- Email: [email protected]
Oblique axis body fracture—Pitfalls in management
Injury, Int. J. Care Injured 43 (2012) 505–508
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Case report
Oblique axis body fracture—Pitfalls in management Tony Goldschlager a,*, John C.D. Leach a, Owen D. Williamson b, Grego M. Malham a,1 a b
Department of Neurosurgery, The Alfred Hospital, Victoria 3181, Australia Department of Epidemiology and Preventive Medicine, Monash University, The Alfred Centre, 99 Commercial Rd, Melbourne, Victoria, 3004, Australia
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 12 April 2010
Background: Transverse fractures through the body of the axis, rather than at the base of the odontoid are uncommon and management with an external orthosis is usually recommended. Oblique fractures through the body of the axis accompanying a hangman’s fracture have not been reported and are not described as part of any classification system. Such fractures may be at high risk for treatment failure in an external orthosis. Case description: We report on a case of an oblique axis fracture that failed treatment with external orthosis. Posterior instrumented fusion was employed successfully using a C1–C3 and C4 poly axial screw rod construct. Frameless stereotaxy and a biomodel were useful surgical adjuncts. Twelve month follow up revealed bony union in an asymptomatic patient. Conclusions: Oblique fractures of the body of the axis can displace in a halo-thoracic orthosis. Serial radiological review is required to detect displacement prior to fracture union. Oblique fractures of the body of the axis can be managed surgically with preservation of atlanto-occipital motion, resulting in satisfactory clinical and radiological outcomes. ß 2010 Elsevier Ltd. All rights reserved.
Keywords: Axis Upper cervical spine Fracture Fracture nonunion Spinal fusion
Case report A 48-year-old female was a restrained front seat passenger in a car involved in a medium speed front on crash. There was significant cabin intrusion on the passenger side and airbags deployed. The patient reported a brief loss of consciousness, but her Glasgow Coma Score at the scene was 14/15. She initially complained of transient bilateral upper limb paraesthesia greater on the right. Examination on arrival at a level one trauma centre, revealed a significant contusion and laceration over the left anterior-lateral aspect of the neck secondary to a seat belt injury. Neurological examination was normal. A CT cervical spine (Fig. 1) revealed a hangman’s fracture (bilateral pars interarticulares fractures) with an oblique fracture through the body of the axis. There was flexion angulation of the C2 fragment. No neural compression was evident. CT angiography revealed normal vertebral arteries and a MRI scan revealed disruption of the anterior and posterior longitudinal ligaments and the atlanto-axial ligaments bilaterally. The patient also had a fractured left 12th rib and a ruptured jejunum. The cervical spine was immobilised and an awake fiberoptic intubation was performed prior to abdominal surgery.
* Corresponding author. Tel.: +61 399050771. E-mail addresses: [email protected] (T. Goldschlager), [email protected] (G.M. Malham). 1 Neurosurgeon, Department of Neurosurgery, The Alfred Hospital Commercial Road, Prahran 3181 Victoria, Australia Tel.: +61 3 907 63716; fax: +61 3 907 63740. 0020–1383/$ – see front matter ß 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2010.04.011
The axis fracture was initially treated in a halo-thoracic orthosis. A CT scan performed 6 weeks post-injury revealed no evidence of fracture union, but the fracture had not displaced. A CT scan performed 12 weeks post-injury again revealed no evidence of fracture union, but did reveal displacement of the fracture, particularly with rotation (Fig. 2). In view of the failure of nonoperative treatment, surgical stabilisation was then considered. The CT scan data was used to plan trajectories for trans-isthmic C1 screws using the planning station of an image guidance system (iPlan! 1.1, BrainLAB AG, Heimstetten, Germany) and for production of an exact biomodel of the patient’s suboccipital cervical spine. Through a standard posterior midline exposure of the suboccipital region and upper cervical spine a reference fiducial array was clamped to the spinous process of C3. Information from the image guidance system was correlated with the local anatomy and the C1 entry point was confirmed by localising the isthmus and lateral mass of C1 with a blunt hook. The C2 dorsal root ganglion and venous plexus were retracted bilaterally and 20 mm 3.5 mm trans-isthmic lateral mass screws inserted. 18 mm 3.5 mm selftapping, polyaxial, top loading screws (Axon, Synthes, Oberdorf, Switzerland) were inserted into the lateral masses of C3 and C4. Rods where then secured bilaterally and cross-linked. The posterior elements were decorticated and autologous bone graft from the posterior iliac crest, supplemented by tricalcium phosphate bone substitute (Vitoss, Orthovita Malvern, Pennsylvania, USA), applied. The halo-thoracic orthosis was reapplied postoperatively.
506
T. Goldschlager et al. / Injury, Int. J. Care Injured 43 (2012) 505–508
Fig. 1. Admission CT scan in the coronal view (A) demonstrating an oblique fracture through the body of the axis involving bilateral foramen transversarium in the axial view (B).
Fig. 2. Delayed CT scan at 12 weeks post-injury in the coronal view (A) and axial view (B) demonstrating further displacement of the oblique axis fracture.
The patient initially complained of some paraesthesia in the right C2 distribution, but this resolved within 48 h. A postoperative CT scan showed satisfactory fracture alignment and confirmed the accurate placement of the implants (Fig. 3). The patient was discharged 5 days post-operatively.
The halo-thoracic orthosis was removed 3 months postoperatively when dynamic radiographs revealed no instability. At 18-month review, she complained of no residual symptoms and a CT scan confirmed fracture union and consolidation of the fusion masses.
Fig. 3. Postoperative CT scan in the sagittal view (A) and 3D reconstruction (8) demonstrating satisfactory position of the C1–C3 and C4 screw rod construct.
T. Goldschlager et al. / Injury, Int. J. Care Injured 43 (2012) 505–508
Discussion Fractures of the body of the axis have been classified by several authors2,10,19; Benzel described three types of body fractures based on fracture orientation2: type 1 coronal, type 2 sagittal and type 3 horizontal. The type 3 fracture was described as being identical in location to Anderson and D’Alonzo’s type III odontoid fracture1 but was proposed as representing an axis body fracture rather than an odontoid process fracture.2 Fujimara however defined a transverse axis body fracture that could be distinguished from the type III fractures of Anderson and D’Alonzo and Benzel.10 Traumatic spondylolisthesis of the axis (hangman’s fracture) has been classified by several authors including those by Francis9 (I–V), Effendi8 (I–III) and Levine and Edwards21 (I, II, IIA and III). In all these classification systems, displacement of the fracture fragment occurs at the C2/C3 disc space. The fracture described in this report fits no classification. We propose that it is an oblique axis body fracture complicating a hangman’s fracture and to our knowledge has not been previously described. Irrespective of the classification utilised, transverse axis body fractures are rare. In Korres series of 674 patients with cervical fractures the transverse axis body fracture constituted an incidence of 0.3%19 Although transverse body fractures occur as the result of hyperextension16,19 or flexion distraction,22 we propose that the oblique body fracture occurs as the result of additional lateral flexion or rotation. Although no guidelines for the management of transverse body fractures have been proposed by the American Association of
507
Neurosurgeons28 previous reports (Table 1) have recommended external immobilisation in the first instance.10,12,13,16,19,22,23 Transverse body or Type III odontoid fractures usually unite following external immobilisation. Large series reporting nonunion rates around 2% and indicate that these patients can be successfully treated by posterior fusion surgery.12,13 Correspondingly Type II hangman’s fractures are usually managed non-operatively with closed reduction (if required) and rigid external orthosis.6,29,30 A relative indication for surgery is severe disco-ligamentous disruption at the C2/C3 disc space with flexion-translation displacement.32 In our case it was evident that the patient required surgical fixation due to failure of non-operative management. In retrospect, a hangman’s fracture with an anterior-posterior axis body fracture represents a significant three column injury and could be considered equivalent to complete C2/C3 disco-ligamentous disruption. There was a high risk of non-operative treatment failure and early posterior instrumented fusion could have been considered. A posterior approach using a screw-rod construct from C1 to C4 was used, both for biomechanical strength and to enable preservation of motion at C0–C1.18,24,26 Biomechanical studies have shown that the majority of coupled flexion extension occurs at the C0–C1 joint15 and rotation at the C1–C2 joint.25 The fixation was extended to C4 and a cross-link used to increase construct stiffness5,14 and avoid any ‘window wiper’ effect that may have occurred if a C1–C3 fixation was employed alone. The usual entry point for a C1 lateral mass screw is on the posterior face of the lateral mass at its junction with the isthmus.
Table 1 Summary of papers describing transverse body fractures. Series
Paper focus
Transverse fracture classified as
Number
Treatment method
Failure rate
Treatment of conservative failure
Fujimara7 (1996)
Axis body fractures
Transverse body fracture
2 (6.5%) of 31 axis body #’s
Philadelphia Collar
0
N/A
Benzel2 (1994)
C2 body fractures
Type III fracture
0 of 15
N/A
N/A
N/A
Acute axis fractures
Not specifically defined Type III odontoid fracture category
49 (22%) of 229
Halo 94%
0
N/A
2%
Posterior C2/C3 wiring
10
Hadley
(1989)
SOMI 4% Surgerya 2% Hadley10 (1989)
Acute axis fractures
Not specifically defined
47 (20%) of 229
Miscellaneous body fracture category
Halo 77% SOMI 9% Collar 6% Surgerya 2% Early Death 6%
Greene9 (1997)
Acute axis fractures
Not specifically defined
67 (19%) of 340
External Orthosis
1.6%
Surgery method not stated
77 (22.6%) of 340
Early surgerya (1.2%) Halo vest
7.9%
Posterior fusion (71%) Odontoid Screw (29%)
Miscellaneous body fracture category Greene9 (1997)
Acute axis fractures
Not specifically defined Type III odontoid fracture category
Early death (2%) Early displacement in halo (6.5%) Non-union in halo (1.4%) Korres16 (2005)
Chance-type fracture of axis
Chance-type or horizontal fracture
2 (0.3%) of all cervical fractures
Skull traction followed by Philadelphia collar or Halo
0%
N/A
Jakim13 (1988)
Transverse body fracture case report
Transverse body fracture
1
Skull traction
N/A
N/A
Maki18 (1985)
Transverse body fracture case report
Transverse body fracture
1
Skull traction followed by Philadelphia Collar
N/A
N/A
a
Marked C2/C3 subluxation requiring early surgery.
T. Goldschlager et al. / Injury, Int. J. Care Injured 43 (2012) 505–508
508
Exposure of this entry point however is frequently accompanied by profuse venous bleeding and requires either inferior mobilisation of the C2 nerve root and dorsal root ganglion or its sacrifice.11 This retraction was probably the cause of the transient C2 paraesthesia that our patient experienced. Although, the entry points, landmarks and trajectories are well known to the spinal surgeon, pathology may distort the anatomy. This places neurovascular structures at risk. Aids to facilitate the safe entry and passage of screws are an invaluable tool. In addition to intraoperative palpation of bony landmarks and fluoroscopy, we used frameless stereotaxy which was first developed as a useful aid to intracranial localization27 and later to spinal surgery.3,4,17,20,31 The biomodel adds a valuable dimension to spinal surgery.7 Not only is the biomodel useful for obtaining informed consent, surgical planning, and teaching, but it can be sterilized and provide intraoperative guidance. Conclusion An oblique axis body fracture complicating a hangman’s fracture has not been previously described. Although transverse axis body fractures and hangman’s fractures can generally be successfully managed with external immobilisation, the combination of hangman’s fracture with a transverse axis body fracture suggests an increased risk for displacement despite external immobilisation and early internal fixation should be considered. Conflicts of interests The authors have no conflicts of interests. References 1. Anderson LD, D’Alonzo RT. Fractures of the odontoid process of the axis. J Bone Joint Surg Am 1974;56:1663–74. 2. Benzel EC, Hart BL, Ball PA, et al. Fractures of the C-2 vertebral body. J Neurosurg 1994;81:206–12. 3. Bloch O, Holly LT, Park J, et al. Effect of frameless stereotaxy on the accuracy of C1–2 transarticular screw placement. J Neurosurg 2001;95:74–9. 4. Bolger C, Wigfield C. Image-guided surgery: applications to the cervical and thoracic spine and a review of the first 120 procedures. J Neurosurg 2000;92:175–80. 5. Brodke DS, Bachus KN, Mohr RA, Nguyen BK. Segmental pedicle screw fixation or cross-links in multilevel lumbar constructs. a biomechanical analysis. Spine J 2001;1:373–9. 6. Coric D, Wilson JA, Kelly Jr DL. Treatment of traumatic spondylolisthesis of the axis with nonrigid immobilization: a review of 64 cases. J Neurosurg 1996;85:550–4.
7. D’Urso PS, Williamson OD, Thompson RG. Biomodeling as an aid to spinal instrumentation. Spine 2005;30:2841–5. 8. Effendi B, Roy D, Cornish B, et al. Fractures of the ring of the axis. A classification based on the analysis of 131 cases. J Bone Joint Surg Br 1981;63-B:319–27. 9. Francis WR, Fielding JW, Hawkins RJ, et al. Traumatic spondylolisthesis of the axis. J Bone Joint Surg Br 1981;63-B:313–8. 10. Fujimura Y, Nishi Y, Kobayashi K. Classification and treatment of axis body fractures. J Orthop Trauma 1996;10:536–40. 11. Goel A, Desai KI, Muzumdar DP. Atlantoaxial fixation using plate and screw method: a report of 160 treated patients. Neurosurgery 2002;51:1351–6. discussion 56–7. 12. Greene KA, Dickman CA, Marciano FF, et al. Acute axis fractures. Analysis of management and outcome in 340 consecutive cases. Spine 1997;22:1843–52. 13. Hadley MN, Dickman CA, Browner CM, Sonntag VK. Acute axis fractures: a review of 229 cases. J Neurosurg 1989;71:642–7. 14. Hart R, Hettwer W, Liu Q, Prem S. Mechanical stiffness of segmental versus nonsegmental pedicle screw constructs: the effect of cross-links. Spine 2006;31:E35–8. 15. Ishii T, Mukai Y, Hosono N, et al. Kinematics of the cervical spine in lateral bending: in vivo three-dimensional analysis. Spine 2006;31:155–60. 16. Jakim I, Sweet MB. Transverse fracture through the body of the axis. J Bone Joint Surg Br 1988;70:728–9. 17. Kalfas IH, Kormos DW, Murphy MA, et al. Application of frameless stereotaxy to pedicle screw fixation of the spine. J Neurosurg 1995;83:641–7. 18. Kim SM, Lim TJ, Paterno J, et al. Biomechanical comparison of anterior and posterior stabilization methods in atlantoaxial instability. J Neurosurg 2004;100:277–83. 19. Korres DS, Papagelopoulos PJ, Mavrogenis AF, et al. Chance-type fractures of the axis. Spine 2005;30:E517–20. 20. Brecknell JE, Malham GM. Os odontoideum; report of three cases. J Clin Neurosci 2008;15:295–301. 21. Levine AM, Edwards CC. The management of traumatic spondylolisthesis of the axis. J Bone Joint Surg Am 1985;67:217–26. 22. Maki NJ. A transverse fracture through the body of the axis. A case report. Spine 1985;10:857–9. 23. Marton E, Billeci D, Carteri A. Therapeutic indications in upper cervical spine instability. Considerations on 58 cases. J Neurosurg Sci 2000;44:192–202. 24. Melcher RP, Puttlitz CM, Kleinstueck FS, et al. Biomechanical testing of posterior atlantoaxial fixation techniques. Spine 2002;27:2435–40. 25. Panjabi MM, Crisco JJ, Vasavada A, et al. Mechanical properties of the human cervical spine as shown by three-dimensional load-displacement curves. Spine 2001;26:2692–700. 26. Richter M, Schmidt R, Claes L, et al. Posterior atlantoaxial fixation: biomechanical in vitro comparison of six different techniques. Spine 2002;27:1724–32. 27. Roberts DW, Strohbehn JW, Hatch JF, et al. A frameless stereotaxic integration of computerized tomographic imaging and the operating microscope. J Neurosurg 1986;65:545–9. 28. Surgeons AAoN. Isolated fractures of the axis in adults. Neurosurgery 2002;50:S125–39. 29. Vaccaro AR, Madigan L, Bauerle WB, et al. Early halo immobilization of displaced traumatic spondylolisthesis of the axis. Spine 2002;27:2229–33. 30. Verheggen R, Jansen J. Hangman’s fracture: arguments in favor of surgical therapy for type II and III according to Edwards and Levine. Surg Neurol 1998;49:253–61. discussion 61–2. 31. Welch WC, Subach BR, Pollack IF, Jacobs GB. Frameless stereotactic guidance for surgery of the upper cervical spine. Neurosurgery 1997;40:958–63. discussion 63–4. 32. Ying Z, Wen Y, Xinwei W, et al. Anterior cervical discectomy and fusion for unstable traumatic spondylolisthesis of the axis. Spine 2008;33:255–8.
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Case report
Oblique axis body fracture—Pitfalls in management Tony Goldschlager a,*, John C.D. Leach a, Owen D. Williamson b, Grego M. Malham a,1 a b
Department of Neurosurgery, The Alfred Hospital, Victoria 3181, Australia Department of Epidemiology and Preventive Medicine, Monash University, The Alfred Centre, 99 Commercial Rd, Melbourne, Victoria, 3004, Australia
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 12 April 2010
Background: Transverse fractures through the body of the axis, rather than at the base of the odontoid are uncommon and management with an external orthosis is usually recommended. Oblique fractures through the body of the axis accompanying a hangman’s fracture have not been reported and are not described as part of any classification system. Such fractures may be at high risk for treatment failure in an external orthosis. Case description: We report on a case of an oblique axis fracture that failed treatment with external orthosis. Posterior instrumented fusion was employed successfully using a C1–C3 and C4 poly axial screw rod construct. Frameless stereotaxy and a biomodel were useful surgical adjuncts. Twelve month follow up revealed bony union in an asymptomatic patient. Conclusions: Oblique fractures of the body of the axis can displace in a halo-thoracic orthosis. Serial radiological review is required to detect displacement prior to fracture union. Oblique fractures of the body of the axis can be managed surgically with preservation of atlanto-occipital motion, resulting in satisfactory clinical and radiological outcomes. ß 2010 Elsevier Ltd. All rights reserved.
Keywords: Axis Upper cervical spine Fracture Fracture nonunion Spinal fusion
Case report A 48-year-old female was a restrained front seat passenger in a car involved in a medium speed front on crash. There was significant cabin intrusion on the passenger side and airbags deployed. The patient reported a brief loss of consciousness, but her Glasgow Coma Score at the scene was 14/15. She initially complained of transient bilateral upper limb paraesthesia greater on the right. Examination on arrival at a level one trauma centre, revealed a significant contusion and laceration over the left anterior-lateral aspect of the neck secondary to a seat belt injury. Neurological examination was normal. A CT cervical spine (Fig. 1) revealed a hangman’s fracture (bilateral pars interarticulares fractures) with an oblique fracture through the body of the axis. There was flexion angulation of the C2 fragment. No neural compression was evident. CT angiography revealed normal vertebral arteries and a MRI scan revealed disruption of the anterior and posterior longitudinal ligaments and the atlanto-axial ligaments bilaterally. The patient also had a fractured left 12th rib and a ruptured jejunum. The cervical spine was immobilised and an awake fiberoptic intubation was performed prior to abdominal surgery.
* Corresponding author. Tel.: +61 399050771. E-mail addresses: [email protected] (T. Goldschlager), [email protected] (G.M. Malham). 1 Neurosurgeon, Department of Neurosurgery, The Alfred Hospital Commercial Road, Prahran 3181 Victoria, Australia Tel.: +61 3 907 63716; fax: +61 3 907 63740. 0020–1383/$ – see front matter ß 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2010.04.011
The axis fracture was initially treated in a halo-thoracic orthosis. A CT scan performed 6 weeks post-injury revealed no evidence of fracture union, but the fracture had not displaced. A CT scan performed 12 weeks post-injury again revealed no evidence of fracture union, but did reveal displacement of the fracture, particularly with rotation (Fig. 2). In view of the failure of nonoperative treatment, surgical stabilisation was then considered. The CT scan data was used to plan trajectories for trans-isthmic C1 screws using the planning station of an image guidance system (iPlan! 1.1, BrainLAB AG, Heimstetten, Germany) and for production of an exact biomodel of the patient’s suboccipital cervical spine. Through a standard posterior midline exposure of the suboccipital region and upper cervical spine a reference fiducial array was clamped to the spinous process of C3. Information from the image guidance system was correlated with the local anatomy and the C1 entry point was confirmed by localising the isthmus and lateral mass of C1 with a blunt hook. The C2 dorsal root ganglion and venous plexus were retracted bilaterally and 20 mm 3.5 mm trans-isthmic lateral mass screws inserted. 18 mm 3.5 mm selftapping, polyaxial, top loading screws (Axon, Synthes, Oberdorf, Switzerland) were inserted into the lateral masses of C3 and C4. Rods where then secured bilaterally and cross-linked. The posterior elements were decorticated and autologous bone graft from the posterior iliac crest, supplemented by tricalcium phosphate bone substitute (Vitoss, Orthovita Malvern, Pennsylvania, USA), applied. The halo-thoracic orthosis was reapplied postoperatively.
506
T. Goldschlager et al. / Injury, Int. J. Care Injured 43 (2012) 505–508
Fig. 1. Admission CT scan in the coronal view (A) demonstrating an oblique fracture through the body of the axis involving bilateral foramen transversarium in the axial view (B).
Fig. 2. Delayed CT scan at 12 weeks post-injury in the coronal view (A) and axial view (B) demonstrating further displacement of the oblique axis fracture.
The patient initially complained of some paraesthesia in the right C2 distribution, but this resolved within 48 h. A postoperative CT scan showed satisfactory fracture alignment and confirmed the accurate placement of the implants (Fig. 3). The patient was discharged 5 days post-operatively.
The halo-thoracic orthosis was removed 3 months postoperatively when dynamic radiographs revealed no instability. At 18-month review, she complained of no residual symptoms and a CT scan confirmed fracture union and consolidation of the fusion masses.
Fig. 3. Postoperative CT scan in the sagittal view (A) and 3D reconstruction (8) demonstrating satisfactory position of the C1–C3 and C4 screw rod construct.
T. Goldschlager et al. / Injury, Int. J. Care Injured 43 (2012) 505–508
Discussion Fractures of the body of the axis have been classified by several authors2,10,19; Benzel described three types of body fractures based on fracture orientation2: type 1 coronal, type 2 sagittal and type 3 horizontal. The type 3 fracture was described as being identical in location to Anderson and D’Alonzo’s type III odontoid fracture1 but was proposed as representing an axis body fracture rather than an odontoid process fracture.2 Fujimara however defined a transverse axis body fracture that could be distinguished from the type III fractures of Anderson and D’Alonzo and Benzel.10 Traumatic spondylolisthesis of the axis (hangman’s fracture) has been classified by several authors including those by Francis9 (I–V), Effendi8 (I–III) and Levine and Edwards21 (I, II, IIA and III). In all these classification systems, displacement of the fracture fragment occurs at the C2/C3 disc space. The fracture described in this report fits no classification. We propose that it is an oblique axis body fracture complicating a hangman’s fracture and to our knowledge has not been previously described. Irrespective of the classification utilised, transverse axis body fractures are rare. In Korres series of 674 patients with cervical fractures the transverse axis body fracture constituted an incidence of 0.3%19 Although transverse body fractures occur as the result of hyperextension16,19 or flexion distraction,22 we propose that the oblique body fracture occurs as the result of additional lateral flexion or rotation. Although no guidelines for the management of transverse body fractures have been proposed by the American Association of
507
Neurosurgeons28 previous reports (Table 1) have recommended external immobilisation in the first instance.10,12,13,16,19,22,23 Transverse body or Type III odontoid fractures usually unite following external immobilisation. Large series reporting nonunion rates around 2% and indicate that these patients can be successfully treated by posterior fusion surgery.12,13 Correspondingly Type II hangman’s fractures are usually managed non-operatively with closed reduction (if required) and rigid external orthosis.6,29,30 A relative indication for surgery is severe disco-ligamentous disruption at the C2/C3 disc space with flexion-translation displacement.32 In our case it was evident that the patient required surgical fixation due to failure of non-operative management. In retrospect, a hangman’s fracture with an anterior-posterior axis body fracture represents a significant three column injury and could be considered equivalent to complete C2/C3 disco-ligamentous disruption. There was a high risk of non-operative treatment failure and early posterior instrumented fusion could have been considered. A posterior approach using a screw-rod construct from C1 to C4 was used, both for biomechanical strength and to enable preservation of motion at C0–C1.18,24,26 Biomechanical studies have shown that the majority of coupled flexion extension occurs at the C0–C1 joint15 and rotation at the C1–C2 joint.25 The fixation was extended to C4 and a cross-link used to increase construct stiffness5,14 and avoid any ‘window wiper’ effect that may have occurred if a C1–C3 fixation was employed alone. The usual entry point for a C1 lateral mass screw is on the posterior face of the lateral mass at its junction with the isthmus.
Table 1 Summary of papers describing transverse body fractures. Series
Paper focus
Transverse fracture classified as
Number
Treatment method
Failure rate
Treatment of conservative failure
Fujimara7 (1996)
Axis body fractures
Transverse body fracture
2 (6.5%) of 31 axis body #’s
Philadelphia Collar
0
N/A
Benzel2 (1994)
C2 body fractures
Type III fracture
0 of 15
N/A
N/A
N/A
Acute axis fractures
Not specifically defined Type III odontoid fracture category
49 (22%) of 229
Halo 94%
0
N/A
2%
Posterior C2/C3 wiring
10
Hadley
(1989)
SOMI 4% Surgerya 2% Hadley10 (1989)
Acute axis fractures
Not specifically defined
47 (20%) of 229
Miscellaneous body fracture category
Halo 77% SOMI 9% Collar 6% Surgerya 2% Early Death 6%
Greene9 (1997)
Acute axis fractures
Not specifically defined
67 (19%) of 340
External Orthosis
1.6%
Surgery method not stated
77 (22.6%) of 340
Early surgerya (1.2%) Halo vest
7.9%
Posterior fusion (71%) Odontoid Screw (29%)
Miscellaneous body fracture category Greene9 (1997)
Acute axis fractures
Not specifically defined Type III odontoid fracture category
Early death (2%) Early displacement in halo (6.5%) Non-union in halo (1.4%) Korres16 (2005)
Chance-type fracture of axis
Chance-type or horizontal fracture
2 (0.3%) of all cervical fractures
Skull traction followed by Philadelphia collar or Halo
0%
N/A
Jakim13 (1988)
Transverse body fracture case report
Transverse body fracture
1
Skull traction
N/A
N/A
Maki18 (1985)
Transverse body fracture case report
Transverse body fracture
1
Skull traction followed by Philadelphia Collar
N/A
N/A
a
Marked C2/C3 subluxation requiring early surgery.
T. Goldschlager et al. / Injury, Int. J. Care Injured 43 (2012) 505–508
508
Exposure of this entry point however is frequently accompanied by profuse venous bleeding and requires either inferior mobilisation of the C2 nerve root and dorsal root ganglion or its sacrifice.11 This retraction was probably the cause of the transient C2 paraesthesia that our patient experienced. Although, the entry points, landmarks and trajectories are well known to the spinal surgeon, pathology may distort the anatomy. This places neurovascular structures at risk. Aids to facilitate the safe entry and passage of screws are an invaluable tool. In addition to intraoperative palpation of bony landmarks and fluoroscopy, we used frameless stereotaxy which was first developed as a useful aid to intracranial localization27 and later to spinal surgery.3,4,17,20,31 The biomodel adds a valuable dimension to spinal surgery.7 Not only is the biomodel useful for obtaining informed consent, surgical planning, and teaching, but it can be sterilized and provide intraoperative guidance. Conclusion An oblique axis body fracture complicating a hangman’s fracture has not been previously described. Although transverse axis body fractures and hangman’s fractures can generally be successfully managed with external immobilisation, the combination of hangman’s fracture with a transverse axis body fracture suggests an increased risk for displacement despite external immobilisation and early internal fixation should be considered. Conflicts of interests The authors have no conflicts of interests. References 1. Anderson LD, D’Alonzo RT. Fractures of the odontoid process of the axis. J Bone Joint Surg Am 1974;56:1663–74. 2. Benzel EC, Hart BL, Ball PA, et al. Fractures of the C-2 vertebral body. J Neurosurg 1994;81:206–12. 3. Bloch O, Holly LT, Park J, et al. Effect of frameless stereotaxy on the accuracy of C1–2 transarticular screw placement. J Neurosurg 2001;95:74–9. 4. Bolger C, Wigfield C. Image-guided surgery: applications to the cervical and thoracic spine and a review of the first 120 procedures. J Neurosurg 2000;92:175–80. 5. Brodke DS, Bachus KN, Mohr RA, Nguyen BK. Segmental pedicle screw fixation or cross-links in multilevel lumbar constructs. a biomechanical analysis. Spine J 2001;1:373–9. 6. Coric D, Wilson JA, Kelly Jr DL. Treatment of traumatic spondylolisthesis of the axis with nonrigid immobilization: a review of 64 cases. J Neurosurg 1996;85:550–4.
7. D’Urso PS, Williamson OD, Thompson RG. Biomodeling as an aid to spinal instrumentation. Spine 2005;30:2841–5. 8. Effendi B, Roy D, Cornish B, et al. Fractures of the ring of the axis. A classification based on the analysis of 131 cases. J Bone Joint Surg Br 1981;63-B:319–27. 9. Francis WR, Fielding JW, Hawkins RJ, et al. Traumatic spondylolisthesis of the axis. J Bone Joint Surg Br 1981;63-B:313–8. 10. Fujimura Y, Nishi Y, Kobayashi K. Classification and treatment of axis body fractures. J Orthop Trauma 1996;10:536–40. 11. Goel A, Desai KI, Muzumdar DP. Atlantoaxial fixation using plate and screw method: a report of 160 treated patients. Neurosurgery 2002;51:1351–6. discussion 56–7. 12. Greene KA, Dickman CA, Marciano FF, et al. Acute axis fractures. Analysis of management and outcome in 340 consecutive cases. Spine 1997;22:1843–52. 13. Hadley MN, Dickman CA, Browner CM, Sonntag VK. Acute axis fractures: a review of 229 cases. J Neurosurg 1989;71:642–7. 14. Hart R, Hettwer W, Liu Q, Prem S. Mechanical stiffness of segmental versus nonsegmental pedicle screw constructs: the effect of cross-links. Spine 2006;31:E35–8. 15. Ishii T, Mukai Y, Hosono N, et al. Kinematics of the cervical spine in lateral bending: in vivo three-dimensional analysis. Spine 2006;31:155–60. 16. Jakim I, Sweet MB. Transverse fracture through the body of the axis. J Bone Joint Surg Br 1988;70:728–9. 17. Kalfas IH, Kormos DW, Murphy MA, et al. Application of frameless stereotaxy to pedicle screw fixation of the spine. J Neurosurg 1995;83:641–7. 18. Kim SM, Lim TJ, Paterno J, et al. Biomechanical comparison of anterior and posterior stabilization methods in atlantoaxial instability. J Neurosurg 2004;100:277–83. 19. Korres DS, Papagelopoulos PJ, Mavrogenis AF, et al. Chance-type fractures of the axis. Spine 2005;30:E517–20. 20. Brecknell JE, Malham GM. Os odontoideum; report of three cases. J Clin Neurosci 2008;15:295–301. 21. Levine AM, Edwards CC. The management of traumatic spondylolisthesis of the axis. J Bone Joint Surg Am 1985;67:217–26. 22. Maki NJ. A transverse fracture through the body of the axis. A case report. Spine 1985;10:857–9. 23. Marton E, Billeci D, Carteri A. Therapeutic indications in upper cervical spine instability. Considerations on 58 cases. J Neurosurg Sci 2000;44:192–202. 24. Melcher RP, Puttlitz CM, Kleinstueck FS, et al. Biomechanical testing of posterior atlantoaxial fixation techniques. Spine 2002;27:2435–40. 25. Panjabi MM, Crisco JJ, Vasavada A, et al. Mechanical properties of the human cervical spine as shown by three-dimensional load-displacement curves. Spine 2001;26:2692–700. 26. Richter M, Schmidt R, Claes L, et al. Posterior atlantoaxial fixation: biomechanical in vitro comparison of six different techniques. Spine 2002;27:1724–32. 27. Roberts DW, Strohbehn JW, Hatch JF, et al. A frameless stereotaxic integration of computerized tomographic imaging and the operating microscope. J Neurosurg 1986;65:545–9. 28. Surgeons AAoN. Isolated fractures of the axis in adults. Neurosurgery 2002;50:S125–39. 29. Vaccaro AR, Madigan L, Bauerle WB, et al. Early halo immobilization of displaced traumatic spondylolisthesis of the axis. Spine 2002;27:2229–33. 30. Verheggen R, Jansen J. Hangman’s fracture: arguments in favor of surgical therapy for type II and III according to Edwards and Levine. Surg Neurol 1998;49:253–61. discussion 61–2. 31. Welch WC, Subach BR, Pollack IF, Jacobs GB. Frameless stereotactic guidance for surgery of the upper cervical spine. Neurosurgery 1997;40:958–63. discussion 63–4. 32. Ying Z, Wen Y, Xinwei W, et al. Anterior cervical discectomy and fusion for unstable traumatic spondylolisthesis of the axis. Spine 2008;33:255–8.