Nonoperative Management of Vertical C2 Body Fractures

[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.

Proposal of Treatment Strategy for Pedicle Fractures of the C2: An Analysis of 49 Cases

Spine surgeons often confuse C2 pedicle fractures (PFs) with pars interarticularis fractures. In addition, little information is available about the characteristics and treatment strategies for C2 PFs. We sought to investigate the characteristics of C2 PFs and to propose an appropriate treatment strategy. A total of forty-nine patients with C2 PFs were included in this study. We divided these patients into unilateral and bilateral C2 PF groups. The incidence rates and characteristics of other associated C2 and C2-3 injuries, and other cervical injuries, were evaluated. In addition, treatment methods and outcomes were analyzed. Twenty-two patients had unilateral C2 PFs and twenty-seven patients had bilateral C2 PFs. Among the cases of unilateral C2 PFs, all patients had one or more other C2 fractures, and twenty patients (90.9%) had one or two C2 body fractures. Meanwhile, among the cases of bilateral C2 PF, all patients had two or more other C2 fractures and one or two C2 body fractures. In unilateral C2 PFs, three patients with C2-3 anterior slip or adjacent cervical spine (C1-3) injury underwent surgery and nineteen patients (86.4%) were treated with conservative methods. In bilateral C2 PFs, three patients with C2-3 anterior slip or SCI at C2-3 underwent surgery and twenty-four patients (88.9%) were treated with conservative methods. Our results showed that C2 PFs do not occur alone and are always accompanied by other associated C2 injuries. C2 PFs should, generally, be thought of as a more complex fracture type than hangman's fracture or dens fracture. Despite the complex fracture characteristics, most C2 PFs can be managed with conservative treatment. However, surgical treatments should be considered if the C2 PFs are accompanied by the C2-3 anterior slip and adjacent cervical spine injury.

LABIOMANDIBULAR GLOSSOTOMY APPROACH FOR CRANIOCERVICAL PATHOLOGIES - SPINE RECONSTRUCTION

ABSTRACT Objectives: Exposing the clivus and upper cervical spine should, ideally, provide an adequate surgical field in which the surgeon can safely decompress and stabilize the craniovertebral junction (CVJ). We present a series of four cases with a narrative review of the literature in which Median Labiomandibular Glossotomy was used to treat CVJ disorders, in order to highlight the importance and indications of this access. Methods: We performed a retrospective analysis of patients who underwent MLMG for several pathologies. The group comprised four patients (two men and two women). Five approaches were performed (one revision surgery). Results: The approach was suitable for all cases, clivus was achieved when necessary. Distally, C4 was exposed to obtain satisfactory osteosynthesis. Laterally, we had a good view of the tumor borders and control of the vertebral artery. Complications encountered were a superficial wound infection that was easily healed, a later pharyngeal wound dehiscence and pseudoarthrosis, all in the same patient. There are 3 main anterior surgical techniques for managing lesions of the clivus, foramen magnum or upper cervical vertebrae. We chose Median Labiomadibular Glossotomy (MLMG) as a primary option, which provided a direct view of the clivus, C3 – C4 caudally and a wider surgical field. The main advantages of the MLMG technique include direct access to spinal pathology, an avascular plane through the median pharyngeal raphe, and a wider surgical field in both the transverse and sagittal dimensions. Conclusion: This approach provides excellent exposure of the craniocervical junction and upper cervical spine. Level of evidence IV; Series of cases analyzed retrospectively.

Development and first application testing of a new protocol for CT-based stability evaluation of the injured upper cervical spine

PURPOSE

For trauma surgeons, the evaluation of the stability of the upper cervical spine may be demanding. The aim of this study was to develop a protocol for decision-making on upper cervical spine stability in trauma patients based on established parameters obtained by CT imaging as well as testing the protocol by having it applied by trauma surgeons.

METHODS

A structured literature search on upper cervical spine stability was performed. The best evaluated instability criteria in CT imaging were determined. Based on these parameters a protocol for stability evaluation of the injured upper cervical spine was developed. A first application testing was performed. In addition to the assessment of instability, the time required for the assessment was analyzed.

RESULTS

A protocol for CT-based stability evaluation of the injured upper cervical spine based on the current literature was developed and displayed in a flow chart. Testing of the protocol found the stability of the cervical spine was correctly assessed in 55 of 56 evaluations (98.2%). In one test run, a stable upper cervical spine was judged to be unstable. Further analysis showed that this case was based on a measurement error. The assessment time of CT-images decreased significantly during repeat application of the protocol (p < 0.0001), from 336 ± 108 s (first case) to 180 ± 30 s (fourth case).

CONCLUSION

The protocol can be applied quickly and safely by non-specialized trauma surgeons. Thus, the protocol can support the decision-making process in CT-based evaluation of the stability of the injured upper cervical spine.

Atypical hangman's fracture with concomitant subaxial fracture-dislocation treated with circumferential fusion of C2-C5-a case report

INTRODUCTION

Atypical hangman's fractures are coronally-oriented vertical fractures of the posterior body of C2. Though these are not uncommon injuries, there is a paucity of data investigating the management of these fractures, especially when they occur in association with subaxial fracture dislocations.

CASE PRESENTATION

A 50-year-old male suffered a cervical extension injury when he dove into a shallow swimming pool while intoxicated. Initial examination demonstrated 2/5 strength in the right deltoid and biceps and 3/5 strength in the left deltoid and biceps with no motor or sensory function distal to the C5 level. Cervical CT scan revealed a C2 atypical hangman's fracture and a C4 right-sided facet fracture with traumatic spondylolisthesis at C4/5. We performed C2-C5 anterior cervical discectomy and fusion followed by a C3-C5 posterior instrumented fusion. At the patient's two year postoperative visit, the patient has had minimal improvement in neurologic function with 4/5 strength in bilateral deltoids and biceps and 2/5 strength in right wrist extension. Radiographs show a solid arthrodesis on flexion-extension radiographs.

DISCUSSION

To our knowledge, this is the first case report discussing the operative management of an atypical hangman's fracture with a concomitant subaxial fracture-dislocation. This case report adds to our current knowledge by demonstrating a novel anterior-posterior approach for treating these complicated injuries.

Traumatic C1-2 rotatory subluxation with dens and bilateral articular facet fractures of C2: A case report

RATIONALE

To the best of our knowledge, this is an extremely rare case of traumatic C1-2 rotatory subluxation associated with multiple C2 fractures.

PATIENT CONCERNS

We report the case of a 63-year-old man with type 2 traumatic C1-2 rotatory subluxation (Fielding and Hawkins classification) associated with type III dens (Anderson and D'Alonzo classification) and bilateral articular facet fractures of C2. This injury occurred as a result of falling down in a drunken state. The patient complained of neck pain and mild degree of torticollis but did not show any neurologic abnormalities.

DIAGNOSES

Plain radiographs of cervical spine showed extensive soft tissue swelling, a fracture fragment, disruption of spinolaminar line at C1-2 level, and bony overlapping of right side lateral joint of C1-2. Two- and three-dimensional reconstructed computed tomography scans clearly demonstrated complicated C1-2 combined injury. The atlantodental interval was normal.

INTERVENTION

By skull traction and derotation, closed reduction of C1-2 rotatory subluxation with a type III dens and bilateral articular facet fractures of C2 was successfully achieved. He was managed with halovest fixation for 3 months.

OUTCOMES

At the 1-year follow-up visit solid fusion and improvement of clinical symptoms were achieved without C1-2 instability.

LESSONS

Despite traumatic C1-2 rotatory subluxation associated with multiple C2 fractures, trial of closed reduction should be considered as the first choice of treatment so as to preserve C1-2 motion.

[Injuries of the upper cervical spine : Update on diagnostics and management]

Injuries to the upper cervical spine represent a diagnostic and therapeutic challenge to the treating surgeon due to the complex anatomical relationships and biomechanical features. In this further education article the diagnostic principles, established classifications and therapeutic recommendations as well as injury-specific characteristics of bony and ligamentous injuries to the upper cervical spine (C0-C2) are presented.

C2 Body Fracture: Report of Cases Managed Conservatively by Philadelphia Collar

Study Design

Case series.

Purpose

To present results of conservative management in patients with pure C2 body fractures.

Overview of Literature

Axis body fractures, a less common subgroup of C2 fractures, are commonly classified as vertical coronal, vertical sagittal, and transverse subtypes. While the treatment paradigm for other C2 fractures is clear, there is insufficient evidence to support treatment guidelines for C2 body fractures.

Methods

Eleven patients with pure C2 body fractures were managed with external immobilization and followed thereafter.

Results

All neurologic examinations were normal. In computed tomography (CT) scans, four, two, three, and two patients had a coronal, sagittal, horizontal, and burst fracture, respectively. Magnetic resonance imaging showed hematoma and partial rupture in the anterior longitudinal ligament in four patients, posterior ligamentous complex injury in one, and normal ligamentous structure in six. All fractures were managed conservatively using the Philadelphia collar, which was continued until complete disappearance of symptoms (within 1–3 months in all patients). The decision to discontinue the neck collar was made by a dynamic neck X-ray and CT scan that showed complete bony fusion. All patients were then followed for an additional 1.5 years (mean follow-up of 21 months for all patients). No patient showed any neurologic symptoms or deficits during the follow-up period.

Conclusions

In patients with pure C2 body fracture, non-operative management with Philadelphia neck collar is a safe and efficacious option, even in the presence of some sort of ligamentous injury.

Direct C2 Pedicle Screw Fixation for Axis Body Fracture

BACKGROUND

Acute complex C2 vertebral body fracture specifically does not involve the odontoid process or C2 pars interarticularis. External stabilization can be effective but may prolong healing and increase morbidity. Many traditional surgical techniques can achieve internal stabilization at the expense of normal cervical motion. We describe direct surgical C2 pedicle screw fixation as an option for managing acute complex C2 vertebral body fracture.

CASE DESCRIPTION

Three patients were treated with direct pedicle screw fixation of acute traumatic complex C2 vertebral body fractures. All fractures were coronally oriented Benzel type 1. None of the patients sustained neurological injury. Stereotactic navigation with intraoperative computed tomography scanning was used for each procedure. Surgery provided immediate internal orthosis and stability, as judged by intraoperative dynamic fluoroscopy. Rigid cervical collar bracing was used for 1 month after surgery when the patients were out of bed. Initial radiographs showed acceptable screw placement and fracture alignment. Dynamic radiographs at 3 months showed structural stability at the fracture site and adjacent levels, and complete bony union was confirmed with late computed tomography scanning (>1 year) in each case. Each patient reported resolution of trauma-related and postsurgical pain at 30-day follow-up. Postoperative Neck Disability Index questionnaires for each patient suggested no significant disability at 1 year.

CONCLUSIONS

Direct pedicle screw fixation of acute complex C2 vertebral body fracture appeared to be safe and effective in our 3 patients. It may provide a more-efficient and less-morbid treatment than halo brace or cervical collar immobilization in some patients.

Management of Typical and Atypical Hangman's Fractures

Study Design Retrospective study of a prospectively maintained database. Objective Our aim was to retrospectively review management and outcomes of patients with low-grade hangman's fractures, specifically looking at differences in outcomes between collars and halo immobilization. We also studied fracture patterns and their treatment outcomes. Methods Forty-one patients with hangman's fractures were identified from 105 patients with axis fractures between 2007 and 2013. Typical hangman's fractures were defined as traumatic spondylolisthesis of the axis causing a bilateral pars interarticularis fracture. Fractures involving the posterior cortex of C2 on one or both sides or an asymmetrical pattern were defined as atypical. Results There were 41 patients with a mean age of 59 years, with 13 (31.7%) typical and 28 (68.2%) atypical fractures. There were 22 (53.6%) type 1 fractures, 7 (41.4%) type 2 fractures, and 2 (4.9%) type 2a fractures in this series. Cervical collars were used to manage 11 patients (27% of all patients with hangman's fractures) and halo orthosis was used in 27 (65.8%). Three (7.3%) patients underwent surgical fixation of the fracture. Bony union was achieved in all patients on radiologic follow-up. Permanent neurologic deficit occurred in one patient due to associated injuries. Neck pain and stiffness were reported more commonly in the atypical group, but this finding was not statistically significant. Conclusions The majority of hangman type fractures can be treated nonoperatively. We found no difference in outcomes between a rigid collar or halo immobilization for treatment of low-grade fractures. Radiologic follow-up is essential to identify cases of nonunion.

Oblique Axis Body Fracture: An Unstable Subtype of Anderson Type III Odontoid Fractures-Apropos of Two Cases

Purpose. Anderson type III odontoid fractures have traditionally been considered stable and treated conservatively. However, unstable cases with unfavorable results following conservative treatment have been reported. Methods. We present the cases of two patients who sustained minimally displaced Anderson type III fractures with a characteristic fracture pattern that we refer to as "oblique type axis body fracture." Results. The female patients aged 90 and 72 years, respectively, were both diagnosed with minimally displaced Anderson type III fractures. Both fractures had a characteristic "oblique type" fracture pattern. The first patient was treated conservatively with cervical spine immobilization in a semirigid collar. However, gross displacement was noted at the 6-week follow-up visit. The second patient was therefore treated operatively by C1-C3/4 posterior fusion and the course was uneventful. Conclusions. Oblique type axis body fractures resemble a highly unstable subtype of Anderson type III fractures with the potential of severe secondary deformity following conservative treatment, irrespective of initial grade of displacement. The authors therefore warrant a high index of suspicion for this injury and suggest early operative stabilization.

Upper cervical spine injuries: indications and limits of the conservative management in Halo vest. A systematic review of efficacy and safety

INTRODUCTION

The integrity of the upper cervical spine is essential for survival and function, because of the neurovascular structures contained within its bony elements. Fractures of the upper cervical spine (C1-C2) are frequent. This systematic review assesses the efficacy and safety of the conservative management in Halo vest for patients with upper cervical spine fractures.

MATERIALS AND METHODS

Two reviewers independently identified studies in English, by a systematic search of CINAHL, Embase, Medline, HealthSTAR, and the Cochrane Central Registry of Controlled Trials, from inception of each database to 28 January 2010, using various combinations of the keywords terms "odontoid fractures", hangman's fractures", "axis fractures", "axis", "atlas", "Jefferson fractures", "C1 arch fractures", "C1 fractures", "C2 fractures", "cervical spine", "injuries", "fracture", "trauma", "neck injury", "surgery".

RESULTS

A total of 43 citations were obtained. An additional 4 papers were obtained from the reference list of the studies included. The 47 studies that were included described a total of 1078 patients with C1-C2 fractures managed by halo fixator.

CONCLUSIONS

The halo fixator has a well defined place in the management of fractures of the cervical spine. Clearly, studies of higher level of evidence, for instance large randomised trials, should be conducted, even though the available evidences suggest that management of upper cervical spine fracture with halo fixator is safe and effective.

Axis fractures

BACKGROUND

Traumatic fractures of the second cervical vertebra are common, representing nearly 20% of all acute cervical spinal fracture-dislocation injuries. They are divided into 3 distinct injury patterns: odontoid fractures, hangman's fracture injuries, and fractures of the axis body, involving all other fracture injuries to the C2 vertebra.

OBJECTIVE

An evidence-based overview of the medical and surgical treatment strategies for each axis fracture injury sub-type.

RESULTS

Current medical and surgical management of traumatic fractures of the axis.

C2-fractures: part II. A morphometrical analysis of computerized atlantoaxial motion, anatomical alignment and related clinical outcomes

Knowledge on the outcome of C2-fractures is founded on heterogenous samples with cross-sectional outcome assessment focusing on union rates, complications and technical concerns related to surgical treatment. Reproducible clinical and functional outcome assessments are scant. Validated generic and disease specific outcome measures were rarely applied. Therefore, the aim of the current study is to investigate the radiographic, functional and clinical outcome of a patient sample with C2-fractures. Out of a consecutive series of 121 patients with C2 fractures, 44 met strict inclusion criteria and 35 patients with C2-fractures treated either nonsurgically or surgically with motion-preserving techniques were surveyed. Outcome analysis included validated measures (SF-36, NPDI, CSOQ), and a functional CT-scanning protocol for the evaluation of C1-2 rotation and alignment. Mean follow-up was 64 months and mean age of patients was 52 years. Classification of C2-fractures at injury was performed using a detailed morphological description: 24 patients had odontoid fractures type II or III, 18 patients had fracture patterns involving the vertebral body and 11 included a dislocated or a burst lateral mass fracture. Thirty-one percent of patients were treated with a halo, 34% with a Philadelphia collar and 34% had anterior odontoid screw fixation. At follow-up mean atlantoaxial rotation in left and right head position was 20.2 degrees and 20.6 degrees, respectively. According to the classification system of posttreatment C2-alignment established by our group in part I of the C2-fracture study project, mean malunion score was 2.8 points. In 49% of patients the fractures healed in anatomical shape or with mild malalignment. In 51% fractures healed with moderate or severe malalignment. Self-rated outcome was excellent or good in 65% of patients and moderate or poor in 35%. The raw data of varying nuances allow for comparison in future benchmark studies and metaanalysis. Detailed investigation of C2-fracture morphology, posttreatment C2-alignment and atlantoaxial rotation allowed a unique outcome analysis that focused on the identification of risk factors for poor outcome and the interdependencies of outcome variables that should be addressed in studies on C2-fractures. We recognized that reduced rotation of C1-2 per se was not a concern for the patients. However, patients with worse clinical outcomes had reduced total neck rotation and rotation C1-2. In turn, C2-fractures, especially fractures affecting the lateral mass that healed with atlantoaxial deformity and malunion, had higher incidence of atlantoaxial degeneration and osteoarthritis. Patients with increased severity of C2-malunion and new onset atlantoaxial arthritis had worse clinical outcomes and significantly reduced rotation C1-2. The current study offers detailed insight into the radiographical, functional and clinical outcome of C2-fractures. It significantly adds to the understanding of C2-fractures.

C2-fractures: part I. Quantitative morphology of the C2 vertebra is a prerequisite for the radiographic assessment of posttraumatic C2-alignment and the investigation of clinical outcomes

Pertinent literature exists concerning indications, techniques, complications of treatment, and risk factors for nonunion in axis and odontoid fractures; however, there are scarce data regarding the incidence and definition of malunion in these fractures. As a prerequisite for the study of anatomical alignment following surgical and nonsurgical treatment of C2-fractures, an understanding of normal C2 anatomy is essential. Therefore, the authors intended to evaluate morphometrical dimensions of the C2 vertebra. The purpose was to provide normalized quantitative data to enable assessment of malalignment following the treatment of C2-fractures within a classification system. Using digitized cervical spine lateral and transoral odontoid radiographs of 100 consecutive patients without any evidence of traumatic or neoplastic disorders, the authors performed measurements on distinct anatomical structures and investigated morphometrical dimensions of the normal axis vertebra. The incidence of atlantoaxial arthritis was also evaluated. In addition, with the assessment of twenty arbitrarily chosen sets of radiographs by three different observers we calculated the interobserver reliability in terms of intraclass correlation coefficients for each parameter. With calculation of SD and 95% confidence limits, pathological cut-offs were reconstructed from measurements performed resembling non-physiological and pathological limits. Distinct parameters were selected to form a new classification system for radiographical follow-up that focuses on the quantitative C1-2 vertebral alignment. The measurement process resulted in 2,400 data points. Distinct morphometrical parameters, such as a quantitative characterization of the sagittal atlantoaxial congruency, the lateral mass inclination and the type of degenerative changes at the atlantoaxial joint could be demonstrated to be valuable and reliably used within a proposed classification for C2-malunions following C2-fractures. The current study offers a template including recommended radiological measurements for further research on the study of clinical outcome and posttraumatic alignment following C2-fractures.

When should a cervical collar be used to treat neck pain?

Neck pain is one of the most prevalent and costly health problems in the United States. It remains a complex, subjective experience with a variety of musculoskeletal causes. Although, cervical collars are a seemingly benign intervention, they can have adverse effects, especially when used for longer periods of time. It is feared that a long period of immobilization, can result in atrophy-related secondary damage. Many physicians cite anecdotal evidence of their clinical utility and soft cervical collars are often prescribed by convention for patients complaining of neck pain. The use of cervical collars to treat neck pain is an area of controversy. This review article examines the current evidence and studies related to recommending cervical collars for neck pain of a variety of etiologies.

Simultaneous Anterior Arthrodesis C2-3 and Anterior Odontoid Screw Fixation for Stabilization of a 4-Part Fracture of the Axis—A Technical Description

Multiple fractures of the axis are rare and present challenging patterns of instability in cervical spine surgery. Once a surgeon is faced with a combination of fractures in the axis vertebra, including stable and unstable components, a sound treatment concept must be worked out to achieve primary stability, early mobilization, and superior outcome. We demonstrate an operative technique for the stabilization of a 4-part fracture of the axis. Utilizing anterior odontoid screw fixation and C2-3 arthrodesis, an unstable traumatic spondylolisthesis with fracture of the odontoid type IIA, and lateral mass of C2 was successfully stabilized at once. The technique enabled early postoperative mobilization of our patient, who, after 1 year, showed a favorable outcome with a pain-free range of motion. The basic thoughts guiding to treatment options in multiple fractures of the axis are discussed and our therapy concept is presented.

Nonoperative management and treatment of spinal injuries

STUDY DESIGN

Review of literature.

OBJECTIVE

To delineate and discuss nonoperative treatment and treatment of spinal injuries.

SUMMARY OF BACKGROUND DATA

Nonoperative methods have been a mainstay of care for spinal injuries since ancient Egypt. The vast majority of all spinal injuries should be treated in the nonoperative fashion. The indications and methods continue to evolve.

METHODS

A PubMed search of the literature returned more than 1000 articles related to spine trauma. A total of 270 were references to nonoperative treatment, and 100 were thought to be relevant and included in this review.

RESULTS

All spine injuries are treated in a nonoperative manner, at least initially. The vast majority of injuries are successfully and appropriately treated in a definitive manner with nonsurgical methods. Over the past 10-15 years, the advent of better rigid cervical fixation has decreased the use of halo vests as definitive treatment of many cervical injuries. In contrast, during the same time, more thoracolumbar injuries are being treated in a nonsurgical fashion because the outcomes have been shown to be similar or superior.

CONCLUSIONS

As with all of medicine, the treatment of spine trauma will continue to evolve with time. It is paramount that the physician selects the treatment that will provide the best short-term recovery with the least impact on long-term function.