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PubMed2006

Clinical and radiological findings after different treatment of odontoid fractures type Anderson II and III.

PURPOSE OF THE STUDY: In the period from 06/00 to 08/02, 31 patients with odontoid fractures type Anderson II and III were treated and stastically recorded. 25 patients were followed up; the progess of 24, documented in detail radiographically, were evaluated independently by a traumatologist and by a radiologist. The usual time of immobilization when treating odontoid fractures type Anderson type II and III with the halo-fixator is 12 weeks. For this 12 weeks that it is worn, objective assessment of bone healing is performed radiographically and the results critically considered in terms of the length of time that the halo-fixator should be worn and whether this duration should be altered on the basis of the clinical and radiological results obtained. MATERIALS AND METHODS: 16 patients with an odontoid fracture type Anderson type II were treated partly with a halo-fixator and partly by additional operative stabilization. 15 patients with a type III fracture were treated in a halo over 12 weeks. At the time of the accident the patients to be treated had to have conventional radiographic examination and a CT scan as well as a position check following reduction. After 4, 8 and 12 weeks radiographic and CT investigation was repeated. These findings were evaluated independently by a surgeon and a radiologist. The clinical follow-up was carried out using the VAS Score and, in addition, the general activity level before and after the accident was recorded in a similar way on the Tegner/Lysholm subjective activity score. RESULTS: In most cases, according to the CT scan, the osseous bridging decreased again between the 8th and 12th weeks, as defined by resorption zones seen during the fracture healing period. Radiological evidence of complete osseous bridging was only seen after 12 weeks in three cases. CONCLUSION: Conventional radiography does not seem to us to be the most suitable technical means to evaluate osseous healing in odontoid fractures. The CT is more reliable for this. According to our radiological results, osseous healing of different types of odontoid fractures takes more than 12 weeks. Despite of its known complications, the halo fixator is still a good instrument for the treatment of odontoid fractures.

Adult↗
PubMed2000

Management of acute odontoid fractures: operative techniques and complication avoidance.

In this article the authors describe the management of Type II odontoid fractures with special attention to operative technique and avoidance of complication. Anterior odontoid screw fixation is a procedure the authors have performed over the last 8 years in cases with acute Type II and rostral Type III odontoid fractures. In cases of Chronic Type II odontoid fractures and in patients with transverse ligament disruption, the authors prefer to undertake posterior transarticular facet screw fixation supplemented by bone graft and interspinous C1-2 wiring. The technical aspects of these procedures are described with a focus on operative nuances. Selection criteria and techniques that the authors have refined over the years have helped them to optimize success rates and minimize complications.

Bone Screws↗
PubMed2000

Epidemiology of spinal cord injury after acute odontoid fractures.

OBJECT: Cervical spinal cord injury (SCI) after odontoid fracture is unusual. To identify predisposing factors, the authors evaluated a consecutive series of patients who sustained SCI from odontoid fractures. METHODS: A consecutive series of 5096 admissions to the Delaware Valley Regional Spinal Cord Injury Center were reviewed, and 126 patients with neurological impairment at the C1-3 levels were identified. Seventeen patients had acute closed odontoid fractures with neurological deficit. Various parameters including demographics, mechanisms of injury, associated injuries, fracture types/displacements, and radiographic cervical canal dimensions were compared between "complete" and "incomplete" spinal cord injured-patients as well as with neurologically intact patients who had suffered odontoid fractures. There were similar demographics, mechanisms of injury, associated injuries, fracture type/displacement, and canal dimensions in patients with complete and incomplete SCIs. However, only patients with complete injury were ventilator dependent. In comparison with patients with intact spinal cords, spinal cord-injured patients were more commonly males (p = 0.011) who had sustained higher velocity injuries (p = 0.027). The computerized tomography scans of 11 of 17 neurologically impaired patients were compared with those of a random sample of 11 patients with intact spinal cords. Although the anteroposterior diameter (p = 0.028) and cross-sectional area (p = 0.0004) of the cervical spinal canal at the C-2 level were smaller in impaired patients, the displacement of the fragment was not different. CONCLUSIONS: Odontoid fractures are an infrequent cause of SCI. Patients with these injuries typically are males who have smaller spinal canals and have sustained high velocity injuries.

Adult↗
PubMed2000

Closed management of displaced Type II odontoid fractures: more frequent respiratory compromise with posteriorly displaced fractures.

OBJECT: Acute respiratory failure has been observed in patients after external immobilization for displaced odontoid fractures. The authors studied the frequency of respiratory deterioration in the acute management of displaced Type II odontoid fractures to identify patients at risk for respiratory failure. METHODS: The authors conducted a retrospective review of a consecutive series of 89 patients with odontoid fractures who were treated over a 5-year period to identify 53 patients with displaced Type II odontoid fractures. Patient demographics, degree of displacement, respiratory status, treatment method, and outcome were examined. Of the 32 patients with posteriorly displaced fractures, 13 experienced acute respiratory compromise, whereas only one of 21 patients with anteriorly displaced fractures had respiratory difficulties (p = 0.0032). The average posterior displacement was 6.9 mm. All 13 were initially managed using flexion traction for reduction of these fractures. Two of these patients died because of failure to emergently secure an airway during closed treatment of the fracture. CONCLUSIONS: Frequent respiratory deterioration during acute closed reduction of posteriorly displaced Type II odontoid fractures was observed, whereas respiratory failure in patients with anteriorly displaced fractures was rare. The use of the flexed cervical position in the setting of retropharyngeal edema rather than the direction of the displacement may substantially increase the risk of respiratory failure. This may prompt early elective nasotracheal intubation during closed reduction of posteriorly displaced Type II odontoid fractures that require a flexed posture.

Female↗
PubMed2000

Efficacy of anterior odontoid screw fixation in elderly patients with Type II odontoid fractures.

OBJECT: Type II odontoid fractures are the most common trauma-related dens fracture. Although Type III odontoid fractures have a high union rate when external immobilization is applied, Type II fractures are associated with high rates of nonunion, particularly in elderly patients and those with posteriorly displaced fractures or fractures displaced by more than 6 mm. Because elderly patients may not also tolerate external immobilization in a halo vest, alternative techniques should be explored to identify a method for managing these higher-risk patients. In this study the authors examine the efficacy of anterior odontoid screw fixation in a high-risk group of 10 elderly patients (> 65 years of age) treated for Type II odontoid fractures. METHODS: A retrospective review of all patients with Type II odontoid fractures treated at two institutions between September 1997 and March 2000 was performed. Demographic data, neurological examination, fracture type and degree of displacement, treatment method, and outcome data were examined at discharge. Ten patients older than 65 years who had sustained a trauma-related odontoid fracture and had undergone an anterior odontoid screw placement procedure were retrospectively reviewed. Fracture displacement (mean 6.6 mm) was observed in all but one patient, and in seven there were posteriorly displaced fractures. Seven were successfully treated with anterior screw fixation and external orthosis alone; in one patient in whom poor intraoperative screw purchase had been observed, the fracture healed after undergoing halo vest therapy. Only one patient was shown to develop a nonunion requiring a subsequent posterior fusion procedure. CONCLUSIONS: Odontoid screw fixation can be safely performed in elderly patients, and frequent bone union is demonstrated. However, osteopenia may preclude adequate screw fixation in some patients.

Aged↗
PubMed2000

Use of an osteoconductive agent (Norian) in anterior surgical management of odontoid fractures. Technical note.

Odontoid fractures can be successfully treated with anterior screw fixation. Odontoid fractures commonly occur in older patients who may have significant osteopenia. The authors examined the use of a bone substitute to overcome limitations encountered during a procedure in which anterior odontoid screw fixation is performed. Two elderly patients with displaced, reducible acute odontoid fractures underwent anterior odontoid screw fixation. The intraoperative failure of the anterior vertebral cortex from osteopenic bone and failure to achieve complete contact between the dens and axis were encountered. The defects were supplemented by using the osteoconductive agent Norian. Outcome was evaluated to determine the utility of this method. Occasional intraoperative failure of anterior odontoid screw fixation may be encountered. Supplementation of bone defects with this osteoconductive agent may facilitate successful bone union in selected patients.

Aged↗
PubMed2006

Treatment of dens fracture in adults: A report of thirty-two cases.

Thirty-two adult patients with dens fractures (30 type II and 2 type III) were treated from 1983 to 2002 at the authors' institutions. The age of the patients ranged from 23 to 58 years. The postoperative follow-up period ranged from 1 to 10 years. The objective of this retrospective study was to evaluate the effectiveness of the osteosynthesis after screw fixation and postoperative bracing. In the 32 cases, 19 patients underwent single screw and 13 underwent double screw fixation. Postoperatively, light head halter traction was applied with the patients in bed for 1 to 4 weeks followed by a halo-vest for 8 to 14 weeks. Fractures healed in 9 weeks on average. There were no cases of delayed union. The overall results were excellent in 26 cases (81.3%), good in 5 (15.6%), and fair in 1 (3.1%) patient (who had a type Il fracture). There were no difference in dens union patterns between those receiving one-screw and two-screw fixation, and there were no complications during or after the operative procedure. Postoperatively there were no restriction of motion in the neck and no residual neck pain. Direct osteosynthesis of the fractured dens with screws is an effective procedure for unstable type II and III fracture of the dens. Postoperative external immobilization with a cervical brace seems to be an important contributing factor to the equal fusion rates in both groups of patients.

Adult↗
PubMed1990

[Pathologic dens fracture in irradiated malignant neurofibroma].

A pathological dens fracture in a 47 year old patient with malignant neurofibroma is described. These tumours are very rare but the prognosis is very poor because of rapid proliferation and early metastatic progression. In the described case, bone osteolysis remained unnoticed until manifestation of clinical symptoms. The pathological fracture occurred despite irradiation of the dens.

Axis, Cervical Vertebra↗
PubMed2006

[Diagnosis and treatment of odontoid fracture combined with lower cervical spinal injury].

OBJECTIVE: To investigate the mechanism, clinical features and treatment of odontoid fracture combined with lower cervical spinal injury. METHODS: From January 1999 to December 2004, 57 cases of type II or shallow type III odontoid fractures were studied retrospectively. Six cases were found combined with lower cervical injury, the mean age was 54 years, and 4 of the 6 cases were complicated with cervical spondylarthrosis or ankylosing spondylitis. For the lower cervical injury, fracture-dislocation was found in 2 cases, the disruption of disc and ligament was found in 4 cases among which 2 cases were suffered from incomplete spinal cord injury; Both were caused by lower cervical spinal injury. All of the 6 cases were performed with surgery in odontoid fracture and lower cervical spinal injury simultaneously; Lower cervical spinal injuries were stabilized firstly in 2 cases, which responsible for neurological involvement; For the other 4 cases without neurological involvement, stabilization was performed in odontoid fracture firstly in 2 cases, due to inability to achieve reduction of odontoid fracture preoperatively, however, for the another 2 cases with anatomic reduction of the odontoid fracture preoperatively, lower cervical injuries were stabilized firstly. RESULTS: After an average follow-up of 10 months, all cases were obtained solid fusion both in odontoid fracture and lower cervical spinal injury, and without the complications associated with operation and prolonged bed rest. Two cases with neurological defect improved 1 scale in Frankel score. CONCLUSIONS: The incidence of odontoid fracture combined with lower cervical spinal injury is about 10.5% of the odontoid fracture, and it is vulnerable in the elderly patient with cervical spondylarthrosis. MRI should be used routinely for accurate diagnosis. Surgical stabilization is the choice of treatment due to facilitating early rehabilitation and reducing the complications. The surgical schedule is planned according to the fact of neurological involvement and the extent of stability between the odontoid fracture and lower cervical spinal injury.

Adolescent↗
PubMed2007

[Retroodontoid mass without atlantoaxial subluxation in an elderly patient: case report].

A Mass at the craniovertebral junction is relatively rare. We report a case of retroodontoid mass without atlantoaxial subluxation. An 84-year-old female presented to our hospital with paresthesia in the right upper and lower limb. She had no history of head or spine injury. Neurological examination revealed slight motor weakness of the right upper and lower limb. Cervical radiographs showed osteoarthrosis without atlantoaxial subluxation. MRI revealed retroodontoid, extra-dural mass that severely compressed the adjacent spinal cord. The patient underwent C1 laminectomy and posterior C1-C2 fusion with polyaxial screw and rod fixation. Simultaneously, the mass was resected partially. Histopathologically, the surgical specimen was a non-neoplastic fibrocartliginous mass and inflammatory cells were not seen. Postoperative course was uneventful and her neurological condition gradually improved. MRI revealed marked reduction of the mass and improvement of the spinal cord compression six months after the operation. We discuss the genesis of the retroodontoid mass and the strategy for surgical treatment.

Aged, 80 and over↗
PubMedDate not supplied

Os odontoideum.

Between January 1981 and December 1985 at the Rizzoli Orthopaedic Institute 8 patients affected with atlo-axial instability secondary to os odontoideum were submitted to surgery: all of the patients were characterized by persistent cervical pain and neurological deficit, which was still at an initial stage in 5 cases, and more severe in the remaining 3 (severe spastic tetraparesis). All of the patients were submitted to a similar treatment protocol in three stages: 1) preoperative reduction in halo-plaster, 2) surgical stabilization of C1-C2 by posterior vertebral fusion (limited to C1-C2 in 6 cases and extended as far as the occiput in the remaining 2), 3) postoperative immobilization in halo-plaster for an average of 12 weeks. At follow-up obtained after an average of 4 years and 2 months there was consolidation of the fusion in all of the cases treated: in 1 case, however, revision of the fusion was required 3 and 1/2 months after surgery, whereupon fusion was finally obtained. The total regression of pain was obtained in all 8 of the cases treated and there was evident neurological recovery in the 3 patients who had been characterized by severe spastic tetraparesis prior to surgery. The treatment protocol used in this series of patients proved to be a reliable one. Thus, it was possible to avoid the onset of chronic atlo-axial instability and its severe neurological sequelae in those cases where neurological deficit was still at an initial stage; furthermore, effective recovery was obtained in patients in whom neurological deficit was severe.

Adolescent↗
PubMed1991

[Bilateral vertebral artery occlusion associated with atlantoaxial dislocation due to os odontoideum].

A 17-year-old boy was hospitalized with transient consciousness disturbance on extension of the neck. At seven years of age, the patient developed delayed-onset posterior circulation stroke after the door struck him a mild blow on his forehead. A computed tomography scan revealed right cerebellar infarction with unknown etiology. He had been followed up without stroke recurrence and CT change until this hospitalization. Cerebral angiography disclosed bilateral vertebral artery occlusion at the C-2 level with the well-developed muscular collateral artery bypassing the occluded left vertebral artery. A cervical X-ray showed a posterior atlanto-axial subluxation with os odontoideum. Compression of the vertebral arteries due to mild trauma aggravating an atlanto-axial subluxation may have caused the bilateral vertebral artery thrombosis resulting in occlusion, and disturbance of the muscular collateral circulation on extension of the neck may have led to the recurrence of vertebrobasilar insufficiency. This is the first report of the angiographically confirmed bilateral vertebral artery occlusion with an established etiology in childhood.

Adolescent↗
PubMed1991

[Tissue-preserving ventral compression osteosynthesis of dens axis fractures using endoscopy and special instruments].

Endoscopic operations are tissue-preserving operative methods, which are increasing constantly in importance. Lag screw osteosynthesis is suitable for performance as an endoscopic operation with specially designed instruments. We have developed a set that allows lag screw osteosynthesis into the axis of the dens. Under endoscopic view the soft tissues are divided and a tube is placed through which the screw is inserted with the aid of an image intensifier. Two patients have so far been operated on in this way, both without complications.

Adult↗
PubMedDate not supplied

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.

Adolescent↗
PubMedDate not supplied

The nonsurgical treatment of fractures of the dens epistrophei.

The authors examined 25 fractures of the dens epistrophei treated conservatively by several methods in order to evaluate the most suitable treatment for this lesion. A Minerva plaster cast proved to be effective in the treatment of type III fractures, while the halo plaster system obtained the best results in type II fractures.

Adolescent↗