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

Dai, Li-Yang; Yuan, Wen; Ni, Bin; Liu, H. K.; Jia, Lianshun; Zhao, Danyun; Xu, Yajun

doi:10.1007/s005860050221

Cited by 32 publications

(19 citation statements)

References 39 publications

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“…In a current literature review [33], the incidence of malunion reported was low in type II and III odontoid fractures following halo treatment (5 and 10%, respectively). However, with the latter the articular facets of C2 are frequently affected and symptomatic malunion or segmental C1-2 deformation after nonsurgical treatment has been observed several times [5,10,13,14,20,24,26,29,33,35,36,42,55,57]. Clark [10] already stretched that type III odontoid fractures were 'not benign as previously reported'.…”

Section: Discussionmentioning

confidence: 87%

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

et al. 2009

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

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Section: Discussionmentioning

confidence: 87%

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

et al. 2009

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“…A meaningful number of subtypes of C2-fractures exists where complete reduction, normal C1-2 rotation and a physiological anatomy is difficult to restore [1,10,11,34,42,43,71,82]. Likewise, a non-anatomical posttreatment C2-alignment, resembling a malunion, can cause significant symptoms even indicating fusion C1-2 [13,26,30,42,47,51,52,67,70,71,78,79] as it had to be done in one of our cases (Fig. 3), two others being scheduled (Fig.…”

Section: Malunion Of C2mentioning

confidence: 88%

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

et al. 2009

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

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“…(13-15) In the literature review produced by Julien et al, (13) 147 patients were retrospectively analyzed with types II and III fractures, obtaining 87% of healing in type II and 100% in type III fractures treated with posterior fixation.…”

Section: Discussionmentioning

confidence: 99%

Retrospective analysis of a case series of patients with traumatic injuries to the craniocervical junction

Esteves

Joaquim

Tedeschi

2016

Einstein (São Paulo)

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Objective: To evaluate the correlation between the treatment, the characteristics of the lesions and the clinical outcome of patients with traumatic injuries to the craniocervical junction. Methods: This was a retrospective study of patients treated conservatively or surgically between 2010 and 2013 with complete data sets. Results: We analyzed 37 patients, 73% were men with mean age of 41.7 years. Of these, 32% were submitted to initial surgical treatment and 68% received conservative treatment. Seven (29%) underwent surgery subsequently. In the surgical group, there were seven cases of odontoid type II fractures, two cases of fracture of posterior elements of the axis, one case of C1-C2 dislocation with associated fractured C2, one case of occipitocervical dislocation, and one case of combined C1 and C2 fractures, and facet dislocation. Only one patient had neurological déficit that improved after treatment. Two surgical complications were seen: a liquoric fistula and one surgical wound infection (reaproached). In the group treated conservatively, odontoid fractures (eight cases) and fractures of the posterior elements of C2 (five cases) were more frequent. In two cases, in addition to the injuries of the craniocervical junction, there were fractures in other segments of the spine. None of the patients who underwent conservative treatment presented neurological deterioration. Conclusion: Although injuries of craniocervical junction are relatively rare, they usually involve fractures of the odontoid and the posterior elements of the axis. Our results recommend early surgical treatment for type II odontoid fractures and ligament injuries, the conservative treatment for other injuries.

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

Cited by 32 publications

References 39 publications

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

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

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

Retrospective analysis of a case series of patients with traumatic injuries to the craniocervical junction

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