Acute fractures of the odontoid process

Apuzzo, Michael L.J.; Heiden, James S.; Weiss, Martin H.; Ackerson, Truman T.; Harvey, J. Paul; Kurze, Theodore

doi:10.3171/jns.1978.48.1.0085

Cited by 218 publications

(99 citation statements)

References 37 publications

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“…In the younger group they are often secondary to high-energy trauma as motor vehicle accidents. The second peak in the incidence of odontoid fractures is in the elderly, where they appear as a result from low-energy injuries, such as falls from standing height [4,12,13,19]. Abstract During skeletal development the two ossification centers of the odontoid process are separated from the corpus of the axis by a subdental synchondrosis.…”

Section: Introductionmentioning

confidence: 99%

Subdental synchondrosis and anatomy of the axis in aging: a histomorphometric study on 30 autopsy cases

et al. 2005

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IntroductionFractures of the odontoid process of the second cervical vertebra comprise 7-13 % of all cervical spine fractures [22]. Moreover, fractures of the axis' odontoid basis-classified as Anderson and D'Alonzo type II fractures-represent the most frequent type of dens fractures with about 66% [3,9,18]. Odontoid fractures occur at all ages with a bimodal distribution. In the younger group they are often secondary to high-energy trauma as motor vehicle accidents. The second peak in the incidence of odontoid fractures is in the elderly, where they appear as a result from low-energy injuries, such as falls from standing height [4,12,13,19]. Abstract During skeletal development the two ossification centers of the odontoid process are separated from the corpus of the axis by a subdental synchondrosis. This synchondrosis is thought to close and disappear spontaneously in adolescence although this has never been studied in detail. The basis of the dens is of clinical relevance as type II dens fractures are located here. To characterize the morphological architecture of the axis with particular attention to the subdental synchondrosis, the complete axis was harvested from thirty age-matched and gender-matched patients of the three different age groups at autopsy. The subdental synchondrosis and the bone structure of the dens, the basis of the dens and the body of C2 were analyzed by radiography, histology and quantitative histomorphometry. At the macroscopic level the persistency of the subdental synchondrosis in the adult cervical spine was detected in 87% (26 of 30) of the specimens. Histomorphometry revealed a residual disc blastema with an average size of 25.8% of the sagittal depth of the basis of the dens at this level. Bony integration of the synchondrosis was poor throughout all ages. Histologically a cartilaginous matrix composition of the subdental synchondrosis persisted throughout all groups. The trabecular microarchitecture demonstrated a significant reduction of bone volume and trabecular number as well as an increased trabecular separation within the basis of the dens as compared to the corpus or the dens of C2. This histomorphometric data regarding a poor integration of the synchondrosis into the trabecular network and the reduced bone mass within the basis of the dens might offer a previously underestimated explanation for the occurrence of type II dens fractures and their association with pseudoarthrosis, respectively. Matthias Gebauer

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Section: Introductionmentioning

confidence: 99%

Subdental synchondrosis and anatomy of the axis in aging: a histomorphometric study on 30 autopsy cases

et al. 2005

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“…Several surgical options are available, but there is no consensus on the best treatment for these fractures. Several authors have suggested more than 4 to 6 mm of dens displacement [6,22], increasing age ([40-65 years) [6,16], posterior odontoid subluxation [16], and comminution of the base of the dens [22] would predict lower rates of fracture union. Therefore, patients with one or more of these criteria or who refuse external immobilization are considered surgical candidates by some surgeons [5].…”

Section: Discussionmentioning

confidence: 99%

“…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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“…Since several authors reported on a morbidity and mortality of geriatric patients following external cervicothoracic immobilization of OF equalling that of surgical treatment [38][39][40], we also prefer surgical treatment of unstable and/or dislocated Type II and III OF for the purpose of faster recuperation and better clinical results. In the light of significant non-union rates of up to 93% [2,4,7,10,11,[41][42][43][44][45][46][47][48][49][50][51] and a fourfold higher risk to suffer from pulmonary or cardiac complications for an elderly patient immobilized in a Halo Thoracic Vest (HTV) for OF treatment [39], a semi-rigid cervical collar is recommended as non-surgical treatment of stable and non-displaced OF or if surgical treatment is not contrivable due to the general state of health. Recently, usage of the semi-rigid cervical collar was shown to confer a comparable capacity in limiting motion at C1-2 if compared to the HTV [12].…”

Section: Discussionmentioning

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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Acute fractures of the odontoid process

Cited by 218 publications

References 37 publications

Subdental synchondrosis and anatomy of the axis in aging: a histomorphometric study on 30 autopsy cases

Subdental synchondrosis and anatomy of the axis in aging: a histomorphometric study on 30 autopsy cases

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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