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PubMed1994

[Surgical management of a dens fracture in a 3-year-old child. Clinical case report and discussion with reference to the literature].

Because of the special features of subdental synchondrosis, fracture of the odontoid process in childhood can be seen as a separate entity. Among the rare fractures of the cervical spine in children this type is the most common. Ontogenetically, the subdental synchondrosis must be regarded as an intervertebral disc and not as a growth plate. Usually conservative treatment with a halo fixateur or minerva jacket leads to consolidation. We report on the case of a 3-year-old boy with a fracture of the odontoid process who was treated operatively with anterior log screw fixation because of extensive anterior dislocation and tetraplegia. Five months after the operation bony consolidation was achieved and the screws could be removed. Full neurological recovery had occurred by this time.

Bone Screws↗
PubMed1979

Paget's disease and the nervous system.

Paget's disease usually is found in patients past the age of 40. Early presenting symptoms include headache, deafness, tinnitus, and pain due to radicular compression. The diagnosis is confirmed by radiographic features and elevated levels of serum alkaline phosphatase and urinary hydroxyproline. Bony overgrowth results in pressure on nearby soft tissues such as the brain, spinal cord, and certain peripheral nerves. The abnormally soft quality of the calvarial bone permits distortion by the weight of the brain. Dorsal inclination of the plane of the foramen magnum and the projection of the odontoid process into the posterior fossa lead to stretching of the brain stem over the odontoid process and the ventral margin of the foramen. Obstructive hydrocephalus may result. Sarcoma of the crainial vault may develop in cases of Paget's disease. Once cervicomedullary or spinal compression has occurred, surgical decompression may be necessary. Three drugs--calcitonin, disodium etidronate, and mithramycin--have been used with some benefit in the treatment of Paget's disease.

Adult↗
PubMed1994

[Injuries of the dens axis in childhood. Biomechanical analysis and surgical and conservative treatment of 2 cases].

Odontoid "fractures" in children are in fact typical lesions of the cartilaginous plate ("synchondrosis") separating the odontoid process from the body of the axis, 54 cases of which have been described in the literature so far. In our review we report about two 2-year-old children who were back-seat passengers restrained by four-point children's seat belts, in a car involved in a head-on motor vehicle accident. According to the accident research unit of our institution, trauma sustained in such circumstances is adequate for the causation of odontoid lesions in healthy children. Head-on collisions at a speed absorption of at least 40 km/h is described as a typical mechanism of such injury. Both children were immediately symptomatic, and the diagnosis was easily made from the X-rays. Neither child had neurologic deficits, which is in keeping with the literature, where neurologic injuries were found to have been reported exclusively in conjunction with head injuries. After closed reduction, conservative treatment was initiated in one child, in whom the extent of the anterior dislocation was smaller than the diameter of the odontoid shaft. In cases of major dislocation and more pronounced instability we recommend primarily open reduction and osteosynthesis with adequate implants. Our second case was treated with a halo fixator and a plaster vest for 12 weeks, but despite anatomic reduction there was no healing of the odontoid process. After temporary posterior fusion of C1/C2 we reamed the synchondrosis from an anterior approach and performed autogenous bone grafting. The posterior cerclage wire was removed after 5 months.(ABSTRACT TRUNCATED AT 250 WORDS)

Accidents, Traffic↗
PubMed1997

[Injury of the dens axis in early childhood. Clinical case report and discussion].

Because of the special features of the subdental synchondrosis, fractures of the odontoid process in childhood can be seen as a separate entity. The subdental synchondrosis must be regarded as sort of an intervertebral disc and not as a growth plate. Among the generally rare fractures of the cervical spine in children this type ist the most common. Usually conservative treatment with a cast-fixation like the halo fixateur or the minerva jacket leads to consolidation. We report on the case of a 2-year-old girl with a fracture of the odontoid process who developed a unilateral syndrome hours after the accident. The treatment was conservative with a halo-like cast fixation. Nine weeks after the fixation bony consolidation was achieved and the cast could be removed. In the first days after fixation full neurological recovery had occurred. In early childhood (till the 7th year of life) according to the literature, patterns of neurologic dysfunction are incomplete injuries of the spinal cord and have the potential for recovery [4, 5, 7, 9, 10, 12].

Child, Preschool↗
PubMed2002

Endoscopic endonasal approach to the ventral cranio-cervical junction: anatomical study.

OBJECTIVE: In order to develop an endoscopic endonasal approach to the ventral cranio-cervical junction and odontoid process under the concept of a minimally invasive surgical strategy, a cadaver study was performed. METHODS: Sixteen artery-injected adult head specimens were used. Endonasal endoscopic approach was made through one- or two-nostril routes following the Jho's endonasal paraseptal technique. Rod-lens endoscopes, which were 2.7 or 4 mm in diameter, 18 cm in length with 0-, 30-, and 70-degree lenses, were used. RESULTS: Surgical landmarks leading to the craniocervical junction were the inferior margin of the middle turbinate, nasopharynx and Eustachian tube. The nasopharynx was readily identified following the inferior margin of the middle turbinate. The line drawn between the Eustachian tubes indicated the juncture between the clivus and atlas. With a midline mucosal incision, the ventral cranio-cervical junction was exposed. Odontoid resection was performed with removal of the anterior arch of the atlas. Clival resection can be performed as much rostral as required. Maneuverability of the surgical instruments was better with a two-nostril technique than with a one-nostril. Although the entire midline clivus was accessible rostrally, C-2 was the caudal limit through this endonasal route. A suturing device needed to be developed for mucosal or dural closure for live operations. CONCLUSION: This cadaver study demonstrates that an endoscopic endonasal approach to the ventral cranio-cervical junction and odontoid process can be a valid alternative to the conventional transoral approach.

Cranial Fossa, Posterior↗
PubMed1999

Shear fracture through the body of the axis vertebra.

STUDY DESIGN: Three cases of a previously undescribed body fracture of the axis vertebra are presented. OBJECTIVES: To describe the radiographic features of the fracture are described, and to point out the differences to other axis body fractures regarding the mechanism of injury, stability, and treatment. SUMMARY OF BACKGROUND DATA: Fractures involving the odontoid process usually are caused by indirect forces, and they are considered unstable injuries. Anderson and D'Alonzo Type III odontoid fractures usually are hyperflexion injuries. Superior articular process fractures with or without associated odontoid peg fractures are caused by lateral hyperflexion injuries. METHODS: Three cases of body fractures of the axis vertebra are described. These fractures occur in an oblique plane shearing off in one piece the odontoid process together with one of the superior articular processes. The fragment displaces anterocaudally, and the odontoid process tilts toward the affected side. RESULTS: All fractures were managed nonsurgically. The two displaced fractures did not reduce in traction, and they had united in the displaced position after the 12 weeks of halo treatment. One patient reported only minor problems, but showed radiologic evidence of facet joint arthritis at 20 months. The second patient was lost to follow-up after discontinuation of halo treatment at 12 weeks. The only undisplaced fracture was managed in a halo body jacket for 10 weeks. The patient was pain free and had regained a full range of movement at 7 months. CONCLUSIONS: The presumed mechanism of injury in the described fracture is one of asymmetrical axial compression. The fracture can be managed safely in a halo jacket.

Adolescent↗
PubMed1982

[Post-traumatic instability between the atlas and the axis in children. Apropos of 5 cases].

The authors have observed 5 cases of atlanto-axial instability in children aged from 18 months to 8 years. All the cases were seen after severe trauma and presented with abnormal neurological signs. All patients were first treated conservatively and were operated on secondarily by atlanto-axial fusion using graft and wiring for persistent radiological instability between the atlas and axis. In two cases instability was due to an atlanto-axial subluxation with rupture of the transverse ligament; one of these was reduced by traction. In one case there was an anterior subluxation without fracture. In one case there was a fracture of the odontoid process in which instability persisted in spite of bony union of the fracture. In the last case, the odontoid process was intact shortly after the trauma but its central portion disappeared secondarily. The cause of this disappearance is discussed.

Atlanto-Axial Joint↗
PubMed1990

[Magnetic resonance imaging of rheumatoid pannus in cranio-vertebral synovial joints--report of an operated case].

MRI imaging can provide useful informations as to the status of the brain stem and spinal cord in patients with rheumatoid cervical spine disease. Especially MRI made it possible to visualize the soft tissue mass in the cranio-vertebral joints. However, as far as we know, there is no report describing the pathology of the soft tissue mass diagnosed by MRI. We would like to report an operated case of RA, showing that the soft tissue mass was verified as the so-called rheumatoid pannus in the field of pathology. A 67-year-old woman was admitted to our hospital because of tetraparesis and anterior limitation of neck movements. She had been suffering from rheumatoid arthritis for 17 years. On admission, her consciousness was alert. Cranial nerves were normal except for swallowing disturbance, hoarseness, weakness of neck and tongue muscles. Muscle weakness with atrophy was observed on both upper and lower extremities. Pain and touch sensations were involved below the C3 spinal levels. Laboratory examination showed mild degree of anemia, positive RA test and 40 times value of antinuclear antibody. Brain CT and cerebro-spinal fluid were normal. X-ray of cranio-vertebral joints showed erosive and sclerotic changes of the atlas and odontoid process. Metrizamide CT myelography revealed that C1 spinal cord or medulla was compressed and flattened. A soft tissue mass surrounding the odontoid process was revealed by MRI with Toshiba 0.15 tesla apparatus, showing low signal intensity on T1 image, and low and partially high signal intensity in T2 image. The first operation was done with laminectomy and posterior fusion of occipital bone and C2 spinal process.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1985

Craniofacial and mucopolysaccharide abnormalities in Kniest dysplasia.

Serial roentgencephalograms of a male patient with Kniest dysplasia were obtained between 1 7/12 and 11 3/12 years of age and were analyzed and compared to cephalometric normative data. The patient displayed macrocephaly with increased size of the neurocranium in all three dimensions. The cranial base angle was significantly flattened, partly as a result of anterior displacement of the sella turcica. The odontoid process was short and wide. At 11 years of age there was bony fusion between the anterior arch of the atlas and the odontoid process as well as between the posterior arch of the atlas and the cranial base. The facial skeleton, including the nasal bones, infra-orbital rims, maxilla and mandible, was retropositioned relative to the anterior cranial base. The mandibular retrognathia was pronounced at an early age but improved with growth. At age 11 years the patient had a straight facial skeletal profile. Examination of the patient's 24-hour urinary excretion of keratan sulfate revealed values markedly elevated for his age. Three additional patients with Kniest dysplasia demonstrated similarly increased excretion of this glycosaminoglycan. The diagnosis of Kniest dysplasia can usually be made from roentgenograms of the extremities, the spine, and the pelvis. However, the morphologic characteristics of the head, as shown by cephalometric analysis, and the increased urinary excretion of keratan sulfate add confirmatory evidence useful in differential diagnosis.

Cephalometry↗
PubMed1983

Fractures of the arches of the atlas: a study of their causation.

The autopsy findings in 32 accidental deaths which showed fracture(s) of the arches of the atlas have been correlated to reconstructions of the course of events in the accidents. Flexion of the head causing fracture(s) of the neural arch or odontoid process of the axis also resulted in fracture(s) of the posterior arch due to downward traction. Extension of the head causing fracture of the odontoid process of the axis gave rise to fractures of the posterior arch due to pressure from below. Tilting of the head caused marginal fractures of the anterior arch due to oblique traction. Tilting of the head also caused fracture(s) of the anterior and/or posterior arch due to transverse extension of the atlas ring and/or superior dislocation of one lateral mass in relation to the other. Oblique flexion or extension of the head resulted in similar fractures. Flexion of the head with some rotation combined with compression of the neck can cause the anterior margin of one upper joint surface of the axis to act as a wedge separating the anterior arch of the atlas from below. Extension of the head with some rotation combined with compression of the neck can lead to a fracture running through one lateral mass due to its tilting-dislocation in posterior direction. It is striking that there was no fracture of the atlas which could be ascribed to a simple and symmetric compression of the neck (classical Jefferson's fracture).

Accidents, Traffic↗
PubMedDate not supplied

MR imaging of the cervical spine in rheumatoid arthritis.

The cervical spine was examined with MR imaging and conventional radiography in 23 patients with severe rheumatoid arthritis. All patients had neck pain and 17 also had neurologic symptoms. MR provided detailed information about soft-tissue lesions, vertebral dislocation, and narrowing of the spinal canal. Pannus surrounding the odontoid process was revealed in 14 patients, all with horizontal atlantoaxial subluxation. Compression of the medulla and/or spinal cord, caused by dislocated vertebrae and/or the soft-tissue mass around the odontoid process, was seen in 15 patients. When there was more than one dislocation the most important level could be determined. Posterior occipitocervical fusion had been performed in six of the patients, and in only two of these was adequate analysis of the upper cervical spine impossible because of artifacts from metal (stainless steel wires and pins). Sagittal MR in the neutral position combined with conventional radiography, including lateral views in flexion and extension, provided all the information necessary for further clinical management of rheumatoid arthritis of the cervical spine.

Adult↗
PubMed1984

[Treatment of fresh fractures of the dens axis by compression screw osteosynthesis].

Today most fractures of the odontoid process are treated conservatively. In 32% a bony stabilization is not achieved. Therefore each third has to have a secondary operation, because the only life-threatening psuedoarthrosis is one in the odontoid process of the axis. For this reason the question is repeatedly raised, whether better results will be achieved by on early primary operation. The advantages of the compression-screw osteosynthesis are compared with the well-known operative procedures. The operative management is described. An illustrative case in regard to diagnostic operation and follow up study is described.

Axis, Cervical Vertebra↗
PubMed1982

[Atlantoaxial dislocation in neurofibromatosis.--Report of three cases--].

Atlantoaxial dislocation has received little attention in many studies of spinal deformity in neurofibromatosis. The only four cases of atlantoaxial dislocation associated with neurofibromatosis has been previously reported in the literature. We reported three rare cases of atlantoaxial dislocation associated with neurofibromatosis. These characteristics in roentgenogram were as follows; (1) marked narrowing of sagittal diameter at C1 level without instability (instability index 0%) (2) association with other mesodermal dysplasia, such as posterior vertebral body scalloping, vertebral body dysplasia, dural ectasia etc. Neurofibromatous tissue was found around the anterior region of the odontoid process in one of our three patients. We speculate that atlantoaxial dislocation in neurofibromatosis may be due to mesodermal dysplasia. On the other hand, a neurofibroma was found around the anterior region of the odontoid process in our third case. Therefore, there is a possibility that atlantoaxial dislocation in the instance was caused by the neurofibroma involving transverse atlantal ligament.

Adult↗
PubMed1977

An unusual atlanto-axial dislocation. Case report.

A case is presented in which the patient sustained a complete dislocation of the odontoid process in front of the anterior arch of the first cervical vertebra. There was no fracture of the arch of C-1 vertebra. The patient was treated successfully by trans-oral excision of the odontoid process and the anterior arch of C-1. Twenty days later the patient's spine was stabilized posteriorly at C-1 through C-3 with wire and methyl-methacrylate.

Aged↗
PubMed1998

Cervical ecchordosis physaliphora: CT and MR features.

We report a case of cervical ecchordosis physaliphora in an elderly man who presented with hemihypoaesthesia and contralateral hemiparesis. MRI showed a well defined, non-enhancing extradural mass lesion on the dorsal surface of the odontoid process of the axis. The lesion was of intermediate signal intensity on T1 weighted images and of low signal intensity on T2 weighted images. CT showed a small bony defect on the adjacent cortex of the odontoid process. Recognition of the imaging features of ecchordosis physaliphora is helpful in suggesting the diagnosis and differentiating the lesion from chordoma.

Aged↗
PubMed1996

Periodontoid calcium pyrophosphate dihydrate deposition disease: "pseudogout" mass lesions of the craniocervical junction.

Between 1984 and 1996, seven patients with symptomatic masses located posterior to the odontoid process and containing calcium pyrophosphate dihydrate crystals were evaluated by the senior author (A.H.M). All patients presented with distal paresthesias and myelopathy and underwent transoral-transpharyngeal resection of the anterior arch of C-I, the odontoid process, and the compressing mass. Histological examination revealed the characteristic changes of calcium pyrophosphate dihydrate (CPPD) deposition disease, with nodular deposits of birefringent rhomboid crystals. On magnetic resonance imaging, the masses appeared predominantly isointense with neural tissue on T1-weighted images and iso-to hyperintense on T2-weighted images. On computerized tomography scans, small area of calcifications within the masses were apparent in all cases. All patients improved postoperatively, with six of seven patients requiring posterior fixation for instability as a second procedure. Calcium pyrophosphate dihydrate deposition causing periodontoid mass lesions is a distinct clinical disease entity that probably is underdiagnosed. In the authors' l opinion, the diagnosis can often be established preoperatively by the distinctive neuroradiological appearance of the masses. Therefore, CPPD deposition disease should be considered in the differential diagnosis of masses of the craniocervical junction, because it is amenable to early surgical intervention. The consulting neuropathologist should be made aware of this diagnostic possibility at the time of surgery.

Aged↗
PubMed1982

Odontoid fractures. A rational approach to treatment.

Twenty-three adults with fractures of the odontoid process are reviewed. Te possible reasons for the high rate of non-union in reported series are considered: these include the type of fracture, its displacement, the presence of a gap at the fracture site, imperfect reduction and inadequate immobilisation. Type 2 fractures (at the base of the odontoid process) are the commonest and also the most liable to nonunion. In their treatment, reduction is important; as seen in the lateral radiograph at least two-thirds of the fracture surfaces should be in contact. Skull traction is not advised and halo-cast fixation is the treatment of choice; with this method 87.5 per cent of recent odontoid fractures united.

Adult↗
PubMed1984

Microscopic decompression of the anterior upper cervical spine: a case of odontoid malunion to the atlas.

For the past 20 years, the transoral approach to the upper cervical spine has been utilized for odontoid fractures, the removal of an abnormal odontoid process, decompression of basilar impression, and biopsy or resection of nasopharyngeal or metastatic tumors. The effectiveness and safety of this procedure is well documented. Use of the surgical microscope adds to the efficiency and safety of the procedure. We are reporting a case of fusion of the odontoid base to the anterior arch of the atlas. To our knowledge, this entity has not been described previously. The spinal cord was protected by an initial posterior fusion of C-1, C-2, followed in 10 days by a tracheostomy and the transoral removal of the anterior C-1 arch and the abnormal dens. Because the medical history did not reveal a source of trauma, it is supposed that the patient had malunion of the odontoid process to C-2, with subsequent migration and fusion of the dens to the C-1 arch.

Axis, Cervical Vertebra↗