CT evaluation of the pattern of odontoid fractures in the elderly?relationship to upper cervical spine osteoarthritis

Lakshmanan, Palaniappan; Jones, Alwyn; Howes, J; Lyons, K.

doi:10.1007/s00586-004-0743-z

Cited by 82 publications

(74 citation statements)

References 17 publications

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“…To analyse degenerative changes of the atlantoaxial joints observed in elderly patients or following C2-fractures in younger patients [20,31], all C1-2 joints were scored on transoral odontoid views according to Lakshamanan [44] (Table 3), and the median height of the C1-2 joints was measured. As the study showed difficulties in differentiating the subtypes 0 and 1, as well as type 2 and 3, statistical calculations were performed to stratify a group A (none or mild degenerative changes C1-2, type 0 and 1 [44]) and a group B (advanced degenerative changes C1-2, type 2 and 3 [44]).…”

Section: Methodsmentioning

confidence: 99%

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: Methodsmentioning

confidence: 99%

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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“…Furthermore, CT scans were analysed regarding atlanto-dental osteoarthritis which was defined as narrowed atlanto-dental joint space with osteophytosis [37].…”

Section: Methodsmentioning

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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“…According to the classification of Lakshamanan [54] AAOA was a mean of 1.1 ± 1.0 points (range 0-3) left and 1.0 ± 1.0 points (range 0-3) right at follow-up. Injury AAJH was assessable in 16 patients (45.7%).…”

Section: Atlantoaxial Jointsmentioning

confidence: 98%

“…In addition, the left and right atlantoaxial joint hights (lAAJH and rAAJH) were measured on injury CT-scans, if available, and on all follow-up CT-scans at the center of the lateral C1-2 joints as described [44]. For the purpose of comparative studies, AAJ degeneration was assessed using the classification of Lakshmanan [54] too.…”

Section: Assessment Of Lateral Atlantoaxial Joint Degenerationmentioning

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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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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CT evaluation of the pattern of odontoid fractures in the elderly?relationship to upper cervical spine osteoarthritis

Cited by 82 publications

References 17 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

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

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

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