Single segment fixation with atlantoaxial pedicle screws in the treatment of Jefferson fracture combined with unstable odontoid fracture

doi:10.3969/j.issn.2095-4344.2017.31.007

Abstract

Abstract:

BACKGROUND: Jefferson fracture associated with unstable odontoid fracture is rare, and little reported. Occipito-cervical fusion is the commonly used treatment method, but it causes a severe loss of the motion of cervical vertebrae, which affects the patients’ quality of life, so the curative effect is poor.

OBJECTIVE: To evaluate the feasibility and therapeutic efficacy of atlantoaxial transpedicular screw fixation for Jefferson fracture associated with unstable odontoid fracture, so as to avoid occipito-cervical fusion and preserve the motion of the atlanto-occipital joint.

METHODS: Fifteen patients with Jefferson fracture associated with unstable odontoid fracture from March 2010 to August 2015, were treated with atlantoaxial transpedicular screw fixation. There were 13 cases of Anderson type II and 2 cases of Anderson shallow type lll odontoid fracture, as well as 5 cases combined with transverse atlantal ligament rupture. All patients underwent skull traction after admission, as well as three-dimensional CT was applied preoperatively to determine the atlas pedicle screw trajectory and chose suitable screws. Atlantoaxial transpedicular screw was placed and atlantoaxial joint was reduced under general anesthesia. Bone graft fusion of atlantoaxial joint was applied only for the transverse atlantal ligament. The pain and neurologic function were evaluated by the Visual Analog Scale and the American Spinal Injury Association Impairment Scale before and after operation. The range of motion of the atlanto-occipital joint was observed during follow-up.

RESULTS AND CONCLUSION: (1) The mean operation time was (150±41) minutes (120-270 minutes). The mean blood loss was (246±95) mL (160-500 mL). (2) Atlantoaxial transpedicular screws were successfully placed in all patients. No spinal and nerve root injury, or vertebral artery injury occurred intraoperatively. The atlantoaxial achieved good reduction. (3) The follow-up time was 12-36 months. There were nine cases of incomplete spinal cord injury, and 7 cases of obviously improved neurologic function. The visual analog scale scores were significantly improved at 1 year postoperatively, from preoperative (8.15±0.62) to postoperative (1.2±1.4) (P < 0.05). (4) All fractures and bone grafts were healed without loosening or rupture of the screws. The range of motion of the atlanto-occipital joint was (14.6±2.8)° postoperatively. (5) To conclude, atlantoaxial transpedicular screw fixation is effective for Jefferson fracture combined with unstable odontoid fracture, which not only exhibits a high rate of bone healing and stable fixation, but also avoids the occipital-cervical fusion and preserves occipito-atlantal motion.

中国组织工程研究杂志出版内容重点：人工关节；骨植入物；脊柱；骨折；内固定；数字化骨科；组织工程

Key words: Axis, Fractures, Bone, Internal Fixators, Tissue Engineering

CLC Number:

R318

Qu Wei, Yan Liang, Song Zong-rang, Liu Ji-jun, Wu Qi-ning, Hao Ding-jun. Single segment fixation with atlantoaxial pedicle screws in the treatment of Jefferson fracture combined with unstable odontoid fracture[J]. Chinese Journal of Tissue Engineering Research, 2017, 21(31): 4957-4962.

Figures/Tables 2

References

[1] 田伟.关于寰枢椎复合骨折的治疗[J]. 中国脊柱脊髓杂志,2013, 23(5): 388-389.

[2] Jefferson G. Fracture of the atlas vertebra. Report of four cases, and a review of those previously recorded. Brit J Surg. 1919; 7(27): 407-422.

[3] 胡东才,王建平. Jefferson骨折的相关勘误及寰椎骨折分型[J].中国脊柱脊髓杂志, 2014, 24(12):1135-1136.

[4] Longo UG, Denaro L, Campi S, et al. Upper cervical spine injuries: indications and limits of the conservative management in Halo vest. A systematic review of efficacy and safety. Injury. 2010; 41(11):1127-1135.

[5] Ergün K, Adem A, Olcay E, et al. Halo vest treatment of upper cervical vertebral fracture. J Clin Exp Inv. 2013; 4(2):171-174.

[6] Bransford RJ, Stevens DW, Uyeji S, et al. Halo vest treatment of cervical spine injuries: a success and survivorship analysis. Spine(Phila Pa 1976). 2009; 34(15):1561-1566.

[7] Vieweg U, Schultheiss R. A review of halo vest treatment of upper cervical spine injuries. Arch Orthop Trauma Surg. 2001; 121(1-2):50-55.

[8] Deen HG, Tolchin S. Combination jefferson fracture of C1 and type II odontoid fracture requiring surgery: report of two cases. Neurosurgery.1989; 25(2):293-297.

[9] Hein C, Richter HP, Rath SA. Atlantoaxial screw fixation for the treatment of isolated and combined unstable jefferson Fractures-experiences with 8 Patients. Acta Neurochir(Wien). 2002; 144(11):1187-1192.

[10] Guiot B, Fessler RG. Complex atlantoaxial fractures. J Neurosurg. 1999; 91(2 Suppl):139-143

[11] Ben Aicha K, Laporte C, Akrout W, et al. Surgical management of a combined fracture of the odontoid process with an atlas posterior arch disruption: a review of four cases. Orthop Traumatol Surg Res. 2009; 95(3):224-228.

[12] Strohm PC, Muller Ch A, Kostler W, et al. Halo-fixator vest--indications and complications. Zentralbl Chir. 2007; 132(1):54-59.

[13] Liu C, Kuang L, Wang L, et al. Management of combination fractures of the atlas and axis: a report of four cases and literature review. Int J Clin Exp Med. 2014; 7(8): 2074-2080.

[14] Kesterson L, Benzel E, Orrison W, et al. Evaluation and treatment of atlas burst fractures(Jefferson fractures). J Neurosurg.1991; 75(2):213-220.

[15] Satyarthee GD, Vaghani G, Mahapatra AK. Surgical management of combined fracture of atlas associated with fracture of axis vertebrae(CAAF): Case series. Romanian Neurosurgery. 2015; 29(3):335-341.

[16] Steinmetz MP, Mroz TE, Benzel EC. Craniovertebral junction: biomechanical considerations. Neurosurgery. 2010; 66 (3 Suppl): 7-12.

[17] Tan M, Wang H, Wang Y, et al. Morphometric evaluation of screw fixation in atlas via posterior arch and lateral mass. Spine. 2003; 28(9):888-895.

[18] Harms J, Melcher RP. Posterior C1-C2 fusion with polyaxial screw and rod fixation. Spine. 2001; 26(22):2467-2471.

[19] Rizvi SA, Fredo HL, Lied B, et al. Surgical management of acute odontoid fractures: surgery-related complications and long-term outcomes in a consecutive series of 97 patients. J Trauma Acute Care Surg. 2012; 72(3):682-690.

[20] Pawar AY, O'Leary PF. Combined Type II Odontoid Fracture with Jefferson's Fracture Treated with Temporary Internal Fixation. Asian Spine J. 2015; 9(6):966-970.

[21] Kalantar SB. Fracture of the C1 and C2 vertebrae. Seminars in spine surgery. 2013; 25(1):23-35.

[22] Walters BC, Hadley MN, Hurlbert RJ, et al. Guidelines for the management of acute cervical spine and spinal cord injuries: 2013 update. Neurosurgery. 2013; 60(Suppl 1): 82-91.

[23] Julien TD, Frankel B, Traynelis VC, et al. Evidence-based analysis of odontoid fracture management. Neurosurg Focus. 2000; 8(6): e1.

[24] Kim SK, Shin JJ, Kim TH, et al. Clinical outcomes of halo-vest immobilization and surgical fusion of odontoid fractures. J Korean Neurosurg Soc. J korean Neurosurg Soc. 2011; 50(1):17-22.

[25] Dickman CA, Hadley MN, Browner C, et al. Neurosurgical management of acute atlas-axis combination fractures. A review of 25 cases. J Neurosurg. 1989; 71(1):45-49.

[26] Anderson LD, D’Alonzo RT. Fractures of the odontoid process of the axis. J Bone Joint Surg Am. 1974; 56(8):1663-1674.

[27] Wang J, Zhou Y, Zhang ZF, et al. Comparison of percutaneous and open anterior screw fixation in the treatment of type II and rostral type III odontoid fractures. Spine. 2011; 36(18):1459–1463.

[28] 刘文亮,蒋欣浩,黄威,等.齿状突骨折的分型与诊治研究进展[J].骨科,2015,6(1):53-56.

[29] Casper DS, Mckenzie J, Schroeder GD. Controversial cervical spine fractures: Classification and treatment. Semin Spine Surg. 2017; 29 : 41-49.

[30] Eysel P, Roosen K. Ventral or dorsal spondylodesis in densbasal fracture-a new classification for choice of surgical approach. Zentralbl Neumchir. 1993; 54(4)：159-165.

[31] 黄威,蔡贤华,李彦锦. II型齿状突骨折手术治疗与并发症分析[J]. 中国矫形外科杂志, 2013,21(4):359-362.

[32] Elliott RE, Tanweer O, Boah A, et al. Outcome comparison of atlantoaxial fusion with transarticular screws and screw-rod constructs: meta-analysis and review of literature. J Spinal Disord Tech. 2014; 27(1):11-28.

[33] 柳超,王前,张杰峰,等.不同内固定手术方式治疗寰枢椎复合骨折稳定性的有限元分析[J]. 中国脊柱脊髓杂志, 2015, 25(10): 904-911.

[34] Haus BM, Harris MB. Case report: nonoperative treatment of an unstable Jefferson fracture using a cervical collar. Clin Orthop Relat Res. 2008; 466(5):1257-1261.

[35] 洪波,向铁城,黄象望,等. 寰枢椎椎弓根螺钉经后路固定融合治疗Jefferson骨折伴齿状突骨折[J]. 医学临床研究, 2014,31(1):90-93.

[36] 陈卫,丁真奇,康两期,等. 寰枢椎椎弓根螺钉固定治疗Jefferson骨折合并齿状突骨折[J]. 中国脊柱脊髓杂志, 2008, 18(1):50-54.

[37] Guo Q, Zhang M, Wang L, et al. Comparison of atlantoaxial rotation and functional outcomes of two nonfusion techniques in the treatment of Anderson-D' Alonzo TypeⅡodontoid fractures. Spine(Phila Pa 1976). 2016; 41(12):e751-758.

[38] Ni B, Guo Q, Lu X, et al. Posterior reduction and temporary fixation for odontoid fracture: a salvage maneuver to anterior screw fixation. Spine(Phila Pa 1976). 2015; Spine(Phila Pa 1976). 2015; 40(3): e167-174.

[39] Guo Q, Deng Y, Wang J, et al. Comparison of clinical outcomes of posterior C1-2 temporary fixation without fusion and C1-2 fusion for fresh odontoid fractures. Neurosurgery. 2015; 78(1):77-83.

[40] Mead LB 2nd, Millhouse PW, Krystal J, et al. C1 fractures: a review of diagnoses, management options, and outcomes. Curr Rev Musculoskelet Med. 2016; 9(3): 255-262.