May 13, 2008- 5:20 PM
Megan Strother, MD: Characterizing spinal
injury at the cranio-cervical junction: who, what,
where?
Craniocervical Junction Anatomy
Characterizing Spinal Injury at
the Craniocervical Junction:
Who, What, Where?
• CC Junction functions
as one joint
Condyles
C1
Megan Strother, M.D.
Vanderbilt
Alar ligaments
Dens
Bilateral alar ligament avulsions
Condyles
C1
Dens
Primarily restrain rotation
Bilateral alar ligament avulsions
Transverse atlantal ligament
Condyles
C1
Dens
• Restrict dens from impaling
cord in flexion
• Maintain atlanto-axial distance
at <3mm (adults) and <5mm
(kids)
• 80% of odontoid fractures are
caused by flexion
•
Stanford Radiology 10th Annual Multidetector
CT Symposium
Lat displacement of C1 lateral
masses compared to C2
lateral masses raises concern
for TAL disruption
1
May 13, 2008- 5:20 PM
Megan Strother, MD: Characterizing spinal
injury at the cranio-cervical junction: who, what,
where?
Transverse atlantal ligament
C1 fxs with tubercle avulsion
C1
Tectorial membrane/ PLL
Condyles
C1
Dens
Craniocervical Junction Trauma
Atlanto-occipital Dissociation
• Atlanto-occipital dissociation
– Usually fatal
– Unstable—all stabilizing
structures disrupted in
distraction injuries—
neurologic deterioration with
delayed treatment
– Check for associated injury
*
Basion-dens interval < 12 mm
Stanford Radiology 10th Annual Multidetector
CT Symposium
2
May 13, 2008- 5:20 PM
Megan Strother, MD: Characterizing spinal
injury at the cranio-cervical junction: who, what,
where?
Atlanto-occipital Dissociation
Atlanto-occipital Dissociation
Left Carotid injection
Atlanto-occipital
Dissociation
Atlanto-occipital Dissociation
Craniocervical Junction Trauma
Craniocervical Junction Trauma
• Atlanto-occipital dissociation
• Atlanto-occipital dissociation
• Occipital condyle
• Occipital condyle
– Comminuted?
*
*widened atlantoaxial joint
Stanford Radiology 10th Annual Multidetector
CT Symposium
3
May 13, 2008- 5:20 PM
Megan Strother, MD: Characterizing spinal
injury at the cranio-cervical junction: who, what,
where?
Craniocervical Junction Trauma
Craniocervical Junction Trauma
• Atlanto-occipital dissociation
• Atlanto-occipital dissociation
• Occipital condyle
• Occipital condyle
– Comminuted?
– Associated occipital skull fx?
–
–
–
–
• Usually stable (type II)
Comminuted?
Associated occipital skull fx?
Non-Displaced?
Displaced
• Potentially unstable (type III)
Craniocervical Junction Trauma
Occipital condylar synchondrosis
• Atlanto-occipital dissociation
• Occipital condyle
–
–
–
–
–
Comminuted?
Associated occipital skull fx?
Non-Displaced?
Displaced?
Associated injury?
Occipital Condylar fx treatment
• 75 cases reviewed
– only 1 pure OCF was
treated surgically
Craniocervical Junction Trauma
• Atlanto-occipital dissociation
• Occipital condyle
• C1 fractures
– Atlas = most fragile vertebrae
– >3 parts = burst fracture
2000. B Cirak, et al Traumatic
Occipital Condyle Fractures
Treatment: hard collar or
halo vest—3 months
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Stanford Radiology 10th Annual Multidetector
CT Symposium
4
May 13, 2008- 5:20 PM
Megan Strother, MD: Characterizing spinal
injury at the cranio-cervical junction: who, what,
where?
C1 fracture:
malaligned lateral masses
C1 fracture
*
Usually heal with conservative treatment
Craniocervical Junction Trauma
Craniocervical Junction Trauma
• Atlanto-occipital dissociation
• Occipital condyle
• C1: lateral mass
• Atlanto-occipital dissociation
• Occipital condyle
• C1: lateral mass
• Dens fractures
• Dens fractures
– Most common c-spine
fracture in elderly
Craniocervical Junction Trauma
– Type I
• Odontoid tip avulsed by alar
ligament
Type II dens fracture
• Atlanto-occipital dissociation
• Occipital condyle
• C1: lateral mass
• Dens fractures
– Type II
• Fractures at odontoid waist
5 months post fall down stairs
Initially treated with ASPEN collar
Stanford Radiology 10th Annual Multidetector
CT Symposium
post-op pin
3 months post-op
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May 13, 2008- 5:20 PM
Megan Strother, MD: Characterizing spinal
injury at the cranio-cervical junction: who, what,
where?
Anterior oblique fracture lines
do not allow
interfragmentary compression
Craniocervical Junction Trauma
• Atlanto-occipital dissociation
• Occipital condyle
• C1: lateral mass
• Dens fractures
– Type III
• Extend into cancellous body
(better vascularized)
• Usually heal with conservative
management
• If >5mm vertical distraction—
treat surgically
NO anterior pin fixation
Type III dens fracture
Spinal cord injury
• Stabilizing structures of spine have
failed, surgical treatment should be
considered
• 17% of patients with cord injury die
during initial hospitalization
• High-level tetraplegia = 10% of spinal
cord injuries but 80% of direct medial
cost of spinal cord injury
Treated conservatively
REFERENCES
Bucholz RW, Heckman KD, Court-Brown CM. Limitations of inferences from biochemical studies.
2006. Rockwood & Green’s Fractures in Adults. 6th Edition, Lippincott Williams & Wilkins Publishers
Lapsiwala SB, Anderson PA, Oza A, et. al. Biomedical comparison of four C1 to C2 rigid fixative
techniques: Anterior transarticular, posterior transarticular, C1 to C2 pedicle, and C1 to C2 intralaminar
screws. Neurosurgery. 2006;58(3):516-521.
Platzer P, Thalhammer G, Oberleitner G, et. al. Surgical treatment of dens fractures in elderly
patients. J. Bone Joint Surg. Am. 2007;89:1716-1722.
Dickman CA, Greene KA, Sonntag VKH. Injuries involving the transverse atlantal ligament:
Classification and treatment guidelines based upon experience with 39 injuries. Neurosurgery. 1996;
January;38(1):44-50.
Deliganis AV, Baxter AB, Hanson JA, et. al. Radiologic spectrum of craniocervical distraction
injuries. Radiographics. 2000; 20:S237-S250.
Bono CM, Vaccaro AR, Fehlings M, et. al. Measurement techniques for upper cervical spine
injuries. Spine. 2007;32(5):593-600.
Alcelik I, Manik KS, Sian PS, et. al. Occipital condylar fractures – Review of the literature and
case reports. The J. of Bone and Joint Surgery. 2006;88-B(5 May): 665-669.
Cirak B, Akpinar G, Palaoglu S. Traumatic occipital condyle fractures. Neurosurg. Rev.
2000;23:161-164.
Caroli E, Rocchi G, Orlando ER, et. al. Occipital condyle fractures: Report of five cases and
literature review. Eur. Spine J. 2005;14:487-492
Momjian S, Dehdashti AR, Kehrli P, et. al. Occipital condyle fractures in children. Case report
and review of the literature. Ped. Neurosurg. 2003;38:265-270.
Hanson JA, Deliganis AV, Baxter AB, et. al. Radiologic and clinical spectrum of occipital condyle
fractures: Retrospective review of 107 consecutive fractures in 95
patients. AJR. 2002;178 May:1261-1268.
Noble ER, Smoker WRK. The forgotten condyle: The appearance, morphology, and
classification occipital condyle fractures. AJNR. 1996;17 March:507-513.
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CT Symposium
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