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Perspectives on the management of odontoid fracture
ELSEVIER
EDITOR'S NOTE This is another installment in Surgical Neurology’s new feature, in which we present a clinical case with selected imaging studies. The management of the case is controversial; the viewpoints of experienced neurosurgeons from around the world are presented to provide a spectrum of opinions for our readers to consider. We hope you find this feature interesting and useful.
This case is a 46-year-old physician who was involved in an automobile accident. He was brought to the hospital complaining of neck pain. He was neurologically intact. X rays and computed tomography (CT) scans were obtained (Figures 1 and 2). How would you manage this case? James I. Ausman, M.D., Ph.D.
Ediior
PERSPECTIVES ON THE MANAGEMENT ODONTOID FRACTURE
OF
The X rays of this patient demonstrate a comminuted fracture of the odontoid process extending into the body of C2. There appears to be an odontoid body fracture with a displacement of the inferior fragment posteriorly, suggesting a partial tear of the transverse ligament. I would feel the tendency for healing with rigid immobilization is fairly good and would recommend placing the patient in a halo vest for 3 months after being reduced in traction prior to application of the rigid fixation. If X rays demonstrate nonunion with continued instability, then a standard posterior fusion from C 1 to C3, as described by Alexander, should be done. This involves sublaminar wiring over a rigid strut of bone obtained from the pelvic brim associated with the application of cancellous bone over the denuded surfaces of the lamina and facet joints. Maintenance in a rigid brace following this operative procedure should suffice until signs of satisfactory healing have been demonstrated. Lateral cervical spine X ray.
ICI
John Paul Wissinger, M.D.
San Antonio, Texas
0 1995 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010
Managing Odontoid
Fractures
This 46year-old physician appears to have suffered a type II odontoid fracture with a small amount of anterolisthesis as demonstrated on both the plain film and the reconstructed computed tomography (CT) scan. Disruption of the odontoid in this manner results in atlantoaxial instability and places the patient in jeopardy of possibly catastrophic cord compromise. Stabilization is therefore imperative. Conventional management of this problem usually consists of a trial period of immobilization using a rigid external halo vest orthosis or Minerva jacket, or a posterior fusion between the first and second cervical vertebrae. The former carries with it a significant amount of restriction of activity and associated social morbidity, as well a small chance of complications such as pin site infections. It requires significant daily care and attention, and often restricts the individual from his normal employment during the period of immobilization, which is usually about 3 months. Because the success of immobilization varies substantially, when one reviews the various published series, but averages perhaps 50%-60%, many individuals have advocated going directly to a surgical stabilization procedure. This traditionally has been a posterior Cl-2 fusion using one of a number of cerclage wire techniques coupled with a bone graft between the posterior arches of Cl and C2. These too have not been universally successful, and, indeed, in many unstable circumstances also require external immobilization to enhance the chance of successful fusion. When successful, such fusion eliminates 50% of the rotation of the head which normally occurs at the Cl-2 level. While this is a good compromise in terms of preventing catastrophic dislocation at Cl-2, it would be desirable to preserve this motion. For the foregoing reasons, we have been in favor of approaching these fractures directly with an anteriorly placed fixation screw that enters the anterior inferior edge of the body of C2 and traverses that body and then into the odontoid, fixating the fracture site without immobilizing the Cl-2 complex. This particular patient would seem to be very ideally suited to this approach. He is relatively young, and I would assume, given the information supplied, that he is basically healthy. He has an anterolisthesed fracture, which normally would reduce in extension, the ideal position to place these patients for screw fixation. Screw fixation would allow him to quickly resume his normal activities as a physician, usually within a few days, avoiding a prolonged period of immobility while waiting for bone healing. At the same time, it provides both immediate stability and facilitates bone fusion for
Surg Neurol 1995;43:428-31
429
(A) Anterior-posterior view: lag screw (partially q threaded) placed first draws odontoid fragment toward body of C2. [B) Lateral view: Screws engage distal odontoid cortex and firmly fixate it to C2 body, restoring stability and providing optimum environment for bony union.
long-term stability of this area. It would also preserve the normal Cl-2 motion segment. This technique, while previously considered somewhat formidable, has been greatly facilitated by the development of a guide tube instrumentation
430
Surg Neurol 1995:43:428-31
set. This allows this operation to be done through a small, low-cervical, natural skin-crease incision under biplane fluoroscopic control for precise screw placement with great safety. Its success rate in acute fractures approaches 100%. The typical configuration of the fixation screws is shown in Figure 3 A and B. Ronald I. Apfelbaum, M.D. Salt Lake City, Utah REFERENCES 1. Apfelbaum RI.Anterior screw fixation of odontoid fractures. In: Camins MD, O’Leary PF, eds. Disorders of the 2.
3. 4.
5.
cervical spine. Baltimore: Williams & Wilkins, 1992: 603-8. Apfelbaum RI. Anterior screw fixation of odontoid fractures. In: Rengachary SS, Wilkins RH, eds. Neurosurgical operative atlas. Baltimore: Williams & Wilkins, 1992:189-99. Apfelbaum RI. Anterior screw fixation of odontoid fractures. Aesculap Scientific Information #24, D7200 Tuttlingen, Germany: Aesculap AC, 1994. Borne GM, Bedou GL, Pinaudeau M, Cristino G, Hussein A. Odontoid process fracture osteosynthesis with a direct screw fixation technique in nine consecutive cases. J Neurosurg 1988;68:223-6. Geisler FH, Cheng C, Poka A, Brumback RJ. Anterior screw fixation of posteriorly displaced type II odontoid fractures. Neurosurg 1989;25:30-8.
Diagnosis: Fracture of the base of the odontoid process, with mild anterior dislocation. There is a possibility of another fracture in the middle part needing more radiologic exposures. In such a fracture there is a disruption of the blood supply which leads to nonunion. There is no apparent widening of the distance between the spinous processes of Cl and C2, excluding a tear in the check ligaments at the atlantoaxial joint. Management: As the patient is neurologically intact and there is no major dislocation, all that is needed is fixation. Under general anesthetic and in face-down position, a midline incision is made between the occiput and C4 spine. Two Roy Camille plates are fixed, one on each side of the spinous processes between the occiput and the midpoint of the lateral mass of C2 and C3 vertebrae. A drill with a stopper is used to protect the underlying structures. The occipital end is fixed 1.5 to 2 cm from the midline, allowing for anatomic variations. Two screws are used, the lower one 1.3 cm above the level of the foramen magnum, and the upper one 1.3 cm above the first screw (i.e., 2.6 cm above the level of the foramen magnum). The cervical end is fixed by a screw at the midpoint of the lateral mass of C2 and C3. A
corticocancellus bone graft taken from the iliac crest is fixed medial to the plate on each side between the occiput and C3 lamina. The wound is closed in layers with drainage. A mold of orthoplast is fixed, beginning under the chin and occiput and extending over the shoulders and upper chest both anteriorly and posteriorly to the level of the manubrium. This is maintained for three weeks. Sayed El-Gindi, F.R.C.S. Cairo, Egypt
In the imaging studies presented there is, in my opinion, a mixed fracture of odontoid apophysis types I and 11.The line of fracture of the odontoid base is horizontal with anterior displacement. This type of fracture, especially in the case discussed, is very unstable due to the horizontal alignment of the fracture, anterior displacement, and multiple fragments in the form of a British police helmet. Whereas fractures of type I are quite stable those of type 11are unstable and, with the characteristics of this case, can produce pseudo-occlusion. None of the treatments used in odontoid apophysis fracture have been universally accepted. If the patient is in pain cranial traction should be carried out, as an initial measure, for the shortest possible time, which in addition reduces muscular contraction. In this case, because the fracture is considered unstable, surgical treatment should be initiated in 2 to 4 days. Once the fracture is reduced through traction, we would carry out an anterior intervention with a screw fixation cortex-sponge, inserted through the anterior side of the odontoid apophysis. If the fracture were not unstable, we would apply a thoracic halo and Minerva plaster for 3 months. The case for posterior arthrodesis could be argued but, in our opinion, it is much more complicated. In our personal series of ten cases, we have not had greater complications than the expulsion of the screw 3 months after intervention, with the fracture already consolidated. Finally, whether or not the treatment is surgical, the consolidation and stability of the articulation must be confirmed radiologically, following these two criteria: (1) the passage of trabecula from one side of the fracture to the other, and (2) the absence of movement at the point of fracture. Vicente Calatayud Maldonado, M.D. Zaragoza, Spain
Managing Odontoid
Surg Neurol 1995;43:428-31
Fractures
REFERENCES Aebi M, Etter C, Coscia M. Fractures of the odontoid process: treatment with anterior screw fixation. Spine 1989;14:1065-70. Anderson LD, Alonzo RT. Fractures of the odontoid process of the axis. J Bone Joint Surg 1974;56(A): 1663-4. Borne GM, Bedou GL, Pinaudeau M, Hussein A. Odontoid process fracture osteosynthesis with a direct screw fixation technique in nine consecutive cases. J Neurosurg 1988;68:223-6. Hanssen AD, Cabanelia ME. Fractures of the dens in
adult patients. J Trauma 1987;27:928-34. This 46-year-old physician, who was involved in a motor vehicle accident, presented with the chief complaint of neck pain with a normal neurologic examination. A radiography and a CT scan revealed a type II odontoid fracture, which is anterior dislocated. The fracture is at the base of the odontoid on the reconstructed CT image. There also appears to be a second fracture through the midportion of the odontoid; however, this may be an artifact often seen on reconstructed images. The treatment of this type of fracture has several alternatives. If the odontoid fracture is dislocated less than 6 mm, in our experience patients treated with an external halo orthosis have a nonunion rate of only 10% and a success rate of 90% [3]. On the other hand, if this dislocation is more than 6 mm, then the use of an external halo orthosis will result in a nonunion rate of approximately 78%. Consequently, because the fracture is dislocated less than 6 mm, this patient would have a good chance of fusing if immobilized in a halo for about 3 months. If the halo is not used, the alternative treatment is to fixate the fracture with an anterior odontoid screw [1,2]. The ideal patient for fixation with a screw is usually one with a posterior dislocated odontoid fracture and an intact transverse ligament. For this patient, I assume that the transverse ligament is intact, because this is an anterior dislocated odontoid. Consequently, this patient could be a candidate for an anterior screw fixation of the
43 1
odontoid if the fracture reduces with a slight amount of tension, or even a minimum amount of traction. I would be less enthusiastic about a posterior transarticular screw fixation of Cl and C2 because of the loss of cervical rotation by almost 50%. For this particular fracture, the two former options are more appropriate [ 41. In conclusion, I would treat the patient with a halo orthosis for 3 months or an anterior odontoid screw, depending upon the extent of reduction that can be achieved and the patient’s desire. Volker K. H. Sonntag, M.D.
Phoenix, Arizona REFERENCES Apfelbaum RI. Apfelbaum surgical technique. Aesculap brochure. February 1993. Geisler FH, Cheng C, Poka A, Brumback RJ. Anterior screw fixation of posteriorly displaced type II odontoid fractures. Neurosurgery 1989;25(1):30-8. Hadley MN, Dickman CA, Browner CM, Sonntag VKH.
Acute axis fractures: a review of 229 cases. J Neurosurg 1989;71:642-7. Marcotte P, Dickman CA, Sonntag VKH, Karahalios DG, Drabier J. Posterior atlantoaxial facet screw fixation. J Neurosurg 1993;79:234-7. In this special case, I would first try to reduce the anterior listhesis by Crutchfield traction, and then do a direct fixation with a screw through an anterolateral approach, starting at the inferior rim of the body of C2; the screw has to be directed towards the top of the odontoid process. Continuous X ray control is mandatory. There is still discussion of whether or not the screw should go through the corticalis of the top of the odontoid. According to my experience, this is not necessary. This operation will allow normal craniospinal mobility. Luc Calliauw, M.D.
Brussels, Belgium
EDITOR'S NOTE This is another installment in Surgical Neurology’s new feature, in which we present a clinical case with selected imaging studies. The management of the case is controversial; the viewpoints of experienced neurosurgeons from around the world are presented to provide a spectrum of opinions for our readers to consider. We hope you find this feature interesting and useful.
This case is a 46-year-old physician who was involved in an automobile accident. He was brought to the hospital complaining of neck pain. He was neurologically intact. X rays and computed tomography (CT) scans were obtained (Figures 1 and 2). How would you manage this case? James I. Ausman, M.D., Ph.D.
Ediior
PERSPECTIVES ON THE MANAGEMENT ODONTOID FRACTURE
OF
The X rays of this patient demonstrate a comminuted fracture of the odontoid process extending into the body of C2. There appears to be an odontoid body fracture with a displacement of the inferior fragment posteriorly, suggesting a partial tear of the transverse ligament. I would feel the tendency for healing with rigid immobilization is fairly good and would recommend placing the patient in a halo vest for 3 months after being reduced in traction prior to application of the rigid fixation. If X rays demonstrate nonunion with continued instability, then a standard posterior fusion from C 1 to C3, as described by Alexander, should be done. This involves sublaminar wiring over a rigid strut of bone obtained from the pelvic brim associated with the application of cancellous bone over the denuded surfaces of the lamina and facet joints. Maintenance in a rigid brace following this operative procedure should suffice until signs of satisfactory healing have been demonstrated. Lateral cervical spine X ray.
ICI
John Paul Wissinger, M.D.
San Antonio, Texas
0 1995 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010
Managing Odontoid
Fractures
This 46year-old physician appears to have suffered a type II odontoid fracture with a small amount of anterolisthesis as demonstrated on both the plain film and the reconstructed computed tomography (CT) scan. Disruption of the odontoid in this manner results in atlantoaxial instability and places the patient in jeopardy of possibly catastrophic cord compromise. Stabilization is therefore imperative. Conventional management of this problem usually consists of a trial period of immobilization using a rigid external halo vest orthosis or Minerva jacket, or a posterior fusion between the first and second cervical vertebrae. The former carries with it a significant amount of restriction of activity and associated social morbidity, as well a small chance of complications such as pin site infections. It requires significant daily care and attention, and often restricts the individual from his normal employment during the period of immobilization, which is usually about 3 months. Because the success of immobilization varies substantially, when one reviews the various published series, but averages perhaps 50%-60%, many individuals have advocated going directly to a surgical stabilization procedure. This traditionally has been a posterior Cl-2 fusion using one of a number of cerclage wire techniques coupled with a bone graft between the posterior arches of Cl and C2. These too have not been universally successful, and, indeed, in many unstable circumstances also require external immobilization to enhance the chance of successful fusion. When successful, such fusion eliminates 50% of the rotation of the head which normally occurs at the Cl-2 level. While this is a good compromise in terms of preventing catastrophic dislocation at Cl-2, it would be desirable to preserve this motion. For the foregoing reasons, we have been in favor of approaching these fractures directly with an anteriorly placed fixation screw that enters the anterior inferior edge of the body of C2 and traverses that body and then into the odontoid, fixating the fracture site without immobilizing the Cl-2 complex. This particular patient would seem to be very ideally suited to this approach. He is relatively young, and I would assume, given the information supplied, that he is basically healthy. He has an anterolisthesed fracture, which normally would reduce in extension, the ideal position to place these patients for screw fixation. Screw fixation would allow him to quickly resume his normal activities as a physician, usually within a few days, avoiding a prolonged period of immobility while waiting for bone healing. At the same time, it provides both immediate stability and facilitates bone fusion for
Surg Neurol 1995;43:428-31
429
(A) Anterior-posterior view: lag screw (partially q threaded) placed first draws odontoid fragment toward body of C2. [B) Lateral view: Screws engage distal odontoid cortex and firmly fixate it to C2 body, restoring stability and providing optimum environment for bony union.
long-term stability of this area. It would also preserve the normal Cl-2 motion segment. This technique, while previously considered somewhat formidable, has been greatly facilitated by the development of a guide tube instrumentation
430
Surg Neurol 1995:43:428-31
set. This allows this operation to be done through a small, low-cervical, natural skin-crease incision under biplane fluoroscopic control for precise screw placement with great safety. Its success rate in acute fractures approaches 100%. The typical configuration of the fixation screws is shown in Figure 3 A and B. Ronald I. Apfelbaum, M.D. Salt Lake City, Utah REFERENCES 1. Apfelbaum RI.Anterior screw fixation of odontoid fractures. In: Camins MD, O’Leary PF, eds. Disorders of the 2.
3. 4.
5.
cervical spine. Baltimore: Williams & Wilkins, 1992: 603-8. Apfelbaum RI. Anterior screw fixation of odontoid fractures. In: Rengachary SS, Wilkins RH, eds. Neurosurgical operative atlas. Baltimore: Williams & Wilkins, 1992:189-99. Apfelbaum RI. Anterior screw fixation of odontoid fractures. Aesculap Scientific Information #24, D7200 Tuttlingen, Germany: Aesculap AC, 1994. Borne GM, Bedou GL, Pinaudeau M, Cristino G, Hussein A. Odontoid process fracture osteosynthesis with a direct screw fixation technique in nine consecutive cases. J Neurosurg 1988;68:223-6. Geisler FH, Cheng C, Poka A, Brumback RJ. Anterior screw fixation of posteriorly displaced type II odontoid fractures. Neurosurg 1989;25:30-8.
Diagnosis: Fracture of the base of the odontoid process, with mild anterior dislocation. There is a possibility of another fracture in the middle part needing more radiologic exposures. In such a fracture there is a disruption of the blood supply which leads to nonunion. There is no apparent widening of the distance between the spinous processes of Cl and C2, excluding a tear in the check ligaments at the atlantoaxial joint. Management: As the patient is neurologically intact and there is no major dislocation, all that is needed is fixation. Under general anesthetic and in face-down position, a midline incision is made between the occiput and C4 spine. Two Roy Camille plates are fixed, one on each side of the spinous processes between the occiput and the midpoint of the lateral mass of C2 and C3 vertebrae. A drill with a stopper is used to protect the underlying structures. The occipital end is fixed 1.5 to 2 cm from the midline, allowing for anatomic variations. Two screws are used, the lower one 1.3 cm above the level of the foramen magnum, and the upper one 1.3 cm above the first screw (i.e., 2.6 cm above the level of the foramen magnum). The cervical end is fixed by a screw at the midpoint of the lateral mass of C2 and C3. A
corticocancellus bone graft taken from the iliac crest is fixed medial to the plate on each side between the occiput and C3 lamina. The wound is closed in layers with drainage. A mold of orthoplast is fixed, beginning under the chin and occiput and extending over the shoulders and upper chest both anteriorly and posteriorly to the level of the manubrium. This is maintained for three weeks. Sayed El-Gindi, F.R.C.S. Cairo, Egypt
In the imaging studies presented there is, in my opinion, a mixed fracture of odontoid apophysis types I and 11.The line of fracture of the odontoid base is horizontal with anterior displacement. This type of fracture, especially in the case discussed, is very unstable due to the horizontal alignment of the fracture, anterior displacement, and multiple fragments in the form of a British police helmet. Whereas fractures of type I are quite stable those of type 11are unstable and, with the characteristics of this case, can produce pseudo-occlusion. None of the treatments used in odontoid apophysis fracture have been universally accepted. If the patient is in pain cranial traction should be carried out, as an initial measure, for the shortest possible time, which in addition reduces muscular contraction. In this case, because the fracture is considered unstable, surgical treatment should be initiated in 2 to 4 days. Once the fracture is reduced through traction, we would carry out an anterior intervention with a screw fixation cortex-sponge, inserted through the anterior side of the odontoid apophysis. If the fracture were not unstable, we would apply a thoracic halo and Minerva plaster for 3 months. The case for posterior arthrodesis could be argued but, in our opinion, it is much more complicated. In our personal series of ten cases, we have not had greater complications than the expulsion of the screw 3 months after intervention, with the fracture already consolidated. Finally, whether or not the treatment is surgical, the consolidation and stability of the articulation must be confirmed radiologically, following these two criteria: (1) the passage of trabecula from one side of the fracture to the other, and (2) the absence of movement at the point of fracture. Vicente Calatayud Maldonado, M.D. Zaragoza, Spain
Managing Odontoid
Surg Neurol 1995;43:428-31
Fractures
REFERENCES Aebi M, Etter C, Coscia M. Fractures of the odontoid process: treatment with anterior screw fixation. Spine 1989;14:1065-70. Anderson LD, Alonzo RT. Fractures of the odontoid process of the axis. J Bone Joint Surg 1974;56(A): 1663-4. Borne GM, Bedou GL, Pinaudeau M, Hussein A. Odontoid process fracture osteosynthesis with a direct screw fixation technique in nine consecutive cases. J Neurosurg 1988;68:223-6. Hanssen AD, Cabanelia ME. Fractures of the dens in
adult patients. J Trauma 1987;27:928-34. This 46-year-old physician, who was involved in a motor vehicle accident, presented with the chief complaint of neck pain with a normal neurologic examination. A radiography and a CT scan revealed a type II odontoid fracture, which is anterior dislocated. The fracture is at the base of the odontoid on the reconstructed CT image. There also appears to be a second fracture through the midportion of the odontoid; however, this may be an artifact often seen on reconstructed images. The treatment of this type of fracture has several alternatives. If the odontoid fracture is dislocated less than 6 mm, in our experience patients treated with an external halo orthosis have a nonunion rate of only 10% and a success rate of 90% [3]. On the other hand, if this dislocation is more than 6 mm, then the use of an external halo orthosis will result in a nonunion rate of approximately 78%. Consequently, because the fracture is dislocated less than 6 mm, this patient would have a good chance of fusing if immobilized in a halo for about 3 months. If the halo is not used, the alternative treatment is to fixate the fracture with an anterior odontoid screw [1,2]. The ideal patient for fixation with a screw is usually one with a posterior dislocated odontoid fracture and an intact transverse ligament. For this patient, I assume that the transverse ligament is intact, because this is an anterior dislocated odontoid. Consequently, this patient could be a candidate for an anterior screw fixation of the
43 1
odontoid if the fracture reduces with a slight amount of tension, or even a minimum amount of traction. I would be less enthusiastic about a posterior transarticular screw fixation of Cl and C2 because of the loss of cervical rotation by almost 50%. For this particular fracture, the two former options are more appropriate [ 41. In conclusion, I would treat the patient with a halo orthosis for 3 months or an anterior odontoid screw, depending upon the extent of reduction that can be achieved and the patient’s desire. Volker K. H. Sonntag, M.D.
Phoenix, Arizona REFERENCES Apfelbaum RI. Apfelbaum surgical technique. Aesculap brochure. February 1993. Geisler FH, Cheng C, Poka A, Brumback RJ. Anterior screw fixation of posteriorly displaced type II odontoid fractures. Neurosurgery 1989;25(1):30-8. Hadley MN, Dickman CA, Browner CM, Sonntag VKH.
Acute axis fractures: a review of 229 cases. J Neurosurg 1989;71:642-7. Marcotte P, Dickman CA, Sonntag VKH, Karahalios DG, Drabier J. Posterior atlantoaxial facet screw fixation. J Neurosurg 1993;79:234-7. In this special case, I would first try to reduce the anterior listhesis by Crutchfield traction, and then do a direct fixation with a screw through an anterolateral approach, starting at the inferior rim of the body of C2; the screw has to be directed towards the top of the odontoid process. Continuous X ray control is mandatory. There is still discussion of whether or not the screw should go through the corticalis of the top of the odontoid. According to my experience, this is not necessary. This operation will allow normal craniospinal mobility. Luc Calliauw, M.D.
Brussels, Belgium