Seminars in Spine Surgery
Volume 19, Issue 4 , Pages 235-243 , December 2007

Odontoid Fractures: Current Evaluation and Treatment Principles

  • David H. Kim, MD

      Affiliations

    • Tufts University Medical School, New England Baptist Hospital, Boston, MA.
    • Corresponding Author InformationAddress reprint requests to David H. Kim, MD, Assistant Clinical Professor of Orthopaedic Surgery, Tufts University Medical School, New England Baptist Hospital, 125 Parker Hill Avenue, Boston, MA 02120.
    • ,
  • K. Daniel Riew, MD

      Affiliations

    • Washington University School of Medicine, St. Louis, MO.

References 

  1. Clark CR, White AA. Fractures of the dens (A multicenter study). J Bone Joint Surg Am. 1985;67:1340–1348
  2. Bucholz RW, Burkhead WZ, Graham W, et al. Occult cervical spine injuries in fatal traffic accidents. J Trauma. 1979;19:768–771
  3. Huelke DF, O’Day J, Mendelsohn RA. Cervical injuries suffered in automobile crashes. J Neurosurg. 1981;54:316–322
  4. Anderson LD, D’Alonzo RT. Fractures of the odontoid process of the axis. J Bone Joint Surg Am. 1974;56:1663–1674
  5. Greene KA, Dickman CA, Marciano FF, et al. Acute axis fractures (Analysis of management and outcome in 340 consecutive cases). Spine. 1997;22:1843–1852
  6. Hadley MN, Browner CM, Liu SS, et al. New subtype of acute odontoid fractures (type IIA). Neurosurgery. 1988;22(1 Pt. 1):67–71
  7. Przybylski GJ, Welch WC. Longitudinal atlantoaxial dislocation with type III odontoid fracture (Case report and review of the literature). J Neurosurg. 1996;84:666–670
  8. Hammer AJ. Lower cranial nerve palsies (Potentially lethal in association with upper cervical fracture-dislocations). Clin Orthop Relat Res. 1991;266:64–69
  9. Kirkpatrick JS, Sheils T, Theiss SM. Type-III dens fracture with distraction: an unstable injury (A report of three cases). J Bone Joint Surg Am. 2004;86:2514–2518
  10. Bergenheim AT, Forssell A. Vertical odontoid fracture (Case report). J Neurosurg. 1991;74:665–667
  11. Johnson JE, Yang PJ, Seeger JF, et al. Vertical fracture of the odontoid: CT diagnosis. J Comput Assist Tomogr. 1986;10:311–312
  12. Kokkino AJ, Lazio BE, Perin NI. Vertical fracture of the odontoid process: case report. Neurosurgery. 1996;38:200–202discussion 202-203
  13. Barker L, Anderson J, Chesnut R, et al. Reliability and reproducibility of dens fracture classification with use of plain radiography and reformatted computer-aided tomography. J Bone Joint Surg Am. 2006;88:106–112
  14. Grauer JN, et al., Shafi B, Hilibrand AS Proposal of a modified, treatment-oriented classification of odontoid fractures. Spine J. 2005;5:123–129
  15. Heggeness MH, Doherty BJ. The trabecular anatomy of the axis. Spine. 1993;18:1945–1949
  16. Amling M, Hahn M, Wening VJ, et al. The microarchitecture of the axis as the predisposing factor for fracture of the base of the odontoid process (A histomorphometric analysis of twenty-two autopsy specimens). J Bone Joint Surg Am. 1994;76:1840–1846
  17. Althoff B. Fracture of the odontoid process (An experimental and clinical study). Acta Orthop Scand Suppl. 1979;177:1–95
  18. Govender S, Maharaj JF, Haffajee MR. Fractures of the odontoid process. J Bone Joint Surg Br. 2000;82:1143–1147
  19. Alker GJ, Oh YS, Leslie EV, et al. Postmortem radiology of head neck injuries in fatal traffic accidents. Radiology. 1975;114:611–617
  20. Mouradian WH, Fretti VG, Cochran GV, et al. Fractures of the odontoid: a laboratory and clinical study of mechanisms. Orthop Clin North Am. 1978;9:985–1001
  21. Doherty BJ, Heggeness MH, Esses SI. A biomechanical study of odontoid fractures and fracture fixation. Spine. 1993;18:178–184
  22. Yoganandan N, Baisden JL, Maiman DJ, et al. Type II odontoid fracture from frontal impact: case report and biomechanical mechanism of injury. J Neurosurg Spine. 2005;2:481–485
  23. Yoganandan N, Pintar FA. Odontoid fracture in motor vehicle environments. Accid Anal Prev. 2005;37:505–514
  24. Graham RS, Oberlander EK, Stewart JE, et al. Validation and use of a finite element model of C-2 for determination of stress and fracture patterns of anterior odontoid loads. J Neurosurg. 2000;93(suppl 1):117–125
  25. Sasso RC, Reilly TM. Odontoid fractures: evaluation and management options. Semin Spine Surg. 2001;13:106–115
  26. Pepin JW, Bourne RB, Hawkins RJ. Odontoid fractures, with special reference to the elderly patient. Clin Orthop Relat Res. 1985;193:178–183
  27. Teo EC, Paul JP, Evans JH, et al. Experimental investigation of failure load and fracture patterns of C2 (axis). J Biomech. 2001;34:1005–1010
  28. Bell HS. Paralysis of both arms from injury of the upper portion of the pyramidal decussation: “cruciate paralysis”. J Neurosurg. 1970;33:376–380
  29. Inamasu J, Hori S, Ohsuga F, et al. Selective paralysis of the upper extremities after odontoid fracture: acute central cord syndrome or cruciate paralysis?. Clin Neurol Neurosurg. 2001;103:238–241
  30. Blacksin MF, Avagliano P. Computed tomographic and magnetic resonance imaging of chronic odontoid fractures. Spine. 1999;24:158–161discussion 162
  31. Greene KA, Dickman CA, Marciano FF, et al. Transverse atlantal ligament disruption associated with odontoid fractures. Spine. 1994;19:2307–2314
  32. Vaccaro AR, An HS, Lin S, et al. Noncontiguous injuries of the spine. J Spinal Disord. 1992;5:320–329
  33. Apuzzo ML, Heiden JS, Weiss MH, et al. Acute fractures of the odontoid process (An analysis of 45 cases). J Neurosurg. 1978;48:85–91
  34. Hadley MN, Dickman CA, Browner CM, et al. Acute axis fractures: a review of 229 cases. J Neurosurg. 1989;71(5 Pt. 1):642–647
  35. Dunn ME, Seljeskog EL. Experience in the management of odontoid process injuries: an analysis of 128 cases. Neurosurgery. 1986;18:306–310
  36. Hadley MN, Browner C, Sonntag VK. Axis fractures: a comprehensive review of management and treatment in 107 cases. Neurosurgery. 1985;17:281–290
  37. Schatzker J, Rorabeck CH, Waddell JP. Fractures of the dens (odontoid process) (An analysis of thirty-seven cases). J Bone Joint Surg Br. 1971;53:392–405
  38. Crockard HA, Heilman AE, Stevens JM. Progressive myelopathy secondary to odontoid fractures: clinical, radiological, and surgical features. J Neurosurg. 1993;78:579–586
  39. Doherty BJ, Heggeness MH. Quantitative anatomy of the second cervical vertebra. Spine. 1995;20:513–517
  40. Seybold EA, Bayley JC. Functional outcome of surgically and conservatively managed dens fractures. Spine. 1998;23:1837–1845discussion 1845-1846
  41. Müller EJ, Schwinnen I, Fischer K, et al. Non-rigid immobilisation of odontoid fractures. Eur Spine J. 2003;12:522–525
  42. Kim DH, Vaccaro AR, Affonso J, et al. Predictive value of supine and upright radiographs in predicting failure of halo vest immobilization for odontoid fractures. Spine J. 2007;May 22 (Epub ahead of print)
  43. Stoney J, O’Brien J, Wilde P. Treatment of type-two odontoid fractures in halothoracic vests. J Bone Joint Surg Br. 1998;80:452–455
  44. Wang GJ, Mabie KN, Whitehall R, et al. The nonsurgical management of odontoid fractures in adults. Spine. 1984;9:229–230
  45. Vaccaro AR, Madigan L, Ehrler DM. Contemporary management of adult cervical odontoid fractures. Orthopedics. 2000;23:1109–1113quiz 1114-1115
  46. Bohlman HH. Acute fractures and dislocations of the cervical spine (An analysis of three hundred hospitalized patients and review of the literature). J Bone Joint Surg Am. 1979;61:1119–1142
  47. Ryan MD, Taylor TK. Odontoid fractures (A rational approach to treatment). J Bone Joint Surg Br. 1982;64:416–421
  48. Aebi M, Etter C, Coscia M. Fractures of the odontoid process (Treatment with anterior screw fixation). Spine. 1989;14:1065–1070
  49. Dickman CA, Crawford NR, Paramore CG. Biomechanical characteristics of C1-2 cable fixations. J Neurosurg. 1996;85:316–322
  50. Grob D, Crisco JJ, Panjabi MM, et al. Biomechanical evaluation of four different posterior atlantoaxial fixation techniques. Spine. 1992;17:480–490
  51. Hajek PD, Lipka J, Hartline P, et al. Biomechanical study of C1-C2 posterior arthrodesis techniques. Spine. 1993;18:173–177
  52. Fielding JW, Hawkins RJ, Ratzan SA. Spine fusion for atlanto-axial instability. J Bone Joint Surg Am. 1976;58:400–407
  53. Magerl F, Seeman PS. Stable posterior fusion of the atlas and axis by transarticular screw fixation. In:  Kehr P,  Weidner A editor. Cervical Spine. vol 1:Wein: Springer Verlag; 1987;p. 322–327
  54. Coyne TJ, Fehlings MG, Wallace MC, et al. C1-C2 posterior cervical fusion: long-term evaluation of results and efficacy. Neurosurgery. 1995;37:688–692discussion 692-693
  55. Marcotte P, Dickman CA, Sonntag VK, et al. Posterior atlantoaxial facet screw fixation. J Neurosurg. 1993;79:234–237
  56. Grob D, et al. Atlanto-axial fusion with transarticular screw fixation. J Bone Joint Surg Br. 1991;73:972–976
  57. Wright NM, Lauryssen C. Vertebral artery injury in C1-2 transarticular screw fixation: results of a survey of the AANS/CNS section on disorders of the spine and peripheral nerves (American Association of Neurological Surgeons/Congress of Neurological Surgeons). J Neurosurg. 1998;88:634–640
  58. Paramore CG, Dickman CA, Sonntag VK. The anatomical suitability of the C1-2 complex for transarticular screw fixation. J Neurosurg. 1996;85:221–224
  59. Song GS, Theodore N, Dickman CA, et al. Unilateral posterior atlantoaxial transarticular screw fixation. J Neurosurg. 1997;87:851–855
  60. Lapsiwala SB, Anderson PA, Oza A, et al. Biomechanical comparison of four C1 to C2 rigid fixative techniques: anterior transarticular, posterior transarticular, C1 to C2 pedicle, and C1 to C2 intralaminar screws. Neurosurgery. 2006;58:516–521discussion 516–521
  61. Kim SM, Lim TJ, Paterno J, et al. Biomechanical comparison of anterior and posterior stabilization methods in atlantoaxial instability. J Neurosurg Spine. 2004;100(suppl 3):277–283
  62. Currier BL, Todd LT, Maus TP, et al. Anatomic relationship of the internal carotid artery to the C1 vertebra: a case report of cervical reconstruction for chordoma and pilot study to assess the risk of screw fixation of the atlas. Spine. 2003;28:E461–E467
  63. Young JP, Young PH, Ackerman MJ, et al. The ponticulus posticus: implications for screw insertion into the first cervical lateral mass. J Bone Joint Surg Am. 2005;87:2495–2498
  64. Nakanishi T. Internal fixation of odontoid fractures. Orthop Trauma Surg. 1980;23:399–406
  65. Sasso R, Doherty BJ, Crawford MJ, et al. Biomechanics of odontoid fracture fixation (Comparison of the one- and two-screw technique). Spine. 1993;18:1950–1953
  66. Jenkins JD, Coric D, Branch CL. A clinical comparison of one- and two-screw odontoid fixation. J Neurosurg. 1998;89:366–370
  67. Apfelbaum RI, Lonser RR, Veres R, et al. Direct anterior screw fixation for recent and remote odontoid fractures. J Neurosurg. 2000;93(suppl 2):227–236
  68. Jeanneret B, Vernet O, Frei S, et al. Atlantoaxial mobility after screw fixation of the odontoid: a computed tomographic study. J Spinal Disord. 1991;4:203–211
  69. Henry AD, Bohly J, Grosse A. Fixation of odontoid fractures by an anterior screw. J Bone Joint Surg Br. 1999;81:472–477
  70. Caglar YS, Pait TG, Ozgen S. Posterior stabilization options. Contem Neurosurg. 1999;21:1–5
  71. Schaffler MB, Alson MD, Heller JG, et al. Morphology of the dens (A quantitative study). Spine. 1992;17:738–743
  72. Elias WJ, Ireland P, Chadduck JB. Transoral digitally manipulated reduction of a ventrally displaced Type II odontoid fracture to aid in screw fixation (Case illustration). J Neurosurg Spine. 2006;4:82
  73. Borm W, Kast E, Richter HP, et al. Anterior screw fixation in type II odontoid fractures: is there a difference in outcome between age groups?. Neurosurgery. 2003;52:1089–1092discussion 1092-1094
  74. Andersson S, Rodrigues M, Olerud C. Odontoid fractures: high complication rate associated with anterior screw fixation in the elderly. Eur Spine J. 2000;9:56–59
  75. Fountas KN, Kapsalaki EZ, Karampelas I, et al. Results of long-term follow-up in patients undergoing anterior screw fixation for type II and rostral type III odontoid fractures. Spine. 2005;30:661–669
  76. Management of combination fractures of the atlas and axis in adults. Neurosurgery. 2002;50(suppl 3):S140–S147
  77. Ryan MD, Henderson JJ. The epidemiology of fractures and fracture-dislocations of the cervical spine. Injury. 1992;23:38–40
  78. Weller SJ, Malek AM, Rossitch E. Cervical spine fractures in the elderly. Surg Neurol. 1997;47:274–280discussion 280-281
  79. Hanigan WC, Powell FC, Elwood PW, et al. Odontoid fractures in elderly patients. J Neurosurg. 1993;78:32–35
  80. Muller EJ, Wick M, Russe O, et al. Management of odontoid fractures in the elderly. Eur Spine J. 1999;8:360–365
  81. Tashjian RZ, et al. Halo-vest immobilization increases early morbidity and mortality in elderly odontoid fractures. J Trauma. 2006;60:199–203
  82. Bednar DA, Parikh J, Hummel J. Management of type II odontoid process fractures in geriatric patients; a prospective study of sequential cohorts with attention to survivorship. J Spinal Disord. 1995;8:166–169
  83. Majercik S, Tashjian RZ, Majercik S, et al. Halo vest immobilization in the elderly: a death sentence?. J Trauma. 2005;59:350–356discussion 356-358
  84. Lennarson PJ, Mostafavi H, Traynelis VC, et al. Management of type II dens fractures: a case-control study. Spine. 2000;25:1234–1237
  85. Ryan MD, Taylor TK. Odontoid fractures in the elderly. J Spinal Disord. 1993;6:397–401
  86. Fairholm D, Lee ST, Lui TN. Fractured odontoid: the management of delayed neurological symptoms. Neurosurgery. 1996;38:38–43
  87. Blockey NJ, Purser DW. Fractures of the odontoid process of the axis. J Bone Joint Surg Br. 1956;38:794–817
  88. Hart R, Saterbak A, Rapp T, et al. Nonoperative management of dens fracture nonunion in elderly patients without myelopathy. Spine. 2000;25:1339–1343
  89. Isolated fractures of the axis in adults. Neurosurgery. 2002;50(suppl 3):S125–S139

PII: S1040-7383(07)00104-9

doi: 10.1053/j.semss.2007.09.004

Seminars in Spine Surgery
Volume 19, Issue 4 , Pages 235-243 , December 2007

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