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Mike-Mayer A, Lam K, Morris RP, Barghouthi AA, Travascio F, Latta LL, Lindsey RW. Posterior atlantoaxial fixation of osteoporotic odontoid fracture: biomechanical analysis of the Magerl versus harms techniques in a cadaver model. Spine J 2024; 24:1510-1516. [PMID: 38685273 DOI: 10.1016/j.spinee.2024.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 04/09/2024] [Accepted: 04/22/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND CONTEXT Odontoid fractures are among the most common cervical spine fractures in the elderly and are associated with increased morbidity and mortality. Clinical evidence suggests improved survival and quality of life after operative intervention compared to nonoperative treatment. PURPOSE This study seeks to examine the stability of an osteoporotic Type II odontoid fracture following posterior atlantoaxial fixation with either the Magerl transarticular fixation technique or the Harms C1 lateral mass screws C2 pedicle screw rod fixation. STUDY DESIGN Biomechanical cadaveric study. METHODS Eighteen cadaveric specimens extending from the cephalus to C7 were used in this study. Reflective marker arrays were attached to C1 and C2 and a single marker on the dens to measure movement of each during loading with C2-C3 and occiput-C1 being allowed to move freely. A biomechanical testing protocol imparted moments in flexion-extension, axial rotation, and lateral bending while a motion capture system recorded the motions of C1, C2, and the dens. The spines were instrumented with either the Harms fixation (n=9) or Magerl fixation (n=9) techniques, and a simulated Type II odontoid fracture was created. Motions of each instrumented spine were recorded for all moments, and then again after the instrumentation was removed to model the injured, noninstrumented state. RESULTS Both Harms and Magerl posterior C1-C2 fixation allowed for C1, C2, and the dens to move as a relative unit. Without fixation the dens motion was coupled with C1. No significant differences were found in X, Y, Z translation motion of the dens, C1 or C2 during neutral zone motions between the Magerl and Harms fixation techniques. There were no significant differences found in Euler angle motion between the two techniques in either flexion-extension, axial rotation, or lateral bending motion. CONCLUSIONS Our findings suggest that both Harms and Magerl fixation can significantly reduce dens motion in Type II odontoid fractures in an osteoporotic cadaveric bone model. CLINICAL SIGNIFICANCE Both Harms and Magerl posterior atlantoaxial fixation techniques allowed for C1, C2, and the dens to move as a relative unit following odontoid fracture, establishing more anatomic stability to the upper cervical spine.
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Affiliation(s)
- Austin Mike-Mayer
- The Department of Orthopedic Surgery and Rehabilitation, The University of Texas Medical Branch, 301 University Blvd., Galveston, TX, USA
| | - Kendrick Lam
- Mount Sinai Medical Center, Max Biedermann Institute for Biomechanics, 4300 Alton Rd., Miami Beach, FL, USA
| | - Randal P Morris
- The Department of Orthopedic Surgery and Rehabilitation, The University of Texas Medical Branch, 301 University Blvd., Galveston, TX, USA.
| | - Abeer Al Barghouthi
- Mount Sinai Medical Center, Max Biedermann Institute for Biomechanics, 4300 Alton Rd., Miami Beach, FL, USA
| | - Francesco Travascio
- Mount Sinai Medical Center, Max Biedermann Institute for Biomechanics, 4300 Alton Rd., Miami Beach, FL, USA; Department of Mechanical and Aerospace Engineering, University of Miami, 1251 Memorial Dr., Coral Gables, FL, USA; Department of Orthopaedics, University of Miami, 1611 NW 12th Ave #303, Miami, FL, USA
| | - Loren L Latta
- Mount Sinai Medical Center, Max Biedermann Institute for Biomechanics, 4300 Alton Rd., Miami Beach, FL, USA; Department of Orthopaedics, University of Miami, 1611 NW 12th Ave #303, Miami, FL, USA
| | - Ronald W Lindsey
- The Department of Orthopedic Surgery and Rehabilitation, The University of Texas Medical Branch, 301 University Blvd., Galveston, TX, USA
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Hamrick FA, Sherrod BA, Cole K, Cox P, Croci DM, Bowers CA, Mazur MD, Dailey AT, Bisson EF. Using Frailty Measures to Predict Functional Outcomes and Mortality After Type II Odontoid Fracture in Elderly Patients: A Retrospective Cohort Study. Global Spine J 2024; 14:1552-1562. [PMID: 36626221 DOI: 10.1177/21925682221149394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
STUDY DESIGN Single-center retrospective cohort study. OBJECTIVES Type II odontoid fractures occur disproportionately among elderly populations and cause significant morbidity and mortality. It is a matter of debate whether these injuries are best managed surgically or conservatively. Our goal was to identify how treatment modalities and patient characteristics correlated with functional outcome and mortality. METHODS We identified adult patients (>60 years) with traumatic type II odontoid fractures. We used multivariate regression controlling for patient demographics, Glasgow Coma Scale (GCS) score, Charlson Comorbidity Index (CCI), modified Rankin Scale (mRS) score, modified Frailty Index (mFI-5 and mFI-11), fracture displacement, and conservative vs operative treatment. RESULTS Of the 59 patients (mean age 77.9 years), 24 underwent surgical intervention and 35 underwent conservative management. Operatively managed patients were younger (73.4 vs 80.6 years, P < .001) and had higher degree of fracture displacement (3.5 vs 1.0 mm, P = .002) than conservatively managed patients but no other differences in baseline characteristics. Twenty-four patients (40.7%) died within the study period (median time to death: 376 days). There were no differences between treatment groups in functional outcomes (mRS or Frankel Grade) or mortality (33.3% in operative group vs 45.7%, P = .34). There was a statistically significant correlation between higher presentation mRS score and subsequent mortality on multivariate analysis (OR = 2.06, 95% CI 1.04-4.10, P = .039), whereas surgical intervention, age, GCS score, CCI, mFI-5, mFI-11, sex, and fracture displacement were not significantly correlated. CONCLUSIONS Mortality after type II odontoid fractures in elderly patients is common. mRS score at presentation may help predict mortality more accurately than other patient factors.
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Affiliation(s)
| | - Brandon A Sherrod
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
| | - Kyril Cole
- School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Parker Cox
- School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Davide M Croci
- Department of Neurosurgery, University of South Florida, Tampa, FL, USA
| | - Christian A Bowers
- Department of Neurosurgery, University of New Mexico, Albuquerque, NM, USA
| | - Marcus D Mazur
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
| | - Andrew T Dailey
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
| | - Erica F Bisson
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
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Ammanuel SG, Page PS, Brooks NP, Resnick DK. Development of a Predictive Model for Persistent Instability Following Conservative Management of Type II Odontoid Fractures. World Neurosurg 2024; 181:e422-e426. [PMID: 37863424 DOI: 10.1016/j.wneu.2023.10.073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 10/12/2023] [Accepted: 10/13/2023] [Indexed: 10/22/2023]
Abstract
BACKGROUND Odontoid fractures are common cervical spine fractures; however, significant controversy exists regarding their treatment. Risk factors for failure of conservative therapy have been identified, although no predictive risk score has been developed to aid in decision-making. METHODS A retrospective review was conducted of all patients evaluated at a level 1 trauma center. Patients identified with type II odontoid fractures as classified by the D'Alonzo Classification system who were treated with external orthosis were included in analysis. Patients were considered to have failed conservative therapy if they were offered surgical intervention. A machine learning method (Risk-SLIM) was then utilized to create a risk stratification score based on risk factors to identify patients at high risk for requiring surgical intervention due to persistent instability. RESULTS A total of 138 patients were identified as presenting with type II odontoid fractures that were treated conservatively; 38 patients were offered surgery for persistent instability. The Odontoid Fracture Predictive Model (OFPM) was created using a machine learning algorithm with a 5-fold cross validation area under the curve of 0.7389 (95% CI: 0.671 to 0.808). Predictive factors were found to include fracture displacement, displacement greater than 5 mm, comminution at the fracture base, and history of smoking. The probability of persistent instability was <5% with a score of 0 and 88% with a score of 5. CONCLUSIONS The OFPM model is a unique, quick, and accurate tool to assist in clinical decision-making in patients with type II odontoid fractures. External validation is necessary to evaluate the validity of these findings.
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Affiliation(s)
- Simon G Ammanuel
- Department of Neurological Surgery, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin, USA.
| | - Paul S Page
- Department of Neurological Surgery, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin, USA
| | - Nathaniel P Brooks
- Department of Neurological Surgery, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin, USA
| | - Daniel K Resnick
- Department of Neurological Surgery, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin, USA
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Yoganandan N, Baisden J, Vedantam A, Varghese V, Banerjee A. Upper cervical spine bone mineral content variations in elderly females. ACCIDENT; ANALYSIS AND PREVENTION 2023; 193:107329. [PMID: 37783162 DOI: 10.1016/j.aap.2023.107329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 09/13/2023] [Accepted: 09/20/2023] [Indexed: 10/04/2023]
Abstract
The purpose of the study was to determine the bone mineral densities (BMDs) of the C1 and C2 vertebrae and discuss their implications for autonomous vehicle environments and vulnerable road users. Using quantitated computed tomography (QCT), the BMDs were obtained at eight regions for the C1 vertebra and seven regions for the C2 vertebra. The spine surgeon author outlined the boundaries of each region, and nine elderly female human cadaver specimens were used. The regions were based on potential stabilization locations for fracture fixation. In the C1 vertebra, the BMD was greatest at the anterior tubercle, followed by the posterior tubercle, the posterior arch, and the lateral and anterior lateral masses. In the C2 vertebra, the distal odontoid had the greatest BMD, followed by the spinous process, the C2-lateral mass, the odontoid-body interface, and the anterior inferior aspect of the body. Use of these data in female-specific finite element models may lead to a better understanding of load paths, injuries, mechanisms, and tolerance.
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Affiliation(s)
| | | | | | | | - Anjishnu Banerjee
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, WI, USA
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ElNemer W, Solomon E, Raad M, Jain A, Lee SH. Predicting Mortality Following Odontoid Fracture Fixation in Elderly Patients: CAADS-16 Score. Global Spine J 2023:21925682231220019. [PMID: 38037824 DOI: 10.1177/21925682231220019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2023] Open
Abstract
STUDY DESIGN Retrospective Review of a National Database. INTRODUCTION By utilizing a national database, this study aims to quantify the predictors of 30-day mortality after odontoid fixation and guide appropriate management for patients in whom the choice between operative and non-operative management is unclear. METHODS The American College of Surgeons National Surgical Quality Improvement Database was queried using Current Procedural Terminology (CPT) codes and International Classification of Disease (ICD) codes to identify patients 60 or older who underwent surgical fixation of an odontoid fracture from 2005 to 2020. Risk factors for mortality significant in univariate and subsequent multivariate analysis were used to develop a scoring system to predict post-operative mortality. RESULTS 608 patients were identified. Patients were split into a non-mortality 30 days post-op group, and into a mortality 30 days post-op group. The following risk factors were included in the scoring system: functional dependency, disseminated cancer, albumin less than 3.5, WBC count greater than 16 k, anterior surgical approach, and pre-op SIRS. Using a cutoff value of 2, the CAAD-16 score had a sensitivity and specificity of 82% and 81%, respectively. The ASA score, cutoff at 4, showed a sensitivity and specificity of 64% and 75% respectively. CONCLUSIONS This sample of 294 patients represents one of the largest samples of odontoid fracture fixation patients available in the literature and comes from a nationally representative database. We structure relevant risk factors into the CAADS-16 score, which has the potential to be a clinically relevant tool to prevent short-term postoperative mortality.
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Affiliation(s)
- William ElNemer
- School of Medicine, The Johns Hopkins University, Baltimore, MD, USA
| | - Eric Solomon
- Department of Orthopaedic Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Micheal Raad
- Department of Orthopaedic Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Amit Jain
- Department of Orthopaedic Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Sang Hun Lee
- Department of Orthopaedic Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
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Castel X, Pelletier JB, Sulpis B, Charier D, Buhot B, Mihail G, Carlioz V, Barral-Clavel F, Sylvain G, Tetard MC, Vassal F. MFI-11 Predicts Post-Operative Serious Complications in Patients Undergoing Surgery for Odontoid Fractures. Global Spine J 2023:21925682231205103. [PMID: 37776203 DOI: 10.1177/21925682231205103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/02/2023] Open
Abstract
STUDY DESIGN Retrospective Cohort. OBJECTIVES The objective of this study was to analyze postoperative complications in different mFI-11 groups after surgery for odontoid fractures in a geriatric population. METHODS A single center retrospective review of odontoid fractures surgery (between 2013 and 2022) in patients aged 65 years and older was conducted. The primary outcome was the occurrence of a major complication (Calvien-Dindo ≥4) within 30 days post-surgery. The secondary outcome was the occurrence of a major complication within 3 months after surgery, and death within 1-month post-surgery. Survival curve, multi-variate analysis was performed and adjusted receiver operating characteristic curves were generated. RESULTS There were 92 patients included in this study, with a mean age of 80.5 years. Serious complication occurred for 16 patients (17%) during hospitalization. Multivariate analysis demonstrated an mFI 11 >.27 was strongly and independently associated with serious complications within 1-month post-surgery (OR = 16.7, 95% CI = 4.50-83), as well as serious complications within 3 months post-surgery (OR = 11.8, 95% CI = 3.48-49.1) and death within 1 month post-surgery (OR = 11.7; 95% CI = 3.02-60.4). The Receiver Operator Characteristics (ROC) curves for the three models all have an Area Under the Curve (AUC) value greater than 0.7. CONCLUSIONS The mFI-11 is a straightforward and validated tool that can be used during the preoperative period to identify the patient's level of frailty and assess their risk of postoperative complications. Patients with mFI-11 ≥.27 are at greater risk of serious complications within 1 and 3 months' post-surgery and death within 1 month post-surgery.
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Affiliation(s)
- Xavier Castel
- Neurosurgery Department, Centre Hospitalier Universitaire de Saint-Etienne, Saint-Etienne, France
| | - Jean-Baptiste Pelletier
- Neurosurgery Department, Centre Hospitalier Universitaire de Saint-Etienne, Saint-Etienne, France
| | - Benoit Sulpis
- Neurosurgery Department, Centre Hospitalier Universitaire de Saint-Etienne, Saint-Etienne, France
| | - David Charier
- Neurosurgery Department, Centre Hospitalier Universitaire de Saint-Etienne, Saint-Etienne, France
| | - Benjamin Buhot
- Neurosurgery Department, Centre Hospitalier Universitaire de Saint-Etienne, Saint-Etienne, France
| | - Gurschi Mihail
- Neurosurgery Department, Centre Hospitalier Universitaire de Saint-Etienne, Saint-Etienne, France
| | - Violette Carlioz
- Dermatology Department, Centre Hospitalier de Firminy, Firminy, France
| | - Fanelie Barral-Clavel
- Neurosurgery Department, Centre Hospitalier Universitaire de Saint-Etienne, Saint-Etienne, France
| | - Granges Sylvain
- Radiology Department, Centre Hospitalier Universitaire de Saint-Etienne, Saint-Etienne, France
| | - Marie-Charlotte Tetard
- Neurosurgery Department, Centre Hospitalier Universitaire de Saint-Etienne, Saint-Etienne, France
| | - Francois Vassal
- Neurosurgery Department, Centre Hospitalier Universitaire de Saint-Etienne, Saint-Etienne, France
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Sunder A, Chhabra H, Aryal A. Geriatric spine fractures - Demography, changing trends, challenges and special considerations: A narrative review. J Clin Orthop Trauma 2023; 43:102190. [PMID: 37538298 PMCID: PMC10393813 DOI: 10.1016/j.jcot.2023.102190] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Accepted: 06/16/2023] [Indexed: 08/05/2023] Open
Abstract
The aim of this manuscript was to summarize the demography and changing trends of geriatric spinal injuries and to enumerate the challenges and special considerations in the care of geriatric spinal injuries. PubMed, Scopus and Embase databases were searched for literature on geriatric spine fractures using MeSH terms 'aged', 'aged, 80 and over', 'elderly', 'spinal fracture/epidemiology', spinal fracture/therapy∗' and keywords pertaining to the same. The search results were screened for appropriate articles and reviewed. There is a high community prevalence of elderly vertebral fractures ranging from 18% to as high as 51%. The proportion of older patients among the spinal injured is rising as well. There is a higher chance of missing spinal injuries in the elderly and clinical guidelines may not be applicable to this patient group. Classification and surgical treatment are different from younger adult counterparts as the elderly osteoporotic spine behaves differently biomechanically. There is a high incidence of respiratory complications both for surgically and conservatively managed groups. Older age generally is associated with a higher complication rate including mortality.
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Affiliation(s)
- Aditya Sunder
- Indian Spinal Injuries Centre, New Delhi, 110070, India
| | - H.S. Chhabra
- Indian Spinal Injuries Centre, New Delhi, 110070, India
| | - Aayush Aryal
- Indian Spinal Injuries Centre, New Delhi, 110070, India
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Aarabi B, Neal CJ, Hersh DS, Harrop JS, Fehlings MG, Toups EG, Guest JD, Ugiliweneza B, Akhtar-Danesh N, Kurpad SN, Grossman RG. Mortality in ASIA Impairment Scale grade A to D Patients With Odontoid Fracture and Magnetic Resonance Imaging Evidence of Spinal Cord Injury. Neurotrauma Rep 2023; 4:375-383. [PMID: 37350794 PMCID: PMC10282967 DOI: 10.1089/neur.2023.0005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/24/2023] Open
Abstract
Odontoid fractures are common, often presenting in the elderly after a fall and infrequently associated with traumatic spinal cord injury (tSCI). The goal of this study was to analyze predictors of mortality and neurological outcome when odontoid fractures were associated with signal change on magnetic resonance imaging (MRI) at admission. Over an 18-year period (2001-2019), 33 patients with odontoid fractures and documented tSCI on MRI were identified. Mean age was 65.3 years (standard deviation [SD] = 17.2), and 21 patients were male. The mechanism of injury was falls in 25 patients, motor vehicle accidents in 5, and other causes in 3. Mean Injury Severity Score (ISS) was 40.5 (SD = 30.2), Glasgow Coma Scale (GCS) score was 13 (SD = 3.4), and American Spinal Injury Association (ASIA) motor score (AMS) was 51.6 (SD = 42.7). ASIA Impairment Scale (AIS) grade was A, B, C, and D in 9, 2, 3, and 19 patients, respectively. Mean intramedullary lesion length was 32.3 mm (SD = 18.6). The odontoid peg was displaced ventral or dorsal in 15 patients. Twenty patients had surgical intervention: anterior odontoid screw fixation in 7 and posterior spinal fusion in 13. Eleven (33.3%) patients died in this series: withdrawal of medical care in 5; anoxic brain injury in 4; and failure of critical care management in 2. Univariate logistic regression indicated that GCS score (p < 0.014), AMS (p < 0.002), AIS grade (p < 0.002), and ISS (p < 0.009) were risk factors for mortality. Multi-variate regression analysis indicated that only AMS (p < 0.002) had a significant relationship with mortality when odontoid fracture was associated with tSCI (odds ratio, 0.963; 95% confidence interval, 0.941-0.986).
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Affiliation(s)
- Bizhan Aarabi
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Christopher J. Neal
- Department of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - David S. Hersh
- Division of Neurosurgery, Connecticut Children's, Hartford, Connecticut, USA
| | - James S. Harrop
- Department of Neurosurgery, Jefferson Medical College, Philadelphia, Pennsylvania, USA
| | - Michael G. Fehlings
- Division of Neurosurgery and Spine Program, University of Toronto, Toronto, Ontario, Canada
| | - Elizabeth G. Toups
- Department of Neurosurgery, University of Texas, Houston at Methodist Hospital, Houston, Texas, USA
| | - James D. Guest
- Department of Neurological Surgery, the Miami Project to Cure Paralysis, Miami, Florida, USA
| | - Beatrice Ugiliweneza
- Department of Neurosurgery, Kentucky Spinal Cord Injury Research Center, Louisville, Kentucky, USA
| | - Noori Akhtar-Danesh
- School of Nursing and Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Shekar N. Kurpad
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Robert G. Grossman
- Department of Neurosurgery, University of Texas, Houston at Methodist Hospital, Houston, Texas, USA
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Osterhoff G, Scholz M, Disch AC, Katscher S, Spiegl UJA, Schnake KJ, Scheyerer MJ. Geriatric Odontoid Fractures: Treatment Algorithms of the German Society for Orthopaedics and Trauma Based on Expert Consensus and a Systematic Review. Global Spine J 2023; 13:13S-21S. [PMID: 37084350 PMCID: PMC10177304 DOI: 10.1177/21925682231157316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/23/2023] Open
Abstract
STUDY DESIGN Systematic review/expert consensus. OBJECTIVES Fractures of the axis represent the most frequent injury of the spine in elderly patients. Both, operative and non-operative treatment are associated with a high rate of complications and mortality. The aim of this article was to summarize the current literature on the management of odontoid fractures in geriatric patients and to weigh it based on an expert consensus process. METHODS In a joint consensus process, members of the Spine Section of the German Orthopaedic and Trauma Society (DGOU) aimed to formulate recommendations for the diagnostic workup and treatment of odontoid fractures in geriatric patients. Based on the previously published recommendations, this article is an updated version with incorporating a systematic review of the recent literature. RESULTS Based on the new data available, the recommendations established in the initial consensus process were adapted. CONCLUSIONS Computed tomography represents the diagnostic standard for patients with suspected injuries of the upper cervical spine. Anderson/D'Alonzo odontoid fractures type 1, non-displaced type 2, and type 3 can be treated conservatively. Even non-unions do not necessarily result in poor clinical outcome. In Anderson/D'Alonzo type 2 fractures, surgical therapy offers the advantage of relatively safe osseous healing with no increased complication rate even in elderly patients and can thus be recommended. In very high aged patients, however, a case-by-case decision should be made. When surgical stabilization of osteoporotic odontoid fractures is indicated, posterior techniques are biomechanically advantageous and can be considered the standard.
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Affiliation(s)
- Georg Osterhoff
- Department of Orthopaedics, Trauma and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Matti Scholz
- ATOS Orthopaedic Clinic Braunfels, Braunfels, Germany
| | - Alexander C Disch
- University Comprehensive Spine Center (UCSC), University Center for Orthopaedics, Traumatology & Plastic Surgery, University Hospital Carl Gustav Carus at the TU Dresden, Germany
| | - Sebastian Katscher
- Interdisciplinary Center for Spine and Neurotrauma, Sana Klinikum Borna, Borna, Germany
| | - Ulrich J A Spiegl
- Department of Orthopaedics, Trauma and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Klaus John Schnake
- Center for Spinal and Scoliosis Surgery, Waldkrankenhaus Erlangen, Erlangen, Germany
- Department of Orthopedics and Traumatology, Paracelsus Private Medical University Nuremberg, Nuremberg, Germany
| | - Max J Scheyerer
- Department of Orthopaedics and Trauma Surgery, University of Cologne, Faculty of Medicine and University Hospital Cologne, Koln, Germany
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Copley PC, Tadross D, Salloum N, Woodfield J, Edlmann E, Poon M, Khan S, Brennan PM. A systematic review identifying outcome measures used in evaluating adults sustaining cervical spine fractures. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2022; 31:3365-3377. [PMID: 36063214 DOI: 10.1007/s00586-022-07369-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 08/22/2022] [Accepted: 08/25/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To assess the outcome measures used in studies investigating cervical spine fractures in adults, with or without associated spinal cord injury, to inform development of a core outcome set. METHODS Medline, Embase and Scopus were searched for relevant studies until May 28, 2022, without a historic limit on study date. Study characteristics, population characteristics and outcomes reported were extracted and analyzed. RESULTS Our literature search identified 536 studies that met criteria for inclusion, involving 393,266 patients. Most studies were single center (87.3%), retrospective studies (88.9%) and involved a median of 40 patients (range 6-167,278). Treatments assessed included: surgery (55.2%), conservative (6.2%), halo immobilization (4.9%), or a mixture (33.2%). Median study duration was 84 months (range 3-564 months); the timing of clinical and/or radiological follow-up assessment after injury was reported in 56.7%. There was significant heterogeneity in outcomes used, with 79 different reported outcomes measures. Differences in use were identified between smaller/larger, retro-/prospective and single/multicenter cohorts. Over time, the use of radiological outcomes has declined with greater emphasis on patient-reported outcome measures (PROMs). Studies of conservative management were more likely to detail PROMs and mortality, whereas surgical studies reported Frankel/ASIA grade, radiological fusion, complication rates, duration of hospital stay and re-operation rates more frequently. In studies assessing the elderly population (> 65 years), use of PROMs, mortality, hospital stay and discharge destination were more common, whereas fusion was reported less often. Response rates for outcome assessments were lower in studies assessing elderly patients, and studies using PROMs. CONCLUSIONS We have classified the various outcome measures used for patients with cervical spine fractures based on the COMET outcome taxonomy. We also described the contexts in which different outcomes are more commonly employed to help guide decision-making when designing future research endeavors.
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Affiliation(s)
- Phillip C Copley
- Department of Clinical Neurosciences, Royal Infirmary of Edinburgh, Edinburgh, UK.
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK.
- Department of Clinical Neurosciences, Edinburgh Spinal Surgery Outcome Studies Group, Edinburgh, UK.
| | - Daniel Tadross
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Nadia Salloum
- Department of Clinical Neurosciences, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Julie Woodfield
- Department of Clinical Neurosciences, Royal Infirmary of Edinburgh, Edinburgh, UK
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Ellie Edlmann
- Southwest Neurosurgical Centre, Derriford Hospital, Plymouth, UK
- Faculty of Health: Medicine, Dentistry and Human Sciences, University of Plymouth, Plymouth, UK
| | - Michael Poon
- Department of Clinical Neurosciences, Royal Infirmary of Edinburgh, Edinburgh, UK
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
- Department of Clinical Neurosciences, Edinburgh Spinal Surgery Outcome Studies Group, Edinburgh, UK
- Centre for Medical Informatics, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Sadaquate Khan
- Department of Clinical Neurosciences, Royal Infirmary of Edinburgh, Edinburgh, UK
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
- Department of Clinical Neurosciences, Edinburgh Spinal Surgery Outcome Studies Group, Edinburgh, UK
| | - Paul M Brennan
- Department of Clinical Neurosciences, Royal Infirmary of Edinburgh, Edinburgh, UK
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
- Department of Clinical Neurosciences, Edinburgh Spinal Surgery Outcome Studies Group, Edinburgh, UK
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11
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Tsukamoto M, Morimoto T, Kobayashi T, Hirata H, Yoshihara T, Mawatari M. Atlanto-axial subluxation secondary to a neglected odontoid fracture. BJR Case Rep 2022; 8:20220110. [PMID: 36632545 PMCID: PMC9809909 DOI: 10.1259/bjrcr.20220110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 09/02/2022] [Indexed: 01/14/2023] Open
Abstract
A 81-year-old female had chronic renal failure and was undergoing hemodialysis, visited orthopaedic clinic after striking her head on the ceiling of a car while driving on a rough road. An odontoid fracture went unidentified on the initial radiograph. One month later, she came to our hospital with persistent neck pain. A radiography and computed tomography revealed a C1-two subluxation secondary to the fracture. Posterior occipito-C1-C2-C3 fixation was performed, and the patient wore a halo-vest for two-month post-surgery. After two months, the halo-vest was removed, and the patient was not experiencing any pain or neurological deficits. In older patients, even minor head trauma can result in cervical vertebral fractures. Therefore, potential fractures should be considered during initial evaluations to avoid the serious consequences of an incorrect initial diagnosis. Care should be taken when choosing between conservative or surgical treatments, considering all potential risks and complications.
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Affiliation(s)
- Masatsugu Tsukamoto
- Department of Orthopaedic Surgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Tadatsugu Morimoto
- Department of Orthopaedic Surgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Takaomi Kobayashi
- Department of Orthopaedic Surgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Hirohito Hirata
- Department of Orthopaedic Surgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Tomohito Yoshihara
- Department of Orthopaedic Surgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Masaaki Mawatari
- Department of Orthopaedic Surgery, Faculty of Medicine, Saga University, Saga, Japan
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12
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Woodfield J, Edlmann E, Black PL, Boyd J, Copley PC, Cranswick G, Eborall H, Keerie C, Khan S, Lawton J, Lowe DJ, Norrie J, Niven A, Reed MJ, Shenkin SD, Statham P, Stoddart A, Tomlinson J, Brennan PM. Duration of External Neck Stabilisation (DENS) following odontoid fracture in older or frail adults: protocol for a randomised controlled trial of collar versus no collar. BMJ Open 2022; 12:e057753. [PMID: 35840308 PMCID: PMC9295672 DOI: 10.1136/bmjopen-2021-057753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Fractures of the odontoid process frequently result from low impact falls in frail or older adults. These are increasing in incidence and importance as the population ages. In the UK, odontoid fractures in older adults are usually managed in hard collars to immobilise the fracture and promote bony healing. However, bony healing does not always occur in older adults, and bony healing is not associated with quality of life, functional, or pain outcomes. Further, hard collars can cause complications such as skin pressure ulcers, swallowing difficulties and difficulties with personal care. We hypothesise that management with no immobilisation may be superior to management in a hard collar for older or frail adults with odontoid fractures. METHODS AND ANALYSES This is the protocol for the Duration of External Neck Stabilisation (DENS) trial-a non-blinded randomised controlled trial comparing management in a hard collar with management without a collar for older (≥65 years) or frail (Rockwood Clinical Frailty Scale ≥5) adults with a new odontoid fracture. 887 neurologically intact participants with any odontoid process fracture type will be randomised to continuing with a hard collar (standard care) or removal of the collar (intervention). The primary outcome is quality of life measured using the EQ-5D-5L at 12 weeks. Secondary outcomes include pain scores, neck disability index, health and social care use and costs, and mortality. ETHICS AND DISSEMINATION Informed consent for participation will be sought from those able to provide it. We will also include those who lack capacity to ensure representativeness of frail and acutely unwell older adults. Results will be disseminated via scientific publication, lay summary, and visual abstract. The DENS trial received a favourable ethical opinion from the Scotland A Research Ethics Committee (21/SS/0036) and the Leeds West Research Ethics Committee (21/YH/0141). TRIAL REGISTRATION NUMBER NCT04895644.
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Affiliation(s)
- Julie Woodfield
- Department of Clinical Neurosciences, NHS Lothian, Edinburgh, UK
- Translational Neurosurgery, The University of Edinburgh Centre for Clinical Brain Sciences, Edinburgh, UK
| | - Ellie Edlmann
- Southwest Neurosurgical Centre, Derriford Hospital, Plymouth, UK
- Peninsula Medical School, University of Plymouth, Plymouth, UK
| | - Polly L Black
- Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
| | - Julia Boyd
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | | | - Gina Cranswick
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Helen Eborall
- University of Edinburgh Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
| | - Catriona Keerie
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Sadaquate Khan
- Department of Clinical Neurosciences, NHS Lothian, Edinburgh, UK
| | - Julia Lawton
- University of Edinburgh Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
| | - David J Lowe
- Department of Emergency, Queen Elizabeth University Hospital Campus, Glasgow, UK
- University of Glasgow Institute of Health and Wellbeing, Glasgow, UK
| | - John Norrie
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Angela Niven
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Matthew J Reed
- Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
- University of Edinburgh Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
| | - Susan Deborah Shenkin
- University of Edinburgh Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
- Advanced Care Research Centre, University of Edinburgh College of Medicine and Veterinary Medicine, Edinburgh, UK
| | - Patrick Statham
- Department of Clinical Neurosciences, NHS Lothian, Edinburgh, UK
| | - Andrew Stoddart
- Edinburgh Health Services Research Unit, The University Of Edinburgh, Edinburgh, UK
| | - James Tomlinson
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Paul M Brennan
- Department of Clinical Neurosciences, NHS Lothian, Edinburgh, UK
- Translational Neurosurgery, The University of Edinburgh Centre for Clinical Brain Sciences, Edinburgh, UK
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13
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Garay RS, Solitro GF, Lam KC, Morris RP, Albarghouthi A, Lindsey RW, Latta LL, Travascio F. Characterization of regional variation of bone mineral density in the geriatric human cervical spine by quantitative computed tomography. PLoS One 2022; 17:e0271187. [PMID: 35802639 PMCID: PMC9269429 DOI: 10.1371/journal.pone.0271187] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 06/24/2022] [Indexed: 11/23/2022] Open
Abstract
Background Odontoid process fractures are among the most common in elderly cervical spines. Their treatment often requires fixation, which may include use of implants anteriorly or posteriorly. Bone density can significantly affect the outcomes of these procedures. Currently, little is known about bone mineral density (BMD) distributions within cervical spine in elderly. This study documented BMD distribution across various anatomical regions of elderly cervical vertebrae. Methods and findings Twenty-three human cadaveric C1-C5 spine segments (14 males and 9 female, 74±9.3 y.o.) were imaged via quantitative CT-scan. Using an established experimental protocol, the three-dimensional shapes of the vertebrae were reconstructed from CT images and partitioned in bone regions (4 regions for C1, 14 regions for C2 and 12 regions for C3-5). The BMD was calculated from the Hounsfield units via calibration phantom. For each vertebral level, effects of gender and anatomical bone region on BMD distribution were investigated via pertinent statistical tools. Data trends suggested that BMD was higher in female vertebrae when compared to male ones. In C1, the highest BMD was found in the posterior portion of the bone. In C2, BMD at the dens was the highest, followed by lamina and spinous process, and the posterior aspect of the vertebral body. In C3-5, lateral masses, lamina, and spinous processes were characterized by the largest values of BMD, followed by the posterior vertebral body. Conclusions The higher BMD values characterizing the posterior aspects of vertebrae suggest that, in the elderly, posterior surgical approaches may offer a better fixation quality.
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Affiliation(s)
- Ryan S. Garay
- Department of Mechanical and Aerospace Engineering, University of Miami, Coral Gables, Florida, United States of America
| | - Giovanni F. Solitro
- Louisiana State University Health-Shreveport, Shreveport, Louisiana, United States of America
| | - Kenrick C. Lam
- University of Texas Medical Branch, Galveston, Texas, United States of America
| | - Randal P. Morris
- University of Texas Medical Branch, Galveston, Texas, United States of America
| | - Abeer Albarghouthi
- Max Biedermann Institute for Biomechanics, Mount Sinai Medical Center, Miami Beach, Florida, United States of America
| | - Ronald W. Lindsey
- University of Texas Medical Branch, Galveston, Texas, United States of America
| | - Loren L. Latta
- Max Biedermann Institute for Biomechanics, Mount Sinai Medical Center, Miami Beach, Florida, United States of America
- Department of Orthopaedic Surgery, University of Miami, Miami, Florida, United States of America
| | - Francesco Travascio
- Department of Mechanical and Aerospace Engineering, University of Miami, Coral Gables, Florida, United States of America
- Max Biedermann Institute for Biomechanics, Mount Sinai Medical Center, Miami Beach, Florida, United States of America
- Department of Orthopaedic Surgery, University of Miami, Miami, Florida, United States of America
- Department of Industrial Engineering, University of Miami, Coral Gables, Florida, United States of America
- * E-mail:
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14
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Pongmanee S, Sarasombath P, Rojdumrongrattana B, Kaensuk S, Liawrungrueang W. A computed tomographic morphometric analysis of the odontoid process for using anterior double Herbert screws fixation in the Southeast Asian population. INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2021.101459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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15
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Reevaluation of a classification system: stable and unstable odontoid fractures in geriatric patients-a radiological outcome measurement. Eur J Trauma Emerg Surg 2022; 48:2967-2976. [PMID: 35597894 PMCID: PMC9360123 DOI: 10.1007/s00068-022-01985-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 04/16/2022] [Indexed: 11/30/2022]
Abstract
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.
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16
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Odontoid fracture complicating ankylosing spondylitis presenting with cervical canal stenosis and quadriparesis: A case report with 5-year follow-up and review of the literature. Int J Surg Case Rep 2022; 94:107067. [PMID: 35421726 PMCID: PMC9019263 DOI: 10.1016/j.ijscr.2022.107067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 04/07/2022] [Accepted: 04/07/2022] [Indexed: 11/20/2022] Open
Abstract
Introduction and importance Spinal fractures, especially cervical fractures, are more common in patients with ankylosing spondylitis in comparison with unaffected patients. However, odontoid fractures are relatively rare in these patients. Also, neurological symptoms are not common in odontoid fractures due to the larger diameter of the spinal canal at this level. Case presentation Here, we presented a 41 year-old man known case of ankylosing spondylitis who develop odontoid fracture and severe cervical stenosis after falling trauma. Quadriparesis and positive Hoffman sign as well as significant thoracolumbar kyphosis were diagnosed in further investigation. Laminectomy and posterior fixation were executed primary and pedicular subtraction osteotomy was performed two years later to manage the kyphosis and sagittal imbalance. On the follow-up period of five years the patient was fully functional. Clinical discussion There are a few cases of odontoid fractures complicating ankylosing spondylitis in the literature. Neurological symptoms are relatively uncommon in odontoid fractures; however, cases with AS can present with neck pain, weakness, and hyperreflexia when having unstable fractures. Conclusion Although there is not any gold standard for the treatment of the odontoid fracture in AS, surgical intervention is preferred. The occurrence of the odontoid fracture is rare in patients with AS. Neurological deficits are more common in posterior subluxation of the odontoid process compared to anterior subluxation. The optimal treatment approach for odontoid fracture in cases with AS is unknown; however, surgical management is preferred.
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17
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Pongmanee S, Kaensuk S, Sarasombath P, Rojdumrongrattana B, Kritworakarn N, Liawrungrueang W. Anterior screw fixation for type II odontoid process fractures: A single-center experience with the double Herbert screw fixation technique (Retrospective cohort study). Ann Med Surg (Lond) 2022; 74:103337. [PMID: 35198171 PMCID: PMC8844744 DOI: 10.1016/j.amsu.2022.103337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 01/29/2022] [Accepted: 02/01/2022] [Indexed: 11/03/2022] Open
Abstract
Background Methods Results Conclusions Type II odontoid fractures with intact transverse ligament is challenging for anterior cervical surgery. Double screw technique in anterior odontoid surgery using a headless 3.0-mm.-diameter cannulated Herbert screw on patients with odontoid process fractures. This study of satisfactory clinical results demonstrates that double anterior screw fixation of type II odontoid process fractures using 3.0-mm screws is highly effective.
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18
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Wang B, Jin J, Shao ZX, Yang GY, Lin Y, Xu HZ, Xie CL, Chen JX, Zhang XL, Hong ZH, Wang XY. Wright's Technique with the Addition of Visualized Axial Cortical Windows in Odontoid Fractures. Orthop Surg 2021; 14:443-450. [PMID: 34914198 PMCID: PMC8867410 DOI: 10.1111/os.13012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 02/24/2021] [Accepted: 03/16/2021] [Indexed: 11/30/2022] Open
Abstract
This study sought to investigate and evaluate a modified axial translaminar screw fixation for treating odontoid fractures. We performed a retrospective study at Wenzhou Medical University Affiliated Second Hospital between March 2016 and June 2018. We retrospectively collected and analyzed the medical records of 23 cases with odontoid fractures. All patients were identified as type II odontoid fractures without neurological deficiency and serious diseases following the classification of Anderson. The average age, gender ratio, and body mass index (BMI) were 54.3 ± 11.1 years, 12 men to 11 women, and 22.6 ± 2.4 kg/m2 , respectively. Patients in this study accepted screw fixation using our modified axial translaminar screw fixation combined with atlas pedicle or lateral mass screw fixation. Within the technique, a small cortical "window" was dug in the middle of the axial contralateral lamina, such that the screws in the lamina were visualized to prevent incorrectly implanting the posterior spinal canal through the visualized "window." A total of 46 bone screws were accurately inserted into the axial lamina without using fluoroscopy. The length of all translaminar screws ranged between 26 and 30 mm, while the diameter was 3.5 mm. During the follow-up survey, the visual analog scale (VAS) and neck disability index (NDI) were measured. We provide a simple modification of Wright's elegant technique with the addition of "visualized windows" at the middle of the axial lamina. In all patients, screws were inserted accurately without bony breach and the screw angle was 56.1 ± 3.0°. Mean operative time was 102 ± 28 min with an average blood loss of 50 ± 25 mL. Postoperative hemoglobin and mean length of hospital stay were 12.0 ± 1.4 g/dL and 10.4 ± 3.4 days, respectively. The average follow-up time of all cases was 14.7 months and no internal fixation displacement, loosening, or breakage was found. All patients with odontoid fractures reported being satisfied with the treatment during the recheck period and good clinical outcomes were observed. At 1, 6, and 12 months, NDI and VAS showed that the symptoms of neck pain and limitations of functional disability improved significantly during follow-up. Our results suggest that the modified translaminar screw fixation technique can efficiently treat Anderson type II odontoid fracture, followed by the benefits of less soft tissue dissection, simple operation, no fluoroscopy, and accurate placement of screws.
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Affiliation(s)
- Ben Wang
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,The Second School of Medicine, Wenzhou Medical University, Wenzhou, China.,Laboratory of Orthopaedics of Zhejiang Province, Wenzhou, China.,Orthopaedic Department, Taizhou Hospital Affiliated to Wenzhou Medical University, Linhai, China
| | - Jie Jin
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,The Second School of Medicine, Wenzhou Medical University, Wenzhou, China.,Laboratory of Orthopaedics of Zhejiang Province, Wenzhou, China
| | - Zhen-Xuan Shao
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,The Second School of Medicine, Wenzhou Medical University, Wenzhou, China.,Laboratory of Orthopaedics of Zhejiang Province, Wenzhou, China
| | - Guang-Yong Yang
- Orthopaedic Department, Taizhou Hospital Affiliated to Wenzhou Medical University, Linhai, China
| | - Yan Lin
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,The Second School of Medicine, Wenzhou Medical University, Wenzhou, China.,Laboratory of Orthopaedics of Zhejiang Province, Wenzhou, China
| | - Hua-Zi Xu
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,The Second School of Medicine, Wenzhou Medical University, Wenzhou, China.,Laboratory of Orthopaedics of Zhejiang Province, Wenzhou, China
| | - Cheng-Long Xie
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,The Second School of Medicine, Wenzhou Medical University, Wenzhou, China.,Laboratory of Orthopaedics of Zhejiang Province, Wenzhou, China
| | - Jiao-Xiang Chen
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,The Second School of Medicine, Wenzhou Medical University, Wenzhou, China.,Laboratory of Orthopaedics of Zhejiang Province, Wenzhou, China
| | - Xiao-Lei Zhang
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,The Second School of Medicine, Wenzhou Medical University, Wenzhou, China.,Laboratory of Orthopaedics of Zhejiang Province, Wenzhou, China
| | - Zheng-Hua Hong
- Orthopaedic Department, Taizhou Hospital Affiliated to Wenzhou Medical University, Linhai, China
| | - Xiang-Yang Wang
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,The Second School of Medicine, Wenzhou Medical University, Wenzhou, China.,Laboratory of Orthopaedics of Zhejiang Province, Wenzhou, China
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19
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Bilateral medial medullary syndrome following anterior screw fixation of type 2 odontoid fracture, a case report of two patients. Spinal Cord Ser Cases 2021; 7:101. [PMID: 34799551 DOI: 10.1038/s41394-021-00462-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 10/26/2021] [Accepted: 11/02/2021] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Medial medullary syndrome (MMS) has not been reported after anterior screw fixation of an odontoid type 2 fracture. CASE PRESENTATION We report on two cases who suffered from an unstable type 2 odontoid fracture following a skiing and a domestic fall accident. Prior to anterior screw fixation surgery both patients presented without neurologic deficits but postoperatively developed a bilateral MMS, including an incomplete tetraparesis, impaired sensation of position and movement as well as tactile discrimination and paralysis of the tongue muscle with deviation to the paralyzed side. MRI showed a typical heart-shaped ischaemic lesion in the medial medulla bilaterally. The search for aetiologic factors was uneventful in both patients except for severe atherosclerosis. DISCUSSION Due to the close proximity of the ischaemic area to the surgical site, we here propose the perioperative mechanical manipulation of the upper cervical spine during surgery of patients with atherosclerosis as a new aetiology for MMS.
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20
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Carlstrom LP, Helal A, Perry A, Lakomkin N, Graffeo CS, Clarke MJ. Too frail is to fail: Frailty portends poor outcomes in the elderly with type II odontoid fractures independent of management strategy. J Clin Neurosci 2021; 93:48-53. [PMID: 34656260 DOI: 10.1016/j.jocn.2021.08.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 08/24/2021] [Accepted: 08/30/2021] [Indexed: 10/20/2022]
Abstract
Type-II odontoid fractures are common and highly morbid injuries, particularly among elderly patients. However, few risk stratification resources exist to predict outcomes and guide management decision making. Frailty indices have been increasingly utilized for these purposes in elective surgery, but have not been assessed for trauma. A single-center prospective trauma registry identified patients aged ≥ 80 years with type-II odontoid fractures. Frailty was the independent variable, using three independent indices: modified-5-item frailty (mFI-5), modified Charlson comorbidity (mCCI), and Davies. 97 patients had complete frailty data and sufficient follow up information, with median mIF-5 of 2 (range 0-4; 34 frail, mFI-5 > 2), median mCCI score of 6 (range 4-14), and median Davies score of 2 (range 0-7). For all indices, increasing score was associated with mortality, mIF-5 (HR = 1.76, 95%CI = 1.06-2.88), mCCI (HR = 1.10, 95%CI = 1.01-1.20), and Davies scores (HR = 1.21, 95%CI = 1.08-1.37). Median post-injury survival among patients with mIF-5 of ≤ 2 was 10-fold longer than patients with mIF-5 of > 2 (70 vs. 710 days, p = 0.0026). After adjusting for initial treatment strategy, frailty status remained an independent predictor of patient mortality; mIF-5 (HR = 1.72, 95%CI = 1.02-2.80), mCCI (HR = 1.10, 95%CI = 1.01-1.20), and Davies scores (HR = 1.21, 95%CI = 1.08-1.37). Among octogenarian patients with type-II odontoid fractures, frailty was associated with increased mortality, independent of treatment strategy.
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Affiliation(s)
| | - Ahmed Helal
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Avital Perry
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Nikita Lakomkin
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
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21
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Bunmaprasert T, Trirattanapikul V, Sugandhavesa N, Phanphaisarn A, Liawrungrueang W, Phinyo P. Reducible Nonunited Type II Odontoid Fracture with Atlantoaxial Instability: Outcomes of Two Different Fixation Techniques. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18157990. [PMID: 34360289 PMCID: PMC8345345 DOI: 10.3390/ijerph18157990] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 07/19/2021] [Accepted: 07/27/2021] [Indexed: 11/16/2022]
Abstract
Displaced nonunited type II odontoid fracture can result in atlantoaxial instability, causing delayed cervical myelopathy. Both Magerl's C1-C2 transarticular screw fixation technique and Harms-Goel C1-C2 screw-rod segmental fixation technique are effective techniques to provide stability. This study aimed to demonstrate the results of two surgical fixation techniques for the treatment of reducible nonunited type II odontoid fracture with atlantoaxial instability. Medical records of patients with reducible nonunited type II odontoid fracture hospitalized for spinal fusion between April 2007 and April 2018 were reviewed. For each patient, specific surgical fixation, either Magerl's C1-C2 transarticular screw fixation technique augmented with supplemental wiring or Harms-Goel C1-C2 screw-rod fixation technique, was performed according to our management protocol. We reported the fusion rate, fusion period, and complications for each technique. Of 21 patients, 10 patients were treated with Magerl's C1-C2 transarticular screw fixation technique augmented with supplemental wiring, and 11 were treated with Harms-Goel C1-C2 screw-rod fixation technique. The bony fusion rate was 100% in both groups. The mean time to fusion was 69.7 (95%CI 53.1, 86.3) days in Magerl's C1-C2 transarticular screw fixation technique and 75.2 (95%CI 51.8, 98.6) days in Harms-Goel C1-C2 screw-rod fixation technique. No severe complications were observed in either group. Displaced reducible, nonunited type II odontoid fracture with cervical myelopathy should be treated by surgery. Both fixation techniques promote bony fusion and provide substantial construct stability.
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Affiliation(s)
- Torphong Bunmaprasert
- Department of Orthopaedics, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand; (T.B.); (V.T.); (N.S.); (A.P.); (W.L.)
| | - Vorapop Trirattanapikul
- Department of Orthopaedics, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand; (T.B.); (V.T.); (N.S.); (A.P.); (W.L.)
| | - Nantawit Sugandhavesa
- Department of Orthopaedics, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand; (T.B.); (V.T.); (N.S.); (A.P.); (W.L.)
| | - Areerak Phanphaisarn
- Department of Orthopaedics, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand; (T.B.); (V.T.); (N.S.); (A.P.); (W.L.)
| | - Wongthawat Liawrungrueang
- Department of Orthopaedics, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand; (T.B.); (V.T.); (N.S.); (A.P.); (W.L.)
| | - Phichayut Phinyo
- Department of Family Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
- Center for Clinical Epidemiology and Clinical Statistics, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
- Musculoskeletal Science and Translational Research (MSTR) Cluster, Chiang Mai University, Chiang Mai 50200, Thailand
- Correspondence: ; Tel.: +66-53-935-180
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22
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Chibbaro S, Mallereau CH, Ganau M, Zaed I, Teresa Bozzi M, Scibilia A, Cebula H, Ollivier I, Loit MP, Chaussemy D, Coca HA, Dannhoff G, Romano A, Nannavecchia B, Gubian A, Spatola G, Signorelli F, Iaccarino C, Pop R, Proust F, Baloglu S, Todeschi J. Odontoid Type II fractures in elderly: what are the real management goals and how to best achieve them? A multicenter European study on functional outcome. Neurosurg Rev 2021; 45:709-718. [PMID: 34232408 DOI: 10.1007/s10143-021-01594-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 05/01/2021] [Accepted: 05/13/2021] [Indexed: 11/27/2022]
Abstract
Odontoid fractures constitute the most common cervical fractures in elderly. External immobilization is the treatment of choice for Type I and III; there is still no wide consensus about the best management of Type II fractures. Observational multicenter study was conducted on a prospectively built database on elderly patients (> 75 years) with Type II odontoid fracture managed conservatively during the last 10 years. All patients underwent CT scan on admission and at 3 months; if indicated, selected patient had CT scan at 6 and 12 months. All patients were clinically evaluated by Neck Disability Index (NDI), Charlson Comorbidity Index (CCI), and American Society of Anaesthesiologists classification (ASA) on admission; NDI was assessed also at 6 weeks, 3, 6, 12, and 24 months; furthermore, a quality of life (QoL) assessment with the SF-12 form was performed at 3 and 12 months. Among the 260 patients enrolled, 177 (68%) were women and 83 (32%) men, with a median age of 83 years. Patients were followed up for a minimum of 24 months: 247 (95%) showed an excellent functional outcome within 6 weeks, among them 117 (45%) showed a good bony healing, whereas 130 (50%) healed in pseudo-arthrosis. The residual 5% were still variably symptomatic at 12 weeks; however, only 5 out of 13 (2% of the total cohort) required delayed surgery. This study showed that a conservative approach to odontoid Type II fracture in elderly is an effective and valid option, resulting in an excellent functional outcome (regardless of bony fusion) in the majority of cases. Failure of conservative treatment can be safely addressed with surgical fixation at a later stage.
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Affiliation(s)
- Salvatore Chibbaro
- Department of Neurosurgery, Strasbourg University Hospital, Strasbourg, France
| | | | - Mario Ganau
- Department of Neurosurgery, Oxford University Hospital, Oxford, UK
| | - Ismail Zaed
- Department of Neurosurgery, Humanitas University Hospital, Rozzano, Italy
| | - Maria Teresa Bozzi
- Department of Neurosurgery, Strasbourg University Hospital, Strasbourg, France
| | - Antonino Scibilia
- Department of Neurosurgery, Strasbourg University Hospital, Strasbourg, France
| | - Helene Cebula
- Department of Neurosurgery, Strasbourg University Hospital, Strasbourg, France
| | - Irene Ollivier
- Department of Neurosurgery, Strasbourg University Hospital, Strasbourg, France
| | - Marie-Pierre Loit
- Department of Neurosurgery, Strasbourg University Hospital, Strasbourg, France
| | - Dominique Chaussemy
- Department of Neurosurgery, Strasbourg University Hospital, Strasbourg, France
| | - Hugo-Andres Coca
- Department of Neurosurgery, Strasbourg University Hospital, Strasbourg, France
| | - Guillaume Dannhoff
- Department of Neurosurgery, Strasbourg University Hospital, Strasbourg, France
| | - Antonio Romano
- Department of Neurosurgery, Parma University Hospital, Parma, Italy
| | | | - Arthur Gubian
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Giorgio Spatola
- Department of Neurosurgery, Poli-Ambulanza Hospital, Brescia, Italy
| | | | - Corrado Iaccarino
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
- Division of Neurosurgery, University Hospital of Modena, Modena, Italy
| | - Raoul Pop
- Neuroradiology Unit, Strasbourg University Hospital, Strasbourg, France
| | - François Proust
- Department of Neurosurgery, Strasbourg University Hospital, Strasbourg, France
| | - Seyyid Baloglu
- Neuroradiology Unit, Strasbourg University Hospital, Strasbourg, France
| | - Julien Todeschi
- Department of Neurosurgery, Strasbourg University Hospital, Strasbourg, France
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Harris L, Arif S, Elliot M, Brady Z, Lawrence A, Lee C, Tsang K. Fusion rates for conservative and surgical management of type II odontoid fractures and its impact. Br J Neurosurg 2021; 35:607-610. [PMID: 33998359 DOI: 10.1080/02688697.2021.1926921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Type II odontoid fractures are known to have low fusion rates following conservative management with a hard collar. However, most patients are elderly with comorbidities and are not fit for surgery. The present study identified the rates of bony fusion, complications, and clinical outcomes following conservative management of type II odontoid fractures. METHODS We included consecutive patients referred with a suspected odontoid fracture to a Major Trauma Centre in the UK between March 2015 and December 2017. Data including patient demographics, fracture management, complications and outcomes. Bony fusion was assessed by two neurosurgeons and one neuroradiologists. Results were analysed with simple statistics and chi-squared test. RESULTS 102 patients were included in the study (mean age = 80.4 ± 15.3). 10 (9.8%) were managed surgically and 92 (90.2%) were managed conservatively with a hard collar, for a mean of 87 days. Patients were followed up for a mean of 28.1 months (range 1-855 days) until discharge. 37% developed collar complications, namely pain, stiffness and non-tolerance. Bony union was achieved in 37.3% of patients treated with a hard collar (versus 80% in the surgical group, p = 0.0096). Increasing age was an independent risk factor for non-union (p < 0.001). Of the patients without bony union, none reported symptoms, and 90% were discharged without a collar. CONCLUSION The management of type II odontoid fractures are difficult in an elderly, co-morbid population. With conservative management fusion rates are low, and collar complications are not insignificant. However, outcomes are good regardless of union.
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Affiliation(s)
- Lauren Harris
- Division of Neurosurgery, Imperial College Healthcare NHS Trust, London, UK
| | | | - Matthew Elliot
- Division of Neurosurgery, Imperial College Healthcare NHS Trust, London, UK
| | | | - Alistair Lawrence
- Division of Neurosurgery, Imperial College Healthcare NHS Trust, London, UK
| | - Cheong Lee
- Division of Neurosurgery, Imperial College Healthcare NHS Trust, London, UK
| | - Kevin Tsang
- Division of Neurosurgery, Imperial College Healthcare NHS Trust, London, UK
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24
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Gold C, Seaman S, Yamaguchi S. Relationship between odontoid fracture angle and cervical sagittal balance. Surg Neurol Int 2021; 12:157. [PMID: 33948327 PMCID: PMC8088494 DOI: 10.25259/sni_829_2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 03/13/2021] [Indexed: 12/02/2022] Open
Abstract
Background: Fractures can occur in various locations within the odontoid process with differing orientations. However, little is known about what factors contribute to the anterior versus posterior angles/orientation of these fractures. Methods: We evaluated 74 patients with odontoid fractures (2013–2018) from a single-institution. Patients’ fracture angles/orientations were measured on computed tomography studies, and were grouped into oblique posterior (OP) or oblique anterior (OA) groups. We also took into account cervical sagittal balance utilizing upright x-rays. Other variables studied included patients’ ages, sagittal balance measurements, and the mechanisms of injury. Results: Fracture angles were significantly steeper in the OP group. OP fractures had larger C2-C7 sagittal vertical axis, occiput-C2 angles, and occiput-C7 angles versus anteriorly oriented fractures. In our linear regression model, advanced age and large occiput-C2 angles were predictive of the odontoid fracture angle. Patients who sustained ground-level falls also had significantly steeper fracture angles versus those involved in motor vehicle accidents. Conclusion: The odontoid tends to fracture at a steep, posterior angle in elderly patients who demonstrate a large positive sagittal balance when the head is extended following a ground-level falls.
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Affiliation(s)
- Colin Gold
- Department of Neurosurgery, University of Iowa, 200 Hawkins Drive, Iowa City, IA, United States
| | - Scott Seaman
- Department of Neurosurgery, University of Iowa, 200 Hawkins Drive, Iowa City, IA, United States
| | - Satoshi Yamaguchi
- Department of Neurosurgery, University of Iowa, 200 Hawkins Drive, Iowa City, IA, United States
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25
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AlSaleh K, Abulras M, Alrehaili O. Temporary spanning internal fixation for management of complex upper cervical spine fractures. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2021; 12:10-14. [PMID: 33850376 PMCID: PMC8035578 DOI: 10.4103/jcvjs.jcvjs_118_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 11/22/2020] [Indexed: 11/09/2022] Open
Abstract
Introduction: Fractures of the upper cervical spine are often but not always amenable to either internal fixation or conservative management using a rigid cervical collar. For all other fractures in this area, management with a halo-vest orthosis is indicated, but it also has limitations. Here, we present an operative alternative to the halo-vest orthosis that provides more secure stability and less complications. Methods: Three patients presented to our hospital with atypical fractures of C1 and C2 and were given the choice of either a halo-vest orthosis or secure internal fixation without fusion and accepted the latter. Internal fixation without fusion from occiput to the subaxial spine was performed for all three and then removed-6 months later -after radiologic confirmation of healing. Results: All three patients underwent the procedure successfully and achieved and maintained acceptable alignment. Range of motion was preserved, and no intermediate-term issues were observed. Conclusion: Spanning internal fixation provides a safe and effective technique in the management of complex upper cervical spine injuries without the drawbacks of using a halo-vest orthosis.
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Affiliation(s)
- Khalid AlSaleh
- Department of Orthopedics College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Muteb Abulras
- Department of Orthopedics College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Osama Alrehaili
- Department of Orthopedics College of Medicine, King Saud University, Riyadh, Saudi Arabia
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26
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Comparative study of 3D printed navigation template-assisted atlantoaxial pedicle screws versus free-hand screws for type II odontoid fractures. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2020; 30:498-506. [DOI: 10.1007/s00586-020-06644-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 09/27/2020] [Accepted: 10/13/2020] [Indexed: 10/23/2022]
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27
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Buttock carbuncle with severe hypothermia and disturbed consciousness: When os odontoideum is the answer. Clin Neurol Neurosurg 2020; 196:105914. [DOI: 10.1016/j.clineuro.2020.105914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 05/08/2020] [Accepted: 05/10/2020] [Indexed: 11/24/2022]
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Ifthekar S, Ahuja K, Mittal S, Sarkar B, Deep G, Thomas W, Kandwal P. Management of Neglected Upper Cervical Spine Injuries. Indian J Orthop 2020; 55:673-679. [PMID: 33995872 PMCID: PMC8081783 DOI: 10.1007/s43465-020-00227-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 08/06/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Injuries involving upper cervical spine are serious and fatal injuries which are associated with alteration of normal occipital-cervical anatomy. These injuries may result in permanent neurologic deficits or neck deformity if not treated in a timely and appropriate manner. OBJECTIVE To evaluate the outcomes of neglected upper cervical spine injuries treated by various methods. STUDY DESIGN Retrospective study. MATERIALS AND METHODS Twelve patients attending ER or OPD with a history of neck trauma and who were diagnosed with fractures and fracture dislocations C1 and C2 were included in the study. Fresh injuries sustained within a week were excluded from study. The outcomes were measured in terms of improvement in VAS, ODI Scores and correction of the neck deformity. Surgical parameters like duration of surgery and blood loss were also observed. RESULTS Eleven males and one female. The mean age was 40.9 ± 16.9 (07-67 years). Eleven patients underwent posterior instrumentation, while one patient was treated anteriorly. The mean delay in presentation was 28 ± 8.67 days (15-42 days). The mean duration of surgery was 188.3 ± 34.35 min (120-240 min), average blood loss was 350 ± 111.8 ml (150-600 ml). The mean VAS improved from 8.45 ± 0.89 to 3.9 ± 0.51 (p < 0.05). The mean ODI Pre-operatively was 88.45 ± 5.89 which improved to 31.9 ± 4.01 (p < 0.05). The neck deformity/torticollis was corrected in all the patients. CONCLUSIONS Neglected upper cervical spine injuries are difficult to treat and a posterior approach is helpful in reducing the subluxations indirectly and to obtain a posterior fusion.
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Affiliation(s)
- Syed Ifthekar
- Department of Orthopaedics, AIIMS Rishikesh, Rishikesh, Uttarakhand 249203 India
| | - Kaustubh Ahuja
- Department of Orthopaedics, AIIMS Rishikesh, Rishikesh, Uttarakhand 249203 India
| | - Samarth Mittal
- Department of Orthopaedics, AIIMS Rishikesh, Rishikesh, Uttarakhand 249203 India
| | - Bhaskar Sarkar
- Department of Trauma and Emergency, AIIMS Rishikesh, Rishikesh, 249203 Uttarakhand India
| | - Gagan Deep
- Department of Orthopaedics, AIIMS Rishikesh, Rishikesh, Uttarakhand 249203 India
| | - Watson Thomas
- Department of Orthopaedics, AIIMS Rishikesh, Rishikesh, Uttarakhand 249203 India
| | - Pankaj Kandwal
- Department of Orthopaedics, AIIMS Rishikesh, Rishikesh, Uttarakhand 249203 India
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29
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Is the Use of a Cervical Collar Necessary in the Nonoperative Management of Type II Peg Fractures in the Elderly? Clin Spine Surg 2020; 33:95-98. [PMID: 30925496 DOI: 10.1097/bsd.0000000000000821] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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30
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Catalino MP, Pate V, Stürmer T, Bhowmick DA. Comparative Propensity-Weighted Mortality After Isolated Acute Traumatic Axis Fractures in Older Adults. Geriatr Orthop Surg Rehabil 2020; 11:2151459320911867. [PMID: 32284902 PMCID: PMC7133078 DOI: 10.1177/2151459320911867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 11/27/2019] [Accepted: 01/16/2020] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION In older patients with axis fractures, the survival benefit from surgery is unclear due to high baseline mortality. Comparative effectiveness research can provide evidence from population level cohorts. Propensity weighting is the preferred methodology for reducing bias when analyzing national administrative cohort data for these purposes but has not yet been utilized for this important surgical conundrum. We estimate the effect of surgery on mortality after isolated acute traumatic axis fracture in older adults. MATERIALS AND METHODS We used a retrospective population-based cohort of Medicare patients and generated a propensity score-weighted nonsurgical cohort and compared mortality with and without surgery. This balanced the comorbid conditions of the treatment groups. Incident fractures were defined using a predetermined algorithm based on enrollment, code timing, and billing location. The primary outcome was adjusted all-cause 1-year mortality. RESULTS From 12 372 beneficiaries with 1-year continuous enrollment and a coded axis fracture, 2676 patients met final inclusion/exclusion criteria. Estimated incidence was 16.5 per 100 000 person-years overall in 2014 (95% confidence interval [CI]: 15.0-18.0) and was stable from 2008 through 2014. Patients with axis fracture had a mean age of 82.8 years, 30.2% were male, and 91.9% were Caucasian. Mortality was 3.8 times higher (CI 3.6-4.1) compared with the general population of older US adults. Propensity-weighted mortality at 1 year for nonsurgical patients was 26.7 of 100 (CI: 24.5-29.0). Mortality for surgical patients was significantly lower (19.7/100; CI 14.5-25.0). Risk difference was 7.0 fewer surgical deaths per 100 patients (CI: 1.3-12.7). Surgical patients aged 65 to 74 years had the largest difference in mortality with 11.2 fewer deaths per 100 (CI: 1.1-21.3). DISCUSSION Patients with axis fractures are predominantly older Caucasian women and have a higher mortality rate than the general population. Propensity-weighted mortality at 1-year was lower in the surgical patients with the largest risk difference occurring in patients 65 to 74 years old. CONCLUSIONS Surgery may provide an independent survival benefit in patients aged 65 to 75 years, and the mortality difference diminishes thereafter.
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Affiliation(s)
| | - Virginia Pate
- Department of Epidemiology, UNC Gillings School of Global Public Health, NC, USA
| | - Til Stürmer
- Department of Epidemiology, UNC Gillings School of Global Public Health, NC, USA
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31
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Kapoor S, Herschkovich O, Lucantoni C, Boszczyk B. Stent augmentation of an anterior odontoid screw for type 2 odontoid fracture-dislocation in the elderly population: Report of two cases and literature review. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2020; 10:254-258. [PMID: 32089621 PMCID: PMC7008655 DOI: 10.4103/jcvjs.jcvjs_91_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 11/06/2019] [Indexed: 11/24/2022] Open
Abstract
The fixation of type 2 odontoid fractures poses significant challenges in the elderly population due to coexistent osteoporosis and communition resulting in a high failure rate with conventional anterior screw fixation. Two elderly patients with unstable odontoid peg fractures and coexistent osteoporosis were treated with stentoplasty and anterior odontoid screw fixation. Additional anterior transarticular C1–2 screws were placed to address C1–2 instability. Both patients made an uneventful clinical recovery. One of the anterior C1–2 screws loosened due to the poor purchase in the osteoporotic bone in one patient. This did not affect the final outcome, and both the patients demonstrated maintained reduction and good alignment of odontoid peg after 2 years of follow-up. There was no intraoperative cement leak, pseudoarthrosis, or loss of reduction. Stentoplasty coupled with the anterior odontoid screw is a safe technique that can provide a biomechanically sound fixation of type 2 odontoid fractures in the presence of osteoporosis and significant communition.
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Affiliation(s)
- Saurabh Kapoor
- Department of Spinal Surgery, Queen's Medical Center, Nottingham, UK
| | - Oded Herschkovich
- Department of Spinal Surgery, Queen's Medical Center, Nottingham, UK
| | - Corrado Lucantoni
- Department of Spinal Surgery, Queen's Medical Center, Nottingham, UK
| | - Bronek Boszczyk
- Spinal Center (Dr. Med Habil), Benedictus Hospital, Tutzing, Germany
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Capek L, Rehousek P, Henys P, Bleibleh S, Jenner E, Kulvajtova M, Skala-Rosenbaum J. Cement augmentation of odontoid peg fractures: the effect of cement volume and distribution on construct stiffness. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2020; 29:977-985. [PMID: 31902000 DOI: 10.1007/s00586-019-06286-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 12/13/2019] [Accepted: 12/31/2019] [Indexed: 11/26/2022]
Abstract
PURPOSE The cement augmentation of a conventional anterior screw fixation in type II odontoid process fractures for elderly patients significantly increased stiffness and load to failure under anterior-posterior load in comparison with non-augmented fixation. The amount and quality of bone cement are usually taken ad hoc in clinical practise. In this study, we wanted to clarify the role of bone cement amount and its quality to the stiffness of odontoid and vertebrae body junction. METHODS Finite-element method was used to achieve different scenarios of cement augmentation. For all models, an initial stiffness was calculated. Model (1) the intact vertebrae were virtually potted into a polymethylmethacrylate base via the posterior vertebral arches. A V-shaped punch was used for loading the odontoid in an anterior-posterior direction. (2) The odontoid fracture type IIa (Anderson-D'Alonzo classification) was achieved by virtual transverse osteotomy. Anterior screw fixation was virtually performed by putting self-drilling titanium alloy 3.5 mm diameter anterior cannulated lag screw with a 12 mm thread into the inspected vertebrae. A V-shaped punch was used for loading the odontoid in an anterior-posterior direction. The vertebrae body was assumed to be non-cemented and cemented with different volume. RESULTS The mean cement volume was lowest for body base filling with 0.47 ± 0.03 ml. The standard body filling corresponds to 0.95 ± 0.15 ml. The largest volume corresponds to 1.62 ± 0.12 ml in the presence of cement leakage. The initial stiffness of the intact C2 vertebrae was taken as the reference value. The mean initial stiffness for non-porous cement (E = 3000 MPa) increased linearly (R2 = 0.98). The lowest stiffness (123.3 ± 5.8 N/mm) was measured in the intact C2 vertebrae. However, the highest stiffness (165.2 ± 5.2 N/mm) was measured when cement leakage out of the odontoid peg occurred. The mean initial stiffness of the base-only cemented group was 147.2 ± 8.4 N/mm compared with 157.9 ± 6.6 N/mm for the base and body cemented group. This difference was statistically significant (p < 0.0061). The mean initial stiffness for porous cement (E = 500 MPa) remains constant. Therefore, there is no difference between cemented and non-cemented junction. This difference was not statistically significant (p < 0.18). CONCLUSION The present study showed that the low porous cement was able to significantly influence the stiffness of the augmented odontoid screw fixation in vitro, although further in vivo clinical studies should be undertaken. Our results suggest that only a small amount of non-porous cement is needed to restore stiffness at least to its pre-fracture level and this can be achieved with the injection of 0.7-1.2 ml of cement. These slides can be retrieved under Electronic Supplementary Material.
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Affiliation(s)
- Lukas Capek
- Technical University of Liberec, Studentska 1402/2, 461 17, Liberec, Czechia
| | - Petr Rehousek
- Royal Orthopaedic Hospital, Bristol Rd South, Birmingham, B32 1AP, UK
- Third Faculty of Medicine, Charles University, Prague, Ruska 2411/87, 100 00, Praha 10, Vinohrady, Czechia
| | - Petr Henys
- Technical University of Liberec, Studentska 1402/2, 461 17, Liberec, Czechia.
| | - Sabri Bleibleh
- Royal Orthopaedic Hospital, Bristol Rd South, Birmingham, B32 1AP, UK
| | - Edward Jenner
- Royal Orthopaedic Hospital, Bristol Rd South, Birmingham, B32 1AP, UK
| | - Marketa Kulvajtova
- Third Faculty of Medicine, Charles University, Prague, Ruska 2411/87, 100 00, Praha 10, Vinohrady, Czechia
| | - Jiri Skala-Rosenbaum
- Third Faculty of Medicine, Charles University, Prague, Ruska 2411/87, 100 00, Praha 10, Vinohrady, Czechia
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Osterhoff G, Schnake K, Scheyerer MJ, Ullrich BW, Hartmann F, Franck A, Koepp H, Reinhold M, Schmeiser G, Sprengel K, Zimmermann V, Siekmann H, Badke A, Gebhard H, Täubel KC, Grüninger S, Verheyden AP, Schleicher P, Spiegl UJA. Recommendations for Diagnosis and Treatment of Odontoid Fractures in Geriatric Patients. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2019; 158:647-656. [PMID: 31634954 DOI: 10.1055/a-0989-2791] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Odontoid fractures in geriatric patients represent an entity of increasing incidence with a high rate of morbidity and mortality. The optimal diagnostic and therapeutic management is being controversially discussed in the literature. METHODS In a consensus process and based on the current literature, the members of the working groups "Osteoporotic Fractures" and "Upper Cervical Spine" of the German Society for Orthopaedics and Trauma Surgery (DGOU) defined recommendations for the diagnostics and treatment of odontoid fractures in geriatric patients. RESULTS For the diagnosis of odontoid fractures in symptomatic patients, computed tomography represents the gold standard, along with conventional radiographs. Magnetic resonance and dynamic imaging can be used as ancillary imaging modalities. With regard to fracture classification, the systems described by Anderson/D'Alonzo and by Eysel/Roosen have proved to be of value. A treatment algorithm was developed based on these classifications. Anderson/D'Alonzo type 1, type 3, and non-displaced type 2 fractures usually can be treated non-operatively. However, a close clinical and radiological follow-up is essential. In Anderson/D'Alonzo type 2 fractures, operative treatment is associated with better fracture healing. Displaced type 2 and type 3 fractures should be stabilized operatively. Type 2 fractures with suitable fracture patterns (Eysel/Roosen 2A/B) can be stabilized anteriorly. Posterior C I/II-stabilization procedures are well established and suitable for all fracture patterns.
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Affiliation(s)
- Georg Osterhoff
- Klinik für Orthopädie, Unfallchirurgie und Plastische Chirurgie, Universitätsklinikum Leipzig
| | - Klaus Schnake
- Zentrum für Wirbelsäulen- und Skoliosetherapie, Schön Klinik Nürnberg/Fürth, Fürth
| | - Max J Scheyerer
- Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Köln
| | - Bernhard W Ullrich
- Klinik für Unfall- und Wiederherstellungschirurgie, BG Klinikum Bergmannstrost GgmbH Halle/Saale
| | - Frank Hartmann
- Zentrum für Unfallchirurgie und Orthopädie, Ev. Stift St. Martin, Gemeinschaftsklinikum Mittelrhein, Koblenz
| | - Alexander Franck
- Klinik für Orthopädie und Unfallchirurgie, Regiomed Klinikum Coburg
| | - Holger Koepp
- Wirbelsäulenzentrum, St. Josefs-Hospital, Wiesbaden
| | - Maximilian Reinhold
- Klinik für Unfallchirurgie, Orthopädie und Handchirurgie, Klinikum Südstadt Rostock
| | | | - Kai Sprengel
- Klinik für Traumatologie, UniversitätsSpital Zürich, Schweiz
| | - Volker Zimmermann
- Abt. Unfallchirurgie und Orthopädische Chirurgie, Klinikum Traunstein
| | - Holger Siekmann
- Department für Orthopädie, Unfall- und Wiederherstellungschirurgie, Martin-Luther-Universität Halle-Wittenberg, Halle
| | - Andreas Badke
- Klinik für Unfall- und Wiederherstellungschirurgie, BG Unfallklinik Tübingen
| | | | - Kai C Täubel
- Orthopädisch-Unfallchirurgisches Zentrum, ALB FILS KLINIKEN, Standort Klinik am Eichert, Göppingen
| | - Sebastian Grüninger
- Universitätsklinik für Orthopädie und Unfallchirurgie, Paracelsus Medizinische Privatuniversität, Klinikum Nürnberg
| | - Akhil P Verheyden
- Klinik für Unfall-, Orthopädische und Wirbelsäulenchirurgie, Ortenau Klinikum Lahr-Ettenheim
| | | | - Ulrich J A Spiegl
- Klinik für Orthopädie, Unfallchirurgie und Plastische Chirurgie, Universitätsklinikum Leipzig
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Abstract
While several papers on mortality and the fusion rate in elderly patients treated surgically or non-surgically for odontoid fractures exist, little information is available on quality of life after treatment. The aim of treatment in these patients should not be fracture healing alone but also quality of life improvement.A literature search using PubMed identified seven papers including information on functional evaluation of 402 patients.Patients treated with anterior screw fixation had a good functional outcome in 92.6% of cases. This percentage seemed to decrease in octogenarians. Less information was available for patients treated with posterior approaches; it would seem that up to a half of such patients experienced pain and limitations in activities of daily living after surgery. Patients treated with a halo device had a functional outcome that was worse (or at least no better) than that of patients treated with surgery, with absence of limitations in activities of daily living in 77.3% of patients. Patients treated with a collar had a good functional outcome in the majority of cases, with absence of limitations in activities of daily living in 89% of patients.More studies are needed for evaluation of functional outcome, especially in patients treated with a collar, a halo device or a posterior approach.
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Wolan-Nieroda A, Maciejczak A, Guzik A, Przysada G, Szeliga E, Drużbicki M. Range of motion in the cervical spine after odontoid fracture treated with anterior screw fixation. J Orthop Surg Res 2019; 14:104. [PMID: 30987654 PMCID: PMC6466774 DOI: 10.1186/s13018-019-1135-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Accepted: 03/27/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND It is believed that direct odontoid screw fixation preserves the physiological cervical range of motion following surgery. However, there are no clinical studies confirming the motion sparing value of this technique. This study aims to (1) to assess active cervical range of motion following types II and III odontoid fracture, successfully treated with anterior odontoid screw fixation, and (2) to examine the relationship between the range of motion of the head and duration of collar usage, neck pain, quality of life, and patients' age. METHODS The study involved 41 patients subjected to a procedure of direct osteosynthesis of the dens with lag screw. Following the operation all the patients had to wear a cervical collar to protect the osteosynthesis. The control group consisted of 41 individuals with no clinical diagnosis of any cervical spine disorders. The spinal motion was assessed using multi-cervical unit, taking into account bending/extension, left and right lateral flexion, and left and right axial rotation. RESULTS In the study group, spine mobility correlated with the duration of hard collar usage following the operation, with a longer duration corresponding to poorer spine mobility at the end of the treatment. Statistically significant correlation was observed in the case of extension (p < 0.021) and axial rotation (p < 0.007). In the study group, there was a negative correlation between the range of motion and the patients' age, i.e., the older the patient the poorer his/her spinal mobility (p < 0.001). CONCLUSIONS Active cervical range of motion in patients following direct osteosynthesis of the dens, augmented with a hard collar, was significantly lower than in the control population, and it correlated negatively with the duration of collar usage, the patients' age, and intensity of spinal pain.
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Affiliation(s)
- Andżelina Wolan-Nieroda
- Medical Faculty, University of Rzeszów, Kopisto 2A Avenue, 35-959, Rzeszow, Poland. .,Institute of Physiotherapy, University of Rzeszow, Warszawska 26 a, 35-205, Rzeszów, Poland.
| | - Andrzej Maciejczak
- Medical Faculty, University of Rzeszów, Kopisto 2A Avenue, 35-959, Rzeszow, Poland.,Department of Neurosurgery, St Luke Hospital, Lwowska 178 Street, 33-100, Tarnow, Poland
| | - Agnieszka Guzik
- Medical Faculty, University of Rzeszów, Kopisto 2A Avenue, 35-959, Rzeszow, Poland
| | - Grzegorz Przysada
- Medical Faculty, University of Rzeszów, Kopisto 2A Avenue, 35-959, Rzeszow, Poland
| | - Ewa Szeliga
- Medical Faculty, University of Rzeszów, Kopisto 2A Avenue, 35-959, Rzeszow, Poland
| | - Mariusz Drużbicki
- Medical Faculty, University of Rzeszów, Kopisto 2A Avenue, 35-959, Rzeszow, Poland
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Shafafy R, Valsamis EM, Luck J, Dimock R, Rampersad S, Kieffer W, Morassi GL, Elsayed S. Predictors of mortality in the elderly patient with a fracture of the odontoid process. Bone Joint J 2019; 101-B:253-259. [DOI: 10.1302/0301-620x.101b3.bjj-2018-1004.r1] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Aims Fracture of the odontoid process (OP) in the elderly is associated with mortality rates similar to those of hip fracture. The aim of this study was to identify variables that predict mortality in patients with a fracture of the OP, and to assess whether established hip fracture scoring systems such as the Nottingham Hip Fracture Score (NHFS) or Sernbo Score might also be used as predictors of mortality in these patients. Patients and Methods We conducted a retrospective review of patients aged 65 and over with an acute fracture of the OP from two hospitals. Data collected included demographics, medical history, residence, mobility status, admission blood tests, abbreviated mental test score, presence of other injuries, and head injury. All patients were treated in a semi-rigid cervical orthosis. Univariate and multivariate analysis were undertaken to identify predictors of mortality at 30 days and one year. A total of 82 patients were identified. There were 32 men and 50 women with a mean age of 83.7 years (67 to 100). Results Overall mortality was 14.6% at 30 days and 34.1% at one year. Univariate analysis revealed head injury and the NHFS to be significant predictors of mortality at 30 days and one year. Multivariate analysis showed that head injury is an independent predictor of mortality at 30 days and at one year. The NHFS was an independent predictor of mortality at one year. The presence of other spinal injuries was an independent predictor at 30 days. Following survival analysis, an NHFS score greater than 5 stratified patients into a significantly higher risk group at both 30 days and one year. Conclusion The NHFS may be used to identify high-risk patients with a fracture of the OP. Head injury increases the risk of mortality in patients with a fracture of the OP. This may help to guide multidisciplinary management and to inform patients. This paper provides evidence to suggest that frailty rather than age alone may be important as a predictor of mortality in elderly patients with a fracture of the odontoid process. Cite this article: Bone Joint J 2019;101-B:253–259.
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Affiliation(s)
- R. Shafafy
- Department of Spinal Surgery, Brighton and Sussex University Hospitals NHS Trust, Royal Sussex County Hospital NHS Foundation Trust, Brighton, UK
| | - E. M. Valsamis
- Department of Trauma and Orthopaedics, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - J. Luck
- Department of Trauma and Orthopaedics, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - R. Dimock
- Department of Trauma and Orthopaedics, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - S. Rampersad
- Department of Spinal Surgery, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - W. Kieffer
- Frimley Health NHS Foundation Trust, Frimley Park Hospital, Camberley, UK
| | - G. L. Morassi
- Department of Spinal Surgery, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - S. Elsayed
- Department of Spinal Surgery, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
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Musa A, Farhan SA, Lee YP, Uribe B, Kiester PD. Traumatic Atlantoaxial Lateral Subluxation With Chronic Type II Odontoid Fracture: A Case Report. Int J Spine Surg 2019; 13:79-83. [PMID: 30805289 DOI: 10.14444/6010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Background We report a case of an elderly patient who was diagnosed with lateral atlantoaxial subluxation with type II odontoid fracture, an extremely uncommon upper cervical spine injury that has not been previously reported in the literature to the knowledge of the authors. Methods An 87-year-old male reported to the emergency room following a syncopal episode after sustaining a fall. He complained of dizziness, fatigue, disruption of vision and audition, and worsening neck pain. Computed tomographic scans were positive of partial dislocation of the C1 relative to C2 and chronic fracture of dens classified as type II according to the Anderson and D'Alonzo classification system. Magnetic resonance imaging further revealed large fracture pannus tissue at the level of the dens, reducing the space in the spinal cord. There was no evidence of spinal cord injury. Atlas-axis fusion with instrumentation was performed to manage the injury. A review of the classification, occurrence, and management of upper cervical spine surgeries was performed. Results An acute injury to a previously unrecognized type II odontoid fracture with partial C1-C2 dislocation was identified as a rare upper cervical spine injury and classified based on the Anderson and D'Alonzo and Fielding and Hawkins classification systems. The decision was made to perform instrumented spinal fusion by inserting mass screws into C1, pars screws into C2, and locking rods to realign the vertebral bodies and address the atlantoaxial instability. Follow-up scans indicated good postsurgical reduction and fixation, including resolution of the pannus overgrowth without direct intervention. Conclusions Lateral atlantoaxial subluxation with chronic type II fracture of the dens constitutes a rare injury of the upper cervical vertebrae. Posterior instrumented spinal fusion was used to effectively manage the injury, leading to reabsorption of retro-odontoid pannus tissue.
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Affiliation(s)
- Arif Musa
- School of Medicine, Wayne State University, Detroit, Michigan
| | - Saif Aldeen Farhan
- Department of Orthopaedic Surgery, University of California Irvine Medical Center, Orange, California
| | - Yu-Po Lee
- Department of Orthopaedic Surgery, University of California Irvine Medical Center, Orange, California
| | - Brittany Uribe
- School of Osteopathic Medicine, Rowan University, Stratford, New Jersey
| | - P Douglas Kiester
- Department of Orthopaedic Surgery, University of California Irvine Medical Center, Orange, California
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Type II odontoid fracture in elderly patients treated conservatively: is fracture healing the goal? EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2019; 28:1064-1071. [PMID: 30673876 DOI: 10.1007/s00586-019-05898-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 11/30/2018] [Accepted: 01/17/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE Analysis of functional outcome of elderly patients with type II odontoid fractures treated conservatively in relation to their radiological outcome. METHODS A total of 50 geriatric patients with type II odontoid fractures were treated with Aspen/Vista collars. On admission, each patient was assessed assigning ASA score, modified Rankin Scale (mRS-pre) and Charlson Comorbidity Index (CCI). From 12-15 months after treatment, functional evaluations were performed employing a second modified Rankin Scale (mRS-post) together with Neck Disability Index (NDI) and Smiley-Webster pain scale (SWPS). Radiological outcome was evaluated through dynamic cervical spine X-rays at 3 months and cervical spine CT scans 6 months after treatment. Three different conditions were identified: stable union, stable non-union and unstable non-union. Surgery was preferred whenever a fracture gap > 2 mm, an antero-posterior displacement > 5 mm, an odontoid angulation > 11° or neurological deficits occurred. RESULTS Among the 50 patients, 24 reached a stable union, while 26 a stable non-union. Comparing the two groups, no differences in ASA (p = 0.60), CCI (p = 0.85) and mRS-pre (p = 0.14) were noted. Similarly, no differences in mRS-post (p = 0.96), SWPS (p = 0.85) and NDI (p = 0.51) were observed between patients who reached an osseous fusion and those with a stable fibrous non-union. No effects of age, sex, ASA, mRS-pre, fracture dislocation and radiological outcome were discovered on functional outcome. At logistic regression analysis, female sex and high values of CCI emerged associated with worse NDI. CONCLUSIONS In geriatric type II odontoid fractures, pre-injury clinical status and comorbidities overcome imaging in determining post-treatment level of function. Hard collar immobilization led to a favourable functional outcome with mRS-post, NDI and SWPS values diffusely encouraging whatever a bony union or a fibrous non-union was obtained. These slides can be retrieved under Electronic Supplementary Material.
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Maugeri R, Iacopino DG, Giammalva GR, Graziano F, Gulì C. Learning Curve in Surgical Treatment of Odontoid Fixation for a Series of Type II C2 Fractures. ACTA NEUROCHIRURGICA. SUPPLEMENT 2019; 125:325-327. [PMID: 30610341 DOI: 10.1007/978-3-319-62515-7_47] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/03/2023]
Abstract
The craniovertebral junction (CVJ) is a complex anatomical area upon which most of the motion of the upper cervical spine depends [1]. Because of its unique range of motion, the CVJ is subject to several types of traumatic injury; it has been shown that odontoid fractures are the most common ones in the general population and are the most common isolated spinal fractures [2]. Accounting for up to 18% of all cervical fractures, odontoid fractures are the most common ones in elderly patients [3], in whom they account for up to 60% of spinal cord injuries [4].
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Affiliation(s)
- Rosario Maugeri
- Neurosurgical Clinic, AOUP "Paolo Giaccone", PostGraduate Residency Program in Neurologic Surgery, Department of Experimental Biomedicine and Clinical Neurosciences, School of Medicine, University of Palermo, Palermo, Italy.
| | - Domenico Gerardo Iacopino
- Neurosurgical Clinic, AOUP "Paolo Giaccone", PostGraduate Residency Program in Neurologic Surgery, Department of Experimental Biomedicine and Clinical Neurosciences, School of Medicine, University of Palermo, Palermo, Italy
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Tisherman R, Vaudreuil N, Ramanathan R, Hartman R, Lee J, Bell K. Biomechanical contributions of upper cervical ligamentous structures in Type II odontoid fractures. J Biomech 2019; 83:28-33. [DOI: 10.1016/j.jbiomech.2018.11.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 11/06/2018] [Accepted: 11/08/2018] [Indexed: 12/01/2022]
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Grasso G, Leone L, Torregrossa F. Management of Odontoid Cervical Fracture. World Neurosurg 2018; 123:246-247. [PMID: 30579013 DOI: 10.1016/j.wneu.2018.12.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 12/05/2018] [Indexed: 11/19/2022]
Affiliation(s)
- Giovanni Grasso
- Section of Neurosurgery, Department of Experimental Biomedicine and Clinical Neurosciences, University of Palermo, Palermo, Italy.
| | - Ludovica Leone
- Section of Neurosurgery, Department of Experimental Biomedicine and Clinical Neurosciences, University of Palermo, Palermo, Italy
| | - Fabio Torregrossa
- Section of Neurosurgery, Department of Experimental Biomedicine and Clinical Neurosciences, University of Palermo, Palermo, Italy
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Bokhari AR, Sivakumar B, Sefton A, Lin JL, Smith MM, Gray R, Hartin N. Morbidity and mortality in cervical spine injuries in the elderly. ANZ J Surg 2018; 89:412-417. [PMID: 30294850 DOI: 10.1111/ans.14875] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Revised: 08/11/2018] [Accepted: 08/22/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND The aim of our study was to identify the demographics and complications in elderly cervical spine injuries and predictive factors for surgery, complications and mortality. We hypothesized younger healthier patients were more likely to undergo surgical intervention. METHODS A retrospective review of 225 consecutive patients aged 65 years and over with cervical spine injuries was carried out over a 3-year period. RESULTS There were 113 males and 112 females with an average of 79.7 years (range 65-98). The most common fracture was C2 peg type (21.8%). Five patients had complete spinal cord injury (2.2%), 25 had incomplete spinal cord injury (11.1%) and 84% were neurologically intact. Fifty-four patients were managed operatively (24%), while 171 patients were managed non-operatively (76%). The operative group had higher rates of pneumonia (odds ratio (OR) 5.3, 95% confidence interval (CI) 2.6-10.7, P < 0.01), cardiac arrhythmia (OR 4.1, 95% CI 1.5-11.2, P < 0.01) and respiratory failure (OR 2.6, 95% CI 1.2-5.5, P < 0.05). There was no difference in mortality between the operative and non-operative group (18.5% and 12.9%, P = 0.3). Patients with complete spinal cord injury had 100% mortality. Significant predictive factors for complications and death were neurological deficits, comorbidities and the presence of other injuries (P < 0.05). Surgery was not predictive for death and the operative group was younger than the non-operative group (P < 0.05). CONCLUSIONS In the setting of a high complication rate, consideration should be given to palliation in elderly patients with complete spinal cord injury and there must be good rational for surgery.
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Affiliation(s)
- Ali R Bokhari
- Department of Orthopaedics and Trauma Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Brahman Sivakumar
- Department of Orthopaedics and Trauma Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Andrew Sefton
- Department of Orthopaedics and Trauma Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Juin-Lih Lin
- Department of Orthopaedics and Trauma Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Margaret M Smith
- Department of Orthopaedics and Trauma Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Randolph Gray
- Department of Orthopaedics and Trauma Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Nathan Hartin
- Department of Orthopaedics and Trauma Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
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Sheikh HQ, Athanassacopoulos M, Doshi AB, Breakwell L, Cole A, Rex Michael AL, Chiverton N. Early mortality and morbidity following a type II odontoid fracture in the elderly. Surgeon 2018; 16:297-301. [DOI: 10.1016/j.surge.2018.03.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 02/13/2018] [Accepted: 03/06/2018] [Indexed: 11/28/2022]
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Sarode DP, Demetriades AK. Surgical versus nonsurgical management for type II odontoid fractures in the elderly population: a systematic review. Spine J 2018; 18:1921-1933. [PMID: 29886165 DOI: 10.1016/j.spinee.2018.05.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 03/25/2018] [Accepted: 05/16/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND Odontoid process fractures, of which type II constitute the majority, are an increasingly important cause of morbidity and mortality in the elderly population. The incidence of geriatric type II fractures is steadily increasing in line with the aging population. However, the decision between surgical and non-surgical intervention for type II fractures in the elderly remains controversial. PURPOSE The present study aims to synthesize the current published literature comparing outcomes following surgical and non-surgical interventions for type II odontoid fractures in the elderly population (≥65 years old). STUDY DESIGN/SETTING Systematic review and meta-analysis were performed. METHODS A systematic search of MEDLINE, MEDLINE In-Progress & Other Non-Indexed Citations, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) was performed to identify available evidence in English language. Studies with extractable data for all type II odontoid fractures in participants aged 65 years or older and which compared surgical and non-surgical intervention were included. Methodological quality was assessed using the Downs & Black checklist. Primary outcomes were mortality at short-term follow-up (≤3 months), mortality at long-term follow-up (predetermined study endpoint or mean follow-up length), and radiological union rate. Funding was provided by The University of Edinburgh for travel expenses to present this paper at the Society of British Neurological Sciences 2016 Conference ($170). RESULTS Twelve studies (n=1,098), all non-randomized, met eligibility criteria. Methodological quality was particularly poor in the confounding, bias, and power domains of assessment. Substantial methodological and statistical heterogeneity allowed only a narrative synthesis of the primary outcomes. Overall, data on mortality at short-term follow-up appeared to favor neither surgical nor non-surgical intervention. A small favorable outcome in surgically managed patients over non-surgically managed patients in terms of mortality at long-term follow-up was not proven conclusive because of considerable heterogeneity in study methodologies. Inadequate reporting of the time point of union assessment introduced the potential for significant intra- and interstudy heterogeneity and precluded assessment of union rates. CONCLUSIONS Evidence on this controversial topic is sparse, markedly heterogeneous, and of poor quality. Well-designed prospective trials adhering to guidance published by the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) initiative are required to inform clinical practice on this contentious but growing issue. Future randomized controlled trials should include an assessment of frailty and medical comorbidities with suitable patients subsequently randomized to surgical or non-surgical treatment.
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Affiliation(s)
- Deep P Sarode
- College of Medicine and Veterinary Medicine, The University of Edinburgh, 47 Little France Crescent, Edinburgh EH16 4TJ, United Kingdom; Edinburgh Spinal Surgery Outcomes Study Group, Department of Clinical Neurosciences, Western General Hospital, Crewe Rd South, Edinburgh EH4 2XU, United Kingdom
| | - Andreas K Demetriades
- College of Medicine and Veterinary Medicine, The University of Edinburgh, 47 Little France Crescent, Edinburgh EH16 4TJ, United Kingdom; Department of Clinical Neurosciences, Western General Hospital, Crewe Rd South, Edinburgh EH4 2XU, United Kingdom; Edinburgh Spinal Surgery Outcomes Study Group, Department of Clinical Neurosciences, Western General Hospital, Crewe Rd South, Edinburgh EH4 2XU, United Kingdom.
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Odontoid Fracture in Patients Age >75 Years Surgically Managed by the Harms Technique: Bone Healing and 1-Year Mortality Rate in 57 Cases. World Neurosurg 2018; 116:e1087-e1091. [PMID: 29864555 DOI: 10.1016/j.wneu.2018.05.172] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2018] [Revised: 05/22/2018] [Accepted: 05/24/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND Odontoid fracture is the most common lesion of the cervical spine in persons age >70 years. Management of these fractures has become a public health issue. In this study, we evaluated bone fusion, early complications, and mortality in a cohort of patients age >75 years who underwent surgical management of odontoid fracture using the Harms technique. METHODS This study is a retrospective analysis of 57 patients treated surgically between 2002 and 2016 in a single spine surgery institution. Age at diagnosis, comorbidities, and American Society of Anesthesiologists (ASA) score were analyzed. At a 6-month follow-up, bone healing was evaluated with computed tomography scans. RESULTS The mean patient age was 85.5 ± 6.6 years, and 53% of the patients had an ASA score ≥3. According to the Anderson classification, 70% of the patients had a type 2 odontoid fracture. The average duration of follow-up was 15.7 months. Ten patients were lost to follow-up. The rate of early complications was 19%, with no mechanical complications reported. At a 6-month follow-up, a solid bony union was seen in all patients. The 1-year mortality was 14%. CONCLUSIONS Surgical management of odontoid fractures in elderly patients using the Harms technique is associated with an excellent rate of bone healing with acceptable rates of early complications and mortality.
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Peck GE, Shipway DJH, Tsang K, Fertleman M. Cervical spine immobilisation in the elderly: a literature review. Br J Neurosurg 2018; 32:286-290. [PMID: 29488398 DOI: 10.1080/02688697.2018.1445828] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Developed populations are ageing rapidly and by 2040, approximately 1 in 4 adults will be over 65 years of age. This is resulting in higher incidence of traumatic injury in older patients. Cognitive and physical comorbidities in this group can pose significant challenges. Due to mechanisms of injury and pre-existing degenerative spinal disease, cervical spine fractures are particularly prevalent in elderly patients. These are associated with significant morbidity and mortality. In this literature review we examine current evidence surrounding the use of cervical spine immobilisation in elderly patients in the pre-hospital and emergency department setting and also as a treatment option for cervical spine fractures. We explore evidence surrounding the complications that can arise from cervical spine immobilisation, including the development of pressure sores, raised intracranial pressure, dysphagia, breathing difficulties, delirium, compliance issues, mobility and functional outcome.
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Affiliation(s)
- George Edward Peck
- a Division of Surgery , Imperial College Healthcare NHS Trust, St Mary's Hospital , London , UK
| | | | - Kevin Tsang
- c Division of Neurosurgery , Imperial College Healthcare NHS Trust, St Mary's Hospital , London , UK
| | - Michael Fertleman
- a Division of Surgery , Imperial College Healthcare NHS Trust, St Mary's Hospital , London , UK
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Perry A, Graffeo CS, Carlstrom LP, Chang W, Mallory GW, Puffer RC, Clarke MJ. Fusion, Failure, Fatality: Long-term Outcomes After Surgical Versus Nonoperative Management of Type II Odontoid Fracture in Octogenarians. World Neurosurg 2018; 110:e484-e489. [DOI: 10.1016/j.wneu.2017.11.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Revised: 11/02/2017] [Accepted: 11/04/2017] [Indexed: 10/18/2022]
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Jareczek FJ, Abode-Iyamah KO, Cox EM, Dahdaleh NS, Hitchon PW, Howard MA. Letter: Reconsidering Bone Morphogenetic Protein in the Cervical Spine: Selective Use for Managing Type II Odontoid Fractures in the Elderly. Oper Neurosurg (Hagerstown) 2017; 13:E39-E42. [PMID: 29040717 DOI: 10.1093/ons/opx212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Francis J Jareczek
- Department of Neurosurgery Carver College of Medicine The University of Iowa Iowa City, Iowa
| | - Kingsley O Abode-Iyamah
- Department of Neurosurgery Carver College of Medicine The University of Iowa Iowa City, Iowa
| | - Efrem M Cox
- Department of Neurological Surgery Case Western Reserve University Cleveland, Ohio
| | - Nader S Dahdaleh
- Department of Neurological Surgery Feinberg School of Medicine Northwestern University Chicago, Illinois
| | - Patrick W Hitchon
- Department of Neurosurgery Carver College of Medicine The University of Iowa Iowa City, Iowa
| | - Matthew A Howard
- Department of Neurosurgery Carver College of Medicine The University of Iowa Iowa City, Iowa
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Faure A, Graillon T, Pesenti S, Tropiano P, Blondel B, Fuentes S. Trends in the surgical management of odontoid fractures in patients above 75 years of age: Retrospective study of 70 cases. Orthop Traumatol Surg Res 2017; 103:1221-1228. [PMID: 28789999 DOI: 10.1016/j.otsr.2017.07.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Revised: 06/06/2017] [Accepted: 07/06/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND Odontoid fractures are the most common upper cervical spine fracture in adults over 70 years of age. Hence, treatment of these fractures has public health implications. OBJECTIVES Evaluate the early complications, bone healing and mortality in patients above 75 years of age who undergo surgical treatment of an odontoid fracture. Compare the results between patients operated with the Harms technique or anterior screw fixation. METHODS This was a retrospective study of 70 patients with an odontoid fracture who were treated surgically between 2000 and 2015 at the Hôpital de la Timone in France. The age at the time of diagnosis, comorbidities, ASA score and autonomy were evaluated. Bone healing was determined using computed tomography. RESULTS In the cohort, 22 patients underwent anterior screw fixation, 38 were treated using the Harms technique and 10 with other procedures. The average age was 85.1 years. Fifty-four percent of patients had an ASA score above 3. The average follow-up was 23.4 months. An Anderson type II fracture was present in 80.6% of patients. In the anterior screw fixation group, the operative time was significantly shorter than in the Harms group and no blood transfusions were needed. However, 13.6% of these patients had to be re-operated because the initial construct was unstable; no patients in the Harms group underwent revision surgery. There were more complications in the anterior screw fixation group than in the Harms group: 41% versus 13.2% (P<0.02). The fractures had healed in all patients reviewed after 1 year. The 3-month survival in the anterior screw fixation group was 64.7% and it was 81.3% in the Harms group. These rates were stable at 1 year with no statistical differences between groups. CONCLUSION Surgical treatment of odontoid fractures in the elderly results in an excellent union rate. The mortality rate is stable after 3 months. In our experience, the Harms technique has a lower risk of complications and better mechanical stability than anterior screw fixation. Despite the steep learning curve, we believe the Harms technique is probably the best choice for treating odontoid fractures in the elderly. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- A Faure
- Unité de chirurgie du rachis, hôpital de la Timone, université Aix-Marseille, CHU Timone, 264, rue Saint-Pierre, 13005 Marseille, France
| | - T Graillon
- Unité de chirurgie du rachis, hôpital de la Timone, université Aix-Marseille, CHU Timone, 264, rue Saint-Pierre, 13005 Marseille, France
| | - S Pesenti
- Unité de chirurgie du rachis, hôpital de la Timone, université Aix-Marseille, CHU Timone, 264, rue Saint-Pierre, 13005 Marseille, France
| | - P Tropiano
- Unité de chirurgie du rachis, hôpital de la Timone, université Aix-Marseille, CHU Timone, 264, rue Saint-Pierre, 13005 Marseille, France
| | - B Blondel
- Unité de chirurgie du rachis, hôpital de la Timone, université Aix-Marseille, CHU Timone, 264, rue Saint-Pierre, 13005 Marseille, France
| | - S Fuentes
- Unité de chirurgie du rachis, hôpital de la Timone, université Aix-Marseille, CHU Timone, 264, rue Saint-Pierre, 13005 Marseille, France.
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Halo-Vest Immobilization in Elderly Odontoid Fracture Patients: Evolution in Treatment Modality and In-Hospital Outcomes. Clin Spine Surg 2017; 30:E1206-E1210. [PMID: 27906741 DOI: 10.1097/bsd.0000000000000483] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE To evaluate the utilization and effectiveness of halo-vest (HV) immobilization for type II odontoid fractures from 2004 to 2014. SUMMARY OF BACKGROUND DATA Controversy persists regarding the optimal treatment method for odontoid fractures in the elderly. Management options include immobilization in a cervical orthosis, HV immobilization, and operative intervention. Over the past decade, high mortality and morbidity rates have been reported following HV immobilization in this patient population. MATERIALS AND METHODS In a retrospective study, patient demographics, presentation, Charlson comorbidity index, treatment method, and outcome data for patients over 65 who had suffered type II odontoid fractures from 2004 to 2014 were compared with a historical cohort from 1997 to 2004. RESULTS One hundred twenty-six patients met inclusion criteria. The mean age was 82.7±8.8 compared with 80.7±0.9 in the 1997-2004 cohort. The in-hospital mortality rate from 2004 to 2014 was 11.1% (14/126) compared with 31% in the historical cohort, and 10 (7.9%) patients were treated with HV compared with 49%. Mortality in the HV group was higher than the surgical group (P=0.01) but no different from the orthosis group (P=0.63).There were no differences in injury severity score, Charlson comorbidity index, or complications between treatment groups. CONCLUSIONS Over the past decade, HV use for elderly odontoid fractures has decreased at our institution. Mortality and morbidity of elderly patients treated with HV has also decreased. These findings are likely the result of improved patient selection and greater attention to respiratory care. This study demonstrates that HV immobilization of odontoid fractures in elderly patients can be as safe as cervical orthosis treatment in select patients.
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