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Background: The management of odontoid fracture has evolved but controversy persists as to the best method for Type II odontoid fractures with or without atlantoaxial (AA) instability.
Number of cases has increased over last 50 years, probably because of an increase in high speed motor vehicle accidents.
40% are associated with head injuries, and 15-20% are associated with additional cervical spine injuries. This is a great diagram from the Mayfield Clinic on a Normal Brain and a Brain with Chiari 1 Malformation. Chiari I malformation is a condition in which the bony space enclosing the lower part of the brain is smaller than normal. Of the several types of Chiari malformations, Chiari I is the most common and affects both children and adults. Cerebrospinal fluid (CSF) is a clear, watery substance that flows within and around the brain and spinal cord to help cushion it from injury. The condition begins with the underdevelopment of the fetal skull forming during pregnancy.
In some cases, the CSF collects within the ventricles of the brain (hydrocephalus); this condition may require placement of a shunt to divert this excess fluid. Chiari I symptoms vary from person to person and are not necessarily related to the size of tonsillar herniation.
Because the brainstem is responsible for most body functions, Chiari causes all kinds of strange symptoms. Ehlers-Danlos syndrome (EDS) is a connective tissue disorder that may increase the incidence and severity of Chiari. The complex symptoms of Chiari I malformation can mimic other diseases – often leading to misdiagnosis and delay in treatment. A complete medical history and physical exam can determine if your symptoms are related to Chiari or another problem. Magnetic resonance imaging (MRI) scan is a noninvasive test used to evaluate the brain, spinal cord, and surrounding CSF. Treatment options vary depending on the severity of symptoms, the extent of tonsillar herniation, and the presence of other conditions such as syringomyelia. Monitoring by regular check-ups and periodic MRI scans may be recommended for those with mild or no symptoms.
During posterior fossa decompression surgery, removal of bone (craniectomy) at the back of the skull and spine widens the foramen magnum.
If you have questions, please contact the Mayfield Chiari Center at 800-325-7787 or 513-221-1100. Mayfield Certified Health Info materials are written and developed by the Mayfield Clinic & Spine Institute in association with the University of Cincinnati College of Medicine. Figure 3: Pre-reduction (A) and post-reduction (B) sagittal T-2 Weighted MRI of the cervical spine of Case #5.
A fracture of the pars interarticularis on the pedicle of the C2 vertebrae (axis) is often called a “hangman’s” fracture. A burst fracture of the C1 vertebrae (atlas) is often called a Jefferson fracture and is not commonly associated with spinal cord damage.
A tear drop fracture is a flexion compression injury often associated with diving accidents.
Any patient admitted to a trauma center or emergency care center with a mechanism of injury that fits the etiology described below should be evaluated for a cervical spine fracture or injury. According to the criteria developed by the American National Emergency X-radiography Utilization Study(NEXUS), conscious, coherent patients with no midline cervical pain, no neurological signs, and no severe distracting injuries, only need a simple physical evaluation to rule out fracture.7 If there are cervical symptoms, imaging is indicated. According to the same criteria, if the patient is intoxicated, unconscious, or uncooperative, they should be considered high risk for cervical fracture and imaging should be done as soon as possible and the use of a CT scan is indicated because it has been shown to be more reliable than x-ray in this population. If a patient with a broken neck came to clinic, it would most likely be after the fracture has healed and been cleared by a physician as ready for rehabilitation.
However, in light of direct access, it is relevant to mention that if a patient does come in complaining of neck pain following a traumatic injury to the head or neck, DO NOT TREAT THEM without medical clearance by a physician.
The mechanism of injury in cervical fractures is often forced hyperextension or extreme flexion. The sensitivity for 3-view x-ray imaging is about 35-72% but this includes high-risk patients. After a patient’s fractured has healed and been cleared by a physician, they may be referred to rehabilitation for range of motion, strengthening and pain relief.
As a part of the initial evaluation, it would be appropriate to include cervical ligament stress tests, a vertebral artery test and a neurological exam if any nerve damage or spinal cord injury is suspected. Treatments for cervical spine fractures vary greatly depending on the stability of the fracture, the location, and involvement of the spinal cord, spinal nerves, and vertebral artery. Type II: Caused by axial loading and hyperextension followed by a rebound flexion and axial loading. Most Type I, II, and some IIA hangman fractures are treated effectively with a halo vest.11,4 This brace utilizes pins placed in the skull attached to metal braces that prevent any neck movement. The best parameters to use for light and laser therapy are still inconclusive at this time. The anterior odontoid screw fixation can be associated with significant morbidity while delayed odontoid screw fixation has shown to be associated with reasonable good fusion rates.
Treatment of remote type II axis fractures in the elderly: feasibility of anterior odontoid screw fixation.
Odontoid fractures: High complication rate associated with anterior screw fixation in elderly. Atlantoaxial joint distraction for the treatment of basilar invagination secondary to rheumatoid arthritis. Crowding causes the cerebellar tonsils to push through the skull and down into the spinal canal. This fluid is produced inside the ventricles by the choroid plexus and is constantly being absorbed and replenished. When cerebrospinal fluid (CSF) flow is obstructed and collects within the spinal canal, it can eventually form a syrinx.
There is a high rate of scoliosis associated with Chiari and syringomyelia, especially in children. At times, Chiari I is mistaken for fibromyalgia, chronic fatigue syndrome, migraine, multiple sclerosis, mental disorder, depression, sinus disease, trigeminal neuralgia, or other neurologic disorders. A neurological exam detects problems with cranial nerves such as gag reflex, facial numbness, hoarseness, double vision, tremors, and vision problems. With each heartbeat, CSF is forced out of the ventricle of the brain, into the cisterna magna, and down the spinal canal.


The goals of surgery are to stop or control the progression of symptoms caused by herniation of the cerebellar tonsils, and relieve compression of the brainstem. The surgeon opens the dura overlying the tonsils and sews a dura patch to expand the space, similar to letting out the waistband on a pair of pants (Fig.
Please respect artists' copyrights by only viewing the content of this site and pages within this site on your computer in its live published form. The distance between the McGregor line and the midpoint of the caudal margin of the second cervical vertebral body is measured. The posterior approach allows for C1 laminectomy in addition to reduction and restoration of cervical alignment which greatly increases the space available for the cord.
Image guidance using intraoperative image acquisition provides a valuable tool in modern surgical treatment of odontoid fractures. There are seven cervical bones and if any of these become fractured or severely dislocated, the neck can be described as broken. The most common Jefferson fractures are from axial compression caused by diving into shallow water, falling from a height onto the head, or motor vehicle accidents that cause the head to be thrown into the windshield.
It is characterized by an anteroinferior bone fragment that rotates anteriorly because of pull from the intact anterior longitudinal ligament. This is especially true in cases where the patient is experiencing a high amount of neck pain or neural issues. X-ray imaging or a CT scan needs to be performed in order to clear the neck for treatment and rule out possible fractures. Straight axial compression to the head and direct trauma to the neck can also cause fractures. Obtaining x-rays in high risk patients can be tricky and often results in poor quality images. These collars just help support the head while the neck is healing but they do not prevent movement so they are not good for unstable fractures. Operative treatment for cervical fracture and dislocation with blunt unilateral vertebral artery injury. However, the use of low level laser and light therapy has been shown to maybe aid in tissue healing and bone growth12. We conducted a retrospective analysis to evaluate the outcome of a trial of conservative management in type II odontoid fractures without atlantoaxial instability (Group A) followed by delayed odontoid screw fixation in cases in which fusion was not achieved by conservative treatment. Smith, Wei Dong Mu, Lian Xin Li, Dong Sheng Zhou European Spine Journal.
If symptoms are severe or worsening, surgery may be recommended to remove a part of the skull bone and create space for the cerebellum and brainstem. The CSF flows through the ventricles and out into the space between the brain and skull (subarachnoid space) and down into the spinal canal (Fig.
However, the small size or shape of the Chiari skull is mismatched to the size of the brain. In some cases, a head or neck injury from a car accident or sports injury triggers the onset of symptoms.
If too small, the effects can be crowding of the brainstem and cerebellum, as well as herniation of the tonsils through the foramen magnum.
Now with increasing use of diagnostic imaging, physicians note that Chiari may be far more common. You may be asked to see an eye (ophthalmologist) or ear (otolaryngologist) specialist, or to undergo a sleep evaluation. Information about current clinical trials, including eligibility, protocol, and locations, are found on the Web. Chiari I malformation redefined: clinical and radiographic findings for 364 symptomatic patients. This information is not intended to replace the medical advice of your health care provider. Altering, printing, copying, saving, distributing or any other unauthorized use of the images or content on this site requires written authorization. A measurement of less than 34 mm in males and less than 29 mm in females indicates basilar invagination.
In some cases, the fractured or dislocated vertebrae can cause compression and damage to the spinal cord resulting in neurological symptoms or paralysis. A combination of hyperextension or flexion with axial compression is the best recipe for a cervical fracture. More research will have to be done in order to understand what the best method is in this population.
For reduction of pain, the application of a cold pack for 10-20 minutes can help increase pain tolerance, decrease muscle spasm, and lower nerve conduction velocity.12 The application of hot packs can also relieve pain through different modes and also should be applied for 10-20 minutes. A nationwide review of the associations among cervical spine injuries, head injuries, and facial fractures. Diagnostic imaging of cervical spine injuries following blunt trauma: A review of the literature and practical guideline. The outcome of type II odontoid fracture with AA subluxation (Group B) was also analysed where closed reduction on traction could be achieved and in those atlantoaxial subluxations that were irreducible an intraoperative reduction was done. In people with Chiari, the cerebellar tonsils are stretched as they push through the foramen magnum.
The herniation may reach to the level of the first two vertebra (C1 or C2) of the cervical spine. Avoid injury or manipulation of the neck as it can make the herniation worse or aggravate the spinal cord.
Protrusion of the odontoid tip posterior to the projection of this line indicates basilar invagination. The patient should always be checked to make sure the ice or heat are not causing any skin damage and If there is sensory nerve damage, ice and heat are contraindicated as the patient may not be able to detect how hot or cold the treatment is.
European Spine Journal: Official Publication Of The European Spine Society, The European Spinal Deformity Society, And The European Section Of The Cervical Spine Research Society.
Materials and Methods: A retrospective evaluation of 53 cases of odontoid fractures treated over a 9-year period is being reported. Uschold,Amanda Loh,Nicholas Theodore Journal of Spinal Disorders and Techniques.
Symptoms may not appear until late childhood or adulthood, causing severe headache, neck pain, dizziness, numbness in the hands, and sleep problems. Crowding pushes the tonsils out of the skull through the opening (foramen magnum) where the spinal cord exits (Fig.
As a result, the diagnosis of Chiari is often delayed until more severe symptoms occur or after current symptoms persist for some time.


The test can determine if, and by how much, a Chiari is blocking the back-and-forth flow of CSF between the brain and spine. All odontoid fractures without AA instability (n=29) were initially managed conservatively.
The classic definition of Chiari I is herniation greater than 5mm below the foramen magnum.
If symptoms worsen or if new ones develop, consult with a neurosurgeon who is a Chiari expert. Three patients who did not achieve union with conservative management were treated with delayed anterior screw fixation.
Herniation of the cerebellar tonsils can extend several millimeters below the foramen magnum. Twenty-four cases of odontoid fractures were associated with AA instability; 17 of them could be reduced with skeletal traction and were managed with posterior fusion and fixation.
The tonsils put pressure on the brainstem and spinal cord, block CSF flow, and result in the Chiari signs and symptoms. Someone without herniation may have severe symptoms while another with 20-mm herniation may have no symptoms.
Of the seven cases that were irreducible, the initial three cases were treated by odontoid excision followed by posterior fusion and fixation; however, in the later four cases, intra operative reduction was achieved by a manipulation procedure, and posterior fusion and fixation was performed. Separation of more than 6 mm and fractures in elderly patients are also associated with poorer union rates.
Results: Twenty-six of 29 cases of odontoid fracture without AA instability achieved fracture union with conservative management whereas the remaining three patients achieved union following delayed anterior odontoid screw fixation. 17 out of 24 odontoid fracture with atlantoaxial dislocation could be reduced on traction and these patients underwent posterior fusion and fixation. Excess CSF can collect and enlarge either the ventricles in the brain (hydrocephalus), or form a cyst in the spinal cord (syringomyelia). Optimal or near optimal reduction was achieved by on table manipulation in four cases which were irreducible with skeletal traction. The outcome of type II odontoid fracture with AA subluxation (Group B) was also analysed where closed reduction on traction could be achieved and in those atlantoaxial subluxations that were irreducible, an intraoperative reduction was done. All patients seen in casualty with suspected cervical spine injuries, restriction of neck movements, or a neurological deficit suggestive of cervical cord injury and patients with concussional head injury were subjected to X-ray analysis of the cervical spine (anterior-posterior and lateral x-rays, further followed by flexion and extension lateral view and open mouth AP view). All patients with neurological deficits were mandatorily subjected to magnetic resonance imaging (MRI) scans, while patients with no neural deficit were subjected to MRI scans if the X-ray showed evidence of fracture instability.Patients who were noted to have associated congenital anomalies as well as all cases where the anterior odontoid screw fixation or C1 lateral mass-C2 transpedicular stabilization was considered were also subjected to computed tomography (CT) scans to assess odontoid separation, the feasibility of placement of the screws, and the proximity to the foramen transversarium. The 53 cases were classified as per Anderson and d'Alonso [2] into Type I (n=3), Type II (n=37), and Type III (n=13). Type II cases were further divided into Type a (n=12), Type b (n=17), and Type c (n=8) of Apfelbaum. All cases were initially subjected to external immobilization with a Halo brace for a period of 6 weeks and later if required odontoid fixation was done. Due to the initial lack of familiarity with transarticular and lateral mass fixation techniques, patients with intact C1 posterior arch were fixed with sublamilar wires (n=6) and those with fractured or hypoplastic C1 arch underwent occipitocervical fixation (n=3).
All these cases were performed as two-stage procedures.The last four cases in whom atlantoaxial subluxation was irreducible with skeletal traction were subjected to intraoperative manipulation of C1-C2 to achieve reduction, after which posterior fixation was performed, obviating the need for transoral odontoid excision. One loop of 21 gauge stainless steel was passed under the C1 lamina while a second loop was passed under C1-C2 laminae. After excision of the C2 spinal ganglion, the capsule of the C1-C2 articular facets and articular cartilage are drilled and curetted to free the joints. Steady traction was applied downwards and backwards on the C1 posterior arch using the sublaminar C1 wire; at the same time the C2 spinous process was pushed forward and upward under constant fluoroscopic guidance [Figure 1].
Once acceptable reduction was achieved, the C1-C2 sublaminar wire was tightened over an iliac bone graft to achieve fixation and the C1 wire was removed. Subsequently, C1-C2 fixation was performed using trans-articular screws or lateral mass fixation using screws and plates (two cases each).All patients were subjected to detailed neurological evaluation as well as cervical spine radiographs, open mouth view and lateral flexion and extension views at the time of discharge.
They were reviewed at 6-week, 12-week, and 6-month intervals and on each of these visits, neurological assessment and X-rays were recorded. Fusion of odontoid fractures and assessment of post-fixation stability were confirmed by radiographs (open mouth view, flexion, and extension lateral films). Of the remaining six patients, three patients (fracture site separation less than 6 mm) achieved union after being subjected to an additional 6 weeks of immobilization.
One patient who had a less than 6 mm fracture separation and did not achieve fusion despite 12 weeks of immobilization also underwent anterior odontoid screw fixation. In all cases, a single cortical screw was used and lag effect was achieved by oversize tapping of the proximal bone [Figure 2]. Of the seven cases of odontoid fracture with irreducible atlantoaxial instability, the initial three cases underwent an initial transoral odontoid exicision followed by a second stage C1-C2 sublamilar wiring with Gallie fusion.
In the remaining four cases, on-table reduction by direct C1-C2 manipulation was performed to achieve complete reduction in three cases and near total reduction in one case. In all four cases, posterior fixation (transarticular fixation in two cases and C1 lateral mass-C2 transpedicular fixation in two cases [Figure 3]) was performed. Six patients with reducible atlantoaxial instability were treated with sublaminar wiring and Gallie fusion.
In two cases with C1 posterior arch fractures and one case with partly occipitalized hypoplastic C1 arch, occipito-C2 fusion was achieved using plates and screws with supplemented onlay graft. In all three cases, fresh wiring with supplementation of graft with transarticular screw fixation was performed.Transarticular screw fixation was performed in a total of eight cases.
In one case, the transarticular fusion was supplemented by an occipitocervical fixation and onlay graft. Neck movement was significantly restricted in a patient in whom occipitocervical fixation was done.All cases treated with transarticular screws with C1 lateral mass-C2 transpedicular fixation [Figure 3] and [Figure 4] showed no evidence of instability on follow-up flexion extension radiographs. Studies have reported success rates of 85-100% in both transarticular fixation and in C1-C2 lateral mass fixation procedures. As the screw was already placed on the opposite side, fixation on the side of vertebral artery injury was deffered. One patient developed an occipital bed sore that needed a small rotation flap.There was no mortality encountered in the study and the complications associated with the procedures performed are enlisted in [Table 2], Chart 2 - [Additional file 2] . However the morbidity and mortality associated with the procedure especially in the elderly and the good results achieved with delayed odontoid fixation prompts us to consider a trial of conservative management in these patients and reserving odontoid fixation for patients in whom conservative treatment has failed. Of the 29 cases of odontoid fractures without subluxation, the fusion rates achieved by us are in keeping touch with fusion rates achieved in earlier studies (100% in Type I and 84-88% in Type III fractures).



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