Upper cervical injuries – A rational approach to guide surgical management

Abstract

Context:The complex anatomy and the importance of ligaments in providing stability at the upper cervical spine region (O-C1-C2) require the use of many imaging modalities to evaluate upper cervical injuries (UCI). While separate classifications have been developed for distinct injuries, a more practical treatment algorithm can be derived from the injury pattern in UCI. Objective: To propose a practical treatment algorithm to guide treatment based on injuries characteristic of UCI. Methods: A literature review was performed on the Pubmed database using the following keywords: (1) "occipital condyle injury"; (2) "craniocervical dislocation or atlanto-occipital dislocation or craniocervical dislocation"; (3) "atlas fractures"; and (4) "axis fractures". Just articles containing the diagnosis, classification, and treatment of specific UCI were included. The data obtained were analyzed by the authors, dividing the UCI into two groups: Group 1 -patients with clear ligamentous injury and Group 2 -patients with fractures without ligament disruption. Results: Injuries with ligamentous disruption, suggesting surgical treatment, include: atlanto-occipital dislocation, mid-substance transverse ligament injury, and C1-2 and C2-3 ligamentous injuries. In contrast, condyle, atlas, and axis fractures without significant displacement/misalignment can be initially treated using external orthoses. Odontoid fractures with risk factors for non-union are an exception in Group 2 once they are better treated surgically. Patients with neurological deficits may have more unstable injuries. Conclusions: Ascertaining the status of relevant ligamentous structures, fracture patterns and alignment are important in determining surgical compared with non-surgical treatment for patients with UCI.

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

“…Patients suffering an AOD often present with concomitant injuries to the lower cervical spine and should undergo a thorough clinical evaluation. In the event of trauma to the occiput or other vertebra, internal fixation is required and should extend to the most inferior affected vertebra [18]. As a general rule, purely bony injuries to the atlas can be successfully treated with immobilization.…”

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

“…The algorithm, divided upper cervical spine injuries into ligamentous injuries (with or without concomitant fractures) and isolated fractures, in an attempt to guide toward the best treatment option 9 . In 2015, preliminary results of a cohort of patients with upper cervical spine injuries, treated according to this rational treatment guide, was published, with 23 patients treated conservatively and 15 surgically managed.…”

“…However, due to the complexity of its anatomy and a multitude of possible injury patterns that affects this region, many classification schemes have been proposed for upper cervical spine injuries in the past decades, precluding an objective and standardized treatment. This context may result in heterogeneous treatment and complex classifications, sometimes not easily applied in the decision-making process of conservative versus surgical treatment 9 . Among numerous schemes some deserve attention, such as the Anderson and D' Alonzo classification, published in 1974, for odontoid fractures, the Effendi et al 2 and the Levine and Edwards classification for injuries of the posterior elements of the axis, the Anderson and Montesano classification for occipital condyle fractures, among many others 1,4,10 .…”

“…Also important is that the majority of these systems were proposed in the era of plain radiographs, without the details of recent 3D CT reconstructions that may display these injuries with higher sensitivity and specificity. In some cases, where soft tissue injuries cannot clearly be identified using CT imaging, an MRI provides additional information about the spinal cord and nerve roots, even though this information is not included in the vast majority of the classical classification systems 3,9 .…”

“…In 2014, Joaquim et al 9 proposed a new upper cervical spine injury treatment algorithm for choosing between conservative and surgical treatment for upper cervical spine injuries, based on a literature review of the accepted surgical indications for traumatic injuries of the upper cervical spine and craniovertebral junction. The idea of this new system is to classify injuries according to: 1) integrity of their ligamentous injuries -disrupted ligaments (with or without fractures) may preferentially be treated with surgical fixation due to their high risk of instability and neurological deterioration; and 2) isolated fractures, which should be managed conservatively, with surgery reserved for those who have had a high rate of nonhealing or failure of conservative treatment (with deformity, misalignment or neurological risk).…”