1
|
Johnstone T, Shah V, Schonfeld E, Sadeghzadeh S, Haider G, Marianayagam NJ, Stienen M, Veeravagu A. Type II odontoid fractures in the elderly presenting to the emergency department: an assessment of factors affecting in-hospital mortality and discharge to skilled nursing facilities. Spine J 2024; 24:682-691. [PMID: 38101547 DOI: 10.1016/j.spinee.2023.11.023] [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: 06/27/2023] [Revised: 11/14/2023] [Accepted: 11/27/2023] [Indexed: 12/17/2023]
Abstract
BACKGROUND CONTEXT Type II odontoid fractures (OF) are among the most common cervical spine injuries in the geriatric population. However, there is a paucity of literature regarding their epidemiology. Additionally, the optimal management of these injuries remains controversial, and no study has evaluated the short-term outcomes of geriatric patients presenting to emergency departments (ED). PURPOSE This study aims to document the epidemiology of geriatric patients presenting to EDs with type II OFs and determine whether surgical management was associated with early adverse outcomes such as in-hospital mortality and discharge to skilled nursing facilities (SNF). STUDY DESIGN This is a retrospective cohort study. PATIENT SAMPLE Data was used from the 2016-2020 Nationwide Emergency Department Sample. Patient encounters corresponding to type II OFs were identified. Patients younger than 65 at the time of presentation to the ED and those with concomitant spinal pathology were excluded. OUTCOME MEASURES The association between the surgical management of geriatric type II OFs and outcomes such as in-hospital mortality and discharge to SNFs. METHODS Patient, fracture, and surgical management characteristics were recorded. A propensity score matched cohort was constructed to reduce differences in age, comorbidities, and injury severity between patients undergoing operative and nonoperative management. Additionally, to develop a positive control for the analysis of geriatric patients with type II OFs and no other concomitant spinal pathology, a cohort of patients that had been excluded due to the presence of a concomitant spinal cord injury (SCI) was also constructed. Multivariate regressions were then performed on both the matched and unmatched cohorts to ascertain the associations between surgical treatment and in-hospital mortality, inpatient length of stay, encounter charges, and discharge to SNFs. RESULTS A total of 11,325 encounters were included. The mean total charge per encounter was $60,221. 634 (5.6%) patients passed away during their encounters. In total, 1,005 (8.9%) patients were managed surgically. Surgical management of type II OFs was associated with a 316% increase in visit charge (95% CI: 291%-341%, p<.001), increased inpatient length of stay (IRR: 2.87, 95% CI: 2.62-3.12, p<.001), and increased likelihood of discharge to SNFs (OR=2.62, 95% CI: 2.26-3.05, p<.001), but decreased in-hospital mortality (OR=0.32, CI: 0.21-0.45, p<.001). The propensity score matched cohort consisted of 2,010 patients, matching each of the 1,005 that underwent surgery to 1,005 that did not. These cohorts were well balanced across age (78.24 vs 77.91 years), Elixhauser Comorbidity Index (3.68 vs 3.71), and Injury Severity Score (30.15 vs 28.93). This matching did not meaningfully alter the associations determined between surgical management and in-hospital mortality (OR=0.34, CI=0.21-0.55, p<.001) or SNF discharge (OR=2.59, CI=2.13-3.16, p<.001). Lastly, the positive control cohort of patients with concurrent SCI had higher rates of SNF discharge (50.0% vs 42.6%, p<.001), surgical management (32.3% vs 9.7%, p<.001), and in-hospital mortality (28.9% vs 5.6%, p<.001). CONCLUSIONS This study lends insight into the epidemiology of geriatric type II OFs and quantifies risk factors influencing adverse outcomes. Patient informed consent should include a discussion of the protective association between definitive surgical management and in-hospital mortality against potential operative morbidity, increased lengths of hospital stay, and increased likelihood of discharge to SNFs. This information may impact patient treatment selection and decision making.
Collapse
Affiliation(s)
- Thomas Johnstone
- Stanford University School of Medicine, 453 Quarry Rd, Palo Alto, CA 94304, USA; Department of Neurosurgery, School of Medicine, Stanford University. 453 Quarry Rd, Stanford, CA 94305 USA.
| | - Vaibhavi Shah
- Stanford University School of Medicine, 453 Quarry Rd, Palo Alto, CA 94304, USA; Department of Neurosurgery, School of Medicine, Stanford University. 453 Quarry Rd, Stanford, CA 94305 USA
| | - Ethan Schonfeld
- Department of Neurosurgery, School of Medicine, Stanford University. 453 Quarry Rd, Stanford, CA 94305 USA
| | - Sina Sadeghzadeh
- Stanford University School of Medicine, 453 Quarry Rd, Palo Alto, CA 94304, USA; Department of Neurosurgery, School of Medicine, Stanford University. 453 Quarry Rd, Stanford, CA 94305 USA
| | - Ghani Haider
- Department of Neurosurgery, School of Medicine, Stanford University. 453 Quarry Rd, Stanford, CA 94305 USA
| | - Neelan J Marianayagam
- Department of Neurosurgery, School of Medicine, Stanford University. 453 Quarry Rd, Stanford, CA 94305 USA
| | - Martin Stienen
- Department of Neurosurgery & Spine Center of Eastern Switzerland, Kantonsspital St.Gallen, St.Gallen, Switzerland
| | - Anand Veeravagu
- Department of Neurosurgery, School of Medicine, Stanford University. 453 Quarry Rd, Stanford, CA 94305 USA
| |
Collapse
|
2
|
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.
Collapse
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.
| |
Collapse
|
3
|
Mousavi SR, Farrokhi MR, Eghbal K, Motlagh MAS, Jangiaghdam H, Ghaffarpasand F. Posterior-only approach for treatment of irreducible traumatic Atlanto-axial dislocation, secondary to type-II odontoid fracture; report of a missed case, its management and review of literature. Int J Surg Case Rep 2024; 114:109104. [PMID: 38070376 PMCID: PMC10755710 DOI: 10.1016/j.ijscr.2023.109104] [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: 09/06/2023] [Revised: 12/01/2023] [Accepted: 12/03/2023] [Indexed: 01/01/2024] Open
Abstract
INTRODUCTION AND IMPORTANCE Odontoid fracture (OF) is among the most common and challenging cervical spine fractures in regards to the treatment and surgical approach. Atlanto-axial dislocation (AAD) is considered a significant complication after failed non-surgical treatment of OF. Traditionally, it requires anterior odontoidectomy followed by posterior C1-C2 reduction and fusion. In latest studies, Atlanto-axial joint (AAJ) remodeling in a posterior-only approach has got attention. CASE PRESENTATION We herein present a 30-year-old man with missed type-II OF, presenting with irreducible anterior AAD and progressive neurological deficit. Old non-united OF with dorsal callous formation, compressing spinal cord, was detected. The patient underwent correction of the deformity and reduction of the fracture utilizing the posterior-only approach. AAJ remodeling, callous release and C1-C2 fusion was performed in standard prone position, under fluoroscopic guide and intraoperative electrophysiological monitoring. The patient had uneventful surgery and postoperative course and was neurologically intact with appropriate alignment in 6-month follow-up. CLINICAL DISCUSSION The irreducible AAD following type-II OF could be successfully treated with posterior-only approach (C1-C2 fusion). CONCLUSION Type-II OF is considered unstable requiring surgical management. Close follow-up and appropriate patient education is mandatory in non-surgical treatment. Irreducible AAD has been managed with anterior odontoid resection and posterior fusion. Several complications of anterior surgery, makes posterior-only approach a noticeable choice.
Collapse
Affiliation(s)
- Seyed Reza Mousavi
- Department of Neurosurgery, Shiraz University of Medical Sciences, Shiraz, Iran; Shiraz Neuroscience Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Majid Reza Farrokhi
- Department of Neurosurgery, Shiraz University of Medical Sciences, Shiraz, Iran; Shiraz Neuroscience Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Keyvan Eghbal
- Department of Neurosurgery, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Hamid Jangiaghdam
- Department of Neurosurgery, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Fariborz Ghaffarpasand
- Research Center for Neuromodulation and Pain, Shiraz University of Medical Sciences, Shiraz, Iran.
| |
Collapse
|
4
|
Somogyi R, Smith S, Kark J, Ryu WHA, Yoo J. Age-Based Incidence of Dens Fracture Has Unimodal Distribution Rather Than Commonly Claimed Bimodal Distribution. JB JS Open Access 2024; 9:e23.00059. [PMID: 38214006 PMCID: PMC10773694 DOI: 10.2106/jbjs.oa.23.00059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2024] Open
Abstract
Background Type-II dens fractures have long been described in the literature as occurring in a bimodal distribution, peaking in young adulthood as well as in older adulthood; however, the origin of this claim is unclear. The primary goal of this study was to examine the incidence of type-II dens fractures and assess for bimodality. Methods This is a retrospective cross-sectional review of the National Trauma Data Bank (NTDB) records on traumatic type-II dens fractures between October 2015 and December 2016. Rates were obtained from the NTDB, and the incidence per 100,000 was ascertained by utilizing U.S. Census data from 2016. Subgroupings by gender and Black or White race were also examined. Results Dens fractures occur unimodally, peaking around 89 years of age overall, skewed left by high rates in older White adults. The Black subgroup demonstrated trimodality, with the fracture incidence peaking at 25, 62, and 82 years of age. Rates among Black and White patients were similar until age 65, after which dens fractures occurred disproportionately in White patients. Fractures prior to age 75 occurred predominantly in men. Conclusions The evidence derived in this study challenges the common belief that type-II dens fractures occur bimodally across the entire population. However, there remains utility in considering younger and older patients as distinct groups for the purposes of management.
Collapse
Affiliation(s)
- Rita Somogyi
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, Oregon
| | - Spencer Smith
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, Oregon
| | - Jonathan Kark
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, Oregon
| | - Won Hyung A. Ryu
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
| | - Jung Yoo
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, Oregon
| |
Collapse
|
5
|
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.
Collapse
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
| |
Collapse
|
6
|
Huybregts JGJ, Barot KA, Recio C, Doucette J, Mekary RA, Vleggeert-Lankamp CLA. The optimal treatment of type II and III odontoid fractures in the elderly: an updated meta-analysis. 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 2023; 32:3434-3449. [PMID: 37439865 DOI: 10.1007/s00586-023-07779-1] [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: 01/03/2023] [Accepted: 05/12/2023] [Indexed: 07/14/2023]
Abstract
PURPOSE Odontoid fractures are the most common cervical spine fractures in the elderly, with a controversial optimal treatment. The objective of this review was to compare the outcome of surgical and conservative treatments in elderly (≥ 65 years), by updating a systematic review published by the authors in 2013. METHODS A comprehensive search was conducted in seven databases. Clinical outcome was the primary outcome. Fracture union- and stability were secondary outcomes. Pooled point estimates and their respective 95% confidence intervals (CIs) were derived using the random-effects model. A random-effects multivariable meta-regression model was used to correct for baseline co-variates when sufficiently reported. RESULTS Forty-one studies met the inclusion criteria, of which forty were case series and one a cohort study. No clinical differences in outcomes including the Neck Disability Index (NDI, 700 patients), Visual Analogue Scale pain (VAS, 180 patients), and Smiley-Webster Scale (SWS, 231 patients) scores were identified between surgical and conservative treatments. However, fracture union was higher in surgically treated patients (pooled incidence 72.7%, 95% CI 66.1%, 78.5%, 31 studies, 988 patients) than in conservatively treated patients (40.2%, 95% CI 32.0%, 49.0%, 22 studies, 912 patients). This difference remained after correcting for age and fracture type. Fracture stability (41 studies, 1917 patients), although numerically favoring surgery, did not appear to differ between treatment groups. CONCLUSION While surgically treated patients showed higher union rates than conservatively treated patients, no clinically relevant differences were observed in NDI, VAS pain, and SWS scores and stability rates. These results need to be further confirmed in well-designed comparative studies with proper adjustment for confounding, such as age, fracture characteristics, and osteoporosis degree.
Collapse
Affiliation(s)
- Jeroen G J Huybregts
- Department of Neurosurgery, Leiden University Medical Center, University Neurosurgical Center Holland, PO Box 9600, 2300 RC, Leiden, The Netherlands.
- Department of Neurosurgery, Haaglanden Medical Center, University Neurosurgical Center Holland, The Hague, The Netherlands.
| | | | - Camila Recio
- Department of Neurosurgery, Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Rania A Mekary
- Department of Neurosurgery, Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- School of Pharmacy, MCPHS University, Boston, MA, USA
| | - Carmen L A Vleggeert-Lankamp
- Department of Neurosurgery, Leiden University Medical Center, University Neurosurgical Center Holland, PO Box 9600, 2300 RC, Leiden, The Netherlands
- Department of Neurosurgery, Spaarne Hospital Haarlem/Hoofddorp, Hoofddorp, The Netherlands
| |
Collapse
|
7
|
Huybregts JGJ, Polak SB, Jacobs WCH, Krekels-Huijbregts IA, Smeets AYJM, Arts MP, Slooff WBM, Öner FC, Peul WC, van Santbrink H, Vleggeert-Lankamp CLA. Low-Threshold-For-Surgery Versus Primarily-Conservative Treatment for Odontoid Fractures in the Elderly: Evaluating Practice Variation in The Netherlands. Global Spine J 2023:21925682231194818. [PMID: 37552933 DOI: 10.1177/21925682231194818] [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: 08/10/2023] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVES Odontoid fractures are the most common cervical spine fractures in the elderly. The optimal treatment remains controversial. The aim of this study was to compare results of a low-threshold-for-surgery strategy (surgery for dislocated fractures in relatively healthy patients) to a primarily-conservative strategy (for all patients). METHODS Patient records from 5 medical centers were reviewed for patients who met the selection criteria (e.g. age ≥55 years, type II/III odontoid fractures). Demographics, fracture types/characteristics, fracture union/stability, clinical outcome and mortality were compared. The influence of age on outcome was studied (≥55-80 vs ≥80 years). RESULTS A total of 173 patients were included: 120 treated with low-threshold-for-surgery (of which 22 primarily operated, and 23 secondarily) vs 53 treated primarily-conservative. No differences in demographics and fracture characteristics between the groups were identified. Fracture union (53% vs 43%) and fracture stability (90% vs 85%) at last follow-up did not differ between groups. The majority of patients (56%) achieved clinical improvement compared to baseline. Analysis of differences in clinical outcome between groups was infeasible due to data limitations. In both strategies, patients ≥80 years achieved worse union (64% vs 30%), worse stability (97% vs 77%), and - as to be expected - increased mortality <104 weeks (2% vs 22%). CONCLUSIONS Union and stability rates did not differ between the treatment strategies. Advanced age (≥80 years) negatively influenced both radiological outcome and mortality. No cases of secondary neurological deficits were identified, suggesting that concerns for the consequences of under-treatment may be unjustified.
Collapse
Affiliation(s)
- Jeroen G J Huybregts
- Department of Neurosurgery, Leiden University Medical Center, University Neurosurgical Center Holland, Leiden, The Netherlands
- Department of Neurosurgery, Haaglanden Medical Center, University Neurosurgical Center Holland, The Hague, The Netherlands
| | - Samuel B Polak
- Department of Neurosurgery, Leiden University Medical Center, University Neurosurgical Center Holland, Leiden, The Netherlands
| | | | - Ilse A Krekels-Huijbregts
- Department of Neurosurgery, Maastricht University Medical Center, Academic Neurosurgical Center Limburg, Maastricht, The Netherlands
- Department of Neurosurgery, Zuyderland Medical Center, Academic Neurosurgical Center Limburg, Heerlen, The Netherlands
| | - Anouk Y J M Smeets
- Department of Neurosurgery, Maastricht University Medical Center, Academic Neurosurgical Center Limburg, Maastricht, The Netherlands
- Department of Neurosurgery, Zuyderland Medical Center, Academic Neurosurgical Center Limburg, Heerlen, The Netherlands
| | - Mark P Arts
- Department of Neurosurgery, Haaglanden Medical Center, University Neurosurgical Center Holland, The Hague, The Netherlands
| | - Willem-Bart M Slooff
- Department of Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - F Cumhur Öner
- Department of Orthopaedics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Wilco C Peul
- Department of Neurosurgery, Leiden University Medical Center, University Neurosurgical Center Holland, Leiden, The Netherlands
- Department of Neurosurgery, Haaglanden Medical Center, University Neurosurgical Center Holland, The Hague, The Netherlands
| | - Henk van Santbrink
- Department of Neurosurgery, Maastricht University Medical Center, Academic Neurosurgical Center Limburg, Maastricht, The Netherlands
- Department of Neurosurgery, Zuyderland Medical Center, Academic Neurosurgical Center Limburg, Heerlen, The Netherlands
- CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
| | - Carmen L A Vleggeert-Lankamp
- Department of Neurosurgery, Leiden University Medical Center, University Neurosurgical Center Holland, Leiden, The Netherlands
- Department of Neurosurgery, Spaarne Gasthuis, Haarlem, The Netherlands
| |
Collapse
|
8
|
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.
Collapse
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
| |
Collapse
|
9
|
A Predictive Model to Identify Treatment-related Risk Factors for Odontoid Fracture Nonunion Using Machine Learning. Spine (Phila Pa 1976) 2023; 48:164-171. [PMID: 36607627 DOI: 10.1097/brs.0000000000004510] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 09/27/2022] [Indexed: 01/07/2023]
Abstract
STUDY DESIGN Multicenter retrospective analysis of routinely collected data. OBJECTIVE The underlying aim of this study was to identify potential treatment-related risk factors for odontoid fracture nonunion while accounting for known patient- and injury-related risk factors. SUMMARY OF BACKGROUND DATA Type II and III odontoid fractures represent the most common cervical spine fracture in elderly patients and are associated with a relatively high nonunion rate. The management of odontoid fractures is controversial and treatment strategies range from conservative treatment to extensive surgical stabilization and fusion. METHODS A total of 415 individuals who sustained odontoid fracture and were treated in either of four tertiary referral centers in Austria and Germany were included in the study. We included the following potential contributing factors for fracture nonunion in cross-validated extreme gradient boosted (XGBoost) and binary logistic regression models: age, gender, fracture displacement, mechanism of injury (high vs. low energy), fracture classification (Anderson II vs. III), presence of comorbidities (Charlson comorbidity index), and treatment (conservative, anterior screw fixation with one or two screws, posterior C1/C2 spondylodesis, cervico-occipital C0-C4 fusion). RESULTS In our cohort, 187 (45%) had radiologically confirmed odontoid nonunion six months postinjury. The odds for nonunion increase significantly with age, and are lower in type III compared to type II fractures. Also, odds for nonunion are significantly lower in posterior C1/C2 spondylodesis, and C0-C4 fusion compared to conservative treatment. Importantly, odds are not statistically significantly lower in the group treated with anterior screw fixation compared to conservative treatment. The factors gender, fracture displacement, mechanism of injury, and the presence of comorbidities did not produce significant odds. CONCLUSION Higher age, type II fractures, and conservative treatment are the main risk factors for odontoid nonunion. Anterior screw fixation did not differ significantly from conservative treatment in terms of fracture union. LEVEL OF EVIDENCE 3.
Collapse
|
10
|
Mourad MA, Ottenbacher A, Rizk AR. Modified anterior transarticular C1/2 fixation for odontoid fractures: An approach with high complication rate in geriatric population. Surg Neurol Int 2022; 13:457. [PMID: 36324909 PMCID: PMC9609875 DOI: 10.25259/sni_707_2022] [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: 08/06/2022] [Accepted: 09/12/2022] [Indexed: 11/16/2022] Open
Abstract
Background: In patients over 75 years of age, we applied a modified anterior transarticular C1/2 fixation with reduced pharyngeal mobilization versus the standard anterior triple/quadruple osteosynthesis procedures. Methods: From 2010 to 2018, 29 patients underwent a modified anterior transarticular C1/2 fixation utilizing single odontoid screw fixation through a right-sided Smith-Robinson – (i.e., short and steep screw trajectory for the right and long trajectory for the left side) approach. All the patients were 75 years of age or older (mean age 82.6) and had sustained odontoid Type II fractures. In addition, a subset exhibited further ligamentous injuries and/or atlas fractures. Their Mean Age-adjusted Charlson Comorbidity Index was 5.3 points (range 3–12), while mean American Society of Anesthesiologists scores averaged 2.9 (range 2–4). Results: The mean operating time was 55.8 min, there were no intraoperative complications, and there was minimal blood loss in all cases. The most common medical complications included aspiration pneumonia (24.1%, n = 7), altered mental status (17.2%, n = 5), and cardiac decompensation (6.9%, n = 2). One patient with delayed dysphagia and an infected implant resulting in loosening/dislocation required implant removal and long-term antibiotic therapy. The 30-day mortality rate was 13.8% (four patients) and the 1-year mortality rate was 27.6% (eight patients). Conclusion: Anterior transarticular C1/2/odontoid fixation with reduced pharyngeal mobilization and shorter operative times was associated with high morbidity/mortality rates. Dysphagia/aspiration was the major postoperative complications leading to some deaths especially in patients with dementia/Parkinsonism.
Collapse
Affiliation(s)
| | - Andy Ottenbacher
- Department of Neurosurgery, der Barmherzigen Brüder Hospital, Trier, Germany
| | - Ahmed R. Rizk
- Department of Neurosurgery, der Barmherzigen Brüder Hospital, Trier, Germany
| |
Collapse
|
11
|
Kotheeranurak V, Pholprajug P, Jitpakdee K, Pruttikul P, Chitragran R, Singhatanadgige W, Limthongkul W, Yingsakmongkol W, Kim J. Full-Endoscopic Anterior Odontoid Screw Fixation: A Novel Surgical Technique. Orthop Surg 2022; 14:990-996. [PMID: 35445547 PMCID: PMC9087464 DOI: 10.1111/os.13271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 02/22/2022] [Accepted: 03/21/2022] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE First, to propose a novel minimally invasive technique of full-endoscopic anterior odontoid fixation (FEAOF) that aims to reduce the risk of retropharyngeal approach (both open and percutaneous techniques) to anterior odontoid screw fixation. Second, to describe steps of the procedure and, lastly, to report the initial outcomes in patients treated with this novel technique. METHODS Four non-consecutive patients who were diagnosed with a displaced odontoid fracture (Anderson-D'Alonzo classification type II and Grauer subclassification type A or B) from 2019 to 2020 underwent surgical fixation by our novel technique for anterior odontoid screw fixation. A detailed technical approach of FEAOF for the surgical treatment of type II odontoid fractures was described, and the patients' outcomes based on postoperative radiographic results including computed tomography (CT), clinical outcome parameters including visual analogue scale (VAS) for neck pain both preoperatively and at postoperative follow-up, and range of neck motion at the final follow-up were reported. RESULTS The mean age was 33.5 years (24-41), three patients were male. The mean operative time was 93.75 min, and the mean blood loss was 7.5 ml. An immediate post-operative thin-sliced CT showed that all patients achieved satisfactory reduction and proper screw position. No screw malposition or penetration was found. At a 6-month follow-up, a thin-sliced CT demonstrated solid bony union in every case. The mean VAS for neck pain was reduced from 6.5 to 0.6 at the 6-months follow-up. At the final follow-up, all patients showed improvement in ranges of motion without any complications; however, one patient was lost to follow-up. CONCLUSIONS FEAOF is a feasible and effective option for treating type II odontoid fractures. The procedure is less invasive than other techniques and provides clear direct visualization of the involved structures.
Collapse
Affiliation(s)
- Vit Kotheeranurak
- Department of OrthopaedicsQueen Savang Vadhana Memorial HospitalSrirachaThailand
| | | | - Khanathip Jitpakdee
- Department of OrthopaedicsQueen Savang Vadhana Memorial HospitalSrirachaThailand
| | | | - Roongrath Chitragran
- Department of OrthopaedicsPhramongkutklao hospital and college of medicineBangkokThailand
| | - Weerasak Singhatanadgige
- Department of Orthopaedics, Faculty of MedicineChulalongkorn UniversityBangkokThailand
- Center of Excellence in Biomechanics and Innovative Spine SurgeryChulalongkorn UniversityBangkokThailand
| | - Worawat Limthongkul
- Department of Orthopaedics, Faculty of MedicineChulalongkorn UniversityBangkokThailand
- Center of Excellence in Biomechanics and Innovative Spine SurgeryChulalongkorn UniversityBangkokThailand
| | - Wicharn Yingsakmongkol
- Department of Orthopaedics, Faculty of MedicineChulalongkorn UniversityBangkokThailand
- Center of Excellence in Biomechanics and Innovative Spine SurgeryChulalongkorn UniversityBangkokThailand
| | - Jin‐Sung Kim
- Department of Neurosurgery, Seoul St. Mary's Hospital, Spine CenterCollege of medicineSeoulSouth Korea
| |
Collapse
|
12
|
Butt BB, Gagnet P, Patel R, Aleem I. Congenital defect of the posterior arch of C1: a case report. JOURNAL OF SPINE SURGERY 2021; 7:214-217. [PMID: 34296035 DOI: 10.21037/jss-20-628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 03/05/2021] [Indexed: 11/06/2022]
Abstract
Odontoid fractures are one of the most common injuries to the cervical spine in geriatric patients. Congenital C1 arch absence, however, is a very rare anomaly found in the population. We describe the first reported case of a congenital C1 posterior arch absence and C1 anterior cleft presenting with odontoid fracture. We present the case of a 58-year-old male who was found to have a comminuted type III odontoid fracture with significant angulation and displacement. CT scan demonstrated this fracture and also demonstrated congenital cleft of his left anterior arch and absence of left C1 posterior arch. Given his anatomic anomaly, we elected to perform occipitocervical fusion. The patient underwent occipito-cervical fusion to avoid iatrogenic vertebral artery injury. He was also immobilized in a halo vest given patient-specific social factors and compromised bone quality. The patient had no intra- or post-operative complications, but a prolonged hospital stay due to alcohol withdrawal. At 3-month postoperatively the patient had no neck pain and return to baseline function. This case highlights the importance of obtaining a CT scan preoperatively to not only to further characterize the fracture but also for surgical planning and recognition of anatomic anomalies as this may significantly impact the operative strategy.
Collapse
Affiliation(s)
- Bilal B Butt
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Paul Gagnet
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Rakesh Patel
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Ilyas Aleem
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI, USA
| |
Collapse
|
13
|
Kim SK, Ko JH, Park JB, Seo HY, Chang DG, Chang K. Proposal of New Radiological Classification and Treatment Strategy for Transverse Fractures of the C2 Axis Body. Orthop Surg 2021; 13:1378-1388. [PMID: 34047054 PMCID: PMC8274192 DOI: 10.1111/os.13013] [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: 12/31/2020] [Revised: 02/22/2021] [Accepted: 03/16/2021] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To investigate the characteristics of transverse fractures of the C2 axis body diagnosed on sagittal computed tomography (CT) and to propose new classification and appropriate treatment strategies. METHODS A retrospective study was performed by enrolling 49 patients (26 men and 23 women) with transverse fractures of the C2 axis body who were treated at four national trauma centers of tertiary university hospitals from January 2000 to December 2017. The mean age of the patients was 60.8 years (ranging from 21 to 90 years). We classified 49 transverse fractures of the C2 body into three types based on fracture trajectories involving superior articular facet (SAF) and lateral cortex (LC) of the C2 body on coronal CT as follows: Type 1, involvement of C2 SAF on both sides; Type 2, unilateral involvement of C2 SAF on one side and LC on the other side; Type 3, involvement of LC on both sides. The characteristics, treatment methods, and results of 49 transverse fractures of the C2 body were analyzed. Mean follow-up was 12.6 months (ranging from 12 to 26 months). RESULTS Twenty-six (53.1%) patients were Type 1, 21 (42.9%) were Type 2, and 2 (4.0%) were Type 3. Correlation coefficients for intra-observer and inter-observer reliabilities of classification were 0.723 and 0.598 (both, P < 0.001), respectively. About 40.8% (7 Type 1 and 13 Type 2) of the patients had fracture displacement >3 mm; Incidence of fracture displacement >3 mm was higher in Type 2 than Type 1 (61.9% vs 26.9%, P < 0.05). About 79.6% (20 Type 1, 17 Type 2 and 2 Type 3) of the patients were treated conservatively, and 20.4% (6 Type 1 and 4 Type 2) underwent surgery. At last follow-up, 47 out of 49 patients achieved fusion; overall fusion rate was 95.9%. All conservatively treated Type 1 and Type 3 patients achieved fusion. Out of 17 conservatively treated Type 2 patients, 15 achieved fusion but two developed nonunion; however, two nonunion patients opted not to undergo surgery. Subgroup analysis showed that Philadelphia brace caused nonunion significantly in fracture displacement >3 mm compared to Minerva brace/Halovest (100% vs 0%, P < 0.05). All surgically treated Type 1 and 2 patients achieved fusion. In terms of clinical outcomes, neck pain visual analog scale and neck disability index were significantly improved (both, P < 0.01). According to Odom's criteria, 93.9% (46/49) of the patients achieved satisfactory outcomes. No major complications occurred. CONCLUSIONS The majority of transverse fractures of C2 body can be treated conservatively. However, surgery or rigid Minerva brace/Halovest should be considered for Type 2 transverse fractures of the C2 body with fracture displacement >3 mm.
Collapse
Affiliation(s)
- Sung-Kyu Kim
- Department of Orthopaedic Surgery, Chonnam National University Medical School and Hospital, Gwangju, Korea
| | - Jong-Hyun Ko
- Department of Orthopaedic Surgery, Chonbuk National University Hospital, Jeonju, Korea
| | - Jong-Beom Park
- Department of Orthopaedic Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyoung-Yeon Seo
- Department of Orthopaedic Surgery, Chonnam National University Medical School and Hospital, Gwangju, Korea
| | - Dong-Gune Chang
- Department of Orthopaedic Surgery, Inje University Sanggye Paik Hospital, Seoul, Korea
| | - Kibong Chang
- Department of Orthopaedic Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
| |
Collapse
|
14
|
Moscolo F, Meneghelli P, Boaro A, Impusino A, Locatelli F, Chioffi F, Sala F. The use of Grauer classification in the management of type II odontoid fracture in elderly: Prognostic factors and outcome analysis in a single centre patient series. J Clin Neurosci 2021; 89:26-32. [PMID: 34119278 DOI: 10.1016/j.jocn.2021.04.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 04/08/2021] [Accepted: 04/17/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To evaluate the results of Type II odontoid fractures management in the elderly, according to the Grauer classification. METHODS Consecutive patients with type II odontoid fracture, age > 65 years and follow-up longer than 3 months were included. Fracture management was proposed according to Grauer classification. Peri-surgical risk factors, NDI, VAS and rate of fusion were evaluated according to the treatment modality and compared between conservative and surgical groups. RESULTS Thirty-four patients were considered eligible for the study; 2 patients showed a Type IIa fracture, 30 patients a type IIb, and 2 patients a type IIc. Type IIa patients underwent conservative treatment that resulted in failure. A conservative management was adopted in 9 cases with type IIb due to patient preference or anaesthesiologic reasons with a treatment success at 6 months of 11%. Trans-odontoid stabilization was adopted in 21 type IIb cases with an evidence of bony or fibrous union at 6 months of 95% and a median NDI of 20%. A posterior approach was reserved for 2 type IIc fracture patients and in 6 cases as rescue surgery (bony union at 6 months of 100%; median NDI 37%). Higher Lakshmanan grade, gap and displacement of the fracture were found as significant risk factor for fracture non-union (p < 0.05). CONCLUSIONS The surgical group presented better clinical and radiological outcome and the anterior approach proved to achieve the best results in type IIb fractures. The presence of osteoporosis and fracture spatial features should be duly considered in the decision-making process.
Collapse
Affiliation(s)
- Fabio Moscolo
- Institute of Neurosurgery, Department of Neuroscience, Verona University and City Hospital, Verona, Italy
| | - Pietro Meneghelli
- Institute of Neurosurgery, Department of Neuroscience, Verona University and City Hospital, Verona, Italy.
| | - Alessandro Boaro
- Institute of Neurosurgery, Department of Neuroscience, Verona University and City Hospital, Verona, Italy
| | - Antonio Impusino
- Institute of Neurosurgery, Department of Neuroscience, Verona University and City Hospital, Verona, Italy; Division of Neurosurgery, Department of Neuroscience, Trieste University Hospital, Trieste, Italy
| | - Francesca Locatelli
- Unit of Epidemiology and Medical Statistics, Department of Diagnostic and Public Health, University of Verona, Verona, Italy
| | - Franco Chioffi
- Division of Neurosurgery, Department of Neuroscience, Padua University Hospital, Padua, Italy
| | - Francesco Sala
- Institute of Neurosurgery, Department of Neuroscience, Verona University and City Hospital, Verona, Italy
| |
Collapse
|
15
|
Identifying factors influencing mortality in patients aged over 65 following an acute type II odontoid process fracture. A retrospective cohort study. 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 2021; 30:1551-1555. [PMID: 33616789 DOI: 10.1007/s00586-020-06694-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 11/18/2020] [Accepted: 12/05/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Compare short-term mortality rates following operative and nonoperative management of geriatric patients following an acute type II odontoid process fracture. METHODS One hundred forty-one patients with a type II odontoid fracture were identified from a single centre between 2002 and 2018. Patient demographics, details of injury and management, plus mortality data were collected. The incidence of mortality at 3 and 12 months was calculated, and a multivariate model built which included the treatment modality variable and allowed adjustment for six individual confounders. RESULTS Of the 141 patients with a type II odontoid process fracture, 39 were managed operatively, while 102 were managed nonoperatively. Relative to the nonoperative group, the operative group was younger (79.0 ± 7.0 vs. 83.7 ± 7.6), more likely to have odontoid angulation > 15° (74.4% vs. 43.1%, p < 0.01), and a greater proportion having fracture displacement > 2 mm (74.4% vs. 31.4%, p < 0.01). Both groups were comparable for gender, comorbidities, and associated injuries. On univariate analysis of treatment modality, the odds ratio of 3-month mortality with nonoperative management was 2.55 (95% CI: 0.82-7.92; p = 0.08), whilst at 12-months it was 3.12 (95% CI: 1.11-8.69; p = 0.02). On multivariate analysis of 12-month mortality, however, treatment modality was not found to be significant. This multivariate analysis suggested that increasing age, male gender, and injury severity were significant predictors of 12-month mortality. CONCLUSION In contrast to the findings of a number of previous studies, operative management may not influence survival at 3- and 12-months.
Collapse
|
16
|
Yang S, Liu YJ, Jiang WM. Experience in surgical treatment of type Ⅱ odontoid fractures: A report of two cases and review of the literature. Chin J Traumatol 2021; 24:57-62. [PMID: 31757743 PMCID: PMC7878463 DOI: 10.1016/j.cjtee.2019.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 09/15/2019] [Accepted: 10/05/2019] [Indexed: 02/04/2023] Open
Abstract
Two cases of type Ⅱ odontoid fractures were reported to share our experience in surgery treatment of such cases. A 33-year-old woman with comminuted type Ⅱ odontoid fracture and a 42-year-old man with fracture end hardened type Ⅱ odontoid fracture received surgical treatment in our hospital. Though imaging examination suggested that these two patients were suitable for anterior screw fixation, we encountered difficulties during the operation. The two patients eventually underwent posterior C1-C2 fusion surgery and recovered well. According to the experience of these two cases, we found that the fracture line angle and the degree of comminution are two important factors affecting surgical decision-making. Although anterior screw fixation is the ideal choice for type Ⅱ odontoid fractures with anterior superior to posterior inferior fracture line, it may not be the best choice for comminuted or fracture end hardened type Ⅱ odontoid fractures.
Collapse
Affiliation(s)
- Sen Yang
- Department of Orthopaedic Surgery, First Affiliated Hospital of Soochow University, Suzhou, 215006, China
| | - Yi-Jie Liu
- Department of Orthopaedic Surgery, First Affiliated Hospital of Soochow University, Suzhou, 215006, China
| | - Wei-Min Jiang
- Department of Orthopaedic Surgery, First Affiliated Hospital of Soochow University, Suzhou, 215006, China.
| |
Collapse
|
17
|
|
18
|
Gahlot N. Traumatic Anterior Atlantoaxial Rotatory Subluxation (Type III) Associated with Type III Odontoid Fracture: A Case Report. JBJS Case Connect 2020; 10:e0485. [PMID: 32649102 DOI: 10.2106/jbjs.cc.18.00485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE A 47-year-old man presented with traumatic anterior atlantoaxial subluxation (type III) associated with type III odontoid fracture with no neurological deficit. He was managed surgically with posterior reduction and C1-C2 fixation and fusion. The association of anterior atlantoaxial rotatory subluxation (Fielding type III) with odontoid fracture (Anderson and D'Alonzo type III) is rare with only 7 reported cases in recent literature. CONCLUSIONS This report adds important information regarding the management and presentation of such an injury and also describes a serious complication associated with type III odontoid fractures, which was managed conservatively.
Collapse
Affiliation(s)
- Nitesh Gahlot
- 1Department of Orthopedics, All India Institute of Medical Sciences (AIIMS), Jodhpur, India
| |
Collapse
|
19
|
Shaaban ATE, Doomi A, Belkheir S. A case of cervical myelopathy following chronic hypertrophic non-union type 2 odontoid fracture managed with posterior C1 decompression and C1-3 instrumentation: Case report and brief review of literature. Surg Neurol Int 2020; 11:132. [PMID: 32547819 PMCID: PMC7294179 DOI: 10.25259/sni_173_2020] [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: 04/11/2020] [Accepted: 05/09/2020] [Indexed: 11/04/2022] Open
Abstract
Background:
Type 2 odontoid fractures are the most common type of fracture of the axis. In rare cases, nonunion of a type 2 odontoid fracture can be hypertrophic resulting in myelopathy due to cervical cord compression.
Case Description:
A 48-year-old male presented with hypertrophic nonunion of a chronic type 2 odontoid fracture resulting in cord compression/myelopathy. This was adequately treated utilizing a C1 decompression and C1-3 instrumented fusion; no anterior procedure was necessary.
Conclusion:
Here, we successfully treated a patient with a hypertrophic nonunion of a chronic type 2 odontoid fracture utilizing a posterior only approach consisting of a C1 laminectomy with C1-C3 fusion.
Collapse
Affiliation(s)
| | - Ahmed Doomi
- Departments of Neurosurgery, Hamad General Hospital, Hamad Medical Corporation, Doha,
| | - Sirajeddin Belkheir
- Departments of Neurosurgery, Hamad General Hospital, Hamad Medical Corporation, Doha,
- Departments of Neurosurgery, Weill Cornell Medical College, Ar-Rayyan, Qatar,
- Departments of Neurosurgery, Michigan State University, Michigan, USA
| |
Collapse
|
20
|
Patil ND, Essam M, Ragab RK, Elsaghir H. Computerized Tomography-Based Morphometric Analysis of Odontoid in 100 Egyptian Patients. Int J Spine Surg 2020; 14:59-65. [PMID: 32128304 DOI: 10.14444/7008] [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: 11/20/2022] Open
Abstract
Background There is still no consensus in the literature regarding the use of 1 screw or 2 screws. A number of studies have proved ethnic variations in the morphometry of the odontoid. There is no literature on the morphometry of odontoid in Egyptian patients. Methods Computerized tomography (CT) scans of the head and cervical spine of 100 healthy (no evidence of cervical spine fracture) patients of Egyptian origin were studied. Measurements were performed using Horos software, which allowed exact morphometric measurements to be taken at a specific angle in the axial, coronal, and sagittal planes. Results The mean age was 48.57 ± 15.39 years (range, 18-79 years; 56 male and 44 female patients). The mean radiologically calculated screw length and the mean radiologically calculated screw insertion angle were 38.21 ± 2.2 mm and 55.7° ± 3.84°, respectively. The mean anteroposterior and transverse diameter of the odontoid at the waist in the axial cut were 11.02 ± 1.05 mm and 8.92 ± 0.93 mm, respectively. A total of 54% and 6% of the study sample had the transverse waist diameter of the odontoid in the axial cut below 9 mm and 7.4 mm, respectively. A total of 48% of the male and 61% of the female patients had their transverse diameter of the odontoid at the waist below 9 mm. There was a statistically significant difference in all the measurements of the odontoid between the male and female patients except in the anteroposterior diameter of the base of odontoid (P = .06) in the axial cut, and the radiologically calculated screw insertion angle (P = .57). The mean distance between the apex of the odontoid and the screw exit was 1.8 ± 0.75 mm (range, 0-3 mm). Conclusions CT-based morphometric analysis of the odontoid is necessary before using 2-screw fixation technique. Single 4.5-mm Herbert screws could be used in all Egyptian patients without the need for CT-based morphometric analysis of the odontoid. The posterior screw can violate the posterior wall of the odontoid, with a reduced fracture hold and a chance of injuring the thecal sac.
Collapse
Affiliation(s)
- Nirmal D Patil
- Department of Spine Surgery, El-Hadra Orthopedic Hospital, Alexandria, Egypt
| | - Mohammad Essam
- Department of Spine Surgery, El-Hadra Orthopedic Hospital, Alexandria, Egypt
| | - Raafat Kamal Ragab
- Department of Spine Surgery, El-Hadra Orthopedic Hospital, Alexandria, Egypt
| | - Hesham Elsaghir
- Department of Spine Surgery, El-Hadra Orthopedic Hospital, Alexandria, Egypt
| |
Collapse
|
21
|
Fan L, Ou D, Huang X, Pang M, Chen XX, Yang B, Wang QY. Surgery vs conservative treatment for type II and III odontoid fractures in a geriatric population: A meta-analysis. Medicine (Baltimore) 2019; 98:e10281. [PMID: 31689741 PMCID: PMC6946417 DOI: 10.1097/md.0000000000010281] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND It is unclear whether surgery or conservative treatment is more suitable for elderly patients with type II and type III odontoid fractures. We performed this meta-analysis to compare the efficacy of surgical and conservative treatments for type II and type III odontoid fractures. METHODS A literature search was performed in PubMed, Embase, Web of Science, and Cochrane Library in January 2017. Only articles comparing surgery with conservative treatment in elderly patients with type II and type III odontoid fractures were selected. After 2 authors independently assessed the retrieved studies, 18 articles were included in this meta-analysis, and the primary endpoints were the nonunion rate and mortality rate. The secondary outcomes were patient satisfaction, complications, and the length of the hospital stay. The quality of the included studies was evaluated using the modified Newcastle-Ottawa scale. Sensitivity analyses were performed for high-quality studies, and the publication bias was evaluated using a funnel plot. RESULTS Lower nonunion (odds ratio [OR]: 0.27, 95% confidence interval [CI]: 0.18-0.40, P < .05) and mortality rates (OR: 0.52, 95% CI: 0.34-0.79, P < .05) confirmed the superiority of surgery in treating type II and type III fractures. The secondary outcomes differed. Patients in the surgery group felt more satisfied with the outcome (OR: 3.44, 95% CI: 1.19-9.95, P < .05), and the complications were similar in the 2 groups (OR: 1.14, 95% CI: 0.78-1.68, P = .5), whereas patients in conservative groups spent less time in the hospital (OR: 5.10, 95% CI: 2.73-7.47, P < .05). The results of the subgroup analyses and sensitivity analysis were similar to the original outcomes, and no obvious publication bias was observed in the funnel plot. CONCLUSION Most elderly (younger than 70 years) patients with type II or type III odontoid fractures should be considered candidates for surgical treatment, due to the higher union rate and lower mortality rate, while statistically significant differences were not observed in the population with an advanced age (older than 70 years). Therefore, the selection of the therapeutic approach for elderly patients with odontoid fractures requires further exploration. Simultaneously, based on our meta-analysis, a posterior arthrodesis treatment was significantly superior to the anterior odontoid screw treatment.
Collapse
Affiliation(s)
- Lei Fan
- Department of Spine Surgery, The Third Affiliated Hospital of Sun Yat-sen University
| | - Dingqiang Ou
- Department of Orthopaedics, The First People's Hospital of Shunde
| | - Xuna Huang
- Department of Medical Research Center, The Third Affiliated Hospital of Sun Yat-sen University
| | - Mao Pang
- Department of Spine Surgery, The Third Affiliated Hospital of Sun Yat-sen University
| | - Xiu-Xing Chen
- State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong Province, China
| | - Bu Yang
- Department of Spine Surgery, The Third Affiliated Hospital of Sun Yat-sen University
| | - Qi-You Wang
- Department of Spine Surgery, The Third Affiliated Hospital of Sun Yat-sen University
| |
Collapse
|
22
|
Chandra A, Moon SJ, Walker B, Yilmaz E, Moisi M, Johnson R. Postoperative intracranial migration of a C2 odontoid screw: A case report and literature review. Surg Neurol Int 2019; 10:173. [PMID: 31583170 PMCID: PMC6763670 DOI: 10.25259/sni_245_2019] [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: 04/09/2019] [Accepted: 08/20/2019] [Indexed: 11/29/2022] Open
Abstract
Background: Intracranial migration of odontoid screws is a rare but serious complication of anterior odontoid screw fixation not often reported in literature by neurosurgeons. Here, we describe the second case in literature of intracranial migration of an odontoid screw. Case Description: A 64-year-old neurologically intact patient with a type II odontoid fracture secondary to trauma underwent anterior odontoid screw fixation without any intraoperative complications. He tolerated the procedure well, and postoperative imaging demonstrated near anatomic correction of the fracture with satisfactory placement of the lag screw. Unfortunately, the patient was subsequently lost to follow up and he presented 7 months later for a routine outpatient computed tomography (CT) of the cervical spine, which demonstrated upward migration of the screw into the intracranial cavity abutting the medulla, with CT angiography of the neck also confirming the screw lying between the two vertebral arteries. Magnetic resonance imaging of the cervical spine also demonstrated the odontoid screw lying within close proximity to the ventral cervicomedullary junction, marginating the left vertebral artery. Subsequently, the patient was managed with removal of the odontoid screw and posterior cervical arthrodesis and instrumented fusion. Conclusion: Our case demonstrates the rare but serious complication of intracranial odontoid screw migration, which we bring to the attention of the neurosurgical community. The recognition of risk factors for this complication and optimized management of this rare occurrence is important for surgeons to recognize.
Collapse
Affiliation(s)
- Ankush Chandra
- Department of Neurological Surgery, Detroit Medical Center, Wayne State University, United States.,Department of Neurological Surgery, School of Medicine, Wayne State University, United States
| | - Seong-Jin Moon
- Department of Neurological Surgery, Detroit Medical Center, Wayne State University, United States.,Department of Neurological Surgery, Sinai Grace Hospital, Detroit, Michigan, United States
| | - Blake Walker
- Department of Neurological Surgery, Detroit Medical Center, Wayne State University, United States.,Department of Neurological Surgery, Sinai Grace Hospital, Detroit, Michigan, United States
| | - Emre Yilmaz
- Seattle Science Foundation, Swedish Neuroscience Institute, Seattle, Washington, United States.,Department of Neurosurgery, Swedish Neuroscience Institute, Seattle, Washington, United States
| | - Marc Moisi
- Department of Neurological Surgery, Detroit Medical Center, Wayne State University, United States.,Department of Neurological Surgery, Sinai Grace Hospital, Detroit, Michigan, United States.,Seattle Science Foundation, Swedish Neuroscience Institute, Seattle, Washington, United States
| | - Robert Johnson
- Department of Neurological Surgery, Detroit Medical Center, Wayne State University, United States.,Department of Neurological Surgery, Sinai Grace Hospital, Detroit, Michigan, United States
| |
Collapse
|
23
|
Xue H, Tao D, Weng Y, Fan Q, Zhou S, Zhang R, Zhang H, Yue R, Wang X, Wang Z, Sun Y. Glycosylation of dentin matrix protein 1 is critical for fracture healing via promoting chondrogenesis. Front Med 2019; 13:575-589. [DOI: 10.1007/s11684-019-0693-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 02/25/2019] [Indexed: 10/26/2022]
|
24
|
Non-union rate of type II and III odontoid fractures in CPPD versus a control population. Skeletal Radiol 2018; 47:1499-1504. [PMID: 29779053 DOI: 10.1007/s00256-018-2960-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 04/16/2018] [Accepted: 04/25/2018] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The objective was to determine if there is a significant difference between rates of non-union of type II and III odontoid fractures in patients with calcium pyrophosphate dihydrate deposition (CPPD) compared with a control population. MATERIALS AND METHODS A 10-year retrospective picture archive and communications system review was performed of 31 CPPD patients and 31 control patients. Imaging studies were reviewed for radiographic or CT evidence of osseous union and complications. RESULTS There was a significant difference in the rates of non-union between the two groups, with the non-union rate reaching 90.3% in the CPPD group and 32% in the control group. Comparing the degree of displacement and angulation of the two groups did not show a significant difference. CONCLUSION The results indicate that odontoid fracture non-union rates are significantly higher in CPPD patients and should be taken into consideration when diagnosing odontoid fractures and deciding on appropriate treatment.
Collapse
|
25
|
Cutler HS, Guzman JZ, Lee NJ, Kothari P, Kim JS, Shin JI, Leven DM, Cho SK. Short-Term Complications of Anterior Fixation of Odontoid Fractures. Global Spine J 2018; 8:47-56. [PMID: 29456915 PMCID: PMC5810891 DOI: 10.1177/2192568217698132] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Retrospective study. OBJECTIVE Anterior fixation of odontoid fracture has been associated with high morbidity and mortality in small, single institution series. Identifying risk factors may improve risk stratification and highlight factors that could be optimized preoperatively. The objective of this study was to determine the 30-day complication rate following anterior fixation of odontoid fractures and to identify associated risk factors among patients in a large national database. METHODS Patients who underwent anterior fixation were identified in the American College of Surgeons National Quality Improvement Program database (ACS NSQIP) from 2007 to 2012. Patient demographics, medical comorbidities, perioperative complications, and postoperative complications up to 30 days were analyzed by univariate and multivariate analysis. RESULTS Overall, 103 patients met criteria for the study. The average age was 73.9 years and patients were predominantly white (85.4%). Cardiac comorbidity was common (66.0%), as were dependent functional status (14.6%) and bleeding disorders (13.6%). Complications occurred in 37.9% of patients, and mortality was high (6.8%). Age, white race, and history of bleeding disorders were independently predictive of complications in the multivariate analysis. The postoperative hospital stay was >5 days for 45.6% of patients. CONCLUSION In a large, multicenter database study, anterior fixation of odontoid fracture was associated with high morbidity and mortality. Although advanced age was associated with increased risk of complications, patients undergoing anterior fixation were older, on average, than in prior studies. Bleeding disorder was a potentially modifiable risk factor for complications that could be optimized prior to surgery.
Collapse
Affiliation(s)
- Holt S. Cutler
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Nathan J. Lee
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Parth Kothari
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jun S. Kim
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - John I. Shin
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Dante M. Leven
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Samuel K. Cho
- Icahn School of Medicine at Mount Sinai, New York, NY, USA,Samuel K. Cho, Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, 5 East 98th Street, Box 1188, New York, NY 10029, USA.
| |
Collapse
|
26
|
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
| |
Collapse
|
27
|
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.
Collapse
|
28
|
Abstract
Fractures of the odontoid process of C2 have become increasingly prevalent in the aging population and are typically associated with a high incidence of morbidity. Dens fractures comprise the majority of all cervical fractures in patients older than 80 years and remain the most common cervical fracture pattern in all geriatric patients. Type II odontoid fractures have been associated with limited healing potential, and both nonoperative and operative management are associated with high mortality rates. Historically, there has been some debate in the literature with regards to optimal management strategies to maximize outcomes in geriatric patients. Recent, high-quality evidence has indicated that surgical treatment of type II odontoid fractures in elderly patients is associated with improvements in both short- and long-term mortality. Additionally, surgical intervention has been shown to improve functional outcomes when compared with nonsurgical treatment. Factors to consider before surgery for geriatric type II odontoid fractures include associated comorbidities and the safety of general anesthesia administration. With appropriate measures of patient selection, surgery can provide an efficacious option for geriatric patients with type II odontoid fractures. We recommend surgical intervention via a posterior C1-C2 arthrodesis for geriatric type II odontoid fractures, provided that the surgery itself does not represent an unreasonable risk for mortality.
Collapse
|
29
|
Aleem IS, Gussous Y, King M, Fogelson J, Nassr A, Currier BL. Does sitting versus standing radiographic assessment of odontoid fractures matter? A case report. JOURNAL OF SPINE SURGERY 2017; 3:283-286. [PMID: 28744514 DOI: 10.21037/jss.2017.05.12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Fractures of the odontoid are the most common cervical spine injury in the geriatric population. The relationship between odontoid fracture displacement and postural change has not been previously described. We present the first described case of an elderly female patient with thoracic kyphosis and a type II odontoid fracture demonstrating significant fracture displacement with a postural change from sitting to standing. Various radiographic parameters are assessed and discussed in an attempt to characterize and explain this finding. We highlight the importance of regional and global spinal alignment and quantify physiologic odontoid fracture behavior with postural changes in this growing demographic. Upright radiographs in both sitting and standing positions may be considered when concern for odontoid fracture stability is questioned.
Collapse
Affiliation(s)
- Ilyas S Aleem
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Yazeed Gussous
- Department of Orthopaedic Surgery, Ohio State University, Columbus, OH, USA
| | | | | | | | | |
Collapse
|
30
|
Fam MD, Zeineddine HA, Nassir RM, Bhatt P, Kamel MH. Patient-reported outcome following nonsurgical management of type II odontoid process fractures in adults. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2017; 8:64-69. [PMID: 28250639 PMCID: PMC5324363 DOI: 10.4103/0974-8237.199871] [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] [Indexed: 01/23/2023] Open
Abstract
Background: Transverse (type II) odontoid process fracture is among the most commonly encountered cervical spine fractures. Nonsurgical management through external immobilization is occasionally preferred to surgical management but is criticized for its higher rates of failure and lower patient satisfaction. Our aim is to analyze patient-reported outcomes in patients who underwent nonsurgical treatment for type II odontoid fractures. Methods: We identified patients >18-year-old who underwent external immobilization as a treatment for isolated type II odontoid fracture between 2007 and 2012. We collected demographic parameters, clinical presentation, mode of injury, imaging studies and modality and duration of treatment (soft collar, halo-vest, or both). Patients were contacted by telephone to participate in a 15-min survey addressing their recovery including their subjective rate of return to preinjury level of functioning. Results: Fifteen patients met the inclusion/exclusion criteria and participated in our survey. Patients were followed up for an average of 19 months after injury. Overall mean age was 61 years. Injury followed a mechanical fall or a road traffic accident in 11 and 4 cases, respectively. External immobilization was achieved by halo vest only in nine patients, soft collar only in two patients (13%), and through a sequential combination in the remaining 4 (27%). This was deployed for a mean of 7.8 months. Radiological studies at the last follow-up showed bony healing (27%), fibrous nonunion (60%), and persistent instability (13%). Patients reported gradual recovery of function throughout the 1st year after injury with levels above 70% of preinjury functioning achieved by 13% of patients at 6 months, 33% at 9 months, and 47% at 12 months. Overall satisfaction with nonsurgical management was 68%. Conclusion: In selected patients with type II odontoid fractures, external immobilization represents a good option with acceptable course of recovery.
Collapse
Affiliation(s)
- Maged D Fam
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa, USA
| | - Hussein A Zeineddine
- Department of Surgery, Section of Neurosurgery, The University of Chicago Medicine and Biological Sciences, Chicago, IL, USA
| | | | - Pragnesh Bhatt
- Department of Neurosurgery, Aberdeen Royal Infirmary, University of Aberdeen, Aberdeen, Scotland, UK
| | - Mahmoud H Kamel
- Department of Neurosurgery, Aberdeen Royal Infirmary, University of Aberdeen, Aberdeen, Scotland, UK
| |
Collapse
|
31
|
Abstract
Odontoid fractures are the most common cervical fracture type among the elderly population. Several treatment options exist for these patients, ranging from immobilization with a semirigid orthosis to surgical arthrodesis. This report reviews the key points in the management of odontoid fractures in the aged patient, including diagnosis, the various forms of conservative therapies, and the options for surgical intervention.
Collapse
Affiliation(s)
- Jian Guan
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 North Medical Drive East, Salt Lake City, UT 84132, USA
| | - Erica F Bisson
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 North Medical Drive East, Salt Lake City, UT 84132, USA.
| |
Collapse
|
32
|
Abstract
Cervical spine injuries are extremely common and range from relatively minor injuries, such as cervical muscle strains, to severe, life-threatening cervical fractures with spinal cord injuries. Although cervical spine injuries are most common in athletes who participate in contact and collision sports, such as American football and rugby, they also have been reported in athletes who participate in noncontact sports, such as baseball, gymnastics, and diving. Cervical spine injuries in athletes are not necessarily the result of substantial spine trauma; some athletes have chronic conditions, such as congenital stenosis, that increase their risk for a serious cervical spine injury after even minor trauma. Therefore, physicians who cover athletic events must have a thorough knowledge of cervical spine injures and the most appropriate ways in which they should be managed. Although cervical spine injuries can be career-ending injuries, athletes often are able to return to play after appropriate treatment if the potential for substantial re-injury is minimized.
Collapse
|
33
|
Schroeder GD, Kepler CK, Kurd MF, Paul JT, Rubenstein RN, Harrop JS, Brodke DS, Chapman JR, Vaccaro AR. A Systematic Review of the Treatment of Geriatric Type II Odontoid Fractures. Neurosurgery 2016; 77 Suppl 4:S6-14. [PMID: 26378359 DOI: 10.1227/neu.0000000000000942] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Odontoid fractures are the most common cervical spine fracture in the geriatric population; however, the treatment of type II odontoid fractures in this age group is controversial. OBJECTIVE To compare the short-term (<3 months) mortality, long-term (≥12 months) mortality, and complication rates of patients >60 years of age with a type II odontoid fracture managed either operatively or nonoperatively. METHODS We performed a systematic review of literature published between January 1, 2000, and February 1, 2015, related to the treatment of type II odontoid fractures in patients >60 years of age. An analysis of short-term mortality, long-term mortality, and the occurrence of complications was performed. RESULTS A total of 452 articles were identified, of which 21 articles with 1233 patients met the inclusion criteria. Short-term mortality (odds ratio, 0.43; 95% confidence interval, 0.30-0.63) and long-term mortality (odds ratio, 0.47; 95% confidence interval, 0.34-0.64) were lower in patients who underwent surgical treatment than in those who had nonsurgical treatment, and there were no significant differences in the rate of complications (odds ratio, 1.01; 95% confidence interval, 0.63-1.63). Surgical approach (posterior vs anterior) showed no significant difference in mortality or complication rate. Similarly, no difference in mortality or complication rate was identified with hard collar or a halo orthosis immobilization. CONCLUSION The current literature suggests that well-selected patients >60 years of age undergoing surgical treatment for a type II odontoid fracture have a decreased risk of short-term and long-term mortality without an increase in the risk of complications.
Collapse
Affiliation(s)
- Gregory D Schroeder
- *Rothman Institute at Thomas Jefferson University, Department of Orthopedic Surgery, Philadelphia, Pennsylvania; ‡Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania; §Department of Orthopedic Surgery, University of Utah, Salt Lake City, Utah; ¶Swedish Neuroscience Institute, Department of Orthopedic Surgery, Seattle, Washington
| | | | | | | | | | | | | | | | | |
Collapse
|
34
|
Abstract
STUDY DESIGN Retrospective, cross-sectional study. OBJECTIVE To evaluate the feasibility of two screws anterior fixation of the odontoid process among Arab adults. SUMMARY OF BACKGROUND DATA Anterior screw fixation is the treatment of choice for type II odontoid fractures. In order to perform the procedure safely, the diameter of the odontoid process should be wide enough to allow for the placement of one or two screws. METHODS A retrospective review of 156 computed tomography scans of the cervical spine was done. The included patients were Arabs, adults (at least 18 years old), and had no evidence of upper cervical spine trauma, deformity, infection, tumor, or surgery. The minimum external transverse diameter (METD), minimum internal transverse diameter (MITD), minimum external anteroposterior diameter (MEAD), and minimum internal anteroposterior diameter (MIAD) of the odontoid process were measured. A P value of ≤0.05 was considered as the cutoff level of statistical significance. RESULTS Our study included 94 (60.3%) males and 62 (39.7%) females. The mean age of the subjects was 37.8 ± 16.9 years (range 18-85). The mean values of the METD, MITD, MEAD, and MIAD were 8.7 ± 1.0 mm, 6.0 ± 1.1 mm, 10.3 ± 1.0 mm, and 7.4 ± 1.1 mm, respectively. Men had larger diameters compared to women. This was statistically significant for METD (P = 0.035) and MEAD (P < 0.001). The METD was <9.0 mm in 95 (60.9%) subjects, while the MITD was <8.0 mm in 153 (98.1%) subjects. These findings were not significantly different between males and females. CONCLUSION Two screws anterior fixation of type II odontoid fracture is not feasible among the majority of Arabs. LEVEL OF EVIDENCE 3.
Collapse
|
35
|
Oblique Axis Body Fracture: An Unstable Subtype of Anderson Type III Odontoid Fractures-Apropos of Two Cases. Case Rep Orthop 2016; 2016:7561682. [PMID: 27042372 PMCID: PMC4799810 DOI: 10.1155/2016/7561682] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2015] [Accepted: 02/14/2016] [Indexed: 01/29/2023] Open
Abstract
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.
Collapse
|
36
|
Pearson AM, Martin BI, Lindsey M, Mirza SK. C2 Vertebral Fractures in the Medicare Population: Incidence, Outcomes, and Costs. J Bone Joint Surg Am 2016; 98:449-56. [PMID: 26984912 DOI: 10.2106/jbjs.o.00468] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Cervical 2 (C2) fractures in the elderly are common, and the incidence of these fractures has been increasing. Surgical and nonoperative treatments are associated with high complication and mortality rates, and these rates have not been evaluated at the population level, to our knowledge. The purpose of this study was to use the Medicare claims database to determine trends in treatment, surgical and nonoperative outcomes, and Medicare reimbursement for treatment of these fractures. METHODS We examined the Medicare claims database from 2000 to 2011 to identify patients admitted for the treatment of a C2 fracture. The incidence of fractures and the rates of nonoperative and surgical treatment were determined across the study period. We compared rates of mortality and life-threatening complications between patients treated nonoperatively and surgically. Centers for Medicare & Medicaid Services (CMS) payments for the initial admission as well as for subsequent inpatient admissions during the ninety-day post-admission period were compared between treatment groups. We used multivariate analysis to control for differences in patient characteristics between groups. RESULTS There were 81,596 admissions for C2 fracture identified, and 53,338 met inclusion criteria. The incidence of C2 fractures increased 135% from 2000 to 2011, but the rate of surgical treatment remained constant at 16%. There was significantly lower mortality at thirty days for the surgical group at 8.3% compared with the nonoperative group at 16.2% (p < 0.001) and at one year for the surgical group at 21.7% compared with the nonoperative group at 32.3% (p < 0.001). Life-threatening complications within thirty days of admission were slightly more common in the surgical group at 10.9% compared with the nonoperative group at 9.0% (p < 0.05). Medicare reimbursements for the initial inpatient admission were significantly higher (p < 0.001) in U.S. dollars for the surgical group at $21,487 compared with the nonoperative group at $8469, and this significant difference (p < 0.001) persisted in the ninety-day post-discharge period at $10,487 for the surgical group compared with $8410 for the nonoperative group. CONCLUSIONS Although the incidence of C2 fractures in the Medicare population increased from 2000 to 2011, the rate of surgery stayed relatively constant. After controlling for baseline differences, patients treated with surgery had significantly lower thirty-day and one-year mortality rates compared with patients treated nonoperatively. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Adam M Pearson
- Department of Orthopaedics, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Brook I Martin
- Department of Orthopaedics, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Matthew Lindsey
- Department of Orthopaedics, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Sohail K Mirza
- Department of Orthopaedics, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| |
Collapse
|
37
|
Combined Type II Odontoid Fracture with Jefferson's Fracture Treated with Temporary Internal Fixation. Asian Spine J 2015; 9:966-70. [PMID: 26713132 PMCID: PMC4686406 DOI: 10.4184/asj.2015.9.6.966] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Revised: 03/06/2015] [Accepted: 03/13/2015] [Indexed: 11/19/2022] Open
Abstract
An 18-year-old male presented after a motor vehicle rollover accident. Computed tomography (CT) scan confirmed the diagnosis of Type II odontoid fracture. Considering the patient's young age and the limitations of C1-C2 fusion including significant loss of cervical rotation, temporary internal fixation with a lateral mass fixation of C1 and pedicle fixation of C2 without fusion was done. CT scan done at 6-month follow-up visit showed healed odontoid fracture and excellent C1-C2 alignment. At ninth postoperative month, internal fixation was removed. Patient had normal movements of cervical spine at 1-year follow-up. Temporary internal fixation can be an important tool in the armamentarium of the surgeon in treating type II odontoid fractures in young adults and children. This strategy avoids the complications halo fixation and immobilizes the unstable C1-C2 segment without fusion. Removal of the internal fixation after healing allows restoration of the rotational motion.
Collapse
|
38
|
Momin E, Harsh V, Fridley J, Winnegan L, Omeis I. Reliability of treating asymptomatic traumatic type II dens fractures in patients over age 80: A retrospective series. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2015; 6:166-72. [PMID: 26692693 PMCID: PMC4660492 DOI: 10.4103/0974-8237.167859] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Background: Management of type II odontoid fractures in elderly remains controversial to whether surgical treatment is favored over conservative one. This is a study of geriatric patients with asymptomatic type II dens fractures who after sustaining a fall were initially evaluated at community hospitals. They were placed in a rigid collar and were followed up in a spine clinic. Purpose: To assess the reliability of treating very old patients with type II dens fracture conservatively and whether surgical intervention if needed would affect the clinical outcome. Study Design: Retrospective study with the literature review. Patient Sample: Consecutive patients above 80 years of age, who sustained a clinically asymptomatic type II dens fracture and were observed after a conservative treatment plan, was initiated. Outcome Measures: Outcome measures included self-reported worsening neck pain, neurological function, and radiographic measures over the follow-up period. Materials and Methods: A retrospective clinical analysis of 5 active geriatric patients with type II asymptomatic dens fracture. After evaluating them, treatment options were discussed with patients and their family members. The decision was to continue to follow them with a rigid collar very closely since they were reluctant to undergo any surgical procedure. Results: Patients were followed for an average of 29 months. They were observed for any worsening neck pain, neurological deficit, or deterioration of fracture on follow-up imaging studies. At last follow-up, 2 of 5 patients continued to be asymptomatic, the 3rd died of unrelated causes while 2 others required surgeries at least 1-year post injury. Conclusions: Treatment of type II dens fractures in the elderly is controversial. Independent elderly patients who are asymptomatic at presentation may be safe to be followed up very closely with a neck brace and serial X-ray. Converting to surgical treatment can be done safely when needed without affecting the overall clinical out.
Collapse
Affiliation(s)
- Eric Momin
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX 77030, USA
| | - Viraat Harsh
- Department of Neurosurgery, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India
| | - Jared Fridley
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX 77030, USA
| | - Lona Winnegan
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX 77030, USA
| | - Ibrahim Omeis
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX 77030, USA
| |
Collapse
|
39
|
Amaral CABD, Nakagawa ET, Ferreira LT, Franco JS, Pires RES, Cavallari F, Labronici PJ. ONE OR TWO SCREWS IN THE FRACTURE OF THE ODONTOID PROCESS? EVALUATION USING COMPUTED TOMOGRAPHY. COLUNA/COLUMNA 2015. [DOI: 10.1590/s1808-185120151403147309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective:To evaluate the bone area of the odontoid process through computed tomography and its relation with the area of one and two screws in the male and female subjects.Methods:188 CT scans of adults were analyzed. The isthmus area was selected and the transverse diameter was measured at 1.2 mm from the base of odontoid.Results:After placement of a screw, the odontoid area remains with 82% of free bone for both men and women. With two screws, 45.6% of women, had a free bone area of the odontoid process between 50% and 75% and 54.4% were above 75%. 26.6% men had percentage from 50% to 75% of free bone area and 73.4% above 75% (p=0.07). After the placement of two screws, the bone area was, in average, 77.3% in men and 75.4% in women. Using the Student t-test, the differences between the average of percentage of free bone area in men and women are significantly lower in women (p=0.0012).Conclusion:The pre-operative planning through CT can help to choose the number of screws in the odontoid process. The choice should be particularly careful when using two screws in women.
Collapse
|
40
|
Stein G, Meyer C, Marlow L, Christ H, Müller L, Isenberg J, Eysel P, Schiffer G, Faymonville C. Typ-II-Densfrakturen des alten Menschen und therapiebedingte Mortalität. Unfallchirurg 2015; 120:122-128. [DOI: 10.1007/s00113-015-0057-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
41
|
Evaniew N, Yarascavitch B, Madden K, Ghert M, Drew B, Bhandari M, Kwok D. Atlantoaxial instability in acute odontoid fractures is associated with nonunion and mortality. Spine J 2015; 15:910-7. [PMID: 24662216 DOI: 10.1016/j.spinee.2014.03.029] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Revised: 02/03/2014] [Accepted: 03/16/2014] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Odontoid fractures are the most common geriatric cervical spine fractures. Nonunion rates have been reported to be up to 40% and mortality up to 35%, and poor functional outcomes are common. Atlantoaxial instability (AAI) is a plausible prognostic factor, but its role has not been previously examined. PURPOSE To determine the effect of severe AAI on the outcomes of nonunion and mortality in patients with acute odontoid fractures. STUDY DESIGN Retrospective cohort/single institution. PATIENT SAMPLE One hundred twenty-four consecutive patients with acute odontoid fractures. OUTCOME MEASURES Rates of nonunion and mortality. METHODS Two independent blinded reviewers measured AAI using postinjury computed tomography scans. Patients were classified as having "severe" or "minimal" AAI on the basis of greater versus less than or equal to 50% mean subluxation across each C1-C2 facet joint. Rates of nonunion and mortality were compared using independent samples t tests and adjusted for age, displacement, and subtype using binary logistic regression. RESULTS One hundred seven patients had minimal AAI and 17 had severe AAI. Mean follow-up was 4.4 months (standard deviation=4.6). Patients with severe AAI were more likely to experience nonunion (29% vs. 10%, respectively; p=.03) and mortality (35% vs. 14%, respectively; p=.03) regardless of treatment modality. Fracture displacement correlated with AAI (r(2)=0.65). When adjusted for patient age, the odds ratio of nonunion with severe AAI approached significance at 3.3 (95% confidence interval [CI]: 0.9-11.7). Mortality prediction with AAI approached a twofold increased risk (odds ratio=2.1; 95% CI: 0.6-6.8). In patients with Type-II fractures, the odds of mortality with severe AAI approached a threefold higher risk (odds ratio=3.3; 95% CI: 0.9-12.3). CONCLUSIONS Patients with acute odontoid fractures and severe AAI may be more likely to experience nonunion and mortality, suggesting the possibility that aggressive management could be warranted. Further investigation with a large prospective study including patient-important functional outcomes is justified.
Collapse
Affiliation(s)
- Nathan Evaniew
- Division of Orthopaedics, Department of Surgery, McMaster University, 293 Wellington St N, Suite 110, Hamilton, Ontario, Canada L8L 8E7.
| | - Blake Yarascavitch
- Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton General Hospital 8N-01, 237 Barton St E, Hamilton ON, L8L 2X2
| | - Kim Madden
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 293 Wellington St N, Suite 110, Hamilton, Ontario, Canada L8L 8E7
| | - Michelle Ghert
- Division of Orthopaedics, Department of Surgery, McMaster University, 293 Wellington St N, Suite 110, Hamilton, Ontario, Canada L8L 8E7
| | - Brian Drew
- Division of Orthopaedics, Department of Surgery, McMaster University, 293 Wellington St N, Suite 110, Hamilton, Ontario, Canada L8L 8E7
| | - Mohit Bhandari
- Division of Orthopaedics, Department of Surgery, McMaster University, 293 Wellington St N, Suite 110, Hamilton, Ontario, Canada L8L 8E7; Department of Clinical Epidemiology and Biostatistics, McMaster University, 293 Wellington St N, Suite 110, Hamilton, Ontario, Canada L8L 8E7
| | - Desmond Kwok
- Division of Orthopaedics, Department of Surgery, McMaster University, 293 Wellington St N, Suite 110, Hamilton, Ontario, Canada L8L 8E7
| |
Collapse
|
42
|
Betsch MW, Blizzard SR, Shinseki MS, Yoo JU. Prevalence of degenerative changes of the atlanto-axial joints. Spine J 2015; 15:275-80. [PMID: 25277533 DOI: 10.1016/j.spinee.2014.09.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Revised: 08/06/2014] [Accepted: 09/15/2014] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Degeneration of the atlantodens and atlanto-axial joints is associated with cervical spine pain and may also be associated with an increased risk of dens fracture. However, there is paucity of literature describing the prevalence of specific degenerative changes in the atlantodens and atlanto-axial facet joints. PURPOSE To document age-related degenerative changes of the cervical spine in a large cohort of patients. STUDY DESIGN/SETTING This is a retrospective cohort study. PATIENT SAMPLE Adult trauma patients were admitted to our Level 1 trauma center. OUTCOME MEASURES Osteoarthritis of the atlantodens and atlanto-axial facet joints of the cervical spine and the presence of intraosseous cyst and calcific synovitis, as determined by computed tomography (CT) scans. METHODS We conducted a retrospective study of 1,543 adult trauma patients who received a cervical spine CT scan. The anterior atlantodens joint interval was measured. The presence or absence of intraosseous cysts and calcific synovitis was recorded. Degeneration of the atlantodens and atlanto-axial facet joints at age intervals was quantified. RESULTS The atlantodens interval narrowed linearly with age (R(2)=0.992, p<.001). The prevalence of intraosseous cysts increased exponentially with age from 4.2% to 37.4%, and calcific synovitis increased from 0% to 11.1%. Intraosseous cyst formation generally began in the second and third decades of life and synovitis in the fifth and sixth decades of life. Facet joints also demonstrated age-related changes; however, the rate of degenerative changes was lower than in the atlantodens joint. CONCLUSIONS To our knowledge, this is the first study that documents specific changes of both atlantodens and atlanto-axial facet joints as a function of age in a large cohort of 1,543 patients. These changes increased exponentially with age and may contribute to pain and limitation in motion. In light of our findings and recent studies demonstrating the association between degeneration and dens fracture in elderly, cervical spine radiographs of elderly patients should be carefully assessed for these changes.
Collapse
Affiliation(s)
- Marcel W Betsch
- Department of Orthopaedics and Rehabilitation, Oregon Health and Science University, Portland, OR, USA
| | - Sabina R Blizzard
- Department of Orthopaedics and Rehabilitation, Oregon Health and Science University, Portland, OR, USA
| | - Matthew S Shinseki
- Department of Orthopaedics and Rehabilitation, Oregon Health and Science University, Portland, OR, USA
| | - Jung U Yoo
- Department of Orthopaedics and Rehabilitation, Oregon Health and Science University, Portland, OR, USA.
| |
Collapse
|
43
|
Han B, Li F, Chen G, Li H, Chen Q. Motion preservation in type II odontoid fractures using temporary pedicle screw fixation: a preliminary study. 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 2014; 24:686-93. [DOI: 10.1007/s00586-014-3693-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Revised: 11/17/2014] [Accepted: 11/18/2014] [Indexed: 10/24/2022]
|
44
|
Age increases the risk of immediate postoperative dysphagia and pneumonia after odontoid screw fixation. Clin Neurol Neurosurg 2014; 126:185-9. [DOI: 10.1016/j.clineuro.2014.09.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2013] [Revised: 09/11/2014] [Accepted: 09/13/2014] [Indexed: 11/20/2022]
|
45
|
|
46
|
Huybregts JGJ, Jacobs WCH, Peul WC, Vleggeert-Lankamp CLA. Rationale and design of the INNOVATE Trial: an international cooperative study on surgical versus conservative treatment for odontoid fractures in the elderly. BMC Musculoskelet Disord 2014; 15:7. [PMID: 24400976 PMCID: PMC3893376 DOI: 10.1186/1471-2474-15-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2013] [Accepted: 12/31/2013] [Indexed: 11/25/2022] Open
Abstract
Background Fractures of the odontoid process of the axis are the most common fractures of the geriatric cervical spine. As the population ages, their incidence is expected to increase progressively, as is the number of very old patients (>80 years) with an odontoid fracture. No consensus exists on the optimal treatment (surgical or conservative) and the most relevant outcome parameter (osseous union, fracture stability or clinical outcome). The aim of the INNOVATE (INterNational study on Odontoid frActure Treatment in the Elderly) Trial is to prospectively assess fracture healing and clinical outcome after surgical and conservative treatment for odontoid fractures in the elderly patient, with a specific focus on the very old patient. Methods/Design The trial is an observational study in which eleven centres in five European countries are involved. All patients admitted to one of these centres who meet the selection criteria (≥55 years, acute (<two weeks) type II/III odontoid fracture, no rheumatoid arthritis, no ankylosing spondylitis, no previous treatment for odontoid fracture) are asked to participate. The applied treatment is in accordance with usual care and chosen by the treating surgeon and patient. A cohort of 275 patients will be included. Clinical and radiological follow-up moments are scheduled at 6, 12, 26, 52 and 104 weeks, at which both surgeon and patient will complete Case Record Forms (CRFs). The primary outcome will be a combination of fracture healing and clinical outcome at 52 weeks. Osseous union and fracture stability will be assessed with CT-imaging and dynamic X-ray. Clinical outcome will be scored by the Neck Disability Index (NDI) and correlated to the imaging data. Additionally, predefined subgroup analysis will be carried out (i.e. for patient age and osteoporosis) and prognostic factors will be identified. Discussion Evidence for the optimal treatment for odontoid fractures is lacking. Focusing on both fracture healing and clinical outcome, the results of this study will yield valuable information enabling more rational decision making in the treatment for odontoid fractures in the elderly. Trial registration Netherlands Trial Register NTR3630
Collapse
Affiliation(s)
- Jeroen G J Huybregts
- Department of Neurosurgery, Leiden University Medical Centre, PO Box 9600, 2300 RC Leiden, The Netherlands.
| | | | | | | |
Collapse
|
47
|
Teriparatide Treatment of a Glucocorticoid-associated Resorbing Nonunion of a Type III Odontoid Process Fracture. ACTA ACUST UNITED AC 2013; 26:E319-22. [DOI: 10.1097/bsd.0b013e31828d6c88] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
48
|
Sime D, Pitt V, Pattuwage L, Tee J, Liew S, Gruen R. Non-surgical interventions for the management of type 2 dens fractures: a systematic review. ANZ J Surg 2013; 84:320-5. [DOI: 10.1111/ans.12401] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/20/2013] [Indexed: 01/17/2023]
Affiliation(s)
- David Sime
- National Trauma Research Institute; The Alfred Hospital; Melbourne Victoria Australia
- Department of Orthopaedic Surgery; The Alfred Hospital; Melbourne Victoria Australia
| | - Veronica Pitt
- National Trauma Research Institute; The Alfred Hospital; Melbourne Victoria Australia
- Faculty of Medicine, Nursing and Health Sciences; Monash University; Melbourne Victoria Australia
| | - Loyal Pattuwage
- National Trauma Research Institute; The Alfred Hospital; Melbourne Victoria Australia
- Faculty of Medicine, Nursing and Health Sciences; Monash University; Melbourne Victoria Australia
| | - Jin Tee
- National Trauma Research Institute; The Alfred Hospital; Melbourne Victoria Australia
- Faculty of Medicine, Nursing and Health Sciences; Monash University; Melbourne Victoria Australia
- Department of Neurosurgery; The Alfred Hospital; Melbourne Victoria Australia
| | - Susan Liew
- Department of Orthopaedic Surgery; The Alfred Hospital; Melbourne Victoria Australia
- Faculty of Medicine, Nursing and Health Sciences; Monash University; Melbourne Victoria Australia
| | - Russell Gruen
- National Trauma Research Institute; The Alfred Hospital; Melbourne Victoria Australia
- Trauma Service; The Alfred Hospital; Melbourne Victoria Australia
| |
Collapse
|
49
|
The AOSpine North America Geriatric Odontoid Fracture Mortality Study: a retrospective review of mortality outcomes for operative versus nonoperative treatment of 322 patients with long-term follow-up. Spine (Phila Pa 1976) 2013; 38:1098-104. [PMID: 23354104 PMCID: PMC3678887 DOI: 10.1097/brs.0b013e318286f0cf] [Citation(s) in RCA: 118] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective, multicenter cohort study. OBJECTIVE Assess for differences in short- and long-term mortality between operative and nonoperative treatment for elderly patients with type II odontoid fractures. SUMMARY OF BACKGROUND DATA There is controversy regarding whether operative or nonoperative management is the best treatment for elderly patients with type II odontoid fractures. METHODS This is a retrospective study of consecutive patients aged 65 years or older with type II odontoid fracture from 3 level I trauma centers from 2003-2009. Demographics, comorbidities, and treatment were abstracted from medical records. Mortality outcomes were obtained from medical records and a public database. Hazard ratios (HRs) and 95% confidence intervals (CI) were calculated. RESULTS A total of 322 patients were included (mean age, 81.8 yr; range, 65.0-101.5 yr). Compared with patients treated nonoperatively (n = 157), patients treated operatively (n = 165) were slightly younger (80.4 vs. 83.2 yr, P = 0.0014), had a longer hospital (15.0 vs. 7.4 d, P < 0.001) and intensive care unit (1.5 vs. 1.1 d, P = 0.008) stay, and were more likely to receive a feeding tube (18% vs. 5%, P = 0.0003). Operative and nonoperative treatment groups had similar sex distribution (P = 0.94) and Charlson comorbidity index (P = 0.11). Within 30 days of presentation, 14% of patients died, and at maximal follow-up (average = 2.05 yr; range = 0 d-7.02 yr), 44% had died. On multivariate analysis, nonoperative treatment was associated with higher 30-day mortality (HR = 3.00, 95% CI = 1.51-5.94, P = 0.0017), after adjusting for age (HR = 1.10, 95% CI = 1.05-1.14; P < 0.0001), male sex (P = 0.69), and Charlson comorbidity index (P = 0.16). At maximal follow-up, there was a trend toward higher mortality associated with nonoperative treatment (HR = 1.35, 95% CI = 0.97-1.89, P = 0.079), after adjusting for age (HR = 1.07, 95% CI = 1.05-1.10; P < 0.0001), male sex (HR = 1.55, 95% CI = 1.10-2.16; P = 0.012), and Charlson comorbidity index (HR = 1.28, 95% CI = 1.16-1.40; P < 0.0001). CONCLUSION Surgical treatment of type II odontoid fracture in this elderly population did not negatively impact survival, even after adjusting for age, sex, and comorbidities. The data suggest a significant 30-day survival advantage and a trend toward improved longer-term survival for operatively treated over nonoperatively treated patients. LEVEL OF EVIDENCE 4.
Collapse
|
50
|
Huybregts JGJ, Jacobs WCH, Vleggeert-Lankamp CLAM. The optimal treatment of type II and III odontoid fractures in the elderly: a systematic review. 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 2013; 22:1-13. [PMID: 22941218 PMCID: PMC3540294 DOI: 10.1007/s00586-012-2452-3] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2012] [Accepted: 07/16/2012] [Indexed: 10/27/2022]
Abstract
PURPOSE Odontoid fractures are the most common cervical spine fractures in the elderly. As the population ages, their incidence is expected to increase progressively. The optimal treatment of this condition is still the subject of controversy. The objective of this review is to summarize and compare the outcome of surgical and conservative interventions in the elderly (≥ 65 years). METHODS A comprehensive search was conducted in nine databases of medical literature, supplemented by reference and citation tracking. Clinical status was considered the primary outcome. Fracture union and stability rates were considered secondary outcomes. RESULTS A total of nineteen studies met the inclusion criteria. All studies were performed retrospectively and were of limited quality. There was insufficient data, especially from direct comparisons, to determine the difference in clinical outcome between surgical and conservative interventions. Osseous union was achieved in 66-85 % of surgically treated patients and in 28-44 % of conservatively treated patients. Fracture stability was achieved in 82-97 % of surgically patients and in 53-79 % of conservatively treated patients. CONCLUSIONS There was insufficient data to determine a potential difference in clinical outcome between different treatment groups. Surgically treated patients showed higher osseous union rates compared to conservatively treated patients, possibly because of different selection mechanisms. The majority of patients appears to achieve fracture stability regardless of the applied treatment. A prospective trial with appropriate sample size is needed to identify the optimal treatment of odontoid fractures in the elderly and predictors for the success of either one of the available treatments.
Collapse
Affiliation(s)
- Jeroen G J Huybregts
- Department of Neurosurgery, Leiden University Medical Center, Albinusdreef 2, PO Box 9600, 2300 RC, Leiden, The Netherlands.
| | | | | |
Collapse
|