Upper cervical injuries - a rational approach to guide surgical management

Congenital atlanto-occipital dislocation in a patient with Down syndrome: a case report

Down syndrome, also known as trisomy 21, is associated with congenital cervical spine abnormalities, including atlantoaxial instability with or without os odontoideum, atlanto-occipital instability, and hypoplasia of the atlas. Herein, we report a case of Down syndrome complicated by congenital atlanto-occipital dislocation. The patient presented with severe cervical myelopathy at 13 years of age after a 10-year follow-up. Radiography and computed tomography revealed os odontoideum protruding into the foramen magnum and congenital anterior atlanto-occipital dislocation. Additionally, a bifurcated internal occipital crest with a thinned central portion of the occipital bone was noted. Magnetic resonance imaging revealed kyphotic alignment of the spinal cord with severe compression at the foramen magnum level. As the neurological impairment was partially improved by halo vest immobilization, we performed in situ O-C2 fusion with an iliac autograft and decompression of the foramen magnum and posterior arch of C1. An improvement was observed immediately after surgery. Two years after surgery, radiography and computed tomography showed solid O-C2 segment fusion. The accumulation of similar cases is essential for determining the prognosis or optimal treatment for this rare congenital condition.

The Reliability of the AO Spine Upper Cervical Classification System in Children: Results of a Multi-Center Study

BACKGROUND

There is no uniform classification system for traumatic upper cervical spine injuries in children. This study assesses the reliability and reproducibility of the AO Upper Cervical Spine Classification System (UCCS), which was developed and validated in adults, to children.

METHODS

Twenty-six patients under 18 years old with operative and nonoperative upper cervical injuries, defined as from the occipital condyle to the C2-C3 joint, were identified from 2000 to 2018. Inclusion criteria included the availability of computed tomography and magnetic resonance imaging at the time of injury. Patients with significant comorbidities were excluded. Each case was reviewed by a single senior surgeon to determine eligibility. Educational videos, schematics describing the UCCS, and imaging from 26 cases were sent to 9 pediatric orthopaedic surgeons. The surgeons classified each case into 3 categories: A, B, and C. Inter-rater reliability was assessed for the initial reading across all 9 raters by Fleiss's kappa coefficient (kF) along with 95% confidence intervals. One month later, the surgeons repeated the classification, and intra-rater reliability was calculated. All images were de-identified and randomized for each read independently. Intra-rater reproducibility across both reads was assessed using Fleiss's kappa. Interpretations for reliability estimates were based on Landis and Koch (1977): 0 to 0.2, slight; 0.2 to 0.4, fair; 0.4 to 0.6, moderate; 0.6 to 0.8, substantial; and >0.8, almost perfect agreement.

RESULTS

Twenty-six cases were read by 9 raters twice. Sub-classification agreement was moderate to substantial with α κ estimates from 0.55 for the first read and 0.70 for the second read. Inter-rater agreement was moderate (kF 0.56 to 0.58) with respect to fracture location and fair (kF 0.24 to 0.3) with respect to primary classification (A, B, and C). Krippendorff's alpha for intra-rater reliability overall sub-classifications ranged from 0.41 to 0.88, with 0.75 overall raters.

CONCLUSION

Traumatic upper cervical injuries are rare in the pediatric population. A uniform classification system can be vital to guide diagnosis and treatment. This study is the first to evaluate the use of the UCCS in the pediatric population. While moderate to substantial agreement was found, limitations to applying the UCCS to the pediatric population exist, and thus the UCCS can be considered a starting point for developing a pediatric classification.

LEVEL OF EVIDENCE

Level III.

Severe dysphagia after a posterior cervical spine fusion at the C1–C3 level and its improvement after correction surgery for malalignment: a case report

Background

The development of dysphagia and trismus following posterior C1–C3 fusion is rare compared to occipitocervical fusion, and there are very few reports in the literature.

Case presentation

A 75-year-old Thai man who had an extradural tumor at the C1/C2 level developed severe dysphagia and trismus immediately after tumor resection and C1–C3 fusion. During the surgery for malalignment correction, the C1–C2 screws were re-aligned into an increased lordotic position. The symptoms resolved immediately post-surgery.

Conclusions

Short upper cervical fusion can produce trismus and dysphagia in a relatively flexed position. Preoperative planning should be individualized based on the patient’s resting neutral alignment to prevent complications.

Upper Cervical Spine Injuries: Profile and Management of 120 Cases

OBJECTIVES

To identify the profile and management of patients with upper cervical spine injury.

METHODS

Retrospective cohort study of patients with upper cervical spine injuries managed at Hospital da Restauração between 2014 and 2020.

RESULTS

It presents the profile of 145 injuries recorded by location and classification among the 120 patients, and the management performed. Men are more affected than women, almost half of the patients (42.5%) were aged 16 to 29 years. Neurological deficit was present in 18 cases (15%). Twenty cases presented injury involving the level C1. Most injuries (109 [90.8%]) occurred at the C2 level, the most frequent of which were as follows: isolated type II odontoid fracture (29.2%), miscellaneous fracture of C2 (20%), and isolated hangman's fracture (13.3%). The most used management in type II odontoid fracture was C1-C2 posterior arthrodesis (17/42) followed by odontoid osteosynthesis (12/42). Regarding isolated hangman's fracture, conservative management was performed in 37.5% (6/16), and the technical approach most performed was anterior C2-C3 discectomy and interbody fusion (5/16).

CONCLUSIONS

Upper cervical spine injury has a higher prevalence in young men and is most often caused by traffic accidents. The main level affected is C2, and type II odontoid fracture is the most frequent subtype. C1 injury is related to conservative treatment, while C2 or combined C1-C2 injury is related to surgical approach. The management of these injuries is mainly performed with surgical treatment, with C1-C2 posterior arthrodesis and anterior odontoid osteosynthesis representing most of the approaches.

Bicycle-related cervical spine injuries

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The incidence of bicycle-related cervical spine injuries (CSI) was 1.7/100,000/year.

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Bicycling was the second most common cause of CSI, only preceded by falls.

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Occipital condyle fracture was common in bicyclists.

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Bicyclists with CSI were associated with more multiple trauma and concomitant head injury than non-bicyclists.

Background

Bicyclists are vulnerable road users. The aim of this paper was to describe all bicycle-related traumatic cervical spine injuries (CSIs) in the South-East region of Norway (2015–2019), and to investigate whether certain types of CSIs are typical for bicyclists.

Methods

Retrospective cohort study of prospectively collected registry data of all CSIs in the South-East region of Norway (3.0 million inhabitants), from 2015 to 2019. Patient characteristics, injury types, and treatment were summarized with descriptive statistics. Bayesian multivariable logistic regression was used to identify potential factors associated with occipital condyle fractures (OC-Fx) or odontoid fractures (OFx).

Results

During the five-year study period, 2,162 patients with CSIs were registered, and 261 (12%) were bicycle-related. The incidence of bicycle-related CSIs was 1.7/100,000 person-years. The median age of the patients with bicycle-related CSIs was 55 (IQR: 22) years, 83% were male, 71% used a helmet, 16% were influenced by ethanol, 12% had a concomitant cervical spinal cord injury (SCI), and 64% sustained multiple traumas. The three most common bicycle-related CSIs were C6/C7 fracture (Fx) (28%), occipital condyle Fx (OC-Fx) (23%) and C5/C6 Fx (19%). Patients with bicycle-related CSIs compared to patients with non-bicycle related CSIs were younger, more often male, had fewer comorbidities, more likely multiple traumas, more often had OC-Fx, and less often sustained an odontoid fracture (OFx). Multivariable logistic regression of potential risk factors for OC-Fx demonstrated a significantly increased risk of OC-Fx for bicyclists compared to non-bicyclists (OR=2.8).The primary treatment for bicycle-related CSIs was external immobilization in 187/261 (71.6%) cases, open surgical fixation in 44/261 (16.8%), and no treatment in 30/261 (11.5%).

Conclusion

Bicycle crashes are a frequent cause of CSIs in the Norwegian population and should be of concern to the public society. The three most common bicycle-related CSIs were C6/C7 fracture, occipital condyle fracture and C5/C6 fracture.

Missed cervical spine injuries: aim for the top

PURPOSE

To determine the incidence of missed cervical spine injuries by radiology registrars in a major trauma centre and to identify any common blind spots.

MATERIALS AND METHODS

All patients with an acute traumatic injury who underwent a CT scan of the cervical spine in our unit, which serves a population of approximately 900,000, between September 2016 and December 2017 and whom had a separate radiology trainee report and final neuroradiology consultant report available were included in the study. We recorded the date and time of the scan, the registrar error and the registrar grade. An error was defined as follows: (1) a missed fracture; (2) a missed ligamentous injury; (3) overcall of a fracture (e.g. degenerative calcification or nutrient vessel). Groups were compared with the chi-square test.

RESULTS

Five hundred seventy-three CT scans of the cervical spine fitted the inclusion criteria and were analysed. There were a total of 149 injuries over eight levels in 96 patients. There were 12 registrar errors (2.1% discrepancy rate), of which 11 were missed acute injuries (9 fractures and 2 disco-ligamentous injuries). The grade of the registrar was not significant (p = 0.603). Seventy-three percent (8/11) missed injuries were disproportionately at the cranio-cervical junction, where only 11.6% of traumatic cervical spine injuries occur p < 0.0001. Forty-five percent of the missed injuries included occipital condyle fractures, which occurred in only 12/149 injuries (8%).

CONCLUSIONS

Radiology registrars safely report emergency CT scans of the cervical spine performed following trauma with a low discrepancy rate. Missed cervical spine injuries commonly occur at the cranio-cervical junction, which should become a standard review area.

Ligament deformation patterns of the craniocervical junction during head axial rotation tracked by biplane fluoroscopes

BACKGROUND

Frequently, treatment decisions for craniocervical injuries and instability are based on imaging findings, but in vivo ligament kinematics were poorly understood. This study was to determine in vivo deformation patterns of primary ligaments in the craniocervical junction (i.e., C0-2), including the cruciform ligament, alar ligaments, and accessory ligaments, during dynamic head axial rotation.

METHODS

The skulls and cervical spines of eight asymptomatic female subjects were dynamically imaged using a biplane fluoroscopic imaging system, when they performed left and right head axial rotations. Using a 3D-to-2D registration technique, the in vivo positions and orientations of cervical segments were determined. An optimization algorithm was implemented to determine ligament wrapping paths, and the resulting ligament deformations were represented by percent elongations. Using paired t-tests, ligament deformations in the end-range position were compared to those in the neutral position.

FINDINGS

No significant differences were observed in segmental motions during left and right head rotations (p > 0.05). In general, slight deformations occurred in each component of the cruciform ligament. For the alar ligaments, the ipsilateral ligament was lengthened from -0.7 ± 13.8% to 16.6 ± 15.7% (p < 0.001*). For the accessory ligaments, the contralateral ligament was lengthened from -2.9 ± 7.5% to 10.1 ± 6.2% (p < 0.001*).

INTERPRETATION

This study reveals that there are distinct deformation patterns in craniocervical junction ligaments during dynamic axial head rotation. These ligament deformation data can enhance our understanding of the synergic function of craniocervical junction ligaments, and guide the treatment of craniocervical instability.

Predictive value of sagittal craniocervical roentgenographic parameters for HRQOL after craniocervical fusion

PURPOSE

Loss of "physiological" sagittal alignment following craniocervical fusion (CCF) for degenerative disease may be associated with loss of horizontal gaze, dysphagia and poor HRQOL. This study reports on sagittal craniocervical roentgenographic predictors of HRQOL (SF-36) in patients following uncomplicated CCF for fresh upper cervical traumatic (UCT) injuries.

METHODS

Twenty-two consecutive adult patients (group P) aged 50 ± 16 years, who had undergone CCF for fresh unstable C₁ and C₂AO/type UCT injuries, were evaluated 39 ± 12 months postoperatively with upright lateral cervical roentgenograms and SF-36as HRQOL measure. Physiological data for cervical sagittal alignment and SF-36 were taken from an age-matched control group (C) of 30 individuals aged 52 ± 12 years. Several commonly used sagittal cervical roentgenographic parameters were tested as potential predictors of the SF-36 domains in both groups. Roentgenographic predictors for each of the nine SF-domains were calculated using stepwise multilinear regression analysis (MLRA).

RESULTS

The roentgenographic predictors in patients included (1) the angle created by McGregor's line and the inferior surface of the axis (OC₂a) for physical function (PF, P = 0.049), role limitations due to physical health (RLPH, P = 0.004),role limitation due to emotional problems (RLEP, P = 0.004), emotional functioning (EF) (P = 0.012), social functioning (SF) (P = 0.028) and general health (GH, P = 0.041). (2) The angle formed between a horizontal line and the superior endplate of T₁-vertebra (T₁-slope) was predictor for SF (P = 0.017) and pain (P = 0.021), and (3) the angle between McGregor's line and the line that links the center of the C₁ anterior arch and the apex of cervical sagittal curvature (PIA) was predictor for health change (HC, P = 0.002).

CONCLUSIONS

This study showed that postoperative OC₂a, PIA and T1-slope safely predict HRQOL outcomes (SF-36) following CCF for fresh trauma. It seems theoretically that the adequate restoration of the upper cervical alignment including C1-C2 upper cervical lordosis (OC₂a) and PIA, in interaction with T1-slope, is important for postoperative HRQOL scores close to physiological values. The authors speculate that C0-C4 fusion restores horizontal gaze and allows for painful regain of pre-trauma quality of life. Spine surgeons should realign and stabilize the craniocervical junction taking in consideration these roentgenographic predictors.

In vivo primary and coupled segmental motions of the healthy female head-neck complex during dynamic head axial rotation

While previous studies have greatly improved our knowledge on the motion capability of the cervical spine, few reported on the kinematics of the entire head-neck complex (C0-T1) during dynamic activities of the head in the upright posture. This study investigated in vivo kinematics of the entire head-neck complex (C0-T1) of eight female asymptomatic subjects during dynamic left-right head axial rotation using a dual fluoroscopic imaging system and 3D-to-2D registration techniques. During one-sided head rotation (i.e., left or right head rotation), the primary rotation of the overall head-neck complex (C0-T1) reached 55.5 ± 10.8°, the upper cervical spine region (C0-2) had a primary axial rotation of 39.7 ± 9.6° (71.3 ± 8.5% of the overall C0-T1 axial rotation), and the lower cervical spine region (C2-T1) had a primary rotation of 10.0 ± 3.7° (18.6 ± 7.2% of the overall C0-T1 axial rotation). Coupled bending rotations occurred in the upper and lower cervical spine regions in similar magnitude but opposite directions (upper: contralateral bending of 18.2 ± 5.9° versus lower: ipsilateral bending of 21.4 ± 5.1°), resulting in a compensatory cervical lateral curvature that balances the head to rotate horizontally. Furthermore, upper cervical segments (C0-1 or C1-2) provided main mobility in different rotational degrees of freedom needed for head axial rotations. Additionally, we quantitatively described both coupled segmental motions (flexion-extension and lateral bending) by correlation with the overall primary axial rotation of the head-neck complex. This investigation offers comprehensive baseline data regarding primary and coupled motions of craniocervical segments during head axial rotation.

C1-C2 Distraction Ligamentous Injury Treated with Halo-Vest Application: A Case Report

CASE

There is a paucity of literature regarding pediatric upper cervical spine traumatic instability, atlanto-occipital dislocations, and fractures, with no clear treatment algorithm. We present a 12-year-old girl with significant posterior C1-C2 distraction and resultant ligamentous injury after a motor vehicle collision who was treated with a halo vest for 3 months. At 8-month follow-up, follow-up magnetic resonance imaging demonstrated complete ligamentous healing without instability on dynamic radiographs, and at 18-month follow-up, the patient made a full recovery.

CONCLUSION

In some pediatric patients with isolated posterior ligamentous injury, as long as anatomic alignment can be achieved with halo-vest application, a fusion may be avoided.

C1-C2 Injury: Factors influencing mortality, outcome, and fracture healing

BACKGROUND

C1-C2 injury represents 25-40% of cervical injuries and predominantly occurs in the geriatric population.

METHODS

A prospective multicentre study was conducted under the aegis of the french spine surgery society (SFCR) investigating the impact of age, comorbidities, lesion type, and treatment option on mortality, complications, and fusion rates.

RESULTS

A total of 417 patients were recruited from 11 participating centres. The mean ± SD age was 66.6 ± 22 years, and there were 228 men (55%); 5.4% presented a neurological deficit at initial presentation. The most frequent traumatic lesion was C2 fracture (n = 308). Overall mortality was 8.4%; it was 2.3% among those aged ≤ 60 years, 5.0% 61-80 years, and 16.0% > 80 years (p < 0.001). Regarding complications, 17.8% of patients ≤ 70 years of age presented with ≥ 1 complication versus 32.3% > 70 years (p = 0.0009). The type of fracture did not condition the onset of complications and/or mortality (p > 0.05). The presence of a comorbidity was associated with a risk factor for both death (p = 0.0001) and general complication (p = 0.008). Age and comorbidities were found to be independently associated with death (p < 0.005). The frequency of pseudoarthrosis ranged from 0 to 12.5% up to 70 years of age and then constantly and progressively increased to reach 58.6% after 90 years of age.

CONCLUSIONS

C1-C2 injury represents a serious concern, possibly life-threatening, especially in the elderly. We found a major impact of age and comorbidities on mortality, complications, and pseudarthrosis; injury pattern or treatment option seem to have a minimal effect.

Fractures of C2 (Axis) Vertebra: Clinical Presentation and Management

BACKGROUND

Injuries of the upper cervical spine are a major cause of morbidity and mortality due to associated spinal cord and head injuries. The injury patterns of the upper cervical spine are numerous, and the neurologic sequelae are diverse. The axis (C2) is the most commonly fractured vertebra in the upper cervical spine; its unique anatomy and architecture pose difficulties in the diagnosis and the management of its fractures.

METHODS

All cases of acute spinal injuries at Prince Mohammed Bin Abdulaziz Hospital in Riyadh, Saudi Arabia, were screened for fractures of C2 vertebrae. These patients underwent computerized tomography (CT) imaging of the cervical spine with special attention paid to the cranio-cervical junction. Magnetic resonance imaging (MRI) and angiography of the neck were performed to exclude ligamentous tears and vascular injuries. Unstable fractures were fixed surgically. In the remaining cases, a conservative trial was given. All patients were followed up once every 3 months for a period of 1 year. During follow-up, some patients underwent additional CT imaging of the cervical spine to monitor the healing of fractures.

RESULTS

Out of 230 spinal trauma patients, 43.5% suffered from cervical spine injury. C2 fractures were recorded in 26% cases, and fractures of the C2 vertebral body, including pedicles, laminae, lateral masses, and articular processes, were found in many cases, followed by odontoid fractures (50%). No case of atlanto-axial or atlanto-occipital dislocation was recorded. Road traffic accidents were found to be responsible for 92% of cases. The majority of patients were young males, and 96% of patients had no neurological deficit. Only 15% of the patients required surgery for their unstable fractures. Half of the patients attended outpatient follow -up appointments, all of whom underwent CT scanning of the cervical spine 9 months after the accident or operation.

CONCLUSIONS

The axis (C2) is the most commonly affected vertebra in cervical spine trauma, and odontoid fractures make up 50% of all C2 fractures. C2 fractures rarely cause any neurological deficit or vascular injury, and the majority of affected patients can be managed conservatively; only a small proportion requires surgical intervention. Surgical intervention leads to early and complete healing.

Biomechanics of the upper cervical spine ligaments in axial rotation and flexion-extension: Considerations into the clinical framework

Context:

The motion of the upper cervical spine (UCS) has a great interest for analyzing the biomechanical features of this joint complex, especially in case of instability. Although investigators have analyzed numerous kinematics and musculoskeletal characteristics, there are still little data available regarding several suboccipital ligaments such as occipito-atlantal, atlantoaxial, and cruciform ligaments.

Objective:

The aim of this study is to quantify the length and moment arm magnitudes of suboccipital ligaments and to integrate data into specific 3D-model, including musculoskeletal and motion representation.

Materials and Methods:

Based on a recent method, suboccipital ligaments were identified using UCS anatomical modeling. Biomechanical characteristics of these anatomical structures were assessed for sagittal and transversal displacements regarding length and moment arm alterations.

Results:

Outcomes data indicated length alterations >25% for occipito-atlantal, atlanto-axial and apical ligaments. The length alteration of unique ligaments was negligible. Length variation was dependent on the motion direction considered. Regarding moment arm, larger magnitudes were observed for posterior ligaments, and consistent alteration was depicted for these structures.

Conclusion:

These outcomes supply relevant biomechanical characteristics of the UCS ligaments in flexion-extension and axial rotation by quantifying length and moment arm magnitude. Moreover, 3D anatomical modeling and motion representation can help in the process of understanding of musculoskeletal behaviors of the craniovertebral junction.

Interobserver reliability of the Gehweiler classification and treatment strategies of isolated atlas fractures: an internet-based multicenter survey among spine surgeons

Purpose

Atlas (C1) fractures are commonly rated according to the Gehweiler classification, but literature on its reliability is scarce. In addition, evaluation of fracture stability and choosing the most appropriate treatment regime for C1-injuries are challenging. This study aimed to investigate the interobserver reliability of the Gehweiler classification and to identify whether evaluation of fracture stability as well as the treatment of C1-fractures are consistent among spine surgeons.

Methods

Computed tomography images of 34 C1-fractures and case-specific information were presented to six experienced spine surgeons. C1-fractures were graded according to the Gehweiler classification, and the suggested treatment regime was recorded in a questionnaire. For data analyses, SPSS was used, and interobserver reliability was calculated using Fleiss’ kappa (κ) statistics.

Results

We observed a moderate reliability for the Gehweiler classification (κ = 0.50), the evaluation of fracture stability (κ = 0.50), and whether a surgical or non-surgical therapy was indicated (κ = 0.53). Type 1, 2, 3a, and 5 fractures were rated stable and treated non-surgically. Type 3b fractures were rated unstable in 86.7% of cases and treated by surgery in 90% of cases. Atlas osteosynthesis was most frequently recommended (65.4%). Overall, 25.8% of type 4 fractures were rated unstable, and surgery was favoured in 25.8%.

Conclusion

We found a moderate reliability for the Gehweiler classification and for the evaluation of fracture stability. In particular, diverging treatment strategies for type 3b fractures emphasise the necessity of further clinical and biomechanical investigations to determine the optimal treatment of unstable C1-fractures.

Reliability of the New AOSpine Classification System for Upper Cervical Traumatic Injuries

BACKGROUND

The new AOSpine Upper Cervical Classification System (UCCS) was recently proposed by the AOSpine Knowledge Forum Trauma team to standardize the treatment of upper cervical traumatic injuries (UCI). In this context, evaluating its reliability is paramount prior to clinical use.

OBJECTIVE

To evaluate the reliability of the new AOSpine UCCS.

METHODS

A total of 32 patients with UCI treated either nonoperatively or with surgery by one of the authors were included in the study. Injuries were classified based on the new AO UCCS according to site and injury type using computed tomography scan images in 3 planes by 8 researchers at 2 different times, with a minimum interval of 4 wk between assessments. Intra- and interobserver reliability was assessed using the kappa index (K). Treatment options suggested by the evaluators were also assessed.

RESULTS

Intraobserver agreement for sites ranged from 0.830 to 0.999, 0.691 to 0.983 for types, and 0.679 to 0.982 for the recommended treatment. Interobserver analysis at the first assessment was 0.862 for injury sites, 0.660 for types, and 0.585 for the treatment, and at the second assessment, it was 0.883 for injury sites, 0.603 for types, and 0.580 for the treatment. These results correspond to a high level of agreement of answers for the site and type analysis and a moderate agreement for the recommended treatment.

CONCLUSION

This study reported an acceptable reproducibility of the new AO UCCS and safety in recommending the treatment. Further clinical studies with a larger patient sample, multicenter and international, are necessary to sustain the universal and homogeneity quality of the new AO UCCS.

AOSpine-Spine Trauma Classification System: The Value of Modifiers: A Narrative Review With Commentary on Evolving Descriptive Principles

STUDY DESIGN

Narrative review.

OBJECTIVES

To describe the current AOSpine Trauma Classification system for spinal trauma and highlight the value of patient-specific modifiers for facilitating communication and nuances in treatment.

METHODS

The classification for spine trauma previously developed by The AOSpine Knowledge Forum is reviewed and the importance of case modifiers in this system is discussed.

RESULTS

A successful classification system facilitates communication and agreement between physicians while also determining injury severity and provides guidance on prognosis and treatment. As each injury may be unique among different patients, the importance of considering patient-specific characteristics is highlighted in this review. In the current AOSpine Trauma Classification, the spinal column is divided into 4 regions: the upper cervical spine (C0-C2), subaxial cervical spine (C3-C7), thoracolumbar spine (T1-L5), and the sacral spine (S1-S5, including coccyx). Each region is classified according to a hierarchical system with increasing levels of injury or instability and represents the morphology of the injury, neurologic status, and clinical modifiers. Specifically, these clinical modifiers are denoted starting with M followed by a number. They describe unique conditions that may change treatment approach such as the presence of significant soft tissue damage, uncertainty about posterior tension band injury, or the presence of a critical disc herniation in a cervical bilateral facet dislocation. These characteristics are described in detail for each spinal region.

CONCLUSIONS

Patient-specific modifiers in the AOSpine Trauma Classification highlight unique clinical characteristics for each injury and facilitate communication and treatment between surgeons.

Variations in treatment of C1 fractures by time, age, and geographic region in the United States: An analysis of 985 patients

The purpose of this investigation was to evaluate the variations in the treatment of C1 fractures over time, by age group, and by geographic region using a nationwide database. The Nationwide Emergency Department Sample (NEDS) database was queried to identify patients ≥18 years who sustained C1 fracture from 2006-2012. Patients were filtered based on the intervention they received: collar, halo, or surgery. Regions of hospital used in analysis were defined as Northeast, Midwest, South, and West. Surgical intervention for C1 fracture increased from 27.1% of cases in 2006 to 55.4% of cases in 2012 (P<0.001). The rate of collar treatment increased with increasing age. In contrast, rate of halo use decreased with increasing age. A greater proportion of patients in the Northeast were treated by collar compared to all other regions (P<0.001). We can conclude that there is considerable variation in the treatment of C1 fractures with regards to age and geographic region. Surgical treatment of these fractures is increasing over time. Future considerations should be given to developing treatment guidelines to decrease variation and potentially create cost-savings.

Occipitocervical Dislocation in Low-Energy Trauma

Traumatic occipitocervical dislocation (OCD) is described in the literature as a potentially fatal injury secondary to high-energy trauma. We describe a case of OCD occurring in a patient who sustained a ground-level fall whose only clinical symptom was posterior neck pain without neurologic compromise. Computed tomography (CT) and magnetic resonance imaging (MRI) were used to diagnose severe injury to the structurally important ligamentous complex that stabilizes the base of the skull to the spine, along with unstable fractures of the occipital condyle and C1. Emergent surgical instrumentation and fusion of occiput-C2 was performed. Postoperatively, neurologic integrity was maintained. This case illustrates that traumatic OCD is not exclusively secondary to high-energy mechanisms. It also demonstrates that severe neck pain as the only clinical manifestation in a patient with head or neck low-energy trauma is suggestive of a possible OCD. We highlight the importance of the use of head and neck CT as the first imaging-based diagnostic tool to aid in identifying this injury. Finally, surgical stabilization should be performed as soon as possible to minimize neurologic sequelae.

Immobilisation in occipital condyle fractures: A systematic review

OBJECTIVES

The objectives of this review are to determine the level of evidence for the management of OCF, compare outcomes of different immobilisation, and to review the prognosis.

PATIENTS AND METHODS

A literature search was conducted using 3 databases (MEDLINE, PubMed and EMBASE). All papers between 1940 and July 2017 were screened using PRISMA guidelines. Inclusion criteria were patients with a confirmed diagnosis of occipital condyle fracture(s) on CT managed with any form of immobilisation with no age restriction. Primary outcome was clinical improvement in symptoms or Neck Disability Index. MINORS and OCEBM level was assigned to each study.

RESULTS

25 studies met the inclusion criteria. Most studies used a single form of C-spine immobilisation support (58%) with a semi rigid collar and halo device being the most common. From these studies, the average length of time for immobilisation was 11.7 weeks, 9 weeks and 8.3 weeks for halo, semi-rigid and rigid cervical collars respectively. Neuro deficit was found in 20.3% of patients. OCEBM level of evidence and MINORS score was low.

CONCLUSION

Management of OCF is associated with low level of evidence. Further studies are needed to determine optimal management of these under-diagnosed fractures.

EPIDEMIOLOGY OF SPINAL TRAUMA SURGICALLY TREATED AT THE UNICAMP HOSPITAL DAS CLÍNICAS

ABSTRACT Objective: To report the epidemiological profile of patients operated for treatment of spinal trauma in the UNICAMP Hospital das Clínicas. Methods: Patients older than 14 years with spinal trauma operated in the service from 2012 to 2017 with complete radiological and clinical data were evaluated. Results: A total of 143 patients were included, 120 men and 23 women, with a mean age of 37.8 years. Falls from height (32%), motorcycle (26%) and car accidents (24%) were the most common trauma mechanisms. The most affected vertebral level was C6 (11%) and most patients (55%) had some neurological deficits. The overall postoperative complication rate was 23%. Conclusions: Spinal trauma has a high socioeconomic impact due to its high morbidity and mortality, and it is necessary to study its epidemiology for the development of public policies for prevention and treatment financing. Level of Evidence: III. Type of study: Retrospective study.

Atlas Fractures and Atlas Osteosynthesis: A Comprehensive Narrative Review

Most atlas fractures are the result of compression forces. They are often combined with fractures of the axis and especially with the odontoid process. Multiple classification systems for atlas fractures have been described. For an adequate diagnosis, a computed tomography is mandatory. To distinguish between stable and unstable atlas injury, it is necessary to evaluate the integrity of the transverse atlantal ligament (TAL) by magnetic resonance imaging and to classify the TAL lesion. Studies comparing conservative and operative management of unstable atlas fractures are unfortunately not available in the literature; neither are studies comparing different operative treatment strategies. Hence all treatment recommendations are based on low level evidence. Most of atlas fractures are stable and will be successfully managed by immobilization in a soft/hard collar. Unstable atlas fractures may be treated conservatively by halo-fixation, but nowadays more and more surgeons prefer surgery because of the potential discomfort and complications of halo-traction. Atlas fractures with a midsubstance ligamentous disruption of TAL or severe bony ligamentous avulsion can be treated by a C1/2 fusion. Unstable atlas fractures with moderate bony ligamentous avulsion may be treated by atlas osteosynthesis. Although the evidence for the different treatment strategies of atlas fractures is low, atlas osteosynthesis has the potential to change treatment philosophies. The reasons for this are described in this review.

Reliability and safety of a new upper cervical spine injury treatment algorithm

Methods

Thirty cases, previously treated according to the new algorithm, were presented to four spine surgeons who were questioned about their personal suggestion for treatment, and the treatment suggested according to the application of the algorithm. After four weeks, the same questions were asked again to evaluate reliability (intra- and inter-observer) using the Kappa index.

Results

The reliability of the treatment suggested by applying the algorithm was superior to the reliability of the surgeons' personal suggestion for treatment. When applying the upper cervical spine injury treatment algorithm, an agreement with the treatment actually performed was obtained in more than 89% of the cases.

Conclusion

The system is safe and reliable for treating traumatic upper cervical spine injuries. The algorithm can be used to help surgeons in the decision between conservative versus surgical treatment of these injuries.

The Dens: A Review of its Diverse Nomenclature and a Recommended Simplified Terminology

Pathology of the dens, such as fractures, demands precise terminology so that communication between physicians are succinct, diagnoses are accurate, and treatment strategies exact. This review aims to summarize the various terms used to describe the parts of the dens and recommend the ideal terminology. Using standard search engines, English language publications were searched for the many terms used to describe parts of the dens. A multitude of terms was identified with many demonstrating overlaps. Terms identified included apex, tip, apicodental, subdental, dentocentral and odontocentral junctions, peg, waist, base, neck, shaft, shoulder, and stem. Exact terminology is necessary when diagnosing or treating patients with pathology of or near the dens. The authors suggest simplified terminology for describing the parts of the dens that can be used in the future in order to be unequivocal and to avoid confusion when classifying and communicating fractures through its parts.

The Impact of Engorged Vein within Traumatic Posterior Neck Muscle Identified in Preoperative Computed Tomography Angiography to Estimated Blood Loss during Posterior Upper Cervical Spine Surgery

Objective

Injuries of upper cervical spine are potentially fatal. Thus, appropriate diagnosis and treatment is essential. In our institute, preoperative computed tomography angiography (CTA) has been performed for evaluation of injuries of bony and vascular structure. The authors confirmed the engorged venous plexus within injured posterior neck muscle. We have this research to clarify the relationship between the engorged venous plexus and engorged vein.

Methods

A retrospective review identified 23 adult patients who underwent 23 posterior cervical spine surgeries for treatment of upper cervical injury between 2013 and 2015. Preoperative CTA was used to identify of venous engorgement within posterior neck muscle. The male to female ratio was 18:5 and the mean age was 53.5 years (range, 25-78 years). Presence of venous engorgement and estimated blood loss (EBL) were analyzed retrospectively.

Results

The EBL of group with venous engorgement was 454.55 mL. The EBL of group without venous engorgement was 291.67 mL. The EBL of group with venous engorgement was larger than control group in significant.

Conclusion

The presence of engorged venous plexus is important factor of intraoperative bleeding. Preoperative CTA for identifying of presence of engorged venous plexus and fine operative techniques is important to decrease of blood loss during posterior cervical spine surgery.

Establishment and evaluation of a prognostic model for surgical outcomes of patients with atlanto-axial dislocations

Objective

Atlanto-axial dislocations (AADs) are potentially fatal disturbances with high spinal cord compression syndrome. As surgeons are still uncertain who is likely to benefit the most from surgery, a prediction tool is needed to provide decision-making support.

Methods

The model was established based on 108 patients with AADs using multiple binary logistic regression analysis and evaluated by calibration plot and the area under the receiver operating curve (AUC). Bootstrapping was used for internal validation.

Results

The prognostic model can be expressed as: logit(P) = −2.2428 + 0.3168SCOPE − 2.0375SIGNAL, in which two covariates were accepted (SCORE represents the preoperative modified Japanese Orthopedic Association (mJOA) score and SIGNAL represents the intramedullary hyperintense T₂-weighted imaging (T₂WI) with AUC = 0.8081).

Conclusions

The model was internally valid, and the preoperative mJOA score and hyperintense T₂WI were important predictors of outcomes. The threshold was defined as logit(P) = −0.7282 according to the receiver operating curve (ROC).

Traumatic atlanto-occipital dislocation: do children and adolescents have better or worse outcomes than adults? A narrative review

BACKGROUND

Traumatic atlanto-occipital dislocation is an uncommon, severely unstable pathology, which can lead to detrimental or even fatal neurological impairment. Specifically, children have consistently been reported to be more susceptible to this type of injury because of their disproportionately larger head, ligament laxity, and injury mechanisms. However, to date, rates of missed injury and outcomes including neurologic recovery of pediatric and adult populations following this insult have not been comparatively evaluated.

METHODS

Standard search engines were used to investigate outcomes of traumatic atlanto-occipital dislocation in children and adolescents compared to adults.

CONCLUSIONS

Based on case reports and small series from the literature, it seems that children and adolescents tend to have a better likelihood of survival with the possibility of long-term neurological complications. Comparatively, adults who suffer traumatic atlanto-occipital dislocation either succumb to their injuries or survive with very little if any neurological complications.

C1 fractures: a review of diagnoses, management options, and outcomes

The atlas is subject to fracture under axial load, often due to traumatic injuries such as shallow dives and automobile accidents. These fractures account for 2-13 % of injuries to the cervical spine [Marcon RM et al. Clinics (Sao Paulo) 68(11):1455-61, 2013]. Fractures of the C1 vertebra are often difficult to diagnose, as there is often no neurological deficit or easily identifiable findings on radiographs. However, injuries to the atlas can be associated with vertebral artery injury and atlantoaxial or atlanto-occipital instability, making prompt and accurate diagnosis imperative. A detailed understanding of the anatomy, inherent stability, and common injury patterns is essential for any surgeon treating spinal trauma. This chapter explores the diagnosis and management of C1 fractures, as well as outcomes after treatment.

Cervical spine evaluation in the bluntly injured patient

BACKGROUND

Cervical spine injuries causing spinal cord trauma are rare in blunt trauma yet lead to devastating morbidity and mortality when they occur. There exists considerable debate in the literature about the best way for clinicians to proceed in ruling out cervical spine injuries in alert or obtunded blunt trauma patients.

METHODS

We reviewed the current literature and practice management guidelines to generate clinical recommendations for the detection and clearance of cervical spine injuries in the blunt trauma patient.

RESULTS

The NEXUS and Canadian C-Spine Rules are clinical tools to guide in the clearance of the cervical spine of patients who have sustained low risk trauma and who are pain free, with the Canadian C-Spine Rules having superior sensitivity and specificity. In the alert, high risk patient with pain (or without, if over the age of 65 years), follow up imaging is required. The best imaging modality to use is Computerized Tomography (CT) of the cervical spine. In the obtunded trauma patient, CT clearance of c-spine injury is adequate, unless there is soft tissue injury or any non-bony abnormalities detected. At such point, definitive clearance may be obtained with Magnetic Resonance Imaging (MRI).

CONCLUSIONS

It is imperative to assume cervical spine injury in the blunt trauma patient. Clinical decision rules for cervical clearance may be used in low risk patients, avoiding imaging. High risk patients require imaging in the form of CT scan of the cervical spine.

Conservative versus surgical treatment for type II odontoid fractures in the elderly: Grading the evidence through a meta-analysis

BACKGROUND

Odontoid fractures are common C-spine fractures in the elderly. However, the optimal treatment of odontoid fractures in the elderly is, still subject to controversy.

HYPOTHESIS

Surgical treatment has several advantages on conservative treatment, such as reduced mortality and lower incidence of non-union. This meta-analysis was performed to identify the efficacy of conservative treatment compared with surgical treatment and provides recommendations for using these procedures to treat type II odontoid fractures in the elderly.

MATERIALS AND METHODS

A systematic search of all studies published was conducted using the PubMed, EMBASE, OVID, ScienceDirect and Cochrane CENTRAL databases. The randomized controlled trials (RCTs) and non-randomized controlled trials (non-RCTs) that compared conservative treatment with surgical treatment and provided data on clinical effects were identified. The included trials were screened out strictly based on the criterion of inclusion and exclusion. The quality of included trials was evaluated. RevMan 5.1 was used for data analysis.

RESULTS

Twelve studies involving 730 patients met the inclusion criteria. There were 441 patients with conservative treatment and 289 with surgical treatment. The results of meta-analysis indicated that no difference with regard to the mortality was noted (P > 0.05) between the two procedures. However, there was statistically significant difference with respect to the non-union numbers (P < 0.05) between the two procedures.

DISCUSSION

Conservative treatment and surgical treatment are both effective procedures for treating type II odontoid fractures in the elderly. Compared with surgical treatment, there is no significant difference in mortality; With respect to non-union numbers, conservative treatment numbers are higher than surgical treatment. Due to the poor quality of the evidence currently available, high quality RCTs are required. Level of evidence Level II: low-powered prospective randomized trial meta-analysis.

Delayed diagnosis of isolated alar ligament rupture: A case report

Ligament disruptions at the craniovertebral junction are typically associated with atlantoaxial rotatory dislocation during upper cervical spine injuries and require external orthoses or surgical stabilization. Only in few patients isolated ruptures of the alar ligament have been reported. Here we present a further case, in which the diagnosis was initially obscured by a misleading clinical symptomatology but finally established six month following the trauma, demonstrating the value of contrast-enhanced high resolution 3 Tesla magnetic resonance imaging in identifying this particular lesion.

Upper cervical injuries: Clinical results using a new treatment algorithm

Introduction:

Upper cervical injuries (UCI) have a wide range of radiological and clinical presentation due to the unique complex bony, ligamentous and vascular anatomy. We recently proposed a rational approach in an attempt to unify prior classification system and guide treatment. In this paper, we evaluate the clinical results of our algorithm for UCI treatment.

Materials and Methods:

A prospective cohort series of patients with UCI was performed. The primary outcome was the AIS. Surgical treatment was proposed based on our protocol: Ligamentous injuries (abnormal misalignment, facet perched or locked, increase atlanto-dens interval) were treated surgically. Bone fractures without ligamentous injuries were treated with a rigid cervical orthosis, with exception of fractures in the dens base with risk factors for non-union.

Results:

Twenty-three patients treated initially conservatively had some follow-up (mean of 171 days, range from 60 to 436 days). All of them were neurologically intact. None of the patients developed a new neurological deficit. Fifteen patients were initially surgically treated (mean of 140 days of follow-up, ranging from 60 to 270 days). In the surgical group, preoperatively, 11 (73.3%) patients were AIS E, 2 (13.3%) AIS C and 2 (13.3%) AIS D. At the final follow-up, the American Spine Injury Association (ASIA) score was: 13 (86.6%) AIS E and 2 (13.3%) AIS D. None of the patients had neurological worsening during the follow-up.

Conclusions:

This prospective cohort suggested that our UCI treatment algorithm can be safely used. Further prospective studies with longer follow-up are necessary to further establish its clinical validity and safety.

A review of cervical spine injury associated with maxillofacial trauma at a UK tertiary referral centre

INTRODUCTION

The aim of this study was to determine the incidence and patterns of cervical spine injury (CSI) associated with maxillofacial fractures at a UK trauma centre.

METHODS

A retrospective analysis was conducted of 714 maxillofacial fracture patients presenting to a single trauma centre between 2006 and 2012.

RESULTS

Of the 714 maxillofacial fracture patients, 2.2% had associated CSI including a fracture, cord contusion or disc herniation. In comparison, 1.0% of patients without maxillofacial trauma sustained a CSI (odds ratio: 2.2, p=0.01). The majority (88%) of CSI cases of were caused by a road traffic accident (RTA) with the remainder due to falls. While 8.8% of RTA related maxillofacial trauma patients sustained a CSI, only 2.0% of fall related patients did (p=0.03, not significant). Most (70%) of the CSIs occurred at C1/C2 or C6/C7 levels. Overall, 455, 220 and 39 patients suffered non-mandibular, isolated mandibular and mixed mandibular/non-mandibular fractures respectively. Their respective incidences of CSI were 1.5%, 1.8% and 12.8% (p=0.005, significant). Twelve patients with concomitant CSI had their maxillofacial fractures treated within twenty-four hours and all were treated within four days.

CONCLUSIONS

The presence of maxillofacial trauma mandates exclusion and prompt management of cervical spine injury, particularly in RTA and trauma cases involving combined facial fracture patterns. This approach will facilitate management of maxillofacial fractures within an optimum time period.