The Contemporary Treatment of Odontoid Injuries

Maak, Travis G.; Grauer, Jonathan N.

doi:10.1097/01.brs.0000217941.55817.52

Cited by 133 publications

(125 citation statements)

References 75 publications

(70 reference statements)

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“…It does not rely on fracture mechanism or morphometric measurements of displacement, but embodies the hierarchy of damage within the C2-vertebra and in particular articulating surfaces. Interpretation of the inherent stability of the various fractures is not different to accepted definitions [56] e.g., qualifiers of instability like discoligamentous injury C2-3, axial osseo-ligamentous distraction of C2, rupture of transverse ligament of C1, burst fracture of C2 or displaced odontoid fracture.…”

Section: Classification Of Fracturesmentioning

confidence: 95%

“…The lack of a comprehensive treatment-oriented classification of C2-fractures, that guides when to operate and when to select conservative treatment, reflects the fact that there exists no ideal solution for the clinical problem, yet [56]. In contrast, there is a large body of literature concerning techniques, indications and union rates in C2-fractures [72], but data regarding the most important outcome measure, the functional and clinical outcome, are scant [24,68].…”

Section: Introductionmentioning

confidence: 99%

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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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Section: Classification Of Fracturesmentioning

confidence: 95%

Section: Introductionmentioning

confidence: 99%

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

et al. 2009

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“…Odontoid fractures account for 5% to 15% of all cervical spine injuries, with an increased rate in elderly patients [27,37]. Type II odontoid fractures [4] are the most common odontoid injury and produce atlantoaxial instability [11].…”

Section: Introductionmentioning

confidence: 99%

“…Nonoperative treatment with a rigid brace can result in fracture healing without need for surgery [5], but a mortality rate of 26% to 47% in elderly patients has been reported, perhaps as a result of respiratory-related complications due to prolonged external immobilization [7,23,31,35]. Reported healing after external immobilization has varied widely from 7% to 100% [26][27][28]. In most series, however, reported rates of successful healing ranged from 37% to 75% [3,6,13,38].…”

Section: Introductionmentioning

confidence: 99%

The Best Surgical Treatment for Type II Fractures of the Dens Is Still Controversial

Denaro

Papalia

Martino

et al. 2011

Clinical Orthopaedics &Amp; Related Research

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Background Odontoid fractures are the most common odontoid injury and often cause atlantoaxial instability. Reports on postoperative status of patients who underwent surgery for such injuries are limited to small case series, and it is unclear whether any one technique produces better outcomes than another. Questions/purposes We assessed the quality of the available literature for management of Type II odontoid fractures and surgery-related parameters, including surgical indications, clinical failure rate, and survivorship, postoperative ROM and function, neurologic deficits, complication and death rates, and radiographic healing rates related to either anterior dens screw or posterior C1-C2 fusion.Methods We performed a systematic search in PubMed, Ovid, Cochrane Reviews, and Google Scholar databases. We used the methodology score proposed by Coleman et al. to rate study quality. Postoperative imaging bone union rates were extracted. Postoperative complications and neurologic impairment data were also collected. Results Sixteen retrospective studies of overall low quality (average methodology score, 37.1) reporting a total of 518 patients were included. The methodology score and publication year were positively associated. The bone union rate approximated 83% (range, 33%-100%), with higher nonunion rates among patients older than 65 years. The death rate ranged widely (0%-28.6%) among different centers. Residual cervical pain was documented postoperatively from 10.5% to 26.7%, while survivorship ranged from 72% to 96.6%. No ROM data were reported. Conclusions Current data on patients who had surgery for fracture of the dens did not allow us to establish superiority of one surgical approach over another.

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“…Odontoid fractures (OF) are the most common cervical spine fracture in patients aged older than 70 years and even the most common spinal fracture of patients aged older than 80 years [1][2][3][4][5]. Treatment of OF yields for stable osseous fusion to avoid the risk of late neurologic deterioration due to instability at C1-C2.…”

Section: Introductionmentioning

confidence: 99%

Efficacy of anterior odontoid screw fixation in the elderly patient: a CT-based biometrical analysis of odontoid fractures

et al. 2011

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In the elderly population, reported union rates with anterior odontoid screw fixation (AOSF) for odontoid fracture (OF) treatment vary between 23 and 93% when using plain radiographs. However, recent research revealed poor interobserver reliability for fusion assessment using plain radiographs compared to CT scans. Therefore, union rates in patients aged C60 years treated with AOSF have to be revisited using CT scans and factors for non-union to be analysed. Prospectively gathered consecutively treated patients using AOSF for odontoid fracture with age C60 years were reviewed. Medical charts were assessed for demographics, clinical outcomes and complications. Patients' preoperative radiographs and CT scans were analysed to characterize fracture morphology and type, fracture displacement, presence of atlanto-dental osteoarthritis as well as a detailed morphometric assessment of fracture surfaces (in mm 2 ). CT scans performed after a minimum of 3 months postoperatively were analysed for fracture union. Those patients not showing CT-based evidence of completely fused odontoid fracture were invited for radiographic follow-up at a minimum of 6 months follow-up. Follow-up CT-scan were studied for odontoid union as well as the number of screws used and the square surface of screws used for AOSF and the related corticocancellous osseous healing surface of the odontoid fragment (in %) were calculated. Patients were stratified whether they achieved osseous union or fibrous non-union. Patients with a non-union were subjected to flexionextension lateral radiographs and the non-union defined as stable if no motion was detected. The sample included 13 male (72%) and 5 female (18%) patients. The interval from injury to AOSF was 4.1 ± 5.3 days (0-16 days). Age at injury was 78.1 ± 7.6 years (60-87 years) and follow-up was 75.7 ± 50.8 months (4.2-150.2 months). 10 patients had dislocated fractures, 14 had Type II and 4 ''shallow'' Type III fractures according to the Anderson classification, 2 had stable C1-ring fractures, 8 had displayed atlantodental osteoarthritis. Fracture square surface was 127.1 ± 50.9 mm 2 (56.3-215.9 mm 2 ) and osseous healing surface was 84.0 ± 6.8% (67.6-91.1%). CT-based analysis revealed osseous union in 9 (50%) and non-union in 9 patients (50%). Union rates correlated with increased fracture surface (P = 0.02). Statistical analysis revealed a trend that the usage of two screws with AOSF correlates with increased fusion rates (P = 0.06). Stability at C1-2 was achieved in 89% of patients. CT scans are accepted as the standard of reference to assess osseous union. The current study offers an objective insight into the union rates of odontoid fractures treated with AOSF using CT scans in consecutive series of 18 patients C60 years. Literature serves evidence that elderly patients with unstable OF benefit from early surgical stabilization. However, although using AOSF for unstable OF yields segmental stability at C1-2 in a high number of patients as echoed in

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The Contemporary Treatment of Odontoid Injuries

Cited by 133 publications

References 75 publications

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

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

The Best Surgical Treatment for Type II Fractures of the Dens Is Still Controversial

Efficacy of anterior odontoid screw fixation in the elderly patient: a CT-based biometrical analysis of odontoid fractures

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