Upper Cervical Spine Injuries: Profile and Management of 120 Cases

Geraldo de Sá Carneiro-Filho; Lívio Pereira de Macêdo; Lidemarcks Irineu Andrade; Brenno Franklynn Alves-Sá; Luan Amaral Magalhães Sousa; Saul Cavalcanti de Medeiros Quirino; Juliano Rodrigues Chaves; Deoclides Lima Bezerra-Júnior; Nivaldo S. Almeida; Hildo Rocha Cirne Azevedo-Filho

doi:10.14444/8321

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Figure 1
Postoperative standard x-ray images showing a patient who benefited from craniocervical fusion.
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Figure 2
Postoperative standard x-ray images showing a patient who underwent a C1-C2 posterior arthrodesis (Goel-Harms technique).
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Figure 3
Intraoperative fluoroscopy showing a type II odontoid fracture. The patient who underwent a transarticular C1-C2 posterior arthrodesis (Magerl technique).
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Figure 4
Preoperative computed tomography images showing a patient with type II odontoid fracture presenting a split in the odontoid process. The patient underwent a C1-C2 posterior arthrodesis (Goel-Harms technique), which is shown on a postoperative standard x-ray image.
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Figure 5
Postoperative computed tomography images showing a patient with type II odontoid fracture who benefited from anterior odontoid screwing.
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Figure 6
Postoperative standard x-ray images showing a patient with type II odontoid fracture who benefited from anterior fixation of the odontoid process with 2 screws.
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Figure 7
Preoperative and postoperative standard x-ray images showing a patient with hangman’s fracture who benefited from C2-C3 discectomy and interbody fusion.
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Figure 8
Intraoperative view showing a case of anterior C2-C3 discectomy and interbody fusion. Recurrent laryngeal nerve was identified and preserved (right).
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Figure 9
Postoperative standard x-ray images showing a patient with hangman’s fracture who submitted to an anterior approach. The patient had an unsatisfactory large gap on fracture place (left) and who benefited from 360° fusion (right).
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Figure 10
Postoperative standard x-ray images showing a patient who benefited from C2-C3 discectomy and interbody fusion and posterior wiring.

Tables

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Table 1

Upper cervical spine injury level and classification (N = 120).

Variable	n (%)
Injury level
C1	11 (9.2)
C2	84 (70.0)
C1-C2	21 (17.5)
C2-C3	4 (3.3)
Injury classification
Type I C1 fracture (ring fractures)	7 (5.8)
Type II C1 fracture (Jefferson’s fracture)	2 (1.7)
Type III C1 fracture (lateral mass fracture)	2 (1.7)
Hangman’s fracture	16 (13.3)
Type II odontoid fractures	35 (29.2)
Type III odontoid fractures	4 (3.3)
Miscellaneous C2 fractures	24 (20.0)
C1-C2 dislocations	4 (3.3)
C2-C3 dislocations	2 (1.7)
Atlanto-occipital displacement	2 (1.7)
Type II C1 fracture (Jefferson’s fracture) + type II odontoid fracture	2 (1.7)
Type II odontoid fracture + atlanto-occipital displacement	2 (1.7)
Type II odontoid fracture + hangman’s fracture	4 (3.3)
Type III odontoid fracture + miscellaneous C2 fractures	2 (1.7)
Type I C1 fracture + type II odontoid fractures	3 (2.5)
Type III odontoid fracture + C1-C2 dislocations	2 (1.7)
Type I odontoid fractures + C1-C2 dislocations + miscellaneous C2 fractures	3 (2.5)
Type II C1 fracture (Jefferson’s fracture) + type III odontoid fracture	2 (1.7)
Type III C1 fracture (lateral mass fracture) + miscellaneous C2 fractures	2 (1.7)

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Table 2

Sample profile and evaluation of variables according to injury level.

Variable	Injury Level										P Value^{^a}
	C1		C2		C1-C2		C2-C3		Total
	n	%	n	%	n	%	N	%
Total	11	100.0	84	100.0	21	100.0	4	100.0	120	100.0
Age, y											0.510
16–29	8	72.7	31	36.9	9	42.9	3	75.0	51	42.5
30–39	1	9.1	17	20.2	3	14.3	-	-	21	17.5
40–59	1	9.1	22	26.2	7	33.3	-	-	30	25.0
60–82	1	9.1	14	16.7	2	9.5	1	25.0	18	15.0
Gender											0.696
Male	11	100.0	75	89.3	18	85.7	4	100.0	108	90.0
Female	-	-	9	10.7	3	14.3	-	-	12	10.0
Trauma mechanisms											0.292
Car accident	3	27.3	21	25.0	3	14.3	2	50.0	29	24.2
Motorcycle accident	2	18.2	24	28.6	10	47.6	2	50.0	38	31.7
Gunshot injury	2	18.2	3	3.6	3	14.3	-	-	8	6.7
Fall from standing height	1	9.1	13	15.5	-	-	-	-	14	11.7
Fall from height	1	9.1	13	15.5	3	14.3	-	-	17	14.2
Others	2	18.2	10	11.9	2	9.5	-	-	14	11.7
Frankel Scale											0.128
A	1	9.1	1	1.2	1	4.8	1	25.0	4	3.3
B	1	9.1	-	-	-	-	-	-	1	0.8
C	1	9.1	6	7.1	2	9.5	-	-	9	7.5
D	-	-	4	4.8	-	-	-	-	4	3.3
E	8	72.7	73	86.9	18	85.7	3	75.0	102	85.0
Neurologic deficit											0.426
Yes	3	27.3	11	13.1	3	14.3	1	25.0	18	15.0
No	8	72.7	73	86.9	18	85.7	3	75.0	102	85.0
Management/outcome											<0.001^{^b}
Surgical	1	9.1	54	64.3	17	81.0	3	75.0	75	62.5
Conservative	10	90.9	30	35.7	3	14.3	1	25.0	44	36.7
Death	-	-	-	-	1	4.8	-	-	1	0.8

↵a Fisher’s exact test.
↵b Data were considered statistically significant at P < 0.05.

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Table 3

Evaluation of variables according to neurological deficit.

Variable	Neurological Deficit						P Value^{^a}
	Yes		No		Total
	n	%	n	%	n	%
Total	18	100.0	102	100.0	120	100.0
Age, y							0.837
16–29	9	50.0	42	41.2	51	42.5
30–39	3	16.7	18	17.6	21	17.5
40–59	3	16.7	27	26.5	30	25.0
60–82	3	16.7	15	14.7	18	15.0
Gender							0.387
Male	15	83.3	93	91.2	108	90.0
Female	3	16.7	9	8.8	12	10.0
Trauma mechanisms							0.107
Car accident	4	22.2	25	24.5	29	24.2
Motorcycle accident	3	16.7	35	34.3	38	31.7
Gunshot injury	4	22.2	4	3.9	8	6.7
Fall from standing height	3	16.7	11	10.8	14	11.7
Fall from height	2	11.1	15	14.7	17	14.2
Others	2	11.1	12	11.8	14	11.7
Management/outcome							= 0.117
Surgical	12	68.7	63	61.8	75	62.5
Conservative	5	27.7	39	38.2	44	36.7
Death	1	5.6	-	-	1	0.8

↵a Fisher’s exact test.

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Table 4

Injury classification and management (N = 120).

Variable	n (%)
Type of injury
Isolated hangman’s fracture	16 (13.3)
Isolated odontoid fracture	42 (35.0)
Isolated C1 fracture	11 (9.2)
Combined C1-C2 fracture	9 (7.5)
Miscellaneous C2 fracture	30 (25.0)
Ligament injury	8 (6.7)
Odontoid fracture + hangman’s fracture	4 (3.3)
Management
C0-C3 posterior fusion	3 (2.5)
C0-C4 posterior fusion	1 (0.8)
C1-C2 posterior fusion	30 (25.0)
C1-C3 posterior fusion	8 (6.7)
C1-C4 posterior fusion	2 (1.7)
C2-C3 discectomy	9 (7.5)
C2-C3 posterior fusion	1 (0.8)
C2-C3 discectomy + C1-C3 posterior fusion	3 (2.5)
Conservative management	44 (36.7)
Occipital craniectomy + bullet removal	1 (0.8)
Transoral odontoidectomy + C0-C4 posterior fusion	2 (1.7)
Transoral odontoidectomy + C1-C2 posterior fusion	1 (0.8)
Odontoid screwing	14 (11.7)
Death^{^a}	1 (0.8)

↵a One patient died due to hemodynamic instability before surgery.

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Table 5

Evaluation of management performed according to the type of injury.

Management	Type of Injury
	Isolated Fracture				Combined Fracture
	Hangman’s Fracture	Odontoid Fracture	C1 Fracture	Ligament Injury	Combined C1- C2 Fracture	Miscellaneous Fracture of C2	Combined Odontoid Fracture and Hangman's Fracture
C0-C3 posterior fusion	-	-	-	-	3	-	-
C0-C4 posterior fusion	-	1	-	-	-	-	-
C1-C2 posterior fusion	1	17	-	5	3	2	2
C1-C3 posterior fusion	1	1	-	-	5	1	-
C1-C4 posterior fusion	1	1	-	-	-	-	-
C2-C3 discectomy	5	-	-	-	1	1	2
C2-C3 posterior fusion	-	1	-	-	-	-	-
C2-C3 discectomy + C1-C3 posterior fusion	2	-	-	-	1	-	-
Odontoid screwing	-	12	-	2	-	-	-
Occipital craniectomy + bullet removal	-	-	1	-	-	-	-
Transoral odontoidectomy + C0-C4 posterior fusion	-	1	-	-	-	1	-
Transoral odontoidectomy + C1-C2 posterior fusion	-	1	-	-	-	-	-
Conservative management^{^b}	6	7	10	2	16	3	-
Death^{^a}	-	-	-	-	1	-	-
Total	16	42	11	9	30	8	4