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A type 2 odontoid fracture in a nine-month-old infant is presented. To the best of our knowledge, this case has the youngest reported patient with this type of injury having occurred by a mechanism other than direct trauma at birth. The purpose of this communication is to review odontoid fractures in the pediatric age group.
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A case of a 19-year-old female with atlanto-axial fusion and dysplasia of odontoid peg in a cleft lip and palate patient is described. Schematic drawings from radiographs were taken to compare six earlier reported cases of anterior atlas arch fusions with epistropheus including dysplasia or aplasia of odontoid peg from literature.
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.
The National Automotive Sampling System (NASS) and Crash Injury Research and Engineering Network (CIREN) databases were used in an analysis of odontoid fracture in motor vehicle crashes. NASS data were evaluated for the years 1996-2002, and CIREN from 1996 to 2003. Out of 58 fractures, 38 were identified in the NASS and 20 in the CIREN databases. There were 3108 weighted cases in the NASS database. Frontal impacts (11:00 to 1:00 h) were most commonly associated with the injury in both databases. Although male and female occupants sustained the injury, females were shorter in stature, older in age, lighter in weight, and crashes were less severe (lower change in velocity) when female occupants were involved in trauma. In both databases, pure odontoid fracture and facet/lamina fracture accounted for approximately one-third of the cases, and a majority of impacts were associated with changes in velocity less than 56 km/h. Although vehicle model years ranged from 1976 to 2002, recent model years were more frequently associated with CIREN data. In the CIREN database, type II odontoid fracture was the most common, but no particular mechanism of injury dominated; such information was not available in the NASS database. To ameliorate odontoid fracture, focus should be on frontal impacts. Because different types of odontoid fracture are not included in the current Abbreviated Injury Scale, appropriate coding schemes should be developed to classify this injury. The CIREN database is unique because it provides important clinical information, i.e., fracture type, and the associated mechanism of injury. The mechanism component in any epidemiologically based injury analyses is valuable to advance improvements in vehicle crashworthiness.
Odontoid fractures account for approximately 20% of all cervical fractures, with the majority being type II fractures according to the Anderson and D'Alonzo classification. The treatment of odontoid fractures is determined by multiple factors, including fracture type, presence of associated injuries, patient age, and patient comorbidities. It is generally well accepted that type I and type III injuries heal well with non-operative treatment. However, some type I injuries can be seen in association with occipito-atlantal dislocation; and some type III fractures can be closer to the neck of the odontoid (high and shallow based), and may act like a type II fracture, that is, with an increased probability of nonunion. The treatment of type II fractures remains controversial. Over the past decade, internal fixation has become an accepted treatment for unstable injuries of the cervical spine. Multiple surgical approaches have been proposed. This article reviews the various alternatives for treating odontoid fractures, attempting to give to the reader a broad perspective on the current techniques, including information taken from evidence-based medicine.
We describe the anesthetic management difficulties of a man with mucopolysaccharidosis I. We also briefly review the anesthesia literature related to this disease.
The use of anterior odontoid screw fixation has grown in popularity for the management of acute, unstable Anderson and d'Alonzo Type II and rostral Type III odontoid fractures. This study critically reviews our clinical experience of 48 patients with single odontoid screw fixation for the treatment of Type II and Type III odontoid fractures between 1997 and 2001. This series had a complication rate of 10% (malposition rate 6% and non-union rate 4%), with a satisfactory overall fusion rate of 96%. Odontoid screw fixation is technically demanding and requires strict patient selection, thorough preoperative planning and careful surgical technique. In our experience, advanced age should not be considered a contraindication to anterior odontoid screw fixation, as satisfactory results can be obtained in some of these patients. This study also emphasises that sagittally oblique type II fractures are associated with a high rate of fusion failure when treated by anterior odontoid screw fixation, and should be treated with other instrumentation methods, such as posterior atlantoaxial arthrodesis.
Crouzon's disease is a well-known disorder affecting multiple organ systems, specifically a craniofacial disorder with highly variable penetrance and severity of deformity. Crouzon's patients typically have anomalies of the skull base leading to gross distortion of the cranium and in some cases the cervicocranium. We present a 5-year-old girl with Crouzon's disease who suffered from an acquired Chiari I malformation after insertion of a ventriculoperitoneal shunt and a coexistent ventral odontoid panus. Both these lesions were causing cervicomedullary compression. The literature is controversial on the surgical management of anterior and posterior compression at the craniocervical junction. We review the literature on surgical options for decompression at the craniocervical junction and offer our surgical case as a treatment option for patients in this rare clinical situation.
BACKGROUND CONTEXT: The classification scheme of odontoid fractures described by Anderson and D'Alonzo is the one most commonly used. However, uncertainty exists in the distinction between Type II and "shallow" Type III fractures. Moreover, fractures at the base of the odontoid (Anderson and D'Alonzo Type II) include a spectrum of injury patterns. PURPOSE: To modify the Anderson and D'Alonzo classification of odontoid fractures based on current clinical treatment options. STUDY DESIGN: Proposal of a modified classification system for odontoid fractures. METHODS: A more precise distinction between Type II and III fractures based on the presence/absence of C1-C2 facet involvement is proposed. A modified classification of Type II fractures based on fracture line obliquity, displacement and comminution is then proposed, because these are factors deemed to influence management. To evaluate the reproducibility of this classification, 52 odontoid fractures were reviewed and classified by four attending spine surgeons and three spine fellows. RESULTS: There was substantial agreement (at least five of seven respondents) in 70% of cases. The overall kappa value for the modified classification system was 0.48, indicating moderate agreement, and there were no differences in kappa values between attending spine surgeons and fellows. CONCLUSIONS: The reproducibility of this system was demonstrated by the moderate agreement observed when applied to odontoid fractures at our institution. The proposed utility of this system is its ability to guide clinical decision making in the treatment of odontoid fractures. Prospective application of this modified classification system and suggested treatment options is now required.
BACKGROUND CONTEXT: In cranio-vertebral junction, retro-odontoid pseudotumor without evidence of rheumatoid arthritis is a rare condition. PURPOSE: To discuss the mechanism of enlarging retro-odontoid pseudotumor after expanding cervical laminoplasty as a predictable complication. STUDY DESIGN: We report a rare case of an elderly man with non-inflammatory retro-odontoid pseudotumor after cervical expanding laminoplasty. PATIENT SAMPLE: A 76-year-old man presented with progressive quadriparesis of two week's duration caused by enlarging retro-odontoid soft tissue mass after cervical laminoplasty. OUTCOME MEASURES: Pre- and postoperative image, including X-ray and MRI, and the Japanese Orthopaedic Association scores for cervical myelopathy were assessed. METHODS: The patient subsequently underwent resection of the posterior arch of the atlas and posterior fusion from the occiput to C6 using Olerud system without removal of the retro-odontoid soft tissue mass. RESULTS: One year after surgery, the Japanese Orthopaedic Association scores for cervical myelopathy improved from 1 to 10 points, and postoperative MRI showed a mild reduction in the size of the retro-odontoid soft tissue mass. CONCLUSIONS: The kyphotic stability from C3 to C7 after laminoplasty, leading to a compensatory hyperlordosis at the occipitocervical junction, may cause the development of a degenerative osteoarthritic change, resulting in the production of an enlarging mass. Not only posterior compression of spinal cord due to posterior arch of the hyperextended atlas but also anterior compression of spinal cord due to retro-odontoid pseudotumor probably triggered the severe myelopathy. Laminoplasty may be inappropriate in cervical myelopathy with kyphosis.
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BACKGROUND: Traumatic hypoglossal nerve palsy is a rare entity and has rarely been described in association with an odontoid fracture. CASE DESCRIPTION: We present a patient with a posttraumatic odontoid fracture who developed selective weakness of his arms and a unilateral hypoglossal nerve palsy. A systematic review of the literature is presented, and hypothetical causes for the injury are discussed. CONCLUSION: Bell's cruciate paralysis and central cord syndrome are probably expressions of the same mechanism rather than 2 separate entities based on a preferential damage of pyramidal crossing arm fibers. C2 fractures with concomitant lower cranial nerve injury are relatively rare and have a reasonably good outcome, especially when unilateral.
BACKGROUND: The combination of odontoid and bilateral transarticular C1-C2 anterior screw fixation is a recent addition in treating C1-type II odontoid fractures. When feasible, it ensures early maximal stability, even if it slightly reduces the mobility of C1-C2 complex. We report a case of combination atlas-type II odontoid fracture that occurred in a 92-year-old man. The instability was treated with odontoid screw fixation and anterior bilateral C1-C2 transarticular screw fixation in a single stage. The aim of the article is to describe the feasibility of "triple" anterior screw fixation in the presence of C1-type II odontoid fracture. METHODS: The diagnosis, treatment, and outcome of a 92-year-old patient with mild tetraparesis caused by C1-type II odontoid fracture were assessed. RESULTS: Cervical x-rays, computed tomographic scan, and magnetic resonance imaging demonstrated a fracture of posterior arch of C1, associated with type II odontoid fracture and with presumable damage of C1 transverse ligament. Magnetic resonance imaging also showed a high cervical centromedullary area slightly hyperintense in T1-weighted images. Treatment consisted of odontoid and bilateral C1-C2 transarticular screw fixation with single anterior approach. The admission neurologic conditions improved and the patient was early mobilized. CONCLUSIONS: The authors suggest that in presence of C1-type II odontoid fracture, the triple anterior screw fixation has to be taken into account as salvage procedure, especially if other methods of stabilization failed or cannot be safely performed. This technique seems to be safety feasible also in old patients, as our report and the experience of others confirm.
Brain abscess after insertion of skull traction is a rare and serious complication. Its development is secondary to superficial infection. Adequate preventive measures have to be taken: proper sterile dressing and daily care. Signs of local irritation are not always synonymous with skull migration. When gradual loosening of the skull occurs, especially associated with superficial infection, the pins must not be tightened. The more appropriate management is to investigate for penetration of the inner cranial cave. When in doubt, repositioning the pins may be necessary, as well as establishing an aggressive treatment against cutaneous infection.
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