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PubMed1999

Epidural abscess of the cervical spine with osteomyelitis of the odontoid process.

STUDY DESIGN: A case report. OBJECTIVES: To document the rare condition of staphylococcal osteomyelitis of the odontoid process and to increase knowledge about the clinical characteristics and favorable outcome if patients are managed appropriately. SUMMARY OF BACKGROUND DATA: Osteomyelitis of the odontoid process caused by Staphylococcus aureus is a rare disease. A handful of cases have been reported within the last 30 years. Destructive odontoid peg involvement is most commonly associated with rheumatoid disease, which has a distinct clinical course compared with that of bacterial infection. METHODS: Two patients with bacterial osteomyelitis of the odontoid peg underwent medical and surgical treatment. They were observed for 3 years. All authors were involved in the care of these patients. RESULTS: Close monitoring of the patients' neurologic status and the use of noninvasive imaging techniques to evaluate the cervical spine led to an individualized treatment plan including antibiotic medication and transoral surgery with good outcomes in both cases. CONCLUSIONS: Awareness of the occurrence of bacterial osteomyelitis of the odontoid process, with or without neurologic symptoms, in patients with neck pain and fever may lead to earlier detection of this potentially critical condition, which has an excellent prognosis when treated early and appropriately.

Abscess↗

PubMed1998

[Fracture of the odontoid process in primary myelopathy. Report of a case].

Fractures of the odontoid are reported to contribute in 15% to cervical spine fractures. The clinical findings range between no symptoms at all and sudden death. Neurological deficits are seen in 6 to 25% of these patients. The overall mortality in this group is 3 to 8%. Fractures of the odontoid process combined with primary myelopathy has been reported seldom. We describe a traumatic fracture of the odontoid process with primary myelopathy, the chosen therapy and the follow-up.

Accidents↗

PubMed1996

Typical and atypical fractures of the odontoid process in young children. Report of two cases and a review of the literature.

The most common injury to the odontoid process in children under the age of seven years is a fracture through the synchondrosis with or without anterior displacement of the odontoid process, but this is not the only type of fracture of the odontoid process in this age-group. Fractures above and below the synchondrosis and fractures with posterior displacement were described. Typical clinical features of these fractures are: (1) major and blunt trauma, (2) neck pain and resistance to active and passive head movements; and (3) no or only slight neurological deficits. Conservative treatment had excellent results in the majority of cases. Nevertheless, there are a few specific indications for surgery.

Child, Preschool↗

PubMed2002

[Primary osteosynthesis of the odontoid process: a multicenter study].

PURPOSE OF THE STUDY: Direct osteosynthesis is a method of choice for the treatment of odontoid process fractures. It is based on insertion, from the anterior approach, of one or two screws from the C2 body into the apex of the odontoid across the fracture line. The tensile action of screws results in compression of fragments and stabilization of the fracture. The aim of the study was to evaluate a group of patients treated by this method and to compare our results with those reported in the foreign literature. MATERIAL: A total of 99 patients were treated by direct osteosynthesis of the odontoid in the departments involved in the study between 1994 and 2001. METHODS: Patients indicated for this surgery were those with fractures of type II according to Anderson and D'Alonzo and those with type III fractures but only when the fracture line went across the articulation surfaces of C1-C2, when closed reduction was not possible or the patients were not indicated for halo fixation. Direct osteosynthesis was not applied to fractures with comminution at the base of the odontoid, irreducible fractures, odontoid fractures combined with dislocated fractures of the atlas or pathological fractures. Severe kyphosis of the cervical spine or a large thoracic cage was also regarded as a contraindication. RESULTS: All the 99 patients were followed up from 3 up to 102 months, with an average of 28.5 months; only in seven patients, the follow-up period was shorter than 6 months. The most frequent subjective complaint was a painful operation wound. This usually resolved within two weeks of surgery. Except for four patients, alle were satisfied with the outcome. Type II fractures were diagnosed in 84 and type III fractures in 15 cases. A total of 174 screws were inserted into the odontoid processes of 99 patients. A single screw was used in 25 and two screws in 73 patients. In one case, three screws had to be inserted. Screw lenght ranged from 36 to 44 mm, diameter was 40.9 mm. Three months after surgery, X-ray examination, both in flexion and extension, did not reveal any instability in any of the patients. No morphological change in the C2-C3 intervertebral space was observed Of 92 (92.9%) paitents under longterm follow-up, 84 (91.3%) showed complete healing of the fracture, three died and five patients eventually developed pseudoarthrosis, which was due to a broken screw in three of them. This condition was treated by dorsal fixation of C1-C2 according to Magerl or by one of the dorsal cerclage techniques. The group was free of any perioperative complications related to the anterior approach or injury to nerve structures by screws. DISCUSSION: The most frequent subjective complaint was a painful operation wound. Treatment of odontoid fractures varies according to the type of injury, bone quality and also practice at each department. Type II injuries are highly unstable and, because of the small fracture surface, their healing ability is much lower than in type III fractures. Previously, most of the patients with odontoid injuries were treated conservatively by immobilization in a plaster cast or a brace or, later, by a halo device. In the long term, however, they showed a high proportion of pseudoarthroses (10 to 100%). Direct osteosynthesis of the odontoid by screws permits the maintenance of rotation of the C1-C2 mobile segment. We followed the scheme of indications used abroad but did not perform osteosynthesis to correct pseudoarthrosis. The number of osteosyntheses healed (91.3%) was also in agreement with the literature data. Earlier, we used two screws for all types of fractures. Recently, we have preferred insertion of a single screw in type II and III fractures in narrow odontoids. In the later, there is no danger of rotational dislocation during screw insertion; to insert one screw from the centre of the C2 base is easy and speeds up the procedure. However, in displaced type II and type II T fractures, two screws are a necessity. Similarly to other authors, we recorded a slight limitation of cervical spine rotation in patients at long-term follow-up, particularly in elderly subjects with advanced osteochondrosis. No complications leading to deterioration of the patient's state were recorded. CONCLUSIONS: Direct osteosynthesis is a method of choice for most of the type II and indicated cases of type III fractures of the odontoid process of the axis. This surgical procedure facilitates restoration of anatomical conditions of the spine and its immediate stability. Consequently, patients can be readily mobilized and rehabilitated.

Adolescent↗

PubMed1981

["Crowned" odontoid process and osteoarthrosis of the anterior atlantoaxial joint (author's transl)].

The so-called "peridentale aureole" ("crowned odontoid"), a horseshoe-like calcification around the odontoid process, can occasionally be shown on transbuccal views of the occipito-atlantoaxial region, but is commonly only seen on a.p. tomography in patients with osteoarthrosis of the anterior atlantoaxial joint. Tomographic examinations reveal that these irregular horseshoe-like calcifications around the odontoid peg represent mainly the osteophyte formation on the superior border of the anterior arch of the atlas. These calcifications are often surrounding a smaller calcification on the tip of the odontoid process. The peridentale aureole or crowned odontoid process is easily overlooked unless tomography is performed, and misinterpretations are possible if the radiologist is not familiar with this appearance of osteoarthrosis and some other joint diseases of the anterior atlantoaxial joint.

Aged↗

PubMed1978

Fractures of the odontoid process in young children.

We reviewed eleven patients less than seven years old with fractures of the odontoid process in an effort to establish a more standard form of treatment for the injury and to determine what complications, if any, occur as a result of fractures of the odontoid process in pediatric patients. Our study showed that children with odontoid fractures that are recognized and treated promptly usually do well. The fracture can usually be reduced by passive manipulation or by the "hanging head technique". Support in the reduced position for two to three months in a Minerva jacket or halo cast should be long enough to permit healing. Our study suggests that fractures of the odontoid process in young patients almost always heal.

Age Factors↗

PubMed1991

[Screw fixation of fractures of the odontoid process].

In the year 1981, J. Böhler completed for the first time a screw fixation for unstable fractures of the odontoid process of the axis. This surgical technique preserves the anatomy and the physiology of the articulation between the atlas and the axis, as a guarantee for a good functional recovery. It is not a very difficult technique when performed by a trained surgeon with a very good X-ray image intensification for the per-operative control. We have treated 32 unstable fractures of the odontoid process without any neurological complication per- or post-operatively. We had a follow-up on only 29 cases. In 19 cases the fracture healed in leading to a good bone union, complete mobility and no residual pain. Seven patients complained of residual pain or a limitation in cervical movement, because of the association with other cervical fractures, an age superior of 70 years, or a major initial instability. In 2 cases the authors noted a non-union and a secondary displacement because of technical faults at the beginning of their experience. These good results determined the authors to prefer the direct screw fixation for the unstable fractures of the odontoid process, to the posterior arthrodesis which leads to functional limitations.

Adolescent↗

PubMed2000

Anderson type II fracture of the odontoid process: results of anterior screw fixation.

Controversy exists in the literature regarding the adequacy of one or two screws for direct fixation of the odontoid process. Proponents of the two-screw technique believe that a single screw is not adequate to stabilize the fracture. Conversely, the insertion of two 3.5-mm screws in the medullary cavity of the odontoid process is technically difficult and can jeopardize the surface area left for fracture healing. The authors conducted a prospective study of 30 cases with Anderson type II fracture of the odontoid process treated by direct anterior fixation using the two-screw technique. The screws used were 2.7-mm cortical screws manufactured from titanium. Two C-arms were used to control reduction of the displaced fracture and for its direct anterior stabilization. The operation was performed with the patients under general anesthesia. The anterolateral incision was made at the level of C4 to facilitate exposure of the C2-C3 disk and for fracture fixation. No evidence of nonunion was encountered. Spontaneous fusion of the C2-C3 segment was found in one case. Limitation of rotation of the cervical spine was a subjective description in a single case. No major complications were attributed to the surgical technique. The two 2.7-mm self-tapping titanium cortical screws provided adequate stability for fixation of type II odontoid fractures.

Adult↗

PubMed2000

[Surgical treatment of fractures of the odontoid process].

Forty-one cases of C2 odontoid process fractures, from a group of 273 surgically treated cervical spine trauma patients, were treated by anterior screw fixation during a 6-year period. There were 37 patients with Anderson and D'Alonzo type II. fractures and 4 with type III. The mean age of the patients was 52 years and the fracture was caused by falls in most cases. Medical complications were not observed during surgery, but in 3 patients, implant-related technical problems were recorded. In the 3-month follow-up, 2 patients died because of medical complications not related to the procedure. There were no other complications in the remaining patients. We included 21 patients in a 6-month follow-up. In 19 of them, the fracture healed (90.5%), while in 2 patients osteosynthesis failed, which required further stabilization. In the authors' opinion, direct osteosynthesis should be considered the method of choice in most C2 type II fractures as well as in some of type III fractures.

Adolescent↗

PubMed2001

[Incidence of complications of the screw osteosynthesis of odontoid process fractures].

In this retrospective clinical study the incidence of complications in 58 consecutive, with anterior screw fixation stabilized patients after fractures of the odontoid process is evaluated. In 51 patients the fracture has been defined as type II according to Anderson, in 6 patients an oblique type II fracture was present and one patient showed a cephalad type III fracture. Preoperatively, in only 19 % of the patients (n = 11) no dislocation of the dens occurred. 32 patients were treated with single screw osteosynthesis, in 26 patients two screws were implanted. Significant complications with clinical relevance were registered in 14 patients (24 %), in 10 cases (17 %) an operative reintervention was required. Intraoperatively, in one patient a rupture of the carotid artery while winding around the motor drill occurred and in another case a complete malplacement of the screw posteriorly to the odontoid process was observed. A clearly excentric positioning of the implant was evaluated in 5 patients with a consecutive high rate of implant migration (n = 3). Two patients died perioperatively not related to the cervical injury. Postoperatively, one patient with a wound infection due to an iatrogenic perforation of the esophagus required reoperation as well as 4 patients with instability because of implant migration. Patients beyond the age of 65 years (n = 3) were significantly overrepresented in that group. In one case, the secondary intervention was caused by a pseudarthrosis of the dens axis. Complications without any relevance to the clinical and functional long term result were fusions in malposition of the odontoid process in 14 patients (24 %) and 10 (17 %) marginal screw perforations laterally. Differences in the use of one or two screws have not been observed in this study, although the investigations showed a tendency between marginal lateral screw perforations and double screw osteosynthesis and an increasing number of complications in the geriatric cohort.

Adolescent↗

PubMed2003

Occurrence of comminution (type IIA) in type II odontoid process fractures: a multi-slice CT study.

The classification of odontoid process fractures introduced by Anderson and D'Alonzo in 1974 has gained wide acceptance among researchers and clinicians. In type II fractures the injury is located in the base of the odontoid process. In 1988 Hadley et al. introduced a comminuted subtype of this fracture, type IIA. Since then several authors have recommended a more aggressive surgical approach in treatment of this subtype. However, only a few cases of comminuted type II fractures have been reported. The objective of this study is to assess the occurrence of comminution in type II fractures. Twenty-six type II fractures imaged by multislice CT were reviewed. Subtle comminution of the fracture was observed in 12 of the cases. We conclude that, when imaged by multislice CT, subtle comminution in type II odontoid fractures is seen more commonly than previously reported in the literature.

Journal Article↗

PubMed1975

Non-union of the odontoid process. An experimental investigation.

A clinical study of fractures of the odontoid process showed a 62 per cent failure on union. Of many features studied, only displacement and its direction had a definite bearing on non-union of the fracture. Blood supply was considered as a possible etiological factor. The blood supply of the human odontoid was elucidated by means of studying 19 human autopsies by means of microangiography. The dog was found to have a similar blood supply and hence, was used as the experimental model. Two osteotomies were performed; one below the accessory ligaments and one above the accessory ligaments. All osteotomies carried out below the accessory ligament united and all carried out above failed to unite. Microangiographic studies revealed however, that avascular necrosis was not the cause of non-union. Further anatomic studies revealed that different size gaps occurred depending on the level of the osteotomy, with a large gap occurring in the osteotomy of the odontoid which was performed above the accessory ligament. First the result of immobilization and the healing of the odontoid osteotomy was derived, by carrying out an instant occipito-cervical fusion by means of wire loops and methylmethacrylate. In distinction to the free floating apical segment of non-immobolized spines, with a high odontoid osteotomy, the occipito-cervical fusion resulted in a dense fibrous tissue stabilizing the apical fragment but at no time was bony union observed. A final attempt was to secure immobilization and reduce the gap, by carrying out only a partial osteotomy. The osteotomy was performed in such a way that the posterior cortex was left intact. Union occurred in all instances. The fracture gap and movement play a definite role in the pathogenesis of pseudarthrosis of the odontoid process. Where gap and movement were eliminated, union occurred. It is difficult to transpose this experimental situation to the clinical one, for the assessment of gap clinically, is only radiographic. This method is much too imprecise to be of value in this assessment. The fact however, that a high rate of non-union is associated with a high degree of displacement, supports the experimental thesis.

Animals↗

PubMed1979

Morphological and functional studies on the odontoid process of the human axis.

Studies on the morphology of the odontoid process by various methods strongly suggest a functional adaption of this bony element. With regard to the inclination of the dens axis and the varying position of its articular facets, a modified trabecular system can be observed. Photoelastic experiments confirm that these modifications are correlated with two specific kinds of mechanical stress. The straight odontoid process is only subjected to stress due to compression, but the dorsally inclined dens to bending stress. Based on the morphological and experimental findings, flexion and extension between the first and second vertebrae (in addition to rotation as the principle movement) are discussed.

Adaptation, Biological↗

PubMed1991

[Screwing the odontoid process. A functional operation].

The authors describe a case of direct screw fixation of the odontoid process via an anterolateral retropharyngeal subhyoid pre-sternomastoid approach and discuss the indications for this operation. In this particular case, immobilization by a cervical collar or a halo vest was not chosen because of its constraining character and the risk of secondary displacement and pseudarthrosis. C1-C2 or occipitospinal arthrodesis, whether performed via a posterior, lateral or anterior approach, is difficult to perform and always leads to a functional handicap. The transoral approach does not allow direct screw fixation of the dens. Dens screwing via an anterior pre-sternomastoid subhyoid approach is the most logical and least disabling technique. The subhyoid approach is much simpler than the suprahyoid approach. This technique is used in fractures of the odontoid process with an ablique downward and backward fracture line, with or without arch fracture of C1, and allows screwing perpendicular to the fracture line. Considering the present results and the literature, the double screw fixation does not seem to be justified.

Adult↗

PubMed1989

Follow-up study of atlanto-axial instability in Down's syndrome without separate odontoid process.

Clinical and roentgenologic studies were performed in 69 children with Down's syndrome, without the separate odontoid process, that could be followed for more than 5 years. At the follow-up examination, the atlanto-odontoid process interval (AOI) in flexion, neutral, and extension of the cervical vertebrae significantly decreased when compared with the one at the initial examination. This was particularly obvious up to 5 years of age. Although 14 of 69 cases (20.3%) had atlanto-axial instability at the initial examination, this decreased to four cases (5.8%) at the follow-up examination. However, there were two cases of atlanto-axial instability who were over 10 years of age. There was no significant difference in the minimum sagittal diameter (MSD) at the atlantal level between each position at both the initial and follow-up examinations. Moreover, there was a tendency for the MSD of the cases of positive instability at the follow-up examination to be smaller than those of the cases of negative instability. The degree of ligament laxity improved with increasing age and there was statistically the negative correlation. Although there was a tendency for the AOI to decrease with improvement of the degree of ligament laxity, the correlation could not be confirmed.

Aging↗

PubMed2006

[Parapharyngeal abscess and osteomyelitic destruction of the odontoid process].

We report the case of a 55 year old man with osteomyelitic destruction of the odontoid process and a parapharyngeal abscess. The patient was admitted with diagnosis of meningitis and degenerative cervical spine disease without compression of spinal cord or nerve roots but progressive impairment of cervical spine mobility. Inflammatory parameters in serum and cerebrospinal fluid were detected and antibiotic therapy was initiated resulting in subjective improvement of symptoms. When impairment of cervical spine motility persisted and gait disturbance developed, a parapharyngeal abscess and an osteomyelitic destruction of the odontoid process caused by infection with staphylococcus aureus was diagnosed. After cleavage of the abscess and four months of antibiotic therapy the gait disturbance disappeared and mild impairment of cervical spine motility persisted.

Anti-Bacterial Agents↗

PubMed2006

Midfacial translocation, a variation of the approach to the rhinopharynx, clivus and upper odontoid process.

OBJECTIVE: A surgical variation of the technique of facial translocation procedure is proposed, which has been called midfacial translocation for approach to the entire medial and lateral region of the middle third of the face, including the rhinopharynx, sphenoid sinus, pterygomaxillary fossa, odontoid process, and clivus. PATIENTS AND METHODS: The medical records of five treated patients accordingly were reviewed for an analysis of the surgical technique, the disease, the topography of the lesion, and the complications. RESULTS: The approach permitted ventral decompression of the bulbomedullary junction with resection of the C1 arch and the odontoid process in four patients and resection of a chordoma of the clivus located along the midline and extending intradurally in the fifth patient. Only one patient presented with dehiscence of the posterior half of the soft palate, this being the only complication observed following surgery in these patients. Three months postoperatively, no patient presented any aesthetic alteration of the face. Functionally, there was only infraorbital hypoaesthesia on the side of flap rotation. CONCLUSION: The technique of midfacial translocation provides both good surgical approach and access to the rhinopharynx, pterygomaxillary fossa, high odontoid process and clivus, with few adverse sequelae for the patient.

Chordoma↗

PubMed1988

[Choice of a technic of stabilization in surgical treatment of recent fractures of the odontoid process. 90 cases].

The objective of this study is to analyse the advantages and disadvantages of different surgical technics of odontoid process fracture stabilization. We try to find the best indications for each of them. We won't consider stable odontoid fractures which haven't treated by surgical therapy. A review of ninety acute dens fractures since 1979 has been analysed before 1985, the most of our injured person had a surgical stabilization by posterior approach. The analysis of our results had incited us, since that date, to vary our indications, by taking possibilities of anterior approach into consideration. So, have been realized 55 C1-C2 lacings, 20 of which with bone graft, 12 occipito-cervical arthrodesis, 10 screw fixations of odontoid process, 9 atlanto-axial arthrodesis by screw fixations, 2 posterior fixations by CD pediatric instrumentation, 1 Knodt instrumentation, 1 osteosynthesis by trans-oral exposure. Patients have been seen again, 1 month, 3 month, 6 month, 1 year later. Results have been estimated: Clinically by cervical mobility study in rotation and by local pain (16 excellent results, 24 good results, 27 middle results, and 23 bad results); Radiologically by analysis of specific complications of each technic (8 secondary removing, 6 incomplete deplacement corrections, 4 excessive corrections, 3 pseudarthrosis). We have regrouped global results technic by technic. We propose a therapeutic planning in which each technic can find the best result. The objective is to assure an effective retention by preserving movings of superior cervical spine.

Adolescent↗