non-union following
halo-treatment.
5.5.2 Combined C1–C2 Injuries
Combined fractures of C1 and C2 are responsible for approximately 4% of all cervical fractures. Fractures of C1 are found in up to 53% of Type II or III odontoid
fractures and in up to 26% of hangman fractures. Combined C1–C2 injuries have
higher rates of neurologic decit and death than isolated C1 or C2 fractures; this is
probably due to the high-energy trauma mechanism needed for these fractures
to occur.
5.5.2.1 Treatment Options
Most hangman fractures are AO Type A or B and can be managed conservatively by
6–12weeks of cervical immobilization with a rigid cervical collar or halo-jacket
(Video 5.1).
Surgery for hangman fractures is necessary in case of nonreducible facet dislocations. When surgery is indicated, options include C1–C3 posterior fusion (Videos
5.2 and 5.7) or C2–C3 anterior cervical fusion.
In the treatment of combined C1–C2 fractures, the type of treatment needed for
the C2 injury dictates the surgical option. Most of these combined injuries can be
managed, with external immobilization using a collar or halo-jacket. Surgery for
combined C1–C2 injuries is reserved for Atlas-Dens Interval >5mm with signs of
mid-substance injury (AO C1 ring and C1–C2 joint Type B and C) of the transverse
ligament on MRI (without avulsion fragment), or painful non-union after nonsurgical management. When instrumentation of C1 is impossible due to the fracture type
of C1, a C1–C2 transarticular screw xation or occipital-cervical fusion can be
considered (Video 5.7) [11].
Further Readings
1. Pang D, Nemzek WR, Zovickian J.Atlanto-occipital dislocation—Part 2: The clinical use of
(occipital) condyle-C1 interval, comparison with other diagnostic methods, and the manifestation, management, and outcome of atlanto-occipital dislocation in children. Neurosurgery.
2007;61(5):995–1015.
2. Harris JH Jr, Carson GC, Wagner LK.Radiologic diagnosis of traumatic occipitovertebral dis-
sociation: 1. Normal occipitovertebral relationships on lateral radiographs of supine subjects.
AJR Am J Roentgenol. 1994;162(4):881–6.
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3. Wholey MH, Bruwer AJ, Baker HL Jr. The lateral roentgenogram of the neck; with comments
on the atlanto-odontoid-basion relationship. Radiology. 1958;71(3):350–6.
4. Powers B, Miller MD, Kramer RS, Martinez S, Gehweiler JA Jr. Traumatic anterior atlanto-
occipital dislocation. Neurosurgery. 1979;4(1):12–7.
5. Sun PP, Poffenbarger GJ, Durham S, Zimmerman RA.Spectrum of occipitoatlantoaxial injury
in young children. J Neurosurg. 2000;93(1 Suppl):28–39.
6. Jefferson G.Fractures of the atlas vertebra: report of four cases and a review of those previ-
ously reported. Br J Surg. 1920;7:407–22.
7. Spence KF Jr, Decker S, Sell KW. Bursting atlantal fracture associated with rupture of the
transverse ligament. J Bone Joint Surg Am. 1970;52(3):543–9.
8. Anderson LD, D’Alonzo RT.Fractures of the odontoid process of the axis. J Bone Joint Surg
Am. 1974;56:1663–74.
9. Patel A, Zakaria R, Al-Mahfoudh R, Clark S, Barrett C, Sarsam Z, Pillay R, Pigott TD, Wilby
MJ.Conservative management of type II and III odontoid fractures in the elderly at a regional
spine centre: a prospective and retrospective cohort study. Br J Neurosurg. 2015;29(2):249–53.
10. Muller EJ, Schwinnen I, Fischer K, Wick M, Muhr G.Non-rigid immobilisation of odontoid
fractures. Eur Spine J. 2003;12:522–5.
11. Divi SN, Schroeder GD, Oner FC, Kandziora F, Schnake KJ, Dvorak MF, Benneker LM,
Chapman JR, Vaccaro AR.AOSpine-spine trauma classication system: the value of modiers: a narrative review with commentary on evolving descriptive principles. Global Spine
J. 2019;9(1 Suppl):77S–88S.
S. P. J. Muijs and F. C. Öner
Sub-axial Cervical Spine Injuries
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LuizR.Vialle andEmilianoN.Vialle
6.1 Definition
The sub-axial area is the one starting at the third cervical vertebra (C3) and ending
in the C7/T1 disc and joints. Any injury occurring from C3 to the C7/T1 disc space
is considered to be a sub-axial cervical spine injury.
6.2 Natural History
Sub-axial injuries account for about 3% of all blunt trauma, with an incidence of 64
per 100,000 cases, according to the most recent data. The majority is due to trafc
accidents in the younger population while falls represent the main cause in the
elderly; diving in shallow water is also one of the main causes of sub-axial cervical
spine injury and spinal cord injury (SCI). When associated with SCI, the treatment
of such injuries is more demanding and expensive. Unfortunately, some cases are
underdiagnosed and may lead to secondary deformity and permanent neural damage; it is of utmost importance to manage all injuries during the index surgical
procedure.
6
Supplementary Information The online version contains supplementary material available at
(https://doi.org/10.1007/978- 3- 030- 80356- 8_6).
L. R. Vialle (*)
Pontical Catholic University of Paraná, Curitiba, Brazil
e-mail: vialle@vialle.com.br
E. N. Vialle
Cajuru University Hospital, Curitiba, Brazil
e-mail: evialle@hotmail.com
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2022
A. Şenköylü, F. Canavese (eds.), Essentials of Spine Surgery,
https://doi.org/10.1007/978-3-030-80356-8_6
39
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L. R. Vialle and E. N. Vialle
6.3 Physical Examination
The simple inspection tells the examiner how severe the cervical injury could be; an
ambulatory patient obviously differs from a tetraplegic one. The physical examination starts with palpation of the neck; the examiner must look for edema, tenderness,
crepitation, or hematoma. Even minor pain with neck movements must be an alert
to the examiner. Neurological evaluation (Video 6.4) should be performed in all
cases followed by established protocols if a SCI is present. It is imperative to annotate all clinical and neurological ndings as changes frequently occur during the
rst posttraumatic period (hours).
6.4 Imaging
Not all cervical spine trauma cases should be screened by all sorts of imaging. There
are two well-established protocols: the Canadian C-spine rule [1] and the North
American National Emergency X-Radiography Utilization Study Low-Risk
(NEXUS) Criteria. The C-spine rule is slightly more precise, as it evaluates local
pain or movement limitations during the examination; patients without major clinical/neurological signs do not need to undergo imaging assessment. This measure
can save time and it is economically sound.
However, any major trauma or symptomatic case should be sent to radiology.
Standard radiographs—anterior-posterior (AP) and lateral, exion-extension
projections—may not be always trustful. Most of the time, the presence of muscle spasms or pain can hide minimal dislocations. A exion-extension radiograph
is not recommended in the emergency room (ER); an unstable spine may put the
patient at risk for spinal cord compression or spine dislocation. Similarly, the
cervicothoracic junction may be difcult to assess on plain radiographs (due to
tissue superposition) in obese patients, patients with large shoulders, and
obtunded patients (Fig.6.1a). In particular, most subtle injuries of the cervicothoracic junction are often misdiagnosed. In order to avoid missing a sub-axial
cervical spine injury, the computed tomography (CT) scan is the imaging of
choice (Fig.6.1b, c); it is fast reliable, and highly sensitive, and it can provide
three-dimensional reconstruction.
In the case of a negative CT scan, or if any doubt, magnetic resonance imaging
(MRI) should be performed to evaluate ligaments, facets, discs, and spinal cord.
However, in the ER setting, the rst-line imaging studies are radiographs and CT
scans while MRI has a limited place. In the presence of pain without radiological
abnormalities, a second radiograph should be requested within 2 weeks from
trauma, once muscle spasms have resolved; in this case, instability may be detected
(Fig.6.2).
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