Upper cervical injuries – A rational approach to guide surgical management

Abstract

ContextThe 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.ObjectiveTo propose a practical treatment algorithm to guide treatment based on injuries characteristic of UCI.MethodsA 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.ResultsInjuries 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.ConclusionsAscertaining the status of relevant ligamentous structures, fracture patterns and alignment are important in determining surgical compared with non-surgical treatment for patients with UCI.