Fractures of the odontoid process

We treated 183 patients with fractures of the odontoid process (109 type II, 74 type III) non-operatively. Union was achieved in 59 (54%) with type-II fractures. All type-III fractures united, but in 16 patients union was delayed. There was no correlation between union and the clinical or radiological outcome of the fractures. Selective vertebral angiography, carried out in 18 patients ten with acute fractures and eight with nonunion, showed that the blood supply to the odontoid process was not disrupted. Studies on ten adult axis vertebrae at post-mortem showed that the difference in the surface area between type-II and type-III fractures was statistically significant. Our findings show that an age of more than 40 years, anterior displacement of more than 4 mm, posterior displacement and late presentation contribute towards nonunion of type-II fractures.     

Management of the fractured odontoid with halo-thoracic bracing

This study of 65 cases of fractured odontoid indicates that halo-thoracic bracing is an effective method for treatment of the Types II and III fractures. There were 28 Type II, and 19 Type III fractures treated with halo-thoracic braces. Of these 47 patients, only 4 went on to nonunion after an average of 8 weeks in the brace, a rate of bony union of 91.5%. Seven of the remaining 18 patients underwent primary fusion at C1-2, two were treated in Guilford braces, and six received no treatment. Surgery was performed if the fracture was unstable, if the patient could not be relied upon to leave the halo in place, or if the patient chose it as primary treatment. All seven of these patients went on to bony fusion. All of the six patients who refused treatment went on to nonunion of the fracture. Three patients were lost to follow-up.     

A review of halo vest treatment of upper cervical spine injuries

Thirty-five relevant studies involving in total 682 patients with 709 different types of injuries were evaluated in a review to determine the outcomes after immobilisation in a halo vest for various injuries to the upper cervical spine between 1962 and 1998. Studies were analysed according to the type of injury pattern and in terms of the treatment outcomes following primary treatment with a halo vest. The following types of injuries were evaluated: odontoid fractures (n = 420), hangman's fractures (n = 172), other axis fractures (n = 75), Jefferson fractures (n = 26), C1 arch fractures (n = 9), atlantooccipital (n = 2) and atlantoaxial dislocations (n = 5). The ligamentary atlantooccipital dislocations never healed. All isolated Cl ring fractures healed completely. The isolated C1 arch fractures healed in 83% of the cases. The ligamentary atlantoaxial dislocations had a 60% rate of healing. Healing was noted in all isolated odontoid type I fractures, 85% of the isolated odontoid type II fractures, and 67% of the odontoid type II fractures with combined injuries. The isolated odontoid type III fractures had a 97% healing rate. The non-classifiable odontoid fractures had a healing rate of 85%. The stable C2 arch fractures (hangman's fracture) healed consistently in 99%, and 90% success was found for other C2 fractures. A halo vest can be recommended for patients with isolated Jefferson fractures, hangman's fractures, odontoid type III and type II fractures, with a low dislocation rate. The results of treatment with a halo vest were unsatisfactory with regard to combined injuries with an odontoid type II fracture. An overall healing rate of 86%, however, allows one to conclude that this treatment continues to be a good alternative to operative stabilisation of bone injuries to the upper cervical spine.     

Axis fractures: a comprehensive review of management and treatment in 107 cases

The combination of movement, location, and anatomy of the axis predisposes it to multiple and varied fracture/dislocations distinct from other vertebrae. We examine all forms of axis fractures and address the appropriate treatment for each specific fracture type. In a retrospective review of 625 cervical spine fractures during an 8-year period, we found 107 axis fractures. There were 25 hangman's fractures (23%), 59 odontoid fractures (55%), and 23 miscellaneous fractures (22%). Each case was characterized by age, sex, the presence of associated injuries, presenting symptoms and findings, initial treatment, and results of that treatment. Excluding 6 early deaths, 90 of 101 patients were located for a median follow-up of 3.2 years. We found that 17% of cervical fractures involve the axis. Axis fractures have a high association with head and other cervical spine injuries, 40% and 18%, respectively. Few neurological deficits result from a fracture of the 2nd cervical vertebra. Hangman's fractures are effectively treated with external stabilization, preferably with a halo vest. We noted a shorter period of treatment using the halo vest as compared to the SOMI brace. Nonunion occurred in 26% of odontoid Type II fractures, but occurred in 67% of those with dens displacement of 6 mm or greater, regardless of age or direction of dislocation. We recommend early surgical therapy for this subgroup. There is no correlation between age and the rate of nonunion. In patients with odontoid Type II fractures with dens displacement of 0 to 5 mm, fusion occurs with external stabilization alone. Odontoid Type III fractures are one-half as common as Type II fractures, and all heal well with external stabilization. Twenty-two per cent of acute axis fractures are not hangman's or odontoid fractures. Miscellaneous fractures of the axis generally do well with external stabilization and immobilization.     

Early morbidity and mortality associated with elderly odontoid fractures

Odontoid fracture treatment is well documented, but challenges remain in treating these fractures in elderly patients. Issues include identifying the optimal treatment for bony union, determining the stability of a nonunion, and understanding the long-term consequences of nonunion. In elderly patients, the focus tends to shift to morbidity and mortality.This retrospective review describes the early morbidity and mortality in the authors' elderly odontoid fracture population. The authors reviewed the medical records, radiographs, and death certificates of 37 patients aged 65 years or older who were diagnosed with type 2 odontoid fractures between 1994 and 2004. Average follow-up was 28.7 ± 32.5 weeks (range, 0-133 weeks). More than three-fourths of the patients were injured in a fall. All of the odontoid fractures were type 2. The 3 most common co-morbidities were hypertension, heart disease, and rheumatoid arthritis. The majority of patients were treated nonoperatively with a collar or halo. Six patients experienced 1 procedure-related complication. Overall, 18 (48.6%) of 37 patients experienced complications, including 3 (8.15%) deaths.In elderly patients with odontoid fractures, one should be prepared for a hospital course complicated by medical issues; early mortality rates are significant. These issues appear to exist regardless of the fracture treatment chosen; one must anticipate respiratory, swallowing, balance, and cardiac problems. Management strategies should be individualized to the patients; operative and nonoperative treatments remain viable options.     

Traumatic fractures of the craniovertebral junction. Management of 23 cases

Twenty-three consecutive cases of traumatic C1-C2 fractures treated at the Department of Neurosurgery, University of Milano, are reported. Of these there were 13 cases of odontoid fractures, 6 hangman fractures, 2 anterior inferior corner fractures, 2 atlas-axis combination fractures and 2 Jefferson fractures. Almost all the patients were young people involved in motor vehicle accidents. Nineteen patients were treated with external immobilization (halo vest, Minerva) for 3-6 months while 4 odontoid fractures underwent early surgical posterior stabilization. At follow-up, 20 patients had a good fusion while 3, aged over 75 years, died due to cardiopulmonary or septic complications. The appropriate management of this type of lesion is still a matter of discussion. In our opinion the Halo device allows good stabilization after correct fracture reduction.     

Type D fractures of the odontoid process

Type D fractures of the odontoid process are rare and usually occur in the elderly. The mechanism of fracture is unclear. Non-operative treatment is indicated provided that adequate immobilization using skull traction followed by either a collar or a halo vest can be achieved. The prognosis is usually favorable for this type of fractures. We present six patients with complex (type D) fractures of the odontoid process admitted and treated at our institution since 1970. There were five men and one woman with a mean age of 57.7 years (range, 16–81 years). Although there were concomitant injuries, no neurological deficits due to the odontoid process fracture was detected. All patients were treated non-operatively using skull traction or a halo vest for 8–12 weeks. One patient deceased 2 days after the injury. At the latest examination, all the remaining five patients had complete union of the odontoid process fracture; three of them had excellent range of motion and two had painful or restricted range of motion of the upper cervical spine.     

Nonoperative treatment of displaced type II odontoid peg fractures with a Philadelphia collar

Although a consensus exists on the nonoperative management of types I and III odontoid peg fractures, treatment of type II fractures remains controversial. An increasing trend exists toward primary fixation of type II peg fractures due to a high rate of nonunion, especially if the displacement is >4 mm. This article reports the results of nonoperative treatment of patients with displaced odontoid peg fractures (>4 mm) using a Philadelphia collar.A retrospective review of clinical and radiological records was performed for nonoperatively treated patients who sustained displaced type II peg fractures between January 2003 and April 2008. The study group comprised 9 patients (2 men and 7 women), and all patients were treated with Philadelphia collars. Patients were followed up for an average of 24.8 months (range, 8-28 months) for clinical and radiological outcomes. Functional outcomes were measured according to the Smiley-Webster scale. Fractures united uneventfully in 6 patients, but nonunion developed in 3 patients. Average time to union was 12.3±2.94 weeks (95% confidence interval, 9.97-14.68 weeks; range, 10-16 weeks). No patient had clinical or radiological signs of instability or delayed onset myelopathy at follow-up. Three patients had excellent, 4 had good, and 2 had fair results as per the Smiley-Webster functional scoring system.Displaced type II peg fractures can be managed nonoperatively in patients who refuse surgery or those with multiple comorbidities. Adequate patient counseling and compliance with close clinicoradiological follow-up is paramount to avoid adverse clinical events and achieve an optimal functional outcome.     

Surgical treatment of odontoid fractures with C1 hook and C2 pedicle screw construct

A number of approaches have been attempted to address the treatment of acute odontoid fractures, spanning from conservative treatment with an external orthotic device to posterior C1-C2 arthrodesis or anterior screw fixation. The current report describes stabilisation of such fractures with a C1 supralaminar hook and a C2 pars interarticularis screw construct. Two patients with odontoid fracture were treated by this technique. Two-year follow-up of both patients revealed complete union without complications. The authors stress that this technique avoids the hazards of C1 lateral mass screws.     

Fixation of odontoid fractures by an anterior screw

We have reviewed 81 patients with fractures of the odontoid process treated between May 1983 and July 1997, by anterior screw fixation. There were 29 patients with Anderson and D'Alonzo type-II fractures and 52 with type III. Roy-Camille's classification identified the direction and instability of the fracture. Operative fixation was carried out on 48 men and 33 women with a mean age of 57 years. Associated injuries of the cervical spine were present in 15 patients, neurological signs in 13, and 18 had an Injury Severity Score of more than 15. Nine patients died and 11 were lost to follow-up. Of 61 patients, 56 (92%) achieved bony union at an average of 14.1 weeks. Two patients required a secondary posterior fusion after failure of the index operation. A full range of movement was restored in 43 patients; only six had a limitation of movement greater than 25%. We conclude that anterior screw fixation is effective and practicable in the treatment of fractures of the dens.     

Type II odontoid fractures in the elderly: an evidence-based narrative review of management

Considerable controversy exists regarding the optimal management of elderly patients with type II odontoid fractures. There is uncertainty regarding the consequences of non-union. The best treatment remains unclear because of the morbidity associated with prolonged cervical immobilisation versus the risks of surgical intervention. The objective of the study was to evaluate the published literature and determine the current evidence for the management of type II odontoid fractures in elderly. A search of the English language literature from January 1970 to date was performed using Medline and the following keywords: odontoid, fractures, cervical spine and elderly. The search was supplemented by cross-referencing between articles. Case reports and review articles were excluded although some were referred to in the discussion. Studies in patients aged 65 years with a minimum follow-up of 12 months were selected. One-hundred twenty-six articles were reviewed. No class I study was identified. There were two class II studies and the remaining were class III. Significant variability was found in the literature regarding mortality and morbidity rates in patients treated with and without halo vest immobilisation. In recent years several authors have claimed satisfactory results with anterior odontoid screw fixation while others have argued that this may lead to increased complications in this age group. Lately, the posterior cervical (Goel–Harms) construct has also gained popularity amongst surgeons. There is insufficient evidence to establish a standard or guideline for odontoid fracture management in elderly. While most authors agree that cervical immobilisation yields satisfactory results for type I and III fractures in the elderly, the optimal management for type II fractures remain unsolved. A prospective randomised controlled trial is recommended.     

Management of combined atlas-axis fractures: a review of forty one cases

Purpose

To outline a management principle for the combined atlas (C1)-axis (C2) fractures and assess its therapeutic effects.

Methods

Forty-one patients with combined C1-C2 fractures were treated according to their C2 fracture types. Non-operative external immobilization in the form of a cervical collar or halo vest was used in 22 patients. Early posterior pedicle screw fixations were performed in 19 patients whose fractures had a combination of any of the three conditions: an atlantodens interval (ADI)?≥?5 mm, lateral mass displacement (LMD)?>?7 mm, and/or C2-C3 angulation?>?11°. Thirty-nine patients were followed up regularly with an average of 19.3 months (range, 12 to 45 months). Clinical and radiographic data were then collected and compared.

Results

At three months following treatment, patients’ visual analog scale (VAS), Neck Disability Index (NDI), American Spinal Injury Association (ASIA) scale, and Frankel grades were all significantly improved when compared to pretreatment. These results indicated that the cervical collar, halo vest, and posterior pedicle screw fixation approaches were all able to effectively treat cases of combined C1-C2 fractures. One patient in the non-surgical group developed nonunion which required late surgical treatment and one patient had pin site infection in the non-surgical group (2/22), while there were three minor complications in the surgical group.

Conclusion

We propose a management principle that bases the treatment of a combined C1-C2 fracture on the nature of the C2 fracture. This treatment strategy has yielded promising results as a satisfactory means for the management of combined C1-C2 fractures.

     

头环背心在颈椎外科的应用

作者观察了用头环背心治疗多种原因所致颈椎不稳定的应用效果。用头环背心治疗了１０７例颈椎不稳定的病人，病种包括结核、损伤、肿瘤和畸形。病人分为非手术治疗组和融合术组。融合术包括寰枢椎后路融合术、枕颈融合术和下颈椎融合术。各种融合术都在头环背心的固定下施行，不用任何内固定。测量了２３例病人用头环背心固定前后的肺功能。１０７例病人中有８９例获得了随访，平均随访时间２５个月，非手术组的病人在头环背心固定下均恢复了颈椎的稳定性。在３１例行寰枢椎后路融合术的病人中有２９例融合成功（９４％），３６例行枕颈融合术的病人中有３２例达到了骨性愈合（８９％）。用头环背心固定的平均时间是１３３天，最长的４５０天。统计学结果显示：用头环背心固定后病人肺活量的均数与固定前相比差异有非常显著性（Ｐ＜０．０１），固定后肺活量减少约１３％。并发症包括颅钉松动（２４例）、钉孔感染（４例）、复位丢失（４例）、颅钉穿透颅骨内板（３例）、背心下皮肤压疮（１例）。作者认为头环背心对颈椎失稳的病人是一种安全、有效的外固定器材。借助这种装置，部分需行颈椎融合术的病人可以免去内固定，使手术更安全、简便。头环背心可使病人的肺活量减少。     

Current controversies in nonoperative management of Type II odontoid fractures in the elderly

The study design was a review of the literature. The objective was to assess the outcomes of nonoperative management of Type II odontoid fractures in the elderly population. Type II odontoid fractures in the elderly population are associated with high morbidity and mortality rates, and the current treatment recommendation is quite controversial. This article reviews the current literature on nonoperative versus operative treatment of Type II odontoid fractures in the elderly population, in hopes of drawing conclusions for the best approach to these patients. MEDLINE and PubMed databases were searched to identify articles. Studies included were those involving elderly patients with Type II odontoid fractures, who were managed nonoperatively. Studies assessing the different methods of operative fixation were excluded. An algorithm taking into account the morbidities associated with the treatment option versus the long-term outcomes in elderly patients with Type II odontoid fractures would be extremely beneficial for spine surgeons to aid in deciding whether or not to operate. Nondisplaced fractures may be appropriately treated nonoperatively in a collar with close follow-up and early mobilization. Halo–vest immobilization should be used sparingly in the elderly population, as it is associated with significant morbidity. Cervical collars appear to have less morbidity than halo–vest immobilization with success in the less displaced fracture patterns. Lastly, operative treatment for displaced, unstable fractures can improve patient outcomes.     

Non-rigid immobilisation of odontoid fractures

Despite various reports on the management of odontoid fractures, there is no consensus on the subject, and the appropriate treatment still remains controversial. While untreated fractures or fractures treated only with a cervical orthosis seem to have the highest rate of non-union, the need for rigid external stabilisation has never been substantiated. In a retrospective analysis we reviewed 26 patients with acute type II and III fractures of the odontoid, treated with a cervical orthosis only. Study inclusion was limited to fractures that had a fracture gap of less than 2 mm, an initial antero-posterior displacement of less than 5 mm and angulation of less than 11 degrees, less than 2 mm displacement on lateral flexion/extension views, and were without neurological deficits. These fractures were defined as stable. There were 19 (73.1%) type II and 7 (26.9%) type III fractures; in 10 (38.5%) of these fractures the odontoid was displaced and/or angulated. The overall complication rate was 11.4% ( n=3). One patient suffered from pulmonary embolism, in two patients (7.7%) with initially minimally displaced fractures, secondary internal stabilisation had to be performed because of persistent instability. In 20 (77%) of the remaining fractures healing was uneventful. In 4 nondisplaced fractures (15%) fibrous union was documented. Three of these patients were over 65 years old. The overall fusion rate was 73.7% for type II and 85.7% for type III fractures. At follow-up 39% of the patients were free of symptoms; however, the clinical outcome did not correlate with the radiological findings. According to our findings, stable type II and type III fractures of the odontoid can be successfully treated with non-rigid immobilisation, even if they are displaced. A thorough assessment of the stability of the odontoid with lateral flexion/extension views or dynamic fluoroscopy is recommended to evaluate the appropriate treatment. Non-rigid immobilisation may be an option in selected cases with stable injuries.     

Caspar plate fixation for the treatment of complex hangman's fractures.

This report details our recent experience with the surgical treatment of complex hangman's fractures after failure of closed reduction and immobilization in external orthosis. We have successfully treated hangman's fractures in 5 patients with anterior Caspar plate stabilization and C2-C3 interbody fusion. The specific anatomical features of these fractures were complex, rendering the spines of the patients highly unstable. The patients were considered surgical candidates when reduction could not be achieved or maintained with axial traction or halo immobilization. Each patient underwent anterior C2-C3 interbody bone fusion and Caspar plating from C2 to C3. All patients achieved adequate intraoperative reduction and were immobilized postoperatively with a halo vest. The follow-up period ranged from 3 to 28 months and provided a 100% fusion rate with no complications related to plating or nonunion. Our initial experience indicates that anterior C2-C3 interbody bone fusion and Caspar plate fixation is a suitable treatment option for patients with complex hangman's fractures who are not successfully managed nonoperatively.     

使用颗粒状自体松质骨植骨的寰枢椎后路融合术

介绍一种在头环背心保护下用颗粒状自体松质骨植骨的寰枢椎后路融合术。对３４例寰枢椎不稳的病人施行了寰枢椎后路融合术。用头环背心维持寰椎的复位，将颗粒状的自体松质骨植于寰椎后弓和枢椎椎板的背面，不用内固定，直至植骨融合。３１例病人获得了随访，平均随访时间３０个月，其中２９例融合成功，术后头不背心固定时间平均为１３周，有３例出现了寰椎再移位。颗粒状自体松质骨比块状的全层骨更有利于融合。用头环背心的外固定     

Odontoid fractures: A retrospective analysis of 53 cases

Background:

The management of odontoid fracture has evolved but controversy persists as to the best method for Type II odontoid fractures with or without atlantoaxial (AA) instability. The anterior odontoid screw fixation can be associated with significant morbidity while delayed odontoid screw fixation has shown to be associated with reasonable good fusion rates. We conducted a retrospective analysis to evaluate the outcome of a trial of conservative management in type II odontoid fractures without atlantoaxial instability (Group A) followed by delayed odontoid screw fixation in cases in which fusion was not achieved by conservative treatment. The outcome of type II odontoid fracture with AA subluxation (Group B) was also analysed where closed reduction on traction could be achieved and in those atlantoaxial subluxations that were irreducible an intraoperative reduction was done.

Materials and Methods:

A retrospective evaluation of 53 cases of odontoid fractures treated over a 9-year period is being reported. All odontoid fractures without AA instability (n=29) were initially managed conservatively. Three patients who did not achieve union with conservative management were treated with delayed anterior screw fixation. Twenty-four cases of odontoid fractures were associated with AA instability; 17 of them could be reduced with skeletal traction and were managed with posterior fusion and fixation. Of the seven cases that were irreducible, the initial three cases were treated by odontoid excision followed by posterior fusion and fixation; however, in the later four cases, intra operative reduction was achieved by a manipulation procedure, and posterior fusion and fixation was performed.

Results:

Twenty-six of 29 cases of odontoid fracture without AA instability achieved fracture union with conservative management whereas the remaining three patients achieved union following delayed anterior odontoid screw fixation. 17 out of 24 odontoid fracture with atlantoaxial dislocation could be reduced on traction and these patients underwent posterior fusion and fixation. Optimal or near optimal reduction was achieved by on table manipulation in four cases which were irreducible with skeletal traction. Atlantoaxial stability was achieved in all cases. All cases were noted to be stable on evaluation with x-rays at six months.

Conclusions:

The initial conservative management and use of odontoid screw fixation only in cases where conservative management for 6–12 weeks has failed to provide fracture union have shown good outcome in type II odontoid fracture without AA instability rates. Intraoperative manipulation and reduction in patients where AA subluxation failed to reduce on skeletal traction followed by posterior fusion obviates the need for transoral odontoid excision.     

Management of odontoid fractures with anterior screw fixation

Type II odontoid fractures are prone to undergo nonunion. Stabilization of such fractures with anterior screw fixation provides rigid internal fixation and preserves C1-C2 motion. During a 5-year period, 17 patients with displaced type II fractures of the odontoid were treated Thirteen were male and four were female with a mean age of 38.2 years. All patients were operated on for anterior screw fixation within a mean of 10.1 days from injury. Postoperatively, the patients were evaluated clinically and radiologically at regular intervals. With a mean follow-up of 3.2 years, union was observed in 16 of 17 patients (94%). One patient developed nonunion for which he required C1-C2 fusion subsequently. Screw back-out by a few millimeters was seen in another patient resulting in mild restriction of neck movements. No approach-related complications were noted. Anterior odontoid screw fixation has relatively low complication and high fusion rates. It not only restores normal anatomy but also gives better functional results by preserving intrinsic C1-C2 motion. Thus it should be considered the treatment of choice in acute displaced type II odontoid fractures.