Nonoperative management of C-2 dens fractures: Single center experience and review of the literature

[Conservative treatment of trauma-associated fractures of the cervical spine with orthoses-A review]

BACKGROUND

Traumatic injuries of the cervical spine are common and can significantly differ in the prognosis and treatment depending on the structure affected. We present the current evidence for conservative treatment of these fractures with orthoses in this review.

METHODOLOGY

The literature search followed the PRISMA protocol. The risk of bias was assessed using ROBINS‑I and evidence levels were determined according to AHCPR.

RESULTS

A total of 22 studies were identified. The level of evidence according to AHCPR is limited (IIb, III and IV) and every study had a serious risk of bias in at least one subdivision. Of the authors 11 presented conservative treatment concepts for C2 dens fractures, 7 studies focussed on vertebral arch fractures and 9 on vertebral body fractures. Radiological parameters (kyphosis angle, bone consolidation) and the neurological status were frequently reported as endpoints.

CONCLUSION

Stable C2 dens fractures without relevant clinical restrictions allow conservative treatment in a rigid cervical orthosis under radiological monitoring every 1-4 weeks. Type II fractures require special attention due to the risk of instability. Hangman's fractures can be safely treated in rigid cervical orthoses. The current state of knowledge does not allow any recommendation for conservative treatment of Hangman's fractures with orthoses. Stable vertebral body fractures without involvement of the spinal canal can also be treated conservatively with orthotic devices. Randomized controlled studies are required to develop a secure state of evidence and are currently not available.

Surgical Outcomes for C2 Tear Drop Fractures: Clinical Relevance to Hangman's Fracture and C2-3 Discoligamentous Injury

Objective

To analyze characteristics of surgically managed tear drop (TD) fractures of the C₂ axis associated with other injuries such as hangman's fracture and C_2‐3 discoligamentous injury as well as treatment outcomes.

Methods

A total of 14 patients (eight men and six women) with TD fractures of the C₂, who were surgically treated at four national trauma centers of tertiary university hospitals from January 2000 to December 2017, were included in this retrospective study. The mean age of the patients was 45.5 years (ranging from 19 to 74 years). The characteristics, surgical treatment methods (anterior fusion vs posterior fusion), and results of 14 TD fractures of the C₂ were analyzed retrospectively. And the clinical relevance between C₂ TD fracture and hangman's fracture and C_2‐3 discoligamentous injury was investigated through the co‐occurrence between injuries. The mean follow‐up time after surgery was 22.6 months (ranging from 12 to 60 months).

Results

Among 14 patients with TD fracture of the C₂, four patients (28.6%) had anterior TD fracture and 10 patients (71.4%) had posterior TD fracture. All 10 posterior TD fracture patients had anterior C_2‐3 displacement. While two of four anterior TD fracture patients had posterior C_2‐3 displacement, the remaining two did not. All 14 patients of TD fracture had at least two or more other associated C₂ injuries as well as C_2‐3 discoligamentous injuries. About 92.9% (13/14) of the patients had typical or atypical hangman's fracture; 100% (10/10) of the posterior TD fracture patients had hangman's fracture, but 75% (3/4) of the anterior TD fracture had hangman's fracture. At admission, 13 patients were neurologically intact. However, the remaining patient had spinal cord injury with American Spinal Injury Association (ASIA) impairment scale B with C_2‐3 bilateral facet dislocation. All four anterior TD fracture patients underwent posterior C_2‐3 fusion. While four of 10 posterior TD fracture patients underwent C_2‐3 anterior fusion, the remaining six underwent posterior fusion. At last follow‐up, 100% (14/14) of the patients achieved solid fusion, and visual analog scale for neck pain was significantly improved (5.9 vs 2.2, P < 0.001). One patient with ASIA impairment scale B had significantly improved to scale D. No major complications occurred.

Conclusion

Our study showed that surgically managed TD fractures of the C₂ showed a high incidence of other associated spine injuries including hangman's fracture and C_2‐3 discoligamentous injury. Therefore, special attention and careful radiologic evaluation are needed to investigate the presence of other associated spine injuries including hangman's fracture and C_2‐3 discoligamentous injury, which are likely to require surgery.

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

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.

Analysis of Nonunion in Conservatively Managed Anterior Tear Drop Fractures of C2 Vertebra

Many anterior C2 (2nd cervical vertebra) tear drop (TD) fractures can be successfully managed with conservative treatment. However, due to the occurrence of nonunion, large-sized or complex anterior C2 TD fractures undergo surgical treatment. To date, no surgical treatment guidelines are available about anterior C2 TD fractures. Therefore, we performed this study to investigate the factors that may affect nonunion for anterior C2 TD fractures and to suggest surgical treatment guidelines. Thirty-three patients with anterior C2 TD fractures, who underwent conservative treatment and had a minimum 1-year follow-up, were divided into union (N = 26) and nonunion (N = 7) groups. Their radiological and clinical data were analyzed retrospectively and compared between the two groups. The avulsion fracture ratio (29.5% vs. 43.3%, p < 0.05) and fracture displacement (3.6 mm vs. 5.1 mm, p < 0.05) were higher in the nonunion group compared to the union group. Incidence of associated C2 injury was higher in the nonunion group compared to the union group (15.4% vs. 57.1%, p < 0.05). Union status was negatively correlated with associated C2 injury (correlation coefficient, CC = -0.398, p < 0.05). Our results suggest that surgical treatment could be considered for anterior C2 TD fractures with an avulsion fracture ratio > 43%, fracture displacement > 5 mm, or associated C2 injury.

Odontoid screw placement for Anderson type II odontoid fractures: how do duration from injury to surgery and clinical and radiological factors influence the union rate? A multicenter retrospective study

OBJECTIVE

Anderson type II odontoid fractures are severe conditions, mostly affecting elderly people (≥ 70 years old). Surgery can be performed as a primary treatment or in cases of failed conservative management. This study aimed to investigate how duration from injury to surgery, as well as clinical, radiological, and surgical risk factors, may influence the union rate after anterior odontoid screw placement for Anderson type II odontoid fractures.

METHODS

The authors conducted a retrospective multicenter study. Demographic, clinical, surgical, and radiological data of patients who underwent anterior odontoid screw placement for Anderson type II fractures were retrieved from institutional databases. Study exclusion criteria were prolonged corticosteroid drug therapy (> 4 weeks), polytraumatic injuries, oncological diagnosis, and prior cervical spine trauma.

RESULTS

Eighty-five patients were included in the present investigation. The union rate was 76.5%, and 73 patients (85.9%) did not report residual instability. Age ≥ 70 years (p < 0.001, OR 6), female gender (p = 0.016, OR 3.61), osteoporosis (p = 0.009, OR 4.02), diabetes (p = 0.056, OR 3.35), fracture diastasis > 1 mm (p < 0.001, OR 8.5), and duration from injury to surgery > 7 days (p = 0.002, OR 48) independently influenced union rate, whereas smoking status (p = 0.677, OR 1.24) and odontoid process angulation > 10° (p = 0.885, OR 0.92) did not.

CONCLUSIONS

Although many factors have been reported as influencing the union rate after anterior odontoid screw placement for Anderson type II fractures, duration from injury to surgery > 7 days appears to be the most relevant, resulting in a 48 times higher risk for nonunion. Early surgery appears to be associated with better radiological outcomes, as reported by orthopedic surgeons in other districts. Prospective comparative clinical trials are needed to confirm these results.

The Anterior Transarticular Fixation of C1/C2 in the Elderly With Dens Fractures

Background

Anterior transarticular screw fixation (ATSF) of C1/C2 can be used for the treatment of unstable dens fractures. Here, we evaluated the feasibility of an anterior C1/C2 fixation in elderly patients with unstable dens fractures. Furthermore, we tried to analyze safe entry zones for ATSF surgery.

Methods

A consecutive cohort of 13 patients with unstable dens fractures were treated with ATSF of C1/C2 between January 2015 and October 2016. If necessary, an additional screw was placed into the odontoid process. The placement was radiographically analyzed using the 3D Arcadis Orbic (Siemens, Erlangen, Germany). Additionally, computed tomography scans of the cervical spine from 50 trauma patients were analyzed to evaluate safe entry zones for anterior odontoid screw fixation and for ATSF.

Results

ATSF was performed in 13 cases (7 female, 6 male; mean age 81.80 years). One screw had to be corrected intraoperatively due to initial malplacement. Neurological deficits or an injury of the vertebral artery were not observed. All patients suffered from swallowing difficulties during the postoperative course, without lesions of the esophagus or the trachea. In 4 patients (30.8%), an additional posterior fixation was offered to the patients due to progressive loosening of the screws.The anatomical-radiographic analyzes revealed a significantly shallower angle of trajectory for anterior odontoid screw fixation (24.9° ± 5.85°) than for ATSF (39.1° ± 6.44° (left); 40.5° ± 6.79° (right) P = 0.02).

Conclusions

The ATSF of C1/C2 might be a valuable option in the treatment of instable C1/C2 fractures, especially in the elderly or in patients with short necks and/or high body mass index due to the steeper trajectory compared with odontoid screw placement. Yet available screws seem to be of inferior resistance compared with the biomechanical properties of a dorsal fixation. Further studies should focus on screws with better mechanical properties and probably additional cement augmentation.

Level of Evidence

4.

Treatment of Odontoid Type II Fractures in Octogenarians: Balancing Two Different Treatment Strategies

OBJECTIVE

Demographic changes have led to a higher incidence of C-2 fractures, especially in elderly patients. For patients with type II fractures, treatment remains controversial, as discussed by Anderson and D'Alonzo, due to the rising morbidity and mortality rates for any treatment. The aim of this study was to compare conservative and surgical management in patients with type II C-2 fractures regarding outcomes, complications, and the mortality rate.

METHODS

A retrospective analysis was performed of the medical records, X-rays, and/or computed tomography scans of patients ≥80 years of age with type II fractures who were admitted to our Department of Neurosurgery between January 1990 and December 2017. The success of treatment was evaluated 3 months after surgery.

RESULTS

In total, 125 patients were included, of whom 98 were treated surgically and 27 were treated conservatively. Surgical treatment was successful in 90.8% of cases, while conservative treatment was successful in 70.0%. The in-hospital mortality was 14.29% and the 3-month mortality was 27.8% in the surgical group, compared to 3.7% and 20% in the conservatively treated group. The in-hospital complication rate was 22.4% in the surgically treated patients and 7.4% in the conservatively treated patients.

CONCLUSION

Surgical treatment of type II fractures seemed to be associated with higher success and complication rates than conservative treatment. Nevertheless, 3-month mortality was comparable in both groups. Therefore, we conclude that surgical treatment for type II fractures in elderly patients is superior to conservative management, although conservative treatment remains a valuable option in elderly patients with severe comorbidities.