8/13/2023 0 Comments Odontoid fracture complicationsThe myelopathy was due to a spinal cord contusion at C1–2 in the other 3 patients. A cervical laminectomy was performed in 4 patients with myelopathy, and the fusion was extended distally to cover these areas. Neurologically, 3 patients had a significant spinal cord injury and 7 had cervical myelopathy. Three other patients suffered a rib, humerus, and hand/wrist fracture, respectively. Two patients had unilateral C2 pars fractures, and 2 had clavicular fractures. There were 30 C1 fractures, the vast majority of which were posterior arch fractures. Thirty-seven patients had an additional fracture. ![]() Seven fractures were the result of a motor vehicle accident and 1 was from an ocean wave. The cause of injury in all but 8 patients was a fall from a standing height. All patients, excluding those who died during the hospitalization, were followed clinically and radiographically (mean 14 months ). The average age was 78 years (range 65–95 years). The CT criteria for a solid arthrodesis included absence of lucencies around the graft(s) and no evidence of hardware failure or loosening. In such cases, the rods obscure the view of the dorsal elements of the axis and atlas on plain radiographs. CT is the best means of visualizing the graft between the C1 and C2 lamina in the setting of C1 lateral mass fixation ( Fig. The criteria for fusion were no motion on the dynamic radiographs, intact hardware, and no lucencies around the graft. The patients were maintained in a rigid orthosis for 6 weeks. The cartilage was removed from the C1–2 joints in 11 patients and machined cortical allografts were impacted into this space (FacetLift Medtronic) in these cases, autograft rib was also used. The remainder of the autograft was cut into the size of matchsticks and placed over the lamina of C1 and C2 laterally. 10 This prevented graft migration, added compression to the graft, and served as a tension band to enhance the strength of the construct. When the C1 and C2 posterior arches were intact, a robust graft was secured between the C1 and C2 dorsal elements with a cable, using the interspinous technique as described by Dickman et al. The rhBMP-2 was placed laterally between C1 and C2 over the dorsal aspect of the joint. Three patients had iliac crest allograft and 4 patients had allograft plus recombinant human bone morphogenetic protein–2 (rhBMP-2) (Infuse Medtronic). The fusion substrate consisted of rib autograft in all but 8 patients. 9 Five patients had a complex situation necessitating occiput to subaxial fixation. C1 lateral mass fixation and polyaxial screws were used as described by Harms and Melcher. Two patients had unilateral pars fixation coupled with unilateral laminar fixation. All patients with unilateral transarticular screw fixation had vascular anatomy that precluded placing bilateral screws. ![]() A variety of fixation techniques were used including bilateral C1–2 transarticular screws (n = 20) unilateral C1–2 transarticular screw (n = 3) unilateral transarticular screw with a contralateral C1–2 pars (n = 2) or C2 laminar (n = 3) screw and bilateral C1 fixation with C2 fixation of the pars (n = 44) or lamina (n = 14). The data were retrospectively reviewed with IRB approval from the University of Iowa and Rush University Medical Center.Īll patients were treated with a posterior instrumented fusion. Ninety-three consecutive patients older than 65 years of age with a type 2 odontoid fracture were treated with a posterior instrumented fusion by a single surgeon (V.C.T.). A consecutive series of patients is reviewed to determine the complication rate and fusion success. ![]() 8 The senior author (V.C.T.) espouses treating all elderly patients who have odontoid fractures with prompt posterior fixation and fusion. 7 Posterior instrumented fusions provide solid fixation and are the favored surgical treatment per the AANS/CNS guidelines. The complication rate for this technique in the older population is relatively high and the fracture fusion rate is suboptimal. Anterior screw fixation requires that the fracture be well aligned and that the patient have robust bone quality. 2–6 Common surgical options include direct reduction and stabilization via anterior screw fixation or a posterior instrumented fusion. 2 Some centers choose to manage type 2 odontoid fractures with a rigid orthosis but there is increasing evidence that this patient population is better treated with surgical stabilization. 1 These fractures do not heal reliably with immobilization, particularly in the older patient. The incidence of these injuries in geriatric individuals is not only increasing, but rising more rapidly than the growth of this population subset. T ype 2 odontoid fractures are the most common cervical spinal fractures in individuals older than 65 years of age.
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