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Li S, Xu X, Chang M, Li H, Xu R, Fu W, Wang L, Li Y, Yuan S, Tian Y, Wang L, Liu X. The establishment of a novel upper cervical complex fracture classification system. Spine J 2024:S1529-9430(24)00929-X. [PMID: 39154938 DOI: 10.1016/j.spinee.2024.08.013] [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] [Received: 04/16/2024] [Revised: 08/11/2024] [Accepted: 08/11/2024] [Indexed: 08/20/2024]
Abstract
BACKGROUND CONTEXT Upper cervical complex fractures are associated with high rates of neurological damage and mortality. The Dickman's classification is widely used in the diagnosis of upper cervical complex fractures. However, it falls short of covering the full spectrum of complex fractures. This limitation hinders effective diagnosis and treatment of these injuries. PURPOSE To address the diagnostic gap in upper cervical complex fractures, the study introduces a novel classification system for these injuries, assessing its reliability and usability. STUDY DESIGN Proposal of a new classification system for upper cervical complex fractures. PATIENT SAMPLE The study comprised the clinical data of 242 patients with upper cervical complex fractures, including 32 patients treated at our hospital, along with an additional 210 cases from the literature. OUTCOME MEASURES The inter-observer and intra-observer reliability (kappa coefficient, κ) of this classification system were investigated by 3 spine surgeons. The 3 researchers independently re-evaluated the upper cervical complex fracture classification system 3 months later. METHODS The proposed classification categorizes upper cervical complex fractures into 3 main types: Type I combines odontoid and Hangman's fractures into 2 subtypes; Type II merges C1 with odontoid/Hangman's fractures into 3 subtypes; and Type III encompasses a combination of C1, odontoid, and Hangman's fractures, divided into 2 subtypes. Meanwhile, a questionnaire was administered in 15 assessors to evaluate the system's ease of use and clinical applicability. RESULTS A total of 45 cases (18.6%) unclassifiable by Dickman's classification were successfully categorized using our system. The mean κ value of inter-observer reliability was 0.783, indicating substantial reliability. The mean κ value of intra-observer reliability was 0.862, indicating almost perfect reliability. Meanwhile, thirteen assessors (87.7%) stated that the classification system is easy to remember, easy to apply, and they expressed intentions to apply it in clinical practice in the future. CONCLUSIONS This system not only offers high confidence and reproducibility but also serves as a precise guide for clinicians in formulating treatment plans. Future prospective applications are warranted to further evaluate this classification system.
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Affiliation(s)
- Shangye Li
- Department of Orthopedics, Qilu Hospital of Shandong University, Jinan, Shandong, P. R. China; Cheeloo College of Medicine, Shandong University, Jinan, Shandong, P.R. China
| | - Xiulian Xu
- Department of Orthopedics, Qilu Hospital of Shandong University, Jinan, Shandong, P. R. China
| | - Mingzheng Chang
- Department of Orthopedics, Qilu Hospital of Shandong University, Jinan, Shandong, P. R. China; Cheeloo College of Medicine, Shandong University, Jinan, Shandong, P.R. China
| | - Hao Li
- Department of Orthopedics, Qilu Hospital of Shandong University, Jinan, Shandong, P. R. China; Cheeloo College of Medicine, Shandong University, Jinan, Shandong, P.R. China
| | - Rongkun Xu
- Department of Orthopedics, Qilu Hospital of Shandong University, Jinan, Shandong, P. R. China; Cheeloo College of Medicine, Shandong University, Jinan, Shandong, P.R. China
| | - Wenyang Fu
- Department of Orthopedics, Qilu Hospital of Shandong University, Jinan, Shandong, P. R. China; Cheeloo College of Medicine, Shandong University, Jinan, Shandong, P.R. China
| | - Lulu Wang
- Department of Orthopedics, Shengli Oilfield Central Hospital, Dongying, Shandong, P.R. China
| | - Yonggang Li
- Department of Orthopedics, Qilu Hospital of Shandong University, Jinan, Shandong, P. R. China
| | - Suomao Yuan
- Department of Orthopedics, Qilu Hospital of Shandong University, Jinan, Shandong, P. R. China
| | - Yonghao Tian
- Department of Orthopedics, Qilu Hospital of Shandong University, Jinan, Shandong, P. R. China
| | - Lianlei Wang
- Department of Orthopedics, Qilu Hospital of Shandong University, Jinan, Shandong, P. R. China
| | - Xinyu Liu
- Department of Orthopedics, Qilu Hospital of Shandong University, Jinan, Shandong, P. R. China; Cheeloo College of Medicine, Shandong University, Jinan, Shandong, P.R. China.
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Frati A, Cimatti M, Ileyassoff H, Capobianco M, Santoro A, Armocida D. Combined Anterior Odontoid Screw Fixation and C1-C2 Jefferson Fracture Anterior Fixation: A Step-by-Step Technical Note. World Neurosurg 2024; 184:112-118. [PMID: 38266989 DOI: 10.1016/j.wneu.2024.01.094] [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: 10/30/2023] [Revised: 01/13/2024] [Accepted: 01/16/2024] [Indexed: 01/26/2024]
Abstract
BACKGROUND Combined triple atlas (C1)-axis (C2) fixation has been described in previous literature as a safe, effective, and minimally invasive procedure for complex atlas and odontoid fractures that allows for a greater range of motion compared with posterior approaches and atlanto-occipital fusion. However, it is rarely performed due to the occipital-cervical diastasis resulting from often-fractured C1 joint masses. No evidence-based consensus has been reached regarding the treatment of complex atlantoaxial fractures, and the choice of surgical strategy is based only on clinical experience. METHODS We report the combined triple C1-C2 fixation technique with manual reduction of the joint masses during patient positioning on the operating table, which allowed for effective stabilization during a single surgical session. We describe our experience in the management of a 75-year-old patient presenting with an acute complex type II fracture of C1, which also involved 1 lateral mass, combined with a type II odontoid fracture and occipital-cervical diastasis. RESULTS We provide a step-by-step guide for combined triple C1-C2 anterior fixation with manual fracture reduction and describe the clinical case of an acute complex type II fracture of C1, which also involved 1 lateral mass, combined with a type II odontoid fracture and occipital-cervical diastasis. CONCLUSIONS Combined triple C1-C2 fixation represents a safe and efficient minimally invasive anterior approach for complex type II fractures of C1 with type II odontoid fractures. Manual reduction of the joint masses during patient positioning allows for effective stabilization in a single surgical session.
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Affiliation(s)
- Alessandro Frati
- Experimental Neurosurgery Unit, IRCCS Ist Neurologico Mediterraneo Neuromed, Pozzilli, Italy
| | - Marco Cimatti
- Neurosurgery Service, Azienda Ospedaliera-Universitaria Sant'Andrea, Sapienza University of Rome, Rome, Italy
| | - Hernán Ileyassoff
- Department of Neurosurgery, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Mattia Capobianco
- Department of Neurosurgery, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Antonio Santoro
- Department of Neurosurgery, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Daniele Armocida
- Experimental Neurosurgery Unit, IRCCS Ist Neurologico Mediterraneo Neuromed, Pozzilli, Italy; Department of Neurosurgery, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy.
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Mohile NV, Kuczmarski AS, Minaie A, Syros A, Geller JS, Maaieh MA. Management of combined atlas and axis fractures: a systematic review. NORTH AMERICAN SPINE SOCIETY JOURNAL 2023; 14:100224. [PMID: 37440984 PMCID: PMC10333716 DOI: 10.1016/j.xnsj.2023.100224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 04/11/2023] [Accepted: 04/19/2023] [Indexed: 07/15/2023]
Abstract
Background Combined atlas-axis fractures are rare occurrences with substantially higher rates of neurologic deficits compared with isolated injuries. Given the intricate anatomic relationship between the atlas and axis vertebra, variable fracture patterns may occur, warranting special considerations from surgeons. Methods A systematic search of PubMed and EMBASE was performed following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. Relevant studies on acute combined atlas-axis fractures that provided data on patient demographics, presentation (injury mechanism, neurologic deficits, fracture type), management, complications, and study conclusions were reviewed. Results A total of 22 articles published from 1977 to 2022, comprising 230 patients, were included in the final analysis. Thirty-seven of the 213 patients (17%) presented with neurologic deficits. The most common atlas injuries were posterior arch fractures (54/169 patients; 32%), combined posterior arch/anterior arch fractures (44/169 patients; 26%), and anterior arch fractures (43/169 patients; 25%). The most common axis injuries were type II odontoid fractures (115/175 patients; 66%). Of the 127 patients managed operatively (127/230 patients; 55%), 45 patients (35%) were treated with C1-C2 posterior spinal fusion, 33 patients (26%) were treated with odontoid screw fixation and anterior/posterior C1-C2 trans-articular screws, 16 patients (13%) were treated with occiputocervical fusion and 12 patients (9%) were treated with odontoid screw fixation alone. Conclusions Management strategies are generally based on the type of axis fracture as well as the condition of the transverse ligament. Patients with stable fractures can be successfully managed nonoperatively with a cervical collar or halo immobilization. Combined atlas-axis fractures with an atlantodental interval >5 mm, C1 lateral mass displacement >7 mm, C2-C3 angulation >11° or an MRI demonstrating a disrupted transverse ligament are suggestive of instability and are often successfully managed with surgical intervention. There is no consensus regarding surgical technique.
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Affiliation(s)
- Neil V. Mohile
- Department of Orthopaedic Surgery, Jackson Memorial Hospital, University of Miami Health System, 1611 NW 12th Ave, Miami, FL 33136, United States
| | - Alexander S. Kuczmarski
- Department of Orthopaedic Surgery, Jackson Memorial Hospital, University of Miami Health System, 1611 NW 12th Ave, Miami, FL 33136, United States
| | - Arya Minaie
- Department of Orthopaedic Surgery, Jackson Memorial Hospital, University of Miami Health System, 1611 NW 12th Ave, Miami, FL 33136, United States
| | - Alina Syros
- Department of Medical Education, University of Miami Miller School of Medicine, 1600 NW 10th Ave #1140, Miami, FL 33136, United States
| | - Joseph S. Geller
- Department of Orthopaedic Surgery, Jackson Memorial Hospital, University of Miami Health System, 1611 NW 12th Ave, Miami, FL 33136, United States
| | - Motasem Al Maaieh
- Department of Orthopaedic Surgery, Jackson Memorial Hospital, University of Miami Health System, 1611 NW 12th Ave, Miami, FL 33136, United States
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Di Francesco ME, Magunia H, Örgel A, Tatagiba M, Radwan M, Adib SD. Case report: Interdisciplinary treatment of complex C1/C2 fractures in a patient with concomitant three-vessel coronary artery disease requiring bypass surgery. Front Surg 2023; 10:1123947. [PMID: 37260599 PMCID: PMC10228685 DOI: 10.3389/fsurg.2023.1123947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 04/25/2023] [Indexed: 06/02/2023] Open
Abstract
Background Acute myocardial infarction (MI) frequently leads to consciousness disturbance following hemodynamic collapse. Therefore, MI can occur together with upper cervical spine trauma. Herein, we report the successful treatment of complex C1/C2 fractures in a patient with concomitant three-vessel coronary artery disease (CAD). Case presentation A 70-year-old patient presented in our emergency outpatient clinic after a hemodynamic collapse without neurological deficits or heart-related complaints. Computed tomography (CT) scan of the cervical spine revealed a dislocated odontoid fracture Anderson and D'Alonzo type II and an unstable Gehweiler type III injury (Jefferson's fracture). An intradiploic arachnoid cyst in the posterior wall of the posterior fossa was a coincident radiological finding. Furthermore, coronary angiography confirmed three-vessel CAD with high-grade coronary artery stenosis. Indication for upper cervical spine surgery and bypass surgery was given. An interdisciplinary team of neurosurgeons, cardiothoracic surgeons and anesthesiologists evaluated the patient's case to develop the most suitable therapy concept and alternative strategies. Finally, in first step, C1-C2 fusion was performed by Harms technique under general anesthesia with x-ray guidance, spinal neuronavigation, Doppler ultrasound and cardiopulmonary monitoring. Cardiothoracic surgeons were on standby. One month later bypass surgery was performed uneventfully. Follow-up CT scan of cervical spine revealed intraosseous screw positioning and beginning fusion of the fractures. The patient did not develop neurological deficits and recovered completely from both surgeries. Conclusions Treating complex C1/C2 fractures with concomitant severe CAD requiring treatment is challenging and carries a high risk of complications. To our knowledge, the literature does not provide any guidelines regarding therapy of this constellation. To receive upper cervical spine stability and to prevent both, spinal cord injury and cardiovascular complications, an individual approach is required. Interdisciplinary cooperation to determine optimal therapeutic algorithms is needed.
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Affiliation(s)
| | - H. Magunia
- Department of Anesthesiology and Intensive Care Medicine, University of Tuebingen, Tuebingen, Germany
| | - A. Örgel
- Department of Diagnostic and Interventional Neuroradiology, University of Tuebingen, Tuebingen, Germany
| | - M. Tatagiba
- Department of Neurosurgery, University of Tuebingen, Tuebingen, Germany
| | - M. Radwan
- Department of Thoracic and Cardiovascular Surgery, University of Tuebingen, Tuebingen, Germany
| | - S. D. Adib
- Department of Neurosurgery, University of Tuebingen, Tuebingen, Germany
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Spiegl UJA, Keil H, Krause J, Osterhoff G, Scheyerer MJ, Schnake KJ, Perl M. Combined Odontoid (C2) and Atlas (C1) Fractures in Geriatric Patients: A Systematic Review and Treatment Recommendation. Global Spine J 2023; 13:22S-28S. [PMID: 37084349 PMCID: PMC10177310 DOI: 10.1177/21925682221127951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/23/2023] Open
Abstract
STUDY DESIGN Systematic review. OBJECTIVE The aim of this study was to conduct a systematic overview of the pathogenesis and the treatment options of combined odontoid and atlas fractures in geriatric patients. METHODS This review is based on articles retrieved by a systematic search in the PubMed and Web of Science databases for articles published until February 2021 dealing with combination fractures of C1 and C2 in geriatric patients. RESULTS Altogether, 438 articles were retrieved from the literature search. A total of 430 articles were excluded. The remaining eight original articles were included in this systematic review depicting the topics pathogenesis, non-operative treatment, posterior approach, and anterior approach. The overall level of evidence of the studies is low. CONCLUSION Combined odontoid and atlas fractures in the geriatric population are commonly caused by simple falls and seem to be associated with atlanto-odontoid osteoarthritis. Non-operative treatment with a cervical orthosis is a feasible treatment option in the majority of patients with stable C2 fractures. In case of surgery posterior C1 and C 2 stabilization and anterior triple or quadruple screw fixation are possible techniques. Some patients may also deserve an occipito-cervical fusion. A possible treatment algorithm is proposed.
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Affiliation(s)
- Ulrich J A Spiegl
- Department of Orthopaedics, Trauma Surgery and Plastic Surgery, University of Leipzig, Leipzig, Germany
| | - Holger Keil
- Department of Trauma and Orthopedic Surgery, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - Johannes Krause
- Department of Trauma and Orthopedic Surgery, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - Georg Osterhoff
- Department of Orthopaedics, Trauma Surgery and Plastic Surgery, University of Leipzig, Leipzig, Germany
| | - Max J Scheyerer
- Department of Orthopedics and Trauma Surgery, University hospital, Duesseldorf, Germany
| | - Klaus John Schnake
- Center for Spinal and Scoliosis Surgery, Malteser Waldkrankenhaus St. Marien gGmbH, Erlangen, Germany
- Department of Orthopedics and Traumatology, Paracelsus Private Medical University Nuremberg, Nuremberg, Germany
| | - Mario Perl
- Department of Trauma and Orthopedic Surgery, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
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Zhao W, Sun Y, Xu G, Yan J. Combined Procedure Allowing Atlantoaxial and Atlanto-Occipital Joint Motion for Complex Injuries in the Upper Cervical Spine. Orthopedics 2020; 43:e329-e333. [PMID: 32379337 DOI: 10.3928/01477447-20200428-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Accepted: 09/23/2019] [Indexed: 02/03/2023]
Abstract
This study was performed to explore an ideal limited fixation method for the treatment of unstable atlantoaxial fractures that can preserve the range of motion of the occipital and atlantoaxial joints and restore the stability of the upper cervical spine. A 64-year-old man was diagnosed with a complicated injury of the upper cervical spine. The anterior and posterior approach was used to reconstruct the stability of the upper cervical spine while preserving the range of motion of the occipital and atlantoaxial joints. Preoperative imaging and neurologic examinations were performed. Follow-up lasted 24 months. The patient clinically improved after undergoing this novel procedure. Seven days postoperatively, the patient's visual analog scale score was 3. Follow-up contrast computed tomography showed good reduction and fixation in the upper cervical spine. Two weeks postoperatively, the patient displayed good cervical vertebral activity, with no restriction during flexion, extension, rotation, or other movements. No intraoperative or postoperative complications occurred. This modified procedure for restoration of cervical stability may be an improvement over traditional posterior fusion because atlantoaxial motion is preserved. [Orthopedics. 2020;43(4):e329-e333.].
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A Method to Prevent Occipitocervical Joint Violation Using Plain Radiography During Percutaneous Anterior Transarticular Screw Fixation. Spine (Phila Pa 1976) 2016; 41:1394-1399. [PMID: 26890950 DOI: 10.1097/brs.0000000000001508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A prospective study of anterior transarticular screw (ATS) fixation patients. OBJECTIVE To develop a method to determine screw tip position through plain radiography after percutaneous ATS fixation to prevent occipitocervical joint (OCJ) violation. SUMMARY OF BACKGROUND DATA No studies using plain radiography to prevent OCJ violation during percutaneous ATS fixation have been performed. METHODS In total, 34 subjects (with 68 screws) who had undergone percutaneous ATS fixation were enrolled. To evaluate the screw tip location in relation to the C1 lateral mass (LM), the screw tip positions were graded 1, 2, or 3 on anteroposterior (AP) radiographs, and I, II, or III on lateral radiographs. OCJ violation was analyzed by postoperative computed tomography (CT). RESULTS Screws with tips located lower (tip I) in the LM did not result in OCJ violation. Only one tip in the tip 3 position showed OCJ perforation, and this screw was also located in tip III. Screw perforation rates of tip 1-tip II, tip 1-tip III, and tip 2-tip III were the highest (100%), followed by tip 2-tip II (10.5%) and tip3-tip III (10%). CONCLUSION This study provides insights into OCJ violation during percutaneous ATS fixation. According to AP radiography, a percutaneous ATS with the screw tip located in the lateral part of the LM resulted in a lower rate of OCJ perforation, whereas screws located in the medial LM resulted in the highest rate of perforation. Percutaneous ATS with the screw tip located in the neutral part of the LM should ensure that the screw tip is below the upper part of the LM, preventing OCJ violation. These findings may help surgeons assess screw positioning both during and after the operation. LEVEL OF EVIDENCE 3.
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Wang L, Liu C, Zhao Q, Tian J. Posterior pedicle screw fixation for complex atlantoaxial fractures with atlanto-dental interval of ≥ 5 mm or C2-C3 angulation of ≥ 11°. J Orthop Surg Res 2014; 9:104. [PMID: 25407360 PMCID: PMC4245791 DOI: 10.1186/s13018-014-0104-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Accepted: 10/17/2014] [Indexed: 11/18/2022] Open
Abstract
Objective Previous studies have demonstrated that the posterior pedicle screw fixation is an effective and safe method to treat atlantoaxial fractures. However, no report focuses on only the complex atlantoaxial fractures with atlanto-dental interval (ADI) of ≥5 mm or C2-C3 angulation of ≥11°. Methods This study was to retrospectively evaluate the outcome of 15 patients (six females and nine males; age, 27–55 years) who underwent posterior pedicle screw fixation for the above complex atlantoaxial fractures between July 2006 and March 2011. Fracture combinations included three Jefferson-type II odontoid, four anterior ring-type II odontoid, two posterior ring-type II odontoid, one lateral mass-type II odontoid, one Jefferson-hangman’s fracture, three anterior ring-hangman’s fracture, and one lateral mass-hangman’s fracture. Fracture healing and bone fusion were determined on X-ray scan. Upper limbs, lower limbs, and sphincter functions were assessed using the Japanese Orthopaedic Association (JOA) score. The Frankel grading system was used to determine the neurological situation. Results The mean operative time, blood loss, and hospital stays were 108.9 ± 25.8 min, 508.0 ± 209.6 ml, and 13.3 ± 2.0 days. Fracture healing and graft fusion were obtained in all patients within 9 months. The ADI or C2-C3 angulation was reduced to ≤5 mm or ≤11°. The JOA score was significantly improved from 7.27 ± 1.10 preoperatively to 15.7 ± 2.1 postoperatively (P <0.001), with 88.1 ± 18.3% recovery rate and 93.3% excellent and good rate. The neurological situation was improved in all patients by at least 1 grade in the Frankel scale. After a mean of 36.5 months of follow-up (range, 18 to 58 months), no operative complications (spinal cord injury, vertebral artery injury, or cerebrospinal fluid leakage) were observed. Conclusion Posterior pedicle screw fixation is a reliable, effective, and minimally invasive procedure for patients suffering from complex atlantoaxial fractures.
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Affiliation(s)
- Lei Wang
- Department of Orthopaedics, Shanghai Jiaotong University Affiliated First People's Hospital, 100 Haining Road, Shanghai, 200080, China.
| | - Chao Liu
- Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China.
| | - Qinghua Zhao
- Department of Orthopaedics, Shanghai Jiaotong University Affiliated First People's Hospital, 100 Haining Road, Shanghai, 200080, China.
| | - Jiwei Tian
- Department of Orthopaedics, Shanghai Jiaotong University Affiliated First People's Hospital, 100 Haining Road, Shanghai, 200080, China.
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Fu Y, Hu ZM, Huo HJ, Yang X, Hao T, Liu WL. Improvement in JOA Score of Treatment for Complex Atlas-Axis fractures. Pak J Med Sci 2013; 29:744-7. [PMID: 24353620 PMCID: PMC3809288 DOI: 10.12669/pjms.293.2995] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2012] [Revised: 03/14/2013] [Accepted: 04/02/2013] [Indexed: 11/22/2022] Open
Abstract
Objective: The aim of this study was to explore the role of treatment for complex Atlas-Axis fractures, and compare the JOA score of surgical and conservation methods. Methodology: From June 2008 to May 2012, 33 patients suffering from Atlas-Axis fracture were included in our study. Fifteen patients received posterior cervical pedicle screw fixation, and 18 patients received the conservation treatment. All the patients were followed up for 12 months after discharge. Results: The mean operative time was about 128 minutes (ranged: 92 to 165 minutes), the mean hospital stay time was 15.5 days (ranged: 8-21 days), and the mean follow-up of all the patients was 27months (ranged: 7 to 43 months). All patients gained a solid fusion, and no one showed any disability at the end of the follow-up. The JOA scores before treatment were 6.4±0.3 and 7.1±0.4 before and after treatment, and they significantly increased to 13.8±0.8 and 13.7±0.9 when following up for 12 months (P<0.05). Conclusions: Posterior cervical pedicle screw fixation is a feasible, effective and safe method for complex atlantoaxial fractures. This technique could achieve high JOA score, decreased blood loss and post-operative complications.
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Affiliation(s)
- Yu Fu
- Yu Fu, Department of Orthopedics, Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhen-Ming Hu
- Zhen-Ming Hu, Department of Orthopedics, Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Hong-Jun Huo
- Hong-jun Huo, Department of Spinal Surgery, The Second Affiliated Hospital of Inner Mongolia Medical University, Hohhot, China
| | - Xuejun Yang
- Xue-jun Yang, Department of Spinal Surgery, The Second Affiliated Hospital of Inner Mongolia Medical University, Hohhot, China
| | - Ting Hao
- Ting Hao, Department of Pediatric Orthopedics, The Second Affiliated Hospital of Inner Mongolia Medical University, Hohhot, China
| | - Wan-Lin Liu
- Wan-lin Liu, Department of Orthopedics, The Second Affiliated Hospital of Inner Mongolia Medical University, Hohhot, China
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Padua MRA, Yeom JS, Lee SY, Lee SM, Kim HJ, Chang BS, Lee CK, Riew KD. Fluoroscopically guided anterior atlantoaxial transarticular screws: a feasibility and trajectory study using CT-based simulation software. Spine J 2013; 13:1455-63. [PMID: 23850256 DOI: 10.1016/j.spinee.2013.05.036] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2013] [Accepted: 05/04/2013] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Anterior transarticular screw (ATAS) fixation has been suggested as a viable alternative to posterior stabilization. However, we are not aware of previous reports attempting to establish the usefulness of specific fluoroscopic landmark-guided trajectories in the use of ATAS, and we could find no reference to it in a computerized search using MEDLINE. PURPOSE To determine the anatomic feasibility of ATAS placement using defined fluoroscopic landmarks to guide screw trajectory. STUDY DESIGN Evaluation using three-dimensional screw insertion simulation software and 1.0-mm-interval computed tomographic scans. PATIENT SAMPLE Computed tomographic scans of 100 patients including 50 men and 50 women. OUTCOME MEASURES Incidence of violation of the vertebral artery groove of C1 and C2, the spinal canal, and the atlanto-occipital joint and screw lengths and lengths of C1 and C2 purchase. METHODS Four screw trajectories were determined: promontory screw (PS), single central facet (CF) screw, and medial (MF) and lateral (LF) double facet screws. Placement of a 4.0-mm screw was simulated using defined fluoroscopic landmarks for each trajectory. The previously mentioned outcome measures were evaluated and compared for the four trajectories. This study was not supported by any financial sources, and there is no topic-specific potential conflict of interest with this study. RESULTS No violation of the C1 or C2 vertebral artery groove or of the spinal canal was observed for any of the screw types. Screw lengths and the length of C2 purchase were by far the longest for PS (40.4±2.8 and 25.7±2.1 mm, respectively; p<.001 in all post hoc comparisons). The length of C1 purchase was longer for CF (16.4±2.3 mm) and LF (15.8±1.6 mm) than PS (14.7±2.0 mm) and MF (14.6±2.4 mm) (p≤.001, respectively). There was no atlanto-occipital joint violation if the length of C1 purchase was set at 12 mm for CF and LF and at 10 mm for PS and MF. CONCLUSIONS Our results suggest that it may be possible to place ATASs without violating the vertebral artery groove, spinal canal, or the atlanto-occipital joint by using the described entry points, trajectories, and fluoroscopic landmarks.
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Affiliation(s)
- Mary R A Padua
- Spine Center and Department of Orthopaedic Surgery, Seoul National University College of Medicine and Seoul National University Bundang Hospital, 166 Gumiro, Bundang-ku, Sungnam 463-707, Republic of Korea
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Ryken TC, Hadley MN, Aarabi B, Dhall SS, Gelb DE, Hurlbert RJ, Rozzelle CJ, Theodore N, Walters BC. Management of Acute Combination Fractures of the Atlas and Axis in Adults. Neurosurgery 2013; 72 Suppl 2:151-8. [DOI: 10.1227/neu.0b013e318276ee55] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Affiliation(s)
- Timothy C. Ryken
- Iowa Spine & Brain Institute, University of Iowa, Waterloo/Iowa City, Iowa
| | - Mark N. Hadley
- Division of Neurological Surgery and Children's Hospital of Alabama, University of Alabama at Birmingham, Birmingham, Alabama
| | - Bizhan Aarabi
- Department of Neurosurgery and University of Maryland, Baltimore, Maryland
| | - Sanjay S. Dhall
- Department of Neurosurgery, Emory University, Atlanta, Georgia
| | - Daniel E. Gelb
- Department of Orthopaedics, University of Maryland, Baltimore, Maryland
| | - R. John Hurlbert
- Department of Clinical Neurosciences, University of Calgary Spine Program, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Curtis J. Rozzelle
- Division of Neurological Surgery, Children's Hospital of Alabama, University of Alabama at Birmingham, Birmingham, Alabama
| | - Nicholas Theodore
- Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Beverly C. Walters
- Division of Neurological Surgery and Children's Hospital of Alabama, University of Alabama at Birmingham, Birmingham, Alabama
- Department of Neurosciences, Inova Health System, Falls Church, Virginia
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Wu AM, Wang XY, Chi YL, Xu HZ, Weng W, Huang QS, Ni WF. Management of acute combination atlas-axis fractures with percutaneous triple anterior screw fixation in elderly patients. Orthop Traumatol Surg Res 2012; 98:894-9. [PMID: 23158783 DOI: 10.1016/j.otsr.2012.09.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2012] [Revised: 07/22/2012] [Accepted: 09/07/2012] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Patients with combined C1-2 fractures were often treated by posterior arthrodesis. However, elderly patients with multiple injuries (such as brain injury), the large surgical trauma of posterior arthrodesis will increase the risk of perioperative mortality. A minimally invasive technique may be better for them, and decrease the risk of perioperative mortality. MATERIALS AND METHODS Seven patients with combined C1-2 fractures underwent percutaneous anterior odontoid screw and anterior C1-2 transarticular screws (percutaneous triple anterior screws fixation). The surgical technique of percutaneous triple anterior screws fixation is described. RESULTS The operation performed on all patients successfully without technical difficulties, and no intra-operative surgery-related complications such as vertebral artery, nerve injury and soft tissue complications occurred. No pullout, loosening, or breakage of internal screws was observed. C1/2 stable was found in all cases and radiographic union achieved in all odontoid fractures. CONCLUSION Using the appropriate instruments allied to intra-operative image-intensification, we suggest that percutaneous triple anterior screw fixation is reliable, effective and minimally invasive procedure for elderly and brain injured patients suffering of combined atlas-axis fractures. LEVEL OF EVIDENCE Level IV. Retrospective study.
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Affiliation(s)
- A M Wu
- Department of Orthopaedic Surgery, Second Affiliated Hospital of Wenzhou Medical College, #109 XueYuan Western Road, WenZhou, ZheJiang, China.
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Minimally invasive technique of triple anterior screw fixation for an acute combination atlas-axis fracture: case report and literature review. Spinal Cord 2009; 48:174-7. [PMID: 19704414 DOI: 10.1038/sc.2009.108] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
STUDY DESIGN A case report to describe the minimally invasive technique of treating C1-type II odontoid combination fractures. OBJECTIVE To introduce a new, minimally invasive technique of triple anterior screw fixation for acute combination atlas-axis fractures. SUMMARY OF BACKGROUND DATA Management for C1-type II odontoid combination fractures includes traction, immobilization and posterior fusion with and without instrumentation and anterior odontoid screw fixation. The combination of odontoid and bilateral transarticular C1-C2 anterior screw fixation is a recent addition in treating C1-type II odontoid fractures. METHODS A case of combination atlas-type II odontoid fracture occurred in a 39-year-old man. Imaging examinations showed a fracture of the unilateral anterior and posterior arch of C1 associated with type II odontoid fracture and with significant prevertebral soft tissue edema. Treatment consisted of odontoid and bilateral C1-C2 transarticular screw fixation through bilateral anterior small incisions. RESULTS The patient was mobilized early postoperatively with a hard cervical collar and discharged 4 days later. On 2-year follow-up, he presented no cervical complaints and only mild reduction in neck rotation. CONCLUSION In case of C1-type II odontoid fracture, the triple anterior screw fixation can be taken into consideration as an alternative because of its superiority of minimal invasion, stability and safety.
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Ben Aïcha K, Laporte C, Akrout W, Atallah A, Kassab G, Jégou D. Surgical management of a combined fracture of the odontoid process with an atlas posterior arch disruption: a review of four cases. Orthop Traumatol Surg Res 2009; 95:224-8. [PMID: 19376763 DOI: 10.1016/j.otsr.2008.11.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2007] [Accepted: 11/17/2008] [Indexed: 02/02/2023]
Abstract
Four cases of operated odontoid process fractures associated with a fracture of the posterior arch of the atlas are presented. Three types of surgery were performed: atlas-axis fusion, occipitocervical fusion, and odontoid process screw fixation. Based on a literature review and our experience, the therapeutic management is discussed according to the type of odontoid fracture and the presence of neurological involvement, with a reminder that wiring is not indicated when C1 posterior arch continuity is compromised.
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Affiliation(s)
- K Ben Aïcha
- Department of Orthopaedics and Traumatology, Meaux Hospital, 6, bis rue Saint-Fiacre, 77100, Meaux, France
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