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Atlanto-axial posterolateral dislocation associated with a type II displaced odontoid fracture
Interdisciplinary Neurosurgery 12 (2018) 45–47
Contents lists available at ScienceDirect
Interdisciplinary Neurosurgery journal homepage: www.elsevier.com/locate/inat
Case Report
Atlanto-axial posterolateral dislocation associated with a type II displaced odontoid fracture
T
⁎
Felix K.K. Ségbédji , Armel Junior Tokpo, Alëna A. Nubukpo-Guménu, M. Benzagmout Neurosurgery Department, HASSAN II Teaching Hospital Fez, Sidi Mohamed Ben Abdellah University of Fez, Morocco
A R T I C L E I N F O
A B S T R A C T
Keywords: Left arm monoparesis Posterolateral atlanto-axial dislocation Intraoperative traction Retropharyngeal anterior approach
Atlanto-axial posterolateral dislocations associated with an odontoid fracture are rare traumatic lesions of the upper cervical spine. Their therapeutic management is discussed. We report the case of a 28-year-old man with no significant medical history admitted to the emergency room with upper cervical spinal trauma following a frontal collision of two vehicles. We found a left arm monoparesis and a posterolateral atlanto-axial dislocation associated with a fracture of the displaced type II odontoid. The patient was treated by a retropharyngeal approach anteriorly after reduction by intraoperative traction by Gardner wells tongs maintained by a weight of 10 kg. The evolution was marked by a complete recovery of the left arm monoparesis at two months followed by physiotherapy.
1. Introduction The combination of atlanto-axial joint dislocation and odontoid process fracture is usually a lethal injury and as a result, reports of survivors are rare. In the last thirty years only fifteen clinical cases have been described [1–2]. The patients had no neurological deficits in seven of the reported cases [1–3]. In only one case a spastic tetraparesis was described [4]. Their therapeutic management is discussed. According to our review of the literature, we report the second case in the literature of these lesions treated by retropharyngeal approach. And the first case with neurological complication treated by this management. 2. Case A 28-year-old man with no significant medical history was admitted to the emergency department with an upper cervical spinal trauma following a head on collision of two vehicles. Initial assessment had found a left arm monoparesis and a posterolateral atlanto-axial dislocation associated with a fracture of the displaced type II odontoid (Fig. 1). The patient was treated by a retropharyngeal approach anteriorly after reduction by intraoperative traction by Gardner Wells tongs and maintained by a weight of 10 kg. The surgical technique consisted of a horizontal right anterolateral incision; opening of the platysma muscle of the neck followed by dissection of the different planes to the cervical spine; opening of the deep cervical aponeurosis and the anterior longitudinal ligament; recording of the space C2–C3 by fluoroscope ⁎
and creating a C3 longitudinal channel orienting the spindle guide; positioning of the spindle guide; drilling of C2 under fluoroscopic guidance to better appreciate the path; and tunneling to the tap and placing a 34 mm screw taking the odontoid. The evolution was marked by a complete recovery of the left arm monoparesis at the end of two months followed by physiotherapy. The CT-scan of the cervical spine five months later showed a consolidation of the fracture (Fig. 2). 3. Discussion The first case of atlanto-axial posterolateral dislocation associated with a type II displaced odontoid fracture treated through retropharyngeal approach reported in the literature by G. Riouallon, concerned a 25-year-old man with no neurological complications. Association between acute odontoid fracture and C1–C2 dislocation is documented in several case reports or short series. Three types of dislocation are reported: rotatory dislocations in 3 case reports [5–7]; lateral dislocations in 19 patients with fixed atlanto-axial dislocation associated with odontoid fracture [8–9]; vertical dislocations in 2 case reports [10–11]. The literature report only two cases of acute fracture dislocation of atlanto-axial complex with posterior displacement: Das-Gupta reported a case of a 75 year-old-patient treated with skull traction applied in flexion10° for 6 weeks and then with external fixation [12] and Zhang et al. published recently a first case in a young man, who was also treated with skull traction applied in flexion 10° for 70 days and then transoralatlanto-axial reduction plate surgery [13].
Corresponding author. E-mail address: [email protected] (F.K.K. Ségbédji).
https://doi.org/10.1016/j.inat.2018.01.001 Received 23 November 2017; Accepted 6 January 2018 2214-7519/ © 2018 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/BY-NC-ND/4.0/).
Interdisciplinary Neurosurgery 12 (2018) 45–47
F.K.K. Ségbédji et al.
Fig. 1. CT-scan showed posterolateral atlanto-axial dislocation associated with a fracture of the displaced type II odontoid.
posterolateral dislocation associated with a type II displaced odontoid fracture treated through retropharyngeal approach as published by G. Riouallon and al [16]. We initially involved/applied traction with a moderate flexion and obtain a partial reduction. We obtained a complete reduction only with a traction combined with extension. The reduction maneuver is probably specific of this type of fracture dislocation C1–C2 with posterior displacement. The screw trajectory through the odontoid appears to be off-centre, but caused no damage to our patient. He had a complete recovery of the left arm monoparesis and any symptoms now.
The mechanism leading to posterior displacement of the odontoid process seems to be hyperextension [14–15]. This kind of injury is rarely seen, because extension fracture-dislocation of the atlas and odontoid process is an injury where the atlas together with the odontoid process is displaced backwards, thus causing narrowing of the spinal canal and compression of its contents by the displaced odontoid process. Patients with major cord damage at this level rarely survive [12]. Therefore the trauma was responsible for a posterior displacement of a unit including the odontoid and the atlas towards the rest of the axis. We report a third case secondary to high-energy trauma in a young man treated with another kind of management. Despite the fact that the entire cervical canal is compromised, our patient miraculously only had a monoparesis of the arm. We applied traction with a moderate flexion combined reduction maneuvers during the surgery and obtained a complete reduction. Then we perform screw fixation through an anterior retropharyngeal approach. The following paragraph recites on the management of atlanto-axial
4. Conclusion The posterior atlanto-axial dislocation can be associated with fracture of the odontoid process. We described the second case treated by C1–C2 screw fixation through retropharyngeal approach. We reported 46
Interdisciplinary Neurosurgery 12 (2018) 45–47
F.K.K. Ségbédji et al.
Fig. 2. The CT-scan of the cervical spine five months later showed a consolidation of the fracture.
an original management for this kind of lesion with neurological complications. While our case has some unique features, they are really minor variations of injuries of C1–C2 that have been reported in the past.
(2001) 830–834. [6] A.B. Spoor, C.H. Diekerhof, M. Bonnet, et al., Traumatic complex dislocation of the atlanto-axial joint with odontoid and C2 superior articular facet fracture, Spine (Phila Pa 1976) 33 (2008) E708–11. [7] E.M. Corner, Rotary dislocations of the atlas, Ann. Surg. 45 (1907) 9–26. [8] B. Lenehan, S. Guerin, J. Street, A. Poynton, Lateral C1–C2 dislocation complicating a type II odontoid fracture, J. Clin. Neurosci. 17 (2010) 947–949. [9] A. Goel, A.G. Kulkarni, P. Sharma, Reduction of fixed atlanto-axial dislocation in24 cases: technical note, J. Neurosurg. Spine 2 (2005) 505–509. [10] G.J. Przybylski, W.C. Welch, Longitudinal atlanto-axial dislocation with type III odontoid fracture. Case report and review of the literature, J. Neurosurg. 84 (1996) 666–670. [11] M. Payer, S. Wetzel, A. Kelekis, et al., Traumatic vertical atlanto-axial dislocation, J. Clin. Neurosci. 12 (2005) 704–706. [12] R. Das-Gupta, An alarming degree of posterior dislocation in fracture of the odontoid process without important neurological injury, Injury 22 (1991) 158–159. [13] K. Zhang, J. Xu, Q. Wang, et al., Treatment of dens fractures with posterior atlantoaxial dislocation with transoralatlanto-axial reduction plate (TARP) surgery: case report and introduction of a novel treatment option, Spine (Phila Pa 1976) 37 (2012) E451–5. [14] D.A. Bednar, J. Parikh, J. Hummel, Management of type II odontoid process fractures in geriatric patients; a prospective study of sequential cohorts with attention to survivorship, J. Spinal Disord. 8 (1995) 166–169. [15] N.B. Chutkan, A.G. King, M.B. Harris, Odontoid fractures: evaluation and management, J. Am. Acad. Orthop. Surg. 5 (1997) 199–204. [16] G. Riouallon, H. Pascal-Moussellard, Orthop. Traumatol. Surg. Res. 100 (2014) 341–345.
Conflict of interest The authors reported no conflict of interest related to this article. References [1] P.E. Moreau, V. Nguyen, A. Atallah, G. Kassab, M.W. Thiong'o, et al., Traumatic atlantoaxial dislocation with odontoid fracture: a case report, Orthop. Traumatol. Surg. Res. 98 (2012) 613–617. [2] H. Meng, Y. Gao, M. Li, Z. Luo, J. Du, Posterior atlantoaxial dislocation complicating odontoid fracture without neurologic deficit: a case report and review of the literature, Skelet. Radiol. 43 (2001) 1001–1006. [3] J.Y. Oh, C.K. Chough, C.B. Cho, H.K. Park, Traumatic atlantoaxial rotatory fixation with accompanying odontoid and C2 articular facet fracture, J. Korean Neurosurg. Soc. 48 (2010) 452–454. [4] A. Autricque, F. Lesoin, L. Villette, K. Franz, J.P. Pruvo, et al., Fracture of the odontoid process and C1–C2 lateral luxation 2 cases, Ann. Chir. 40 (1986) 397–400. [5] S. Fuentes, P. Bouillot, O. Palombi, et al., Traumatic atlanto-axial rotatory dislocation with odontoid fracture: case report and review, Spine (Phila Pa 1976) 26
47
Contents lists available at ScienceDirect
Interdisciplinary Neurosurgery journal homepage: www.elsevier.com/locate/inat
Case Report
Atlanto-axial posterolateral dislocation associated with a type II displaced odontoid fracture
T
⁎
Felix K.K. Ségbédji , Armel Junior Tokpo, Alëna A. Nubukpo-Guménu, M. Benzagmout Neurosurgery Department, HASSAN II Teaching Hospital Fez, Sidi Mohamed Ben Abdellah University of Fez, Morocco
A R T I C L E I N F O
A B S T R A C T
Keywords: Left arm monoparesis Posterolateral atlanto-axial dislocation Intraoperative traction Retropharyngeal anterior approach
Atlanto-axial posterolateral dislocations associated with an odontoid fracture are rare traumatic lesions of the upper cervical spine. Their therapeutic management is discussed. We report the case of a 28-year-old man with no significant medical history admitted to the emergency room with upper cervical spinal trauma following a frontal collision of two vehicles. We found a left arm monoparesis and a posterolateral atlanto-axial dislocation associated with a fracture of the displaced type II odontoid. The patient was treated by a retropharyngeal approach anteriorly after reduction by intraoperative traction by Gardner wells tongs maintained by a weight of 10 kg. The evolution was marked by a complete recovery of the left arm monoparesis at two months followed by physiotherapy.
1. Introduction The combination of atlanto-axial joint dislocation and odontoid process fracture is usually a lethal injury and as a result, reports of survivors are rare. In the last thirty years only fifteen clinical cases have been described [1–2]. The patients had no neurological deficits in seven of the reported cases [1–3]. In only one case a spastic tetraparesis was described [4]. Their therapeutic management is discussed. According to our review of the literature, we report the second case in the literature of these lesions treated by retropharyngeal approach. And the first case with neurological complication treated by this management. 2. Case A 28-year-old man with no significant medical history was admitted to the emergency department with an upper cervical spinal trauma following a head on collision of two vehicles. Initial assessment had found a left arm monoparesis and a posterolateral atlanto-axial dislocation associated with a fracture of the displaced type II odontoid (Fig. 1). The patient was treated by a retropharyngeal approach anteriorly after reduction by intraoperative traction by Gardner Wells tongs and maintained by a weight of 10 kg. The surgical technique consisted of a horizontal right anterolateral incision; opening of the platysma muscle of the neck followed by dissection of the different planes to the cervical spine; opening of the deep cervical aponeurosis and the anterior longitudinal ligament; recording of the space C2–C3 by fluoroscope ⁎
and creating a C3 longitudinal channel orienting the spindle guide; positioning of the spindle guide; drilling of C2 under fluoroscopic guidance to better appreciate the path; and tunneling to the tap and placing a 34 mm screw taking the odontoid. The evolution was marked by a complete recovery of the left arm monoparesis at the end of two months followed by physiotherapy. The CT-scan of the cervical spine five months later showed a consolidation of the fracture (Fig. 2). 3. Discussion The first case of atlanto-axial posterolateral dislocation associated with a type II displaced odontoid fracture treated through retropharyngeal approach reported in the literature by G. Riouallon, concerned a 25-year-old man with no neurological complications. Association between acute odontoid fracture and C1–C2 dislocation is documented in several case reports or short series. Three types of dislocation are reported: rotatory dislocations in 3 case reports [5–7]; lateral dislocations in 19 patients with fixed atlanto-axial dislocation associated with odontoid fracture [8–9]; vertical dislocations in 2 case reports [10–11]. The literature report only two cases of acute fracture dislocation of atlanto-axial complex with posterior displacement: Das-Gupta reported a case of a 75 year-old-patient treated with skull traction applied in flexion10° for 6 weeks and then with external fixation [12] and Zhang et al. published recently a first case in a young man, who was also treated with skull traction applied in flexion 10° for 70 days and then transoralatlanto-axial reduction plate surgery [13].
Corresponding author. E-mail address: [email protected] (F.K.K. Ségbédji).
https://doi.org/10.1016/j.inat.2018.01.001 Received 23 November 2017; Accepted 6 January 2018 2214-7519/ © 2018 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/BY-NC-ND/4.0/).
Interdisciplinary Neurosurgery 12 (2018) 45–47
F.K.K. Ségbédji et al.
Fig. 1. CT-scan showed posterolateral atlanto-axial dislocation associated with a fracture of the displaced type II odontoid.
posterolateral dislocation associated with a type II displaced odontoid fracture treated through retropharyngeal approach as published by G. Riouallon and al [16]. We initially involved/applied traction with a moderate flexion and obtain a partial reduction. We obtained a complete reduction only with a traction combined with extension. The reduction maneuver is probably specific of this type of fracture dislocation C1–C2 with posterior displacement. The screw trajectory through the odontoid appears to be off-centre, but caused no damage to our patient. He had a complete recovery of the left arm monoparesis and any symptoms now.
The mechanism leading to posterior displacement of the odontoid process seems to be hyperextension [14–15]. This kind of injury is rarely seen, because extension fracture-dislocation of the atlas and odontoid process is an injury where the atlas together with the odontoid process is displaced backwards, thus causing narrowing of the spinal canal and compression of its contents by the displaced odontoid process. Patients with major cord damage at this level rarely survive [12]. Therefore the trauma was responsible for a posterior displacement of a unit including the odontoid and the atlas towards the rest of the axis. We report a third case secondary to high-energy trauma in a young man treated with another kind of management. Despite the fact that the entire cervical canal is compromised, our patient miraculously only had a monoparesis of the arm. We applied traction with a moderate flexion combined reduction maneuvers during the surgery and obtained a complete reduction. Then we perform screw fixation through an anterior retropharyngeal approach. The following paragraph recites on the management of atlanto-axial
4. Conclusion The posterior atlanto-axial dislocation can be associated with fracture of the odontoid process. We described the second case treated by C1–C2 screw fixation through retropharyngeal approach. We reported 46
Interdisciplinary Neurosurgery 12 (2018) 45–47
F.K.K. Ségbédji et al.
Fig. 2. The CT-scan of the cervical spine five months later showed a consolidation of the fracture.
an original management for this kind of lesion with neurological complications. While our case has some unique features, they are really minor variations of injuries of C1–C2 that have been reported in the past.
(2001) 830–834. [6] A.B. Spoor, C.H. Diekerhof, M. Bonnet, et al., Traumatic complex dislocation of the atlanto-axial joint with odontoid and C2 superior articular facet fracture, Spine (Phila Pa 1976) 33 (2008) E708–11. [7] E.M. Corner, Rotary dislocations of the atlas, Ann. Surg. 45 (1907) 9–26. [8] B. Lenehan, S. Guerin, J. Street, A. Poynton, Lateral C1–C2 dislocation complicating a type II odontoid fracture, J. Clin. Neurosci. 17 (2010) 947–949. [9] A. Goel, A.G. Kulkarni, P. Sharma, Reduction of fixed atlanto-axial dislocation in24 cases: technical note, J. Neurosurg. Spine 2 (2005) 505–509. [10] G.J. Przybylski, W.C. Welch, Longitudinal atlanto-axial dislocation with type III odontoid fracture. Case report and review of the literature, J. Neurosurg. 84 (1996) 666–670. [11] M. Payer, S. Wetzel, A. Kelekis, et al., Traumatic vertical atlanto-axial dislocation, J. Clin. Neurosci. 12 (2005) 704–706. [12] R. Das-Gupta, An alarming degree of posterior dislocation in fracture of the odontoid process without important neurological injury, Injury 22 (1991) 158–159. [13] K. Zhang, J. Xu, Q. Wang, et al., Treatment of dens fractures with posterior atlantoaxial dislocation with transoralatlanto-axial reduction plate (TARP) surgery: case report and introduction of a novel treatment option, Spine (Phila Pa 1976) 37 (2012) E451–5. [14] D.A. Bednar, J. Parikh, J. Hummel, Management of type II odontoid process fractures in geriatric patients; a prospective study of sequential cohorts with attention to survivorship, J. Spinal Disord. 8 (1995) 166–169. [15] N.B. Chutkan, A.G. King, M.B. Harris, Odontoid fractures: evaluation and management, J. Am. Acad. Orthop. Surg. 5 (1997) 199–204. [16] G. Riouallon, H. Pascal-Moussellard, Orthop. Traumatol. Surg. Res. 100 (2014) 341–345.
Conflict of interest The authors reported no conflict of interest related to this article. References [1] P.E. Moreau, V. Nguyen, A. Atallah, G. Kassab, M.W. Thiong'o, et al., Traumatic atlantoaxial dislocation with odontoid fracture: a case report, Orthop. Traumatol. Surg. Res. 98 (2012) 613–617. [2] H. Meng, Y. Gao, M. Li, Z. Luo, J. Du, Posterior atlantoaxial dislocation complicating odontoid fracture without neurologic deficit: a case report and review of the literature, Skelet. Radiol. 43 (2001) 1001–1006. [3] J.Y. Oh, C.K. Chough, C.B. Cho, H.K. Park, Traumatic atlantoaxial rotatory fixation with accompanying odontoid and C2 articular facet fracture, J. Korean Neurosurg. Soc. 48 (2010) 452–454. [4] A. Autricque, F. Lesoin, L. Villette, K. Franz, J.P. Pruvo, et al., Fracture of the odontoid process and C1–C2 lateral luxation 2 cases, Ann. Chir. 40 (1986) 397–400. [5] S. Fuentes, P. Bouillot, O. Palombi, et al., Traumatic atlanto-axial rotatory dislocation with odontoid fracture: case report and review, Spine (Phila Pa 1976) 26
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