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Upper Cervical Spine Fractures Originally created by Daniel Gelb, MD January 2006 Updated by 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 Upper Cervical Spine Fractures • • • Epidemiology Anatomy Imaging Characteristics Common Injuries Management Issues

Epidemiology • 717 cervical spine fractures in 657 patients over 13 years • C Epidemiology • 717 cervical spine fractures in 657 patients over 13 years • C 1 and Hangman fractures found more in the young – Odontoid fractures evenly distributed • Younger patients have higher energy injuries • C 2 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

Upper Cervical Anatomy • Biomechanically Specialized – Support of “large” Cranial mass – Large Upper Cervical Anatomy • Biomechanically Specialized – Support of “large” Cranial mass – Large range of motion • Flexion/extension • Axial rotation • Unique osteological characteristics

Large Cranial Mass • Keel below the SNL is thick bone Roberts, DA; Doherty, Large Cranial Mass • Keel below the SNL is thick bone Roberts, DA; Doherty, BJ; Heggeness MH. Quantitative Anatomy of the Occiput and the Biomechanics of Occipital Screw Fixation Spine 23(10), 15 May 1998, pp 1100 -1107

Confluence of Issues • Bicortical screws in the occiput may enter the transverse sinus Confluence of Issues • Bicortical screws in the occiput may enter the transverse sinus • Decreased risk below the superior nuchal line Roberts, DA; Doherty, BJ; Heggeness MH. Quantitative Anatomy of the Occiput and the Biomechanics of Occipital Screw Fixation Spine 23(10), 15 May 1998, pp 1100 -1107

Occipital Screw Mechanics Roberts, DA; Doherty, BJ; Heggeness MH. Quantitative Anatomy of the Occiput 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 C 1 and C 2 determines the The course of the vertebral artery through C 1 and C 2 determines the possibility of placing screws for fixation of fractures and dislocations • C 1 lateral mass screws • C 1 -2 transarticular screws • C 2 pedicle/pars screws

Normal Vertebral Artery Normal Vertebral Artery

Tortuous Vertebral Artery Tortuous Vertebral Artery

C 1 - Atlas • No body • 2 articular pillars – Flat articular C 1 - Atlas • No body • 2 articular pillars – Flat articular surface – Vertebral artery foramen • 2 arches – Anterior – Posterior • Vertebral artery groove

C 2 Anatomy • Dens – Embriological C 1 body – Base poorly vascularized C 2 Anatomy • Dens – Embriological C 1 body – Base poorly vascularized – Osteoporotic • Flat C 1 -2 joints • Vertebral artery foramena – Inferomedial to superolateral

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

Anatomy – The Ligaments • Allow for the wide ROM of upper C-spine while 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 Tectorial Membrane

Atlanto-Axial Anatomy Tranverse Ligament C 1 -C 2 joint Occiput C 1 C 2 Atlanto-Axial Anatomy Tranverse Ligament C 1 -C 2 joint Occiput C 1 C 2 Alar Ligament

Atlanto-Axial Anatomy Facet for Occipital Condyle Transverse Ligament Atlanto-Axial Anatomy Facet for Occipital Condyle Transverse Ligament

Vertebral Artery Atlanto-Axial Anatomy Vertebral Artery Atlanto-Axial Anatomy

Radiographic Evaluation Radiographic Evaluation

Plain Radiographic Evaluation Lateral View Prevertebral Swelling Soft Tissue Shadow <6 mm at C Plain Radiographic Evaluation Lateral View Prevertebral Swelling Soft Tissue Shadow <6 mm at C 2 Concave/Flat Pre-dental space < 3 mm Atlanto-Occipital Joint Congruence Radiographic Lines* Open Mouth AP Distraction C 1 -2 Symmetry

Radiographic Diagnosis – Screening Lines Harris’s lines Powers’s Ratio Radiographic Diagnosis – Screening Lines Harris’s lines Powers’s Ratio

Radiographic Lines Harris’ Lines • Basion-Dental Interval (BDI) • Basion to Tip of Dens Radiographic Lines Harris’ Lines • Basion-Dental Interval (BDI) • Basion to Tip of Dens • <12 mm in 95% • >12 mm ABNORMAL • Basion-Axial Interval (BAI) • Basion to Posterior Dens • -4 -12 mm in 98% • >12 mm Anterior Subluxation • >4 mm Posterior Subluxation Harris et al, Am J Radiol, 1994

Radiographic Lines Powers’ Ratio • BC/OA – >1 considered abnormal • Limited Usefulness • Radiographic Lines Powers’ Ratio • BC/OA – >1 considered abnormal • Limited Usefulness • Positive only in Anterior Translational injuries • False Negative with pure distraction Powers et al, Neurosurg, 1979

Radiographic Diagnosis CT Scan • Same rules as with plain films • Better visualization Radiographic Diagnosis CT Scan • Same rules as with plain films • Better visualization of craniocervical junction • Subluxation • Focal hematomas • Occipital condyle fractures • Dens fractures

Radiographic Diagnosis MRI Increased Signal Intensity in : • • C 0 -C 1 Radiographic Diagnosis MRI Increased Signal Intensity in : • • C 0 -C 1 Joint C 1 -2 Joint Spinal Cord Cranio-cervical ligaments • Pre-vertebral soft tissues Dickman et al, J Neurosurg, 1991 Warner et al, Emerg Radiol, 1996

Upper Cervical Spine Fractures • Common Injuries – Occipital Condyle Fracture – Craniocervical sprain? Upper Cervical Spine Fractures • Common Injuries – Occipital Condyle Fracture – Craniocervical sprain? – C 1 ring injuries – Odontoid Fracture – Hangman’s Fracture • Uncommon Injuries – Craniocervical Dislocation – Rotatory subluxation

Occipital Condyle Fracture Type I Impaction Fracture Type II Extension of basilar skull fracture Occipital Condyle Fracture Type I Impaction Fracture Type II Extension of basilar skull fracture Type III ALAR ligament Avulsion Anderson , SPINE 1988 Tuli, NEUROSURGERY, 1997

Cranio-cervical Dislocation • • Antlanto-Occipital Joint Occipito-Cervical Joint Cranio-cervical Joint Atlanto-Axial Joint Cranio-cervical Dislocation • • Antlanto-Occipital Joint Occipito-Cervical Joint Cranio-cervical Joint Atlanto-Axial Joint

 • Cranio-cervical sprain (stage 1) may be treated nonoperatively • Cranio-cervical sprain (stage 1) may be treated nonoperatively

Cranio-cervical Dislocation Commonly Fatal Present 6 -20% of post mortem studies – Alker et Cranio-cervical Dislocation Commonly Fatal Present 6 -20% of post mortem studies – Alker et al, 1978 – Bucholz & Burkhead, 1979 – Adams et al, 1992 50% missed injury rate 1/3 Neurological Worsening – Davis et al, 1993

Symptoms/Findings • Lower Cranial nerve deficits • Horner’s syndrome • Cerebellar ataxia • Bell’s Symptoms/Findings • Lower Cranial nerve deficits • Horner’s syndrome • Cerebellar ataxia • Bell’s cruciate paralysis • Contralateral loss of pain and temperature Wallenberg Syndrome

Check the Cranial Nerves! www. med. yale. com www. meddean. luc. edu Check the Cranial Nerves! www. med. yale. com www. meddean. luc. edu

Cranio-cervical Dislocation • Treatment • Emergency Room • Collar/sandbag • Halo vest • Definitive Cranio-cervical Dislocation • Treatment • Emergency Room • Collar/sandbag • Halo vest • Definitive • Posterior occipital cervical fusion • ALWAYS include C 1 and C 2

Atlas Fractures - Treatment Collar 1. Isolated anterior arch 2. Isolated posterior arch 3. Atlas Fractures - Treatment Collar 1. Isolated anterior arch 2. Isolated posterior arch 3. Non-displaced Jefferson fracture

Atlas Fractures - Treatment Displaced <6. 9 mm • Halo vest * 3 mos Atlas Fractures - Treatment Displaced <6. 9 mm • Halo vest * 3 mos Displaced >6. 9 mm • Halo traction (reduction) * several weeks followed by halo vest • Immediate halo vest • Posterior C 1 -2 fusion (unable to tolerate halo) After brace treatment complete confirm C 1 -2 stability Flexion/extension films C 1 -2 fusion for ADI > 5 mm

Transverse ligament avulsion • Bony avulsions may heal with nonoperative management • TAL rupture Transverse ligament avulsion • Bony avulsions may heal with nonoperative management • TAL rupture does not heal with nonoperative management and requires C 1 -C 2 arthrodesis

Atlas Fractures - Treatment Fusion options Gallie Post-op halo Brooks Jenkins Transarticular Screws C Atlas Fractures - Treatment Fusion options Gallie Post-op halo Brooks Jenkins Transarticular Screws C 1 lateral mass/C 2 pars-pedicle screws

Odontoid Fractures Most common fracture of Axis (nearly 2/3 of all C 2 Fxs) Odontoid Fractures Most common fracture of Axis (nearly 2/3 of all C 2 Fxs) 10 – 20 % of all cervical fractures Etiology Bimodal distribution Young - high energy, multi-trauma Elderly - low energy, isolated injury (most common C-spine Fx elderly)

Elderly and the Odontoid • Platzer Studies • Harrop and Vaccaro – Elderly increased Elderly and the Odontoid • Platzer Studies • Harrop and Vaccaro – Elderly increased – 9/10 “union” pseudarthrosis rate( 12% v. – 5/10 postop halo 8%) – 1/10 perioperative death – Elderly tolerated pseudarthosis • Multiple series of high well(1/5) mortality rates – Elderly tolerated halo well – 10% mortality (4/41) Anterior screw fixation of odontoid fractures comparing younger and elderly – 22% complication rate patients. Authors: Platzer, P. ; Thalhammer, G. ; Ostermann, R. ; Wieland, T. ; Vecsei, V. ; Gaebler, C. Source: Spine, 2007, 32, 16, 1714 -1720, United States • Chapman studies – Elderly did not heal the odontoid fracture (4/17) – Elderly tolerated halo well (7/8) – 15% mortality (3/20) Nonoperative management of odontoid fractures using a halothoracic vest. Authors: 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 nonunions. Authors: 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 treatment. Authors: Kuntz, C. , 4 th; Mirza, S. K. ; Jarell, A. D. ; Chapman, J. R. ; Shaffrey, C. I. ; Newell, D. W. Source: Neurosurg. Focus. , 2000, 8, 6, e 7, United States Efficacy of anterior odontoid screw fixation in elderly patients with Type II odontoid fractures. Authors: Harrop, J. S. ; Przybylski, G. J. ; Vaccaro, A. R. ; Yalamanchili, K. Source: Neurosurg. Focus. , 2000, 8, 6, e 6, United States

Fracture Classification Anderson and D’Alonzo Type I 2 % (2/49) Type II 50 -75 Fracture Classification Anderson and D’Alonzo Type I 2 % (2/49) Type II 50 -75 % (32/49) Type III 15 -25 % (15/49) Fractures of the odontoid process of the axis. Authors: Anderson, L. D. ; D'Alonzo, R. T. Source: J. Bone Joint Surg. Am. , 1974, 56, 8, 1663 -1674, UNITED STATES

Subtypes of Type II Fractures • Type IIA and B are amenable to anterior 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 Acute Management • Spinal cord injury rare (17/226) • Airway compromise – 0/8 nondisplaced – 1/21 anterior displacement – 13/32 posterior displacement (2 deaths) Epidemiolgy of spinal cord injury after acute odontoid fractures JAMES S. HARROP, M. D. , ASHWINI D. SHARAN, M. D. , AND GREGORY J. PRZYBYLSKI, M. D. Neurosurgical Focus 2000 Don’t do flexion reductions! Closed management of displaced Type II odontoid fractures: more frequent respiratory compromise with posteriorly displaced fractures GREGORY J. PRZYBYLSKI, M. D. , JAMES S. HARROP, M. D. , AND ALEXANDER R. VACCARO, M. D. Neurosurgical Focus 2000

Definitive Treatment Options Type 1 C-Collar beware unrecognized CCD Evidence-based analysis of odontoid fracture Definitive Treatment Options Type 1 C-Collar beware unrecognized CCD Evidence-based analysis of odontoid fracture management. Authors: Julien, T. D. ; Frankel, B. ; Traynelis, V. C. ; Ryken, T. C. Source: Neurosurg. Focus. , 2000, 8, 6, e 1, United States Type 3 C-Collar 10 -15% nonunion SOMI brace Halo Vest

Treatment Options odontoid fracture Type 2 • • • C-Collar SOMI / Minerva Halo Treatment Options odontoid fracture Type 2 • • • C-Collar SOMI / Minerva Halo Vest Odontoid Screw C 1 -2 posterior fusion

Anterior Odontoid Screw Fixation Indications • • • Displaced Type II, Shallow Type III 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 History • Note reduced dorsal cortex

Anterior Screw Technique • Skin incision at C 5 • Note slight extension • Anterior Screw Technique • Skin incision at C 5 • 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 fractures. Authors: 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 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 fractures. Authors: 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 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 fractures. Authors: 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 • 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 Screw Mechanics A comparative study of fixation techniques for type II fractures of the odontoid process. Authors: 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 – 450 oblique Screw Mechanics • 13 cadavers • Load to failure – Extension-deflection – 450 oblique • 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 technique. Authors: Sasso, R. ; Doherty, B. J. ; Crawford, M. J. ; Heggeness, M. H. Source: Spine, 1993, 18, 14, 1950 -1953, UNITED STATES

Apfelbaum Clinical Outcomes • 147 patients – 129 (117) <6 months – 18 > Apfelbaum Clinical Outcomes • 147 patients – 129 (117) <6 months – 18 > 6 months • 88% fusion rate – Recent fractures – Horizontal and posterior oblique – No difference between one or two screws • 25% fusion rate in remote fractures • 10% implant complication – Screw pullout of C 2 body • 1% perioperative mortality – 6% within 30 days

Jenkins Clinical Outcomes • 42 patients • 8. 5 month followup • 15% nonunion Jenkins Clinical Outcomes • 42 patients • 8. 5 month followup • 15% nonunion rate (plain radiographs) • 5% perioperative mortality • 10% 3 month mortality • Mal-reduction A clinical comparison of one- and two-screw odontoid fixation. Authors: Jenkins, J. D. ; Coric, D. ; Branch, C. L. , Jr Source: J. Neurosurg. , 1998, 89, 3, 366 -370, UNITED STATES • Incorrect entry point

Posterior Odontoid Stabilization Posterior Odontoid Stabilization

Posterior Odontoid Stabilization • Options – Posterior wiring • Up to 25% pseudoarthrosis • 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 – C 1 lateral mass - C 2 pars/pedicle/lamina screw

Wiring Techniques Biomechanical comparison of C 1 -C 2 posterior arthrodesis techniques. Authors: Papagelopoulos, Wiring Techniques Biomechanical comparison of C 1 -C 2 posterior arthrodesis techniques. Authors: 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, E 363 -70, United States

Trans-articular Screw Technique Primary posterior fusion C 1/2 in odontoid fractures: indications, technique, and Trans-articular Screw Technique Primary posterior fusion C 1/2 in odontoid fractures: indications, technique, and results of transarticular screw fixation Authors: Jeanneret, B. ; Magerl, F. Source: J. Spinal Disord. , 1992, 5, 4, 464475, UNITED STATES

Wiring Mechanics Biomechanical comparison of C 1 -C 2 posterior arthrodesis techniques. Authors: Papagelopoulos, Wiring Mechanics Biomechanical comparison of C 1 -C 2 posterior arthrodesis techniques. Authors: 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, E 363 -70, United States

Posterior Wiring Outcomes Posterior Wiring Outcomes

C 1 C 2 Segmental Instrumentation Posterior C 1 -C 2 fusion with polyaxial C 1 C 2 Segmental Instrumentation Posterior C 1 -C 2 fusion with polyaxial screw and rod fixation. Authors: Harms, J. ; Melcher, R. P. Source: Spine, 2001, 26, 22, 2467 -2471, United States

. . . .

pedicle Pars Trans-articular C 2 pars/pedicle pedicle Pars Trans-articular C 2 pars/pedicle

Harm’s Mechanics • LC 1 -PC 2 performs similar to transarticular screws • Transarticular Harm’s Mechanics • LC 1 -PC 2 performs similar to transarticular screws • Transarticular screws with graft stiffest construct • Interspinous graft behaves as intact specimen regarding lateral bending Hott et al: Biomechanical comparison of C 1 -2 posterior fixation techniques. J Neurosurg Spine 2: 175 -181. 2005

Harm’s Outcomes • 37 patients • 100% fusion • 1 wound infection Posterior C Harm’s Outcomes • 37 patients • 100% fusion • 1 wound infection Posterior C 1 -C 2 fusion with polyaxial screw and rod fixation. Authors: Harms, J. ; Melcher, R. P. Source: Spine, 2001, 26, 22, 2467 -2471, United States • • • 102 patients 98% fusion rate Navigation Allograft/BMP 2 dissection VA injury 1 neuropathic pain (C 2 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 techniques. Authors: 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, 222229, United States

Posterior Fusion Takehome • Catastrophic failures reported for trans-articular screws alone • Trans-articular screws Posterior Fusion Takehome • Catastrophic failures reported for trans-articular screws alone • Trans-articular screws with wired bone graft is stiffest construct – Requires intact C 1 lamina – Requires reducible C 1 -2 facets – Requires favorable anatomy • Gallie wiring is inadequate without two supplemental screws • No advantage of either wiring construct with two transarticular screws • Harm’s technique is most flexible • Think about hooks?

Traumatic Spondylolisthesis Axis (Hangman’s Fracture) Second most common fracture of axis 25% of C Traumatic Spondylolisthesis Axis (Hangman’s Fracture) Second most common fracture of axis 25% of C 2 injuries Most common mechanism of injury is MVA

Hangman’s Fracture Younger age group (Avg 38 yrs) Usually due to hyperextension-axial compression forces Hangman’s Fracture Younger age group (Avg 38 yrs) Usually due to hyperextension-axial compression forces (windshield strike) Neurologic injury seen in only 5 -10 % (acutely decompresses canal) Traditional treatment has been Halo-vest Collar adequate if < 6 mm displaced Coric et al JNS 1996

Where Cranio-cervical meets Subaxial Levine AM, Edwards CC: The management of traumatic spondylolisthesis of Where Cranio-cervical meets Subaxial Levine AM, Edwards CC: The management of traumatic spondylolisthesis of the axis. J Bone Joint Surg Am 1985; 67: 217 -226

Hangman Fracture • Intact disk defines Type I • Halo treatment difficult with torn Hangman Fracture • Intact disk defines Type I • Halo treatment difficult with torn disk (types II and III) • Exercise caution Dysphagia and Dysphonia Resolved immediately with halo adjustment

Hangman’s Fracture Treatment Types II and III Treatment Posterior – Open reduction and C Hangman’s Fracture Treatment Types II and III Treatment Posterior – Open reduction and C 1 -C 3 fusion – Direct pars repair and C 2 -C 3 fusion Anterior – C 2/C 3 ACDF with instrumentation

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

Atlanto-axial Rotatory Subluxation • • Traction/halo Posterior fusion Lateral facetectomy, reduction, fusion Transoral facetectomy, Atlanto-axial Rotatory Subluxation • • Traction/halo Posterior fusion Lateral facetectomy, reduction, fusion Transoral facetectomy, reduction, fusion

Halo Immobilization Halo Immobilization

Halo • Frank Bloom – Apparatus for stabilization of facial fractures – “Maxillofacial surgeon” Halo • Frank Bloom – Apparatus for stabilization of facial fractures – “Maxillofacial surgeon” (actually a Navy orthopaedic surgeon) – World War II: treated pilots with inwardly displaced facial fractures – Similar design • Incomplete ring with 3 pin tiara The history of the halo skeletal fixator O'Donnell, P. W. ; Anavian, J. ; Switzer, J. A. ; Morgan, R. A. Spine, 2009, 34, 16, 1736 -1739

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

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

Halo in Elderly • Tashijan J. Trauma 2006 – 78 patients, age > 65 Halo in Elderly • Tashijan J. Trauma 2006 – 78 patients, age > 65 yo – Type II or III odontoid fractures – Increased early morbidity and mortality • Compared with treatment using operative fixation or rigid collar • Van Middendorp JBJS 2009 – 239 patients – All ages in halo – No increased risk of pneumonia or death in patients >65 years old If you would like to volunteer as an author for the Resident Slide Project or recommend updates to any of the following slides, please send an e-mail to [email protected] org Halo vest immobilization in the elderly: a death sentence? Majercik, S. ; Tashjian, R. Z. ; Biffl, W. L. ; Harrington, D. T. ; Cioffi, W. G. J. Trauma, 2005, 59, 2, 350 -6; discussion 356 -8 Incidence of and risk factors for complications associated with halovest immobilization: a prospective, descriptive cohort study of 239 patients van Middendorp, J. J. ; Slooff, W. B. ; Nellestein, W. R. ; Oner, F. C. J. Bone Joint Surg. Am. , 2009, 91, 1, 71 -79

Thank You If you would like to volunteer as an author for the Resident Thank You If you would like to volunteer as an author for the Resident Slide Project or recommend updates to any of the following slides, please send an e-mail to [email protected] org E-mail OTA about Questions/Comments • Return to • Spine • Index