Pdf retrospective case series of elderly patients with type ii odontoid fractures, with prospective functional followup. Traumatic atlantoaxial lateral subluxation with chronic type. Odontoid process fracture, also known as a peg or dens fracture, occurs where there is a fracture through the odontoid process of c2 pathology. Type i fractures occur very rarely and type ii is the most common type i.
Therefore, the aim of our study was to describe and evaluate a novel technique, cabledragged reduction cantilever beam internal fixation for the treatment of type ii odontoid fracture. Nonsurgical measures include immobilization, prevent or restrict movement, in a. The biomechanics in the atlantoaxial joint carry more than 50% of the rotational movement which can be affected in transverse ligament tear associated with odontoid fracture type ii. To evaluate fracture healing, functional outcomes, complications, and mortality associated with rigid cervical collars. Manage types ii and iii fractures by applying traction with cervical tongs. Evaluation and treatment of odontoid and hangmans fractures. In cases of type ii fracture, analysis of the class iii evidence suggests that both operative and nonoperative management remain treatment options. Treatment modality in type ii odontoid fractures defines the. The aim of this study was to compare conservative and surgical management in patients with type ii c2 fractures regarding outcomes, complications, and the mortality rate. Recommendations for diagnosis and treatment of odontoid. Management of isolated fractures of the axis in adults. Odontoid fractures type ii according to anderson and dalonzo are not uncommon in the elderly patients. Vast majority of type ii fractures treated with cervical collar anterior odontoid screw fixation in selected patients with fracture pattern and body habitus amenable to procedure c1 c2 psf for markedly displaced fractures cant remember the last time i put a halo on an elderly patient.
Fractures at the dens base, classified by the anderson and dalonzo 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. A more effective way to achieve bone fusion with the lowest possible surgical risk is needed. They represent the most common cervical spine injury for patients older than 70 years, the majority being type ii fractures 6574%, which are considered to be relatively unstable. Reliability of the stir sequence for acute type ii. Sometimes, type ii fracture is associated with a comminuted fragment at the base of the dens called the type ii a variety. Lateral subluxation of the atlas c1 and axis c2 associated with type ii odontoid fracture of the dens is very rare. The mechanism of injury is variable, and can occur both during flexion or extension, and with or without compression 5. This was a retrospective study enrolled 34 patients underwent posterior cabledragged reductioncantileverbeam internal fixation surgery. Original article treatment of odontoid type ii fractures in. Surgical outcome of type ii odontoid fracture, harms technique. First is the difficulty in precise differentiation between a low type ii and a high type iii fractures. Nonoperative treatment is usually the treatment of choice for odontoid fracture types i and iii. Odontoid fractures are relatively common fractures of the c2 vertebral body axis that can be seen in low energy falls in eldery patients and high energy traumatic injuries in younger patients.
Treatment is with anterior odontoid screw if adequate bone density. Patients who were treated with the halo vest had a higher fusion rate than those managed with the philadelphia collar. Direct transoral reduction of anteriorly displaced type ii. Management of acute combination fractures of the atlas and axis. How are odontoid process fractures of the cervical spine. High risk of nonunion 30% due to interruption of blood supply.
Pdf nonoperative management of type ii odontoid fractures in. Type ii odontoid fracture the spine hospital at the neurological. Management of type iii dens fracture taipei medical. Vaccaro ar, kepler ck, kopjar b, chapman j, shaffrey c, arnold p, et al. Conservative treatment in patients with type 2 odontoid. This type is unstable and has a high rate of nonunion. The base of the dens represents a watershed region between 2 arcades1 supplying the body of c2 and another supplying the tip of the dens.
Every patient with an odontoid fracture presents a unique clinical challenge. Extension of the fracture through upper portion of body of c2 unstable fracture. What are the types of odontoid process fractures of the. The nonoperative management of type ii odontoid fractures in elderly patients results in fracture stability, by either osseous union or fibrous union in almost all patients. Type ii fractures were defined with plain radiography as per the andersondalonzo classification. Original article treatment of odontoid type ii fractures.
This is a very important case of providing spine surgeons with a treatment plan for treating patients with old type ii odontoid fractures complicated. This is the only spinal fixation technique for fractures that restores spinal stability yet. Lennarson pj1, mostafavi h, traynelis vc, walters bc. This is the only spinal fixation technique for fractures that restores spinal stability yet completely preserves normal spinal motion. The roycamille classification of fractures of the odontoid process of c2 depends on the direction of the fracture line 1 the level of fracture line as described by the anderson and dalonzo classification is not predictive of the degree of instability or the risk of nonunion. It is associated with excellent clinical results and a high rate of fusion. Type iii odontoid fractures are managed quite efficiently with closed immobilization in a hard collar and heal without incidence. Surgical methods for type ii odontoid fracture can be classified into 2 main groups.
Type ii fractures are the most common odontoid frac. Functional and qualityoflife outcomes in geriatric patients with typeii dens fracture. Odontoid fracture type ii is considered an unstable fracture with a high rate of nonunion in. Thirtythree patients with isolated type ii dens fractures treated with halo vest immobilization at the university of iowa hospitals and clinics between. Type i fracture extends through the tip of the dens. The odontoid fracture is the most common type of injury to the cervical spine in people over.
These injuries may be missed clinically because of the lack of clinical signs except for neck pain. Cervical trauma is a common cause of disability following spinal cord injury especially in athletic populations. The most common upper cervical fracture in elderly people aged. Initial management of a type i dens fracture is use of a cervical orthosis. We sought to compare the outcomes of patients managed with these devices in terms of risk factors for non. It is the most commonly encountered fracture for this region of the axis. Approximately 50% of axial rotation of the cervical spine occurs at the c1c2 articulation. Considerable controversy exists regarding the optimal management of elderly patients with type ii odontoid fractures. Type i is a rarely occurring fracture of the apical portion of the odontoid process.
Type ii is the most common dens fracture and occurs at the base of the dens. A casecontrol study of patients with isolated type ii dens fractures treated with halo vest immobilization. This classification scheme aids the management of odontoid fractures. Treatment of type ii odontoid fracture with a novel techniqu. May 15, 2000 therefore, a casecontrol study based on class ii data was designed to evaluate age as a risk factor for failure of halo vest immobilization in patients with type ii dens fractures. Fracture at base of odontoid where it meets c2 body unstable fracture. Nondisplacedminimally displaced with no comminution. The commonest type of the axis injury is an odontoid fracture at the junction of the dens and the body type ii odontoid fracture2. Nonoperative treatment of odontoid fractures should be considered when possible, especially in elderly patients. Unstable injuries to the upper cervical spine are a hazard to every elderly person, since associated dysphagia and respiratory restrictions are potential deadly complications. Anterior osteosynthesis with 1 or 2 screws leads to good results in the classical unstable type ii odontoid fracture in patients with good bone. Medical records, rates of reduction, the location of the instrumentation and fracture healing during followup were analyzed. Contemporary management of adult cervical odontoid fractures. Instability at this level occurs most commonly as a result of fractures of the odontoid or bursting injuries of the atlas with disruption of the transverse ligament.
Thirtyfour patients with surgical management by fusion. Aug 22, 2018 displaced odontoid fractures in the elderly are treated nonsurgically with a cervical collar or surgically with c1c2 fusion. Odontoid fractures comprise as many as 20% of all cervical spine fractures. Displaced fracture with fracture line from anterosuperior to posteroinferior. Seventyfive patients with type ii odontoid fracture and 75 healthy controls mean and median age of 57 years were identified. Case report type ii old odontoid fractures in the ankylosing. Despite the publication of numerous studies, there remains controversy regarding the non. Type iii odontoid fractures may occur without major trauma 10. Odontoid screw fixation is the preferred method for stabilization of acute, unstable type ii odontoid fractures. In addition, the authors noted the difficulty in differentiating a low type ii fracture from a high type iii fracture. Although a consensus exists on the nonoperative management of types i and iii odontoid peg fractures, treatment of type ii fractures remains controversial.
Odontoid fractures comprise 920% of all cervical spine fractures. N2 external immobilization with a halo vest is the traditional treatment of choice for type iii fracture of the odontoid process of c2 dens. Thirtythree patients with isolated type ii dens fractures treated with halo vest immobilization at the university of iowa hospitals and clinics between 1983 and 1997 were included. Treatment depends on the location of the fracture within the c2 vertebrae defined by the anderson and dalonzo classification system and the patients risk factors for nonunion failed bone healing. Nov 18, 2011 to evaluate fracture healing, functional outcomes, complications, and mortality associated with rigid cervical collars. Request pdf management of type ii dens fractures study design, a casecontrol study of patients with isolated type ii dens fractures treated with halo vest immobilization.
Treatment modality in type ii odontoid fractures defines. Fractures of the odontoid process comprise 18% to 20% of cervical injuries, of which 65% to 74% are type ii fractures. Grauer classification of type ii odontoid fractures. Possible treatment options are either conservative or surgical. Sep 12, 2010 the objective of the study was to evaluate the published literature and determine the current evidence for the management of type ii odontoid fractures in elderly. This type iia fracture was highly unstable and was. B type ii odontoid fracture is a fracture at the base of the dens. C with type iii odontoid fracture, the fracture line extends into the body. Management of type ii odontoid process fractures in geriatric patients. Fractures of the dens, however, are the most common injury to the c2 vertebra. Surgical methods for type ii odontoid fracture can be classified into 2 main. The treatment of specific c1c2 fracture combinations has been the subject of numerous reports.
A search of the english language literature from january 1970 to date was performed using medline and the following keywords. Nonoperative treatment of displaced type ii odontoid peg. Whereas type i fractures are very rare, type ii and iii fractures are frequently experienced in clinical practice. Apr 12, 2020 initial management of a type i dens fracture is use of a cervical orthosis. Imaging of the cervical spine fractures dens fracture type ii.
Rigid cervical collar treatment for geriatric type ii. Type iii fractures occur through the body of the axis with frequent extension into the atlantoaxial facet joints 9. Nonunion occurs in 30% to 50% in the elderly and those with significant displacement angulation of more than 10 degrees or translation of more than 5 mm. Still, due to the paucity of evidence the published treatment guidelines are far from equivocal. Odontoid fractures account for approximately 20% of all fractures of the cervical spine. The sensitivity of stir to detect fracture in the age group 57 years and older was significantly worse than that in the age group younger than 57 years 54% and 82%, respectively. How are odontoid process fractures of the cervical spine treated. Jan 23, 2019 cervical trauma is a common cause of disability following spinal cord injury especially in athletic populations. Type iii odontoid fractures of the axis are the second most common injuries of the cervical spine. Reliability of the stir sequence for acute type ii odontoid. A type i fracture involves only the proximal tip of the odontoid process, while a type ii fracture, like our patients, passes through the base of the odontoid process.
Similar to the literature on isolated type ii odontoid fracture. Factors that affect fracture healing include the anderson and dalonzo classification of fracture line anatomy, the magnitude of distraction andor angulation 4, 12, and the age of the patient 2, 4, 6, 7, 18. It has the highest incidence of nonunion and is considered unstable. Hangmans fractures, a traumatic spondylolisthesis through the pars interarticularis. Outcome scores were compared with a group of 40 agematched control subjects average age 79. The management of these fractures is controversial. The optimum treatment of type ii odontoid fractures in the elderly remains controversial. Nonoperative management of types ii and iii odontoid. The most common fracture types according to the anderson and dalonso classification are type ii fractures 6574%, which are considered to be relatively unstable 4, 5. Odontoid fractures account for 9%15% of cervical spine fractures. Type ii fracture extends through the base of the dens.
The optimal treatment of odontoid fractures in elderly. Displaced odontoid fractures in the elderly are treated nonsurgically with a cervical collar or surgically with c1c2 fusion. Surgical management of odontoid fractures at level one. The goal of management with these fractures is to achieve clinical or radiological union. Therefore, a casecontrol study based on class ii data was designed to evaluate age as a risk factor for failure of halo vest immobilization in patients with type ii dens fractures. Odontoid process fracture, also known as a peg or dens fracture, occurs where there is a fracture through the odontoid process of c2. When considering the optimal treatment for a type ii of in the elderly, several factors need to be taken into consideration including associated injuries, medical comorbidities american society of anaesthesiologists asa grade, healing potential of fracture, anticipated tolerance of the halo vest hv or surgery and patients wishes 3, 6, 34, 37, 46, 63, 70. Roycamille classification of odontoid process fracture. The objective of the study was to evaluate the published.
There is uncertainty regarding the consequences of nonunion. Conservative management of type ii and iii fractures. Treatment of type ii odontoid fracture with a novel. Odontoid process fracture an overview sciencedirect topics. The optimal treatment of type ii and iii odontoid fractures. The fracture line involves the junction of the body of the dens with the body of the axis. For patients with type ii fractures, treatment remains controversial, as discussed by anderson and dalonzo, due to the rising morbidity and mortality rates for any treatment. Fractures of the dens can be seen at any time of life, but especially in young adolescents and also in those after 60. Pdf nonoperative management of type ii odontoid fractures. Approximately 9% to 20% of all cervical fractures are dens fractures, 2, 6 10 with most 65% to 74% being type ii fractures. Ii, is the commonest injury in the upper cervical spine. Nonunion is common in type ii dens fracture and ranges from 11% to 63% of all cases3. Nonunion occurs in 30% to 50% in the elderly and those with significant displacement angulation of more than. Pdf evidencebased analysis of odontoid fracture management.
The uppsala study on odontoid fracture treatment usoft is a multicentre, openlabel, randomised controlled superiority trial evaluating the clinical. The best treatment remains unclear because of the morbidity associated with prolonged cervical immobilisation versus the risks of surgical intervention. Other potential variables include the presence of more pressing sequelae of trauma and the. Current concepts in the management of type ii odontoid fractures. Fractures of the dens can be seen at any time of life, but. Cochrane form ii for rcts 9, cochrane table 1 the medline search strategy odontoid fractures or odontoid fracture or os odontoideum or c2 fracture or c2 fractures or c2. Due to the paucity of evidence, the treatment decision is often left to the discretion of the expert surgeon. Fractures at the dens base, classified by the anderson and dalonzo 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. The fracture occurs at the base of the odontoid between the level of the transverse ligament and the base of the odontoid process. Odontoid fractures are typically categorized by the andersondalonzo classification as type iiii 1, 6.
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