Where is odontoid fracture

C joint. Blood Supply. Normal Cervical Kinematics. Lateral Bend. Occipitocervical joint OC. Atlantoaxial joint C Subaxial Spine C Total Motion degrees. Anderson and D'Alonzo Classification. Type I. Oblique avulsion fx of tip of odontoid. Due to avulsion of alar ligament.

Although rare,atlantooccipital instability should be ruled out with flexion and extension films. Type II. Fracture through waist high nonunion rate due to interruption of blood supply. Type III. Fx extends into cancellous body of C2 and involves a variable portion of the C1-C2 joint. Type IIA. Treatment is external immobilization. Type IIB. Displaced fracture with fracture line from anterosuperior to posteroinferior.

Treatment is with anterior odontoid screw if adequate bone density. Type IIC. Fracture from anteroinferior to posterosuperior, or with significant comminution. Treatment is with posterior stabilization. Physical exam. AP, lateral, open-mouth odontoid view of cervical spine. CT angiogram. Treatment Overview Table. Halo Vest. If operative management is chosen, a posterior approach is preferred when fracture- or patient-related factors make an anterior approach challenging.

The high levels of morbidity and mortality associated with odontoid fractures should encourage all providers to pursue medical co-management and optimization of bone health. The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article. The epidemiology of fractures and fracture-dislocations of the cervical spine. Accessed March 16, Google Scholar. C2 vertebral fractures in the medicare population: incidence, outcomes, and costs.

J Bone Joint Surg Am. Incidence and cost of treating axis fractures in the United States from to Structural properties of the axis studied in cadaveric specimens.

Clin Orthop. The trabecular anatomy of the axis. Computational anatomy of the dens axis evaluated by quantitative computed tomography: implications for anterior screw fixation.

J Orthop Res. 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. Structural heterogeneity within the axis: the main cause in the etiology of dens fractures. J Neurosurg. Architecture and distribution of cancellous bone yield vertebral fracture clues.

Arch Orthop Trauma Surg. Quantitative internal dens morphology. Fractures of the odontoid process of the axis. New subtype of acute odontoid fractures type IIA Neurosurgery.

Proposal of a modified, treatment-oriented classification of odontoid fractures. Spine J. Fractures of the dens. A multicenter study. Nonoperative management of dens fracture nonunion in elderly patients without myelopathy. Efficacy of anterior odontoid screw fixation in elderly patients with type II odontoid fractures.

Neurosurg Focus. Nonoperative management of odontoid fractures using a halothoracic vest. Functional and quality-of-life outcomes in geriatric patients with type-II dens fracture.

Fractures of the odontoid process. J Bone Joint Surg Br. Govender S , Grootboom M. Fractures of the dens—the results of non-rigid immobilization. Evidence-based analysis of odontoid fracture management. Non-surgical interventions for the management of type 2 dens fractures: a systematic review.

ANZ J Surg. A systematic review of the treatment of geriatric type II odontoid fractures. External immobilization of odontoid fractures: a systematic review to compare the halo and hard collar. World Neurosurg. Management of odontoid fractures. Southwick WO. Management of fractures of the dens odontoid process. Axis fractures. Management of type II dens fractures. Experience in the management of odontoid process injuries: an analysis of cases.

Factors associated with nonunion in conservatively-treated type-II fractures of the odontoid process. Acute axis fractures. Odontoid fractures in elderly patients. Treatment of type-two odontoid fractures in halothoracic vests. Fractures of the dens in adult patients. J Trauma. Odontoid fractures in the elderly. J Spinal Disord. Epidemiolgy of spinal cord injury after acute odontoid fractures. Accessed April 17, Odontoid fractures with neurologic deficit have higher mortality and morbidity.

Clin Orthop Relat Res. Management of odontoid fractures in the elderly. Eur Spine J ; 8 5 : - Axis fractures: a comprehensive review of management and treatment in cases. Odontoid fractures, with special reference to the elderly patient. Transverse atlantal ligament disruption associated with odontoid fractures. The utility of MRI in the evaluation of odontoid fractures. J Spinal Disord Tech.

Traumatic type II odontoid fracture with transverse atlantal ligament injury: a controversial event. Am J Neuroradiol. Bunta AD. It is time for everyone to own the bone. Osteoporos Int. Survival analysis of elderly patients with a fracture of the odontoid peg.

Bone Joint J. Predictors of mortality following conservatively managed fractures of the odontoid in elderly patients. Risk factors for immediate postoperative complications and mortality following spine surgery: a study of patients from the National Surgical Quality Improvement Program.

Treating the aging spine. Instr Course Lect. Cervical orthoses. A study comparing their effectiveness in restricting cervical motion in normal subjects. Halo-vest immobilization increases early morbidity and mortality in elderly odontoid fractures. Halo vest immobilization in the elderly: A death sentence? Halo-vest immobilization in elderly odontoid fracture patients: evolution in treatment modality and in-hospital outcomes. Clin Spine Surg. Incidence of and risk factors for complications associated with halo-vest immobilization: a prospective, descriptive cohort study of patients.

Thromboembolic complications after spinal surgery in trauma patients. Acta Orthopaedica. Nonoperative management of type II odontoid fractures in the elderly. Management and outcome of dens fracture nonunions in geriatric patients. Odontoid fractures treated with halo— vest. Functional outcome of surgically and conservatively managed dens fractures. EQ VAS self-assessed health : the individual estimates a value for their current state of health on a scale graded from 0 to The Katz ADL Index comprises six basic functions: bathing, dressing, toileting, transfer, continence and feeding.

For each activity six in total , there is a question. Each question has two possible answers: independent or dependent [ 32 ]. F is considered to be an indicator of a dependent patient. CT is the most reliable radiographic tool to classify and evaluate healing in relation to type-2 odontoid fractures [ 33 ].

Bony union is assessed by a radiologist, independently from the study. Dynamic flexion-extension radiographs are used to assess the functional stability — the healing — of a type-2 odontoid fracture [ 34 ]. Osteoporosis will be evaluated with DXA of the hip and lumbar spine [ 36 ]. Charlson Comorbidity Index [ 37 , 38 ]. Prior to inclusion, the data from each patient are collected by a spinal surgeon or a dedicated study nurse.

All physician-reported outcome measurements are recorded during and after the evaluation in the folder. Any protocol deviations are recorded either in the case file or in the medical records; a clinical study nurse ensures that all protocol deviations and adverse events are recorded in the database. Every allocated subject will be coded with a specific patient number. The study data will be transferred to a pre-made computer-based table Microsoft Excel, V.

The completed files will be stored securely in the clinical research unit for the next 15 years. Data safety, data quality and statistical analysis will be managed by the principal investigator who is responsible for notifying any issues that may arise during the USOFT. Data are collected and stored according to Good Clinical Practice guidelines and are available to all participating study sites.

Any data safety issue occurring during the clinical trial will be reported to the principal investigator. For statistical analysis, R version 3. The analysis will be performed by intention-to-treat ITT , and sensitivity analyses will include a per-protocol analysis. Details of the statistical analysis are listed in Table 1.

The baseline features of the patients will be described with descriptive statistics using absolute numbers n and percentages for categorical variables and the minimum, maximum, mean, SD and quartiles for quantitative variables. The number of patients crossing over to surgical treatment or dropping out from follow-up will be documented. Multiple regression analysis of subgroup factors will allow for the determination of important factors affecting the NDI. The differences will be considered statistically significant if the p value is less than 0.

The Kaplan-Meier method will be used for the determination of the non-surgical and surgical treatment mean survival at 1 year. Proportional survival differences according to treatment will be tested with the chi-squared test. We will perform a separate analysis of participant socio-demographics, type-2 odontoid fracture subgroup, the specific type of surgery categorical: Magerl-Atlas claw or Goel-Harms and osteoporosis status DXA score.

Up to 50 participants will be included in the study, based on the following calculation of sample size:. Spine J. A minimum of 24 subjects must be included in each group. An interim analysis will be performed on the primary endpoint NDI improvement when 30 patients have been randomised and completed the 1-year follow-up. The interim analysis will be performed by a statistician. The council, which will decide on the continuation of the trial, will report to the Central Ethics Committee if the trial is stopped prematurely [ 41 ].

An SAE is considered if it results in the following outcomes: in-hospital death, life-threatening event or neurological worsening. The council will then decide on whether to continue the trial, reporting to the Central Ethics Committee if the trial is stopped prematurely. The SweSpine board governed by the Swedish Society of Spinal Surgeons reviews the patient-reported outcome measure forms and clinical data at regular intervals.

This study is conducted in compliance with the current version of the Declaration of Helsinki. The research project was approved by the Uppsala Regional Ethics Committee on 18 May registration no. Modifications to the protocol require approval by the Regional Ethics Committees, will be registered with ClinicalTrials.

Prior to the trial, patients must consent orally and in writing after the possible consequences of the clinical study are explained in an understandable way. All documents must be written in Swedish.

If the patient is unable to give informed consent, a close relative will be asked to take the decision instead. The patient will receive a copy of the signed patient information.

A patient may withdraw from the study at any time if they are unwilling to continue on the trial. In this case, the data from a patient who requests full withdrawal will not be considered in the data analysis. All original documents will be kept in the clinical research unit for the next 15 years.

All original records will be kept on file at the trial sites or coordinating data managing centre for 10 years. The electronic clinical trial database in SweSpine will be kept on file for at least 10 years. The principal investigators have full access to the final datasets. There are no contractual agreements that limit such access for investigators. The study results will be published in peer-reviewed medical journals, and communicated at medical conferences.

The original principal investigators AR, YR and CO will appear as co-authors on all publications based on results from this study cohort. The participant-level dataset and the statistical code will not be publicly available and remain with the principal investigators. This is the first randomised controlled study on the treatment of type-2 odontoid fractures in the elderly. The key results of this study will be applicable to evidence-based guidelines and benefit the growing elderly population.

Since surgery among the elderly is associated with a 4-day longer hospital stay, the results of this randomised controlled trial RCT will have direct implications on health policy and medical decision-making unpublished data.

Function and HRQoL are important pillars of value-based care. Thus, this study uses a functional patient-reported questionnaire as its primary endpoint. We discarded mortality as the primary endpoint due to the fragility of patients above 70 years of age, where hazard causes overlap and sample size issues arise [ 43 ].

This randomised controlled study employs an open-label design, where both the investigator and the patient know which treatment they will receive. Unfortunately, the open-label design has an inherent selection bias, where patients can drop out during enrolment or give informed consent prior to inclusion in this study. The sealed envelope technique requires good clinical practice and discipline of the part of the enrolling physician, since translucency and premature opening can corrupt the randomisation process [ 45 ].

Simple randomisation avoids deciphering block randomisation but risks different sample sizes in treatment and control groups. One-year progression-free survival and 1-year all-cause mortality are common primary endpoints for RCTs. Due to the frailty of the elderly study participants, an overlap of an unrelated and natural cause of death with injury-related mortality causes high variation and would require a significantly greater sample size.

We have planned to deal with dropouts for death in our sample size calculation, adopting an inflation rate. However, death will represent an important competing event. It is possible that if surgery has a favourable impact on mortality, more people will die in the control group, and earlier. These people who die might be those more compromised.

This is probably due to the increased risk of falls in the elderly, as well as the greater incidence of osteoporosis a condition of weak and brittle bones. Type II odontoid fractures can also occur in younger patients, most commonly as the result of trauma from a motor vehicle accident. Treatment options for type II odontoid fractures can be nonsurgical or surgical. Nonsurgical measures include immobilization, prevent or restrict movement, in a cervical collar or halo vest.

One surgical option is a procedure called anterior screw fixation. During this procedure, the surgeon approaches the vertebra from the front of the neck an anterior approach and places an internal fixation, like screws, to hold the vertebrae in place while the bone heals.

Another option is a similar procedure performed from the back of the neck a posterior approach. During this procedure, the surgeon fuses C1 and C2, the first and second vertebrae. The treatment of stable odontoid fractures remains controversial. The surgeon will determine the best treatment for each patient and each situation.

Type II Odontoid Fracture. Request an Appointment Online. Telehealth Services.