Fractured Odontoid: The Management of Delayed Neurological Symptoms

Abstract

Undiagnosed and untreated odontoid fractures are relatively common in developing countries where treatment for minor injuries is not considered. As a result, patients frequently present with neurological deterioration secondary to delayed odontoid dislocation. Fifty-one consecutive patients with this problem were entered into a management protocol and reviewed for this report. After diagnosis, reducibility was analyzed by extension films, and all patients who could not be reduced were initially managed in cranial long traction. Thirty-seven were reduced spontaneously or by traction alone, and 12 required transoral decompression. All underwent posterior C1-C2 fusion. Postoperatively, all were treated in external orthoses. The neurological recovery was excellent in 34 patients. Seven patients could function but had some disability, three patients had disabling spasticity, and three remained bedridden. Four deaths occurred as a result of respirator-dependent patients being taken home for social and financial reasons. As a result of this case-controlled study, we recommend that the treatment protocol first analyze reducibility by extension x-rays and then try traction for as long as 14 days to attempt reduction in patients who did not reduce in extension. Failure of reduction is indication for transoral decompression, and all patients require C1-C2 fusion. The neurological recovery is related to initial impairement but can be satisfactory in > 75% of patients.

Surgical treatment of nonunited fractures of the odontoid process, with special reference to occipitocervical fusion for unreducible atlantoaxial subluxation or instability

“…When an odontoid fracture is nonunited or malunited, operative treatment is generally required [9,11,13,17,23], especially for those with progressive instability and neurological deficits. Theoretically, atlantoaxial arthrodesis is a more logical and effective choice in stabilizing a united odontoid fracture and in decompression of neural contents.…”

“…Although some restriction of occipitocervical motion was noted, the patients usually rated the outcome as satisfactory when these restrictions were balanced against their neurological recovery. Transoral anterior decompression has been proposed by some authors [11,13,22,24]. This technique provides a straightforward route for removing the anterior abnormalities, but fails to stabilize atlantoaxial articulation at the same time, so that posterior fusion remains necessary [11].…”

“…Maltreated or untreated odontoid fractures may develop into nonunion or malunion, thereby leading to atlantoaxial subluxation or instability. When delayed neurological symptoms are caused, surgical management is usually indicated [11,13]. This study was a retrospective review of 57 consecutive patients who underwent posterior fusion for nonunion of odontoid fractures, particularly occipitocervical arthrodesis for unreducible atlantoaxial subluxation or instability subsequent to nonunion.…”

Delayed diagnosis and treatment of complete tracheal rupture and dens fracture: Anaesthetic and surgical management

“…4,7 Later, if it is left undiagnosed, they suffer from neck pain and progressive neurological disability. 3 We present a case with delayed diagnosis of both fracture of odontoid process (dens) and complete tracheal disruption.…”

Clinical experience with rigid occipitocervical fusion in the management of traumatic upper cervical spinal instability

“…[1][2][3][4][5][6][7][8][9][10] These injuries may cause immediate fatality or delayed deterioration of neurological function. 3,[11][12][13] Rigid internal fixation can provide immediate stability to the unstable CVJ or the upper cervical spine. Several reports have been published describing excellent results obtained when treating CVJ and upper cervical instability with occipitocervical (OC) fixation using a plate and screw system.…”