Download PDF
Indian Journal of Neurotrauma 2005; 02(02): 117-125
DOI: 10.1016/S0973-0508(05)80026-7
Original Article
Thieme Medical and Scientific Publishers Private Ltd.

Management of post traumatic cranio vertebral junction instability

Manas Kumar Panigrahi
,
Beeram Vamsee Mohan
,
AK Purohit
Subject Editor:
Further Information

Publication History

Publication Date:
05 April 2017 (online)

  PDF Download  Permissions and Reprints

Abstract

The occipito-atlanto-axial complex is a transition zone between vertebral joint structures and the skull. It is unique in that it allows extensive motion and yet its vertebrae are inter-locked to form an amazingly stable structure. Trauma in this region constitutes to above 25–30% cervical spine injuries. In a retrospective review of 490 cervical spine fractures during a 9-year period, we found 91 fractures involving cranio vertebral junction. Of the 91 patients, 54 had odontoid fractures, 22 had Hangman's fractures, 9 had miscellaneous fractures of C2, 5 had isolated C1 fractures and 1 patient presented with occipito atlantal dislocation. Age, sex, presence of associated injuries, neurological status at admission, treatment, and results of the treatment characterized each case. Excluding two patients who died within the first month of injury and two patients who went against medical advice, follow up data is available for 85 of 91 patients. Two patients were lost to follow up. In all 85 out of 91 patients followed for a median duration of 3.8 years ranging from one week to 8 years. Cranio Vertebral junction trauma constituted about 18.5% of total cervical spinal injuries admitted during this period.

Neurological compromise in cranio vertebral junction trauma was noted to be 40.6% in our series. The patients with isolated atlas fractures, stable type I and type III odontoid fractures, hangman's fractures and miscellaneous fractures do well with non operative management.

For type II odontoid fractures because of the high nonunion rates associated with non operative treatment, we recommend surgical management with direct anterior odontoid screw fixation within 6 months of injury, and Posterior transarticular screw fixation for fractures after 6 months of injury.

The overall patient satisfaction for daily survival was better with surgery and collar as compared to halo.

Keywords

Atlas fracture - Axis fracture - CV junction - Halo stabilization - Hangman's fracture - Odontoid fracture
 

  • References

  • 1 Traynelis VC. Evidence based management of type II odontoid fractures. Clin Neurosurg 44 1997; 41-49
    PubMedGoogle Scholar
  • 2 Keller RB. Outcomes research in orthopedics. J Am Acad Orthp Surg 01 1993; 122-129
    PubMedGoogle Scholar
  • 3 Alexander JT, Haid Jr RW. Upper cervical spine trauma. Outcome assessment. Clin Neurosurg 44 1993; 305-313
    PubMedGoogle Scholar
  • 4 Landells CD, Van Peteghem PK. Fractures of the atlas: Classification, treatment and morbidity. Spine 13 1988; 450-452
    CrossrefPubMedGoogle Scholar
  • 5 Dickman CA, Papadopoulos SM, Sonntag VK. et al Traumatic occipitoatlantal dislocations [review]. J Spinal Disord 06 1993; 300-313
    CrossrefPubMedGoogle Scholar
  • 6 Powers B, Miller MD, Kramer RS. et al Traumatic anterior atlanto occipital dislocation. Neurosurgery 04 1979; 12-17
    CrossrefPubMedGoogle Scholar
  • 7 Bohlman HH. 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 1979; 1119-1142
    PubMedGoogle Scholar
  • 8 Fowler JL, Sandhu A, Faser RD. A review of fractures of the atlas vertebra (review). J Spinal Disord 03 1990; 19-24
    PubMedGoogle Scholar
  • 9 Hadley MN, Dickman CA, Browner CM. et al Acute traumatic atlas fractures: Management and long term outcome. Neurosurgery 23 1998; 31-35
    PubMedGoogle Scholar
  • 10 Lipson SJ. Fractures of the atlas associated with fractures of the odontoid process and transverse ligament ruptures. J Bone Joint Surg (Am) 59 1977; 940-943
    PubMedGoogle Scholar
  • 11 Sherk HH, Nicholoson JT. Fractures of the atlas. J Bone Joint Surg (Am) 52 1970; 1017-1024
    PubMedGoogle Scholar
  • 12 Spence Jr KF, Decker S, sell KW. Bursting atlantal fractures associated with rupture of the transverse ligament. J Bone Joint Surg (Am) 52 1970; 543-549
    PubMedGoogle Scholar
  • 13 Bracken MB, Freeman Jr DH, HHellenbrand K. Incidence of acute traumatic hospitalised spinal cord injury in the United States, 1970–1977. Am J Epidemiol 113 1981; 615-622
    PubMedGoogle Scholar
  • 14 Hadley MN, Dickman CA, Browner CM. et al Acute axis fractures: a review of 229 cases. J Neurosurg 71 1989; 642-647
    CrossrefPubMedGoogle Scholar
  • 15 Huelke DF, O’Day J, Mendelsohn RA. Cervical injuries suffered in automobile crashes. J Neurosurg 54 1981; 316-322
    CrossrefPubMedGoogle Scholar
  • 16 Lee TT, Green BA, Petrin DR. Treatment of stable burst fractures of the atlas (Jefferson fracture) with rigid cervical collar. Spine 23 1998; 1963-1967
    CrossrefPubMedGoogle Scholar
  • 17 Kesterson L, Benzel E, Orrison W. et al Evaluation and treatment of atlas burst fractures (Jefferson fractures). J Neurosurg 75 1991; 213-220
    CrossrefPubMedGoogle Scholar
  • 18 Amyes EW, Anderson FM. Fracture of odontoid process: Report of sixty-three cases. Arch Surg 72 1956; 377-393
    CrossrefPubMedGoogle Scholar
  • 19 Anderson LD, D’Alonzo RT. Fractures of the odontoid process of the axis. J Bone Joint Surg (Am) 56 1974; 1663-1674
    PubMedGoogle Scholar
  • 20 Apuzzo MLJ, Heiden JS, Weiss MH, Ackerson TT, Harvey JP, Kurze T. Acute fractures of the odontoid process: An analysis of 45 cases. J Neurosurg 48 1978; 85-91
    CrossrefPubMedGoogle Scholar
  • 21 Dunn ME, Seljeskog EL. Experience in the management of odontoid process injuries: an analysis of 128 cases. Neurosurgery 18 1986; 306-310
    CrossrefPubMedGoogle Scholar
  • 22 Schatzker J, Rorabeck CH, Waddell JP. Fractures of the dens (odontoid process):An analysis of thirty-seven cases. J Bone Joint Surg (Br) 53B 1971; 392-405
    PubMedGoogle Scholar
  • 23 Southwick WO. Management of fractures of the dens (odontoid process). J Bone Joint Surg (Am) 62A 1980; 482-486
    PubMedGoogle Scholar
  • 24 Hadley MN, Browner C, Sonntag VK. Axis fractures: a comprehensive review of management and treatment in 107 cases. Neurosurgery 17 1985; 281-290
    CrossrefPubMedGoogle Scholar
  • 25 Alexander EJ, Davis CHJ, Field CH. Hyperextension injuries of the cervical spine. Arch Neurol Psychiatry 79 1958; 146-150
    CrossrefPubMedGoogle Scholar
  • 26 Bucholz RW, Burkhead WA, Graham W. et al Occult cervical spine injuries in fatal traffic accidents. J Trauma Infect Crit Care 19 1979; 768-771
    CrossrefPubMedGoogle Scholar
  • 27 Alker Jr GJ, Leslie EV. High Cervical Spine and craniocervical junction injuries in fatal traffic accident: Radiological study. Orthop Clin North Am 09 1978; 1003-1010
    PubMedGoogle Scholar
  • 28 Traynelis VC, Marano GD, Dunker RO. et al Traumatic atlanto occipital dislocation: Case report. J Neurosurg 66 1987; 789
    CrossrefPubMedGoogle Scholar
  • 29 Taggard DA. Treatment of occipital C1 Injury. In: Winn HR. (ED). Youmans Neurological surgery. IV 2004. Saunders; Philadelphia: 4925-4937
    Google Scholar
  • 30 Levine AM, Edwards CC. Fractures of the atlas. J Bone Joint Surg (Am) 73 1991; 680-691
    PubMedGoogle Scholar
  • 31 York JE. Treatment of Axis Fractures. In: Winn HR. (ED). Youmans Neurological Surgery. IV 2004. Saunder; Philadelphia: 4939-4949
    Google Scholar
  • 32 Johnson RM, hart DL, Simmons EF. et al Cervical orthoses: A study comparing their effectiveness in restricting cervical motion in normal subjects. J Bone Joint Surg Am 59 1977; 332-339
    PubMedGoogle Scholar
  • 33 Ekong CE, Schwartz ML, Tator CH. et al Odontoid fracture: management with early mobilization using the halo device. Neurosurgery 09 1981; 631-637
    CrossrefPubMedGoogle Scholar
  • 34 Clark CR, White AA. Fractures of the dens. A multicenter study. J Bone Joint Surg (Am) 67 1985; 1340-1348
    PubMedGoogle Scholar
  • 35 Hanssen Ad, Cabanela ME. Fractures of the dens in adult patients. J Trauma 27 1987; 928-934
    CrossrefPubMedGoogle Scholar
  • 36 Schweigel JF. Management of the fractured odontoid with halothoracic bracing. Spine 12 1987; 838-839
    CrossrefPubMedGoogle Scholar
  • 37 Ryan MD, Taylor Tk. Odontoid Fractures in the elderly. J Spinal Disord 06 1993; 397-401
    CrossrefPubMedGoogle Scholar
  • 38 Seybold EA, Bayley JC. Functional outcome of surgically and conservatively managed dens fractures. Spine 23 1998; 1837-1846
    CrossrefPubMedGoogle Scholar
  • 39 Greene KA, Dickman CA, Marciano FF. et al Acute axis fractures: Analysis of management and outcome in 340 consecutive cases. Spine 22 1997; 1843-1852
    CrossrefPubMedGoogle Scholar
  • 40 Aldrich EF, Weber PB, Crow WN. Halifax interlaminar clamp for posterior cervical fusion: A long term follow-up review. J Neurosurg 78 1993; 702-708
    CrossrefPubMedGoogle Scholar
  • 41 Dickman CA, Sonntage VKH, Papadopoulos Sm. et al The interspinous method of posterior atlantoaxial arthrodesis. J Neurosurg 74 1991; 190-198
    CrossrefPubMedGoogle Scholar
  • 42 Geisler FH, Cheng C, Poka A. et al Anterior screw fixation of posteriorly displaced type II odontoid fractures. Neurosurgery 25 1989; 30-38
    CrossrefPubMedGoogle Scholar
  • 43 Marcotte P, Dickman CA, Sonntag VKH. et al Posterior atlantoaxial facet screw fixation. J Neurosurg 79 1993; 234-237
    CrossrefPubMedGoogle Scholar
  • 44 Apfelbaum RL, Lonser RR, Veres R. et al Direct anterior screw fixation for recent and remote odontoid fractures. J Neurosurg 93 (Suppl. 02) 2000; 227-236
    PubMedGoogle Scholar
  • 45 Schneider RC, Livingston KE, Cave AJ. et al “Hangman's Fracture” of the cervical spine. J Neurosurg 22 1965; 141-154
    CrossrefPubMedGoogle Scholar
  • 46 Effendi B, Roy D, Cornish B. et al Fractures of the ring of the axis: A classification based on the analysis of 131 cases. J Bone Joint Surg (Br) 63 1981; 319-327
    PubMedGoogle Scholar
  • 47 Levine AM, Edwards CC. The management of traumatic spondylolisthesis of the axis. J Bone Joint Surg (Am) 67 1985; 217-226
    PubMedGoogle Scholar
  • 48 Francis WR, Fielding JW, Hawkins RJ. et al Traumatic spondylolisthesis of the axis. J Bone Joint Surg (Br) 63 1981; 313-318
    PubMedGoogle Scholar
  • 49 An HS. Cervical spine trauma. Spine 23 1998; 2713-2729
    CrossrefPubMedGoogle Scholar
  • 50 Barros TE, Bohlman HH, Capen DA. et al Traumatic spondylolisthesis of the axis; Analysis of management. Spinal Cord 37 1999; 166-171
    CrossrefPubMedGoogle Scholar