Treatment of odontoid fracture combined with lower cervical spinal cord injuries without fracture or dislocation_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

ZHANG Wei ,  YU Haiyang , LIANG Chengmin , JIAO Wei , CAO Jie , LI Chao

Department of Spinal Surgery, Fuyang City People’s Hospital, Fuyang Anhui, 236000, P.R.China;

Corresponding author：

YU Haiyang, Email: fyyhy@163.com

Keywords：

Odontoid fracture; cervical spinal cord injury; internal fixation

DOI：

10.7507/1002-1892.201703113

Video：

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Objective To discuss the clinical characteristics, mechanism, and treatment of odontoid fracture combined with lower cervical spinal cord injuries without fracture or dislocation. Methods According to the inclusion and exclusion criteria, 7 male patients aged 37-71 years (mean, 51.4 years), suffered from odontoid fractures combined with lower cervical spinal cord injuries without fracture or dislocation were analyzed retrospectively between June 2007 and October 2015. The trauma causes were traffic accidents in 2 cases, fall in 2 cases, and hit injury in 3 cases. The time from injury to admission was 2 hours to 3 days with an average of 9 hours. According to Anderson-Grauer classification of odontoid fracture, 1 case of type IIA, 3 cases of type IIB, 2 cases of type IIC, and 1 case of shallow type III were found. The cervical spinal cord injuries affected segments included C_{4, 5} in 1 case, C_4–6 in 2 cases, and C_5–7 in 4 cases. All the cervical spine had different degenerative changes: 2 of mild, 3 of moderate, and 2 of severe. The lower cervical spinal cord injury was assessed by Sub-axial Injury Classification (SLIC) with scoring of 4-6 (mean, 5.1). The visual analogue scale (VAS) score was used to evaluate the occipital neck pain with scoring of 7.8±1.0; the neurological function was assessed by American Spinal Injury Association (ASIA) as grade B in 1 case, grade C in 4 cases, and grade D in 2 cases; and Japanese Orthopedic Association score (JOA) was 9.2±3.9. For the odontoid fractures, 4 cases were fixed with anterior screw while the others were fixed with posterior atlantoaxial fixation and fusion. For the lower cervical spine, 4 cases were carried out with anterior cervical corpectomy and titanium fusion while the others with anterior cervical disecotomy and Cage fusion. Results The operation time was 178-252 minutes (mean, 210.2 minutes); the intraoperative blood loss was 60-140 mL (mean, 96.5 mL) and with no blood transfusion. All incisions healed primarily. All the patients were followed up 12-66 months (mean, 18 months). There was no direct surgical related complications during operation, and all bone grafting got a fusion at 6-9 months (mean, 7.7 months) after operation. There was no inter-fixation failure or loosening. At last follow-up, the VAS score declined to 1.7±0.7 and JOA score improved to 15.1±1.7, showing significant differences when compared with preoperative ones (t=18.064, P=0.000; t=–7.066, P=0.000). The neurological function of ASIA grade were also improved to grade D in 5 cases and grade E in 2 cases, showing significant difference (Z=–2.530, P=0.011). Conclusion Complex forces and degeneration of lower cervical spine were main reasons of odontoid fracture combined with lower cervical spinal cord injuries without fracture or dislocation. The type of odontoid fracture and neurological deficit status of lower cervical spinal cord were important to guide making strategy of one-stage operation with a satisfactory clinic outcome.

Citation： ZHANG Wei, YU Haiyang, LIANG Chengmin, JIAO Wei, CAO Jie, LI Chao. Treatment of odontoid fracture combined with lower cervical spinal cord injuries without fracture or dislocation. Chinese Journal of Reparative and Reconstructive Surgery, 2017, 31(8): 982-986. doi: 10.7507/1002-1892.201703113 Copy

1.	Joaquim AF, Patel AA. Surgical treatment of type II odontoid fractures: anterior odontoid screw or posterior cervical instrumented fusion? Neurosurg Focus, 2015, 38(4): E11.
2.	Schroeder GD, Kepler CK, Kurd MF, et al. A systematic review of the treatment of geriatric type II odontoid fractures. Neurosurgery, 2015, 77 Suppl 4: S6-14.
3.	Waschke A, Ullrich B, Kalff R, et al. Cement-augmented anterior odontoid screw fixation for osteoporotic type II odontoid fractures in elderly patients: prospective evaluation of 11 patients. Eur Spine J, 2016, 25(1): 115-121.
4.	Takao T, Morishita Y, Okada S, et al. Clinical relationship between cervical spinal canal stenosis and traumatic cervical spinal cord injury without major fracture or dislocation. Eur Spine J, 2013, 22(10): 2228-2231.
5.	Grauer JN, Shafi B, Hilibrand AS, et al. Proposal of a modified, treatment-oriented classification of odontoid fractures. Spine J, 2005, 5(2): 123-129.
6.	Llopis E, Belloch E, León JP, et al. La columna cervical degenerativa. Radiología, 2016, 58 (S1): 13-25.
7.	何伟, 钱宇, 张军, 等. 颈椎退变对外伤性颈髓损伤的影响. 中国骨伤, 2012, 25(9): 737-742.
8.	Vaccaro AR, Hulbert RJ, Patel AA, et al. The sub-axial cervical spine injury classification system: a novel approach to recognize the importance of morphology, neurology and integrity of the disco-ligamentous complex. Spine (Phila Pa 1976), 2007, 32(21): 2365-2374.
9.	徐广辉, 贾连顺. 颈前路减压融合术后植骨融合的影像学评价方法及标准. 中华外科杂志, 2009, 47(23): 1824-1826.
10.	Singla M, Goel P, Ansari MS, et al. Morphometric analysis of axis and its clinical significance-an anatomical study of Indian human axis vertebrae. J Clin Diagn Res, 2015, 9(5): AC04-9.
11.	Boughton OR, Bernard J, Szarko M. Odontoid process fractures: the role of the ligaments in maintaining stability. A biomechanical, cadaveric study. SICOT J, 2015, 1: 11.
12.	Harrop JS, Naroji S, Maltenfort M, et al. Cervical myelopathy: a clinical and radiographic evaluation and correlation to cervical spondylotic myelopathy. Spine (Phila Pa 1976), 2010, 35(6): 620-624.
13.	张静涛, 申勇, 张英泽, 等. 轻中度颈脊髓压迫患者产生脊髓损害症状与体征的危险因素. 中国脊柱脊髓杂志, 2013, 23(2): 145-150.
14.	Ames CP, Blondel B, Scheer JK, et al. Cervical radiographical alignment: comprehensive assessment techniques and potential importance in cervical myelopathy. Spine (Phila Pa 1976), 2013, 38 (22 Suppl 1): S149-160.
15.	Takeuchi K, Yokoyama T, Aburakawa S, et al. Inadvertent C2-C3 union after C1-C2 posterior fusion in adults. Eur Spine J, 2015, 15(3): 270-277.
16.	黄季晨, 钱邦平, 邱勇. 寰枢椎后路融合术后下颈椎曲度及退变影响因素的研究进展. 中国脊柱脊髓杂志, 2016, 26(6): 545-548.
17.	王建元, 刘华, 盛伟斌. SLIC 评分在下颈椎损伤术式选择中的应用价值. 中国脊柱脊髓杂志, 2016, 26(5): 415-420.
18.	Samuel S, Lin JL, Smith MM, et al. Subaxial injury classification scoring system treatment recommendations: external greement study based on retrospective review of 185 patients. Spine (Phila Pa 1976), 2015, 40(3): 137-142.
19.	Li F, Chen Q, Xu K. The treatment of concomitant odontoid fracture and lower cervical spine injuries. Spine (Phila Pa 1976), 2008, 33(19): E693-698.
20.	Miller CP, Brubacher JW, Biswas D, et al. The incidence of noncontiguous spinal fracturesand other traumatic injuries associated with cervical spine fractures. Spine (Phila Pa 1976), 2011, 36(19): 1532-1540.

1. Joaquim AF, Patel AA. Surgical treatment of type II odontoid fractures: anterior odontoid screw or posterior cervical instrumented fusion? Neurosurg Focus, 2015, 38(4): E11.
2. Schroeder GD, Kepler CK, Kurd MF, et al. A systematic review of the treatment of geriatric type II odontoid fractures. Neurosurgery, 2015, 77 Suppl 4: S6-14.
3. Waschke A, Ullrich B, Kalff R, et al. Cement-augmented anterior odontoid screw fixation for osteoporotic type II odontoid fractures in elderly patients: prospective evaluation of 11 patients. Eur Spine J, 2016, 25(1): 115-121.
4. Takao T, Morishita Y, Okada S, et al. Clinical relationship between cervical spinal canal stenosis and traumatic cervical spinal cord injury without major fracture or dislocation. Eur Spine J, 2013, 22(10): 2228-2231.
5. Grauer JN, Shafi B, Hilibrand AS, et al. Proposal of a modified, treatment-oriented classification of odontoid fractures. Spine J, 2005, 5(2): 123-129.
6. Llopis E, Belloch E, León JP, et al. La columna cervical degenerativa. Radiología, 2016, 58 (S1): 13-25.
7. 何伟, 钱宇, 张军, 等. 颈椎退变对外伤性颈髓损伤的影响. 中国骨伤, 2012, 25(9): 737-742.
8. Vaccaro AR, Hulbert RJ, Patel AA, et al. The sub-axial cervical spine injury classification system: a novel approach to recognize the importance of morphology, neurology and integrity of the disco-ligamentous complex. Spine (Phila Pa 1976), 2007, 32(21): 2365-2374.
9. 徐广辉, 贾连顺. 颈前路减压融合术后植骨融合的影像学评价方法及标准. 中华外科杂志, 2009, 47(23): 1824-1826.
10. Singla M, Goel P, Ansari MS, et al. Morphometric analysis of axis and its clinical significance-an anatomical study of Indian human axis vertebrae. J Clin Diagn Res, 2015, 9(5): AC04-9.
11. Boughton OR, Bernard J, Szarko M. Odontoid process fractures: the role of the ligaments in maintaining stability. A biomechanical, cadaveric study. SICOT J, 2015, 1: 11.
12. Harrop JS, Naroji S, Maltenfort M, et al. Cervical myelopathy: a clinical and radiographic evaluation and correlation to cervical spondylotic myelopathy. Spine (Phila Pa 1976), 2010, 35(6): 620-624.
13. 张静涛, 申勇, 张英泽, 等. 轻中度颈脊髓压迫患者产生脊髓损害症状与体征的危险因素. 中国脊柱脊髓杂志, 2013, 23(2): 145-150.
14. Ames CP, Blondel B, Scheer JK, et al. Cervical radiographical alignment: comprehensive assessment techniques and potential importance in cervical myelopathy. Spine (Phila Pa 1976), 2013, 38 (22 Suppl 1): S149-160.
15. Takeuchi K, Yokoyama T, Aburakawa S, et al. Inadvertent C2-C3 union after C1-C2 posterior fusion in adults. Eur Spine J, 2015, 15(3): 270-277.
16. 黄季晨, 钱邦平, 邱勇. 寰枢椎后路融合术后下颈椎曲度及退变影响因素的研究进展. 中国脊柱脊髓杂志, 2016, 26(6): 545-548.
17. 王建元, 刘华, 盛伟斌. SLIC 评分在下颈椎损伤术式选择中的应用价值. 中国脊柱脊髓杂志, 2016, 26(5): 415-420.
18. Samuel S, Lin JL, Smith MM, et al. Subaxial injury classification scoring system treatment recommendations: external greement study based on retrospective review of 185 patients. Spine (Phila Pa 1976), 2015, 40(3): 137-142.
19. Li F, Chen Q, Xu K. The treatment of concomitant odontoid fracture and lower cervical spine injuries. Spine (Phila Pa 1976), 2008, 33(19): E693-698.
20. Miller CP, Brubacher JW, Biswas D, et al. The incidence of noncontiguous spinal fracturesand other traumatic injuries associated with cervical spine fractures. Spine (Phila Pa 1976), 2011, 36(19): 1532-1540.

Chinese Journal of Reparative and Reconstructive Surgery

Treatment of odontoid fracture combined with lower cervical spinal cord injuries without fracture or dislocation

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