Vertebral Column Injury (specific injuries)

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occipital-cervical pain

  • myelopathy - transient (commonly after trauma), static, or progressive.

  • vertebrobasilar ischemia

    • sudden spinal cord injury in association with os odontoideum after minor trauma have been reported.

    Evaluation – flexion-extension lateral XR.

    • most often, there is anterior instability, with os odontoideum translating forward in relation to body of C2.

    • at times, one will see either no discernible instability or “posterior instability” with os odontoideum moving posteriorly into spinal canal during neck extension.

    • degree of C1-C2 instability on XR does not correlate with presence of myelopathy; sagittal diameter of spinal canal at C1-C2 level < 13 mm does correlate with myelopathy detected on clinical examination.

    Classification - 2 anatomic types:

    Orthotopic - ossicle that moves with anterior arch of C1.

    Dystopic - ossicle that is functionally fused to basion; dystopic os odontoideum may sublux anterior to arch.

    Management – indications for surgery:

    1. neurological symptoms → C1-2 fusion

    2. irreducible dorsal* cervicomedullary compression → occipital-cervical fusion ± C1 laminectomy

    3. associated occipital-atlantal instability → occipital-cervical fusion ± C1 laminectomy

    *vs. irreducible ventral cervicomedullary compression → ventral decompression.

    N.B. Odontoid screw fixation has no role!

    Hangman’s fracture (s. traumatic spondylolysis of C2)

    (unstable - but cord damage is rare because AP diameter of neural canal is greatest at C2 level and because bilateral pedicular fractures permit spinal canal to decompress itself with forward displacement of C2 body)

    • abrupt deceleration (e.g. hanging with knot in submental position, striking chin on steering wheel in head-on automobile crash) → cervicocranium (skull, atlas, and axis functioning as unit) is thrown into extreme hyperextensionbilateral pedicle fractures of axis (± broken subjacent disc bond → forward subluxation of C2 on C3).

    • cervical spine / spinal cord damage happens in only those hangings that involve fall from distance greater than body height.

    Potential dislocation:


    1. fracture lines extending through pedicles of C2 (i.e. anterior to inferior articular facets).

    2. disrupted posterior cervical line (base of C2 spinous process lies > 2 mm behind posterior cervical line).

    3. prevertebral swelling (may cause respiratory obstruction!).

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