5/31/2013 MANAGEMENT OF THE PAINFUL Disclosures ACUTE GERIATRIC ODONTOID FRACTURE � Research � NIH � Medtronic � Fellowship Support � NREF Vincent C. Traynelis � Globus Department of Neurosurgery Rush University Medical Center � Consultant � Medtronic � Royalties � Medtronic ODONTOID FRACTURES ODONTOID FRACTURES CLASSIFICATION � 10-18% of all cervical fxs � Anderson, D’Alonzo � 60% of all C2 fxs � 3 fracture types � Neuro deficit: 18-26% � Anatomically simple � Most patients are older � Guides treatment � Predicts outcome 1
5/31/2013 ODONTOID FRACTURES Type II Odontoid Fractures TYPE II � No Treatment � Fx at base of odontoid � Collar � 65-70% of odontoid fxs � Halo � 35-85% nonunion rate with external orthosis � Anterior Screw Fixation � Posterior Fusion � Vascular supply � Brooks � Inadequate immobilization � Screw fixation � Transarticular � C1 – C2 pars/pedicle � C1 – C2 laminar Type II Odontoid Fractures Type II Odontoid Fractures � Collar � No Treatment � Clark CR, White AA III. Fractures of the dens: a � Halo multicenter study. J Bone Joint Surg � 0 – 79% success 1985;67A:1340-1348. � Traynelis VC: Evidence-based management of Type II odontoid fractures. Clin Neurosurg 44:41-49, 1997. � 18 patients - 100% nonunion � Patients > 50 years 21 times more likely to fail halo than those less than 50. � Lennarson PJ, Mostafavi H, Traynelis VC, Walters BC: Management of Type II dens fractures. A case-control study. Spine 25:1234-1237, 2000. 2
5/31/2013 Risk Factors for Nonuinon of Type II Odontoid Fracture in Type II Odontoid Fractures treated the Elderly with a Halo � Immobilization � Age > 50 � Low fusion rate - 22% � Displacement greater � Complications – 52% than 6 mm � Mortality (in hospital) – 35% � Comminution of fracture � ? Posterior displacement Frangen et al J Trauma 2007 Anterior Screw Fixation � Apfelbaum et al. Direct anterior screw fixation for recent and remote odontoid fractures. J Neurosurg 93:227-36, 2000 � 127 patients with recent fractures (Type II and III) � 88% fusion rate � 10% hardware complications, 1 death 3
5/31/2013 Anterior Fixation of Odontoid Fractures Anterior Fixation of Odontoid Fractures in the Elderly Daily et al J Neurosurg Spine 2010 in the Elderly Daily et al J Neurosurg Spine 2010 � 57 patients overall � 42 patients >70; mean 15 month � Dysphagia f/u � 35% early postoperative period � Fusion 57% � 25% feeding tube � Stable fibrous union 24% � Nonunion 19% � 2 days – 4 months � Single screw � Pneumonia � 56% stability � 19% � Two screws � Perioperative MI � 96% stability � 5% Anterior Screw Fixation in the Anterior Screw Fixation Elderly � “We conclude that anterior screw fixation according to � Fusion rate 57 – 77% Bohler is associated with an unacceptably high rate of � Complication rate 10 – 35% problems in the elderly. Probable causes may be osteoporosis with comminution at the fracture site, or � Preservation of normal C1C2 rotation - stiffness of the cervical spine preventing ideal positioning unproven of the screws. As non-operative treatment also often fails, the method of choice seems to be posterior C1-C2 fusion.” � Andersson S, Rodrigues M, Olerud C. Odontoid fractures: high complication rate associated with anterior screw fixation in the elderly. Eur Spine J 9:56 – 9, 2000 4
5/31/2013 Posterior Fixation Transarticular Screw Fixation � 98% fusion � Brooks Fusion � 5 DVT, one deep wound infection � 35 – 92% success � Dickman C, Sonntag VKH. Posterior C1-C2 Transarticular Screw Fixation for Atlantoaxial � Traynelis VC: Evidence-based management Arthrodesis Neurosurgery 43:275-280, 1998. of Type II odontoid fractures. Clin Neurosurg 44:41-49, 1997. Atlantal-Axial Fusion Transarticular Screw Fixation � 2002 65 consecutive patients with 2 year � 96% fusion followup � 2 wound infections � 20% unilateral screw � Haid et al. C1-C2 � One nonunion in each Transarticular screw fixation group for atlantoaxial instability: a � Bilateral 6-year experience. � Unilateral Neurosurgery 49:65-70, 2001. 5
5/31/2013 Harms, Melcher: Posterior C1C2 C1-C2 Screw Fixation fusion with polyaxial screw and rod fixation. Spine 2001 � 100% fusion � “No neurological, vascular, or infective 100% fusion complications.” no neural or vascular � Goel et al. Atlantoaxial injuries fixation using plate and screw method: a report of 160 treated patients. Neurosurgery 51:1351-6, 2002. Wright NM. Posterior C2 fixation using bilateral, crossing C2 laminar screws: case series and technical note. J Spinal Disord Tech 2004 6
5/31/2013 Geriatric Odontoid Fractures Geriatric Odontoid Fractures � 68 consecutively operated patients older than � Treatments 65 years � Transarticular screws 24 � Mean 78.5 (65 – 93) (27 female, 41 male) � C1 – pars/pedicle 20 � Follow up � C1 – laminar 16 � 3 deaths � Hybrid 8 � Quadraplegic, PE, pulmonary insufficiency did not � Rib autograft, cable C12 when possible want vent � Less than 4 months - 8 patients (some recent) � Postoperative Immobilization � 57 patients � 17 none � 18 months mean follow up � MJ Mean 7.5 weeks (4 – 12) Geriatric Odontoid Fractures Geriatric Odontoid Fractures � C1 fractures � 80% had preop pain � Posterior arch 7 � Mean VAS � Preop 4.1, Postop 1.0 � Jefferson 7 � 11 treated 6 months post injury � Misc injuries � Significant instability, Pain � Long bone, facial fractures, single head injury � Mean VAS � Expected comorbidities � Preop 4.7, Postop 0.5 HTN (26), cardiac (21), COPD (7), diabetes (5), cancer, dementia, Parkinson, COPD, CVA 7
5/31/2013 Geriatric Odontoid Fractures Geriatric Odontoid Fractures � Complication Rate 18% � Nonunion Rate 9%, 2 reoperated � Pneumonia (5), wound infection (3, only 1 subfascial), pulmonary edema, MI, PE, ARDS � Transarticular 1 � Dysphagia 12% (3 with short term Dobhoff) � C1 lateral mass/C2 translaminar 4/16 (25%) � Neurological decline 8% � All C2 hypesthesia � Pars/Pedicle (4), Laminar (1) � Mean Nurick Pre – 0.8 (0 – 5); Post 0.5 (0 – 5) 8
5/31/2013 Geriatric Odontoid Fractures � Interarticular spacers � Stiffens the segment � Load shares with the instrumentation � Requires section of the C2 roots Geriatric Odontoid Fractures � Posterior fusion morbidity and mortality is acceptable � Dysphagia and nonunion rates much less than with anterior procedure � C1 – C2 translaminar technique only if no other option 9
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