Transcript Dia 1
Trauma of the upper cervical spine Dr. J. VAN LERBEIRGHE AZ ST LUCAS GENT 17-7-2015 Orthopedica Belgica Antwerpen Upper cervical spine • • 17-7-2015 Atlantooccipital junction C1-C2 trauma Orthopedica Belgica Antwerpen Upper cervical spine • 1/3 of all injuries of the cervical spine • High-energy trauma, polytrauma • Often demanding diagnostic work out 17-7-2015 Orthopedica Belgica Antwerpen Indication fot surgery ? • Understanding of the mechanism • Stability classification 17-7-2015 Orthopedica Belgica Antwerpen Upper cervical spine • ½ of the flexion- extension between C0-C1 • ½ of the rotation between C1-C2 • = High kinematic demands 17-7-2015 Orthopedica Belgica Antwerpen OBJECTIVES OF TREATMENT • Prevent or reverse neurologic deficit • Restore spinal stability • Prevent deformity or restore normal alignment • Allow early mobilisation 17-7-2015 Orthopedica Belgica Antwerpen Upper cervical spine • • • • • Atlantooccipital dislocation Fractures of the occipital condyles Fractures of the ATLAS, Jefferson # Atlantoaxial instability, fixed rotatory subluxation Traumatic spondylolisthesis of the AXIS, Hangman’s # • Odontoïd fractures. 17-7-2015 Orthopedica Belgica Antwerpen Upper cervical spine • • • • • Atlantooccipital dislocation Fractures of the occipital condyles Fractures of the ATLAS, Jefferson # Atlantoaxial instability, fixed rotatory subluxation Traumatic spondylolisthesis of the AXIS, Hangman’s # • Odontoïd fractures. 17-7-2015 Orthopedica Belgica Antwerpen Atlantooccipital dislocations • TYPE I – Anterior dislocation is the most common form • TYPE II – Longitudinal dislocation without anterior or posterior shifting • TYPE III – Posterior dislocation ( very rare) • TYPE IV – Lateral dislocation 17-7-2015 Orthopedica Belgica Antwerpen Atlantooccipital dislocations 17-7-2015 Orthopedica Belgica Antwerpen Learning points C0-C1 dislocation Most C0-C1 dislocation end in death; often children; if survival significant neurological deficit. They need stable occipitocervical fixation Plate fixation to occiput and C1-C2 transarticular fixation ( 100 % surgical indication) 17-7-2015 Orthopedica Belgica Antwerpen Upper cervical spine • • • • • Atlantooccipital dislocation Fractures of the occipital condyles Fractures of the ATLAS, Jefferson # Atlantoaxial instability, fixed rotatory subluxation Traumatic spondylolisthesis of the AXIS, Hangman’s # • Odontoïd fractures. 17-7-2015 Orthopedica Belgica Antwerpen Fractures of the occipital condyles 17-7-2015 Orthopedica Belgica Antwerpen Fractures of the occipital condyles Learning points Compression fractures or extensions of fractures of the skull. They are generally stable. Avulsion fractures, however, may suggest significant ligamentous disruption and instability Traction under c-arm can help to asses stability 17-7-2015 Orthopedica Belgica Antwerpen Upper cervical spine • • • • • Atlantooccipital dislocation Fractures of the occipital condyles Fractures of the ATLAS, Jefferson # Atlantoaxial instability, fixed rotatory subluxation Traumatic spondylolisthesis of the AXIS, Hangman’s # • Odontoïd fractures. 17-7-2015 Orthopedica Belgica Antwerpen Fractures of the atlas 17-7-2015 Orthopedica Belgica Antwerpen Atlas Fractures 17-7-2015 Orthopedica Belgica Antwerpen Atlas fracture • Type I – Isolated fracture of the anterior ring • Type II – Isolated fracture of the posterior ring • Type III – Combined fracture of the anterior and posterior arch (Jefferson fracture) • Type IV – Isolated fracture of the lateral mass • Type V – Fracture of the transverse process 17-7-2015 Orthopedica Belgica Antwerpen Fractures of the atlas 17-7-2015 Orthopedica Belgica Antwerpen Atlas fracture Non-operative treatment • Minimal dislocation of only one lateral mass • No Instability on flexion extension X-Ray • 12 weeks orthosis followed by physical therapy 17-7-2015 Orthopedica Belgica Antwerpen “Jefferson” fractures learning points May be treated nonoperatively if there is no atlantoaxial instability on the lateral view Lateral flexion/extension x-rays must be performed once the fracture has healed to rule out late instability Halo traction usually does not reduce lateral mass dislocation 17-7-2015 Orthopedica Belgica Antwerpen “Jefferson” fracture Operative treatment Unstable two-part Jefferson fracture with osseous avulsion of the transverse ligament Patient’s preference Definitive treatment 17-7-2015 Orthopedica Belgica Antwerpen “Jefferson” fracture Operative treatment C1-C2 transarticular fixation and bone grafting after reduction ( special clamp) or Direct osteosynthesis of the C1 arch with lateral mass screws or C1-C2 rod construction without fusion and removal of the implants after healing 17-7-2015 Orthopedica Belgica Antwerpen Upper cervical spine • • • • • Atlantooccipital dislocation Fractures of the occipital condyles Fractures of the ATLAS, Jefferson # Atlantoaxial instability, fixed rotatory subluxation Traumatic spondylolisthesis of the AXIS, Hangman’s # • Odontoïd fractures. 17-7-2015 Orthopedica Belgica Antwerpen Atlanto-axial instability • Type A: Anterior atlantoaxial instability • Type B: Posterior atlantoaxial instability • Type C: Rotatory atlantoaxial instability 17-7-2015 Orthopedica Belgica Antwerpen Atlanto-axial instability • Type A: Anterior antlantoaxial instability – Flexion injury – Adults > 3.5 mm atlantodental distance – Children > 5 mm atlantodental distance – Due to rupture or bony avulsion of the transverse ligament 17-7-2015 Orthopedica Belgica Antwerpen Atlanto-axial instability • Type A: Anterior antlantoaxial instability 17-7-2015 Orthopedica Belgica Antwerpen Atlanto-axial instability • Type B : Posterior atlantoaxial instability – Probably hyperextension – The tectorial as well as the alar ligaments must be torn 17-7-2015 Orthopedica Belgica Antwerpen Atlanto-axial instability • Type B : Posterior atlantoaxial instability – Probably hyperextension – The tectorial as well as the alar ligaments must be torn 17-7-2015 Orthopedica Belgica Antwerpen Atlanto-axial instability • Type C : Rotatory atlantoaxial instability – Type I • Without anterior gliding – Type II • Atlantodental interval up to 5 mm – Type III • Atlantodental interval of > 5 mm 17-7-2015 Orthopedica Belgica Antwerpen Atlanto-axial instability • Type C : Rotatory atlantoaxial instability – Type I • Without anterior gliding 17-7-2015 Orthopedica Belgica Antwerpen Atlanto-axial instability • Type C : Rotatory atlantoaxial instability – Type II • Atlantodental interval up to 5 mm 17-7-2015 Orthopedica Belgica Antwerpen Atlanto-axial instability • Type C : Rotatory atlantoaxial instability – Type III • Atlantodental interval of > 5 mm 17-7-2015 Orthopedica Belgica Antwerpen Atlantoaxial sagittal instability learning points Preexisting or acute trauma of the transverse ligament CT scan and TC 99 scan for bony avulsion MRI for the direct visualisation of the rupture Transarticular fusion !!! Position and anomalies of the arteria vertebralis. 17-7-2015 Orthopedica Belgica Antwerpen Atlanto-axial instability • Possibility of tetraplegia after another accident > prevention surgery • Possibility of slow onset myelopathy due to repeated trauma to the cord. 17-7-2015 Orthopedica Belgica Antwerpen Type C : Rotatory atlantoaxial instability – Skull traction – Stiff collar or Halo vest for 6-8 weeks – Manipulation under anesthesia? – Anterior transoral release and rotation under traction > C1-C2 fusion 17-7-2015 Orthopedica Belgica Antwerpen Type C : Rotatory atlantoaxial instability learning points Closed reduction and immobilization if diagnosis is made early For late deformities : C1-C2 fusion Persistent RAAI is to be avoided in children because torticollis induce facial asymmetries during growth 17-7-2015 Orthopedica Belgica Antwerpen Upper cervical spine • • • • • Atlantooccipital dislocation Fractures of the occipital condyles Fractures of the ATLAS, Jefferson # Atlantoaxial instability, fixed rotatory subluxation Traumatic spondylolisthesis of the AXIS, Hangman’s # • Odontoïd fractures. 17-7-2015 Orthopedica Belgica Antwerpen Traumatic Spondylolisthesis Hangman’s Fracture • Type I – Stable undislocated. C2-C3 disc is intact and C2-C3 is stable ( 65%) • Type II – Unstable. The C2-C3 disc is torn and anteriorly displaced. • Type III – Type II injury with additional unilateral dislocation. 17-7-2015 Orthopedica Belgica Antwerpen Traumatic Spondylolisthesis Hangman’s Fracture 17-7-2015 Orthopedica Belgica Antwerpen Traumatic Spondylolisthesis Hangman’s Fracture 17-7-2015 Orthopedica Belgica Antwerpen Traumatic Spondylolisthesis Hangman’s Fracture learning points A hangman’s fracture will lead to enlargement of the spinal canal and is unlikely to cause a neurological injury In many cases, a hangman’s fracture will eventually lead to ankylosis or spontanneous fusion across the anterior part of the C2-C3 disc space 17-7-2015 Orthopedica Belgica Antwerpen Traumatic Spondylolisthesis Hangman’s Fracture surgical treatment rationale Type II lesions not willing to undergo halo vest or minerva cast Progressive subluxation of C2 on C3 17-7-2015 Orthopedica Belgica Antwerpen Traumatic Spondylolisthesis Hangman’s Fracture surgical treatment rationale Type III lesions can not be reduced closed because of the destroyed structures of C2-C3 and manipulation of the head does not have effect on C2-C3 Posterior open reduction of the facets is mandatory with posterior fusion using the anchorage screws as a direct repair 17-7-2015 Orthopedica Belgica Antwerpen Atypical hangman’s fracture • Spinal stenosis • Trough the posteror body of C2 ! • Surgical treatment after reduction to maintain stability 17-7-2015 Orthopedica Belgica Antwerpen Upper cervical spine • • • • • Atlantooccipital dislocation Fractures of the occipital condyles Fractures of the ATLAS, Jefferson # Atlantoaxial instability, fixed rotatory subluxation Traumatic spondylolisthesis of the AXIS, Hangman’s # • Odontoïd fractures. 17-7-2015 Orthopedica Belgica Antwerpen Odontoïd fractures Anderson and D’Alonzo • Type I – Tip of the dens • Type II – Fracture of the dens itself • Type III – Fracture of the dens with extension into the vertebral body 17-7-2015 Orthopedica Belgica Antwerpen Odontoïd fractures 17-7-2015 Orthopedica Belgica Antwerpen Roy Camille type II • HORIZONTAL • OBAV • OBAR 17-7-2015 Orthopedica Belgica Antwerpen Odontoïd fractures surgical treatment odontoïd fixation ( 2 screws) Unstable type II fractures OBAR fractures C2H5OH Difficult Halo or Minerva treatment 17-7-2015 Orthopedica Belgica Antwerpen Anterior screw fixation Type II fractures • 2 C-arms • No arthrodesis but slight advantage in mobility ! • Not in osteoporotic patiënts • Horizontal or OBAR 17-7-2015 Orthopedica Belgica Antwerpen All other type II fractures • • • • C1-C2 fusion Transarticular fusion ( + Gallie procedure ) Aspecially in the older patiënt. Occipito-cervical fusion. 17-7-2015 Orthopedica Belgica Antwerpen Entry points 17-7-2015 Orthopedica Belgica Antwerpen Gallie procedure 17-7-2015 Orthopedica Belgica Antwerpen Gallie 17-7-2015 Orthopedica Belgica Antwerpen Transarticular fixation 17-7-2015 Orthopedica Belgica Antwerpen Transarticular fixation 17-7-2015 Orthopedica Belgica Antwerpen Even simple procedures need expertise 17-7-2015 Orthopedica Belgica Antwerpen Thank YOU ! Thank 17-7-2015You Orthopedica Belgica Antwerpen