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Injuries of the Cervicocranium Injuries of the Cervicocranium
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Andrew C. Hecht, M.D. D. Hal Silcox III, M.D. Thomas E. Whitesides, Jr., M.D.
Fractures and dislocations from the occiput to the axis, the cervicocranium, are a treacherous yet interesting and important group of injuries that are relatively uncommon in clinical practice. They include occipital condyle fractures, occipitoatlantal dislocations, dislocations and subluxations of the atlantoaxial joint, fractures of the ring of the atlas, odontoid fractures, fractures of the arch of the axis, and lateral mass fractures. All are similar in that the basic mechanisms of these injuries have been relatively well delineated and many share a common mechanism of injury. They are vastly different, however, in both their potential for causing neurologic injury and their optimal method of treatment. The true incidence of these injuries is difcult to determine and is obscured by their often devastating nature. Most cervicocranial injuries are the result of automobile accidents or falls.16 The predominant mechanism of injury is usually forced exion or extension secondary to unrestrained deceleration forces, causing anterior displacement of the occiput and upper two cervical segments in relation to the more caudal segments. The prognosis for patients who sustain these injuries has been highlighted by Alker and colleagues.1 In their analysis of 312 victims of fatal trafc accidents, 24.4% had evidence of injury to the cervical spine. Of this group, 93% involved injuries from the occiput to the C2 vertebra. The work of Bohlman further underscores the perilous nature of these injuries.2 In his analysis of 300 patients who sustained acute cervical spine injuries, it was noted that the correct diagnosis was missed in one third of the patients. Of these, 30% involved the occiput, atlas, and axis. In those who survived, occipitoatlantal dislocations occurred in only 0.67%, and atlantoaxial injuries were sustained by only 23%. The main factor responsible for missed diagnoses was related mainly to error or lack of suspicion on the part of the physician because of associated problems, including the presence of a head injury, decreased level of consciousness,
alcohol intoxication, multiple injuries, and inadequate radiographs.
ANATOMY
zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz As a result of the complex anatomic and kinematic relationships of the occipitoatlantoaxial complex, knowledge of regional anatomy is essential to those dealing with patients who have injuries in this region (Figs. 281 through 283). The skull and atlas are bound together by the paired occipitoatlantal joints laterally and by the anterior and posterior occipitoatlantal membrane. Each occipitoatlantal joint is formed by the caudally convex occipital condyle, along with the reciprocally concave superior articular facet of the atlas. The articular capsules are thin, loose ligaments that blend laterally with ligaments that connect the transverse processes of the atlas with the jugular processes of the skull; these capsular ligaments provide very little stability. The anterior occipitoatlantal membrane is a structural extension of the anterior longitudinal ligament that connects the forward rim of the foramen magnum to the arch of C1, homologous to the ligamentum avum, and unites the posterior rim of the foramen magnum to the posterior arch of C1. The tectorial membrane, a continuation of the posterior longitudinal ligament, runs from the dorsal surface of the odontoid process to the ventral surface of the foramen magnum. It is thought to be the prime ligament responsible for stability of the occipitoatlantal articulation.42 The atlas is a bony ring consisting of two lateral masses connected by an anterior and a posterior arch. The superior articular surfaces face upward and medially to receive the occipital condyles of the skull. The inferior articulating surfaces face downward and slightly medially and rotate on the convex slope of the shouldering facets of the axis. In addition, they are cup shaped to accommodate
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Opisthion Basion Apical (dental) ligament Anterior atlanto-occipital membrane Print Graphic Anterior arch of atlas Transverse (atlantal) ligament Lamina of atlas Dens Presentation Body of axis Anterior longitudinal ligament Lamina of axis Posterior longitudinal ligament Posterior atlanto-occipital membrane Tectorial membrane
FIGURE 281. Sagittal anatomy of the cervicocranium.
the convex surfaces of the occipital condyles. The posterior arch consists of a modied lamina that is more round than at in cross section and a posterior tubercle that gives rise to the suboccipital muscles. The anterior arch forms a short bar between the lateral masses and has a tubercle on which the longus colli muscles insert. The atlantoaxial articulation comprises three joints: the paired lateral atlantoaxial facet joints and the central atlantoaxial joint. The lateral atlantoaxial facet joints are formed by the corresponding superior and inferior facet joints, facets of the C1 and C2 vertebrae. They are covered by thin, loose capsular ligaments that accommodate the large amount of rotation at this level. The central atlantoaxial joint is the articulation of the odontoid process with the atlas and is stabilized by the transverse atlantal ligament (cruciform ligament). This ligament takes origin from two internal tubercles on the posterior aspect of the anterior arch of C1 (see Fig. 283). Its function is to hold the dens against the anterior arch of the atlas and allow rotation. The paired alar ligaments are alar expansions of the transverse ligament that attach to tubercles on the lateral rim of the foramen magnum; they provide important, additional rotational and translational stability to the occipitoatlantal articulation. The
Tectorial membrane (divided)
apical dental ligament runs from the tip of the odontoid process to the ventral surface of the foramen magnum and is only a minor stabilizer of the craniocervical junction.28, 32 The axis provides a bearing surface on which the atlas may rotate. It possesses a vertically projecting odontoid process that, together with the transverse atlantal ligaments, serves as a pivotal restraint against horizontal displacement of the atlas. The apex of the odontoid is slightly pointed and serves as the origin for the paired alar ligaments and solitary apical dental ligament. The superior articulating surfaces of the axis are convex and directed slightly laterally to receive the direct thrust of the lateral masses of the atlas. The inferior articulating surfaces are typical of those of the more caudal cervical vertebrae. The pedicles of the axis project 20 superiorly and 33 medially when tracing the course of the pedicle in a posterior-to-anterior direction.273 The pedicles dimensions average 7 to 8 mm in height and width, with slight variations between males and females.273 The vertebral artery begins to angulate laterally at the base of the C2 pedicle and then courses through the foramen transversarium of C2 and C1 only to then move medially and superiorly into the foramen magnum.
Apical (dental) ligament
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Alar (dental) ligament
FIGURE 282. Coronal anatomy of the cervicocranium.
Transverse (atlantal) ligament Presentation Body of axis
Accessory ligaments
Tectorial membrane (divided)
CHAPTER 28 Injuries of the Cervicocranium
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Spinous process of axis Transverse (atlantal) ligament Print Graphic Superior articular facet of atlas
extension views should be performed to rule out any residual instability. Only three cases of surgical intervention have been reported. The indications included brain stem compression, vertebral artery injury, and concomitant suboccipital injury.8, 18 Any ndings of instability of the occipitoatlantal joint will require denitive treatment with occiputC1 arthrodesis.
Presentation Anterior arch of atlas
Odontoid
zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz because of the strength of the supporting ligaments, and reports of survival are even more unusual.27, 30 Although rst reported by Blackwood in 1908, the true incidence is unknown and obscured by the devastating, usually fatal nature of these injuries when they occur.20 Moreover, the diagnosis is often subtle and may easily be overlooked on routine radiographs. The dislocations are thought to represent approximately 0.67% to 1.0% of all acute cervical spine injuries, and Bucholz and Burkhead noted this injury in 8% of victims of fatal motor vehicle accidents.21, 22, 39 Craniocervical dislocations have been classied into three types, depending on which direction the occiput is displaced in relation to the atlas.19, 26, 35 Although anterior, posterior, and longitudinal dislocations have been reported, by far the most common is anterior dislocation, which occurs in nearly all reported cases in the literature.33, 39 Because of anatomic variations, this injury is thought to be roughly twice as common in children as in adults.22, 28 This difference in incidence may be a result of the fact that the occipital condyles in children are smaller and the plane of the occipitoatlantal joint is relatively horizontal in an immature skeleton when compared with the steep inclination that develops with aging.22, 23, 27, 28 Anterior occipitoatlantal dislocations, which were rst described in postmortem specimens by Kissinger36 and Malgaigne,37 are probably the result of a hyperextension and distraction mechanism such as that frequently seen in trafc accidents. This mechanism is conrmed by their frequent association with submental lacerations, mandibular fractures, and posterior pharyngeal wall laceration.22, 23, 25, 28, 30, 32, 38, 45 Also supporting this theory is Wernes classic description of the anatomy of this region.42 His work demonstrated that occipitoatlantal exion is limited by skeletal contact between the foramen magnum and the apex of the odontoid process. Similarly, hyperextension is limited by the tectorial membrane and by contact between the posterior arch of the atlas and the occiput. Lateral tilting is controlled by the alar ligaments. By carefully dividing the tectorial membrane and the alar ligaments, Werne was able to show that these two structures are the primary stabilizers of this inherently unstable joint and that division of these structures allows for forward dislocation of the occiput on the axis.42 Although frequently overlooked, radiographic diagnosis of the injury is usually made from lateral cervical spine radiographs taken in neutral, exion, and extension. Soft tissue planes may be enlarged (often >7 mm at the occipital-cervical junction). Any soft tissue swelling in
FIGURE 283. The atlantoaxial articulation.
OCCIPITAL CONDYLE FRACTURES
zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz Fractures of the occipital condyle are rarely reported and usually occur in conjunction with other fractures of the cervical spine, most commonly C1 fractures. As with all upper cervical spine fractures, injuries in this region are associated with a high rate of mortality. In patients who manage to survive these injuries, the incidence of these fractures remains unknown because such fractures go undiagnosed in many patients secondary to vague complaints of neck pain. Evaluation of the craniovertebral junction by computed tomography (CT) has enabled more subtle detection. Bloom and colleagues reported that 9 of 55 patients (16.4%) had occipital condyle fractures detected on CT scans but had nondiagnostic plain cervical radiographs.8 Important physical ndings suggestive of an occult injury are paravertebral swelling, impaired skull mobility, torticollis, and cranial nerve symptoms (nerves IX to XII).913, 15, 17 These nerve injuries can occur acutely or in a delayed fashion. Occipital condyle fractures can be divided into three injury patterns, depending on whether the injury was produced by axial compression, a direct blow, or shear or lateral bending (or both). These fractures are commonly associated with cranial nerve injuries.7, 14 The Anderson and Montesano classication of occipital condyle fractures is based on the mechanism of injury. Type I injuries are impaction fractures of the condyle secondary to an axial load (Fig. 284). Type II injuries are basilar skull fractures that extend through the condyle and communicate with the foramen magnum. These injuries are due to a direct blow to the occipital region. Type III injuries are avulsion fractures of the condyle caused by tension placed on the alar ligaments secondary to shear, lateral bending, rotational forces, or a combination of these mechanisms. The key to treating these injuries is to maintain a high degree of suspicion because of the subtlety of their signs and symptoms. Treatment of these injuries is based on the degree of associated occipitoatlantal instability. Type I and type II fractures are stable injuries and are therefore best treated with a rigid cervical orthosis or halo vest for 3 months. Type III injuries represent a potentially unstable injury that at the very least requires 3 months of halo vest immobilization, but because of the rarity of this fracture, surgical indications are not well dened. After 3 months of immobilization for all three fracture types, exion-
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this area is a signicant nding and warrants further evaluation. Alterations in the normal cervicocranial prevertebral soft tissue contour because of hemorrhage into the retropharyngeal fascial space from subtle fractures or ligamentous injuries should prompt further assessment of the cervicocranium by CT. Cervicocranial CT performed to evaluate an abnormal cervicocranial prevertebral soft tissue contour has yielded a 16% positive injury rate, approximately three times the rate of acute cervical spine injuries reported in the literature. The dens-basion relationship and the Powers ratio are useful in making the diagnosis. In a normal cervical spine with the head in neutral, the tip of the odontoid is in vertical alignment with the basion.16, 46, 118, 143, 175 The normal distance between these two points in adults is 4 to 5 mm, and any increase in this distance is considered signicant.43, 44 In children, however, this distance may approach 10 mm.43 The maximal amount of horizontal translation between the odontoid tip and the basion on
exion and extension radiographs is 1 mm.40, 42, 44 Anything greater than 1 mm is thought to represent instability. Because these relationships are somewhat dependent on the position of the skull, Powers and co-workers in 1979 described a method suitable for pure discrimination of anterior occipitoatlantal dislocations.39 In their technique, two distances are measured between four points: the distance between the basion and the posterior arch of C1 is measured in relation to the distance between the opisthion and the anterior arch of C1. This distance is expressed as a ratio that, if greater than 1, establishes the radiographic diagnosis of anterior occipitoatlantal dislocation (Fig. 285). Ratios less than 1 are normal except in posterior occipitoatlantal dislocations, associated fractures of the odontoid process or ring of C1, and congenital abnormalities of the foramen magnum.23, 39 The ratio does not vary with skull exion or extension and is not affected by magnication. If difculties are encountered in interpreting the relationships on a lateral radiograph, these
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FIGURE 284. A, A lateral cervical spine radiograph shows subluxation of C5C6 in a patient with neck pain who was involved in a motor vehicle accident. B, An axial computed tomographic (CT) scan shows a lateral mass fracture of C5. The patients inability to speak normally was initially mistaken as a tongue bite injury. C, In reality, he had a hypoglossal nerve palsy caused by the displaced occipital condyle fracture (OC) as seen on the axial CT scan.
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Opisthion Basion
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B C
Presentation
Anterior arch of atlas
Posterior arch of atlas
FIGURE 285. Powers ratio. If BC/OA is greater than 1, an anterior occipitoatlantal dislocation exists. Ratios less than 1 are normal except in posterior dislocations, associated fractures of the odontoid process or ring of the atlas, and congenital anomalies of the foramen magnum. Abbreviations: B, basion; C, posterior arch of C1; O, opisthion; A, anterior arch of C1.
relationships may be established easily on a lateral tomogram or sagittal reconstruction obtained by a CT scan of the area (Fig. 286). Associated injuries are noted frequently in survivors. The most susceptible areas of neurologic injury are the 10
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caudal pairs of cranial nerves (with the abducens nerve being most frequently injured), the brain stem, the proximal portion of the spinal cord, and the upper three cervical nerves.25, 28, 30, 32, 38, 39 Fatalities are usually caused by transection of the medulla oblongata or the spinomedullary junction and are due to respiratory compromise secondary to compression or injury to the respiratory centers in the lower brain stem. The clinical manifestations may vary from mild to catastrophic, depending on the nature and degree of injury. Peripheral motor defects are relatively common and may often demonstrate improvement. Neurologic lesions secondary to central cranial nerve lesions are frequent as well, and most appear to be permanent.32 In addition, injuries to the vertebral artery are occasionally seen.29, 31, 45 Lesions include vasospasm, intimal tears, thrombosis, dissection, and pseudoaneurysmal dilatation. Vertebral artery injuries can result in a neurologic decit that is acute or delayed from minutes to days. They can appear even with normal-appearing radiographs. Carotid artery injuries have also been reported secondary to compression by the malrotated lateral mass of C1. Typical clinical features of a vertebral artery injury include altered consciousness, nystagmus, ataxia, diplopia, and dysarthria. The diagnosis is made by magnetic resonance angiograms or conventional arteriography.24 Initial management of patients with these injuries should focus on respiratory support and stabilization of the cervical spine, with early halo trunk immobilization or 1 to 2 kg of skeletal traction to avoid distraction of the occipitoatlantal joint and further neurologic injury. Denitive treatment is not universally agreed on. Most authors would advocate surgical stabilization28, 31, 32, 38, 39, 45 in preference to prolonged immobilization.39, 45 Because of the potential dangers of persistent instability at the occipitoatlantal junction secondary to severe ligamentous disruption, cervical stabilization by posterior spinal fusion from the occiput to the upper cervical spine should be accomplished with the use of internal xation (i.e., occipitocervical plates) as soon after the injury as the patients overall medical and neurologic condition permits. Important determinants of the type of xation include the presence or absence of posterior arch fractures, which may preclude the use of these structures for fusion. Vieweg and Schultheiss performed a retrospective review of upper cervical spine injuries treated with halo vest immobilization. They identied 2 patients out of 682 with atlantooccipital ligament injuries, and both injuries failed to unite or heal.41 As with most ligamentous injuries in the cervical spine, nonoperative treatment rarely results in stability.
ATLAS FRACTURES
zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz First described by Cooper in 1823, atlantal fractures are usually the result of falls or automobile accidents.47, 53, 68 Jefferson subsequently described their mechanism of injury, reviewed the world literature at the time, and proposed a classication system.56 Fractures of the ring of the atlas, unlike most other fractures of the cervical spine,
FIGURE 286. The Powers ratio shows a normal relationship with the basion (B), opisthion (O), anterior arch of C1 (A), and posterior arch of C1 (C). The BC/OA ratio should be approximately 0.77 in the normal population. A value greater than 1.15 indicates anterior dislocation. (From Levine, A.M; Edwards, C.C. Clin Orthop 239:5368, 1989.)
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Posterior arch fracture
Burst fracture
Anterior arch fracture Print Graphic
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Transverse process fracture

FIGURE 287. Classication of fractures of the atlas.
Comminuted, or lateral mass, fracture
are rarely associated with neurologic decit unless they are seen in association with an odontoid fracture or rupture of the transverse atlantal ligament.48 As a group, they account for 2% to 13% of all cervical spine fractures and approximately 1.3% of all spine fractures.48, 52, 69 Jefferson, whose name is usually associated with the bursting type of atlantal fracture, actually proposed an anatomic classication system in 1920 that included burst fractures, posterior arch fractures, anterior arch fractures, and lateral mass and transverse process fractures (Fig. 28-7).56 Before the advent of CT, the exact incidence of these injuries could only be estimated, and it was thought that posterior arch fractures made up the largest group.60, 69 Since the introduction of CT scanning for the routine evaluation of most cervical spine injuries, concepts of fracture classication and incidence have changed. Segal and associates in 1987 expanded Jeffersons original
fracture classication to include six subtypes useful in predicting patient outcome.68 Most recently, a seventh subtype has been added by Levine and Edwards14: 1. Burst fractures (33%) are usually the result of an axial loading force transmitted through the occipital condyles to the superior articulations of C1; these structures are radically forced apart, and either three- or four-part fractures are produced.65, 67 They are the most common and least likely to cause neurologic injury (Fig. 288). 2. Posterior arch fractures (28%) are generally the result of hyperextension injuries and are often associated with odontoid fractures or traumatic spondylolisthesis of the axis60, 68 (Fig. 289). 3. Comminuted fractures (22%) are usually the result of combined axial compression and lateral exion forces.
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FIGURE 288. A patient sustained a Jefferson fracture while diving into a pool. A, An anteroposterior tomogram demonstrates splaying of the lateral mass of C1. B, A computed tomographic scan in the plane of C1 demonstrates the four fractures of the ring, two anterior and two posterior (arrows). (A, B, From Levine, A.M.; Edwards, C.C. Orthop Clin North Am 17:3144, 1986.)
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fractures of the odontoid process, traumatic spondylolisthesis of C2, or an occipital condyle fracture.48, 61 Bursting atlantal fractures have been subdivided by Spence and colleagues into stable and unstable types based on radiographic assessment of the integrity of the transverse ligament.72 In their classic study, the atlantoaxial offset was measured in experimentally produced burst fractures. Burst fractures in which the transverse ligament remained intact produced an atlantoaxial offset of less than 5.7 mm, whereas those associated with rupture of the transverse ligament produced an atlantoaxial offset greater than 6.9 mm (Figs. 2812 and 2813). The latter injuries are somewhat less common, and the usual case is that of a stable burst fracture with an intact transverse ligament. It should be appreciated that simple rotation and lateral bending of the normal cervical spine may produce up to 4 mm of lateral offset on the open-mouth odontoid view at the C1C2 articulation.53, 69 Congenital anomalies should also be considered because they may produce 1 to 2 mm of lateral offset.51 The radiographic diagnosis of these injuries has been greatly enhanced in recent years with the advent of CT scanning. Plain radiographs are also helpful in their evaluation. Aside from routine plain lm evaluation, exion-extension lateral and open-mouth odontoid views
FIGURE 289. Lateral cervical spine radiograph demonstrating an isolated posterior arch fracture (arrow). (From Levine, A.M.; Edwards, C.C. Orthop Clin North Am 17:3144, 1986.)
4.
5. 6. 7.
They generally include an avulsion fracture of the transverse ligament in addition to ipsilateral anterior and posterior arch fractures. These fractures are the most likely to result in nonunion and a poor functional outcome. Anterior arch fractures are thought to be caused by hyperextension with the atlantoaxial facet xed and the anterior arch of C1 abutting the dens57, 72 (Fig. 2810), with subsequent avulsion of the fragment. Lateral mass fractures are generally the result of combined axial loading and lateral compression (Fig. 2811). Transverse process fractures may be unilateral or bilateral as a result of avulsion or lateral bending. Inferior tubercle avulsion fractures are thought to be an avulsion injury of the longus colli muscle caused by hyperextension of the neck.
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Levine and Edwards59 classied atlas fractures according to the mechanism of injury and head position at the time of injury: bilateral fractures of the posterior arch caused by hyperextension with an axial load, unilateral lateral mass fracture caused by lateral bending and an axial load, and a Jefferson (burst) fracture caused by a straight axial load. Posterior arch fractures have a greater than 50% chance of concomitant fracture, usually type II or type III
FIGURE 2810. Lateral radiograph showing a horizontal fracture of the anterior arch of C1 (arrow). (From Levine, A.M; Edwards, C.C. Clin Orthop 239:5368, 1989.)
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FIGURE 2811. Lateral mass fracture of the atlas. A, An open-mouth view shows no displacement of one lateral mass and marked displacement of the opposite side. B, A computed tomographic scan through the ring of the atlas shows the fractures (arrows) anterior and posterior to the lateral mass on one side, with no fractures in the posterior arch on the second side. (A, B, From Levine, A.M; Edwards, C.C. Clin Orthop 239:5368, 1989.)
should be regularly obtained. Other cervical spine injuries, particularly odontoid fractures and traumatic spondylolisthesis of the axis, should be carefully sought during plain lm evaluation because they are frequently associated injuries. As noted previously, the open-mouth odontoid view should be reviewed for atlantoaxial overhang to aid in assessing the integrity of the transverse ligament. Lateral exion and extension radiographs should be reviewed for specic evaluation of the atlantodental interval, which is normally less than 3 mm in adults and less than 5 mm in children49, 52, 73 (Fig. 2814). Injuries associated with atlas fractures most commonly include neurapraxia of the suboccipital and greater occipital nerves as they course around the posterior arch of C1, cranial nerve palsies of the lower six pairs of cranial nerves, and injuries to the vertebral artery or vein as they cross the posterior atlantal arch.50, 51, 5457 Occipital nerve injuries may cause neurologic symptoms in the suboccipital region, such as scalp dysesthesias. However, vertebral artery injuries may cause symptoms of basilar artery insufciency, including vertigo, dizziness, blurred vision, and nystagmus.
These fractures tend to decompress the spinal canal, and thus rarely produce neurologic symptoms. Most isolated injuries will heal with conservative nonoperative treatment.62 Inferior tubercle avulsion fractures will heal with simple orthotic immobilization. Simple, uncomplicated arch fractures, minimally displaced burst and lateral mass fractures (combined atlantoaxial offset <5.7 mm), and transverse process fractures can be reliably managed with halo or semirigid collar immobilization until union occurs.60 Lee and co-workers performed a retrospective review to evaluate the use of a rigid cervical collar alone as treatment of stable Jefferson fractures. All patients in their series healed and showed no signs of instability at 12 weeks.58 According to Levine and Edwards,59 atlas fractures that show 2 to 7 mm of combined lateral mass offset on the open-mouth anteroposterior view can be treated with a halo and vest for 3 months. Fractures with an offset greater than 7 mm should rst be treated with 4 to 6 weeks of axial traction to maintain reduction and allow preliminary bone healing, followed by 1 to 2 months of halo vest wear.
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Presentation Presentation X Y
FIGURE 2813. Admission open-mouth view demonstrating the method for determining total lateral translation. (From Levine, A.M.; Edwards, C.C. Orthop Clin North Am 17:3144, 1986.)
FIGURE 2812. Atlantoaxial offset. If X + Y is greater than 6.9 mm, transverse atlantal ligament rupture is implied. (Redrawn from White, A.A.; et al. Clin Orthop 109:85, 1975.)
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ADI
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prolonged bedrest and traction, as well as the need for halo vest immobilization. The downside to C1C2 fusion is the sacrice of 50% of normal cervical rotation. Occipitocervical fusion is also an option for the treatment of massively unstable atlas fractures with concomitant fractures of the upper cervical spine. However, this type of treatment requires sacrice of occiputC1 motion, which constitutes 50% of cervical exionextension, as well as sacrice of C1C2 motion, which is responsible for 50% of normal cervical rotation.66, 74 We would strongly recommend traction or transarticular screw xation followed by immobilization, as outlined previously, before sacricing occiputC2 motion. Regardless of treatment, many patients with fractures of the atlas have long-term clinical complaints of scalp dysesthesias, neck pain, and decreased range of motion.59, 68 The incidence of these long-term complications increases with involvement of the lateral masses, as well as with other injuries to the occiput or C1C2 articulation.71 Other reported complications include nonunion.68
FIGURE 2814. Atlantodental interval (ADI). If the ADI is greater than 3 mm on exion and extension radiographs, rupture of the transverse ligament is implied. If the ADI is larger than 5 mm, the accessory ligaments are also functionally incompetent.
ATLANTOAXIAL INSTABILITY
zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz Although atlantoaxial dislocations and subluxations are relatively common in the cervical spines of patients with rheumatoid arthritis,77, 78 traumatic atlantoaxial subluxations and dislocations secondary to rupture of the transverse ligament are relatively rare.79 Even rarer are dislocations without evidence of spinal cord injury because these injuries are usually fatal.81, 88, 89, 99 They differ from other injuries of the upper cervical spine in that they most frequently occur in an older age group than do more traumatic cervical spine injuries.91, 92 Post-traumatic C1C2 instability is generally seen in the fth decade of life and beyond, whereas most other injuries are seen during the third decade. As with other injuries of the upper cervical spine, these injuries usually result from automobile accidents or falls, and the mechanism of injury is most frequently forced exion of the neck.79, 91, 92 The stability of the atlantoaxial articulation depends on the ligamentous integrity of this area. Anterior stability of the atlantoaxial joint is maintained primarily by the transverse ligament, with the paired alar ligaments acting as secondary stabilizers (see Fig. 282). Other ligaments that act to a much lesser degree as tertiary stabilizers are the apical ligament of the odontoid, the cruciate and accessory atlantoaxial ligaments, and the capsular ligaments of the facet joints.82 Posterior stability depends on mechanical abutment of the anterior arch of the ring of the atlas against the odontoid process. Fielding and associates noted that after rupture of the transverse ligament, the secondary and tertiary stabilizers are usually inadequate to prevent further signicant displacement of the atlantoaxial complex when a subsequent force similar to the one that resulted in rupture of the transverse ligament is applied.82 Although this injury is usually fatal, patients occasionally survive and may have a clinical picture ranging from a dense, mixed neurologic decit to only severe upper neck pain.80, 85, 91, 92 Radiographic diagnosis of patients with suspected C1C2 instability may be difcult and mislead-
After 3 months of immobilization, stability of the atlantoaxial articulation should be veried with lateral exionextension lms, and any signicant instability (atlantodental interval >5 mm in adults, >4 mm in children) should then be treated with posterior C1C2 fusion. Levine and Edwards did not nd any instability in their patient group with the use of this treatment algorithm; furthermore, other authors who have treated these injuries nonoperatively have noted an extraordinarily low incidence of problems associated with late C1C2 instability.41, 57, 60, 64, 68, 70, 72 This low incidence is most likely a result of the fact that portions of facet capsules and alar ligaments may remain intact.60, 64 Previous cadaveric studies found that the atlantodental interval increases to approximately 5 mm when the transverse ligament is transected alone and the alar ligaments, apical ligament, and facet capsules are left intact.82 The transverse ligament tear that occurs with atlas fractures is due to spreading of the lateral masses secondary to axial compression and is different from a tear of the ligament secondary to a hyperexion injury, which is more unstable because it includes tears in the accessory supporting structures (alar and apical ligaments, facet capsule). An alternative to treatment of massively unstable atlas fractures (lateral mass offset >7 mm) is that of internal xation/fusion of C1C2 after the fracture is reduced in traction. Transarticular screws can be used to secure the C1C2 articulation in the appropriate position without requiring an intact ring of C1 as is necessary with older posterior wiring techniques.63, 241, 245 Furthermore, transarticular screws can aid in the treatment of patients with concomitant odontoid fractures or traumatic spondylolisthesis of C2.241 This technique, though technically demanding, is attractive because it can negate the need for
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ing because of the unfamiliar anatomy of this region and also because if the radiograph is made with the neck in slight extension, the spatial relationships of the C1C2 articulation may appear relatively normal.79 Routine radiographic evaluation should consist of open-mouth odontoid, anteroposterior, lateral, and oblique views of the cervical spine. In an awake, neurologically intact patient with neck pain, carefully supervised exion-extension radiographs with constant neurologic monitoring are indicated to assess the atlantodental interval. A lack of apparent instability may be caused by protective paraspinous muscle spasm, and repeat radiographs should be obtained after resolution of the muscle spasm. In patients with neurologic decits, a myelogram and CT scan are usually helpful. Flexion-extension radiographs in a patient with a swollen cord and neurologic decit are contraindicated because of the potential for further neurologic injury. Fielding and others noted that up to 3 mm of anterior displacement of C1 on C2, as measured by the atlantodental interval, implies that the transverse ligament is intact. If the displacement is 3 to 5 mm, the transverse ligament is ruptured, and if the displacement is greater than 5 mm, the transverse ligament and accessory ligaments are probably ruptured and decient82, 86, 90, 93, 94, 97, 98 (Fig. 2815; see also Fig. 2814). Traumatic overdistraction between C1 and C2 may
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occur when all the ligaments connecting C2 to the skull are ruptured and may be manifested when an attempt is made to reduce C1C2 subluxation by traction. A recent case report discussed a patient with traumatic anterior atlantoaxial dislocation in whom atlantoaxial vertical dissociation developed after Gardner-halo skull traction with 4.02 lb (1.5 kg). Five pounds of skeletal traction was associated with marked neurologic deterioration from unanticipated longitudinal instability. Identication of patients who are susceptible to this complication is difcult. In this case, avoiding spinal traction might have prevented it. Several reports have suggested that vertical dissociation may occur in C1C2 anterior dislocation treated by spinal traction and that other forms of reduction must be used to treat these pathologies and avoid this potentially fatal complication.75, 95 Atlantoaxial instability can be the result of a purely ligamentous injury or an avulsion fracture, but in either case, no effective nonoperative method is available to reliably reestablish the stability of the atlantoaxial articulation. Most authors agree that nonoperative management is not indicated and that reduction followed by posterior fusion is the treatment of choice.79, 82, 83, 91, 92 The timing of surgery is somewhat controversial, however. Delaying fusion for several days seems reasonable to allow cord edema to subside and enable the patients neurologic condition to stabilize without greatly enhancing the risk of prolonged recumbency. Because axial rotation is the major motion that occurs at the C1C2 articulation, a fusion that resists this type of motion is most appropriate. Biomechanical studies have compared the Brooks-type fusion76 with that of Gallie wiring, Halifax clamps, and Magerls transarticular screw technique.87, 240 One study found that rotational stability was greatest with the transarticular screw and Brooks fusion techniques and that the strongest overall xation was achieved with the transarticular screw.240 Other authors, however, believe that because the purpose of the surgical construct should be to reduce and prevent further anterior translation of C1 on C2, transarticular screws (see Fig. 2830) or a Gallie wiring technique should be considered for the reason that anterior translation is best prevented with these two techniques.84, 87, 91, 92, 240 If a patient has a concurrent injury to the upper cervical spine that is adequately treated by immobilization (e.g., a ring fracture of C1 or traumatic spondylolisthesis of the axis), nonoperative treatment until healing has occurred, followed by posterior C1C2 fusion, is a reasonable alternative. However, transarticular screw technique allows for immediate surgical stabilization and eliminates the time necessary to heal the posterior element fractures of C1 or C2. However, the screw xation without supplemental wire xation needs to be augmented with rigid cervical immobilization, potentially halo xation.
ATLANTOAXIAL ROTATORY SUBLUXATIONS AND DISLOCATIONS

FIGURE 2815. Lateral exion radiograph showing an atlantodental interval of 12 mm, which is diagnostic of complete rupture of the transverse ligament and the alar and apical ligaments as well as disruption of some bers of the C1C2 joint capsule. (From Levine, A.M; Edwards, C.C. Clin Orthop 239:5368, 1989.)
zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz Rotatory injuries of the atlantoaxial joint, rst described by Corner in 1907, include a rare spectrum of lesions ranging from rotatory xation within the normal range of C1C2
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FIGURE 2816. The atlantoaxial joint in neutral position (A) and on rotation to the right (B). With rotation, the anteroposterior view demonstrates (1) an apparent approximation of the left atlantal articular mass to the odontoid, (2) an increase in width of the left atlantal articular mass with decreased width of the right atlantal articular mass, and (3) a widened left and a narrowed right atlantoaxial joint because of the slope of these joints, as is evident on a lateral view. (A, B, Redrawn from Wortzman, G. Radiology 90:479487, 1960.)
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motion to frank rotatory atlantoaxial dislocation.100 The signicance of these injuries lies in the fact that with an intact transverse ligament, complete bilateral dislocation of the articular processes can occur at approximately 65 of atlantoaxial rotation with signicant narrowing of the neural canal and subsequent potential damage to the spinal cord.101 With deciency of the transverse ligament, complete unilateral dislocation can occur at approximately 45 with similar consequences. In addition, the vertebral arteries can be compromised by excessive rotation with resultant brain stem or cerebellar infarction and death.112, 114 Levine and Edwards pointed out that rotatory dislocations at the C1C2 articulation rarely occur in adults and are signicantly different from those in children.103, 104, 111 Subluxations in children usually are related to a viral illness, are almost always self-limited, and generally resolve with conservative treatment. The injury seen in adults is a more severe form of subluxation or dislocation and usually is related to vehicular trauma. Additionally, the adult form is frequently associated with a fracture of a portion of one or both lateral masses and is due to an injury mechanism of exion and rotation. Because of the rarity of the injury, the infrequency of neurologic involvement, and the difculty in obtaining adequate radiographs, the diagnosis may be difcult to make and is usually delayed. With minimal amounts of subluxation, patients may complain of only neck pain. With more severe degrees of subluxation or dislocation, torticollis may be noted and the patient may present with the typical cock robin posture with the head tilted toward one side and rotated toward the other and in slight exion. The anterior arch of the atlas and the step-off at C1C2 may be palpable orally. Plagiocephaly is commonly seen in younger patients with late symptoms.103 Neuro-
logic involvement is rare but may be catastrophic as a result of compromise of the neural canal at the medullocervical junction.103, 110 The diagnosis, therefore, requires a certain degree of clinical suspicion based on the patients history, symptoms, and physical examination. It should always be considered in the evaluation of patients with cervical spine trauma and secondary angulatory deformities of the neck. The mechanism of injury is thought to be a exion-extension type of injury or a relatively minor blow to the head.116 Jacobson and Adler in 1956 and Fiorani-Gallotta and Luzzatti in 1957 were the rst to describe the radiologic manifestations of these injuries, which were also seen in cases of torticollis.105, 108 Wortzman and Dewar suggested a dynamic method of differentiating rotatory xation from torticollis by using plain radiographs, and Fielding and co-workers suggested cineradiography and CT as additional tools for evaluation of these injuries.103, 104, 116 On an open-mouth odontoid radiograph with the atlantoaxial joint in neutral rotation, the articular masses of the atlas and axis are symmetrically located with the odontoid midway between the lateral masses of the atlas (Fig. 2816). With rotation to the right, the left lateral mass of C1 travels forward and to the right with an apparent approximation of the left atlantal articular mass to the odontoid process. Associated with forward movement of the left articular mass and posterior movement of the right articular mass, the leftward lateral mass increases in width because of a larger radiographic shadow, whereas the right lateral mass demonstrates a diminished width because of a narrower radiographic shadow. The facet joint on the left appears widened, and the right facet joint appears narrowed because of the corresponding slope of these joints. This abnormality produces the so-called wink
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be considered if it is available. Alternatively, a CT scan through the C1C2 articulation with the patients head rotated to the right and to the left approximately 15 will conrm or disprove the presence or absence of rotatory xation at the atlantoaxial joint. Most commonly, acute or chronic traumatic injuries are in a xed position. Currently, CT with two- or three-dimensional reconstruction gives the most accurate delineation of the injury. Flexionextension lateral radiographs are also essential to inspect the integrity of the transverse atlantal ligament. Fielding and associates in 1977 rst coined the term rotatory xation to describe this injury because rotatory xation of the atlas on the axis may occur with subluxation or dislocation or when the relative positions of the atlas and axis are still within the normal range of atlantoaxial rotation.102, 103 Fielding and associates classication, which does not include frank dislocations, divides these injuries into four types based on their radiographic appearance (Fig. 2818). Levine and Edwards added to this classication by describing the extreme injury pattern of rotatory dislocation.110 Type I rotatory xation, the most common, was seen in 47% of Fielding and associates series. Rotatory xation without anterior displacement at the atlas was noted, and the atlantodental interval was less than 3 mm because the transverse ligament was intact and acting as a pivot. This type of xation is thought to occur within the normal range of motion at the C1C2 articulation (Fig. 2819). Type II rotatory xation occurred with 3- to 5-mm anterior displacement of the atlas. It was the second most common injury (30%) and was associated with deciency of the transverse ligament and unilateral anterior displacement of one lateral mass of the atlas when the opposite intact joint acted as a pivot. The amount of abnormal anterior displacement of the atlas from the axis and the amount of xed rotation were in excess of the normal maximal rotation of the atlantoaxial joint. Type III rotatory xation was seen with greater than 5-mm anterior displacement of the atlas on the axis. It was observed in patients with associated deciency of the transverse ligament and the secondary stabilizers. Both lateral masses of the atlas were subluxated anteriorly, one more than the other, thus producing the rotated position.
FIGURE 2817. Open-mouth radiograph showing a wink sign in which the lateral mass of C1 overlaps the lateral mass of C2 on the affected side (arrow). (From Levine, A.M.; Edwards, C.C. Clin Orthop 239:5368, 1969.)
sign110 (Fig. 2817). When plain cervical spine radiographs demonstrate evidence of a rotational anomaly at the atlantoaxial joint, additional radiographic investigation is indicated and should consist of open-mouth odontoid views with the patients head rotated 15 to each side to determine whether true atlantoaxial xation is present. Persistent asymmetry of the odontoid and its relationship to the articular masses of the atlas, with the asymmetry not being correctable by rotation, forms the basic radiologic criteria for the diagnosis of atlantoaxial rotatory xation.116 Additionally, cineradiography in the lateral projection may
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FIGURE 2818. Drawings showing the four types of rotatory xation. A, Type I: rotatory xation with no anterior displacement and the odontoid acting as the pivot. B, Type II: rotatory xation with anterior displacement of 3 to 5 mm and one lateral articular process acting as the pivot. C, Type III: rotatory xation with anterior displacement of more than 5 mm. D, Type IV: rotatory xation with posterior displacement.
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FIGURE 2819. Computed tomographic scan slices showing rotatory xation with the transverse ligament intact. A, The ring of C1 is shown, with the left lateral mass rotated anteriorly in comparison to the C2 lateral mass. B, The C2 ring shows that the right lateral mass is rotated posteriorly. (A, B, From Levine, A.M; Edwards, C.C. Clin Orthop 239:53 68, 1989.)
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Type IV rotatory xation was the most uncommon, with posterior displacement of the atlas noted on the axis. It was seen in association with a decient dens (Fig. 2820). Type V, frank rotatory dislocation, may also be seen, although it is extremely uncommon.109, 110 The cause of this injury in adults is almost universally associated with trauma involving a exion-rotation mechanism of injury; however, the cause of the nontraumatic form of this condition is unknown, and many different theories have been proposed. Wittek suggested that effusion of the synovial joint produced stretching of the ligaments.115 Coutts indicated that synovial fringes, when inamed or adherent, may block atlantoaxial reduction.101 Fiorani-Gallotta and Luzzatti postulated rupture of one or both of the alar ligaments and transverse ligament, whereas Watson-Jones proposed hyperemic decalcication with loosening of the ligaments.105, 113 Grisel related the condition to muscle contraction that might follow a combination of factors, including muscle spasm that prevents reduction in the early stages.106, 107 More recently, Fielding and colleagues noted that this injury is occasionally associated with lateral mass articular fractures, and they consider most swollen capsular and synovial tissues to be associated with muscle spasm.104 They believe that if the abnormal position persists because of failure to achieve reduction, ligament and capsular contractures may develop secondarily and cause xation.
FIGURE 2820. Computed tomographic scan showing traumatic, posteriorly displaced rotatory xation after an automobile accident. Posterior displacement of the right lateral mass of C1 in reference to the right lateral mass of C2 is causing a neurologic decit. This abnormality is well demonstrated on the sagittal reconstruction of that side. The opposite side is nondisplaced. (From Levine, A.M; Edwards, C.C. Clin Orthop 239:5368, 1989.)
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ODONTOID FRACTURES
zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz As a result of their signicant potential for neurologic injury and nonunion, no other injury of the upper cervical
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spine has generated as much controversy as fractures of the odontoid process. In the early 1900s, odontoid fractures were thought to be almost uniformly fatal. Later evaluations dropped the estimated mortality to approximately 50%, and more recent gures indicate that the mortality rate is approximately 4% to 11%.117, 121, 122, 140, 146 These gures may be misleading in that some patients with this injury may never reach the hospital because of rapidly fatal brain stem or spinal cord injury. This scenario is probably more a possibility than a reality inasmuch as Bohler in an autopsy series reported only one case of fatal quadriplegia from an odontoid fracture.124 The overall incidence of odontoid fractures ranges from 7% to 14% of all cervical fractures,122, 124, 132, 161, 166 and as with most other injuries to the upper cervical spine, they are usually the result of falls or motor vehicle accidents.121, 122, 130, 146, 159, 174 The odontoid, in conjunction with the transverse atlantal ligament, is the prime stabilizer of the atlantoaxial articulation and acts to prevent anterior and posterior dislocation of the atlas on the axis. The apophyseal joints of the atlantoaxial complex confer little stability at this level because they lie in a horizontal plane; thus, with fractures of the dens, stability is lost and anterior and posterior subluxation and dislocation may occur.169 Despite a large number of autopsy and biomechanical studies, the exact mechanism of injury remains unknown but probably includes a combination of exion, extension, and rotation.120, 126, 159, 172 An understanding of the ligamentous and vascular anatomy of this region is important to appreciate the potential for problems with healing of these controversial injuries, particularly those occurring at the odontoid base. The dens is connected to the occiput and C1 by a number of small, but important ligamentous structures (see Fig. 282). From the cephalic aspect of the dens, the single apical and paired alar ligaments fan out in a rostral direction to their attachments on the anterior lip of the foramen magnum and occipital condyles, respectively.
More caudally, the transverse ligament arises from the anteromedial aspect of the lateral masses of the atlas, curves posteriorly around the dens, and is separated from the dens by a small synovial joint (see Fig. 283). Additionally, ligamentous bands called the accessory ligaments arise in conjunction with the transverse ligament and pass directly into their attachment on the lateral aspect of the dens immediately above the base. This complex ligamentous arrangement attached to the dens allows for movement of the dens separate from the body of C2 in most fractures and explains in part why displacement and associated problems with union are frequent with these injuries. The vascular anatomy of the odontoid has also been said to contribute to the problem of nonunion in these injuries. The paired right and left posterior and anterior ascending arteries of the axis form the principal blood supply to the dens and are branches of the vertebral arteries. A third source of supply is the paired cleft perforating arteries from each carotid artery that anastomose with the anterior ascending arteries. The ascending arteries penetrate the axis at the base of the dens and also continue outside the dens in a cephalic direction to form the apical arcade over the tip of the dens. Because of this complex vascular anatomy, fractures of the base of the dens probably cause damage to the vessels in this area and create problems with healing170 (Fig. 2821). The concept of end-vessel supply does not exist; therefore, the high nonunion rates of many odontoid fractures may result from other factors such as the degree of displacement, distraction, motion, and soft tissue interposition.174 However, autopsy retrieval studies of odontoid nonunion have not shown evidence of osteonecrosis, so this notion has for the most part been discarded. Many authors espouse the view that the odontoid actually has a rich blood supply.117 Govender and colleagues performed selective vertebral angiography on 18 patients, 10 with acute fractures and 8 with nonunion, and revealed that the blood supply to the odontoid process was not disrupted.143
Apical arcade
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FIGURE 2821. Vascular anatomy of the odontoid process.
Posterior ascending artery
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Another factor that may contribute to the potential for nonunion is that the dens is almost completely surrounded by synovial cavities, thus making it almost entirely an intra-articular structure.126 The tip of the dens is also tethered by ligaments as noted previously, which would tend to distract a fracture of the base of the dens because the injury is below its attachments to the alar and apical ligaments. Therefore, an injury to the dens at or above the accessory ligaments would leave the tip of the dens fragment oating entirely within a synovial cavity. With almost no soft tissue to provide periosteal blood supply, healing must rely on new bone formation from an intact endosteal blood supply. One last cause of odontoid fracture nonunion is the potential for soft tissue interposition between the fracture fragments. Crockard and co-workers reported several cases in which the transverse ligament was caught between the fracture fragment of the odontoid process and the body of C2.133 Govender and associates performed postmortem studies on 10 adult axis vertebrae and showed that the difference in surface area between type II and type III fractures was statistically signicant and may represent another factor contributing to the increased nonunion rates seen with this fracture pattern.143 The frequent association of head trauma, drug and alcohol abuse, and the occurrence of concomitant cervical spine fractures may cause these injuries to be overlooked on initial evaluation.146, 158, 174 In addition, some of these injuries will not be evident initially on plain radiographs but will be visualized on subsequent follow-up lms as early callus formation is seen. In the evaluation of a patient with a suspected odontoid fracture, it is important to rule out associated cervical spine injuries by appropriate plain radiographs, tomography, and CT.136 Widening of the prevertebral soft tissue space, as is occasionally found in lower cervical spine injuries, is relatively less frequent with injuries to C1 and C2.160 However, an increase in the prevertebral soft tissue shadow greater than 10 mm anterior to the ring of C1 suggests an anterior fracture. As with other injuries to the craniocervical junction, most of these injuries result from motor vehicle accidents or falls, and a high percentage of patients with this injury also have injuries to the skull, mandible, other cervical vertebrae, long bones, and trunk.126, 171 Thus, a complete and thorough physical examination is essential. Neurologic injury, which is seen in approximately 25% of patients, may range from high tetraplegia with respiratory center involvement to minimal motor and sensory weakness involving a portion of an upper limb secondary to minor loss of one or several cervical nerve roots.117, 174 Anderson and DAlonzo classied these injuries into three anatomic types based on the level of injury117 (Fig. 2822). Type I fractures account for approximately 5% of these injuries and are the least common. They are characterized by oblique fractures through the upper end of the odontoid process and probably represent avulsion fractures in which the alar ligaments attach to the tip of the odontoid. However, type I fractures may be accompanied by gross instability because of traction injury to the alar or apical ligaments. Type II fractures, which account for approximately 60% in most series, are fractures occurring at the junction of the odontoid process and the body of the
Type I
Type II
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Type III
FIGURE 2822. Three types of odontoid fractures as seen in the anteroposterior (left) and lateral (right) planes. Type I is an oblique fracture through the upper part of the odontoid process itself. Type II is a fracture at the junction of the odontoid process and the vertebral body of the second cervical vertebra. Type III is really a fracture through the body of the atlas. (Redrawn from Anderson, L.D.; DAlonzo, R.T. J Bone Joint Surg Am 56:16631674, 1974.)
axis. These injuries are the most controversial with regard to management because of their signicant potential for nonunion135, 141, 146, 160, 171 (Fig. 2823). Type III fractures account for approximately 30% of odontoid fractures. In these injuries, the fracture line extends down into the cancellous portion of the body and is really a fracture through the body of the axis. In addition, the fracture line may extend laterally into the articular facet. Problems associated with obtaining union are thought to be relatively infrequent with this injury.174 Not included in the classication is a fracture pattern described as that of a vertical fracture through the odontoid process with the fracture continuing inferiorly through the body of C2.123 This fracture, although it involves the odontoid, behaves more like a variant of traumatic spondylolisthesis of C2. The issue of treatment of these injuries is a complex one, and the optimal treatment remains to be resolved. Because all methods of treatment are associated with problems, no single method has been universally accepted; however, certain principles do apply. Type I fractures represent an avulsion fracture of the alar or apical ligaments. These injuries do not compromise the integrity of the C1C2 articulation and are not of great clinical signicance. However, after muscle spasm from the injury has resolved, subtle injury to the occipitoatlantal region
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must be ruled out with exion-extension lateral radiographs. These injuries will heal quite well with a brief period of simple collar immobilization.117 Type II injuries in particular and type III injuries to a certain degree are the fractures for which answers are less clear. Both surgical* and nonsurgical management have strong advocates. However, if the surgeon understands the risk factors for nonunion and appropriately selects patients for surgical treatment, nonoperative techniques in low-risk patients have yielded fracture union rates of 90%. Several factors have been pointed out that predispose to problems with nonunion or malunion of type II fractures, including displacement of greater than 4 to 5 mm,121, 130, 143 the type of immobilization, and angulation greater than 10.130 Type II fractures with anterior or posterior displacement of greater than 5 mm have been associated with nonunion rates approximating 40% regardless of the treatment method, and some reports suggest that posterior displacement is a worse prognostic indicator. The effect of increased age of the patient on union rate and tolerance to halo immobilization has been increasingly stressed as an important factor and will be discussed in detail later in the chapter.143, 148 When angulation is greater than 10, the nonunion rate approximates 22%.130 The two most critical factors inuencing union are obtaining and holding a reduced fracture. Union rates with halo immobilization for type II and type III fractures have been reported to be 66% and 93%, respectively.121, 130 Vieweg and Schultheiss performed a meta-analysis of 35 studies to determine the outcome of immobilization in a halo vest for various injuries to the upper cervical spine. This study reviewed the results of
*See references 117, 124, 125, 129, 130, 135, 138, 141, 167, 174, 233. See references 118, 121, 128, 131, 149, 156, 161, 162, 164, 165, 175, 179.
312 patients with odontoid fractures. Of the fractures studied, only two were type I odontoid fractures and both were treated with halo vests. Treatment outcomes were reviewed for 189 patients with type II fractures (177 isolated fractures and 12 combined C1/C2 injuries). Complete healing took place in 150 cases (85% union rate). A 67% healing rate was noted in the 12 patients with combined injuries. In 123 type III odontoid fractures, the authors observed a 96% union rate.41 Information in the literature regarding successful healing of type II odontoid fractures varies to a great extent. Union rates of injuries managed by internal xation of the dens have been reported to be 92% to 100%,129, 138, 167, 233 and stabilization rates associated with posterior spinal fusion have been reported to be on the order of 96% to 100%.121, 130, 243, 245, 262 No randomized or controlled studies on this subject can be found in the literature. Seybold and Bayley evaluated the functional outcome of surgically and conservatively managed odontoid fractures (37 type II and 20 type III) over a 10-year period at a single institution.189 Pain scores were higher in patients with type II fractures and in patients treated conservatively with halo immobilization, especially those older than 60 years. No statistical differences in these parameters were found. Older patients treated surgically did not have a better functional outcome score than did those treated nonoperatively. The rate of union for halo immobilization, regardless of fracture type, was 80.9%. The healing rate for type II fractures was 65.3%. Patients with displaced fractures were treated with reduction and placement into a halo. They found no differences in the nonunion and union groups with regard to age, fracture type, delay in diagnosis, displacement, and direction of displacement or mechanism of injury. However, more nonunions were noted in the type II group. Older patients treated by halo xation had more compli-
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FIGURE 2823. A, A posteriorly displaced type II dens fracture. B, Reduction of the fracture by using a bone block construct with a sublaminar wire beneath the arch of C1 and the lamina of C2. (A, B, From Levine, A.M.; Edwards, C.C. Orthop Clin North Am 17:3144, 1986.)
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793
cations: increased rates of pin loosening, decreased range of motion and shoulder discomfort, and dysphagia. Some trends toward improved outcome scores were observed in elderly patients treated operatively, but the trends were not statistically signicant. A recent case-control study by Lennarson and colleagues studied 33 patients with isolated type II fractures treated with halo vest immobilization. Cases were dened as those with nonunion after halo immobilization, whereas control subjects represented those with successful bony union attained with halo immobilization. The groups had similar concomitant medical conditions, sex ratios, amount of fracture displacement, direction of fracture displacement, length of hospital stay, and length of follow-up. Age older than 50 years was found to be a highly signicant risk factor for failure of halo immobilization. The odds ratio indicated that the risk of failure of halo immobilization is 21 times higher in patients 50 years or older.155 Julien and associates performed an evidence-based analysis of odontoid fracture management by reviewing 95 articles based on the American Medical Association data classication schema. Only 35 articles met the selection criteria of at least class III evidence (based on retrospectively collected dataclinical series, database reviews, case reviews). No class I or class II papers (which are prospective studies or retrospective studies using reliable data) were included. The remainder of the studies were class IV data. This study used fusion as the only outcome criterion. They grouped the studies by treatment: no treatment, halo/Minerva, traction, posterior surgery, or anterior surgery. They concluded that for type I and type III fractures, immobilization yields satisfactory results in 84% to 100% of cases. Anterior xation for type III fractures improves the union rate to nearly 100%. For type II fractures, halo vest application and posterior fusion have similar fusion rates of 65% to 84%, respectively. Anterior xation produces a fusion rate of 90%, whereas traction alone is less successful at 57%. These observations were based on review of class III data that are inadequate to establish a treatment standard or guideline. Therefore all management modalities described remain treatment options.152 However, the generally accepted standards will be reviewed. The reported incidence of nonunion in the literature for type II injuries ranges from 10% to 60%.169, 176 Because of the potential catastrophic pitfalls with surgery, including the risk of infection and paralysis, it would seem reasonable to initially manage type II injuries with attempted reduction and halo immobilization for 12 weeks for displaced fractures. Before the introduction of odontoid screw xation methods, surgical alternatives for type II fractures consisted of posterior C1C2 fusion by several techniques, with predictably good fusion results. Most studies reported success rates of 90% to 100%. However, the expense to the patient was not the only potential pitfall of surgery; 50% of normal cervical rotation is also sacriced. The attractiveness of odontoid screw xation lies in preservation of atlantoaxial motion, as well as negation of the need for halo immobilization or posterior fusion.151 Unfortunately, odontoid screw xation is technically demanding. Furthermore, studies of external and
internal dens morphology have found that not all odontoid processes are created equal; close attention must be paid when evaluating preoperative CT scans because some odontoid processes and C1C2 articulations cannot accommodate screws.* Patients with type II injuries that demonstrate inadequate reduction and those initially seen more than 2 weeks after injury166 should be considered candidates for surgical stabilization. Also, patients with fractures that are treated with halo thoracic immobilization for a period of 12 to 16 weeks and afterward demonstrate residual instability on lateral exion and extension radiographs should also be considered for surgery. Odontoid screw xation for nonunion has been shown to give reasonable results.119, 129, 233 Apfelbaum and co-workers found that anterior screws produce union rates of 88% if done before 6 months but that the rate drops to 25% after 18 months.119 Late instability may be found in patients who had transverse ligament injuries in addition to their odontoid fracture.145 As previously stated, posterior wiring or C1C2 transarticular screws and fusion produce good results in stabilization of C1C2.147, 154 As demonstrated by Clark and White, type III injuries are more problematic than previously thought.130 With signicant fracture displacement or angulation, the incidence of malunion and possibly nonunion increases. Cervical orthoses are therefore probably not adequate management for type III injuries. Displaced, angulated fractures should be reduced in halo traction and held in halo thoracic immobilization until united.108 Alternatively, shallow type III fractures have been found to heal well with the odontoid screw technique.129, 137, 138, 233 Malunion of odontoid fractures can lead to potential problems of cervical myelopathy133 and post-traumatic C1C2 arthrosis.
FRACTURES IN OLDER PATIENTS
zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz Upper cervical spine fractures in older patients are encountered with relative frequency and account for up to 23% of all cervical fractures.193 Ryan and Henderson, in a review of 17 cervical spine fractures, found that the incidence of C1C2 fractures progressively rises with age because of the preponderance of odontoid fractures in this patient group.188 Mortality rates have approached 25% to 30%.124, 193 Many series have reported a high incidence of combination fractures of C1 and C2, with most of the C2 fractures being odontoid.182, 193 Management of cervical spine fractures in older patients is often complicated by preexisting medical conditions, poor ability to tolerate halo immobilization, and poor healing potential. The decision to treat with immobilization or surgery remains controversial. Most studies are retrospective reviews with low patient numbers that vary in their decision making, so conclusions cannot be drawn.124, 156, 183, 185187, 191193 However, many important trends have started to emerge. Olerud and colleagues retrospectively examined whether cervical spine fractures carried an increased risk of death in patients older than 65 years and tried to dene risk factors
*See references 139, 142, 150, 153, 157, 162, 163, 168, 173
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inuencing survival. Five years after the injury, 25 of 65 patients had died. Severe co-morbidity (ASA physical status classication >2), neurologic injury (Frankel grades A to C), age, and ankylosing spondylitis proved to be signicant risk factors for death.186 This study did not address differences in outcome between surgical and nonsurgical treatment. Finelli and colleagues found that trauma in the elderly population results in increased mortality for a given level of injury severity in comparison to younger persons.181 Proponents of halo immobilization as the treatment of choice for most C1 and C2 fractures in elderly patients stress that it obviates the need for surgery and allows for reduction and prompt mobilization, a positive effect because prolonged periods of bedrest are poorly tolerated.124, 183 Hannigan and coauthors reported that one third of patients with odontoid fractures treated by bedrest suffered respiratory complications, as opposed to no patients who ambulated early after treatment. They attributed two deaths to bedrest.148 Many investigators have stressed that halos are well tolerated in this patient subset.124, 183, 193 Several studies also maintain that halos are associated with a high complication rate in this patient population189 and that the risk of nonunion is increased with halo treatment in older patients.155 Age older than 50 years was found to be a highly signicant risk factor for failure of halo immobilization. The odds ratio for these data indicates that the risk of failure of halo immobilization is 21 times higher in patients 50 years or older. Surgical intervention should be considered in patients 50 years or older who have a type II dens fracture, if it can be performed with acceptable risk of morbidity and death.155 Taitsman and Hecht recently examined the rate of complications associated with halo immobilization in the elderly population.192 Seventy-ve patients older than 65 years were treated over a 10-year period at two Level I trauma centers. Patients were excluded if they were multitrauma patients, if they died of obvious complications of their other injuries or within the rst week of hospitalization, or if they were in respiratory arrest on admission. Finally, patients were excluded if they underwent surgery within 1 month of admission. Isolated odontoid fractures were most common and were found in 32 of the 75 patients (43%). Five patients (7%) had C1 fractures. Fourteen patients (19%) had combination C1/C2 fractures; 10 (13%) of this group had a C1/ odontoid fracture. Nine people (12%) had other C2 fractures. Two patients (3%) had three or more cervical vertebrae involved. Thirteen (17%) had other cervical injuries. Most elderly patients who are placed in halos are unable to return home immediately after leaving the acute care hospital. Only 11 of the 75 patients (15%) were discharged directly to home. Two of the 11 were readmitted and then placed in a rehabilitation center or nursing home. Forty-one patients (55%) experienced at least one complication. Twenty-two patients (29%) had pin problemsprimarily loose or infected pins. Aspiration pneumonia is a signicant risk for elderly patients in halos. Pneumonia developed in 17 patients (23%) either during their initial hospitalization or during readmission. All 17 were treated with intravenous antibiotics. Thirteen pa-
tients experienced signicant respiratory compromise or arrest necessitating intubation or tracheostomy and intensive care management. All deaths were related to respiratory compromise. Because of the risk of aspiration, eight patients (11%) had gastric (7) or jejunal (1) feeding tubes placed. Six patients (8%) died while in the hospital. Five expired during their initial hospitalization and one on readmission. All these patients sustained isolated cervical spine fractures except for one, who had a head injury as discharged to rehabilitation. He returned to the hospital 1 month later with aspiration pneumonia, became septic, and expired shortly thereafter. This number does not include several multitrauma patients who died of other causes (i.e., bleeding diathesis after acetabular surgery) or ve patients who had cervical spinal fractures and were immediately intubated in the eld or the emergency room. The literature is unclear regarding the union rates of these types of fractures managed operatively versus nonoperatively. Many authors continue to advocate treatment with halo vests. Several reports indicate that the older age group has increased morbidity and mortality when managed with halo vests; however, most studies are limited by the number of patients and the details of the complications. Andersson and colleagues conducted a retrospective analysis of 29 consecutive patients older than 65 years (mean age, 78) with odontoid fractures. Eleven patients were treated with anterior screw xation according to the technique of Bohler, 7 with posterior C1C2 fusion. Ten patients with either minimally displaced fractures or with complicating medical conditions were treated conservatively. At follow-up, 7 of 7 patients who underwent posterior fusion had healed without any problems, whereas 8 of 11 patients treated with anterior screw xation and 7 of 10 conservatively treated patients either failed treatment or had healed, but after a complicated course of events. Anterior screw xation is associated with an unacceptably high rate of problems in the elderly population. Probable causes may be osteoporosis with comminution at the fracture site or stiffness of the cervical spine preventing ideal positioning of the screws. They also maintained that nonoperative treatment often fails. They advocated posterior C1C2 fusion.118, 180 Other studies have also conrmed that posterior instrumentation with C1C2 transarticular screws may permit early mobilization, with complications related to halo immobilization. Campanelli and co-workers revealed that this procedure can be performed safely in elderly patients with good results and few complications.127 Hannigan and colleagues reached similar conclusions in their retrospective review of 19 patients 80 years or older with odontoid fractures. Eight patients with posterior displacement of 5 mm or less were treated with cervical immobilization, three of whom had stable nonunion of the fracture site at follow-up review. One patient with 10 mm of displacement refused operative treatment. Three of the patients without surgical treatment subsequently died of unrelated causes; all remaining patients resumed their routine activity. Five patients with displacement of 5 mm or greater and instability at the fracture site were treated with posterior C1C2 fusion using wire and autologous iliac bone grafts. In this group, no operative morbidity or mortality was
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noted, and stable constructs developed in all patients. One patient died of an unrelated cause during the follow-up period, and the other patients resumed their normal activity. Prolonged bedrest caused respiratory complications in two of six patients who survived the initial hospitalization; complications requiring alternative treatment developed in two of three patients treated with rigid immobilization.148
occur after injury and necessitate C1C2 stabilization at a later date.
TRAUMATIC SPONDYLOLISTHESIS OF THE AXIS
zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz The term hangmans fracture has been used extensively in the literature to describe both the injury produced by judicial hanging and axis pedicle fractures after motor vehicle accidents and falls.195, 196, 198 The historical description of these injuries has led to confusion in nomenclature. In 1866 Haughton was the rst to describe fracture-dislocations of the axis secondary to hanging.208 Wood-Jones, in the early 1900s, claried the injuries produced by varying positions of the hanging knot and recommended a submental position to produce a consistently fatal result.223 These studies were later conrmed by Vermooten.220 Grogono, in 1954, rst published radiographs of a fracture of the posterior arch sustained in a motor vehicle accident.205 Garber proposed the term traumatic spondylolisthesis for this injury because he thought that the primary distraction force seen with hanging was absent in these cases.203 Schneider and co-workers in 1965 actually coined the phrase hangmans fracture for these injuries because of their radiographic similarity to the injuries produced by judicial hanging.214 The choice of this phrase is unfortunate because these two separate lesions differ markedly in their mechanism of injury, associated soft tissue disruption, clinical features, and prognosis.222 Although this fracture appears to be radiographically similar to that incurred in a hanging injury, it is different in that a hanging injury produces bilateral axis pedicle fractures with complete disruption of the disc and ligaments between C2 and C3 by hyperex-
C2 LATERAL MASS FRACTURES
zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz Lateral mass fractures of the C2 vertebra are rarely reported injuries and have a mechanism of injury similar to that causing lateral mass fractures of the atlas. Axial compression and lateral bending forces combine to compress the C1C2 articulation and result in a depressed fracture of the articular surface of C2 (Fig. 2824). Patients generally have a history of pain without neurologic decit. Plain radiographs may be unremarkable, although anteroposterior and open-mouth views will sometimes demonstrate lateral tilting of the arch of C1 and asymmetry of the height of the C2 lateral mass. If suspected, CT scanning of the area is helpful to more clearly delineate the injury. A search for additional fractures in the cervical spine should also be made because these injuries are frequently combined with other C1C2 fractures.184, 190 Treatment is based on the degree of articular involvement. In patients in whom depression of the articular surface is slight and incongruity is minimal, simple collar immobilization is sufcient. More extensive involvement of the lateral mass may require cervical traction to realign the lateral mass, followed by halo vest immobilization until healing has occurred. In those in whom articular incongruity remains, degenerative changes may
FIGURE 2824. Lateral mass fracture of C2. A, Computed tomographic scan showing minimal impaction of the joint surface of C2 (arrow). B, Open-mouth view showing bilateral, lateral mass fractures of C2 (arrows) from a severe vehicular accident with axial loading of the spine. (A, B, From Levine, A.M; Edwards, C.C. Clin Orthop 239:5368, 1989.)
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tension and distraction.216, 220, 223 This mechanism is in contradistinction to the injury produced by falls and motor vehicle accidents, which results from various combinations of extension, axial compression, and exion, along with associated varying degrees of disc disruption.198, 203, 205, 214, 218, 222 The exact incidence of these injuries is unknown; however, in individuals involved in fatal motor vehicle accidents, only occipitoatlantal dislocations are more common.196 Traumatic spondylolisthesis of the axis is also noted to be approximately half as common (a reported incidence of 27%) as odontoid fractures in patients who have sustained cervical trauma in motor vehicle accidents.207 The unusual anatomy of the axis accounts for its injury pattern. The axis is thought to be a transitional vertebra between the ringlike atlas above and the more typical cervical vertebra below. The narrow elongated isthmus between the superior and inferior articular processes of the axis functions as a fulcrum in exion and extension between the cervicocranium (skull, atlas, dens, and body of the axis) and the relatively xed lower cervical spine, to which the neural arch of the axis is anchored by its inferior articular facets, stout bid spinous process, and strong nuchal muscles. The elongated pedicles are the thinnest portion of the bony ring of the axis and are additionally weakened by the foramen transversarium on either side, which further enhances the susceptibility of this area to injury.195, 222 Because traumatic spondylolisthesis tends to produce acute decompression of the neural canal by fracture of the pedicles, neurologic involvement is relatively uncommon in survivors (seen in 6% to 10%).195, 196, 198, 201, 202, 214 Most investigators have noted a high incidence of craniofacial injuries associated with this fracture.202, 212 Vertebral artery and cranial nerve injuries have also been reported.211 As regards other injuries in the spine, Francis and co-workers noted that approximately 31% of patients sustaining this injury have associated injuries of the cervical spine, 94% of which are in the upper three vertebrae.201, 202 In addition, 7% of patients had other spinal fractures below the neck. Bucholz was the rst to divide these injuries into stable and unstable congurations based on the integrity of the C2C3 disc.196 Effendi and associates further subdivided these injuries according to radiographic evidence of displacement and stability.200 The most recent and most useful classication is that proposed by Levine and Edwards, which is essentially a modication of Effendi and associates radiographic system.200, 209 The classication system is based on pretreatment lateral cervical spine radiographs and is useful in predicting the mechanism of injury and planning treatment: Type I fractures are nondisplaced fractures and all fractures showing no angulation and less than 3 mm of displacement (Fig. 2825A). Type II fractures have signicant angulation and translation (see Fig. 2825B). Type IIA fractures show slight or no translation but very severe angulation of the fracture fragments (see Fig. 3025C). Type III fractures have severe angulation and displacement,
as well as concomitant unilateral or bilateral facet dislocations at the level of C2 and C3 (see Fig. 2825D). Type I fractures are stable with an intact C2C3 disc; types II, IIA, and III are unstable fractures because of disruption at the C2C3 interspace. Type II fractures are the most common and are seen in 55.8% of patients, followed by type I injuries, which account for 28.8%. Types IIA and III are relatively uncommon and are found in 5.8% and 9.6% of patients, respectively. Although most hangmans fractures do not compromise the spinal canal, reports of atypical hangmans fractures have shown the potential for spinal canal compromise.217 These fractures extend into the posterior vertebral body, with a fragment of the posterior vertebral body being displaced dorsally into the spinal canal. It is important to recognize this injury because it has signicant potential to cause neurologic injury. Although hangmans fractures are relatively benign injuries because of the large diameter of the vertebral canal at this level of injury, optimal management of these injuries is very controversial.195, 210, 214 Despite the fact that the vast majority of these injuries do well with conservative treatment195, 200, 202, 206, 209, 210, 212, 215, 218 and that the reported nonunion rate with external immobilization is approximately 5%,195, 201, 221 some authors have continued to advocate primary surgical treatment.194, 198, 210, 213, 218, 222 Given the usually good prognosis in survivors of these injuries, a conservative approach seems justied in most cases. Gross and Benzel reviewed 533 reported cases of nonoperatively managed hangmans fractures of any classication available for follow-up and noted that only 8 patients did not achieve bony union. The cases of nonunion were complicated by complex additional cervical injuries and completely disrupted C2C3 intervertebral discs.204, 206 Their meta-analysis found a 98.5% union rate and suggested that nonoperative treatment should be the primary method except in cases of failure of this therapy, compressive lesions, or extreme contraindications to bracing. They stress that the ability to achieve osseous union despite incomplete or nonanatomic closed fracture reduction is well recognized.197 According to Levine and Edwards, type I fractures are stable, as determined by physician-supervised exionextension radiographs.209 Varying degrees of reduction are noted with extension. Cord damage is extremely rare with these injuries because of their inherent stability. The mechanism of injury is probably the result of a hyperextension and axial loading force that fractures the neural arch posteriorly but is not strong enough to disrupt the integrity of the disc or seriously compromise the integrity of the anterior or posterior ligaments. Because the restraining ligaments have little laxity, anterior displacement is minimal and the fracture is stable. A high association is seen with other hyperextension and axial loading injuries, such as fractures of the posterior arch of the atlas, fractures of the lateral mass of the atlas, and odontoid fractures. Because these injuries are stable, treatment with the Philadelphia collar or a halo until healing of the fracture is satisfactory, and no further displacement is expected with healing.
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FIGURE 2825. Classication of traumatic spondylolisthesis of the axis. A, Type I injuries have a fracture through the neural arch with no angulation and as much as 3 mm of displacement. B, Type II fractures have both signicant angulation and displacement. C, Type IIA fractures show minimal displacement, but severe angulation is present. D, Type III axial fractures combine bilateral facet dislocation between C2 and C3 with a fracture of the neural arch of the axis. (AC, From Levine, A.M.; Edwards, C.C. J Bone Joint Surg Am 67:217226, 1985. D, From Levine, A.M. Orthop Clin North Am 17:42, 1986.)
Type II fractures are noted to be unstable on physiciansupervised exion and extension radiographs. They are frequently associated with other cervical spine fractures, especially wedge compression fractures of the anterosuperior portion of the body of C3. The mechanism of injury, as with type I fractures, is initially hyperextension plus axial loading, which fractures the neural arch or lamina but causes no more than slight injury to the anterior longitudinal ligament, disc, or posterior capsular structures. The second force in this injury is anterior exion and compression, which when coupled with the initial fracture through the neural arch, allows the entire cervicocranium to be displaced anteriorly and caudally. This displacement causes rupture of the posterior longitudinal ligament and disc in a posterior-to-anterior direction and frequently results in a compression fracture of the anterosuperior portion of the body of C3. Treatment of these injuries is usually conservative, with halo or tongs traction in extension and a weight of 6.8 to 9.1 kg for 5 to 7 days. If the reduction is adequate and demonstrates less than 4 to 5 mm of displacement or less than 10 to 15 of angulation, a halo vest may be applied. If the reduction is inadequate, continued traction in extension for 4 to 6 weeks is recommended, followed by further halo treatment for an additional 6 weeks. The presence of C2C3 disc herniation is a contraindication to traction.
An alternative to conservative treatment or failure of bony union after adequate immobilization of type II fractures is the use of a C2 transpedicular screw or anterior cervical plate. The fracture must rst be reduced with halo traction, and then xation can be achieved with a pedicle lag screw. Originally described by Roy-Camille and colleagues,260 the transpedicular technique, though technically demanding, can replace the need for long-term immobilization and give very satisfactory results.246 Anterior cervical plating for unstable, inadequately reduced Effendi type II fractures has been reported and has yielded good results with no complications.219 Anterior plating allows the reconstitution of two columns of vertebral stability; it can address the level of pathology with only a single motion segment and allows for decompression of the disrupted C2C3 disc. Type IIA fractures are also unstable to exion and extension. The predominant mechanism of injury with this fracture is exion with distraction, which causes a distraction type of injury through the pedicles with the injury extending anteriorly. These injuries are not usually recognized before obtaining radiographs in traction, and such radiographs will demonstrate opening of the posterior disc space between C2 and C3. Reduction is therefore obtained by applying mild compression and extension in a halo vest under uoroscopic control until
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the reduction is adequate. Treatment is continued until fracture healing has occurred. As with type II fractures, it has been found that type IIA fractures can be treated with
C2 transpedicular screws246 or anterior C2C3 plating,219 although experience in treating this fracture with these techniques is limited (Fig. 2826).
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FIGURE 2826. Technique for screw xation of a type II hangmans fracture. Fluoroscopy should be used, preferably biplanar, to visualize reduction of the fracture, as well as screw trajectory. A, The medial wall of the C2 pedicle should be visualized. Dissection performed in a posterior-to-anterior direction will usually expose the fracture of the pedicle. B, The trajectory of the screws should be along the line of the pedicle just lateral to the medial wall of the pedicle and slightly convergent. C, The screw should be oriented to capture the distal fragment with the screw threads. A lag screw can be used. The C1C2 facet joint should be avoided. D, The nal axial view. E, The patient has a markedly displaced type II traumatic spondylolisthesis of the axis, which can be totally reduced with traction (F). G, Rather than prolonged traction, the patient elected operative treatment with lag screw xation. (From Levine, A.M.; et al. In: Spine Trauma. Philadelphia. W.B. Saunders, 1998, p. 293.)
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Type III fractures occur with concomitant unilateral or bilateral facet dislocations and are also unstable. They are unique in that patients with dislocated facets and fracture of the neural arch of the axis have a higher mortality rate (33% versus 5%), a higher incidence of permanent neurologic injury (11% versus 1%), and a higher incidence of cerebral concussion (55% versus 21%) than do patients with intact facets.199 The mechanism of these injuries is primarily exion-compression, which produces failure through the pedicles in an injury pattern that extends anteriorly. Virtually all type III injuries require surgery for one of two indications. First, if the fracture line of the neural arch is anterior to either a unilateral or bilateral facet dislocation, the facet dislocation is irreducible with traction because of loss of integrity of the neural arch. Therefore, the facet dislocation should be reduced surgically and stabilized with interspinous wiring or lateral mass plates. The fracture of the neural arch is then treated conservatively in traction or a halo, or at the time of surgery, a transpedicular C2 screw can potentially be used to secure the neural arch. Second, if the fracture of the neural arch is at the level of the facet dislocation or just posterior to it, surgical stabilization by bilateral oblique wiring or lateral mass plating is necessary after reduction of the dislocation in traction because the reduction of the facet dislocation is usually unstable. Transpedicular screws can be placed in C2 and lateral mass screws in C3 along with the application of lateral mass plates; this technique affords very stable xation and can negate the need for postoperative halo immobilization. If satisfactory reduction can be maintained in a halo vest, however, immobilization may be a reasonable option. Teardrop fractures involving the axis are unusual and deserve mention because these injuries differ greatly from those of the lower cervical spine. Lower cervical spine teardrop fractures are due to a exion injury, are unstable, and are associated with neurologic injury 75% of the time. C2 teardrop fractures are caused by an extension injury, are stable, and are not associated with neurologic injury. Radiographically, exion- and extension-type teardrop fractures are distinguishable by the fact that in an extension-type injury, the teardrop fragment is rotated 35 anteriorly. Conversely, a exion-type teardrop fracture remains aligned with the anterior margin of the spine. A C2 extension-type teardrop fracture is associated with traumatic spondylolisthesis of C2. Fortunately, an extension-type fracture is stable and can be successfully treated with a rigid cervical orthosis unless precluded by a concomitant unstable fracture.
Increasing rigidity and length of the orthosis correlate with improved ability to restrict motion. The braces recommended for some of the injuries discussed in this chapter are presented in Table 275. This chapter does not discuss applications of the halo ring or its complications.
Skeletal Traction
Skeletal traction with either tongs or a halo is frequently indicated in the initial stabilization and ultimate management of patients with upper cervical spine injuries. Considerations should include the nature of the injury, the presence or absence of other injuries, and the estimated duration of treatment. Indications for the use of skeletal traction, as well as halo vest immobilization, were discussed earlier in this chapter.
Occipitocervical Arthrodesis
Occipitocervical arthrodesis can be accomplished with one of several posterior techniques and can be performed more safely with spinal cord monitoring. All techniques involve placing the patient in a halo or tongs traction apparatus and radiographically assessing the reduction preoperatively. A cross-table lateral radiograph should specically conrm that the occiput is not distracted from the atlas. After standard skin preparation and draping, a longitudinal midline skin incision is fashioned from the inion to the midcervical spine. With meticulous hemostasis and careful subperiosteal dissection, the base of the occiput, from the inion to the foramen magnum, and the upper cervical spine are exposed. During dissection of the upper cervical spine, it should be appreciated that the vertebral vessels lie on the superior aspect of the arch of C1 approximately 1.5 to 2.0 cm lateral to the midline. One should also be wary of frequently encountered congenital anomalies, particularly defects in the posterior arch, which are seen in approximately 1.4% of atlases and in approximately 60% of those associated with congenital occipitoatlantal fusion.268 The simplest method for obtaining fusion involves careful decortication of the posterior elements of C1, C2, and the suboccipital area with a bur, followed by the application of a copious amount of freshly obtained iliac crest bone graft. After routine closure over drains, the patient is immobilized in a halo vest or cast for 12 weeks or until serial radiographs demonstrate healing of the fusion mass. The limitations of this technique are that early xation is not obtained and the risk of nonunion is considerable.231, 253 More involved methods of performing occipitocervical arthrodesis incorporate different types of metal xation devices intended to add stability to the fusion construct.228, 241, 242, 250, 256, 257, 270, 271 These devices vary from simply occipital and cervical sublaminar wires, which require additional halo immobilization, to posterior occipitocervical plates, which require only soft or semirigid cervical collars postoperatively. Oda and colleagues performed a biomechanical evaluation of ve different occipitoatlantoaxial xation techniques. They found that
SURGICAL TECHNIQUES Bracing
zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz
A variety of braces were discussed in Chapter 27. Methods of immobilization range from soft collars to cervical thoracic orthoses to halo vests. These devices immobilize the spine to varying degrees, and specic devices are best for certain regions of the cervical spine (see Table 272).
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the addition of C2 transpedicular or C1C2 transarticular screws signicantly increased the stabilizing effect when compared with sublaminar wiring and laminar hooks.255 Occipital and cervical sublaminar wires are used to secure bone graft plates, either iliac corticocancellous grafts or rib grafts, from the occiput to the upper cervical spine.229, 248, 258, 259, 272 This technique allows for early stabilization and is thought to diminish the chance of nonunion. The technique of Robinson and Southwick, which involves the use of iliac crest grafts, has been most popular and is summarized here258 (Fig. 2827). After exposure of the base of the occiput and upper cervical spine, two 1-cm bur holes are fashioned through both tables of the skull approximately 0.5 cm lateral to the midline and 0.5 mm from the edge of the foramen magnum. Great care must be taken to avoid damage to the dura. The underlying dura and periosteum adherent to the posterior arches of C1, C2, and the foramen magnum are then carefully separated from the bone with small, angled curettes and a dural dissector. Two 24-gauge twisted wires are then passed under each of these bony structures,
looped through or around a previously harvested iliac crest graft, and gently secured into place by gradually twisting the wires tight. Strips of cancellous graft can then be added to ll any remaining gaps. After closure of the wound in routine fashion, the patient is immobilized in a halo until healing has occurred. The use of posterior occipitocervical plating affords rigid internal xation and is growing in popularity (Fig. 2828). Three different groups reported fusion rates varying from 94% to 100% when posterior occipitocervical plates were used.241, 242, 261, 262 In all three studies, postoperative immobilization involved the use of a soft or semirigid cervical collar; halo immobilization was not used. Other than degeneration of adjacent segments, no signicant complications occurred with the use of posterior occipitocervical plates.242 Application of posterior occipitocervical plates requires the same surgical dissection as described previously. Screws are placed in the occiput as close to the midsagittal line as possible, at or below the level of the inion. One advantage of this type of xation is that screws can be
Foramen magnum Bone graft
A
Vertebral artery
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FIGURE 2827. AD, Method of occipitocervical fusion. This method is particularly useful if the posterior arch of C1 has to be partly removed to relieve dural and cord compression.
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FIGURE 2828. Method of posterior occipitocervical plating and fusion. This type of rigid internal xation allows for postoperative cervical immobilization with a soft collar. (Redrawn from Frymoyer, J.W., ed. The Adult Spine: Principles and Practice, 2nd ed. Philadelphia, Lippincott-Raven, 1997, p. 1428.)
placed in the pedicles of C2, which give excellent bony purchase, but C1C2 transarticular screws can also be used to anchor the plate and augment stability at the C1C2 articulation when no posterior bony purchase of C1 can be obtained. The plate is contoured to restore the normal curvature of the occipital cervical region (105). Dual plates or a Y plate has been used. At the C2 level, the pedicle is used for screw xation. The entry point is at the upper and inner quadrant, and the drill is angled 10 to 15 medially and 35 superiorly to avoid injury to the vertebral artery. Alternatively, a transarticular C1C2 screw can be used. Holes are drilled in the occiput through the plate holes after the plate has been screwed to the cervical spine, and two or three screws are inserted into the occiput (Y plate). The second plate is secured with the same technique. Corticocancellous and cancellous bone grafts can be packed into the area between the plates.239, 241, 260 Several other techniques that allow rigid xation of the occipitocervical spine use rod-wire constructs such as contoured Wisconsin or Loquat rods with occipital wires or stainless steel or titanium cables230 or occipital bolts. These techniques have likewise been highly successful, with fusion rates ranging from 89% to 93%.252 Halo immobilization has also not been necessary with these methods.
Atlantoaxial Arthrodesis
Several different techniques are available for posterior fusion of the atlantoaxial joint. Gallie in 1939 popularized a technique involving midline posterior wiring with bone
grafting and facet joint arthrodesis.237 Unfortunately, reported failure rates with this technique have ranged from 60% to 80%.235, 251 Other techniques, however, including a posterior bone block between the posterior arches of the atlas and axis and wiring to achieve a wedge compression arthrodesis, are associated with consistently successful fusion rates of 92% to 100%.96, 226, 267, 269 These techniques include the modied Gallie fusion as described separately by Fielding and co-workers (Fig. 2829) and by McGraw and Rusch, as well as the Brooks or modied Brooks technique.226, 234, 238 A C1C2 transarticular screw technique was rst described by Magerl,251 and fusion rates ranging from 95% to 100% have subsequently been reported.243, 245, 263 Biomechanical testing has found the transarticular screw technique to be superior to Gallie wiring, Brooks-Jenkins wiring, and Halifax clamp xation in exion-extension, rotation, and lateral bending.240 The Brooks technique has been the most popular because of the theoretical mechanical considerations previously noted and because it is less technically demanding than transarticular screws226 (Fig. 2830). Once a satisfactory level of general anesthesia has been obtained and reduction radiographically conrmed, a standard posterior exposure of the upper cervical spine is carried out. A No. 2 Mersilene suture is passed on either side of the midline in a cranial-to-caudal direction under the arch of the atlas and then the axis. Two doubled 20-gauge stainless steel wires or titanium cables230 are then passed into place by using the previously placed suture as a guide. Two full-thickness bone grafts measuring 1.25 3.5 cm are then harvested from the posterior iliac
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FIGURE 2829. Surgical technique. A, Exposure, with the wire loop being passed under the arch of the atlas. Note the proximity of the vertebral vessels. B, Wire passed below the spine of the axis. Note the decortication of the atlas and axis. C, The graft conguration. D, The graft and wire in place, with the wire being tightened over the graft.
FIGURE 2830. A, The occipital nerves emerge through the interlaminar space between the atlas and the axis; the vertebral arteries are more lateral. With a midline approach, the arteries and nerves are fairly well protected by the neck muscles. B, On the left, a suture is passed under the posterior arch of the atlas. On the right, the suture is used to guide the wire under the arch of the atlas and the lamina of the axis. C, The wires are now in place and lie anterior to the anterior portion of the atlantoaxial membrane, which was not removed during exposure of the posterior elements of the atlas and axis. On the right, the graft, with edges beveled to t in the interval between the atlas and the axis, is being held with a towel clip. When wired in place, the beveled edges will be in contact with the arch of the atlas and the lamina of the axis. D, The grafts are secured, and stability is maintained by the wires.
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crest. These grafts are beveled to t between the posterior arches of the atlas and the axis on either side of the midline, and the wires are tightened while held in place to maintain the width of the interlaminar space. If the atlantoaxial membrane has been left intact, it will help prevent displacement of the grafts into the neural canal. Postoperatively, the patient can then be mobilized in a sternal-occipital-mandibular immobilizer (SOMI) or fourposter brace until the arthrodesis is solidly united. Griswold and colleagues described a modication of the original Brooks technique that incorporates the use of four doubled 24-gauge wires to hold trapezoidal grafts measuring 1.55 1.2 to 1.5 1.0 cm in place.238 Transarticular screw stabilization of C1 and C2 is growing in popularity, especially given its superior biomechanics.240 Although consecutive cases have been reported without signicant complications, Jeanneret and Magerl cautioned that this procedure is exacting.245 The surgeon must become familiar with the local neurovascular anatomy and bone morphology of the
atlantoaxial interval as determined best by CT evaluation.139, 142, 153, 157, 162, 163, 173 CT will help discern anatomic variations, the size and location of vertebral artery, and the isthmus diameter of C2.249 Contraindications to this procedure include incomplete reduction of C1C2 subluxation, pathologic destruction or collapse of C2, aberrant vertebral artery anatomy or a large vertebral artery groove with a secondarily narrow C2 isthmus (20% of cases), previous transoral resection of the odontoid, or cranial assimilation of C1.157, 173, 227 The entrance point and trajectory of the screws are critical and difcult to achieve (Fig. 2831). Visualization of the C2 pedicle allows the surgeon to aim just lateral to the pedicles medial wall to avoid penetration of the spinal canal. Because lateral deviation may threaten the vertebral artery, intraoperative uoroscopy is essential in this procedure. Failure to angle the screws sufciently cephalad will compromise purchase in the C1 articular mass; too steep an angle risks injury to the occipitoatlantal joints.243 Depending on the patients size and the amount of thoracic
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FIGURE 2831. Method of Magerl for xation with transarticular C1C2 screws. The patient is placed prone and the head immobilized with Mayeld skull tongs. The position of the neck needed for reduction of the deformity will inuence the exposure. A1, If the head can be exed forward, the transarticular screws can be placed through the same posterior incision; however, if extension is needed to maintain the reduction of C1 (A2), a shorter incision is needed for exposure of the posterior elements of C1C2, and the drill bit and instrumentation are passed into the wound through percutaneous incisions. B, The medial wall of the C2 pedicle should be exposed to aid in orienting the direction of the drill. The starting point for drilling is just medial to the edge of the facet joint and the inferior margin of the lamina of C2. Progress of the drill bit across the C1C2 facet should be monitored using image intensication. Illustration continued on following page
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FIGURE 2831 Continued. C, A wire or suture can be passed around the arch of C1 to assist in reduction or manipulation (or both) and for later use in securing a bone graft to the posterior elements of C1C2. D, The drill bit should be directed anteriorly and cephalad under lateral uoroscopic visualization and exit the posterior aspect of the C2 lateral mass. E, The holes are tapped, and 3.5-mm fully threaded screws between 40 and 50 mm long are inserted. F, A tricortical bone graft is harvested and secured between the posterior arches of C1 and C2. The nal lateral view is shown. (From Levine, A.M., et al. Spine Trauma. Philadelphia, W.B. Saunders, 1998, pp. 274, 275.)
kyphosis, obtaining the correct trajectory for screw placement may be difcult. It is not unusual to carry the posterior incision down to T2 to obtain the correct trajectory, or alternatively, special instruments must be used to make percutaneous approaches to the C2 pedicles. Furthermore, examination of a large number of C2
specimens has demonstrated that the size and location of the vertebral arteries within the lateral masses of C2 are quite variable.266, 273 On occasion, a vertebral artery and its associated venous plexus may ll an entire lateral mass. In view of these potential problems, it is important that preoperative CT scans be thoroughly scrutinized to
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identify these variants. Sagittal reconstructions of the axis are extremely helpful in deciding whether the vertebral artery will interfere with the placement of screws. Jeanneret and Magerl245 described the use of screws in this technique to augment Gallie wiring and posterior fusion, and under these circumstances, they did not recommend postoperative immobilization; however, in the event that wiring is not used in addition to screw placement and posterior fusion, immobilization with a semirigid collar brace is recommended.263
Anterior Stabilization of the Dens

Direct internal xation of fractures of the dens was introduced in 1980 by Nakanishi.254 Several authors have since reported on the utility of this approach for type II and type III odontoid fractures and fracture nonunions, and fracture union rates of 92% to 100% were achieved.129, 137, 225, 231, 233, 236 The reported advantage of this technique is preservation of atlantoaxial motion and the requirement for minimal postoperative immobilization.225, 236, 254 The disadvantage is that the procedure is technically difcult with the potential for catastrophic neurologic complications, as well as injury to the adjacent segment (C2C3).178 Physical characteristics that have been found to hinder fracture reduction or adequate surgical clearance of the chest include short-necked patients, cervical spines with limited motion, extreme thoracic kyphosis, barrel-chested habitus, and fracture congurations that can be held reduced only while in exion.138 Bohler recommended standard anteromedial exposure of the upper cervical spine after reduction of the fracture.225 The anterior longitudinal ligament is split longitudinally over the body of the axis. Then, under biplanar image intensication, one or two holes are drilled, starting at the anteroinferior border of C2 and progressing through the body of C2 and into the dens. After gauging depth and tapping the hole, a small-fragment cancellous lag screw is inserted (Fig. 2832). Great debate exists over the use of one or two interfragmentary screws for xation.137, 144, 233 Biomechanical studies suggest that there is no signicant biomechanical difference between the use of one or two screws and that screw xation restores the dens to half its prefracture strength.134, 144, 167 Double-threaded compression screws have been used with good results.129, 246 Postoperatively, rigid collar immobilization is recommended until union is solid.
muscle. The limitations of this technique lie in its signicant potential for morbidity and mortality. The major catastrophic complication associated with this approach was wound infection, which was initially reported to occur in 33% to 50% of cases.232, 271 More recent series have addressed the issue of wound closure in detail, and subsequently, wound infection rates have dropped tremendously.224, 247 In addition, whereas initial studies reported a 25% perioperative death rate, more recent series have not found perioperative mortality to be a problem.224, 247 Initially, the procedure involved a tracheostomy, which was fraught with complications,232 but the procedure is now performed with oral endotracheal intubation.224 The primary indication for this approach is the need for anterior decompression of the atlantoaxial region because of fracture nonunion, malunion, or infection.224, 265 Fusion of C1 and C2 can be performed from this approach with predictable success, but from the authors viewpoint, more accessible ways are available to fuse C1 and C2. After establishing the endotracheal airway, the skin and hypopharynx are prepared and draped. A self-retaining oral retractor is inserted. This retractor depresses the tongue as well as the soft palate. A separate arm of the retractor holds the endotracheal and nasogastric tubes to the side. An operating microscope is necessary for the procedure. After inltrating the posterior pharyngeal wall with a dilute epinephrine solution, a longitudinal midline incision measuring approximately 5 to 6 cm is made at the center of the anterior tubercle of the atlas. The anterior arch of the atlas and the body of the axis, as well as the atlantoaxial joints on either side, are then exposed. After the conclusion of the procedure, wound cultures are obtained in the event that the patient shows any signs of infection postoperatively. The wound is closed in layers, and antibiotic use is discontinued at 72 hours.
Lateral Retropharyngeal Approach to the Upper Cervical Spine

In the vast majority of patients, problems requiring surgery in the upper cervical spine can be handled through a standard posterior exposure. Infrequently, an anterior approach may be necessary. The problems with direct transoral approaches have already been mentioned. Therefore, a safe, extensile exposure based on Henrys approach to the vertebral artery has been developed that allows anterior exposure from the atlas caudally to the upper thoracic spine244, 269, 270 (Fig. 2833). Because instability is usually present, patients are placed in a halo preoperatively, and in the absence of contraindications, the neck is extended and rotated to the opposite side. After induction of anesthesia and sterile preparation, a hockey stick incision is begun transversely across the tip of the mastoid process and carried distally along the anterior border of the sternocleidomastoid muscle. The greater auricular nerve is identied and retracted cephalad; if it is in the way, it may be resected with a negligible sensory decit. In most cases, the sternocleidomastoid muscle is detached from the mastoid process. The spinal accessory nerve is then identied at its entrance into the sternocleidomastoid muscle approximately 3 cm from the
Transoral Approach to C1C2

The direct transoral approach to the upper cervical spine, rst described by Southwick and Robinson and later popularized by Fang and Ong, allows relatively easy access to the occipitoatlantoaxial complex for arthrodesis and decompression.232, 264 With lateral approaches, the mandible, parotid gland, branches of the external carotid artery, and the 7th, 9th, 10th, 11th, and 12th cranial nerves may interfere with exposure.232 With a more direct anterior exposure, the front of the spine is separated from the pharynx by only the pharyngeal mucosa, the constrictor muscles, the buccopharyngeal fascia, and the prevertebral
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mastoid tip. If only the C1C2 area needs to be approached, it is retracted anteriorly with the contents of the carotid sheath. If a more extensive approach is necessary, the nerve is dissected from the jugular vein up to an area near the jugular foramen and retracted laterally with the sternocleidomastoid muscle. After eversion of the sternocleidomastoid muscle, the transverse processes of the cervical vertebrae are easily palpable. The transverse process of C1 extends more
laterally than the rest and is thus especially prominent. By proceeding anteriorly along the front border of these processes and posterior to the carotid sheath and after identifying the internal jugular vein and delineating it with certainty, the vertebral artery can be avoided with safety. With further medial dissection, Sharpeys bers can be divided and the retropharyngeal space entered. Exposure of the appropriate vertebral bodies is then possible with subperiosteal stripping and, if necessary,
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Presentation
FIGURE 2832. Anterior stabilization of the dens. Positioning of the patient for anterior dens stabilization is critically important. The patient is placed in the supine position with the neck extended so that exposure of the inferior edge of C2 is possible. If fracture reduction is lost (as may happen with posteriorly displaced dens fractures), less extension should be obtained until provisional xation has been achieved. A, Biplanar image intensication is essential. B, A standard transverse incision is made on either the left or right side. A retropharyngeal approach as described by Smith-Robinson is performed at the C5C6 disc space level and the dissection carried up to the C2C3 disc space. An incision is made in the anterior longitudinal ligament at the level of the inferior portion of the C2 body. A one- or two-screw technique can then be used. C, Starting points are either side of the midline and on the caudal edge of the body, and a 1.5-mm K-wire is initially placed to ascertain the trajectory and stabilize the fragment. Two K-wires can be placed and a cannulated system used, but inadvertent advancement of the wire is a serious complication; preferably, one wire is removed and replaced at a time, with a solid 2.5-mm drill bit advancing to the tip of the dens. D, Because interfragmentary compression is desired, either a partially threaded screw can be used or one drill bit can be removed and the near fragment overdrilled with a 3.5-mm drill bit. The near cortex only is tapped.
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FIGURE 2832 Continued. E to G, This technique can be accomplished with a cannulated set as well. H and I, Final screw xation should have the screw slightly oblique toward the midline and may optionally perforate the cortex of the tip of the dens. Care should be taken to begin the screw on the undersurface and not the anterior surface of the C2 body to achieve the proper trajectory (I). (From Levine, A.M., et al. Spine Trauma. Philadelphia, W.B. Saunders, 1998, pp. 243, 244.)
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FIGURE 2833. A and B, Lateral retropharyngeal approach to the upper cervical spine. (A, B, Redrawn from Whitesides, T.E.; Kelly, R.P. South Med J 59:879883, 1966.)
Presentation Carotid sheath Sternomastoid muscle
A
Carotid sheath
Sternomastoid muscle
removal of the anterior cervical muscles down to the upper thoracic region. Localization is easy because of the prominent, transversely oriented anterior arch of C1 and the prominent vertical midline ridge of the base of the odontoid and body of C2. At the conclusion of the procedure, the sternocleidomastoid is sewn back into place over suction drains. The platysma and skin are closed in layers. Because of the potential for signicant retropharyngeal edema, postoperative intubation or prophylactic tracheostomy should be considered.
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45. Woodring, J.H.; Selke, A.C.; Duff, D.E. Traumatic atlantooccipital dislocation with survival. AJR Am J Roentgenol 137:2144, 1981. Atlas Fractures 46. Botelho, R.V.; de Souza Palma, A.M.; Abgussen, C.M.; Fontoura, E.A. Traumatic vertical atlantoaxial instability: The risk associated with skull traction. Case report and literature review. Eur Spine J 9:430433, 2000. 47. Cooper, A. A Treatise on Dislocations and Fractures of the Joints. London, Longman, Hurst Rees, Orme Browne, E. Cox & Son, 1823, p. 542. 48. Esses, S. Fracture of the atlas associated with fracture of the odontoid process. Injury 12:310312, 1981. 49. Fielding, J.W.; Cochran, G.V.B.; Lawsing, J.F Hohl, M. Tears of the .; transverse ligament of the atlas. A clinical and biomechanical study. J Bone Joint Surg Am 56:16831691, 1974. 50. Gaudagni, A.P. Fracture of the rst cervical vertebra, complicated by a cervical rib. JAMA 130:276277, 1946. 51. Gehweiler, J.A.; Daffner, R.H.; Roberts, L. Malformations of the atlas vertebra simulating the Jefferson fracture. AJR Am J Roentgenol 140:10831086, 1983. 52. Grogano, B.J.S. Injury of the atlas and axis. J Bone Joint Surg Br 33:397410, 1954. 53. Han, S.Y.; Witten, D.M.; Musselman, J.P. Jefferson fracture of the atlas. Report of six cases. J Neurosurg 44:368371, 1976. 54. Hinchey, J.J.; Bickel, W.H. Fracture of the atlas, review and presentation of data on eight cases. Ann Surg 121:826832, 1945. 55. Hohl, M.; Baker, H.R. The atlantoaxial joint. Roentgenographic and anatomical study of normal and abnormal motion. J Bone Joint Surg Am 46:17391752, 1964. 56. Jefferson, G. Fracture of the atlas vertebra. Report of four cases and a review of those previously recorded. Br J Surg 7:407422, 1920. 57. Landels, C.D.; Petegher, K.V. Fractures of the atlas: Classication, treatment and morbidity. Spine 13:450452, 1988. 58. Lee, T.T.; Green, B.A.; Petrin, D.R. Treatment of stable burst fracture of the atlas (Jefferson fracture) with rigid cervical collar. Spine 23:19631967, 1998. 59. Levine, A.M.; Edwards, C.C. Fractures of the atlas. J Bone Joint Surg Am 73:680691, 1991. 60. Levine, A.M.; Edwards, C. Treatment of injuries in the C1C2 complex. Orthop Clin North Am 17:3144, 1986. 61. Lipson, S.J. Fractures of the atlas associated with fractures of the odontoid process and transverse ligament ruptures. J Bone Joint Surg Am 59:940942, 1977. 62. Marlin, A.E.; Williams, G.R.; Lee, J.F Jefferson fractures in children. . J Neurosurg 58:277279, 1983. 63. McGuire, R.A., Jr.; Harkey, H.L. Trauma update: Unstable Jeffersons fracture treated with transarticular screws. Orthopedics 18:207 209, 1995. 64. OBrien, J.J.; Buttereld, W.L.; Gossling, J.R. Jefferson fracture with disruption of the transverse ligament. A case report. Clin Orthop 126:135138, 1977. 65. Pierce, D.S.; Ojemann, R.G. Injuries of the spine, neurologic considerations. Fractures and dislocations. In: Cave, E.G.; Burke, J.F Boyd, R.J., eds. Trauma Management. Chicago, Year Book, .; 1974, pp. 343397. 66. Rogers, W.A. Fractures and dislocations of the cervical spine. An end-result study. J Bone Joint Surg Am 39:341376, 1957. 67. Ruge, D. Spinal Disorders: Diagnosis and Treatment. Philadelphia, Lea & Febiger, 1977, p. 358. 68. Segal, L.S.; Grimm, J.O.; Stauffer, E.S. Nonunion of fractures of the atlas. J Bone Joint Surg Am 69:14231434, 1987. 69. Sherk, H.H. Lesions of the atlas and axis. Clin Orthop 109:3341, 1976. 70. Shilke, L.H.; Calahan, R.A. A rational approach to burst fractures of the atlas. Clin Orthop 154:1821, 1981. 71. Silveri, C.P.; Nelson, M.C.; Vaccaro, A.; Cotler, J.M. Traumatic injuries of the adult upper cervical spine. In: Cotler, J.M.; Simpson, J.M.; An, H.S.; Silveri, C., eds. Surgery of Spinal Trauma. Philadelphia, Lippincott Williams & Wilkins, 2000, pp. 179217. 72. Spence, K.F Decker, S.; Sell, K.W. Bursting atlantal fracture .; associated with rupture of the transverse ligament. J Bone Joint Surg Am 52:543549, 1970.
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SECTION II Spine 103. Fielding, W.J.; Stillwell, W.T; Chynn, K.Y.; Spyropoulos, E.C. Use of computed tomography for the diagnosis of atlantoaxial rotatory xation. J Bone Joint Surg Am 60:11021104, 1978. 104. Fielding, W.J.; Hawkins, R.J.; Hensinger, R.N.; Francis, W.R. Atlantoaxial rotary deformities. Orthop Clin North Am 9:955967, 1978. 105. Fiorani-Gallotta, G.; Luzzatti, G. Sublussazione lateral e sublessazione rotatoria dellante. Arch Ortop 70:467484, 1957. 106. Grisel, P. Enucleation de latlas et torticollis nasopharyngien. Presse Med 38:5053, 1930. 107. Hess, J.H.; Bronstein, I.P.; Abelson, S.M. Atlantoaxial dislocations. Unassociated with trauma and secondary to inammatory foci in the neck. Am J Dis Child 49:11371147, 1935. 108. Jacobson, G.; Adler, D.C. Examination of the atlantoaxial joint following injury: With particular emphasis on rotational subluxation. AJR Am J Roentgenol 76:10811094, 1956. 109. Jones, R.N. Rotatory dislocation of both atlantoaxial joints. J Bone Joint Surg Br 66:67, 1984. 110. Levine, A.M.; Edwards, C.C. Treatment of injuries in the C1C2 complex. Orthop Clin North Am 17:3144, 1986. 111. Levine, A.M.; Edwards, C.C. Traumatic lesions of the occipitoatlantoaxial complex. Clin Orthop 239:530568, 1989. 112. Schnieder, R.C.; Schemm, G.W. Vertebral artery insufciency in acute and chronic spinal trauma. With special reference to the syndrome of acute central cervical spinal cord injury. J Neurosurg 18:348360, 1961. 113. Watson-Jones, R. Spontaneous hyperaemic dislocation of the atlas. Proc Soc Med 25:586590, 1932. 114. Werne, S. Studies on spontaneous atlas dislocation. Acta Orthop Scand 23:1150, 1957. 115. Wittek, A. Ein Fall von Distensionsluxation im Atlantoepistrophealgelenke. Muench Med Wochenschr 55:18361837, 1908. 116. Wortzman, G.; Dewar, F Rotatory xation of the atlantoaxial .P. joint: Rotational atlantoaxial subluxation. Radiology 90:479487, 1968.
73. Steel, H.H. Anatomical and mechanical considerations of the atlantoaxial articulations. Proceedings of the American Orthopedic Association. J Bone Joint Surg Am 50:14811482, 1968. 74. White, A.A., III; Panjabi, M.M. Clinical Biomechanics of the Spine. Philadelphia, J.B. Lippincott, 1978, pp. 9297. 75. Zimmerman, E.; Grank, J.; Vise, W.M.; et al. Treatment of Jefferson fracture with a halo apparatus. J Neurosurg 44:372375, 1976. Atlantoaxial Instability 76. Brooks, A.L.; Jenkins, E.W. Atlantoaxial arthrodesis by the wedge compression method. J Bone Joint Surg Am 60:279284, 1978. 77. Cabot, A.; Becker, A. The cervical spine in rheumatoid arthritis. Clin Orthop 121:130140, 1978. 78. Conlon, P.W.; Isdale, I.C.; Rose, B.S. Rheumatoid arthritis of the cervical spine: An analysis of 333 cases. J Am Rheum Dis 25:120126, 1966. 79. De Beer, J.D.; Thomas, M.; Walter, J.; Anderson, P. Traumatic atlantoaxial subluxation. J Bone Joint Surg Br 70:652655, 1988. 80. Dunbar, H.S.; Ray, B.S. Chronic atlantoaxial dislocations with late neurologic manifestation. Surg Gynecol Obstet 113:757762, 1961. 81. Evarts, C.M. Traumatic occipitoatlantal dislocation. Report of a case with survival. J Bone Joint Surg Am 52:16531660, 1970. 82. Fielding, J.W.; Cochran, G.V.B.; Lawsing, J.F Hall, M. Tears of the .; transverse ligament of the atlas: A clinical and biomechanical study. J Bone Joint Surg Am 56:16811691, 1974. 83. Fielding, J.W.; Hawkins, R.J.; Ratzan, S.A. Spine fusion for atlantoaxial instability. J Bone Joint Surg Am 58:400407, 1976. 84. Gallie, W.E. Fractures and dislocations of the cervical spine. Am J Surg 46:495499, 1939. 85. Goel, A.; Muzumdar, D.; Dindorkar, K.; Desai, K. Atlantoaxial dislocation associated with stenosis of canal at atlas. J Postgrad Med 43:7577, 1997. 86. Grogono, B.J.S. Injuries of the atlas and axis. J Bone Joint Surg Br 36:397410, 1954. 87. Hanson, P.B.; Montesano, P.X.; Sharkey, N.A.; Rauschning, W. Anatomic and biomechanical assessment of transarticular screw xation for atlantoaxial instability. Spine 16:11411145, 1991. 88. Hensinger, R.N.; MacEwen, G.D. Congenital anomalies of the spine. In: Rothman, R.H.; Simeone, F .A., eds. The Spine. Philadelphia, W.B. Saunders, 1982, pp. 194201. 89. Hentzer, L.; Schalimtzek, M. Fractures and subluxations of the atlas and axis. Acta Orthop Scand 42:251258, 1971. 90. Hinck, V.C.; Hopkins, C.E.; Savara, B.S. Sagittal diameter of the cervical spinal canal in children. Radiology 79:97108, 1962. 91. Jackson, H. The diagnosis of minimal atlantoaxial subluxations. Br J Radiol 23:672674, 1950. 92. Levine, A.M.; Edwards, C.C. Traumatic lesions of the occipitoatlantoaxial complex. Clin Orthop 239:5368, 1989. 93. Levine, A.M.; Edwards, C.C. Treatment of injuries in the C1C2 complex. Orthop Clin North Am 17:3144, 1986. 94. Martel, W. The occipitoatlantoaxial joints in rheumatoid arthritis and ankylosing spondylitis. AJR Am J Roentgenol 86:223240, 1960. 95. Przybylski, G.J.; Welch, W.C. Longitudinal atlantoaxial dislocation with type III odontoid fracture. Case report and review of the literature. J Neurosurg 84:666670, 1996. 96. Rodrigues, F .A.C.; Hodgson, B.F Craig, J.B. Posterior atlantoaxial .; arthrodesis: A simplied method. Spine 16:878880, 1991. 97. Steel, H.H. Anatomical and mechanical considerations of the atlantoaxial articulations. Proceedings of the American Orthopaedic Association. J Bone Joint Surg Am 50:14811482, 1968. 98. von Torklus, D.; Gehle, W. The Upper Cervical Spine. New York, Grune & Stratton, 1972. 99. Wigren, A. Traumatic atlantoaxial dislocation without neurological disorder. A case report. J Bone Joint Surg Am 55:642644, 1973. Atlantoaxial Rotatory Subluxations and Dislocations 100. Corner, E.S. Rotary dislocations of the atlas. Ann Surg 45:926, 1907. 101. Coutts, M.B. Rotary dislocations of the atlas. Ann Surg 29:297311, 1934. 102. Fielding, W.J.; Hawkins, R.J. Atlantoaxial rotatory xation (xed rotatory subluxation of the atlantoaxial joint). J Bone Joint Surg Am 59:3744, 1977.
Odontoid Fractures 117. Anderson, L.D.; DAlonzo, R.T. Fractures of the odontoid process of the axis. J Bone Joint Surg Am 56:663674, 1974. 118. Andersson, S.; Rodrigues, M.; Olerud, C. Odontoid fractures: High complication rate associated with anterior screw xation in the elderly. Eur Spine J 9:5659, 2000. 119. Apfelbaum, R.I.; Lonser, R.R.; Veres, R.; Casey, A. Direct anterior screw xation for recent and remote odontoid fractures. J Neurosurg 93:227236, 2000. 120. Alker, G.J., Jr.; Oh, Y.S.; Leslie, E.V. High cervical spine and craniocervical injuries in fatal trafc accidents. Orthop Clin North Am 9:10031010, 1978. 121. Apuzzo, M.L.J.; Heiden, J.S.; Weiss, M.H.; et al. Acute fractures of the odontoid process. An analysis of 45 cases. J Neurosurg 48:8591, 1978. 122. Aymes, E.W.; Anderson, E.M. Fracture of the odontoid process. Arch Surg 72:377393, 1956. 123. Bergenheim, A.T.; Forssel, A. Vertical odontoid fracture: Case report. J Neurosurg 74:665667, 1991. 124. Bohler, J. Fractures of the odontoid process. J Trauma 5:386390, 1965. 125. Bohlman, H.H. Acute fractures and dislocations of the cervical spine. An analysis of three hundred hospitalized patients and review of the literature. J Bone Joint Surg Am 61:11191142, 1979. 126. Bucholz, R.W.; Burkhead, W.Z. The pathological anatomy of fatal atlantooccipital dislocations. J Bone Joint Surg Am 61:248250, 1979. 127. Campanelli, M.; Kattner, K.A.; Stroink, A.; et al. Posterior C1C2 transarticular screw xation in the treatment of displaced type II odontoid fractures in the geriatric populationreview of seven cases. Surg Neurol 51:596600, 1999. 128. Chan, D.D.K.; Morwessel, R.M.; Leung, K.Y.K. Treatment of odontoid fractures with halo cast immobilization. Orthop Trans 5:118119, 1981. 129. Chang, K.W.; Liu, Y.W., Cheng, P.G.; et al. One Herbert doublethreaded compression screw xation of displaced type II odontoid fractures. J Spinal Disord 7:6269, 1994.
CHAPTER 28 Injuries of the Cervicocranium 130. Clark, C.R.; White, A.A. Fractures of the dens. A multicenter study. J Bone Joint Surg Am 67:13401348, 1985. 131. Cooper, P.R.; Maravilla, K.R.; Sklar, F .H.; et al. Halo immobilization of cervical spine fractures. Indications and results. J Neurosurg 50:603610, 1979. 132. Crooks, F Birkett, A.N. Fractures and dislocations of the cervical .; spine. Br J Surg 31:252265, 1944. 133. Crockard, H.A.; Heilman, A.E.; Stevens, J.M. Progressive myelopathy secondary to odontoid fractures: Clinical, radiological, and surgical features. J Neurosurg 78:579586, 1993. 134. Doherty, B.J.; Heggeness, M.H.; Esses, S.I. A biomechanical study of odontoid fractures and fracture xation. Spine 18:178184, 1993. 135. Donovan, M.M. Efcacy of rigid xation of fractures of the odontoid process. Retrospective analysis of fty-four cases. Orthop Trans 4:46, 1980. 136. Ehara, S.; el-Khoury, G.Y.; Clark, C.R. Radiologic evaluation of dens fracture: Role of plain radiography and tomography. Spine 17:475 479, 1992. 137. Esses, S.I.; Bednar, D.A. Screw xation of odontoid fractures and nonunions. Spine 16(Suppl):483485, 1991. 138. Etter, C.; Coscia, M.; Jaberg, H.; Aebi, M. Direct anterior xation of dens fractures with a cannulated screw system. Spine 16(Suppl): 2532, 1991. 139. Farey, I.D.; Nadkarni, S.; Smith, N. Modied Gallie technique versus transarticular screw xation in C1C2 fusion. Clin Orthop 359:126135, 1999. 140. Fielding, J.W.; Hensinger, R.N.; Hawkins, R.J. Os odontoideum. J Bone Joint Surg Am 62:376383, 1980. 141. Fielding, J.W.; Hawkins, R.R.; Ratzan, S.A. Spine fusion for atlantoaxial instability. J Bone Joint Surg Am 58:400407, 1976. 142. Fuji, T.; Oda, T.; Kato, Y.; et al. Accuracy of atlantoaxial transarticular screw insertion. Spine 25:17601764, 2000. 143. Govender, S.; Maharaj, J.F Haffajee, M.R. Fractures of the odontoid .; process. J Bone Joint Surg Br 82:11431147, 2000. 144. Graziano, G.; Jaggers, C.; Lee, M.; Lynch, W. A comparative study of xation techniques for type II fractures of the odontoid process. Spine 18:23832387, 1993. 145. Greene, K.A.; Dickman, C.A.; Marciano, C.F et al. Transverse .; atlantal ligament disruption associated with odontoid fractures. Spine 19:23072314, 1994. 146. Griswold, D.M.; Albright, J.A.; Schiffman, E.; et al. Atlantoaxial fusion for instability. J Bone Joint Surg Am 60:285292, 1978. 147. Hacker, R.J. Screw xation for odontoid fracture; a comparison of the anterior and posterior technique. Nebr Med J 81:275278, 1996. 148. Hanigan, W.C.; Powell, F .C.; Elwood, P.W.; Henderson, J.P. Odontoid fractures in elderly patients. J Neurosurg 78:3235, 1993. 149. Hart, R.; Saterbak, A.; Rapp, T.; Clark, C. Non-operative management of dens fracture nonunion in elderly patients without myelopathy. Spine 25:13391343, 2000. 150. Heller, J.G.; Alson, M.D.; Schafer, M.B.; Garn, S.R. Quantitative internal dens morphology. Spine 17:861866, 1992. 151. Henry, A.D.; Bohly, J.; Grosse, A. Fixation of odontoid fractures by an anterior screw. J Bone Joint Surg Br 81:472477, 1999. 152. Julien, T.D.; Frankel, B.; Traynelis, V.C.; Ryken, T.C. Evidencebased analysis of odontoid fracture management. Neurosurg Focus 8:16, 2000. 153. Jun, B.Y. Anatomic study for ideal and safe posterior C1C2 transarticular screw xation. Spine 23:17031707, 1998. 154. Jun, B.Y. Complete reduction of retro-odontoid soft tissue mass in os odontoideum following the posterior C1C2 transarticular screw xation. Spine 24:19611964, 1999. 155. Lennarson, P.J.; Mostafavi, H.; Traynelis, V.C.; Walters, B.C. Management of type II dens fractures: A case-control study. Spine 25:12341237, 2000. 156. Lind, B.; Nordwall, A.; Sihlbom, H. Odontoid fractures treated with halo-vest. Spine 12:173177, 1987. 157. Madawi, A.A.; Casey, A.T.; Solanki, G.A.; et al. Radiological and anatomical evaluation of the atlantoaxial transarticular screw xation technique. J Neurosurg 86:961968, 1997. 158. Marar, B.C.; Tay, C.K. Fracture of the odontoid process. Aust N Z J Surg 46:231236, 1976.
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159. Mouradian, W.H.; Fietti, V.G., Jr.; Cochran, G.V.B.; et al. Fracture of the odontoid: A laboratory and clinical study of mechanisms. Orthop Clin North Am 9:9851001, 1978. 160. Murphy, M.J.; Wu, J.C.; Southwick, W.O. Complications of halo xation. Orthop Trans 3:126, 1979. 161. Nachemson, A. Fracture of the odontoid process of the axis: A clinical study based on 26 cases. Acta Orthop Scand 29:185217, 1959. 162. Nadim, Y.; Sabry, F Xu, R.; Ebraheim, N. Computed tomography .; in the determination of transarticular C1C2 screw length. Orthopedics 23:373375, 2000. 163. Paramore, C.G.; Dickman, C.A.; Sonntag, V.K. The anatomical suitability of the C12 complex for transarticular screw xation. J Neurosurg 85:221224, 1996. 164. Pepin, J.W.; Bourne, R.B.; Hawkins R.J. Odontoid fractures of the axis with special reference to the elderly patient. Orthop Trans 5:119, 1981. 165. Polin, R.S.; Szabo, T.; Bogaev, C.A.; et al. Non-operative management of types II and III odontoid fractures: The Philadelphia collar versus the halo vest. Neurosurgery 38:450456, 1996. 166. Ryan, M.D.; Taylor, T.K.F Odontoid fractures. A rational approach . to treatment. J Bone Joint Surg Br 64:416421, 1982. 167. Sasso, R.; Doherty, B.J.; Crawford, M.J.; Heggeness, M.H. Biomechanics of odontoid fracture xation: Comparison of the one- and two-screw technique. Spine 18:19501953, 1993. 168. Schafer, M.B.; Alson, M.D.; Heller, J.G.; Garn, S.R. Morphology of the dens: A quantitative study. Spine 17:738743, 1992. 169. Schatzker, J.; Rorabeck, C.H.; Waddell, J.P. Fractures of the dens. Analysis of thirty-seven cases. J Bone Joint Surg Br 53:392405, 1971. 170. Schiff, D.C.M.; Parke, W.W. The arterial supply of the odontoid process. J Bone Joint Surg Am 55:14501456, 1973. 171. Sherk, H.H. Fractures of the atlas and odontoid process. Orthop Clin North Am 9:973984, 1978. 172. Skold, G. Fractures of the neural arch and odontoid process of the axis. A study of their causation. Z Rechtsmed 82:89103, 1978. 173. Solanki, G.A.; Crockard, H.A. Preoperative determination of safe superior transarticular screw trajectory through the lateral mass. Spine 24:14771482, 1999. 174. Southwick, W.O. Current concepts review. Management of fractures of the dens (odontoid process). J Bone Joint Surg Am 62:482486, 1980. 175. Stoney, J.; OBrien, J.; Wilde, P. Treatment of type-two odontoid fractures in halothoracic vests. J Bone Joint Surg Br 80:452455, 1998. 176. Sweigel, J.G. Halothoracic brace in the management of odontoid fractures. Orthop Trans 3:126, 1979. 177. Vaccaro, A.R.; Cook, C.M.; McCullen, G.; Garn, S.R. Cervical trauma: Rationale for selecting the appropriate fusion technique. Orthop Clin North Am 29:745754, 1998. 178. Verheggen, R.; Jansen, J. Fractures of the odontoid process: Analysis of the functional results after surgery. Eur Spine J 3:146 150, 1994. 179. Ziai, W.C.; Hurlbert, R.J. A six-year review of odontoid fractures: The emerging role of surgical intervention. Can J Neurol Sci 27:297301, 2000. C2 Lateral Mass Fractures 180. Blauth, M.; Lange, U.F Knop, C.; Bastian, L. [Spinal fractures in the .; elderly and their treatment.] Orthopade 29:302317, 2000. 181. Finelli, F .C.; Jonsson, J.; Champion, H.R.; et al. A case control study for major trauma in geriatric patients. J Trauma 29:541548, 1989. 182. Hadley, M.N.; Dickman, C.A.; Browner, C.M.; Sonntag, V.K. Acute traumatic atlas fractures: Management and long term outcome. Neurosurgery 23:3135, 1988. 183. Johnston, R.A. Management of old people with neck trauma. BMJ 299:633634, 1989. 184. Levine, A.M.; Edwards, C.C. Traumatic lesions of the occipitoatlantoaxial complex. Clin Orthop 239:5368, 1989. 185. Lind, B.; Bake, B.; Lundqvist, C.; Nordwall, A. Inuence of halo vest treatment on vital capacity. Spine 12:449452, 1987.
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SECTION II Spine 213. Roy-Camille, R. Recent Advances in Orthopaedics, Vol. 3. Edinburgh, Churchill Livingstone, 1979. 214. Schneider, K.C.; Livingston, D.; Cave, A.; Hamilton, G. Hangmans fracture of the cervical spine. J Neurosurg 22:141, 1965. 215. Seljeskog, E.L. Nonoperative management of acute upper cervical injuries. Acta Neurochir (Wien) 41:87100, 1978. 216. Sherk, H.H.; Howard, T. Clinical and pathologic correlations in traumatic spondylolisthesis of the axis. Clin Orthop 174:122126, 1983. 217. Starr, J.K.; Eismont, F Atypical hangmans fractures. Spine .J. 18:19541957, 1993. 218. Termansen, N.B. Hangmans fracture. Acta Orthop Scand 445:529 539, 1974. 219. Tuite, G.F Papadoupoulos, S.M.; Sonntag, V.K.H. Caspar plate .; xation for the treatment of complex hangmans fractures. Neurosurgery 30:761765, 1992. 220. Vermooten, V. A study of the fracture of the epistropheus due to hanging with a note of the possible causes of death. Anat Rec 20:305311, 1921. 221. White, A.A. Hangmans fracture with nonunion and late cord compression. A case report. J Bone Joint Surg Am 60:839840, 1978. 222. Williams, T.G. Hangmans fracture. J Bone Joint Surg Br 57:8288, 1975. 223. Wood-Jones, F The ideal lesion produced by judicial hanging. . Lancet 1:53, 1913.
186. Olerud, C.; Andersson, S.; Svensson, B.; Bring, J. Cervical spine fractures in the elderly: Factors inuencing survival in 65 cases. Acta Orthop Scand 70:509513, 1999. 187. Pepin, J.W.; Bourne, R.B.; Hawkins, R.J. Odontoid fractures, with special reference to the elderly patient. Clin Orthop 193:178183, 1985. 188. Ryan, M.D.; Henderson, J.J. The epidemiology of fractures and fracture-dislocations of the cervical spine. Injury 23:3840, 1992. 189. Seybold, E.A.; Bayley, J.C. Functional outcome of surgically and conservatively managed dens fractures. Spine 23:18371845, 1998. 190. Signoret, F Feron, J.M.; Bunfait, H.; Patel, A. Fractured odontoid .; with fractured superior articular process of the axis: Repair of three cases. J Bone Joint Surg Am 68:182184, 1985. 191. Sonntag, V.K.; Hadley, M.N. Nonoperative management of cervical spine injuries. Clin Neurosurg 34:630649, 1988. 192. Taitsman, L.; Hecht, A.C.; Pedlow, F Complications of halo .X. treatment in elderly patients with cervical spine fractures. Submitted for publication. 193. Weller, S.J.; Malek, A.M.; Rossitch, E. Cervical spine fractures in the elderly. Surg Neurol 47:274280, 1997. Traumatic Spondylolisthesis of the Axis 194. Borne, G.M.; Bedou, G.L.; Pinaudeau, M. Treatment of pedicular fractures of the axis. A clinical study and screw xation technique. J Neurosurg 60:8893, 1984. 195. Brashear, H.R.; Venters, G.C.; Preston, E.T. Fractures of the neural arch of the axis. A report of twenty-nine cases. J Bone Joint Surg Am 57:879887, 1975. 196. Bucholz, R.W. Unstable hangmans fractures. Clin Orthop 154:119 124, 1981. 197. Coric, D.; Wilson, J.A.; Kelly, D.L., Jr. Treatment of traumatic spondylolisthesis of the axis with nonrigid immobilization: A review of 64 cases. J Neurosurg 85:550554, 1996. 198. Cornish, B.L. Traumatic spondylolisthesis of the axis. J Bone Joint Surg Br 50:3143, 1968. 199. Dussult, R.G.; Effendi, B.; Roy, D.; et al. Locked facets with fracture of the neural arch of the axis. Spine 8:365367, 1983. 200. Effendi, B.; Roy, D.; Cornish, B.; et al. Fractures of the ring of the axis. A classication based on the analysis of 131 cases. J Bone Joint Surg Br 63:319327, 1981. 201. Francis, W.R.; Fielding, J.W. Traumatic spondylolisthesis of the axis. Orthop Clin North Am 9:10111027, 1978. 202. Francis, W.R.; Fielding, J.W.; Hawkins, R.J.; et al. Traumatic spondylolisthesis of the axis. J Bone Joint Surg Br 63:313318, 1981. 203. Garber, J.N. Abnormalities of the atlas and axis vertebra: Congenital and traumatic. J Bone Joint Surg Am 46:17821791, 1964. 204. Greene, K.A.; Dickman, C.A.; Marciano, F .; et al. Acute axis .F fractures. Analysis of management and outcome in 340 consecutive cases. Spine 22:18431852, 1997. 205. Grogono, B.J.S. Injuries of the atlas and axis. J Bone Joint Surg Br 36:397410, 1954. 206. Gross, J.D.; Benzel, E.C. Non-operative treatment of hangmans fracture. In: Zdeblick, T.A.; Benzel, E.C.; Anderson, P.A.; Stillerman, C.B., eds. Controversies in Spine Surgery. St Louis, Quality Medical Publishing, 1999, pp. 5171. 207. Hadley, M.N.; Sonntag, V.K.; Graham, T.W.; et al. Axis fractures resulting from motor vehicle accidents. The need for occupant restraints. Spine 11:861864, 1986. 208. Haughton, S. On hanging, considered from a mechanical and physiological point of view. Lond Edinb Dublin Philos Mag J Sci 32:2334, 1886. 209. Levine, A.M.; Edwards, C.C. The management of traumatic spondylolisthesis of the axis. J Bone Joint Surg Am 67:217226, 1985. 210. Marar, B.C. Fracture of the axis arch. Clin Orthop 106:155165, 1975. 211. Pelker, R.R.; Dorfman, G.S. Fracture of the axis associated with vertebral artery injury. A case report. Spine 11:621623, 1986. 212. Pepin, J.W.; Hawkins, R.J. Traumatic spondylolisthesis of the axis: Hangmans fracture. Clin Orthop 157:133138, 1981.
Surgical Techniques 224. Ashraf, J.; Crockard, H.A. Transoral fusion for high cervical fractures. J Bone Joint Surg Br 72:7679, 1990. 225. Bohler, J. Anterior stabilization for acute fractures and nonunions of the dens. J Bone Joint Surg Am 64:1827, 1982. 226. Brooks, A.L.; Jenkins, E.B. Atlantoaxial arthrodesis by the wedge compression method. J Bone Joint Surg Am 60:279284, 1978. 227. Casey, A.T.; Madawi, A.A.; Veres, R.; Crockard, H.A. Is the technique of posterior transarticular screw xation suitable for rheumatoid atlanto-axial subluxation? Br J Neurosurg 11:508519, 1997 228. Cantore, G.; Ciappetta, P.; Delne, R. New steel device of occipitocervical xation. J Neurosurg 60:11041106, 1984. 229. Cone, W.; Turner, W.G. The treatment of the fracture-dislocation of the cervical vertebrae by skeletal traction and fusion. J Bone Joint Surg Am 19:584602, 1937. 230. Crockard, A. Evaluation of spinal laminar xation by a new, exible stainless steel cable (Sofwire): Early results. Neurosurgery 35:892 898, 1994. 231. Elia, M.; Mazzara, J.T.; Fielding, J.W. Onlay technique for occipitocervical fusion. Clin Orthop 280:170178, 1992. 232. Fang, H.S.Y.; Ong, G.B. Direct anterior approach to the upper cervical spine. J Bone Joint Surg Am 44:15881604, 1962. 233. Fehlings, M.G.; Errico, T.; Cooper, P.; et al. Occipitocervical fusion with a ve-millimeter malleable rod and segmental xation. Neurosurgery 32:198207, 1993. 234. Fielding, J.W.; Hawkins, R.J.; Ratzan, S.A. Spine fusion for atlantoaxial instability. J Bone Joint Surg Am 58:400407, 1976. 235. Fried, L.C. Atlantoaxial fractures. Failure of posterior C1 to C2 fusion. J Bone Joint Surg Br 55:490496, 1973. 236. Fujii, E.; Kobayashi, K.; Hirabayashi, K. Treatment in fractures of the odontoid process. Spine 13:604609, 1988. 237. Gallie, W.E. Fractures and dislocation of the cervical spine. Am J Surg 46:495499, 1939. 238. Griswold, D.M.; Albright, J.A.; Schiffman, E.; et al. Atlantoaxial fusion for instability. J Bone Joint Surg Am 60:285292, 1978. 239. Grob, D.; An, H.S. Posterior occiput and C-1 and C-2 instrumentation. In: An, H.S.; Cotler, J.M., eds. Spinal Instrumentation. Philadelphia, Lippincott Williams & Wilkins, 2000, pp. 191201. 240. Grob, D.; Crisco, J.J., III; Panjabi, M.M.; et al. Biomechanical evaluation of four different posterior atlantoaxial xation techniques. Spine 17:480490, 1992.
CHAPTER 28 Injuries of the Cervicocranium 241. Grob, D.; Dvorak, J.; Panjabi, M.; et al. Posterior occipitocervical fusion: A preliminary report of a new technique. Spine 16(Suppl): 1724, 1991. 242. Grob, D.; Dvorak, J.; Panjabi, M.; Antinnes, J.A. The role of plate and screw xation in occipitocervical fusion in rheumatoid arthritis. Spine 19:25452551, 1994. 243. Grob, D.; Jeanneret, B.; Aebi, M. Atlantoaxial fusion with transarticular screw xation. J Bone Joint Surg Br 73:972976, 1991. 244. Henry, A.K. Extensile Exposure, 2nd ed. Edinburgh, E. & S. Livingstone, 1957, pp. 5380. 245. Jeanneret, B.; Magerl, F Primary posterior fusion C1/2 in odontoid . fractures: Indications, technique, and results of transarticular screw xation. J Spinal Disord 5:464475, 1992. 246. Knoringer, P. Osteosynthesis of injuries and rheumatic or congenital instabilities of the upper cervical spine using double-threaded screws. Neurosurg Rev 15:275283, 1992. 247. Levine, A.M.; Lutz, B. Extension teardrop injuries of the cervical spine. Paper presented at the 21st Annual Meeting of the Cervical Spine Research Society, New York, December 1993. 248. Louis, R. Anterior surgery of the upper cervical spine. Chir Organi Mov 77:7580, 1992. 249. Mandel, I.M.; Kambach, B.J.; Petersilge, C.A.; et al. Morphologic considerations of C2 isthmus dimensions for the placement of transarticular screws. Spine 25:15421547, 2000. 250. McAfee, P.C.; Cassidy, J.R.; Davis, R.F et al. Fusion of the occiput .; to the upper cervical spine: A review of 37 cases. Spine 16(Suppl):490494, 1991. 251. McGraw, R.W.; Rusch, R.M. Atlantoaxial arthrodesis. J Bone Joint Surg Br 55:482489, 1973. 252. Montesano, P.X.; Anderson, P.A.; Schlehr, F et al. Odontoid .; fractures treated by anterior odontoid screw xation. Spine 16(Suppl):3337, 1991. 253. Murphy, M.J.; Southwick, W.O. Posterior approaches and fusions. In: Editorial Committee of Cervical Spine Research Society. The Cervical Spine. Philadelphia, J.B. Lippincott, 1989, pp. 775791. 254. Nakanishi, T. [Internal xation of odontoid fracture] [Japanese]. Orthop Traumat Surg 23:399406, 1980. 255. Oda, I.; Abumi, K.; Sell, L.C.; et al. Biomechanical evaluation of ve different occipito-atlanto-axial xation techniques. Spine 24:2377 2382, 1999. 256. Perry, J.; Nickel, V. Total cervical fusion of neck paralysis. J Bone Joint Surg Am 41:3760, 1959. 257. Ransford, A.O.; Crockard, H.A.; Pozo, J.L.; et al. Craniocervical instability treated by contoured loop xation. J Bone Joint Surg Br 68:173177, 1986.
813
258. Robinson, R.A.; Southwick, W.O. Surgical approaches to the cervical spine. Instr Course Lect, Vol. 17, 1960. 259. Rogers, W.A. Treatment of fracture-dislocation of the cervical spine. J Bone Joint Surg 24:245258, 1942. 260. Roy-Camille, R.; Saillant, G.; Mazel, C. Internal xation of the unstable cervical spine by a posterior osteosynthesis with plates and screws. In: Sherk, H.H.; Dunn, H.J.; Eismont, J.J.; et al., eds. The Cervical Spine, 2nd ed. Philadelphia, J.B. Lippincott, 1989, pp. 390403. 261. Sasso, R.C.; Jeanneret, B.; Fischer, K.; Magerl, F Occipitocervical . fusion with posterior plate and screw instrumentation: A long-term follow-up study. Spine 19:23642368, 1994. 262. Smith, M.D.; Anderson, P.; Grady, M.S. Occipitocervical arthrodesis using contoured plate xation. Spine 18:19841990, 1993. 263. Stillerman, C.B.; Wilson, J.A. Atlantoaxial stabilization with posterior transarticular screw xation: Technical description and report of 22 cases. Neurosurgery 32:948955, 1993. 264. Southwick, W.O.; Robinson, R.A. Surgical approaches to the vertebral bodies in the cervical and lumbar regions. J Bone Joint Surg Am 39:631644, 1957. 265. Subin, B.; Liu, J.F Marshall, G.J. Transoral anterior decompression .; and fusion of chronic irreducible atlantoaxial dislocation with spinal cord compression. Spine 20:12331240, 1995. 266. Tominaga, T.; Dickman, C.A.; Sonntag, V.K.H.; Coons, S. Comparative anatomy of the baboon and the human cervical spine. Spine 20:131137, 1995. 267. Weiland, D.J.; McAfee, P.C. Posterior cervical fusion with triple-wire strut graft technique: One hundred consecutive patients. J Spinal Disord 4:1521, 1991. 268. Wheeler, T. Variability in the spinal column as regards defective neural arches (rudimentary spina bida). Contrib Embryol 9:97 107, 1920. 269. White, A.A., III; Panjabi, M.M. Biomechanics of the occipitoatlantoaxial complex. Orthop Clin North Am 9:867883, 1966. 270. Whitesides, T.E.G., Jr.; Kelly, R.P. Lateral approach to the upper cervical spine for anterior fusion. South Med J 59:879883, 1966. 271. Whitesides, T.E.G., Jr.; McDonald, A.P. Lateral retropharyngeal approach to the upper cervical spine. Orthop Clin North Am 9:11151127, 1978. 272. Willard, D.; Nicholson, J.T. Dislocation of the rst cervical vertebra. Ann Surg 113:464475, 1941. 273. Xu, R.; Nadaud, M.C.; Ebraheim, N.A.; Teasting, R.A. Morphology of the second cervical vertebra and the posterior projection of the C2 pedicle. Spine 20:259263, 1995.

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alcohol intoxication, multiple injuries, and inadequate radiographs.

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Apical (dental) ligament

Alar (dental) ligament

FIGURE 282. Coronal anatomy of the cervicocranium.

Transverse (atlantal) ligament Presentation Body of axis

Tectorial membrane (divided)

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CHAPTER 28 Injuries of the Cervicocranium

Presentation Anterior arch of atlas

FIGURE 283. The atlantoaxial articulation.

OCCIPITAL CONDYLE FRACTURES

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CHAPTER 28 Injuries of the Cervicocranium

Anterior arch of atlas

Posterior arch of atlas

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Posterior arch fracture

Anterior arch fracture Print Graphic

Transverse process fracture

Comminuted, or lateral mass, fracture

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CHAPTER 28 Injuries of the Cervicocranium

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Print Graphic Print Graphic

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CHAPTER 28 Injuries of the Cervicocranium

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ATLANTOAXIAL ROTATORY SUBLUXATIONS AND DISLOCATIONS

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CHAPTER 28 Injuries of the Cervicocranium

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CHAPTER 28 Injuries of the Cervicocranium

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Print Graphic Anterior ascending artery Presentation Left vertebral artery

FIGURE 2821. Vascular anatomy of the odontoid process.

Posterior ascending artery

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CHAPTER 28 Injuries of the Cervicocranium

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CHAPTER 28 Injuries of the Cervicocranium

FRACTURES IN OLDER PATIENTS

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CHAPTER 28 Injuries of the Cervicocranium

occur after injury and necessitate C1C2 stabilization at a later date.

TRAUMATIC SPONDYLOLISTHESIS OF THE AXIS

C2 LATERAL MASS FRACTURES

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CHAPTER 28 Injuries of the Cervicocranium

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CHAPTER 28 Injuries of the Cervicocranium

SURGICAL TECHNIQUES Bracing

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Foramen magnum Bone graft

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