Anterior Reduction, Discectomy, and Three Cortical Iliac Bone Grafting With Instrumentation to Treat A Huge Tear Drop Fracture of the Axis

Abstract

Fractures of the axis body have been little reported and treatment strategies remain controversial and individualized. Not more than 10 cases of huge tear drop fracture of the axis (HTDFA) have been reported in previous studies and the treatment method varies from conservative treatment to an anterior, or posterior, approach surgery. Considering the sparse knowledge of HTDFA, we present a special case report to share our experience and to explore the safety and effectiveness of anterior reduction and fusion to treat HTDFA.A 24-year-old man was referred to our department; he presented with neck pain lasting for 12 h since being involved in a roll-over motor vehicle accident. His neck movement was limited but there was no neurological compromise. Physical examination of the patient showed myodynamia of four limbs Grade 5, Hoffmann sign (–), and Babinski sign (–). Three-dimensional reconstruction computed tomography (CT) confirmed a huge tear drop fracture of the anterior–inferior corner of the axis and discontinuity of the cortex of the axis. After discussion with the spinal surgeon team in the department and an effective conversation with the patient, surgery involving anterior reduction, discectomy, and three cortical iliac bone grafts with instrumentation after transnasal induction of general anesthesia was performed. The patient was instructed to wear a cervical collar until he returned to our department for a follow-up examination some 3 months after surgery. The 3-month postoperative x-ray and CT scan showed a good position of the implant and bony fusion at the C2/3 segment.Anterior reduction, discectomy, and three cortical iliac bone grafts with instrumentation to treat HTDFA are effective, safe, and simple. Of course, longer follow-up duration and more cases are warranted to verify this procedure. Anterior reduction, discectomy, and bone grafting with instrumentation are warranted for most HTDFA cases. However, if HTDFA incorporates other complex fractures, such as fracture of the posterior structure, an anterior and posterior union surgery is recommended.

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

“…They reported that all C2 tear drop fractures were well treated with conservative treatment [ 19 ]. On the other hand, a few case reports have described surgical treatments for huge or large-sized anterior C2 TD fractures [ 9 , 10 , 11 , 12 , 13 , 14 ]. According to the review of the literature, as the fracture displacement of C2 increased, the proportion of nonunion after conservative treatment increased.…”

“…However, a close analysis of previous studies showed that anterior C2 TD fractures successfully managed with conservative treatment were small-sized or simple anterior TD fractures. Furthermore, a few case reports have suggested that if anterior C2 TD fractures are huge or massive, it is better to reconstruct the anterior column through surgery [ 9 , 10 , 11 , 12 , 13 , 14 ]. However, the exact criteria for determining indications for surgical treatment of large-sized anterior C2 TD fractures have not been provided and are controversial.…”

Anterior Hollow Screw Fixation Combined with Posterior Lateral Mass Screws Fixation to Treat A Huge Tear Drop Fracture of The Axis

“…When the hyperextension of the cervical spine occurs, the odontoid process of the axis acts as a moment arm of leverage to transfer the backward stress, the posterior elements of axis acts as a fulcrum. At this moment, extension of the anterior longitudinal ligament could cause the avulsion fracture at anterior inferior portion of the axis body and various degrees of injury of the anterior longitudinal ligament [9][10]. The hyperextension has also leaded to intervertebral disc injury and C2/3 instability in this patient.…”

“…There is lots of controversy over the conservative and surgical methods because both seems to be effective in the treatment of HTDFA. Due to the lack of reducement completely with skull traction or cervical collar, the fracture bone fragment usually had healed with significant malunion when choosing conservative management [10]. Furthermore, the HTDFA could cause the compression of esophagus and induce the dysphagia during conservative treatment in some patients [11].…”

Incidence of dysphagia and dysphonia after Hangman's fractures

“…In some cases the huge tear-drop fracture fragments of the C2 vertebra can cause direct esophagus compression consequently leading to dysphagia. [24] The posterior approach surgery is also not free from postoperative dysphagia in Hangman fracture patients. Our results demonstrate that the incidence of dysphagia after the posterior surgical approach in Hangman fracture patients was 10.0% (1 of 10 patients), which was similar to previous studies.…”