Table 5 - uploaded by John Martin O'Byrne
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Odontoid fractures currently account for 9-15% of all adult cervical spine fractures, with type II fractures accounting for the majority of these injuries. Despite recent advances in internal fixation techniques, the management of type II fractures still remains controversial with advocates still supporting non-rigid immobilization as the definitiv...
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Context 1
... 92.42% (61/66 patients), fracture healing was uneventful (Table 5). These patients developed a solid bony union and their treatment was discontinued at 3 months (12 weeks); 6.06% (4/66 patients) developed a stable pseudoarthrosis, where there was insufficient evidence of bony fusion in the absence of mechanical failure. ...
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Citations
... The selection between these methodologies continues to be a subject of disagreement as medical practitioners and researchers strive to find substantiating data favoring one method over the other. Due to the intricate nature of these fractures and the possible long-term effects, it is essential to ascertain which method provides better clinical results, such as fusion rates, pain alleviation, functional healing, and the frequency of complications (Butler et al., 2010;Schuberth et al., 2006). This metaanalysis aims to resolve the existing debate by combining and analyzing the existing data and comparing shortsegment fixation (SSF) and long-segment fixation (LSF) in treating thoracolumbar burst fractures. ...
This comprehensive meta-analysis evaluates the comparative effectiveness of short-segment pedicle screw fixation (SSF) and long-segment pedicle screw fixation (LSF) in treating thoracolumbar burst fractures. Our study examines various outcomes, including fusion rates, pain relief, functional recovery, and complication rates. Data from studies conducted between January 2018 and January 2022 were reviewed, involving a collective patient cohort of 100 individuals diagnosed with thoracolumbar burst fractures. We conducted an extensive review of the literature, including six investigations, with a total sample size of 100 patients, drawn from studies by Smith et al. (2018), Johnson et al. (2019), Brown et al. (2020), White et al. (2021), Davis et al. (2022), and Wilson et al. (2022). Fusion rates were 90% for SSF and 91% for LSF. The risk difference (RD) between SSF and LSF was -1%, indicating a marginal advantage favoring LSF (RD M-H = -0.95, 95% CI: -4.02 to 2.11). Analysis of postoperative pain scores showed that SSF patients had a mean pain level of 2.4, while LSF patients reported 2.3. With low heterogeneity (T = 12%) and a Z-score of 3.42, our findings demonstrated no statistically significant difference in postoperative pain levels between SSF and LSF. Functional outcomes were assessed using the Oswestry Disability Index (ODI) and Short Form 36, revealing an RD of -1% in favor of LSF. However, this difference was insignificant (RD M-H = -0.82, 95% CI: -3.80 to 2.16). The complication rate for SSF was 12%, and for LSF, it was 11%, with an RD of 1%, suggesting a slightly higher complication rate for SSF, although this difference was not statistically significant (RD M-H = 1.05, 95% CI: -1.38 to 3.48).Our meta-analysis found no statistically significant differences in fusion rates, postoperative pain scores, or complication rates between SSF and LSF in the context of thoracolumbar burst fractures. The choice between SSF and LSF for treating thoracolumbar burst fractures is a pivotal consideration. Our findings indicate that SSF and LSF yield comparable outcomes in fusion, postoperative pain relief, functional recovery, and complication rates. The marginal advantages associated with LSF are of negligible clinical significance. This study underscores the importance of individualized decision-making, emphasizing patient-specific criteria and surgeon expertise in selecting the most appropriate fixation strategy for thoracolumbar burst fracture management. Personalized treatment plans are paramount in optimizing patient outcomes in this clinical scenario.
... Although the majority of patients arriving at the hospital will not have a noticeable neurologic injury, a detailed neurologic evaluation is required, as displaced fracture fragments can compress the spinal cord and lead to cervical myelopathy. In a review of 446 T II-OF, Przybylsky found that 82% of the patients were neurologically intact, 8% had minimal sensory disturbances in the scalp or extremities and 10% had significant neurological deficits 16 . However, in a retrospective analysis of 16 patients with neglected odontoid fractures, Crockard et al. 1 found that all patients had neck pain at 1 year and 69% had clinical signs of myelopathy, including upper extremity weakness and gait disturbances 1,7 . ...
Introduction:
Odontoid fractures correspond to 9-15% of cervical spine fractures. Atlas fracture is rare (3-13%)8.
Case presentation:
Male with Anderson and D´Alonzo Type II Odontoid fracture with unstable fragment treated with occipitocervical fixation with occipital plate, C2-C3 transfacet screws; Female with type E Jefferson fracture + anterolateral atloaxial dislocation, treated with occipitocervical fixation, C2-C3-C4 transfacet screws.
Discussion:
Anderson and D'Alonzo Type II fractures and Jefferson type E fractures are a surgical emergency due to instability and neurological deficit.
... Our results are comparable to previous studies that have examined mortality among geriatric patients with odontoid fractures. White et al. performed a meta-analysis of geriatric patients treated surgically for type 2 odontoid fractures and reported an in-hospital mortality rate of 6.2% [27]. Chen [17]. ...
Odontoid fractures are increasingly prevalent in older adults and associated with high morbidity and mortality. Optimal management remains controversial. Our study aims to investigate the association between surgical management of odontoid fractures and in-hospital mortality in a multi-center geriatric cohort. We identified patients 65 years or older with C2 odontoid fractures from the Trauma Quality Improvement Program database. The primary study outcome was in-hospital mortality. Secondary outcomes were in-hospital complications and hospital length of stay. Generalized estimating equation models were used to compare outcomes between operative and non-operative cohorts. Among the 13218 eligible patients, 1100 (8.3%) were treated surgically. The risk of in-hospital mortality did not differ between surgical and non-surgical groups, after patient and hospital-level adjustment (OR: 0.94, 95%CI: 0.55–1.60). The risks of major complications and immobility-related complications were higher in the operative cohort (adjusted OR: 2.12, 95%CI: 1.53–2.94; and OR: 2.24, 95%CI: 1.38–3.63, respectively). Patients undergoing surgery had extended in-hospital length of stay compared to the non-operative group (9 days, IQR: 6–12days vs. 4 days, IQR: 3-7days). These findings were supported by secondary analyses that considered between-center differences in rates of surgery. Among geriatric patients with odontoid fractures surgical management was associated with similar in-hospital mortality, but higher in-hospital complication rates compared to non-operative management. Surgical management of geriatric patients with odontoid fractures requires careful patient selection and consideration of pre-existing comorbidities.
... The 30-day case fatality rate showed a hazard ratio of 1.47, indicating a slightly higher rate of survival among patients that were treated nonoperatively (95% [confidence interval] CI = 0.44-4.87, P = 0.4064), but was not significant as described by other authors [47]. The highest rate of fatality in patients with neurological deficiencies could be observed in geriatric patients with quadriplegia below C2. ...
Objectives
We carried out a retrospective cohort study to differentiate geriatric odontoid fractures into stable and unstable and correlated it with fracture fusion rates. Results are based on the literature and on our own experience. The authors propose that the simple Anderson and D’Alonzo classification may not be sufficient for geriatric patients.
Methods
There were 89 patients ≥ 65 years who presented at our institution with type II and III odontoid fractures from 2003 until 2017 and were included in this study. Each patient was categorized with CT scans to evaluate the type of fracture, fracture gap (mm), fracture angulation (°), fracture displacement (mm) and direction (ventral, dorsal). Fractures were categorized as stable [SF] or unstable [UF] distinguished by the parameters of its angulation (< / > 11°) and displacement (< / > 5 mm) with a follow-up time of 6 months.
SFs were treated with a semi-rigid immobilization for 6 weeks, UFs surgically—preferably with a C1–C2 posterior fusion.
Results
The classification into SFs and UFs was significant for its angulation ( P = 0.0006) and displacement ( P < 0.0001). SF group ( n = 57): A primary stable union was observed in 35, a stable non-union in 10, and an unstable non-union in 8 patients of which 4 were treated with a C1/2 fixation. The overall consolidation rate was 79%. UF group ( n = 32): A posterior C1–C2 fusion was carried out in 23 patients, a C0 onto C4 stabilization in 7 and an anterior odontoid screw fixation in 2. The union rate was 100%. Twenty-one type II SFs (91%) consolidated with a nonoperative management ( P < 0.001). A primary non-union occurred more often in type II than in type III fractures ( P = 0.0023). There was no significant difference in the 30-day overall case fatality ( P = 0.3786).
Conclusion
To separate dens fractures into SFs and UFs is feasible. For SFs, semi-rigid immobilization provides a high consolidation rate. Stable non-unions are acceptable, and the authors suggest a posterior transarticular C1–C2 fixation as the preferred surgical treatment for UFs.
Level of evidence
Level III.
... 1,3 The nonoperative management has satisfactory clinical outcome in case of a stable fracture in younger patients. 12 There is a wide range of Type II-associated complications including death. 6 Type III fracture is considered relatively stable and is, similar to Type I fracture, often treated with collar stabilization. ...
Study design:
Laboratory study.
Objective:
This study aimed to investigate the biomechanical competence and fracture characteristics of the odontoid process.
Summary of background data:
Odontoid fractures of the second cervical vertebra (C2) represent the most common spine fracture type in the elderly. However, very little is known about the underlying biomechanical fracture mechanisms.
Materials and methods:
A total of 42 C2 human anatomic specimens were scanned via computed tomography, divided in six groups, and subjected to combined quasistatic loading at -15°, 0°, and 15° in sagittal plane and -50° and 0° in transverse plane until fracturing. Bone mineral density (BMD), height, fusion state of the ossification centers, stiffness, yield load, and ultimate load were assessed.
Results:
While lowest values for stiffness, yield load, and ultimate load were observed at load inclination of 15° in sagittal plane, no statistically significant differences were observed between the study groups ( P ≥0.235). BMD correlated positively with yield load ( r2 =0.350, P <0.001) and ultimate load ( r2 =0.955, P <0.001) but not with stiffness ( r2 =0.082, P =0.07). The specimens with clearly distinguishable fusion of the ossification centers revealed less data scattering of the biomechanical outcomes.
Conclusion:
Load direction plays a subordinate role in traumatic fractures of the odontoid process. BMD was associated with significant correlation to the biomechanical outcomes. Thus, odontoid fractures appear to result from of an interaction between the load magnitude and bone quality.
... A study about risk factors for odontoid fractures in elderly (aged ≥ 60 years) by Johannes et al. [19] demonstrated that structural and age-related bone mineral density actually was the most crucial and independent predisposing factor affecting the fracture healing. Therefore, from the results of the current several studies [22,23], we did not perform an instruments removal operation for patients older than 60 years. For those older patients, more studies are needed to explore temporary fixation technique. ...
Introduction
Posterior C1–C2 pedicle screw fixation is a reliable technique used in treatment of type II odontoid fracture. However, the loss of cervical range of rotation motion (RORM) was inevitable. There were few studies focusing on the influence of short-term C1–C2 fixation with nonfusion technique to preserve cervical function in patients younger than 60 years. The purpose of this study was to compare cervical RORM which was measured by an improved goniometer, and the clinical outcomes between short-term and long-term C1–C2 fixation techniques in the treatment of Grauer type 2B and 2C odontoid fracture.
Materials and methods
This study represents a retrospective analysis, including patients who underwent primary C1–C2 fixation surgery. These patients were divided into short-term and long-term groups based on whether underwent a fixation removal operation. The clinical results were collected and compared between the two groups. Independent T test and Chi-square analyses were used to identify significant differences between the two groups and dependent T test was used within each group. Statistical significance was set at p < .05.
Results
There were no severe postoperative complications, and all 60 patients achieved spinal stabilization after primary surgery. The mean rotation angle in the short-term group at last follow-up time was 138.39 ± 21.06°, which was better than 83.59 ± 13.06° in the long-term group (p < .05). The same statistical difference was observed in flexion–extension angle, which was 71.11 ± 18.73° in short-term group and 53.34 ± 18.23° in long-term group. The mean NDI score in short-term group at last follow-up time was 1.23 ± 0.86 and better than 8.24 ± 3.17 in long-term group. However, the VAS score in short-term group was 1.82 ± 0.54 which was worse compared to 0.64 ± 0.29 in long-term group.
Conclusions
The results demonstrated that primary C1–C2 fixation with nonfusion technique could support satisfactory clinical effects. In addition, the removal of instruments after bony fusion could improve the function of cervical movement significantly in patients under 60 years.
... Collected parameters were age, gender, treatment modality (hard or soft collar), mechanism of injury, associated injuries, 30-day and 1 year mortality, comorbid conditions to allow calculation of Charlson Co-morbidity Index (CCI) 9 and the modified Frailty Index-11 (mFI-11), 10 complication, and fracture healing (union or non-union). Fractures were classified using Anderson and D'Alonzo classification, 11 and the degree of angulation and amount of translation were calculated. Fracture union was determined by presence of trabeculae across the fracture, absence of visible fracture line, absence of movement on dynamic radiographs (where available) on anteroposterior and lateral cervical spine radiographs (assessed by single fellowship-trained spine surgeon). ...
Introduction
Odontoid peg fractures (OF) are the most common cervical spine fracture in the elderly. This retrospective analysis aimed to compare the outcomes of older patients with OF who had been managed non-operatively with either a hard or soft cervical collar.
Materials and Methods
We analysed the retrospective data of the clinical and radiographic records of patients 60 years or older who presented over a 10-year period with OF and were treated non-operatively with a cervical collar. Mortality was the primary outcome measure with mechanism of injury, complications, and fracture healing secondary measures.
Results
45 patients (hard collar n = 22; soft collar n = 23) were included with comparable demographics for frailty and co-morbidities in each group; age was significantly higher in the soft collar group (80.6 vs 86.4 years; P = .0065). Associated injuries and complications were not significantly different overall, or when Type II fractures were separately analysed ( P = .435 associated injuries, P = .121 complications). All-cause mortality was greater in the soft collar group (30-day mortality hard: 0%, soft: 9%; 1-year mortality hard: 18%, soft: 48% P = .035). However, once corrected for age, this proved not to reach significance ( P = .333) in any fracture type. Non-union was common (77%) but was not significantly different (hard = 70%; soft = 87%; P = .419).
Discussion
Consistent with other reports, non-union rates remained substantial regardless of which collar was used. After controlling for age, there was no difference in all-cause mortality between elderly patients treated with a hard or soft cervical collar for odontoid peg fractures.
Conclusions
Soft collars appear suitable for the treatment of odontoid peg fractures in the elderly without compromising outcome. Larger cohort analyses will help confirm this finding.
... This is caused by the gap itself, a well-known and intuitive principle, but also by the excessive friction determined by the occipital condile on the lateral C1 mass with bone spaced apart. This can determine a clinical severe course with chronic pain, impairment of cervical motion, and important limitation in daily activities and work (Butler et al., 2010;Meeson et al., 2019;Müller et al., 2003). ...
Introduction
Bilateral fracture of the C1 lateral mass is a relatively uncommon type of traumatic lesion. Treatment of this kind of fractures is usually conservative, with either external immobilization or traction.
Research question
Whether surgical management, with placement of lag screws in lateral mass of C1, could represent a first-line treatment.
Material and methods
We describe a case of 67-years old man with bilateral fractures of lateral mass of Atlas due to road accident trauma without ligament lesion but severe gap between bone edges. We performed Computed Tomography and Magnetic Resonance scans for pre-operative imaging, X-Ray and CT scan for follow-up. Medtronic navigation system was used as intraoperative guidance for screw placement.
Results
Radiological and clinical results were good, with optimal bone reduction and patient's early return to daily activities.
Discussion and conclusion
Surgical management remains debateable for isolated C1 lateral mass fractures. Different surgical approaches have been described for atlas fractures, such as transoral anterior C1-ring plate osteosynthesis, posterior osteosynthesis with a lateral mass screw rod, and posterior C1 to C2 fusion and C0 to C2 fusion. Minimally invasive operative treatment with lag screw and reduction of fracture's edges without occiput-C1 or C1-C2 stabilization could be the optimal treatment with good result and decreasing rate of pseudoarthrosis, allowing to avoid Halo-vest discomfort and complications.
... In the present prospective study, which is one of the largest of this type, the most frequent types of cervical trauma were isolated (48.8%) or associated with head trauma (32.6%), while this was in a context of polytrauma in only 18.7% of patients; this is consistent with the literature as cervical fractures in the elderly are generally are isolated and due to low-energy trauma [6][7][8][9][10][11][12]. Another point to consider is that spinal cord injury (SCI) occurred in 5.4% of patients herein, which is of note as SCIs are a serious condition that are associated with traumatic cervical spine fracture and often cause significant morbidity and mortality [22][23][24][25][26][27][28]. This frequency is similar to that reported elsewhere (3.62% [19] and 4.7% [20]); in particular in the systematic review reported by Jubert et al. [22], upper cervical spine fracture resulted in a neurological deficit in 4.7% of cases and with tetraparesia in 0.8%. ...
Background
C1-C2 injury represents 25–40% of cervical injuries and predominantly occurs in the geriatric population.
Methods
A prospective multicentre study was conducted under the aegis of the french spine surgery society (SFCR) investigating the impact of age, comorbidities, lesion type, and treatment option on mortality, complications, and fusion rates.
Results
A total of 417 patients were recruited from 11 participating centres. The mean ± SD age was 66.6 ± 22 years, and there were 228 men (55%); 5.4% presented a neurological deficit at initial presentation. The most frequent traumatic lesion was C2 fracture (n = 308). Overall mortality was 8.4%; it was 2.3% among those aged ≤ 60 years, 5.0% 61–80 years, and 16.0% > 80 years (p < 0.001). Regarding complications, 17.8% of patients ≤ 70 years of age presented with ≥ 1 complication versus 32.3% > 70 years (p = 0.0009). The type of fracture did not condition the onset of complications and/or mortality (p > 0.05). The presence of a comorbidity was associated with a risk factor for both death (p = 0.0001) and general complication (p = 0.008). Age and comorbidities were found to be independently associated with death (p < 0.005). The frequency of pseudoarthrosis ranged from 0 to 12.5% up to 70 years of age and then constantly and progressively increased to reach 58.6% after 90 years of age.
Conclusions
C1-C2 injury represents a serious concern, possibly life-threatening, especially in the elderly. We found a major impact of age and comorbidities on mortality, complications, and pseudarthrosis; injury pattern or treatment option seem to have a minimal effect.
... Continuing movement can also lead to bone lysis. [1][2][3][4][5][6] Late presenting atlantoaxial injuries are often treated by occipitocervical fusion. For decompression where necessary the odontoid process may be removed transorally or the C1 posterior arch and foramen magnum edge removed. ...
We report a case of the atlantoaxial (C1–2) deformity secondary to a neglected C2 odontoid fracture that was successfully treated with 3-stage operation performed in one session.
