Trends in Epidemiology and Management of Traumatic Type II Odontoid Fracture: Experience in Latin America

Introduction Odontoid fractures account for 9% to 15% of adult, cervical spine fractures, and are the most common fractures in the geriatric cervical spine. The mechanism of injury generally results from hyperflexion or hyperextension of the cervical spine during low-energy impacts in the elderly or high-energy impacts in the young and middle aged. No consensus exists on the optimal treatment (surgical or conservative) and the most relevant outcome parameter (osseous union, fracture stability or clinical outcome). Neurologic injuries associated with these fractures are rare. Material and Methods This study was a retrospective chart review of 13 patients who were treated for odontoid process fractures between November 2010 and May 2015. Inclusion criteria: Patients with odontoid fractures submitted to surgical treatment. Data were obtained from medical charts and spinal column imaging reports. Medical charts, imaging studies and the patient's outcomes were submitted to descriptive analysis in the pre-operative and post-operative period. The data submitted to descriptive analysis were: Fracture gaps; the direction and degree of odontoid process displacement; the odontoid fracture line anatomy; the degrees of the atlantoaxial instability; and the contact between the fractured odontoid and the axis vertebrae. We used conventional radiographs, three-dimensional computed tomographic (3D-CT) scans, and magnetic resonance images. We used the Grauer Algorithm for defining the surgical treatment modality. We identified the solid bone union through the presence of bony bridges and the definite continuity of cortical bone. Results A total of 13 patients who underwent surgical treatment for odontoid fracture were identified. The patients were 76.9% men, the mean age = 32.92 years. Traffic accidents (69,2%) were the most common cause of trauma. The main symptom was pain (84.6%) in the posterior cervical region. The elapsed median time from accident to surgery was 30 days. Mean follow-up was 20 months. Odontoid screw technics (38,4%) and Harms posterior technic (38,4%) were the most common surgical treatment adopted as primary surgical treatment. The most common Grauer's line fracture type was type B on 8 cases. 2 patients referred chronic cervical pain after surgery, 1(20%) were submitted to anterior technic and 1 (12,5%) posterior technic. We had 2 cases with complications, all submitted to posterior technic, 1 with CSF leak and 1 with vertebral artery lesion. No mortality was observed. Conclusion There was no difference between anterior or posterior approach when analyzing the cervical chronic pain and mortality. However, there were more complications in cases covered by the posterior approach. A well-designed prospective study with a larger number of cases is needed to better elucidate optimal treatment algorithms from both an outcomes and cost-effectiveness perspective.

Retrospective study. To analyze geriatric patients with Type II odontoid fractures treated either with rigid cervical orthosis (CO) or surgery (Odontoid Screw or Transarticular screw). Our literature search did not yield any studies on the outcome of Type II odontoid fractures in geriatric population treated with the rigid CO. We therefore designed a study to analyze geriatric patients with Type II odontoid fractures treated with either rigid cervical collar or surgery. This is a retrospective chart review of patients with Type II odontoid fractures between July 1998 and June 2006. Inclusion criteria consists of males and females of 70 years of age or older with Type II odontoid fractures who were treated with rigid cervical collar or surgery. Exclusion criteria were displacement >4 mm, posteriorly displaced fracture, neurologic compromise, multilevel cervical spine injury, and treatment in a halo vest. Medical comorbidities were assessed using the Modified Cumulative Illness Rating Scale for Geriatrics. Primary outcomes were mortality and fusion (union, stable nonunion, nonunion). Minimum of 3 months follow-up was acceptable. One hundred eighty four odontoid fractures were identified in 8 years. Twenty patients met our inclusion criteria (9 treated in rigid collar and 11 treated surgically). Median follow-up was 5.5 months. Out of 20 patients, 4 patients died (1 treated in CO, 3 treated surgically). Cumulative Illness Rating Scale for Geriatrics index was highest in patient treated in CO. In the rigid collar group, 6 patients had union (66.6%), and 2 developed stable nonunion (22.2%); whereas in the surgically treated group, 7 patients had union (87.5%), and 1 patient developed nonunion (12.5%). Patients treated nonoperatively in rigid collar seem to have an overall favorable outcome. A well-designed prospective study, to compare the outcomes of surgical intervention with nonsurgical management of Type II odontoid in elderly is recommended.

Objective To explore the treatment options for fresh Grauer type Ⅱ odontoid fractures and discuss corresponding clinical outcome.Methods The study involved 40 patients with fresh odontoid fractures including seven with type Ⅱ A fractures, 18 with type Ⅱ B and 15 with type ⅡC according to Grauer classification.There were five patients with incomplete cervical cord injuries.Type Ⅱ A fractures were treated by traction of occipital-jaw band or skull for 1-2 weeks and then fixed with head-neck-chest plaster or brace.Type Ⅱ B fractures were treated with anterior odontoid screw system fixation.Fifteen patients with type Ⅱ C fractures and three patients with type Ⅱ B fractures combined with severe fracture displacement were managed with posterior atlantoaxial pedicle screw fixation. Results All the patients were followed up for 6-24 months.Seven patients with type Ⅱ A fractures showed union after fixation with head-neck-chest plaster or brace for 3-6 months.Fifteen patients treated with odontoid screw fixation had good positions of screws, with no injury to the spinal cord, of which 14 patients obtained bone union, with union rate of 93.3％.Eighteen patients (including 15 patients with type Ⅱ C fractures and three with type Ⅱ B fractures combined with severe displacement) managed with atlantoaxial pedicle screw system showed no injury to the vertebral artery and spinal cord.Solid bone fusion was achieved.in 31 patients after 3 to 6 months.The X-ray and SCT scans verified proper fixation of the screws, with no deformation, loosening or breakage of the screws.Five patients with incomplete cervical cord injuries obtained neural function recovery at various degrees after surgery. Conclusions Conservative treatment cau be alternative to type ⅡA fractures.Anterior odontoid hollow screw fixation is better for type ⅡB fractures (non-displaced or reducible) and has advantages of minor trauma, fast postoperative recovery and high union rate.However, posterior atlantoaxial pedicle screw system fixation and fusion is suitable to type Ⅱ C and ⅡB fractures with severe displacement and has the advantages of stable three-dimension fixation, direct screw placement, intraoperative reduction, short-segment fixation and high fusion rate. Key words: Spinal fractures; Cervical vertebrae ; Fracture fixation

Objectives: Odontoid screw fixation is an accepted surgical approach for type 2 odontoid fractures with an intact transverse ligament. Typically, intraoperative bi-planar flouroscopy is used for placement of an odontoid screw. However, the quality of the images obtained with biplanar flouroscopy in the operating room is variable (due to patient body habitus) and screws may be misplaced. We report our technique for the use of the O-arm (Medtronic Navigation, Louisville, Colorado) to place and revise odontoid screw fixation. Methods and Results: The O-arm is sterilely draped into the surgical field. Intraoperative navigation is not needed. Using anteroposterior and lateral flouroscopic images obtained from the O-arm, the trajectory of the Kirschner wire, drill, tap, and screw can be visualized in real time. The final screw position can then be checked with a computed tomographic reconstruction view done with the O-arm while the patient is still draped sterilely in the operating room. We have utilized the Oarm to avoid a screw malposition in one patient with an odontoid fracture with osteopenia (which made visualization of the cervical spine difficult with standard flouroscopy). We have also utilized O-arm visualization to retrieve a malpositioned and migrated odontoid screw placed outside of our institution.

BackgroundAnkle fractures involving the posterior malleolus generally lead to worse outcome. However, no studies on gait in trimalleolar ankle fractures have evaluated the influence of size and comminution of the posterior malleolar fragment. MethodsWe expected patients with more severely comminuted posterior malleolus, more severe fracture type and larger posterior fragment to have reduced gait kinematics and poorer patient-reported outcomes. 26 trimalleolar ankle fracture patients were compared with 14 healthy controls and kinematically analyzed using the Oxford Foot Model. Functional outcome was based on 4 patient reported outcome questionnaires. Effects of posterior fragment size, comminution and Haraguchi fracture classification were determined on conventional and 3D CT-scans. FindingsTrimalleolar patients had lower walking speed and reduced range of motion between the hindfoot and tibia in both loading and push-off phases in the sagittal and transverse planes. The range between the hindfoot and tibia in the sagittal plane in the push-off phase correlated significantly with patient reported outcomes. The absolute and relative surface area of the posterior fragment on conventional CT-scans and 3D CT-scans, correlated significantly with range of motion. Patients with a posterior malleolus size >10% of the posterior malleolus had lower flexion-extension between forefoot and hindfoot during loading phase than patients with a size ≤10%. InterpretationTrimalleolar fractures reduce walking speed and range of motion in the talocrural joint. Reduced range in the talocrural joint is associated with poorer outcomes. Posterior fragment size correlated significantly with range of motion in talocrural and midfoot joints and with patient reported outcomes.Level of evidence: Level 3, retrospective study.

The superoanterior portion of the third cervical vertebra may need to be rimmed during anterior odontoid screw fixation procedures. We, therefore, retrospectively evaluated radiological data to analyze the anatomical relation between the second and third cervical vertebra of the patients who were operated by an anterior cervical approach with respect to the question if odontoid screw fixation would have been possible without rimming or not. Patients in whom the anterior approach for cervical disc prolapse and/or cervical stenosis was used between 2008 and 2010 were included in this study. The odontoid screw angle, and the angle between the lower second and the upper third cervical vertebral endplate were measured on intraoperative cervical lateral radiographs. If the screw line passed through the superior anterior portion of the third vertebral body, it was determined that the third cervical vertebra would have been needed to be rimmed if odontoid screwing would have been planned. 100 patients were included. There were 50 males and 50 females with a mean age of 47.9 years (mean ± SD: 47.9 ± 12.6 years). The mean odontoid screw angle, and the angle between the lower second and the upper third cervical vertebral endplate were 65.61° ± 3.75° and 15.24° ± 4.85° (nonparallel vertebral endplates only), respectively. The odontoid screw angle, in which the third cervical vertebra would not have been needed to be rimmed, was 63.87° ± 2.84°. In addition, the odontoid screw angle in which the third cervical vertebra would have been needed to be rimmed was 67.28° ± 3.77°. The odontoid screw angle may be easily measured on lateral radiographs. In cases in which the odontoid screw angle is 67.28° ± 3.77° or higher, the superoanterior portion of the third cervical vertebra would be needed to be rimmed for proper screw fixation of odontoid fractures.

BackgroundThe objective of this study is to investigate the outcomes and safety of using percutaneous anterior C1/2 transarticular screw fixation as a salvage technique for odontoid fracture if percutaneous odontoid screw fixation fails.MethodsFifteen in 108 odontoid fracture patients (planned to be treated by percutaneous anterior odontoid screw fixation) were failed to introduce satisfactory odontoid screw trajectory. To salvage this problem, we chose the percutaneous anterior C1/2 transarticular screw fixation technique in treatment of these patients. The visual analogue score (VAS) of neck pain and Neck Disability Index (NDI) of all patients were scored at pre-operation, 3 months after operation, and final follow-up. Additional, technique-related complications were recorded and collected.ResultsPercutaneous C1/2 transarticular screw fixation was performed successfully in all 15 patients whose odontoid screw fixation failed. No technique-related complications (such as nerve injury, spinal cord injury, and esophageal injury) occurred. The VAS of neck pain and NDI score improved significantly (P = 0.000) after operation, and no significant differences were found when compared to 93 non-salvage patients who successfully performed the percutaneous anterior odontoid screw fixation. No screw loose or breakage occurred, all of the odontoid fractures achieve radiographic fusion, bony fusion bridge could be observed at the C1/2 lateral articular facet on 9/15 patients.ConclusionsWe suggest that percutaneous anterior C1/2 transarticular screw fixation is a good alternative salvage technique if percutaneous odontoid screw fixation failed, and it is a minimally invasive, feasible, and safe technique.

Background Data: Several methods of treatment of odontoid fractures have been used. These have ranged from rigid immobilization to atlantoaxial fusion. Odontoid screw osteosynthesis is gaining popularity. Purpose: To define the efficacy and safety of odontoid screw fixation in the management of odontoid fractures and to report the clinical and radiological results. Study Design: A prospective cohort study of odontoid fractures treated with odontoid screw osteosynthesis. The study was conducted in Cairo university hospital, Egypt and AOA Neuro-spinal Centre, Libya in the period from January 2007 to October 2010. Patients and Methods: Over the period from January 2007 to October 2010, twentytwo patients, 17 males and 5 females, with a mean age of 32.5 years were included in this study. These were 19 odontoid type-II and 3 shallow type-III fractures. All patients underwent odontoid screw fixation using a single screw.Results: Mean operative time was 80 minutes and mean blood loss 150 ml Patients were followed for a mean period of 20.6 months. Nineteen patients (87%) obtained a good or excellent result on the Smiley Webster scale. Fourteen patients (64%) obtained a bony union, 7 (32%) a stable fibrous union and one patient (4%) developed a pseudoarthrosis. One patient had a misplaced screw that was successfully revised and another patient had displacement of the screw with re-displacement of the fracture at three months follow up. He had removal of the screw and underwentatlanto-axial fusion. Conclusion: This study has proven the efficacy and safety of odontoid screw osteosynthesis in selected types of odontoid type II and shallow type III fractures. (2012ESJ024)

Full-endoscopic assisted surgery using anterior double odontoid screw fixation in type II odontoid fractures: A clinical study of the surgical technique.

OBJECTIVE As odontoid process fractures become increasingly common in the aging population, a technical understanding of treatment approaches is critical. 3D image guidance can improve the safety of posterior cervical hardware placement, but few studies have explored its utility in anterior approaches. The authors present in a stepwise fashion the technique of odontoid screw placement using the Medtronic O-arm navigation system and describe their initial institutional experience with this surgical approach. METHODS The authors retrospectively reviewed all cases of anterior odontoid screw fixation for Type II fractures at an academic medical center between 2006 and 2015. Patients were identified from a prospectively collected institutional database of patients who had suffered spine trauma. A standardized protocol for navigated odontoid screw placement was generated from the collective experience at the authors' institution. Secondarily, the authors compared collected variables, including presenting symptoms, injury mechanism, surgical complications, blood loss, operative time, radiographically demonstrated nonunion rate, and clinical outcome at most recent follow-up, between navigated and nonnavigated cases. RESULTS Ten patients (three female; mean age 61) underwent odontoid screw placement. Most patients presented with neck pain without a neurological deficit after a fall. O-arm navigation was used in 8 patients. An acute neck hematoma and screw retraction, each requiring surgery, occurred in 2 patients in whom navigation was used. Partial vocal cord paralysis occurred after surgery in one patient in whom no navigation was used. There was no difference in blood loss or operative time with or without navigation. One patient from each group had radiographic nonunion. No patient reported a worsening of symptoms at follow-up (mean duration 9 months). CONCLUSIONS The authors provide a detailed step-by-step guide to the navigated placement of an odontoid screw. Their surgical experience suggests that O-arm-assisted odontoid screw fixation is a viable approach. Future studies will be needed to rigorously compare the accuracy and efficiency of navigated versus nonnavigated odontoid screw placement.

Odontoid fractures are the most common cervical spine fractures in elderly patients. Treatment options included operative fixation (OP) or nonoperative management with either a halo-vest (HV) or rigid cervical orthosis (CO). Our previous study suggested increased morbidity and mortality with the use of HV in the treatment of elderly patients with cervical spine fractures. We review a series of odontoid fractures in elderly patients and evaluate for predictors for in-hospital morbidity and mortality. There were 78 patients >65 years of age who sustained a type II or III odontoid fracture from January 1997 to June 2004 identified from the Rhode Island Hospital Trauma registry. Demographic, mechanism, injury pattern, treatment, and outcome data were recorded. Patients were analyzed according to treatment method. The mean age was 80.7 +/- 0.9 years. There were 50 type II, 17 type III, and 11 combined fractures. There were 38 (49%) patients treated with HV: 34 with halo alone, and 4 after OP; 40 (51%) patients were treated without HV: 27 with CO, and 13 with OP. There was no difference in injury severity or baseline medical condition between HV and non-HV patients. There were 24 (31%) patients who died during their hospital stay. Of the HV patients, 42% died compared with 20% in the non-HV group (p = 0.03). Major complications occurred in 66% of HV patients compared with 36% of non-HV patients (p = 0.003). Odontoid fractures are associated with significant morbidity and mortality in elderly patients. Outcomes after treatment with HV appear inferior to those achieved with CO or OP.

Age increases the risk of immediate postoperative dysphagia and pneumonia after odontoid screw fixation

A case of a 3-part fracture of the axis combining an odontoid dens and a hangman fracture is reported. To describe a single anterior procedure allowing stabilization with an odontoid screw fixation and a C2-C3 fusion in a case of complex fracture of the axis. Even if fractures of the axis are common, multiples fractures of the axis are rare and their management is still challenging for surgeons who have to achieve primary stability, early mobilization, preserved cervical range of motion, and favorable outcome. A 79-year-old man was referred in our neurosurgical department 3 weeks after a bicycle accident. He had persistent neck pain without radicular pain. Neurologic examination was normal. The initial CT scan showed a rare and complex fracture of the axis consisting of a fracture of the dens and a traumatic spondylolisthesis of C2-C3. The surgical procedure was performed using an anterior cervical approach under fluoroscopic guidance. First, a C2-C3 fusion was performed using an iliac crest graft. Then an anterior odontoid screw was placed under fluoroscopic guidance. Finally, an anterior plating of C2-C3 covering the odontoid screw was achieved. Postoperative course was uneventful and patient was discharged at day 6. This single time procedure was able to achieve primary stability of the fractures of the axis and offers the possibility of an early mobilization of the patient with a good outcome. This approach allowed a better preservation of the cervical range of motion compared with a classic posterior fusion.

Several controversial issues arise in the management of unstable hangman's fractures. Some surgeons perform external reduction and immobilize the patient's neck in a halo vest, while others perform surgical reduction and internal fixation. The nonsurgical treatments with rigid collar or halo vest immobilization present problems, including nonunion, pseudarthrosis, skull fracture, and scalp laceration and may also fail to achieve anatomical realignment of the local C2-3 kyphosis. With recent advances in surgical technique and technology, surgical intervention is increasingly performed as the primary treatment in high cervical fractures. The outcomes of such surgeries are often superior to those of conservative treatment. The authors propose that surgical intervention as a primary management for hangman's fracture may avoid risks inherent in conservative management when severe circumferential discoligamentous instability is present and may reduce the risk of catastrophic results at the fracture site. The purposes of this study were to assess fracture healing following expedient reduction and surgical fixation and to propose a guideline for treatment of unstable hangman's fractures. From April 2006 to December 2011, the authors treated 105 patients with high cervical fractures. This study included 23 (21.9%) of these patients (15 men and 8 women; mean age 46.4 years) with Type II, IIa, and III hangman's fractures according to the Levine and Edwards classification. The patient's age, sex, mechanism of injury, associated injuries, neurological status, and complications were ascertained. The authors retrospectively assessed the clinical outcome (Neck Disability Index), radiological findings (disc height, translation, and angulation), and bony healing. The average follow-up period was 28.9 months (range 12-63.2 months). The overall average Neck Disability Index score at the time of this study was 6.6 ± 2.3. The average duration of hospitalization was 20.3 days, and fusion was achieved in all cases by 14.8 ± 1.6 weeks after surgery, as demonstrated on dynamic radiographs and cervical 3D CT scans. The mean pretreatment translation was 6.9 ± 3.2 mm, and the mean postoperative translation was 1.6 ± 1.8 mm (mean reduction 5.2 ± 3.1 mm). The initial angulation was 4.7° ± 5.3° and the postoperative angulation was 2.5° ± 1.8° (mean reduction 6.1° ± 5.3°). The preoperative and postoperative values for translation and angulation differed significantly (p < 0.05). The overall C2-3 disc height was 6.7 ± 1.2 mm preoperatively, whereas 3 months after surgery it was 6.4 ± 1.1 mm. These values did not differ significantly (p = 0.0963). The authors observed effective reduction and bony healing in cases of unstable hangman's fractures after fixation, and all patients experienced favorable clinical outcomes with neck pain improvement. The protocols allowed for physiological reconstruction of the fractured deformities and avoided external fixation. The authors suggest that posterior reduction and screw fixation should be used as a primary treatment to promote stability of hangman's fracture in the presence of discoligamentous instability or combined fractures.

The optimal treatment of Type II odontoid fractures is controversial. Various therapies have been used, including nonrigid immobilization, halo orthosis, posterior atlantoaxial arthrodesis, and odontoid screw fixation. Of these, odontoid screw fixation is the only treatment modality that provides immediate stabilization and preserves normal motion at C1-2. It has been suggested in cadaveric biomechanical studies that there is no advantage to using more than one screw for anterior odontoid fixation. The authors compared the clinical safety and efficacy of one- and two-screw anterior odontoid fixation. The authors retrospectively reviewed the medical records and radiographs of 42 consecutive patients who had undergone fixation for treatment of odontoid fractures at a single institution between 1989 and 1995. The group treated with a single screw consisted of 20 patients (11 males and nine females) with an average age of 54 years. The union rate in this group, as determined by postoperative dynamic radiographs, was 81%. The group treated with two screws consisted of 22 patients (13 men and nine women) with an average age of 64 years, whose union rate was 85%. Anterior odontoid screw fixation is a safe and efficacious treatment for odontoid fractures. In the authors' experience there was no significant difference in the successful union rates achieved with either the one- or two-screw fixation techniques (81% and 85%, respectively; chi(2) = 0.09, p = 0.76).