Surgical Treatment for Odontoid Fractures in Patients with Long-Standing Ankylosing Spondylitis: A Report of 3 Cases and Review of the Literature

Odontoid Fractures: A Review of the Current State of the Art

Odontoid fractures (OFs) represent up to 15% of all cervical fractures encountered and present most commonly amongst elderly patients, typically in the setting of low energy trauma such as falls. The Anderson and D'Alonzo classification and Roy-Camille subtype description are the most clinically noteworthy descriptions of OFs used. Even though most patients will not present with neurological injury, mechanical instability can occur with type II and type III (Anderson and D'Alonzo) fractures, particularly if the transverse ligament of the atlas is ruptured; however, this is very rare. Conservative treatment is usually employed for type I and type III injuries, and to a varying degree for non-displaced type II injuries. Surgical treatment is typically reserved for type II fractures, patients with neurological injury, and in the setting of other associated fractures or ligamentous injury. Anterior screw fixation is a viable option in the setting of a favorable fracture line orientation in type II fractures, whereas posterior C1-C2 screw fixation is an option for any type II or type III fracture presentation. There is evidence that surgery for type II fractures has higher rates of union and lower mortality than nonoperative treatments. While surgical options have increased over the decades and the management of OF has been optimized by considering fracture subtypes and patient factors, there remains a significant morbidity and mortality associated with OFs. The aging population and changing demographics suggest that there will be an ongoing rise in the incidence of OFs. Therefore, the appropriate management of these cases will be essential for ensuring optimization of health care resources and the quality of life of affected patients.

Traumatic lateral atlantoaxial dislocation combined with a type II odontoid fracture in a patient with ankylosing spondylitis: A case report

RATIONALE

Traumatic lateral atlantoaxial dislocation (AAD) combined with an odontoid fracture is extremely rare. The standards applicable to management of the traumatic lateral AAD are still in flux due to the infrequency of this injury.

PATIENT CONCERNS

We present a unique case of traumatic lateral AAD combined with a type II odontoid fracture in a patient with ankylosing spondylitis (AS).

DIAGNOSIS

Spinal computed tomography showed ankylosis of the entire spine from the sacroiliac joint to the cervical spine. On the cervical X-ray the head was rotated to the right with anterior subluxation of the C1 and odontoid tip relative to C2. The coronal computed tomography (CT) scan also revealed left lateral dislocation of C1 on C2 with a horizontal translation of the odontoid tip. On the axial and sagittal CT scan, the left C1 lateral mass was displaced anteriorly and locked by C2 body.

INTERVENTIONS

We performed occipito-cervical fusion (OCF) after successful manual reduction under general anesthesia.

OUTCOMES

The patient's recovery from surgery was uneventful and without complication. At the 3 year follow-up the patient was asymptomatic and reportedly satisfied with the surgery.

LESSONS

Traumatic AAD with an odontoid fracture is an exceedingly uncommon cervical spine injury. A lateral subluxation with a type II odontoid fracture in a patient with AS is rarer still, so much so that this type of subluxation was not classifiable using any of the previously developed classification systems. In this patient with AS, posterior OCF with internal fixation was necessary to avoid hardware failure, particularly in light of the intensive stress caused by AS.

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

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.

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The occurrence of the odontoid fracture is rare in patients with AS.

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Neurological deficits are more common in posterior subluxation of the odontoid process compared to anterior subluxation.

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The optimal treatment approach for odontoid fracture in cases with AS is unknown; however, surgical management is preferred.

Single nucleotide polymorphisms of TRAF2 and TRAF5 gene in ankylosing spondylitis: a case-control study

Objective To investigate the role of eight locus polymorphisms of tumor necrosis factor receptor-associated factor 2 (TRAF2) and TRAF5 gene and their interaction in the susceptibility to ankylosing spondylitis (AS) in Chinese Han population. Methods Eight single nucleotide polymorphisms (SNPs) of TRAF2 (rs3750511, rs10781522, rs17250673, rs59471504) and TRAF5 (rs6540679, rs12569232, rs4951523, rs7514863) gene were genotyped in 673 AS patients and 687 controls. Results The SNPs of TRAF2 and TRAF5 do not indicate a correlation with the susceptibility of AS in Chinese Han population. Genotype frequencies of rs3750511 were statistically significant in females between patients and controls. The allele frequencies of rs10781522 and genotype frequencies of rs3750511 were statistically significant between groups of different diseases activity. One three-locus model, TRAF2 (rs10781522, rs17250673) and TRAF5 (rs12569232), had a maximum testing accuracy of 52.67% and a maximum cross-validation consistency (10/10) that was significant at the level of P = 0.0001, after determined empirically by permutation testing. As to environmental variables, only marginal association was found between sleep quality and AS susceptibility. Conclusion TRAF2 rs3750511 polymorphism may be associated with the susceptibility and severity of AS. Besides, the interaction of TRAF2 and TRAF5 genes may be associated with AS susceptibility, but many open questions remain.

The surgical treatment strategies for thoracolumbar spine fractures with ankylosing spondylitis: a case report

Background

Ankylosing spondylitis (AS) is a chronic inflammatory disease that primarily affects spine and paraspinal soft tissue. Ankylosing spondylitis is one of the causes of osteoporosis and patients with ankylosing spondylitis tend to have spinal fractures due to limited mobility and osteoporosis. In recent years, due to the increase in the number of patients with AS, patients with AS and thoracolumbar spine fractures have gradually increased. In the past 1 year, we have treated 3 cases of AS with thoracolumbar spine fractures via simple posterior internal fixation and this paper aims to report its clinic effect.

Case presentation

All the three patients selected had a history of ankylosing spondylitis for nearly 30 years, and one of them developed a thoracolumbar spine fracture after falling when he walked, and the other two developed a thoracolumbar spine fracture without any reason. They were hospitalized for “low back pain” and were diagnosed as fractures after careful physical examination and imaging examinations such as X-ray, CT, and MRI. After the preoperative preparation was completed, all the three patients underwent surgery with simple posterior internal fixation-reduction of the fracture and pedicle screw fixation via posterior approach. All the implants-pedicle screws and connecting rods-are made of titanium alloy. For postoperative management, we asked all the patients to stay in bed for 3 weeks after the operation, and then slowly move down with the help of crutches. Fracture healing and neurological function recovery were observed postoperatively. All the three patients recovered satisfactorily after surgery, and the follow-up confirmed that the fracture healed successfully after 3 months.

Conclusions

The 3 patients included 2 men and 1 women. All the 3 patients recovered well after surgery, and the follow-up confirmed that the fracture healed successfully after 3 months. One man developed urination dysfunction after operation and recovered to normal 3 months after rehabilitation exercise.