cervical spine fractures 上颈椎骨折图文课件

Upper Cervical Spine Fractures Originally created by Daniel Gelb, MD January 2006 Updated by Robert Morgan, MD; November 2010 Upper Cervical Spine Fractures Epidemiology Anatomy Imaging Characteristics Common Injuries Management Issues Epidemiology 717 cervical spine fractures in 657 patients over 13 years C1 and Hangman fractures found more in the young Odontoid fractures evenly distributed Younger patients have higher energy injuries C2 fractures most common The epidemiology of fractures and fracture-dislocations of the cervical spine Ryan,M.D.; Henderson,J.J. Injury, 1992, 23, 1, 38-40 Upper Cervical Anatomy Upper Cervical Anatomy Biomechanically Specialized Support of “large” Cranial mass Large range of motion Flexion/extension Axial rotation Unique osteological characteristics Large Cranial Mass Roberts, DA; Doherty, BJ; Heggeness MH. Quantitative Anatomy of the Occiput and the Biomechanics of Occipital Screw Fixation Spine 23(10), 15 May 1998, pp 1100-1107 Keel below the SNL is thick bone Confluence of Issues Roberts, DA; Doherty, BJ; Heggeness MH. Quantitative Anatomy of the Occiput and the Biomechanics of Occipital Screw Fixation Spine 23(10), 15 May 1998, pp 1100-1107 Bicortical screws in the occiput may enter the transverse sinus Decreased risk below the superior nuchal line Occipital Screw Mechanics Roberts, DA; Doherty, BJ; Heggeness MH. Quantitative Anatomy of the Occiput and the Biomechanics of Occipital Screw Fixation Spine 23(10), 15 May 1998, pp 1100-1107 The course of the vertebral artery through C1 and C2 determines the possibility of placing screws for fixation of fractures and dislocations C1 lateral mass screws C1-2 transarticular screws C2 pedicle/pars screws Normal Vertebral Artery Tortuous Vertebral Artery C1 - Atlas No body 2 articular pillars Flat articular surface Vertebral artery foramen 2 arches Anterior Posterior Vertebral artery groove Anatomy The Atlas Transition zone between head and c-spine Important anatomical points Superior articular processes allow flex/ext Inferior articular processes are important for rotation Notch for vertebral artery is a common fracture site C2 Anatomy Dens Embriological C1 body Base poorly vascularized Osteoporotic Flat C1-2 joints Vertebral artery foramena Inferomedial to superolateral Trabecular Anatomy The trabecular anatomy of the axis Authors:Heggeness,M.H. ; Doherty,B.J.Source:Spine, 1993, 18, 14, 1945-1949, UNITED STATES Trabecular Anatomy The trabecular anatomy of the axis Authors:Heggeness,M.H. ; Doherty,B.J.Source:Spine, 1993, 18, 14, 1945-1949, UNITED STATES Anatomy The Axis Important transition point for forces within the c-spine Important anatomical points Superior and inferior articular processes are “offset” in the AP direction- due to different functions at each articulation Pars interarticularis- due to this transition is a frequent fracture site Odontoid process- the “pivot” for rotation The trabecular anatomy of the axis Authors:Heggeness,M.H. ; Doherty,B.J.Source:Spine, 1993, 18, 14, 1945-1949, UNITED STATES Anatomy The Ligaments Allow for the wide ROM of upper C-spine while maintaining stability Classified according to location with respect to vertebral canal Internal: Tectorial membrane Cruciate ligament including transverse ligament Alar and apical ligaments External Anterior and posterior atlanto-occipital membranes Anterior and posterior atlanto-axial membranes Articular capsules and ligamentum nuchae Atlanto-Axial Anatomy Tectorial Membrane Atlanto-Axial Anatomy Occiput C1 C2 Tranverse Ligament C1-C2 joint Alar Ligament Atlanto-Axial Anatomy Transverse Ligament Facet for Occipital Condyle Atlanto-Axial Anatomy Vertebral Artery Radiographic Evaluation Plain Radiographic EvaluationPlain Radiographic Evaluation Lateral View Prevertebral Swelling Soft Tissue Shadow 12 mm ABNORMAL Basion-Axial Interval (BAI) Basion to Posterior Dens -4-12 mm in 98% 12 mm Anterior Subluxation 4 mm Posterior Subluxation Harris Lines Radiographic Lines BC/OA 1 considered abnormal Limited Usefulness Positive only in Anterior Translational injuries False Negative with pure distraction Powers et al, Neurosurg, 1979 Powers Ratio Radiographic DiagnosisRadiographic Diagnosis CT Scan Same rules as with plain films Better visualization of cranio- cervical junction Subluxation Focal hematomas Occipital condyle fractures Dens fractures Radiographic Diagnosis MRI Increased Signal Intensity in : C0-C1Joint C1-2 Joint Spinal Cord Cranio-cervical ligaments Pre-vertebral soft tissues Warner et al, Emerg Radiol, 1996 Dickman et al, J Neurosurg, 1991 Upper Cervical Spine Fractures Common Injuries Occipital Condyle Fracture Craniocervical sprain? C1 ring injuries Odontoid Fracture Hangmans Fracture Uncommon Injuries Craniocervical Dislocation Rotatory subluxation Occipital Condyle FractureOccipital Condyle Fracture Type I Impaction Fracture Type II Extension of basilar skull fracture Type III ALAR ligament Avulsion Anderson ,SPINE 1988 Tuli, NEUROSURGERY, 1997 Cranio-cervical Dislocation Antlanto-Occipital Joint Occipito-Cervical Joint Cranio-cervical Joint Atlanto-Axial Joint Cranio-cervical sprain (stage 1) may be treated nonoperatively Cranio-cervical Dislocation Commonly Fatal Present 6-20% of post mortem studies Alker et al, 1978 Bucholz Thalhammer,G.; Ostermann,R.; Wieland,T.; Vecsei,V.; Gaebler,C.Source:Spine, 2007, 32, 16, 1714-1720, United States Nonoperative management of odontoid fractures using a halothoracic vestAuthors:Platzer,P.; Thalhammer,G.; Sarahrudi,K.; Kovar,F.; Vekszler,G.; Vecsei,V.; Gaebler,C.Source:Neurosurgery, 2007, 61, 3, 522-9; discussion 529-30, United States Posterior atlanto-axial arthrodesis for fixation of odontoid nonunionsAuthors:Platzer,P.; Vecsei,V.; Thalhammer,G.; Oberleitner,G.; Schurz,M.; Gaebler,C.Source:Spine, 2008, 33, 6, 624-630, United States Type II odontoid fractures in the elderly: early failure of nonsurgical treatmentAuthors:Kuntz,C.,4th; Mirza,S.K. ; Jarell,A.D.; Chapman,J.R.; Shaffrey,C.I.; Newell,D.W.Source:Neurosurg.Focus., 2000, 8, 6, e7, United States Efficacy of anterior odontoid screw fixation in elderly patients with Type II odontoid fracturesAuthors:Harrop,J.S. ; Przybylski,G.J.; Vaccaro,A.R.; Yalamanchili,K.Source:Neurosurg.Focus., 2000, 8, 6, e6, United States Fracture Classification Anderson and DAlonzo Type I 2 % (2/49) Type II 50-75 % (32/49) Type III 15-25 % (15/49) Fractures of the odontoid process of the axisAuthors:Anderson,L.D.; DAlonzo,R.T.Source:J.Bone Joint Surg.Am., 1974, 56, 8, 1663-1674, UNITED STATES Subtypes of Type II Fractures Type IIA and B are amenable to anterior fixation Type IIC is not Does not include part of facet, not a Type III Grauer,J.N et al Proposal of a modified, treatment-oriented classification of odontoid fractures. Spine J., 2005, 5, 2, 123-129 Acute Management Spinal cord injury rare (17/226) Airway compromise 0/8 nondisplaced 1/21 anterior displacement 13/32 posterior displacement (2 deaths) Dont do flexion reductions! Closed management of displaced Type II odontoid fractures:more frequent respiratory compromise with posteriorly displaced fractures GREGORY J. PRZYBYLSKI, M.D., JAMES S. HARROP, M.D., AND ALEXANDER R. VACCARO, M.D. Neurosurgical Focus 2000 Epidemiolgy of spinal cord injury after acute odontoid fractures JAMES S. HARROP, M.D., ASHWINI D. SHARAN, M.D., AND GREGORY J. PRZYBYLSKI, M.D. Neurosurgical Focus 2000 Definitive Treatment Options Type 1 C-Collar beware unrecognized CCD Type 3 C-Collar 10-15% nonunion SOMI brace Halo Vest Evidence-based analysis of odontoid fracture managementAuthors:Julien,T.D.; Frankel,B. ; Traynelis,V.C. ; Ryken,T.C. Source:Neurosurg.Focus., 2000, 8, 6, e1, United States Treatment Options odontoid fracture Type 2 C-Collar SOMI / Minerva Halo Vest Odontoid Screw C1-2 posterior fusion Anterior Odontoid Screw Fixation Indications Displaced Type II, Shallow Type III Polytrauma patient Unable to tolerate halo-vest Early displacement despite halo-vest (Reduces in extension) Contraindications Non-reducible odontoid fracture (Reduces in flexion) Body habitus (Barrel chest ) Associated TAL injury Subacute injury ( 6 months) Reverse oblique (elderly) Roy-Camille Classification Anterior Screw History Note reduced dorsal cortex Anterior Screw Technique Skin incision at C5 Note slight extension Missing key element in diagram (need to atraumatically obtain open mouth fluoroscopy) Biplanar fluoroscopy Direct anterior screw fixation for recent and remote odontoid fracturesAuthors:Apfelbaum,R.I. ; Lonser,R.R. ; Veres,R.; Casey,A.Source:J.Neurosurg., 2000, 93, 2 Suppl, 227-236, UNITED STATES Anterior Screw Technique Need to enter body caudal portion of promontory Midline for single screw placement Direct anterior screw fixation for recent and remote odontoid fracturesAuthors:Apfelbaum,R.I. ; Lonser,R.R. ; Veres,R.; Casey,A.Source:J.Neurosurg., 2000, 93, 2 Suppl, 227-236, UNITED STATES Anterior Screw Technique Critical to cross rostral cortex Critical to use lag screw technique Limited support for second screw Direct anterior screw fixation for recent and remote odontoid fracturesAuthors:Apfelbaum,R.I. ; Lonser,R.R. ; Veres,R.; Casey,A.Source:J.Neurosurg., 2000, 93, 2 Suppl, 227-236, UNITED STATES One or Two Screws? No significant difference biomechanically Sasso Graziano No difference clinically Apfelbaum Jenkins Screw Mechanics A comparative study of fixation techniques for type II fractures of the odontoid processAuthors:Graziano,G.; Jaggers,C.; Lee,M.; Lynch,W.Source:Spine, 1993, 18, 16, 2383-2387, UNITED STATES Screw Mechanics 13 cadavers Load to failure Extension-deflection 450oblique No difference between one and two screws Failure mode is screw pullout from body Anatomic reduction without comminution Biomechanics of odontoid fracture fixation. Comparison of the one- and two-screw techniqueAuthors:Sasso,R.; Doherty,B.J.; Crawford,M.J.; Heggeness,M.H. Source:Spine, 1993, 18, 14, 1950-1953, UNITED STATES Apfelbaum Clinical Outcomes 147 patients 129 (117) 6 months 88% fusion rate Recent fractures Horizontal and posterior oblique No difference between one or two screws 25% fusion rate in remote fractures 10% implant complication Screw pullout of C2 body 1% perioperative mortality 6% within 30 days Jenkins Clinical Outcomes 42 patients 8.5 month followup 15% nonunion rate (plain radiographs) 5% perioperative mortality 10% 3 month mortality A clinical comparison of one- and two-screw odontoid fixationAuthors:Jenkins,J.D.; Coric,D.; Branch,C.L.,Jr Source:J.Neurosurg., 1998, 89, 3, 366-370, UNITED STATES Mal-reduction Incorrect entry point Posterior Odontoid Stabilization Posterior Odontoid Stabilization Options Posterior wiring Up to 25% pseudoarthrosis Halo vest necessary (?) Dickman JNS 1996, Grob Spine 1992 Transarticular screw fixation Magerl and Steeman Cerv Spine 1987 Reilly et al, JSD 2003 C1 lateral mass - C2 pars/pedicle/lamina screw Wiring Techniques Biomechanical comparison of C1-C2 posterior arthrodesis techniquesAuthors:Papagelopoulos,P.J.; Currier,B.L. ; Hokari,Y.; Neale,P.G.; Zhao,C.; Berglund,L.J.; Larson,D.R.; An,K.N. Source:Spine, 2007, 32, 13, E363-70, United States Trans-articular Screw Technique Primary posterior fusion C1/2 in odontoid fractures: indications, technique, and results of transarticular screw fixation Authors:Jeanneret,B.; Magerl,F.Source:J.Spinal Disord., 1992, 5, 4, 464- 475, UNITED STATES Wiring Mechanics Biomechanical comparison of C1-C2 posterior arthrodesis techniquesAuthors:Papagelopoulos,P.J.; Currier,B.L. ; Hokari,Y.; Neale,P.G.; Zhao,C.; Berglund,L.J.; Larson,D.R.; An,K.N. Source:Spine, 2007, 32, 13, E363-70, United States Posterior Wiring Outcomes C1C2 Segmental Instrumentation Posterior C1-C2 fusion with polyaxial screw and rod fixationAuthors:Harms,J.; Melcher,R.P.Source:Spine, 2001, 26, 22, 2467-2471, United States pedicle Pars Trans-articular C2 pars/pedicle Harms Mechanics Hott et al: Biomechanical comparison of C1-2 posterior fixation techniques. J Neurosurg Spine 2: 175-181. 2005 LC1-PC2 performs similar to transarticular screws Transarticular screws with graft stiffest construct Interspinous graft behaves as intact specimen regarding lateral bending Harms Outcomes 37 patients 100% fusion 1 wound infection 102 patients 98% fusion rate Navigation Allograft/BMP 2 dissection VA injury 1 neuropathic pain (C2 root sacrifice) 4 wound infections Stabilization of the atlantoaxial complex via C-1 lateral mass and C-2 pedicle screw fixation in a multicenter clinical experience in 102 patients: modification of the Harms and Goel techniquesAuthors:Aryan,H.E.; Newman,C.B.; Nottmeier,E.W.; Acosta,F.L.,Jr; Wang,V.Y.; Ames,C.P.Source:J.Neurosurg.Spine, 2008, 8, 3, 222- 229, United States Posterior C1-C2 fusion with polyaxial screw and rod fixationAuthors:Harms,J.; Melcher,R.P.Source:Spine, 2001, 26, 22, 2467-2471, United States Posterior Fusion Takehome Catastrophic failures reported for trans-articular screws alone Trans-articular screws with wired bone graft is stiffest construct Requires intact C1 lamina Requires reducible C1-2 facets Requires favorable anatomy Gallie wiring is inadequate without two s