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Odontoid osteomyelitis is a rare entity and can be confused with other disease processes, requiring imaging to clarify the diagnosis. The following describes a pediatric case and the associated MR and CT findings.
A number of disease processes including congenital anomalies, malunited odontoid fractures, rheumatoid arthritis and tuberculosis can result in atlanto axial subluxation. The patient population presenting for surgery is therefore varied in age and general condition, ranging from fit young men to steroid dependent frail arthritic patients. The degree of instability and the spinal cord compression are also variable. Gauging these parameters has an important bearing on the anaesthetic management. We present management of six patients with atlanto axial subluxation in our institution.
Spinal injuries referring to banal falls are common injuries in elderly persons. Up to 55 years of age spinal fractures are more frequent in men while its opposite in older persons. There are two typical lesions: odontoid fracture in the upper cervical spine and compression fracture in thoracolumbar spine. Odontoid fracture is the most frequent lesion in cervical spine in the elderly. This is caused by trabecular structure of dens axis and spine's stiffness in old age. Instable fractures in extension type II are most common. In many cases the instability of the lesion is hidden and can be first seen in functional examination controlled by x-ray. Conservative treatment is efficient in stable lesions type III while there is a high risk for pseudarthrosis in treatment of instable lesions in elderly with Halo Fixateur e.g. We think that the best operation for these fractures is the anterior screw fixation. If this is not sufficient because of low bone mass or early dislocation of the screws a dorsal fusion C1/C2 with trans-articular screwing e.g. should be done. Because of rare symptoms thoracolumbar fractures in osteoporosis are hidden frequently. In many cases it's not easy to distinguish acute lesions from healed fractures or tumor lesions. Neurological deficit is rare. Therefore there are just few compression fractures (A type) that have to be treated operatively. Instable lesions type B and C must be operated as well in the elderly as in the young. Because of low bone mass in elderly the dorsal instrumentation should include more than just the two injured segments. An even more adequate stabilisation is done with an additional vertebral replacement.
The surface area, thickness and composition of articular cartilage of the atlanto-odontoid joints were investigated in twenty human cadaveric cervical spine specimens. The specimens were also examined grossly and by light microscopy to determine the location of the synovium. The anterior arch of the atlas and ventral and dorsal articular surfaces of the dens were covered with hyaline cartilage. The mean values of the articular surface areas on the ventral surface of the dens and anterior arch of the atlas were 55.10 and 58.24 mm2, respectively. The mean thickness of the articular cartilage of the anterior arch of the atlas, ventral and dorsal surfaces of the dens was 0.80, 0.81 and 0.82 mm, respectively. Synovial membranes were associated with the joint capsules and surrounding tissues of both anterior and posterior atlanto-odontoid joint spaces, where the synovial membranes were attached to the margins of the articular surfaces of the dens and anterior arch of the atlas anteriorly and the region of the cruciate ligament immediately peripheral to the cartilage region apposed to the dens and dens cartilage itself, posteriorly.
OBJECT: The placement of an anterior atlantoaxial plate after transoral odontoid resection has been described by Harms. Recently, the authors of biomechanical and clinical studies have shown that this procedure, especially in combination with posterior wiring, is a good alternative to established, isolated posterior atlantoaxial fixation techniques. Reports on the anatomy of the atlas and axis primarily focus on the posterior surgical approach. Scarce research regarding the quantitative anatomy of the anterior aspect of C-1 and C-2 has been reported. This study was undertaken to measure relevant dimensions of C-1 and C-2 and their relation to the anterior transoral approach. The aim of the study was to determine "safe zones" for screw placement in anterior atlantoaxial plate fixation. METHOD: Fifty human dry C-1 and C-2 vertebrae were obtained for direct anatomical, radiographic, and computerized tomography (CT) measurements. Thirty-two linear and four angular parameters were evaluated. All measurements were made using a digital caliper, ruler, or goniometer. Anatomical measurements were correlated with radiographic (anteroposterior, lateral, and craniocaudal) and CT (0.5-mm-slice thickness) measurements of the corresponding vertebrae. Additionally, bone mineral density (BMD) measurements of C-1 and C-2 were obtained in 20 patients. A safe zone for anterior screw placement in an atlas of bilateral trapezoid shape could be characterized. The average medial and lateral height of the trapezoid was 4.1 +/- 1.01 mm (range 1.4-6.7 mm) and 12.9 +/- 1.73 mm (range 8.7-17.4 mm), respectively. The distance between the sagittal plane and the medial and lateral walls of the trapezoid was 10.2 +/- 1.42 mm (range 8.9-12.8 mm) and 23.5 +/- 2.98 mm (range 21.7-30.7 mm), respectively. The average depth of the lateral masses was 22.3 +/- 2.04 mm (range 17.0-26.7 mm) in the sagittal plane. The average BMD in the safe zone of C-1 was 0.89 +/- 0.11 g/cm3 (range 0.75-1.01 g/cm3). Bone mineral density measurements at C-2 revealed a spheroid zone of low density at the basis of the dens (0.68 +/- 0.09 g/cm3). In contrast, high zones of BMD were found near the articular surfaces (C1-2: 0.97 +/- 0.11 g/cm3; C2-3: 0.94 +/- 0.12 g/cm3). The safe zone for anterior axis screw placement was V-shaped, limited cranially by a zone of low bone density and laterally by the vertebral artery groove. Correlations between radiographic and anatomical measurements were generally good (r2 = 0.78-0.95), but they were higher between CT and anatomical measurements (r2 = 0.86-0.99). CONCLUSIONS: A quantitative understanding of the anterior anatomy of C-1 and C-2 is necessary when considering anterior atlantoaxial plate fixation after transoral odontoid resection. In this study the authors defined safe zones for anterior atlas and axis screw placement. The anterior atlantoaxial plate, as originally described by Harms, only partially respects these safe zones.
Two patients with cervical myelopathy and C1-C2 retro-odontoid masses were examined. Preoperative magnetic resonance imaging studies suggested soft tissue pannus, as might be seen in rheumatoid arthritis; however, the results of serologic testing for rheumatoid factor were negative in both patients. Intraoperative findings and pathologic examination revealed degenerative fibrocartilage without inflammation or neoplasia. Similar lesions reported in the literature have been described as retro-odontoid disk hernia, damaged transverse ligaments, transverse ligament degeneration, synovial cysts, ganglion cysts, and degenerative articular cysts. These lesions may share a common pathophysiologic origin and represent a single disease process, namely exuberant degeneration of the transverse ligament.
BACKGROUND: The management of odontoid fractures represents both a clinical and a technical challenge due to the singular anatomy and biomechanics of the region. At present there is still much controversy as far as any form of management (surgical vs. conservative) is concerned and in any case there is not sufficient evidence to support a standardized form of treatment. This study was designed to further evaluate safety and efficacy of anterior odontoid single-screw fixation and to better determine the usefulness of Image Guided Surgery Virtual Fluoroscopy in treating such cases assessing also its advantages over traditional fluoroscopy and CT-guided frameless stereotaxy in the upper cervical spine surgery. METHODS: This was a retrospective review of ten patients presented during a short period of 18 months with acute traumatic Type II odontoid fractures. Nine underwent fixation within a mean of 3 days after injury, whereas a patient had to be operated upon on the 22nd day due to poor alignment with conservative treatment and ongoing instability. All patients postoperatively were fitted in a collar and then followed-up with serial clinical and radiographic examinations. FINDINGS: Radiological signs of fusion were seen in 10 cases (100%) (mean follow-up: 16 months). No complications occurred during the surgical procedure, nor were any instrumentation failures recorded; all patients remained neurologically intact. CONCLUSIONS: We believe that anterior odontoid screw fixation using Image Guided Surgery virtual fluoroscopy is a safe, effective, less time consuming and low x-ray exposure technique and we recommend this as the preferred treatment method for acute Type II odontoid fractures. Moreover, the use of image guided technology affords more precision, confidence and safety enabling the surgeon to approach the upper cervical spine in an easier and faster way.
This is a cross-sectional study on the use of halovest appliance in the Orthopaedic and Traumatology Department, Kuala Lumpur Hospital from June 1993 to September 1996. Fifty-three patients with cervical spine injuries were treated by halovest stabilization. Majority of cases was caused by motor-vehicle accident; others were fall from height at construction sites, fall at home, hit by falling object and assault. The injuries were Jefferson fracture of C1, odontoid fractures, hangman fractures, open spinous process fracture and fracture body of C2, and fracture, and fracture-dislocation of the lower cervical spines. Majority of patients had hospital stay less than 30 days. The use of the halovest ranges from 4 to 16 weeks and the healing rate was 96%. Two patients of lower cervical spine injury had redislocation and one of them was operated. There was one case of non-union of type II odontoid fracture and treated by posterior fusion. Other complications encountered during halovest treatment were minor. They were pin-site infection, pin-loosening, clamp loosening and neck pain or neck stiffness. This method of treatment enables patient to ambulate early and reduces hospital stay. We found that halovest is easy to apply, safe and tolerable to most of the patients.
We report on a 38-year-old man with post-traumatic posterior displacement of the atlas with respect to the axis without any associated fracture or neurological deficit caused by the displacement. Radiographs, computed tomography (CT) and magnetic resonance imaging (MRI) revealed posterior displacement of the atlas with the odontoid peg lying anterior and to the right of the anterior arch of the atlas.
Twenty-seven cases of craniovertebral junction compression treated with transoral surgery were reviewed to assess the influences of pathological processes and surgical interventions on spinal stability. All patients presented with signs and symptoms of spinal-cord or brain-stem dysfunction. Pathology included rheumatoid arthritis in 11 patients, congenital osseous malformations in 11, spinal fractures in two, plasmacytoma in one, osteomyelitis in one, and a gunshot injury in one. Instability was defined as clear radiographic evidence of mobile subluxation in conjunction with clinical assessment. Of 19 patients (70%) requiring internal fixation, nine underwent upper cervical fusion and 10 had occipitocervical fusion. When instability occurred, all subluxations were at the C1-2 level. There were no occipito-atlantal subluxations. Eight patients (30%) had preoperative instability of the craniovertebral junction due solely to their pathology, 11 patients (40%) suffered instability after transoral surgery, and eight (30%) were without clinical or radiographic evidence of instability (mean follow-up period 14 months). Craniovertebral junction instability predominated among patients with rheumatoid arthritis: 91% required fusion and 45% presented with pre-existing instability. Among individuals with congenital osseous malformations, 45% required fusion and only one patient (9%) had pre-existing instability. Patients who required subsequent posterior decompression of a Chiari malformation were at risk for developing instability; three of four became unstable after posterior decompression. Transoral resection of the dens, the anterior arch of C-1, and the lower clivus does not fully destabilize the spine; however, this operation may potentiate incipient pathological instability. The primary determinants of instability are the extent of pathological bone destruction, ligamentous weakening, and operative bone removal. Long-term follow-up monitoring is needed after transoral surgery to detect cases of late instability.
Non-invasive imaging methods are increasingly entering the field of forensic medicine. Facing the intricacies of classical neck dissection techniques, postmortem imaging might provide new diagnostic possibilities which could also improve forensic reconstruction. The aim of this study was to determine the value of postmortem neck imaging in comparison to forensic autopsy regarding the evaluation of the cause of death and the analysis of biomechanical aspects of neck trauma. For this purpose, 5 deceased persons (1 female and 4 male, mean age 49.8 years, range 20-80 years) who had suffered odontoid fractures or atlantoaxial distractions with or without medullary injuries, were studied using multislice computed tomography (MSCT), magnetic resonance imaging (MRI) and subsequent forensic autopsy. Evaluation of the findings was performed by radiologists, forensic pathologists and neuropathologists. The cause of death could be established radiologically in three of the five cases. MRI data were insufficient due to metal artefacts in one case, and in another, ascending medullary edema as the cause of delayed death was only detected by histological analysis. Regarding forensic reconstruction, the imaging methods were superior to autopsy neck exploration in all cases due to the post-processing possibilities of viewing the imaging data. In living patients who suffer medullary injury, follow-up MRI should be considered to exclude ascending medullary edema.
We present a posttraumatic esophageal tear that occurred in a 55-year old patient after a truck accident. He sustained a two-level injury with a type II odontoid fracture and a unilateral fracture of the left superior articular process of C6 with an incomplete quadriplegia at C5. Both lesions were treated nonoperatively. The tear was attributed to the stretching of the esophagus over anterior degenerative spurs at the level of the lesion (C5-C6) during hyperextension. The diagnosis of the esophageal perforation was delayed for 6 days. The treatment consisted of surgical debridement, volume expansion, antibiotic therapy, hyperbaric oxygenation, assisted ventilation, and esophageal exclusion. A complete review of the literature was performed.
OBJECTIVE: Trauma and degenerative joint disease are the most common pathological conditions observed in archaeological skeletal remains. We describe the prevalence of different types of cervical bone diseases observed in the early Middle Ages (6th to 8th centuries AD). METHODS: Human skeletons were excavated from Germanic row graves in southwestern Germany. One hundred ninety-six cervical spines thus obtained were examined for bone disease. The degenerative changes were classified into Grades 1 (marginal osteophytes), 2 (uneven joint surfaces), and 3 (osseous ankylosis). Cervical spinal canal stenosis was defined as anteroposterior diameters of <11 mm and intervertebral foraminal stenosis as <3.0 mm in the smallest diameter. RESULTS: Of the skeletons, 27.5% demonstrated degenerative changes of the cervical spine. The mean age of the skeletons at the time of death was 33.4 years, compared with 43.7 years for those with degenerative disease. Degenerative changes of the vertebral bodies (usually Grades 1 and 2) were most common in the C5-C6 (12.4%, P < 0.05) and C6-C7 (15.3%, P < 0.05) segments. The medial (6.1%) and lateral (0.6%) atlantoaxial joints were rarely involved in degenerative disease. The facet joints from C3-C4 to C6-C7 demonstrated degenerative changes (usually Grades 1 and 2) in 8.0 to 11.8% of cases. The C2-C3 facet joints were significantly involved in degenerative disease in 19.7% of cases (P < 0.05), one-fourth of which demonstrated osseous ankylosis. We observed cervical spinal canal stenosis in 5 skeletons (2.6%) and osseous intervertebral foraminal stenoses in 12 (6.1%). Isolated cases of other pathological processes, i.e., spondylitis ankylopoietica, occipitalization of the atlas and axis, and an odontoid fracture with pseudoarthrosis, were also recorded. CONCLUSION: In the early Middle Ages, the prevalence of degenerative cervical spine disease was the same as that observed today. The C2-C3 facet joints demonstrated high rates of degenerative disease.
The frequency of fractures of the cervical spine has increased with the rise in traffic accidents, but the radiological diagnosis of fractures at the initial examination remains unsatisfactory. A false negative diagnosis in the accident department was made in 25 out of 86 patients (29%) by a surgeon and in 12 patients (14%) by a radiologist. Poor radiographic quality was an important source of error, particularly for the diffult fractures in the cranial and caudal parts of the cervical spine. Half the fractures of the arch of the atlas and of the odontoid were missed initially. There was also difficulty in diagnosing fractures of the articular processes, evulsion fractures of the vertebrae and unilateral subluxation. Since the late results of missed vertebral fractures may be fatal, it is necessary to make more use of those signs which may indicate a fracture. Widening of the pre-vertebral soft tissues was seen in 33 out of 100 patients and an increased distance between articular facets on the A. P. projection in 19 out of 100 patients. Angled A. P. projections are useful for the diagnosis of fractures of articular facets in bed-ridden patients. Fractures in the lower cervical spine are well seen on oblique supine views. In larger accident departments, tomography and immediate radiological consultation should be available.
Cervical spine involvement by rheumatoid arthritis is common; brain-stem compression secondary to vertical subluxation of the odontoid in patients with rheumatoid arthritis is rare. Vertical subluxation results from 1) destruction of the transverse atlantal, apical, and alar ligaments of the atlas and odontoid, and 2) bone resorption in the occipital condyles, lateral masses of the atlas, and basilar processes of the skull. Neurological symptoms result from direct compression of the brain stem or from ischemia secondary to compression of vertebral arteries, anterior spinal arteries, or small perforating arteries of the brain stem and spinal cord. A case is reported in which a slowly progressive neurological deficit developed in a woman with rheumatoid arthritis following a fall from a stretcher. Neruological symptoms represented direct compression of the medulla by the dens, a mechanism confirmed at operation and autopsy. Recognition of progressive neurological deficit is often difficult in patients with rheumatoid arthritis because of their inactivity and their atrophic and immobile joints, but is essential if appropriate decompressive or stabilizing procedures are to be done. In patients with vertical subluxation of the dens, the transoral approach with removal of the odontoid is recommended. Decompression should be extensive, including the fibrous capsule around the odontoid and overlying synovial tissue as well as the odontoid itself.
This article summarizes the current evidence and expert opinion on making return-to-play decisions after cervical spine injuries. Injuries discussed include fractures, central cord neuropraxia, stringers, disc herniations, strains, sprains, and instability. Each of these injuries may be complicated by coexistence of other conditions making return-to-play decisions more complicated. The congenital, developmental, and disease processes discussed include spear tackler's spine, congenital and developmental stenosis, Klippel-Feil syndrome, odontoid abnormalities, rheumatoid arthritis, spina bifida, and Arnold-Chiari malformations. Postsurgical considerations are also discussed. This review represents an abundant amount of expert opinion that was overwhelmingly based on case series, case reports, and biomechanical studies to support the return-to-play guidelines.
The cervical spine is an especially important area, not only for the diagnosis of the skeletal dysplasias, but also for the management of the patient. By the "cervical spine" I refer not only to the vertebral bodies and posterior elements of this region, but also to the neural elements contained within, especially the cervical cord. The spine is supported by a group of ligaments both anteriorly and posteriorly, with special fixation of the odontoid and C2 by a ligament which normally affixes it firmly to C1. Multiple things may go wrong with the development of the cervical spine. There may be abnormal development of the "vertebrae" in this region, ranging from hypoplasia to developmental failure and/or abnormal ossification of the cervical vertebrae; associated or unassociated odontoid hypoplasia; poor ligamental fixation of C2 resulting in C1-2 subluxation; abnormal development of the posterior processes; abnormal ligamental development or laxity with abnormal cervical kyphosis or lordosis; and, in the case of more fragile/brittle bone development (osteoporosis or increased bone density), fractures can lead to cervical spine problems. The skeletal dysplasias that involve cervical spine problems constitute about 35 of the 150 well-described disorders. These include certain families of disorders like the type II collagenopathies, as well as many individual disorders. It is very important for the clinician to be able to pilot patients through the various appropriate imaging modalities - conventional radiographs of the cervical spine; lateral flexion/extension views; CT; MRI - so that proper management and therapy will result.
Congenital atlanto-axial dislocation (AAD) usually presents with chronically progressive compression of the cervico-medullary junction. However, even a minor trauma can cause acute compression with development of quadruplegia and respiratory impairment. At times these may be transient, or trauma may aggravate the compression and lead to progressive quadriplegia. Of 60 children seen with congenital AAD, in 15 it had been associated with trauma. Nine of these 15 AADs were of the mobile variety, and 6 of the fixed variety with odontoid invagination. In 6 children with mobile and 2 with fixed AAD, trauma led to an acute manifestation with quadriplegia. Three of the children also experienced respiratory distress and needed ventilatory support. All 15 were initially treated with skull traction. Once the condition was stabilised, those with the mobile variety underwent fixation in a reduced position and grafting. One of the children with respiratory distress died within 2 days of admission. In 4 of them, sublaminar wiring between C1 and C2 was carried out, and in 3 others wiring between occiput and base of spinous process of C2 was performed. In 1 case a Hartshill loop was used. Among the children with fixed AAD, reduction of the odontoid invagination was obtained in 2, and they underwent fusion. In 4 cases with unsatisfactory reduction, posterior decompression of the foramen magnum and the fused posterior arch of the atlas was performed. The results depended on the degree of neurological deficit in each child.