Abstract
OBJECTIVES:
The aim of this study was to review the literature on cervical spine fractures.
METHODS:
The literature on the diagnosis, classification, and treatment of lower and upper cervical fractures and dislocations was reviewed.
RESULTS:
Fractures of the cervical spine may be present in polytraumatized patients and should be suspected in patients complaining of neck pain. These fractures are more common in men approximately 30 years of age and are most often caused by automobile accidents. The cervical spine is divided into the upper cervical spine (occiput-C2) and the lower cervical spine (C3-C7), according to anatomical differences. Fractures in the upper cervical spine include fractures of the occipital condyle and the atlas, atlanto-axial dislocations, fractures of the odontoid process, and hangman's fractures in the C2 segment. These fractures are characterized based on specific classifications. In the lower cervical spine, fractures follow the same pattern as in other segments of the spine; currently, the most widely used classification is the SLIC (Subaxial Injury Classification), which predicts the prognosis of an injury based on morphology, the integrity of the disc-ligamentous complex, and the patient's neurological status. It is important to correctly classify the fracture to ensure appropriate treatment. Nerve or spinal cord injuries, pseudarthrosis or malunion, and postoperative infection are the main complications of cervical spine fractures.
CONCLUSIONS:
Fractures of the cervical spine are potentially serious and devastating if not properly treated. Achieving the correct diagnosis and classification of a lesion is the first step toward identifying the most appropriate treatment, which can be either surgical or conservative.
Cervical Atlas; Cervical Vertebrae; Spinal Fractures; Classification; Therapeutics
INTRODUCTION
The most common causes of cervical spine injury are automobile accidents, followed by diving into
shallow water, firearm injuries, and sports activities (11. Blackmore CC, Emerson SS, Mann FA, Koepsell TD. Cervical spine imaging in
patients with trauma: determination of fracture risk to optimize use. Radiology.
1999;211(3):759-65.,22. Barros Filho TEP, Oliveira RP, Barros EK, Von Uhlendorff EF, Iutaka AS, Cristante
AF, et al. Ferimento por projétil de arma de fogo na coluna vertebral: estudo
epidemiológico [Gunshot wounds of the spine: epidemiological study]. Coluna/Columna.
2002;1(2):83-7. Disponível em: http://www.plataformainterativa2.com/coluna/html/revistacoluna/volume1/ferimento_projetil.htm.
Acessado em 2012 (9 out).
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). There is a bimodal age distribution among
patients with spinal cord injuries: the first peak occurs in patients between 15 and 24 years, and
the second in patients over 55 years of age (22. Barros Filho TEP, Oliveira RP, Barros EK, Von Uhlendorff EF, Iutaka AS, Cristante
AF, et al. Ferimento por projétil de arma de fogo na coluna vertebral: estudo
epidemiológico [Gunshot wounds of the spine: epidemiological study]. Coluna/Columna.
2002;1(2):83-7. Disponível em: http://www.plataformainterativa2.com/coluna/html/revistacoluna/volume1/ferimento_projetil.htm.
Acessado em 2012 (9 out).
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3. Kraus JF, Franti CE, Riggins RS, Richards D, Borhani NO. Incidence of traumatic
spinal cord lesions. J Chronic Dis. 1975;28(9):471-92,
http://dx.doi.org/10.1016/0021-9681(75)90057-0.
http://dx.doi.org/10.1016/0021-9681(75)9...
-44. Cristante AC, Barros Filho TEP, Marcon RM, Letaif OB, Rocha ID. Therapeutic
approaches for spinal cord injury. Clinics (Sao Paulo). 2012;67(10):1219-24,
http://dx.doi.org/10.6061/clinics/2012(10)16.
http://dx.doi.org/10.6061/clinics/2012(1...
).
Occipital condyle fractures
Extension of the upper part of the cervical spine is limited mainly by the transverse portion of
the alar ligaments. When flexion is added to the head rotation, the alar ligament is maximally
dilated and the cervical spine becomes more vulnerable to injury (55. Dvorak J, Panjabi MM. Functional anatomy of the alar ligaments. Spine (Phila Pa
1976). 1987;12(2):183-9, http://dx.doi.org/10.1097/00007632-198703000-00016.
http://dx.doi.org/10.1097/00007632-19870...
).
The first description of occipital condyle fractures in the literature was provided by Bell
(66. Bell C. Surgical observations. Middlesex Hospital Journal.
1817;4:469-70.) in 1817, and the second was not published before 1900
(77. Kissinger P. Luxationfraktur im atlantooccipital Gelenke. Zentralbl Chirurgie.
1900;37:933-4.). Further cases were published from 1962 (88. Ahlgren P, Mygind T. [Fracture in the epistrophic arch in hanging without
fatal outcome]. Fortschr Geb Rontgenstr Nuklearmed. 1962;97:655-7,
http://dx.doi.org/10.1055/s-0029-1227120.
http://dx.doi.org/10.1055/s-0029-1227120...
9. Ahlgren P, Dahlerup JV. [Fracture of the occipital condyle. a new case
of isolated fracture]. Fortschr Geb Rontgenstr Nuklearmed. 1964;101:202-4,
http://dx.doi.org/10.1055/s-0029-1227541.
http://dx.doi.org/10.1055/s-0029-1227541...
10. Schliack H, Schaefer P. [Hypoglossal and accessory nerve paralysis in a
fracture of the occipital condyle]. Nervenarzt. 1965;36(8):362-4.-1111. Wackenheim A. Roentgen diagnosis of the craniovertebral region. Berlin:
Springer-Verlag; 1974.) to 1978 (1212. Bolender N, Cromwell LD, Wendling L. Fracture of the occipital condyle. AJR
Am J Roentgenol. 1978;131(4):729-31,
http://dx.doi.org/10.2214/ajr.131.4.729.
http://dx.doi.org/10.2214/ajr.131.4.729...
), with this type of fracture characterized as very rare.
Fractures of the occipital condyle require conservative treatment. Outcomes are favorable if
there are no other associated injuries, such as those caused by cranioencephalic trauma or cervical
vertebral fractures (1313. Anderson PA, Montesano PX. Morphology and treatment of occipital condyle
fractures. Spine (Phila Pa 1976). 1988;13(7):731-6,
http://dx.doi.org/10.1097/00007632-198807000-00004.
http://dx.doi.org/10.1097/00007632-19880...
).
In general, this type of fracture is caused by accidents involving high-energy traumas, such as
sports-related injuries and, in the vast majority of cases, automobile accidents (1212. Bolender N, Cromwell LD, Wendling L. Fracture of the occipital condyle. AJR
Am J Roentgenol. 1978;131(4):729-31,
http://dx.doi.org/10.2214/ajr.131.4.729.
http://dx.doi.org/10.2214/ajr.131.4.729...
). In addition, these fractures generally affect younger
individuals in the second and third decades of life, particularly males (1212. Bolender N, Cromwell LD, Wendling L. Fracture of the occipital condyle. AJR
Am J Roentgenol. 1978;131(4):729-31,
http://dx.doi.org/10.2214/ajr.131.4.729.
http://dx.doi.org/10.2214/ajr.131.4.729...
).
In 1987, Dvorak and Panjabi (55. Dvorak J, Panjabi MM. Functional anatomy of the alar ligaments. Spine (Phila Pa
1976). 1987;12(2):183-9, http://dx.doi.org/10.1097/00007632-198703000-00016.
http://dx.doi.org/10.1097/00007632-19870...
) published their study on
the functional anatomy of the alar ligaments, and in 1988, Anderson and Montesano (1313. Anderson PA, Montesano PX. Morphology and treatment of occipital condyle
fractures. Spine (Phila Pa 1976). 1988;13(7):731-6,
http://dx.doi.org/10.1097/00007632-198807000-00004.
http://dx.doi.org/10.1097/00007632-19880...
) proposed a classification for fractures of the occipital
condyle according to the regional anatomy, biomechanics of the structures involved, and fracture
morphology. Three types of occipital condyle fractures have been described. Type I is an impact
fracture of the occipital condyle for which the trauma mechanism is the axial load of the skull on
the atlas. In this fracture, there is communication of the occipital condyle with or without minimum
deviation of the fragments toward the foramen magnum. The tectorial membrane remains intact, as does
the alar ligament contralateral to the fracture, which ensures the fracture's stability. Type
II fractures are part of a cranial base fracture that causes a fracture line extending towards the
foramen magnum. This fracture is caused by direct regional trauma and is stable because the alar
ligaments and the tectorial membrane remain intact. In type III fractures, there is a
fracture-avulsion of the occipital condyle by the alar ligament, which is caused by a rotation of
the head, a lateral tilt of the head, or both movements together. In this case, because the
contralateral alar ligament and the tectorial membrane do not remain intact, the injury is
potentially unstable.
The clinical signs of occipital condyle fractures are highly non-specific, which makes diagnosis
difficult. The patient generally only complains of pain on the posterior side of the neck and
cervical paravertebral muscle spasms (1010. Schliack H, Schaefer P. [Hypoglossal and accessory nerve paralysis in a
fracture of the occipital condyle]. Nervenarzt. 1965;36(8):362-4.). Because specific
exams are needed to diagnose these fractures, they often go unnoticed. The patient may present with
persistent pain in the posterior cervical region accompanied by muscle spasms over long periods,
without ever suspecting that there is an injury (1111. Wackenheim A. Roentgen diagnosis of the craniovertebral region. Berlin:
Springer-Verlag; 1974.,1212. Bolender N, Cromwell LD, Wendling L. Fracture of the occipital condyle. AJR
Am J Roentgenol. 1978;131(4):729-31,
http://dx.doi.org/10.2214/ajr.131.4.729.
http://dx.doi.org/10.2214/ajr.131.4.729...
). These fractures are extremely difficult to detect using
conventional radiographic techniques, so the use of other methods is necessary. Computed tomography
(CT) is the preferred examination method (1111. Wackenheim A. Roentgen diagnosis of the craniovertebral region. Berlin:
Springer-Verlag; 1974.,1212. Bolender N, Cromwell LD, Wendling L. Fracture of the occipital condyle. AJR
Am J Roentgenol. 1978;131(4):729-31,
http://dx.doi.org/10.2214/ajr.131.4.729.
http://dx.doi.org/10.2214/ajr.131.4.729...
). The occipitocervical transition should be carefully evaluated,
particularly in patients with associated facial and cranial traumas (1111. Wackenheim A. Roentgen diagnosis of the craniovertebral region. Berlin:
Springer-Verlag; 1974.,1212. Bolender N, Cromwell LD, Wendling L. Fracture of the occipital condyle. AJR
Am J Roentgenol. 1978;131(4):729-31,
http://dx.doi.org/10.2214/ajr.131.4.729.
http://dx.doi.org/10.2214/ajr.131.4.729...
).
Cranioencephalic trauma occurs in the vast majority of patients with these fractures, which
contributes to the clinical symptoms of these patients, making diagnosis difficult and often leading
to death. There is a possible association of these injuries with fractures of the cervical
vertebrae, and occipital condyle fractures are often mistakenly diagnosed as cervical vertebral
fractures (1111. Wackenheim A. Roentgen diagnosis of the craniovertebral region. Berlin:
Springer-Verlag; 1974.,1212. Bolender N, Cromwell LD, Wendling L. Fracture of the occipital condyle. AJR
Am J Roentgenol. 1978;131(4):729-31,
http://dx.doi.org/10.2214/ajr.131.4.729.
http://dx.doi.org/10.2214/ajr.131.4.729...
).
Conservative treatment of occipital condyle fractures results in good outcomes; the patient
becomes free of neck pain, and full range of motion of the segment involved can be regained after
three months of treatment. The use of a Philadelphia cervical collar is recommended for cases
categorized as type I or II in the Anderson and Montesano classification, and a more rigid
immobilization, such as a halo brace or Minerva cast for 12 weeks, is recommended in the case of
type III fractures. If radiographic images indicate instability after an appropriate period of
immobilization with a halo brace, occiput-C2 arthrodesis may be necessary (1313. Anderson PA, Montesano PX. Morphology and treatment of occipital condyle
fractures. Spine (Phila Pa 1976). 1988;13(7):731-6,
http://dx.doi.org/10.1097/00007632-198807000-00004.
http://dx.doi.org/10.1097/00007632-19880...
,1414. Spencer JA, Yeakley JW, Kaufman HH. Fracture of the occipital condyle.
Neurosurgery. 1984;15(1):101-3, http://dx.doi.org/10.1227/00006123-198407000-00019.
http://dx.doi.org/10.1227/00006123-19840...
).
C1 and C2 fractures and dislocations
Atlas fractures
Atlas fractures represent 2% of all vertebral spine fractures (1515. Jefferson G. Fracture of the atlas vertebra. Report of four cases,
and a review of those previously recorded. British Journal of Surgery. 1919;7(27):407-22.
Available from: http://onlinelibrary.wiley.com/doi/10.1002/bjs.1800072713/abstract. Accessed in 2012
(Oct 30). http://dx.doi.org/10.1002/bjs.1800072713.
http://onlinelibrary.wiley.com/doi/10.10...
) and occur when an axial (vertical) compression of the skull on the atlas forces it onto
the axis, resulting in a rupture at the weakest points (the anterior and posterior arches) and
causing the lateral masses to split; this is known as a Jefferson fracture (1515. Jefferson G. Fracture of the atlas vertebra. Report of four cases,
and a review of those previously recorded. British Journal of Surgery. 1919;7(27):407-22.
Available from: http://onlinelibrary.wiley.com/doi/10.1002/bjs.1800072713/abstract. Accessed in 2012
(Oct 30). http://dx.doi.org/10.1002/bjs.1800072713.
http://onlinelibrary.wiley.com/doi/10.10...
).
Pressure exerted on the atlas may lead not only to fracture of the arches but also to rupture of
the transverse ligament, which is the main structure that gives this vertebra its anterior stability
and prevents it from slipping on the axis (55. Dvorak J, Panjabi MM. Functional anatomy of the alar ligaments. Spine (Phila Pa
1976). 1987;12(2):183-9, http://dx.doi.org/10.1097/00007632-198703000-00016.
http://dx.doi.org/10.1097/00007632-19870...
). Thus, in
Jefferson fractures, the status of the transverse ligament is essential to the prognosis.
The diagnosis of an atlas fracture is made by observation of the C1-C2 joint in frontal radiographs. Normally, there should be continuity of the vertical line traced on the lateral margins of the lateral masses of the atlas and of the joint masses of the axis; however, when there is a fracture of the anterior and posterior arches of the atlas, this continuity disappears due to splitting of the lateral masses.
It has yet to be determined how much of a separation is consistent with the integrity of the
transverse ligament. Experimental studies on cadavers (1414. Spencer JA, Yeakley JW, Kaufman HH. Fracture of the occipital condyle.
Neurosurgery. 1984;15(1):101-3, http://dx.doi.org/10.1227/00006123-198407000-00019.
http://dx.doi.org/10.1227/00006123-19840...
)
have demonstrated that if the separation is greater than 7 mm, rupture of the ligament has occurred
with C1-C2 instability, which continues even after consolidation of the arch
fractures and results in a greater risk of C1-C2 dislocation; this is also
true for small traumas (55. Dvorak J, Panjabi MM. Functional anatomy of the alar ligaments. Spine (Phila Pa
1976). 1987;12(2):183-9, http://dx.doi.org/10.1097/00007632-198703000-00016.
http://dx.doi.org/10.1097/00007632-19870...
).
The treatment indicated for Jefferson fractures is reduction by cranial traction and immobilization for three to four months. However, in cases where there is rupture of the transverse ligament, immediate occipito-cervical arthrodesis is necessary.
Sometimes, routine radiographic study of the Jefferson fracture only reveals a fracture of the posterior arch, while a fracture of the anterior arch only appears on CT scans.
Atlas-axis dislocation
Patient survival following dislocations between the occiput and the atlas is rare. We do not have
any personal experience with these cases, and there have been very few reports in the literature
(1414. Spencer JA, Yeakley JW, Kaufman HH. Fracture of the occipital condyle.
Neurosurgery. 1984;15(1):101-3, http://dx.doi.org/10.1227/00006123-198407000-00019.
http://dx.doi.org/10.1227/00006123-19840...
). Pure C1-C2 dislocations, i.e.,
without fracture of the odontoid process, are also rare because they can only be caused by a violent
flexion mechanism with rupture of the transverse ligament, projection of the odontoid dens to the
neural canal, and spinal cord trauma that is generally incompatible with life.
Subluxations determined by existing instability are more common, as in dysplasias of the odontoid
dens and rheumatoid arthritis (1616. Astolfi RS, Tachibana WT, Letaif OB, Cristante AF, Oliveira RP, Barros Filho
TEP. Análise tomográfica para colocação de parafusos em C2 nos pacientes com
artrite reumatoide [Tomographic analysis for C2 screw placement in rheumatoid arthritis
patients]. Acta Ortop Bras. 2012;20(4):207-9,
http://dx.doi.org/10.1590/S1413-78522012000400002.
http://dx.doi.org/10.1590/S1413-78522012...
). We should also
differentiate between this and other types of injury, such as Grisel's syndrome, in which a
fixed rotatory subluxation of C1-C2 can be observed, which is of an inflammatory origin and with a
distinct previous history.
Radiographic diagnosis of a C1-C2 dislocation is typically made in the profile view, in which the distance between the posterior margin of the anterior arch of the atlas and the anterior margin of the odontoid peg is greater than 3 mm in adults or 5 mm in children. If there is uncertainty, the recommendation is to conduct radiographic imaging in the profile view, in both flexion and extension; normally, there should be no significant difference in the distance. In this dynamic study, especially when a dislocation is suspected, precautions should be taken; for example, complaints of pain should be interpreted as a limitation of movement, and the exam should not be performed on unconscious patients (1111. Wackenheim A. Roentgen diagnosis of the craniovertebral region. Berlin: Springer-Verlag; 1974.).
In cases of C1-C2 dislocations, the treatment should always be surgical.
C1-C2 arthrodesis can be performed using various methods: wire fixation between the posterior arches
of C1-C2; transarticular fusion of C1-C2 (Magerl technique); the Harms technique, in which a screw
is placed in the lateral mass of C1 and in the pedicle of C2; or the Wright technique, in which a
screw is placed in the lateral mass of C1 and intralaminarly in C2 (1714. Spencer JA, Yeakley JW, Kaufman HH. Fracture of the occipital condyle.
Neurosurgery. 1984;15(1):101-3, http://dx.doi.org/10.1227/00006123-198407000-00019.
http://dx.doi.org/10.1227/00006123-19840...
). Recent anatomical studies show that, with more modern techniques, surgical treatment is
even a possibility in children (1818. Cristante AF, Torelli AG, Kohlmann RB, Dias da Rocha I, Biraghi OL, Iutaka AS,
et al. Feasibility of intralaminar, lateral mass, or pedicle axis vertebra screws in children under
10 years of age: a tomographic study. Neurosurgery. 2012;70(4):835-8; discussion 838-9,
http://dx.doi.org/10.1227/NEU.0b013e3182367417.
http://dx.doi.org/10.1227/NEU.0b013e3182...
).
Odontoid dens fractures
Odontoid dens fractures represent 5 to 15% of cervical spine fractures. The mechanism of these fractures is not clear (1919. Anderson LD, D'Alonzo RT. Fractures of the odontoid process of the axis. J Bone Joint Surg Am. 1974;56(8):1663-74.), but biochemical studies suggest that they are caused by shear forces (1919. Anderson LD, D'Alonzo RT. Fractures of the odontoid process of the axis. J Bone Joint Surg Am. 1974;56(8):1663-74.).
If there is a hyperflexion component to the fracture, then an anterior deviation with anterior dislocation of the atlas can occur. This injury is known as a C1-C2 fracture dislocation. In this case, there is a higher possibility of spinal cord integrity than in pure dislocation; therefore, the probability of survival is greater.
If the odontoid dens fracture occurs by hyperextension, there may be posterior deviation (1919. Anderson LD, D'Alonzo RT. Fractures of the odontoid process of the axis. J Bone Joint Surg Am. 1974;56(8):1663-74.). In radiographic studies of fractures without deviation, whether in the anteroposterior or profile views, only the fracture line of the odontoid peg fracture will be visible, whereas in fractures with deviation, the fracture will be visible with deviation of the distal fragment and dislocation of the atlas. In fractures without deviation, it is sometimes very difficult to see the fracture line, and diagnosis is only possible with CT imaging.
Special care should be taken with children when performing a radiological diagnosis of fractures
without deviation because vertebral ossification is incomplete. In radiographs of children, the
odontoid process and the body of the axis are separated by a strip of tissue that is transparent to
X-rays. This strip of tissue becomes progressively narrower until it disappears in 10-11-year-olds
(1919. Anderson LD, D'Alonzo RT. Fractures of the odontoid process of the axis.
J Bone Joint Surg Am. 1974;56(8):1663-74.,2020. Pontin PA, Bumlai RUM, Letaif OB, Damasceno ML, Cristante AF, Marcon RM, et al.
Tratamento das fraturas do processo odontóide [Treatment of odontoid fractures]. Acta
Ortop Bras. 2011;19(4):189-92, http://dx.doi.org/10.1590/S1413-78522011000400003.
http://dx.doi.org/10.1590/S1413-78522011...
).
Anderson and D‘Alonzo (1919. Anderson LD, D'Alonzo RT. Fractures of the odontoid process of the axis. J Bone Joint Surg Am. 1974;56(8):1663-74.) created a classification linking the height of the line with the fracture prognosis:
Type I: fracture of the upper part of the odontoid dens;
Type II: fracture at the base of the odontoid dens; and
Type III: fracture affecting the body of the axis.
Treatment is guided by the type of odontoid fracture (1919. Anderson LD, D'Alonzo RT. Fractures of the odontoid process of the axis.
J Bone Joint Surg Am. 1974;56(8):1663-74.
20. Pontin PA, Bumlai RUM, Letaif OB, Damasceno ML, Cristante AF, Marcon RM, et al.
Tratamento das fraturas do processo odontóide [Treatment of odontoid fractures]. Acta
Ortop Bras. 2011;19(4):189-92, http://dx.doi.org/10.1590/S1413-78522011000400003.
http://dx.doi.org/10.1590/S1413-78522011...
21. Dunn ME, Seljeskog EL. Experience in the management of odontoid process
injuries: an analysis of 128 cases. Neurosurgery. 1986;18(3):306-10,
http://dx.doi.org/10.1227/00006123-198603000-00008.
http://dx.doi.org/10.1227/00006123-19860...
-2222. Clark CR, White AA 3rd. Fractures of the dens. A multicenter study.
J Bone Joint Surg Am. 1985;67(9):1340-8.). Type I fractures that do not involve injury
to the ligament structures supporting the atlanto-occipital joint can be treated with cervical
arthrodesis for three months. There is some debate as to the best treatment of type II fractures due
to the documented poor potential for consolidation of the fracture in elderly patients and the known
morbidity associated with prolonged treatment with a halo brace (1919. Anderson LD, D'Alonzo RT. Fractures of the odontoid process of the axis.
J Bone Joint Surg Am. 1974;56(8):1663-74.
20. Pontin PA, Bumlai RUM, Letaif OB, Damasceno ML, Cristante AF, Marcon RM, et al.
Tratamento das fraturas do processo odontóide [Treatment of odontoid fractures]. Acta
Ortop Bras. 2011;19(4):189-92, http://dx.doi.org/10.1590/S1413-78522011000400003.
http://dx.doi.org/10.1590/S1413-78522011...
21. Dunn ME, Seljeskog EL. Experience in the management of odontoid process
injuries: an analysis of 128 cases. Neurosurgery. 1986;18(3):306-10,
http://dx.doi.org/10.1227/00006123-198603000-00008.
http://dx.doi.org/10.1227/00006123-19860...
-2222. Clark CR, White AA 3rd. Fractures of the dens. A multicenter study.
J Bone Joint Surg Am. 1985;67(9):1340-8.).
Relative indications for surgery include the following (2020. Pontin PA, Bumlai RUM, Letaif OB, Damasceno ML, Cristante AF, Marcon RM, et al.
Tratamento das fraturas do processo odontóide [Treatment of odontoid fractures]. Acta
Ortop Bras. 2011;19(4):189-92, http://dx.doi.org/10.1590/S1413-78522011000400003.
http://dx.doi.org/10.1590/S1413-78522011...
21. Dunn ME, Seljeskog EL. Experience in the management of odontoid process
injuries: an analysis of 128 cases. Neurosurgery. 1986;18(3):306-10,
http://dx.doi.org/10.1227/00006123-198603000-00008.
http://dx.doi.org/10.1227/00006123-19860...
-2222. Clark CR, White AA 3rd. Fractures of the dens. A multicenter study.
J Bone Joint Surg Am. 1985;67(9):1340-8.):
-
-
A more than 5-mm fracture dislocation;
-
A more than 10-degree angulation;
-
Failed attempts at closed reduction.
-
In fractures requiring surgical treatment, an alternative is osteosynthesis with the use of a
cannulated screw. In this technique, a radioscopy-guided anterior incision is made at C4-C5 with
dissection and placement of a guide wire in the inferior cortex of C2. A cannulated screw is then
inserted with the assistance of simultaneous images in the anteroposterior and profile views (1919. Anderson LD, D'Alonzo RT. Fractures of the odontoid process of the axis.
J Bone Joint Surg Am. 1974;56(8):1663-74.
20. Pontin PA, Bumlai RUM, Letaif OB, Damasceno ML, Cristante AF, Marcon RM, et al.
Tratamento das fraturas do processo odontóide [Treatment of odontoid fractures]. Acta
Ortop Bras. 2011;19(4):189-92, http://dx.doi.org/10.1590/S1413-78522011000400003.
http://dx.doi.org/10.1590/S1413-78522011...
21. Dunn ME, Seljeskog EL. Experience in the management of odontoid process
injuries: an analysis of 128 cases. Neurosurgery. 1986;18(3):306-10,
http://dx.doi.org/10.1227/00006123-198603000-00008.
http://dx.doi.org/10.1227/00006123-19860...
-2222. Clark CR, White AA 3rd. Fractures of the dens. A multicenter study.
J Bone Joint Surg Am. 1985;67(9):1340-8.). Contraindications
for this technique include the following: osteoporosis, comminuted fractures, unfavorable fracture
line angulation (oblique anterior line), diastasis of the fragments, and pseudoarthrosis.
Hangman's fracture
Traumatic spondylolisthesis of the axis, also known as hangman's fracture, is the typical
fracture resulting from hyperextension-distraction in which there is a fracture of the pedicle of
C2 with dislocation of the body of this vertebra on C3 (2323. Ferro FP, Borgo GD, Letaif OB, Cristante AF, Marcon RM, Iutaka AS.
Espondilolistese traumática do áxis: epidemiologia, conduta e evolução
[Traumatic spondylolisthesis of the axis: epidemiology, management and outcome]. Acta
Ortop Bras. 2012;20(2):84-7, http://dx.doi.org/10.1590/S1413-78522012000200005.
http://dx.doi.org/10.1590/S1413-78522012...
). This fracture, despite the major dislocation of C2 on C3
that often occurs, rarely leads to spinal cord injury because it causes the canal to widen rather
than narrow (2323. Ferro FP, Borgo GD, Letaif OB, Cristante AF, Marcon RM, Iutaka AS.
Espondilolistese traumática do áxis: epidemiologia, conduta e evolução
[Traumatic spondylolisthesis of the axis: epidemiology, management and outcome]. Acta
Ortop Bras. 2012;20(2):84-7, http://dx.doi.org/10.1590/S1413-78522012000200005.
http://dx.doi.org/10.1590/S1413-78522012...
).
The Levine and Edwards classification (2424. Levine AM, Edwards CC. Traumatic lesions of the occipitoatlantoaxial complex. Clin Orthop Relat Res. 1989;(239):53-68.) divides traumatic spondylolisthesis of the axis into four types:
Type I: fracture without an angular deviation and translational deviation of less than 3.5 mm that occurs due to hyperextension and axial compression;
Type II: fracture with a significant translational or angular deviation that occurs due to hyperextension and axial compression combined with a mechanism of flexion-compression;
Type IIa: fracture with a small translational deviation and wide angulation, with an increase in posterior disc space between C2-C3 upon application of traction that occurs due to a flexion-distraction; and
Type III: fracture with a large translational and angular deviation, which is associated with unilateral or bilateral dislocation of the C2-C3 joint facets and occurs due to a flexion-compression mechanism.
Type I fractures are stable injuries and can be treated with the use of a neck brace, halo-cast, halo-vest, or Minerva cast for a period of 12 weeks. Type II fractures are unstable injuries, and the mechanism by which the fracture is produced requires a reduction through distraction and slight hyperextension with posterior immobilization and application of a halo-cast for 12 weeks. In type IIa fractures, cranial traction is indicated so that reduction can be achieved by means of slight compression and extension, as flexion-distraction is the probable injury mechanism. These fractures should be treated with a halo-cast for 12 weeks or surgically stabilized by means of C2-C3 anterior arthrodesis or transpedicular fixation of C2. Surgical treatment is indicated in type III fractures and is aimed at reduction of the joint facets and stabilization by arthrodesis (2424. Levine AM, Edwards CC. Traumatic lesions of the occipitoatlantoaxial complex. Clin Orthop Relat Res. 1989;(239):53-68.).
Lower cervical spine fractures
Previously, the most commonly used classifications of cervical fractures were those of
Allen-Ferguson (2525. Allen BL Jr, Fergusson RL, Lehmann TR, O'Brien RP. A mechanistic
classification of closed, indirect fractures and dislocations of the lower cervical spine. Spine
(Phila Pa 1976). 1982;7(1):1-27,
http://dx.doi.org/10.1097/00007632-198200710-00001.
http://dx.doi.org/10.1097/00007632-19820...
) and the AO. More recently, the SLIC
classification (2626. Dvorak MF, Fisher CG, Fehlings MG, Rampersaud YR, Oner FC, Aarabi B, et al. The
surgical approach to subaxial cervical spine injuries: an evidence-based algorithm based on the SLIC
classification system. Spine (Phila Pa 1976). 2007;32(23):2620-9,
http://dx.doi.org/10.1097/BRS.0b013e318158ce16.
http://dx.doi.org/10.1097/BRS.0b013e3181...
) has added neurological status as another
factor to consider.
The Allen-Ferguson classification was one of the first classifications to be used, but its
importance today is only historical. It divides injuries into six types (2323. Ferro FP, Borgo GD, Letaif OB, Cristante AF, Marcon RM, Iutaka AS.
Espondilolistese traumática do áxis: epidemiologia, conduta e evolução
[Traumatic spondylolisthesis of the axis: epidemiology, management and outcome]. Acta
Ortop Bras. 2012;20(2):84-7, http://dx.doi.org/10.1590/S1413-78522012000200005.
http://dx.doi.org/10.1590/S1413-78522012...
): compression-flexion, vertical compression, distraction-flexion,
compression-extension, distraction-extension, and lateral flexion (2525. Allen BL Jr, Fergusson RL, Lehmann TR, O'Brien RP. A mechanistic
classification of closed, indirect fractures and dislocations of the lower cervical spine. Spine
(Phila Pa 1976). 1982;7(1):1-27,
http://dx.doi.org/10.1097/00007632-198200710-00001.
http://dx.doi.org/10.1097/00007632-19820...
).
Still widely used by various centers, the classification of lower cervical fractures recommended by the AO group consists of three types (A, B and C), which are extended into groups and subgroups. The types describe the trauma mechanism (A: compression; B: distraction; C: rotation), while the groups and subgroups define the morphological parameters. This classification represents a ranking that follows a prognostic hierarchy, i.e., as one progresses through the classification, the severity becomes theoretically higher and the prognosis worsens. The AO classification of fractures of the lower cervical spine (C3-C7) (2727. Aebi M, Nazarian S. Klassification der Halswirbelsäulenverletzungen [Classification of injuries of the cervical spine]. Orthopade. 1987;16(1):27-36.) is shown in Figures 1 to 3.
AO classification. B distraction: B.1 = posterior distraction with vertebral body intact; B.2 = posterior distraction + fracture of the vertebral body; B.3 = anterior distraction + hyperextension.
AO classification. C rotation: C.1 = unilateral facet fracture-dislocation; C.2 = unilateral facet dislocation; C.3 = rotational shear injury of the joint mass.
The Subaxial Injury Classification (SLIC) Scale was created to remedy the lack of consensus among
classification groups. To create the scale, a systematic review of the surgical treatment of lower
cervical spine trauma was conducted, and a treatment algorithm was created with the evidence-based
consensus of a group of specialists (2626. Dvorak MF, Fisher CG, Fehlings MG, Rampersaud YR, Oner FC, Aarabi B, et al. The
surgical approach to subaxial cervical spine injuries: an evidence-based algorithm based on the SLIC
classification system. Spine (Phila Pa 1976). 2007;32(23):2620-9,
http://dx.doi.org/10.1097/BRS.0b013e318158ce16.
http://dx.doi.org/10.1097/BRS.0b013e3181...
). This classification
of lower cervical spine injuries takes into account the following characteristics:
-
Morphology;
-
Status of the disco-ligamentous complex; and
-
Neurological assessment.
Based on these parameters, a table is used to assign scores to each injury: individuals with a
score lower than 4 do not require surgical intervention; a score of 4 means the treatment could be
either surgical or conservative (often, the decision is made based on the personal experience of the
surgeon); and a score higher than 4 normally means that surgical intervention is required (2626. Dvorak MF, Fisher CG, Fehlings MG, Rampersaud YR, Oner FC, Aarabi B, et al. The
surgical approach to subaxial cervical spine injuries: an evidence-based algorithm based on the SLIC
classification system. Spine (Phila Pa 1976). 2007;32(23):2620-9,
http://dx.doi.org/10.1097/BRS.0b013e318158ce16.
http://dx.doi.org/10.1097/BRS.0b013e3181...
) (Table 1).
Treatment
The correct way to transport a patient with a suspected cervical fracture is in the dorsal
decubitus position on a rigid surface with a person hands or pads placed beside the patient to
secure the head and prevent rotation. Ideally, a collar should be fitted immediately (2828. Kool DR, Blickman JG. Advanced Trauma Life Support®. ABCDE
from a radiological point of view. Emerg Radiol. 2007;14(3):135-41,
http://dx.doi.org/10.1007/s10140-007-0633-x.
http://dx.doi.org/10.1007/s10140-007-063...
). The patient should be examined while still in the dorsal
decubitus position with an inspection of the ear canals to rule out the possibility of fluid fistula
or otorrhagia behind the tympanic membrane, which would indicate a skull fracture. The head and
spinous processes should be palpated (11. Blackmore CC, Emerson SS, Mann FA, Koepsell TD. Cervical spine imaging in
patients with trauma: determination of fracture risk to optimize use. Radiology.
1999;211(3):759-65.
2. Barros Filho TEP, Oliveira RP, Barros EK, Von Uhlendorff EF, Iutaka AS, Cristante
AF, et al. Ferimento por projétil de arma de fogo na coluna vertebral: estudo
epidemiológico [Gunshot wounds of the spine: epidemiological study]. Coluna/Columna.
2002;1(2):83-7. Disponível em: http://www.plataformainterativa2.com/coluna/html/revistacoluna/volume1/ferimento_projetil.htm.
Acessado em 2012 (9 out).
http://www.plataformainterativa2.com/col...
-33. Kraus JF, Franti CE, Riggins RS, Richards D, Borhani NO. Incidence of traumatic
spinal cord lesions. J Chronic Dis. 1975;28(9):471-92,
http://dx.doi.org/10.1016/0021-9681(75)90057-0.
http://dx.doi.org/10.1016/0021-9681(75)9...
,66. Bell C. Surgical observations. Middlesex Hospital Journal.
1817;4:469-70.).
If there are signs of spinal cord injuries or factors potentially leading to such injuries,
treatment measures should be commenced immediately. Recent studies support the idea that the sooner
the spine is stabilized with decompression of the injured spinal cord, the greater the chances of
recovery (2929. Fehlings MG, Vaccaro A, Wilson JR, Singh A, W Cadotte D, Harrop JS, et al. Early
versus delayed decompression for traumatic cervical spinal cord injury: results of the Surgical
Timing in Acute Spinal Cord Injury Study (STASCIS). PLoS One. 2012;7(2):e32037,
http://dx.doi.org/10.1371/journal.pone.0032037.
http://dx.doi.org/10.1371/journal.pone.0...
). Radiographic exams should be performed that
include profile, anteroposterior, oblique, and transoral views of the cervical spine. CT may be used
to clarify any unclear findings in the simple radiographs, reveal an occult injury, and assess an
identified fracture or fracture-dislocation in greater depth (11. Blackmore CC, Emerson SS, Mann FA, Koepsell TD. Cervical spine imaging in
patients with trauma: determination of fracture risk to optimize use. Radiology.
1999;211(3):759-65.,3030. Lozorio AR, Borges M, Batista Junior JC, Chacob Junior C, Machado IC, Rezende R
[Correlation between the clinic and the index of cervical myelopathy Torg].
Correlação clinica entre a mielopatia cervical e o índice de Torg. Acta Ortop Bras.
2012;20(3):180-3, http://dx.doi.org/10.1590/S1413-78522012000300009.
http://dx.doi.org/10.1590/S1413-78522012...
).
Orthopedic treatment to reduce the fracture or dislocation will re-conduct the vertebral canal to
its normal form and dimension and lead to spinal cord decompression (3131. Miranda TA, Vicente JM, Marcon RM, Cristante AF, Morya E, Valle AC. Time-related
effects of general functional training in spinal cord-injured rats. Clinics. 2012;67(7):799-804,
http://dx.doi.org/10.6061/clinics/2012(07)16.
http://dx.doi.org/10.6061/clinics/2012(0...
). Reduction through traction with a cranial halo is a method commonly used in some
emergency services and is efficient and well tolerated by the patient. Reduction by manipulation
under general anesthesia is contraindicated because it is an extremely dangerous method; even with
gradual traction, care must be taken and small weights should be utilized first (3232. Barros Filho TEP, Jorge HMH, Oliveira RP, Kalil EM, Cristante AF, Iutaka AS, et
al. Risco de tração excessiva nas lesões tipo distração-flexão da
coluna cervical baixa [Risk of excessive traction on distraction-flexion-type injuries of the
low cervical spine]. Acta Ortop Bras. 2006;14(2):75-7,
http://dx.doi.org/10.1590/S1413-78522006000200003.
http://dx.doi.org/10.1590/S1413-78522006...
).
Because of the instability associated with dislocations, most recent guidelines indicate that
surgery is required to achieve adequate reduction and stabilization, ensure spinal cord
decompression, and prevent uncomfortable immobilization. Surgery may be performed via the anterior,
posterior, or double routes (3333. Letaif OB, Damasceno ML, Cristante AF, Marcon RM, Iutaka AS, Oliveira RP, et al.
Escolha da via cirúrgica para tratamento das fraturas cervicais [The choice of surgical
approach for treatment of cervical fractures]. Coluna/Columna. 2010;9(4):358-62,
http://dx.doi.org/10.1590/S1808-18512010000400003.
http://dx.doi.org/10.1590/S1808-18512010...
). More recent anatomical and
biomechanical studies support the use of instrumentation with the most modern synthesis materials,
such as cages and anterior plates, or posterior lateral mass screws (3434. Cristante AF, Schor B, Cavalheiro MG, Iutaka AS, Reiff RBM, Cho AB, et al.
Avaliação biomecânica da estabilidade da coluna cervical em cadáveres humanos
após hemilaminectomia e facetectomia unilateral. Coluna/Columna.
2002;1(1):15-22.).
Posterior fixation of the cervical spine by means of implants anchored in the lateral vertebral masses has been extensively used due to its mechanical advantage over fixations that use the interspinous cerclage technique. In addition, this procedure has other technical advantages, such as the possibility to be used in cases where the posterior elements are absent or fractured.
The most recent guidelines (2626. Dvorak MF, Fisher CG, Fehlings MG, Rampersaud YR, Oner FC, Aarabi B, et al. The
surgical approach to subaxial cervical spine injuries: an evidence-based algorithm based on the SLIC
classification system. Spine (Phila Pa 1976). 2007;32(23):2620-9,
http://dx.doi.org/10.1097/BRS.0b013e318158ce16.
http://dx.doi.org/10.1097/BRS.0b013e3181...
) for surgical treatment are
described in Table 2).
Guidelines for the surgical treatment (3232. Barros Filho TEP, Jorge HMH, Oliveira RP, Kalil EM, Cristante AF, Iutaka AS, et al. Risco de tração excessiva nas lesões tipo distração-flexão da coluna cervical baixa [Risk of excessive traction on distraction-flexion-type injuries of the low cervical spine]. Acta Ortop Bras. 2006;14(2):75-7, http://dx.doi.org/10.1590/S1413-78522006000200003.
http://dx.doi.org/10.1590/S1413-78522006... ) of cervical fractures.
Complications
In addition to the commonly known complications involved in the treatment of fractures of the
cervical spine with spinal cord or nerve injury (for example, pseudarthrosis, or defective
consolidation, and postoperative infection), less common complications should also be considered,
such as lead poisoning in cases of fractures caused by firearm injuries (3535. Cristante AF, de Souza FI, Barros Filho TE, Oliveira RP, Marcon RM. Lead
poisoning by intradiscal firearm bullet: a case report. Spine (Phila Pa 1976). 2010;35(4):E140-3,
http://dx.doi.org/10.1097/BRS.0b013e3181ba023e.
http://dx.doi.org/10.1097/BRS.0b013e3181...
,3636. Meyer GPC, Gomes FCP, Lima ALLM, Cristante AF, Marcon RM, Iutaka AS, et al.
Estudo retrospectivo das infecções pós-operatórias em cirurgia de coluna:
correlação com o número de limpezas cirúrgicas realizadas [Retrospective
study of post-operative infections in spine surgery: correlation with the number of surgical
debridement performed]. Coluna/Columna. 2011;10(2):127-31,
http://dx.doi.org/10.1590/S1808-18512011000200009.
http://dx.doi.org/10.1590/S1808-18512011...
).
In conclusion, fractures of the cervical spine are potentially serious and can lead to devastating consequences if not properly treated. Correct diagnosis and classification of the injury is the first step toward determination of the most appropriate treatment, which can be either surgical or conservative.
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21Dunn ME, Seljeskog EL. Experience in the management of odontoid process injuries: an analysis of 128 cases. Neurosurgery. 1986;18(3):306-10, http://dx.doi.org/10.1227/00006123-198603000-00008.
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22Clark CR, White AA 3rd. Fractures of the dens. A multicenter study. J Bone Joint Surg Am. 1985;67(9):1340-8.
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23Ferro FP, Borgo GD, Letaif OB, Cristante AF, Marcon RM, Iutaka AS. Espondilolistese traumática do áxis: epidemiologia, conduta e evolução [Traumatic spondylolisthesis of the axis: epidemiology, management and outcome]. Acta Ortop Bras. 2012;20(2):84-7, http://dx.doi.org/10.1590/S1413-78522012000200005.
» http://dx.doi.org/10.1590/S1413-78522012000200005 -
24Levine AM, Edwards CC. Traumatic lesions of the occipitoatlantoaxial complex. Clin Orthop Relat Res. 1989;(239):53-68.
-
25Allen BL Jr, Fergusson RL, Lehmann TR, O'Brien RP. A mechanistic classification of closed, indirect fractures and dislocations of the lower cervical spine. Spine (Phila Pa 1976). 1982;7(1):1-27, http://dx.doi.org/10.1097/00007632-198200710-00001.
» http://dx.doi.org/10.1097/00007632-198200710-00001 -
26Dvorak MF, Fisher CG, Fehlings MG, Rampersaud YR, Oner FC, Aarabi B, et al. The surgical approach to subaxial cervical spine injuries: an evidence-based algorithm based on the SLIC classification system. Spine (Phila Pa 1976). 2007;32(23):2620-9, http://dx.doi.org/10.1097/BRS.0b013e318158ce16.
» http://dx.doi.org/10.1097/BRS.0b013e318158ce16 -
27Aebi M, Nazarian S. Klassification der Halswirbelsäulenverletzungen [Classification of injuries of the cervical spine]. Orthopade. 1987;16(1):27-36.
-
28Kool DR, Blickman JG. Advanced Trauma Life Support® ABCDE from a radiological point of view. Emerg Radiol. 2007;14(3):135-41, http://dx.doi.org/10.1007/s10140-007-0633-x.
» http://dx.doi.org/10.1007/s10140-007-0633-x -
29Fehlings MG, Vaccaro A, Wilson JR, Singh A, W Cadotte D, Harrop JS, et al. Early versus delayed decompression for traumatic cervical spinal cord injury: results of the Surgical Timing in Acute Spinal Cord Injury Study (STASCIS). PLoS One. 2012;7(2):e32037, http://dx.doi.org/10.1371/journal.pone.0032037.
» http://dx.doi.org/10.1371/journal.pone.0032037 -
30Lozorio AR, Borges M, Batista Junior JC, Chacob Junior C, Machado IC, Rezende R [Correlation between the clinic and the index of cervical myelopathy Torg]. Correlação clinica entre a mielopatia cervical e o índice de Torg. Acta Ortop Bras. 2012;20(3):180-3, http://dx.doi.org/10.1590/S1413-78522012000300009.
» http://dx.doi.org/10.1590/S1413-78522012000300009 -
31Miranda TA, Vicente JM, Marcon RM, Cristante AF, Morya E, Valle AC. Time-related effects of general functional training in spinal cord-injured rats. Clinics. 2012;67(7):799-804, http://dx.doi.org/10.6061/clinics/2012(07)16.
» http://dx.doi.org/10.6061/clinics/2012(07)16 -
32Barros Filho TEP, Jorge HMH, Oliveira RP, Kalil EM, Cristante AF, Iutaka AS, et al. Risco de tração excessiva nas lesões tipo distração-flexão da coluna cervical baixa [Risk of excessive traction on distraction-flexion-type injuries of the low cervical spine]. Acta Ortop Bras. 2006;14(2):75-7, http://dx.doi.org/10.1590/S1413-78522006000200003.
» http://dx.doi.org/10.1590/S1413-78522006000200003 -
33Letaif OB, Damasceno ML, Cristante AF, Marcon RM, Iutaka AS, Oliveira RP, et al. Escolha da via cirúrgica para tratamento das fraturas cervicais [The choice of surgical approach for treatment of cervical fractures]. Coluna/Columna. 2010;9(4):358-62, http://dx.doi.org/10.1590/S1808-18512010000400003.
» http://dx.doi.org/10.1590/S1808-18512010000400003 -
34Cristante AF, Schor B, Cavalheiro MG, Iutaka AS, Reiff RBM, Cho AB, et al. Avaliação biomecânica da estabilidade da coluna cervical em cadáveres humanos após hemilaminectomia e facetectomia unilateral. Coluna/Columna. 2002;1(1):15-22.
-
35Cristante AF, de Souza FI, Barros Filho TE, Oliveira RP, Marcon RM. Lead poisoning by intradiscal firearm bullet: a case report. Spine (Phila Pa 1976). 2010;35(4):E140-3, http://dx.doi.org/10.1097/BRS.0b013e3181ba023e.
» http://dx.doi.org/10.1097/BRS.0b013e3181ba023e -
36Meyer GPC, Gomes FCP, Lima ALLM, Cristante AF, Marcon RM, Iutaka AS, et al. Estudo retrospectivo das infecções pós-operatórias em cirurgia de coluna: correlação com o número de limpezas cirúrgicas realizadas [Retrospective study of post-operative infections in spine surgery: correlation with the number of surgical debridement performed]. Coluna/Columna. 2011;10(2):127-31, http://dx.doi.org/10.1590/S1808-18512011000200009.
» http://dx.doi.org/10.1590/S1808-18512011000200009
-
No potential conflict of interest was reported.
Publication Dates
-
Publication in this collection
Nov 2013
History
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Received
21 Mar 2013 -
Reviewed
26 Mar 2013 -
Accepted
26 Mar 2013