Min-invasive surgical treatment for multiple axis fractures: A case report

BACKGROUND Fractures of the axis are commonly seen in spinal injuries. Upper cervical fractures are usually managed conservatively. However, the complications due to long-term external immobilization cannot be ignored. The traditional open surgery has the disadvantages of too much blood loss and soft tissue injury. The aim of our paper is to introduce a minimally invasive surgical treatment for multiple axis fractures.CASE SUMMARY We report a 40-year-old Chinese male who had severe neck pain and difficult neck movement after falling from 3 meters. X-ray and computed tomography(CT) scan revealed an axis injury consisting of an odontoid Type Ⅲ fracture associated with a Hangman fracture categorized as a Levine-Edwards Type Ⅰ fracture. The patient underwent anterior odontoid screw fixation and posterior percutaneous screw fixation using intraoperative O-arm navigation. Neck pain was markedly improved after surgery. X-rays and CT scan reconstructions of 3-mo follow-up showed good stability and fusion. The range of cervical motion was well preserved.CONCLUSION Anterior odontoid screw fixation and posterior direct C2 percutaneous pedicle screw fixation with the aid of O-arm navigation and neurophysiological monitoring can be an interesting alternative option for complicated multiple axis fractures.     

Unsuspected upper cervical spine fractures associated with significant head trauma: role of CT

Several recent studies report the sensitivity of computed tomography (CT) to be far greater than that of traditional plain film radiographic studies for evaluation of cervical spine fractures and spinal cord pathology. Nevertheless, plain films continue to be the standard screening examination. CT is used only if fractures are demonstrated or suspected on plain film survey. Recently, three patients with significant head and neck trauma (all three patients had intracranial hemorrhage) had cervical spine evaluation by computed tomography and standard plain film views. CT demonstrated significant C1-C2 fractures, while plain films were completely normal in all three cases. Prospectively studying the next 50 patients with significant head trauma, we added a few more slices to the routine head scan protocol to cover the first three cervical vertebrae. This added very little time or cost to the procedure. The additional CT images demonstrated four upper cervical fractures that could not be seen on plain films, even in retrospect. Our findings suggest that routine inclusion of the upper cervical spine with head CT is appropriate in the evaluation of patients with significant head trauma as defined by intracranial hemorrhage or skull fracture.     

Are computed tomography scans adequate in assessing cervical spine pain following blunt trauma?

Good quality three-view radiographs (anteroposterior, lateral, and open-mouth/odontoid) of the cervical spine exclude most unstable injuries, with sensitivity as high as 92% in adults and 94% in children. The diagnostic performance of helical computed tomography (CT) scanners may be even greater, with reported sensitivity as high as 99% and specificity 93%. Missed injuries are usually ligamentous, and may only be detected with magnetic resonance imaging (MRI) or dynamic plain radiographs. With improvements in the accessibility of advanced imaging (helical CT and MRI) and with improvements in the resolution of such imaging, dynamic screening is now used less commonly to screen for unstable injuries. This case involves a patient with an unstable cervical spine injury whose cervical subluxation was only detected following use of dynamic radiographs, despite a prior investigation with helical CT. In this way, the use of dynamic radiographs following blunt cervical trauma should be considered an effective tool for managing acute cervical spine injury in the awake, alert, and neurologically intact patient with neck pain.     

What must the family practitioner know about spinal injuries

Spine injuries in a general practitioner's environment are mainly related to osteoporosis fractures in the elderly as well as cervical spine injuries in the elderly especially fractures of the odontoid process that need to be excluded if there is any suspicion. For osteoporotic spine fractures the invention of vertebroplasty offers a new treatment option and therefore patients should be transferred to a spine surgeon for further evaluation. The fracture of the odontoid process can end up in a non-union problem if not treated early; therefore this injury must be excluded in patients after sustaining any head contusion and complaints of neck pain afterwards.     

Occipital condyle fracture in a victim of a motor vehicle collision

Occipital condyle fractures are rarely reported in the Emergency Medicine literature. It is unclear whether these fractures are rare or under-diagnosed. Occipital condyle fractures are associated with high-energy blunt trauma with significant cranial-cervical torque or axial loading. We report a case of a female patient with an occipital condyle fracture. The patient only complained of shoulder pain, but was found to have high cervical spine tenderness, after a moderate-speed front-end motor vehicle collision. Initial cervical spine radiographs were non-diagnostic. Computed tomography of the cervical spine demonstrated a non-displaced occipital condyle fracture. Conservative management with a semi-rigid cervical collar was successful in treating this patient's fracture. A review of the literature covers the diagnosis, radiographic findings, and management of this fracture.     

Trauma radiology: Part V. Imaging of acute cervical spine trauma

Cervical spine injury constitutes a major cause of morbidity resulting from trauma. The consequences of a missed "significant" injury can be devastating for the patient and can create potential medical legal consequences for involved physicians. Multiple imaging modalities can be applied to imaging of the cervical spine after trauma, including radiography, computed tomography (CT), myelography, CT myelography and magnetic resonance imaging (MRI). Controversy exists concerning the appropriate number of radiographic views required for the screening assessment of cervical spine injuries. CT clarifies uncertain radiological findings, identifies subtle fractures in patients with neck pain or with neurological deficits but with normal radiographs, determines details of injury, and assists in operative planning. MRI has virtually replaced myelography and CT myelography in evaluating the traumatized cervical spine. MRI is more accurate than CT with intrathecal contrast in delineating epidural pathology, ligament injury, soft-tissue edema, and cord parenchymal injury. Information derived from MRI guides appropriate management and has value in predicting injury outcome. We consider indications for and relative merits of these various diagnostic modalities, and we describe imaging features of major patterns of cervical spine injury.     

Delayed Subluxation of an Occult Traumatic Odontoid Fracture in an Elderly Patient

The issue of whether a traumatic but occult cervical spine fracture can exist has generated significant debate in emergency medicine. The profound clinical and legal implications of missing an unstable cervical spine injury are well known to the emergency care provider. An elderly patient who satisfies all of the rigorous criteria for this type of injury is discussed. The patient experienced delayed subluxation of her acute odontoid fracture during a flexion/extension examination completed in the ED, with resultant development of cervical discomfort. Elderly victims of trauma with an appropriate mechanism of injury should be suspected of subtle or occult neck injuries.     

Utility of flexion–extension radiography for the detection of ligamentous cervical spine injury and its current role in the clearance of the cervical spine

Detecting the presence of injuries to the cervical spine is an important component of the initial assessment of patients sustaining blunt trauma. A small proportion of cervical spine injuries consists of ligamentous disruption. Accurate detection of ligamentous injury is essential as it may result in sequelae including radiculopathy, quadriplegia and death. Flexion–extension (FE) radiography has traditionally been utilised for the detection of ligamentous injury in patients who have been cleared of bony injury. There are controversies surrounding the use of FE for alert patients with neck pain. There are studies that call into question the diagnostic accuracy of FE, the high proportion of inadequate FE images due to muscle spasm and the adverse effects of prolonged cervical collar immobilisation while awaiting FE. Other literature indicates that FE provides no additional diagnostic information following a multi‐detector helical computed tomography. This review evaluates the literature on the utility of FE for the detection of ligamentous injury and explores alternate strategies for clearing the cervical spine of ligamentous injury.     

Surgical treatment of acute type II and rostral type III odontoid fractures managed by anterior screw fixation

OBJECTIVES: In the present study, the authors comment on their experience with anterior odontoid screw fixation in the management of odontoid fractures, in an attempt to further assess the safety and the efficacy of this procedure. MATERIALS AND METHODS: A retrospective analysis of 50 consecutive patients with reducible type II or rostral type III odontoid fractures, operated at our hospital with anterior odontoid screw fixation. Radiographic bony fusion, complications, and clinical outcome were evaluated. RESULTS: Solid bony fusion was evident in 38 (90.5%) of the patients. One mechanical instrumentation-related complication occurred, without clinical significance. No other major complications related to the procedure were noted. A satisfactory range of motion in the cervical spine was observed in all patients. CONCLUSIONS: Anterior odontoid screw fixation is a safe and effective procedure for the treatment of type II and rostral type III odontoid fractures. Compliance to the specific indications and contraindications of this operation is crucial for optimal outcome.     

Cervical spine clearance and neck extension during percutaneous tracheostomy in trauma patients

INTRODUCTION: The lack of cervical spine clearance and inability to extend the neck are assumed to be relative contraindications for percutaneous tracheostomy. OBJECTIVE: To determine the necessity of cervical spine clearance and neck extension in trauma patients receiving percutaneous tracheostomy. DESIGN: Prospective analysis of case series from August 1, 1995 to August 31, 1998. SETTING: A university-based Level I trauma center. PATIENTS: A total of 88 consecutive trauma patients receiving percutaneous tracheostomy. Patients were divided into two groups based on the radiographic or clinical status of their cervical spine: cleared and noncleared. RESULTS: The overall success and complication rate were 99% (87/88) and 11% (10/88), respectively. There were no procedure-related deaths. The cleared group consisted of 60 patients; three patients in this group who had "bull" or "thick" necks did not have full neck extension during percutaneous tracheostomy. The noncleared group consisted of 28 patients, 13 of which had known cervical spine fractures; 27 noncleared patients were maintained in the neutral position (no extension) during percutaneous tracheostomy, whereas one patient with low suspicion of spinal injury was partially extended. Of the 13 patients with cervical spine fractures, six patients had been stabilized with a halo or operative fixation, and seven patients were stabilized with a cervical collar at the time of percutaneous tracheostomy. The success rate was 100% (60/60) for the cleared group compared with 96% (27/28) for the noncleared group (p > .05). The complication rate was 13% (8/60) for the cleared group compared with 7.1% (2/28) for the noncleared group (p > .05). We had a 100% success rate and no complications in the seven patients with cervical spine injury who were stabilized with a cervical collar. No patient had spinal cord injury caused by percutaneous tracheostomy. CONCLUSION: Percutaneous tracheostomy can be safely performed in trauma patients without cervical spine clearance and neck extension, including patients with stabilized cervical spine or spinal cord injury.     

Isolated Retrodental Epidural Hematoma Without Dens Fracture

BackgroundTraumatic spinal epidural hematomas (TSEDH) are rare, with the reported incidence being < 1% of all spinal injuries. Causes of TSEDHs include vertebral fractures, obstetrical birth trauma, lumbar punctures, postsurgical bleeding, epidural anesthesia, and missile injuries. The retrodental location has not been reported as a location for spontaneous epidural hematoma.Case ReportA 4-year-old boy was admitted to our Emergency Department after falling down and experiencing head trauma. Glasgow Coma Scale score was 15/15 with no neurologic deficit. Brain computed tomography scan showed isolated hyperdense hematoma in the retrodental area without any fractures in the skull or cervical vertebrae. Brain and cervical magnetic resonance imaging showed a retrodental acute hematoma that was isointense in T1-weighted sequences and hypointense in T2-weighted sequences. The hematoma was in the epidural space with possible odontoid process intracapsular origin.Why Should an Emergency Physician Be Aware of This?Isolated retrodental epidural hematoma without dens fracture is an extremely rare pathology and finding, and to the best of our knowledge, this is the first case to be reported in the literature. Emergency physicians should consider this pathology for any patients presenting for head trauma with head hematoma.     

Is the anteroposterior cervical spine radiograph necessary in initial trauma screening?

The usefulness of the anteroposterior (AP) radiograph of the cervical spine in contributing to the diagnosis of cervical spine injuries in the acute trauma patient was examined in a retrospective study. All cases of cervical spine fracture or dislocation seen at a level I trauma center over a 3-year period and at a rehabilitation center over a 10-year period were reviewed. The lateral radiograph, open-mouth odontoid radiograph, and AP radiograph of each case were sequentially examined by a neuroradiologist (blinded to the original diagnosis) to determine the contribution of each view in making a diagnosis of cervical spine injury. Results of these reviews showed that there were no cases of cervical spine injury evident on the AP view without an obvious corresponding abnormality on the lateral or open-mouth view. It was concluded that the AP view could be dropped from the initial screening radiographic study of the cervical spine in the trauma patient. Only an adequate lateral view and open-mouth odontoid view would then be necessary to initially evaluate the cervical spine in the trauma patient, and decisions to obtain further studies could be based safely on only the lateral and open-mouth views.     

Clearance of the cervical spine in multitrauma patients: The role of advanced imaging

The cervical spine is injured in 3% of major trauma patients. Radiographic clearance for injury must be provided efficiently and accurately. There are numerous choices for clearance that are now in clinical practice: lateral radiograph only, 3-view or 5-view cervical-spine (c-spine) series, flexion-extension radiographs, computed tomography (CT) with multiplanar reformations, and magnetic resonance imaging (MRI). This article reviews the literature on methods of c-spine clearance, and emphasizes the pitfalls of each modality. Although lateral radiographs detect 60% to 80% of c-spine fractures, a significant number of fractures are not visible, even when three views of the spine are obtained. The sensitivity of plain radiographs can be improved by attention to several subtle features, which are discussed. Flexion-extension radiographs in the acute setting have an unacceptably high false-negative and false-positive rate. CT detects 97% to 100% of fractures, but its accuracy in detection of purely ligamentous injuries has not been documented. Furthermore, CT is limited in patients with severe degenerative disease. MRI is highly sensitive in the detection of ligamentous injury, but not all cases of injury may cause instability. MRI is also much less sensitive than CT to fractures of the posterior elements of the spine, and to injuries of the craniocervical junction. The causes of missed cervical spine injury and delayed instability are discussed and shown in this article. An algorithm for the use of advanced imaging is proposed.     

Fractures of the axis: a review of pediatric,adult, and geriatric injuries

Fractures of the second cervical vertebra (C2, axis) are common in adult spine surgery. Those fractures occurring in younger adult patients are often associated with high-energy mechanism trauma, resulting in a “Hangman’s Fracture.” Management of these fractures is often successful with nonoperative means, though surgery may be needed in those fractures with greater displacement and injury to the C2-C3 disc. Older patients are more likely to sustain fractures of the odontoid process. The evidence supporting surgical management of these fractures is evolving, as there may be a mortality benefit to surgery. Regardless of treatment, longer-term mortality rates are high in this patient population, which should be discussed with the patient and family at the time of injury. Pediatric patients may suffer fractures of the axis, though differentiation of normal and pathologic findings is necessary and more difficult with the skeletally immature spine.     

Missed cervical spine fracture-dislocations: the importance of clinical and radiographic assessment

OBJECTIVE: To review the case of a patient who suffered a cervical spine fracture-dislocation missed at a hospital emergency department. CLINICAL FEATURES: A 77-year-old man involved in a motor vehicle accident was transported to a local emergency hospital where cervical spine x-ray films taken were reported as demonstrating no evidence of acute injury. The patient visited a chiropractic clinic 6 days later, where x-ray films were again obtained, finding that the patient sustained fractures of C5 and C6, as well as a bilateral facet dislocation at C5/C6. Computed tomography confirmed the fractures, and magnetic resonance imaging findings demonstrated cervical spinal cord compression and posterior spinal cord displacement. INTERVENTION AND OUTCOME: The patient was referred for preoperative medical evaluation. He underwent C5-6 closed reduction and anterior/posterior fusion surgery and was released without complication. Patient follow-up indicated full recovery with minimal neurologic symptoms. CONCLUSION: Cervical spine fracture-dislocations are often missed during standard radiographic examinations in emergency department settings. Chiropractors are encouraged to perform a comprehensive evaluation of patients presenting with cervical trauma even if they have had prior x-ray films reported as normal. Standard x-ray films taken at emergency department facilities are not entirely reliable for detecting or revealing cervical spine fracture-dislocations. This case stresses the importance of careful clinical assessment and imaging procedures on patients who have encountered cervical spine trauma.     

颈椎前路单枚空心螺钉置入治疗II型齿状突骨折

背景：齿状突骨折前路加压螺钉内固定治疗后可以获得较高的愈合率,并且最大限度的保留寰枢椎间的活动功能. 目的：分析颈椎前路加压螺钉内固定治疗Ⅱ型齿状突骨折的疗效以及并发症. 方法：收集2002年8月至2012年12月上海交通大学医学院附属第三人民医院骨科经前路单枚空心螺钉内固定治疗的齿状突骨折患者,选取48例患者在C型臂X射线机监视下行前路单枚加压螺钉内固定治疗新鲜Ⅱ型齿状突骨折,进行回顾性分析.通过内固定治疗前后以及末次随访时的体格检查,拍摄患者上颈椎正侧位及张口位X射线片,评价并分析其治疗后疗效以及并发症情况. 结果与结论：患者在颈椎前路单枚空心螺钉置入内固定治疗后进行随访,随访时间6-47个月,平均13.4个月.有7例患者发生并发症,吞咽困难3例,经3-6个月随访治愈,螺钉松动3例,经延长外固定时间后治愈,不愈合患者1例,二期行后路寰枢椎融合固定后治愈,其余患者均获得良好骨愈合,愈合后寰枢椎旋转功能无明显受限.颈前路单枚空心螺钉固定治疗Ⅱ型齿状突骨折并发症低,骨折愈合率高,功能恢复好.严格选择适应证、内固定治疗中精细操作,是避免并发症出现的关键.     

The modified odontoid view: an alternative visualization of the atlantoaxial joint

The sensitivity of the cross table lateral view (CTLV) alone, as a determinant in the radiographic disposition in patients with cervical spine fracture/dislocation has been challenged. A cervical spine trauma series that includes the CTLV, the anteroposterior view (APV), and the open-mouth view (OMV) has been suggested. Whereas the CTLV and APV present no difficulty, the OMV is often not possible in the uncooperative or unconscious patient, or in those patients with rigid forms of neck support. The modified odontoid view (MOV) can replace the OMV in these patients. The MOV allows for satisfactory visualization of the C1/C2 complex and is easily obtained as a portable technique. In addition, it requires neither patient cooperation nor neck movement. The technique is described and its interpretation reviewed.     

数字化颈前路螺钉内固定方案设计：Ⅱ型齿状突骨折的临床应用

背景：Ⅱ型齿状突骨折的治疗存在难度大、风险高以及颈椎稳定性和颈椎活动度之间的选择难点。目的：探讨计算机软件应用于Ⅱ型齿状突骨折三维重建、复位以及数字化内固定设计的方法和临床应用。方法：将1具颈椎标本制作成Ⅱ型齿状突骨折类型,进行高速CT薄层扫描,在Mimics中对骨折模型进行重建、复位,以Solidworks进行螺钉的设计,并在骨折复位三维模型上进行虚拟内固定,以此指导临床。结果与结论：对骨折标本模型进行了三维重建、复位,根据三维模型测量数据,完成虚拟螺钉内固定,并成功指导临床手术。结果显示,应用Mimics及Solidworks可在计算机上设计出用于治疗Ⅱ型齿状突骨折的数字化螺钉固定,对临床手术有很好的参考意义。     

Clinical decision rules and cervical spine injury in an elderly patient: a word of caution

We report a case of a clinically significant cervical spine fracture in an elderly patient without midline cervical tenderness. Application of the NEXUS rule by the treating physicians ruled out the need for radiography. However, knowledge of the Canadian C-spine rule and clinical judgment prompted obtaining a three-view trauma series of the cervical spine and, when the patient’s pain increased, a computed tomography scan of the cervical spine. A type III fracture of the dens was found. In review of the case it was recognized that application of the NEXUS rule for this patient was problematic regarding the assessment of mental status. Specifically, the treating physicians did not strictly adhere to the detailed explanations attached to the NEXUS criteria regarding mental status. Clinicians may wish to preferentially apply the Canadian rule for patients over the age of 64 years.     

Best Practice in Diagnostic Imaging after Blunt Force Trauma Injury to the Cervical Spine: A Systematic Review

IntroductionThe aim of this study was to investigate best practice in evidence-based clinical examinations to determine the diagnostic efficacy of plain radiography, computed tomography (CT), and magnetic resonance imaging (MRI) of a cervical spine injury after blunt force trauma.MethodsA systematic review of recent literature was performed, with the intention of analysing only original research articles focusing on at least two imaging modalities or clinical decision guidelines in relation to blunt force trauma injuries involving the cervical spine. The search used the following databases: ProQuest Central, ScienceDirect, and Scopus. A total of 18 studies were identified as suitable for review; these were further supported by relevant secondary studies.ResultsIt was found that the National Emergency X-Radiology Utilization Study and the Canadian C-Spine Rule are both highly sensitive methods for screening patients after cervical spine injuries. CT was shown to have a higher validity than plain radiography and MRI for the detection of a bony cervical spine injury. MRI is recommended for obtunded or unevaluable patients with suspected neurologic deficit.ConclusionsOverall, the literature appears to suggest that individuals with a suspected high risk of injury after examination using clinical decision rules should undergo a cervical CT examination. For patients who are found to have a low risk of injury after clinical decision guidelines, good-quality plain radiography is recommended as sufficient.