Occiput to C1-2 Fractures: Assessment, Bracing, and Reconstructive Techniques

The craniocervical junction is a transitional segment from the cranium to the cervical spine with a unique architecture that accommodates a high degree of motion and requires considerable contributions from surrounding ligamentous structures for stability. The assessment, immobilization, and management of upper cervical spine injuries requires consideration of the complex architecture that exists and the movement that occurs in the craniocervical junction. Early diagnosis and stabilization of upper cervical spine injuries is crucial because devastating complications may occur in patients with an upper cervical spine injury. Several clinical and radiographic findings should elicit suspicion for occipitocervical dissociation, which is a highly unstable injury that requires surgical management via occipitocervical fusion. In general, the management of C1 fractures is based on the status of the transverse atlantal ligament. Isolated atlantoaxial dislocations are rare injuries and commonly are observed as translation injuries rather than rotation injuries in adults. The management of type II dens fractures is challenging and controversial, particularly in elderly patients; therefore, multiple factors must be considered in the management of type II dens fractures. Although many hangman fractures can be managed nonsurgically, atypical hangman fractures must be observed closely, and unstable or displaced hangman fractures are reduced and managed surgically.