Management of Isolated Fractures of the Axis in Adults

Ryken, Timothy C.; Hadley, Mark N.; Aarabi, Bizhan; Dhall, Sanjay S.; Gelb, Daniel E.; Hurlbert, R. John; Rozzelle, Curtis J.; Theodore, Nicholas; Walters, Beverly C.

doi:10.1227/neu.0b013e318276ee40

Cited by 97 publications

(83 citation statements)

References 87 publications

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“…However, surgical treatment through an anterior or posterior approach is reasonable as these fractures may displace within the halo and the C2-C3 disc is disrupted. As noted by Vaccaro, fracture angulation more than 11.5°was associated with redisplacement within the halo, and surgical treatment of those injuries with greater angulation should be considered [42,47].…”

Section: Type Iiamentioning

confidence: 85%

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Fractures of the axis: a review of pediatric, adult, and geriatric injuries

Gornet

Kelly

2016

Curr Rev Musculoskelet Med

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Fractures of the second cervical vertebra (C2, axis) are common in adult spine surgery. Those fractures occurring in younger adult patients are often associated with highenergy mechanism trauma, resulting in a "Hangman's Fracture." Management of these fractures is often successful with nonoperative means, though surgery may be needed in those fractures with greater displacement and injury to the C2-C3 disc. Older patients are more likely to sustain fractures of the odontoid process. The evidence supporting surgical management of these fractures is evolving, as there may be a mortality benefit to surgery. Regardless of treatment, longerterm mortality rates are high in this patient population, which should be discussed with the patient and family at the time of injury. Pediatric patients may suffer fractures of the axis, though differentiation of normal and pathologic findings is necessary and more difficult with the skeletally immature spine.

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Section: Type Iiamentioning

confidence: 85%

“…As the anterior fragment is not attached to the posterior fragment, ACDF will not allow for reduction of the facet joints. Similar to type II fractures, nonoperative management can still be successful [47]. Initial fracture displacement and angulation are associated with treatment failure and delayed surgery.…”

Section: Type IIImentioning

confidence: 99%

Fractures of the axis: a review of pediatric, adult, and geriatric injuries

Gornet

Kelly

2016

Curr Rev Musculoskelet Med

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“…According to the recent Guidelines of the American Association of 32 However, the decision of which approach to use is influenced by individual clinical and radiological factors. For this reason, we present the primary advantages and limitations of each approach in the next section, as well as the best indications for each.…”

Section: Choosing the Surgical Approach: Aosf Versus Pcifmentioning

confidence: 99%

Surgical treatment of Type II odontoid fractures: anterior odontoid screw fixation or posterior cervical instrumented fusion?

Joaquim

Patel

2015

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Odontoid fractures comprise as many as 20% of all cervical spine fractures. Fractures at the dens base, classified by the Anderson and D’Alonzo system as Type II injuries, are the most common pattern of all odontoid fractures and are also the most common cervical injuries in patients older than 70 years of age. Surgical treatment is recommended for patients older than 50 years with Type II odontoid fractures, as well as in patients at a high risk for nonunion. Anterior odontoid screw fixation (AOSF) and posterior cervical instrumented fusion (PCIF) are both well-accepted techniques for surgical treatment but with unique indications and contraindications as well as varied reported outcomes. In this paper, the authors review the literature about specific patients and fracture characteristics that may guide treatment toward one technique over the other. AOSF can preserve atlantoaxial motion, but requires a reduced odontoid, an intact transverse ligament, and a favorable fracture line to achieve adequate fracture compression. Additionally, older patients may have a higher rate of pseudarthrosis using this technique, as well as postoperative dysphagia. PCIF has a higher rate of fusion and is indicated in patients with severe atlantoaxial misalignment and with poor bone quality. PCIF allows direct open reduction of displaced fragments and can reduce any atlantoaxial subluxation. It is also used as a salvage procedure after failed AOSF. However, this technique results in loss of atlantoaxial motion, requires prone positioning, and demands a longer operative duration than AOSF, factors that can be a challenge in patients with severe medical conditions. Although both anterior and posterior approaches are acceptable, many clinical and radiological factors should be taken into account when choosing the best surgical approach. Surgeons must be prepared to perform both procedures to adequately treat these injuries.

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“…13,24 Studies have shown flexion/extension radiographs to be suboptimal in the evaluation of obtunded trauma patients, 1,16 and current guidelines emphasize the use of MRI rather than dynamic radiographs in these patients. [32][33][34][35] It is our current practice to use MRI rather than flexion/extension radiographs in all patients in whom ligamentous injury is suspected.…”

Section: 42mentioning

confidence: 99%

Magnetic resonance imaging of traumatic injury to the craniovertebral junction: a case-based review

Roy¹,

Miller²,

Holland³

et al. 2015

FOC

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OBJECT The craniovertebral junction (CVJ) is unique in the spinal column regarding the degree of multiplanar mobility allowed by its bony articulations. A network of ligamentous attachments provides stability to this junction. Although ligamentous injury can be inferred on CT scans through the utilization of craniometric measurements, the disruption of these ligaments can only be visualized directly with MRI. Here, the authors review the current literature on MRI evaluation of the CVJ following trauma and present several illustrative cases to highlight the utility and limitations of craniometric measures in the context of ligamentous injury at the CVJ. METHODS A retrospective case review was conducted to identify patients with cervical spine trauma who underwent cervical MRI and subsequently required occipitocervical or atlantoaxial fusion. Craniometric measurements were performed on the CT images in these cases. An extensive PubMed/MEDLINE literature search was conducted to identify publications regarding the use of MRI in the evaluation of patients with CVJ trauma. RESULTS The authors identified 8 cases in which cervical MRI was performed prior to operative stabilization of the CVJ. Craniometric measures did not reliably rule out ligamentous injury, and there was significant heterogeneity in the reliability of different craniometric measurements. A review of the literature revealed several case series and descriptive studies addressing MRI in CVJ trauma. Three papers reported the inadequacy of the historical Traynelis system for identifying atlantooccipital dislocation and presented 3 alternative classification schemes with emphasis on MRI findings. CONCLUSIONS Recognition of ligamentous instability at the CVJ is critical in directing clinical decision making regarding surgical stabilization. Craniometric measures appear unreliable, and CT alone is unable to provide direct visualization of ligamentous injury. Therefore, while the decision to obtain MR images in CVJ trauma is largely based on clinical judgment with craniometric measures used as an adjunct, a high degree of suspicion is warranted in the care of these patients as a missed ligamentous injury can have devastating consequences.

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Management of Isolated Fractures of the Axis in Adults

Cited by 97 publications

References 87 publications

Fractures of the axis: a review of pediatric, adult, and geriatric injuries

Fractures of the axis: a review of pediatric, adult, and geriatric injuries

Surgical treatment of Type II odontoid fractures: anterior odontoid screw fixation or posterior cervical instrumented fusion?

Magnetic resonance imaging of traumatic injury to the craniovertebral junction: a case-based review

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