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Contemporary
Spine Surgery
VOLUME 11 I NUMBER 3 I MARCH 2010

C1 and C2 Spine Trauma: Evaluation,


Classification, and Treatment
Andrei F. Joaquim, MD, and Alpesh A. Patel, MD

T
he axis (C1) and the atlas (C2) greater than 10 feet. Projectile trauma
LEARNING OBJECTIVES: After partici-
vertebrae are part of the upper (e.g., gunshot wounds) and direct punc-
pating in this activity, the surgeon should
cervical spine. Although trauma ture or stab wounds to the spine are other
be better able to:
involving these vertebrae is not as com- potential causes.2
1. Interpret critical variables in the evaluation
mon as subaxial cervical trauma, it can
and treatment of upper cervical trauma.
present a difficult diagnostic dilemma.1 PRIMARY EVALUATION
2. Evaluate the most commonly used classi-
Most of the rotation in the upper cervi- A primary survey of the patient’s
fication systems for these injuries.
cal spine occurs at the atlantoaxial com- airway, respiratory status, and circula-
3. Analyze and employ appropriate treat-
plex, which can be compromised by tion (ABCs) is performed immediately.
ment strategies for patients with C1 and
trauma and result in spinal instability.2 Spinal cord injuries above C4 can lead to
C2 spine trauma.
Furthermore, the upper cervical spine difficulty with respiratory effort and can
relies heavily on ligamentous support to require emergent intubation. Another
Dr. Joaquim is Neurosurgeon PhD Student,
provide stability. This adds complexity important, systemic finding in this
Department of Neurology, State University to the evaluation of traumatic injuries group of patients is neurogenic shock—
of Campinas, Campinas-SP, São Paulo, and the determination of post-traumatic hypotension secondary to the loss of
Brazil; and Dr. Patel is Assistant Professor, stability. Unless these injuries are
Department of Orthopaedic Surgery,
sympathetic nervous system control
encountered and treated frequently, a over peripheral vascular resistance,
University of Utah School of Medicine, 590
Wakara Way, Salt Lake City, UT 84108, knowledge gap may exist for the spine with a low heart rate and warm, flushed
E-mail: alpesh2@gmail.com. care provider. extremities due to the loss of sympa-
Dr. Joaquim and all staff in a position to con- thetic nervous system input—that can
trol the content of this CME activity and CLINICAL EVALUATION be found in patients with cervical or
their spouses/life partners (if any) have dis-
closed that they have no financial relation-
Upper cervical injuries most common- middle to high thoracic spinal cord
ships with or financial interests in any com- ly present after a high-energy traumatic injuries.2 In contrast, post-traumatic
mercial companies pertaining to this educa- event, most often in younger patients and hypotension is generally caused by
tional activity. Dr. Patel has disclosed that he in males. Low-energy injuries to the upper hypovolemia, which presents with an
is/was the recipient of grant/research sup-
cervical spine (ex odontoid fractures) may elevated heart rate and cool, pale
port from Stryker Spine; is/was a member of
the speaker’s bureau for Amedica, Stryker occur, especially in older individuals. The extremities attributable to compensato-
Spine, Biomet, and Medtronic; and is/was a main causes of spinal trauma worldwide ry sympathetic activation.
stock shareholder in Amedica, and that his vary according to the degree of economic After completion of ABC stabilization,
spouse/life partner has nothing to disclose. development: in developed nations, trau- a search for other injuries is of paramount
The authors have disclosed that the use of ma typically involves motor vehicle colli- importance and includes thoracoabdomi-
posterior cervical instrumentation for treat-
ment of cervical fractures as discussed in this
sions or falls from height greater than 10 nal injuries, extremity fractures, facial and
article has not been approved by the U.S. Food feet; in developing nations, injury occurs head trauma, and spinal injuries. Spinal
and Drug Administration. most commonly after a fall from height immobilization and careful movement

Lippincott Continuing Medical Education Institute is accredited by the Accreditation Council for Continuing Medical Education to provide contin-
uing medical education for physicians. Lippincott Continuing Medical Education Institute designates this educational activity for a maximum of 1.5
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Contemporary Spine Surgery VOLUME 11 I NUMBER 3

until complete clinical and radiographic energy accidents, with a high likelihood
Editor-in-Chief evaluations are performed can avoid a cat- of a concomitant spinal injury. Given the
Gunnar B.J. Andersson, MD, PhD* astrophic neurologic event. External limitations of physical and neurologic
Chairman, Department of Orthopedic Surgery examination with direct inspection and examinations in these patients, radi-
Rush-Presbyterian—St. Luke’s Medical Center ographic imaging and advancements in
palpation of the dorsal spinal elements
Chicago, IL
should be performed; ecchymosis, tender- MRI can provide valuable information in
Associate Editor ness to palpation, and evidence of spinal these difficult circumstances.
Kern Singh, MD
misalignment may be hallmark signs of
Assistant Professor, Department of spinal trauma. Neurologic examination DIAGNOSTIC IMAGING
Orthopaedic Surgery includes motor and sensory testing of the All patients should undergo radi-
Rush University Medical Center extremities, perineal and perirectal sensa-
Chicago, IL
ographic assessment of the cervical
tion testing, assessment of rectal tone, spine, most commonly with plain x-rays.
Editorial Board and American Spinal Injury Association Concomitant spinal injuries may be pre-
(ASIA) score.2 sent in 20%–30% of the patients with a
Howard S. An, MD cervical fracture.3,4 In this setting, tho-
Spinal shock, a transient loss of the
Chicago, IL
spinal reflex, can be present in the racic and lumbar images also should be
Greg Anderson, MD absence of a bulbocavernosus reflex obtained. Otherwise, clinical findings
Philadelphia, PA
(contraction of the anal sphincter with and patient symptoms can guide imaging
Edward C. Benzel, MD bulbocavernosus pressure). Spinal shock of the thoracolumbar spine. In some cir-
Cleveland, OH is a descriptor of acute neurological dys- cumstances, plain x-rays may be insuffi-
Scott D. Boden, MD function and should be distinguished cient to rule out an injury, either because
Atlanta, GA from neurogenic shock, a descriptor of of radiographic technique or patient body
Yu-Po Lee, MD acute postinjury hypotension. The simi- habitus, especially at the craniocervical
San Diego, CA larities in nomenclature often lead to and cervicothoracic (C7–T1) junction.
Steven C. Ludwig, MD confusion when these two very different In the setting of a spinal fracture or
Timonium, MD conditions are discussed.2 dislocation, CT scans of the spine provide
The neurologic and clinical status of greater detail of fracture patterns. CT is
Alpesh A. Patel, MD
Salt Lake City, UT the patient remains crucial to the medical widely available at nearly all trauma cen-
decision-making process. However, mul- ters in the United States and is of critical
Michael Y. Wang, MD importance in the rapid evaluation and
Miami, FL tisystem trauma often limits a detailed
examination. Patients with multiple treatment of trauma patients. Some trau-
internal thoracoabdominal injuries, head ma centers now perform routine CT eval-
injuries, or multiple extremity injuries uation of the thorax and abdomen. With
have been involved in extremely high- only a few extra minutes of imaging time,
a cervical spine CT can be obtained, with
This continuing education activity is intended for orthopaedic and neurologic surgeons and other physicians
axial and sagittal reconstructed images,
with an interest in spine surgery. improving the sensitivity of fracture
Contemporary Spine Surgery (ISSN 1527-4268) is published monthly detection.3 At some centers, MRI is also
by Lippincott Williams & Wilkins, Inc., 16522 Hunters Green available, allowing assessment of the
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call customer service (410) 528-8572, 24-Hour Fax (410) 528-4105, or E-mail audrey.dyson@ spinal cord and ligamentous lesions.
wolterskluwer.com. Visit our website at LWW.com. Because MRI is less sensitive than CT for
Copyright 2010 Lippincott Williams & Wilkins, Inc. All rights reserved. Priority postage paid at Hagerstown, diagnosis of fractures and dislocations,
MD, and at additional mailing offices. POSTMASTER: Send address changes to Contemporary Spine Surgery, MRI scans should be reserved to assess
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COPYING: Contents of Contemporary Spine Surgery are protected by copyright. Reproduction, photocopying, and vical spine can be quite expansive given
storage or transmission by magnetic or electronic means are strictly prohibited. Violation of copyright will result
in legal action, including civil and/or criminal penalties. Permission to reproduce in any way must be secured the wide range of injury patterns as well as
in writing; e-mail journalpermissions@lww.com. For reprints, e-mail matt.westcoat@wolterskluwer.com. the complex upper cervical anatomy. We
PAID SUBSCRIBERS: Current issue and archives (from 2000) are available FREE online at www. categorize upper cervical injuries as fol-
lwwnewsletters.com. lows: atlanto-occipital dislocation (AOD);
Contemporary Spine Surgery is independent and not affiliated with any organization, vendor, or company. occipital condyle fractures; atlas (C1) frac-
Opinions expressed do not necessarily reflect the views of the Publisher, Editor, or Editorial Board. A
mention of the products or services does not constitute endorsement. All comments are for general guid- tures; transverse ligament disruption; and
ance only; professional counsel should be sought for specific situations. axis (C2) fractures comprising: a) odontoid

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MARCH 2010 Contemporary Spine Surgery

B
A
Fig. 1 A 52-year-old man sustained a fall while skiing and pre-
sents with severe neck pain. A, Open-mouth AP “odontoid” x-ray
of the cervical spine. Due to overlying structures (teeth, maxillary
bone, and mandible) clear visualization of the upper cervical spine
is difficult. The right lateral mass (*) appears to be laterally trans-
lated. B, Axial CT scan through C1 demonstrates a C1 burst frac-
ture with displacement of the both right and left C1 lateral mass
away from the dens. Disruption places the transverse ligament at
risk for injury. C, Coronal reconstructed CT scan of C1–C2
demonstrates lateral translation of both the right (a) and left (b)
C1–C2 articulations. The amount of overhang (a = 6 mm, b = 3
mm) is calculated to be 9 mm. As this is greater than 6.9 mm, this
injury is deemed unstable, and surgical treatment is recommended.

Diagnosis. Atlas fractures can be adequately diagnosed


with a CT scan (Figure 1).
Treatment. This fracture is usually treated with either cer-
vical orthosis or halo-vest immobilization. Surgical treatment is
indicated in patients with associated unstable C2 injury or
transverse ligament injury and subsequent C1–C2 instability.
C Surgical treatment typically involves occipitocervical (O–C2) or
atlantoaxial fixation (C1–C2) and posterior arthrodesis.
fractures; and b) traumatic spondylolisthesis of the axis, or
Transverse Ligament Injuries
“hangman’s” fracture.
As previously described, transverse ligament injuries
Atlas (C1) Fractures can lead to atlantoaxial instability requiring surgical stabi-
C1 fractures correspond to about 1%–2% of all spine lization. Traumatic disruption of the transverse ligament may
fractures and about 15% of the cervical spine fractures.6 be seen as an isolated injury pattern, without concomitant
Atlas fractures include a wide range of lesions, typically bony injuries. Reported radiographic criteria for transverse
defined by the location of anatomic injury: anterior arch, pos- ligament injuries include: 1) atlanto-dens interval greater
terior arch, or combined (burst or Jefferson fracture). than 3 mm; 2) lateral mass displacement of more than 6.9
Additional lateral mass fractures or injuries associated with mm, (measured on a plain open-mouth x-ray);7 or 3) MRI
C2 or other vertebrae fractures may be seen. In the setting of scan showing transverse ligament disruption or avulsion.8 In
C1 burst (or Jefferson) fracture, the status of the transverse an anatomic system, Dickman and Sonntag classified the
ligament is of critical importance. With significant lateral transverse lesions in two types (according to MRI findings):9
mass separation, disruption of the transverse ligament may type 1—lesion of the transverse ligament substance; and
occur. The critical degree of separation has been reported to type 2—avulsion of the insertion of the ligament.
be as low as 6.9 mm.7 Disruption of the transverse ligament Diagnosis. Transverse ligament injury is commonly
renders the C1–C2 articulation unstable. diagnosed on the basis of radiographic criteria of C1–C2

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Contemporary Spine Surgery VOLUME 11 I NUMBER 3

Table 1. Effendi Modified Classification of Posterior Element Fractures

Type Description Radiographic Findings Treatment (Initial Option)

1 Axial loading and extension, with vertical Less than 3 mm of C2–C3 subluxation and Rigid immobilization
pars fracture no angulation

1A Hyperextension Fracture may not be visible on x-ray Rigid immobilization


Fracture lines on each side are not parallel C2 body can be 2–3 mm anteriorly subluxated
(may pass to the foramen transversarium)

2 Axial loading and extension with rebound Subluxation C2–C3 >3 mm or angulation Surgical treatment can be an option
flexion in severe angulation, disruption of
Vertical fracture through the pars with C2–C3 disc or inability to establish
disruption of the C2–C3 disc and lesion alignment with external
of the posterior longitudinal ligament immobilization

2A Flexion distraction injury, with an Little subluxation C2–C3 but with more
oblique fracture (usually anteroinferior angulation
to posterosuperior)

3 Vertical pars fracture with facet disruption Locked C2–C3 facets may be presented Traction may be dangerous in type 3
and may disrupt the anterior lesions.
longitudinal ligament

instability. The diagnosis also may be made from MRI images three subclassifications of type 2 odontoid fractures based on
of the upper cervical spine, although the sensitivity and the fracture slope and the potential for displacement:
specificity of MRI remain poorly defined. 1. Oblique fracture in which the fracture line slopes for-
Treatment. Type 1 lesions generally fail conservative ward, and the displacement will typically be in an ante-
treatment given the lack of effective ligamentous healing. rior direction;
Patients with these injuries typically require surgical stabi-
2. Oblique fracture in which the fracture line slopes back-
lization (C1–C2) with posterior arthrodesis. Due to the poten-
ward, and the displacement will normally be in a poste-
tial for bone healing, patients with type 2 lesions may be
rior direction; and
treated with external immobilization comprising either a cer-
vical orthosis or halo-vest immobilization. 3. Fracture in which the line is horizontal; these fractures
may displace either anteriorly or posteriorly.
Axis (C2) Fractures
Diagnosis. The diagnosis is typically made with plain x-
Odontoid Fractures. Odontoid fractures, also called rays, including lateral cervical films as well as an open-
dens fractures, are the most common of the C2 injuries and mouth odontoid view. CT may further identify fracture pat-
represent about 15% of all cervical spine fractures.10 Injury terns (as described by Roy-Camille), fracture comminution,
patterns can dictate the degree of instability and guide surgi- and involvement of the C1–C2 articulation. Involvement of
cal decision making. In 1974, Anderson and D’Alonzo pro- the C1–C2 articulation is a useful means of distinguishing
posed the most commonly used classification, which defines type 3 from type 2 odontoid fractures (Figure 2).
three types of odontoid injuries:11 Treatment. Fracture type, according to Anderson and
• Type 1—an oblique fracture through the upper part of D’Alonzo classification,11 patient age and functional status,
the odontoid process; fracture line pattern (Roy-Camille et al.13), degree of dens
displacement, comminuting, and fragment angulation can
• Type 2—fracture at the base of the odontoid as it attach-
influence the treatment proposed.
es to the body of C2; and
As a general rule, collar immobilization is sufficient for
• Type 3—dense fracture line extends into the body of the treatment of types 1 and 3 fractures without significant com-
atlas and typically involves the C1–C2 articulation. minution. For type 3 fractures with comminution, halo vest
Type 1 fractures are rarely reported but may be seen in immobilization is recommended.14 Type 2 fractures are general-
associated with other upper cervical injuries, most notably ly surgically treated in patients older than 50 years, transverse
atlanto-occipital dislocation. A variation of type 2 fractures ligament rupture, with a dens displacement greater than 6 mm,
(also known as type 2A) was proposed by Hadley et al.12 It type 2A fractures, fractures not adequately stabilized with
corresponds to fractures at the base of the dens, but with external immobilization, and inadequate healing after conserv-
fracture comminution. Another important classification of ative treatment. The technique to obtain arthrodesis is general-
odontoid fractures, with treatment implications, was pro- ly C1–C2 posterior fusion, with many techniques available.10,15
posed by Roy-Camille et al.13 The Roy-Camille system defines Patients with acute type 2 or 3 fractures, without rupture of the
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MARCH 2010 Contemporary Spine Surgery

transverse ligament, and


with a favorable fracture
line (slopes anterior-cra-
nial to posterior-caudal)
can be treated with an
anterior odontoid screw.
Type 2A fractures are a
relative contraindication
to use of anterior odon-
toid screw.16,17
Traumatic Spon-
dylolisthesis of the
Axis or “Hangman’s”
Fracture. Fractures of
the posterior elements
(pedicle, pars, lamina, or
facet joints) of C2 are
also known as hang-
man’s fracture or, more
descriptively, traumatic
B spondylolisthesis of the
axis. These injuries can
be grouped in two types
of lesions, according to
the mechanism of injury:
1) distraction and hyper-
extension lesions; and
2) the result of hyper-
extension, compression,
and possible rebound
A
flexion. A higher inci-
dence of head injury is
present in the latter
hangman’s fracture in-
jury type due to the
mechanism of injury
as well as the associ-
ated high-energy trau-
ma. The Effendi modi-
fied classification, de-
fining three types of in-
juries, is commonly used
(Table 1).18,19
Diagnosis. Diag-
nosis of C2 pars frac-
D
tures can be made with
Fig. 2 A 78-year-old man presents with neck pain after a ground-level
fall. A, Lateral x-ray demonstrates an odontoid fracture with posterior
displacement measuring 8 mm. B, Sagittal reconstructed CT scan reveals
spontaneous reduction of the type 2 odontoid fragment, suggesting sig-
nificant instability. Fracture line slopes posteriorly (from anterosuperior
to posteroinferior). Slight comminution is visualized at the fracture site.
C, Coronal reconstructed CT scan demonstrates lack of fracture involve-
ment of the C1–C2 articular surface. This confirms a type 2 rather than a
type 3 odontoid fracture. D, Given the location of the fracture (type 2),
findings of displacement, comminution, and the patient’s age, a posterior
C
C1–C2 instrumented arthrodesis was performed.

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Contemporary Spine Surgery VOLUME 11 I NUMBER 3

Fig. 3 A 65-year-old woman presents with neck pain after a fall. A,


Lateral x-ray demonstrates a type 2A C2 pars fracture (“hangman’s
fracture”). Displacement across the pars is visualized as is angulation
across the C2–C3 disc space. In addition, an associated C1 fracture
is seen. B, After traction and reduction, angulation across the disc
space is diminished, although fracture displacement remains. This B
injury pattern may be treated with either halo-vest immobilization or
through instrumented C1–C3 posterior spinal arthrodesis.

plain x-rays. CT may further demonstrate fracture location nia, and skin pressure ulcerations. Moreover, adequate treat-
and comminution as well as facet alignment (Figure 3). MRI ment may also improve neurologic outcomes. A better under-
in the setting of C2 pars fractures may demonstrate disrup- standing of the relevant upper cervical anatomy, commonly
tion of the C2–C3 articulation as well as the C2–C3 disc seen injury patterns, and critical factors in surgical decision
space, suggesting an unstable fracture pattern. making may improve management of upper cervical trauma.
Treatment. Treatment of C2 pars fractures is based on
implied instability of the injury pattern. Wide fracture dis- REFERENCES
placement, fracture angulation, disruption of the C2–C3 disc 1. Hadley MN. Guidelines for management of acute cervical injuries.
space, and dislocation of the facet joint are all reported oper- Neurosurgery 2002;50:S1-6.
ative indications. Closed treatment, however, remains the 2. Patel A. Subaxial cervical trauma: evaluation, classification, and treat-
most common form of treatment. Closed halo-traction reduc- ment. Contemp Spine Surg 2008;10:1-8.
3. Barrett TW, Mower WR, Zucker MI, et al. Injuries missed by limited
tion can be performed safely to reduce and maintain dis- computed tomographic imaging of patients with spine injuries. Ann
placed or angled fracture patterns. Patients with nondis- Emerg Med 2006;47:129-33.
placed C2 pars fractures may be treated with either rigid cer- 4. Sharma OP, Oswanski MF, Yazdi JS, et al. Assessment for additional spinal
vical orthosis or halo-vest immobilization. trauma in patients with cervical spine injury. Am Surg 2007;73:7074.
5. Crim JR, Moore K, Brodke D. Clearance of the cervical spine in multi-
trauma patients: the role of advanced imaging. Semin Ultrasound CT
CONCLUSIONS MR 2001;22:283-305.
Diagnosis and treatment of upper cervical spinal injuries 6. Hadley MN, Dickman CA, Browner CM, et al. Acute traumatic atlas frac-
remains a challenge for spinal surgeons. Early diagnosis and tures: management and long term outcome. Neurosurgery 1988;23:31-5.
7. Heller JG, Viroslav S, Hudson T. Jefferson fractures: The role of magnification
treatment may improve clinical outcomes, allowing early
artifact in assessing transverse ligament integrity. J Spinal Disord 1993;6:392-6.
mobilization and diminishing potential complications such as 8. Oda T, Panjabi MM, Crisco 3rd JJ, et al. Multidirectional instabilities of
deep venous thrombosis, pulmonary atelectasis and pneumo- experimental burst fractures of the atlas. Spine 1992;17:1285-90.

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MARCH 2010 Contemporary Spine Surgery

9. Dickman CA, Sonntag VK. Injuries involving the transverse atlantal 15. Campanelli M, Kattner KA, Stroink A, et al. Posterior C1-C2 transartic-
ligament: classification and treatment guidelines based upon experi- ular screw fixation in the treatment of displaced type II odontoid frac-
ence with 39 injuries. Neurosurgery 1997;40:886-7. tures in the geriatric population—review of seven cases. Surg Neurol
10. Julien TD, Frankel B, Traynelis VC, et al. Evidence based analysis of 1999;51:596-600.
odontoid fracture management. Neurosurg Focus 2000;8:Article 1 16. Apfelbaum RI, Lonser RR, Veres R, et al. Direct anterior screw fixation
11. Anderson LD, D’Alonzo RT. Fractures of the odontoid process of the for recent and remote odontoid fractures. J Neurosurg 2000;93:227-36.
axis. J Bone Joint Surg Am 1974;56:1663-74.
17. Reilly TM, Sasso RC. Anterior odontoid screw techniques. Techniques
12. Hadley MN, Browner CM, Liu SS, et al. New subtype of acute odontoid
Orthopaed 2002;17:306-15.
fractures (type IIA). Neurosurgery 1988;22:67-71.
18. Effendi B, Roy D, Cornish B, et al. Fractures of the ring of the axis: a
13. Roy-Camille R, De La Caffiniere JH, Saillant G. Traumatisme du rachis
cervical supérieur C1–C2. Paris: Masson et Cie, 1973;51. classification based on the analysis of 131 cases. J Bone Joint Surg Br
14. Polin RS, Szabo T, Bogaev CA, Replogle RE, Jane JA. Nonoperative 1981;63:319-27.
management of Type II and III odontoid fractures: the Philadelphia col- 19. Levine AM, Edwards CC. The management of traumatic spondylolisthe-
lar versus the halo vest. Neurosurgery 1996;38:450-6. sis of the axis. J Bone Joint Surg Am 1985; 67:217-26.

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Contemporary Spine Surgery VOLUME 11 I NUMBER 3

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1. With a clinical concern for atlanto-occipital 5. An injury to the transverse ligament 8. An individual with a C1 ring fracture pre-
dislocation (AOD), the initial evaluation of with associated bony avulsion injury sents with neck pain. Open-mouth odon-
the traumatically injured patient should be usually is best treated with toid views demonstrate lateral mass over-
focused on A. halo-vest orthosis hang of C1 on C2 of 8.4 mm. The most
A. cervical stabilization B. halo traction appropriate treatment is
B. the patient’s airway, ventilation, and C. posterior instrumented C1-C2 arthrodesis A. cervical orthosis
circulation D. posterior instrumented occiput-C2 B. traction reduction followed by halo-
C. CT evaluation of the entire spine arthrodesis vest orthosis
D. plain radiography of the neck C. anterior odontoid screw
6. A patient presents with bilateral mini- D. posterior C1-C2 instrumentation and
2. A patient presents with systemic hypo- mally displaced fractures of the C2 arthrodesis
tension and bradycardia as well as a pars. The patient is neurologically
spinal cord injury at C2. The patient has intact with no evidence of facet sublux- 9. A patient with a nondisplaced C1 ring frac-
an absent bulbocavernosus reflex. The ation or dislocation. The best method ture presents with 9 mm of lateral mass
most appropriate diagnosis is for treatment is overhang on open-mouth odontoid x-rays.
A. C1-C2 instability A. rigid cervical orthosis Which one of the following anatomic struc-
B. spinal shock B. halo traction reduction tures is most likely to be disrupted?
C. neurogenic shock C. anterior C2-C3 arthrodesis A. Vertebral artery
D. incomplete spinal cord injury D. posterior instrumented C1-C2 arthro- B. Apical ligament
desis C. Posterior longitudinal ligament
3. A nondisplaced odontoid fracture is D. Transverse ligament
found to involve the base of the dens on 7. A patient presents with a widely displaced
lateral radiographs. CT demonstrates C2 pars fracture and dislocation of C2-C3 10. The patient presents with no spontaneous
extension of the fracture into the C1-C2 facet joint. After traction reduction, the respirations, a complete spinal cord injury
articulation. The most appropriate clas- C2-C3 facet is aligned well, but the C2 pars in the upper cervical spine, and cranial
sification of this injury is type fracture remains displaced. The most nerve palsy. A displaced fracture is identi-
A. 1 appropriate treatment at this time is fied at the tip of the odontoid. Severe soft
B. 2 A. halo-vest orthosis tissue swelling is noted anterior to the
C. 2A B. cervical orthosis occiput and upper cervical spine. The most
D. 3 C. posterior C2-C3 instrumentation and appropriate diagnosis is
arthrodesis A. cerebrovascular accident
4. Type 2 odontoid fractures may be treated D. posterior C1-C3 instrumentation and B. atlanto-occipital dislocation
either surgically or with external immobi- arthrodesis C. type 1 odontoid fracture
lization. Which one of the following is not D. type 3 odontoid fracture
a risk factor for failure in external immobi-
lization?
A. Type 2A fracture
B. Higher age
C. Female sex
D. Dens displacement >6 mm

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