Upper Cervical Spine

Fractures

Originally created by Daniel Gelb, MD

January 2006

Updated by Robert Morgan, MD; November 2010

 Upper Cervical Spine Fractures
• Epidemiology
• Anatomy
• Imaging Characteristics
• Common Injuries
• Management Issues
 Epidemiology
Upper Cervical Spine Fracture
• 717 cervical spine Demographics
fractures in 657 patients
over 13 years 30

• C1 and Hangman fractures 25

20
found more in the young Number of
Patients
15
c1 ring
10
– Odontoid fractures evenly 5
odontoid
distributed 0
hangman's
• Younger patients have higher

<20

30-39

50-59
energy injuries

70-79
• C2 fractures most Age

common
The epidemiology of fractures and fracture-dislocations of
the cervical spine Ryan,M.D.; Henderson,J.J. Injury, 1992,
23, 1, 38-40
Upper Cervical Anatomy
 Upper Cervical Anatomy
• Biomechanically Specialized
– Support of “large” Cranial mass
– Large range of motion
• Flexion/extension
• Axial rotation
• Unique osteological characteristics
 Large Cranial Mass

•Keel below the SNL is thick bone

Roberts, DA; Doherty, BJ; Heggeness MH. Quantitative Anatomy of the Occiput and the Biomechanics of
Occipital Screw Fixation Spine 23(10), 15 May 1998, pp 1100-1107
 Confluence of Issues

•Bicortical screws in the occiput may enter the transverse sinus

•Decreased risk below the superior nuchal line

Roberts, DA; Doherty, BJ; Heggeness MH. Quantitative Anatomy of the Occiput and the Biomechanics of
Occipital Screw Fixation Spine 23(10), 15 May 1998, pp 1100-1107
 Occipital Screw Mechanics

Roberts, DA; Doherty, BJ; Heggeness MH. Quantitative Anatomy of the Occiput and the Biomechanics of
Occipital Screw Fixation Spine 23(10), 15 May 1998, pp 1100-1107
 The course of the vertebral artery through C1
and C2 determines the possibility of placing
screws for fixation of fractures and dislocations

• C1 lateral mass screws

• C1-2 transarticular screws
• C2 pedicle/pars screws
Normal Vertebral Artery
Tortuous Vertebral Artery
C1 - Atlas
• No body
• 2 articular pillars
– Flat articular surface
– Vertebral artery
foramen
• 2 arches
– Anterior
– Posterior
• Vertebral artery groove
 C2 Anatomy

• Dens
– Embriological C1 body
– Base poorly vascularized
– Osteoporotic
• Flat C1-2 joints
• Vertebral artery foramena
– Inferomedial to
superolateral
 Trabecular Anatomy

The trabecular anatomy of the axis Authors:Heggeness,M.H. ; Doherty,B.J.Source:Spine, 1993, 18, 14, 1945-1949, UNITED STATES
 Trabecular Anatomy

The trabecular anatomy of the axis Authors:Heggeness,M.H. ; Doherty,B.J.Source:Spine, 1993, 18, 14, 1945-1949, UNITED STATES
 Anatomy – The Ligaments

• Allow for the wide ROM of upper C-spine while

maintaining stability
• Classified according to location with respect to vertebral
canal
– Internal:
• Tectorial membrane
• Cruciate ligament – including transverse ligament
• Alar and apical ligaments
– External
• Anterior and posterior atlanto-occipital membranes
• Anterior and posterior atlanto-axial membranes
• Articular capsules and ligamentum nuchae
Atlanto-Axial Anatomy

Tectorial Membrane
 Atlanto-Axial Anatomy
Tranverse Ligament
Occiput

C1-C2 joint C1
C2
Alar Ligament
 Atlanto-Axial Anatomy

Transverse
Facet for
Ligament
Occipital
Condyle
Vertebral Atlanto-Axial Anatomy
Artery
Radiographic Evaluation
 Plain Radiographic Evaluation
Lateral View
Prevertebral Swelling
Soft Tissue Shadow
<6mm at C2
Concave/Flat
Pre-dental space < 3mm
Atlanto-Occipital Joint Congruence
Radiographic Lines*

Open Mouth AP
Distraction
C1-2 Symmetry
Radiographic Diagnosis – Screening Lines

Harris’s lines

Powers’s Ratio
 Radiographic Lines
Harris’ Lines

• Basion-Dental Interval (BDI)

• Basion to Tip of Dens
• <12 mm in 95%
• >12 mm ABNORMAL

• Basion-Axial Interval (BAI)

• Basion to Posterior Dens
• -4-12 mm in 98%
• >12 mm Anterior Subluxation
• >4 mm Posterior Subluxation

Harris et al, Am J Radiol, 1994

 Radiographic Lines
Powers’ Ratio
• BC/OA
– >1 considered abnormal
• Limited Usefulness
• Positive only in Anterior
Translational injuries
• False Negative with pure
distraction

Powers et al, Neurosurg, 1979

 Radiographic Diagnosis

CT Scan

• Same rules as with plain films

• Better visualization of cranio-
cervical junction
• Subluxation
• Focal hematomas
• Occipital condyle fractures
• Dens fractures
 Radiographic Diagnosis
MRI

Increased Signal Intensity in :

• C0-C1Joint
• C1-2 Joint
• Spinal Cord
• Cranio-cervical
ligaments
• Pre-vertebral
soft tissues

Dickman et al, J Neurosurg, 1991

Warner et al, Emerg Radiol, 1996
 Upper Cervical Spine Fractures
• Common Injuries • Uncommon Injuries
– Occipital Condyle – Craniocervical
Fracture Dislocation
– Craniocervical sprain? – Rotatory subluxation
– C1 ring injuries
– Odontoid Fracture
– Hangman’s Fracture
 Occipital Condyle Fracture
Type I
Impaction Fracture
Type II
Extension of basilar skull
fracture
Type III
ALAR ligament Avulsion

Anderson ,SPINE 1988

Tuli, NEUROSURGERY, 1997
Cranio-cervical Dislocation

• Antlanto-Occipital Joint
• Occipito-Cervical Joint
• Cranio-cervical Joint
• Atlanto-Axial Joint
•Cranio-cervical sprain (stage 1) may
be treated nonoperatively
 Cranio-cervical Dislocation

Commonly Fatal
Present 6-20% of post
mortem studies
– Alker et al, 1978
– Bucholz & Burkhead,1979
– Adams et al, 1992
50% missed injury rate
1/3 Neurological Worsening
– Davis et al, 1993
 Symptoms/Findings
• Lower Cranial nerve
deficits
• Horner’s syndrome
• Cerebellar ataxia
• Bell’s cruciate
paralysis
• Contralateral loss of
pain and temperature
Wallenberg
Syndrome
Check the Cranial Nerves!

www.med.yale.com
www.meddean.luc.edu
 Cranio-cervical Dislocation
•Treatment
•Emergency Room
•Collar/sandbag
•Halo vest
•Definitive
•Posterior occipital
cervical fusion
•ALWAYS include
C1 and C2
 Atlas Fractures - Treatment

Collar
1. Isolated anterior
arch
2. Isolated posterior
arch
3. Non-displaced
Jefferson fracture
 Atlas Fractures - Treatment
Displaced <6.9 mm
•Halo vest * 3 mos
Displaced >6.9 mm
•Halo traction (reduction) * several weeks
followed by halo vest
•Immediate halo vest
•Posterior C1-2 fusion (unable to tolerate
halo)
After brace treatment complete confirm C1-2
stability
Flexion/extension films
C1-2 fusion for ADI > 5mm
Transverse ligament avulsion

•Bony avulsions may heal with nonoperative

management
•TAL rupture does not heal with nonoperative
management and requires C1-C2 arthrodesis
 Atlas Fractures - Treatment
Fusion options
Gallie
Post-op halo

Brooks Jenkins

Transarticular Screws

C1 lateral mass/C2 pars-pedicle screws

 Odontoid Fractures

Most common fracture of Axis

(nearly 2/3 of all C2 Fxs)
10 – 20 % of all cervical fractures
Etiology Bimodal distribution
Young - high energy, multi-trauma
Elderly - low energy, isolated injury

(most common C-spine Fx elderly)

 Elderly and the Odontoid
• Platzer Studies
– Elderly increased
pseudarthrosis rate( 12% v.
8%)
– Elderly tolerated pseudarthosis
well(1/5)
– Elderly tolerated halo well
– 10% mortality (4/41)
– 22% complication rate
• Chapman studies
– Elderly did not heal the
odontoid fracture (4/17)
– Elderly tolerated halo well
(7/8)
– 15% mortality (3/20)
• Harrop and Vaccaro
– 9/10 “union”
– 5/10 postop halo
– 1/10 perioperative death
• Multiple series of high
mortality rates
Anterior screw fixation of odontoid fractures comparing younger and elderly
patientsAuthors:Platzer,P.; Thalhammer,G.; Ostermann,R.; Wieland,T.; Vecsei,V.;
Gaebler,C.Source:Spine, 2007, 32, 16, 1714-1720, United States
Nonoperative management of odontoid fractures using a halothoracic vestAuthors:
Platzer,P.; Thalhammer,G.; Sarahrudi,K.; Kovar,F.; Vekszler,G.; Vecsei,V.;
Gaebler,C.Source:Neurosurgery, 2007, 61, 3, 522-9; discussion 529-30, United
States
Posterior atlanto-axial arthrodesis for fixation of odontoid nonunionsAuthors:
Platzer,P.; Vecsei,V.; Thalhammer,G.; Oberleitner,G.; Schurz,M.; Gaebler,C.
Source:Spine, 2008, 33, 6, 624-630, United States
Type II odontoid fractures in the elderly: early failure of nonsurgical
treatmentAuthors:Kuntz,C.,4th; Mirza,S.K. ; Jarell,A.D.; Chapman,J.R.; Shaffrey,C.I.
; Newell,D.W.Source:Neurosurg.Focus., 2000, 8, 6, e7, United States
Efficacy of anterior odontoid screw fixation in elderly patients with Type II
odontoid fracturesAuthors:Harrop,J.S. ; Przybylski,G.J.; Vaccaro,A.R.;
Yalamanchili,K.Source:Neurosurg.Focus., 2000, 8, 6, e6, United States
 Fracture Classification
Anderson and D’Alonzo
Type I 2 % (2/49)

Type II 50-75 %
(32/49)

Type III 15-25 %

(15/49)
Fractures of the odontoid process of the axisAuthors:Anderson,L.D.; D'Alonzo,R.T.Source:
J.Bone Joint Surg.Am., 1974, 56, 8, 1663-1674, UNITED STATES
 Subtypes of Type II Fractures
• Type IIA and B are
amenable to anterior
fixation
• Type IIC is not
• Does not include part
of facet, not a Type
III
Grauer,J.N et al Proposal of a modified, treatment-oriented classification of odontoid fractures. Spine J.,
2005, 5, 2, 123-129
 Acute Management
• Spinal cord injury rare
(17/226)
• Airway compromise
– 0/8 nondisplaced
– 1/21 anterior
displacement
– 13/32 posterior
displacement (2
deaths)
Epidemiolgy of spinal cord injury after acute odontoid fractures
JAMES S. HARROP, M.D., ASHWINI D. SHARAN, M.D., AND
GREGORY J. PRZYBYLSKI, M.D. Neurosurgical Focus 2000 Don’t do flexion reductions!
Closed management of displaced Type II odontoid fractures:more frequent respiratory compromise with posteriorly
displaced fractures GREGORY J. PRZYBYLSKI, M.D., JAMES S. HARROP, M.D., AND ALEXANDER R. VACCARO, M.D.
Neurosurgical Focus 2000
 Definitive Treatment Options

Type 1
C-Collar
beware unrecognized
CCD

Type 3
C-Collar 10-15%
nonunion SOMI brace
Evidence-based analysis of odontoid fracture managementAuthors:Julien,T.D.; Frankel,B. ;
Traynelis,V.C. ; Ryken,T.C. Source:Neurosurg.Focus., 2000, 8, 6, e1, United States Halo Vest
 Treatment Options
odontoid fracture
Type 2
• C-Collar
• SOMI / Minerva
• Halo Vest
• Odontoid Screw
• C1-2 posterior fusion
 Anterior Odontoid Screw Fixation
Indications
• Displaced Type II, Shallow Type III
• Polytrauma patient
• Unable to tolerate halo-vest
• Early displacement despite halo-vest
• (Reduces in extension)
Contraindications
• Non-reducible odontoid fracture
• (Reduces in flexion)
• Body habitus (Barrel chest )
• Associated TAL injury
• Subacute injury (> 6 months)
• Reverse oblique
• (elderly)
Roy-Camille
Classification
Anterior Screw History

•Note
reduced
dorsal
cortex
 Anterior Screw Technique
• Skin incision at C5
• Note slight extension
• Missing key element
in diagram (need to
atraumatically obtain
open mouth
fluoroscopy)
• Biplanar fluoroscopy

Direct anterior screw fixation for recent and remote odontoid fracturesAuthors:Apfelbaum,R.I. ;
Lonser,R.R. ; Veres,R.; Casey,A.Source:J.Neurosurg., 2000, 93, 2 Suppl, 227-236, UNITED STATES
 Anterior Screw Technique
• Need to enter body
caudal portion of
promontory
• Midline for single
screw placement

Direct anterior screw fixation for recent and remote odontoid fracturesAuthors:Apfelbaum,R.I. ;
Lonser,R.R. ; Veres,R.; Casey,A.Source:J.Neurosurg., 2000, 93, 2 Suppl, 227-236, UNITED STATES
 Anterior Screw Technique
• Critical to cross rostral
cortex
• Critical to use lag
screw technique
• Limited support for
second screw

Direct anterior screw fixation for recent and remote odontoid fracturesAuthors:Apfelbaum,R.I. ;
Lonser,R.R. ; Veres,R.; Casey,A.Source:J.Neurosurg., 2000, 93, 2 Suppl, 227-236, UNITED STATES
 One or Two Screws?
• No significant difference biomechanically
– Sasso
– Graziano
• No difference clinically
– Apfelbaum
– Jenkins
 Screw Mechanics

A comparative study of fixation techniques for type II fractures of the odontoid processAuthors:Graziano,G.; Jaggers,C.;
Lee,M.; Lynch,W.Source:Spine, 1993, 18, 16, 2383-2387, UNITED STATES
 Screw Mechanics

• 13 cadavers
• Load to failure
– Extension-deflection
– 450oblique
• No difference between one
and two screws
• Failure mode is screw
pullout from body
• Anatomic reduction
without comminution

Biomechanics of odontoid fracture fixation. Comparison of the one- and two-screw

techniqueAuthors:Sasso,R.; Doherty,B.J.; Crawford,M.J.; Heggeness,M.H. Source:Spine,
1993, 18, 14, 1950-1953, UNITED STATES
 Apfelbaum Clinical Outcomes
• 147 patients
– 129 (117) <6 months
– 18 > 6 months
• 88% fusion rate
– Recent fractures
– Horizontal and posterior oblique
– No difference between one or
two screws
• 25% fusion rate in remote
fractures
• 10% implant complication
– Screw pullout of C2 body
• 1% perioperative mortality
– 6% within 30 days
 Jenkins Clinical Outcomes
• 42 patients
• 8.5 month followup
• 15% nonunion rate
(plain radiographs)
• 5% perioperative
mortality
• 10% 3 month
mortality •Mal-reduction
A clinical comparison of one- and two-screw odontoid
fixationAuthors:Jenkins,J.D.; Coric,D.; Branch,C.L.,Jr Source:J.Neurosurg.,
1998, 89, 3, 366-370, UNITED STATES
•Incorrect entry point
Posterior Odontoid Stabilization
 Posterior Odontoid Stabilization
• Options
– Posterior wiring
• Up to 25% pseudoarthrosis
• Halo vest necessary (?) Dickman JNS 1996, Grob Spine 1992
– Transarticular screw fixation
• Magerl and Steeman Cerv Spine 1987
• Reilly et al, JSD 2003

– C1 lateral mass - C2 pars/pedicle/lamina screw

 Wiring Techniques

Biomechanical comparison of C1-C2 posterior arthrodesis techniquesAuthors:Papagelopoulos,P.J.;

Currier,B.L. ; Hokari,Y.; Neale,P.G.; Zhao,C.; Berglund,L.J.; Larson,D.R.; An,K.N. Source:Spine, 2007, 32, 13,
E363-70, United States
 Trans-articular Screw Technique

Primary posterior fusion C1/2 in odontoid fractures:

indications, technique, and results of transarticular
screw fixation Authors:Jeanneret,B.; Magerl,F.
Source:J.Spinal Disord., 1992, 5, 4, 464-475,
UNITED STATES
 Wiring Mechanics

Biomechanical comparison of C1-C2 posterior arthrodesis techniquesAuthors:Papagelopoulos,P.J.;

Currier,B.L. ; Hokari,Y.; Neale,P.G.; Zhao,C.; Berglund,L.J.; Larson,D.R.; An,K.N. Source:Spine, 2007, 32, 13,
E363-70, United States
Posterior Wiring Outcomes
 C1C2 Segmental Instrumentation

Posterior C1-C2 fusion with polyaxial screw and rod fixationAuthors:Harms,J.; Melcher,R.P.Source:Spine, 2001, 26, 22, 2467-2471, United States
. .
 pedicle

Pars

Trans-articular

C2 pars/pedicle
 Harm’s Mechanics

•LC1-PC2 performs similar to transarticular screws

•Transarticular screws with graft stiffest construct
•Interspinous graft behaves as intact specimen regarding
lateral bending

Hott et al: Biomechanical comparison of C1-2 posterior fixation techniques. J Neurosurg Spine 2: 175-181. 2005
 Harm’s Outcomes
• 102 patients
• 37 patients
• 98% fusion rate
• 100% fusion • Navigation
• 1 wound infection • Allograft/BMP
• 2 dissection VA injury
• 1 neuropathic pain (C2
root sacrifice)
• 4 wound infections
Posterior C1-C2 fusion with polyaxial screw and rod
fixationAuthors:Harms,J.; Melcher,R.P.Source:Spine, 2001, Stabilization of the atlantoaxial complex via C-1 lateral mass and C-2 pedicle screw
26, 22, 2467-2471, United States fixation in a multicenter clinical experience in 102 patients: modification of the
Harms and Goel techniquesAuthors:Aryan,H.E.; Newman,C.B.; Nottmeier,E.W.;
Acosta,F.L.,Jr; Wang,V.Y.; Ames,C.P.Source:J.Neurosurg.Spine, 2008, 8, 3, 222-
229, United States
 Posterior Fusion Takehome
• Catastrophic failures reported for trans-articular screws alone
• Trans-articular screws with wired bone graft is stiffest
construct
– Requires intact C1 lamina
– Requires reducible C1-2 facets
– Requires favorable anatomy
• Gallie wiring is inadequate without two supplemental screws
• No advantage of either wiring construct with two
transarticular screws
• Harm’s technique is most flexible
• Think about hooks?
 Traumatic Spondylolisthesis Axis
(Hangman’s Fracture)

Second most common fracture of axis

25% of C2 injuries
Most common mechanism of injury is
MVA
 Hangman’s Fracture
Younger age group (Avg 38 yrs)
Usually due to hyperextension-axial compression forces
(windshield strike)
Neurologic injury seen in only 5-10 % (acutely
decompresses canal)
Traditional treatment has been Halo-vest
Collar adequate if < 6 mm displaced
Coric et al JNS 1996
 Where Cranio-cervical meets
Subaxial

Levine AM, Edwards CC: The management of traumatic spondylolisthesis of the axis. J Bone Joint Surg Am 1985; 67:217-226
 Hangman Fracture

• Intact disk defines

Type I
• Halo treatment
difficult with torn
disk (types II and
III)
• Exercise caution Dysphagia and Resolved
Dysphonia immediately with
halo adjustment
 Hangman’s Fracture Treatment
Types II and III
Treatment
Posterior
– Open reduction and C1-C3 fusion
– Direct pars repair and C2-C3 fusion
Anterior
– C2/C3 ACDF with instrumentation
Atlanto-axial Rotatory Subluxation

Fuentes et al Traumatic atlantoaxial rotatory dislocation with odontoid fracture: case report and review. Spine 2001; 26(7) 830 -834
 Atlanto-axial Rotatory Subluxation

• Traction/halo
• Posterior fusion
• Lateral facetectomy, reduction, fusion
• Transoral facetectomy, reduction, fusion
Halo Immobilization
 Halo
• Frank Bloom
– Apparatus for stabilization
of facial fractures
– “Maxillofacial surgeon”
(actually a Navy
orthopaedic surgeon)
– World War II: treated pilots
with inwardly displaced
facial fractures
– Similar design
• Incomplete ring with 3
pin tiara

The history of the halo skeletal fixator O'Donnell,P.W.;

Anavian,J.; Switzer,J.A.; Morgan,R.A. Spine, 2009, 34, 16,
1736-1739
 The Basics

The halo fixator Bono,C.M. J.Am.Acad.Orthop.Surg., 2007, 15, 12, 728-737

 Pin Placement

The halo fixator Bono,C.M. J.Am.Acad.Orthop.Surg., 2007, 15, 12, 728-737

 Halo in Elderly
• Tashijan J. Trauma 2006
– 78 patients, age > 65yo
– Type II or III odontoid fractures
– Increased early morbidity and mortality
• Compared with treatment using
operative fixation or rigid collar
• Van Middendorp JBJS 2009
– 239 patients
– All ages in halo
– No increased risk of pneumonia or
death in patients >65 years old Halo vest immobilization in the elderly: a death sentence? Majercik,S.;
Tashjian,R.Z.; Biffl,W.L.; Harrington,D.T.; Cioffi,W.G. J.Trauma, 2005, 59,
2, 350-6; discussion 356-8
Incidence of and risk factors for complications associated with halo-
vest immobilization: a prospective, descriptive cohort study of 239
If you would like to volunteer as an author for the Resident patients van Middendorp,J.J.; Slooff,W.B.; Nellestein,W.R.; Oner,F.C.
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 Thank You

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