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Original Article Management of Combination Fractures of the Atlas and Axis: a Report of Four Cases and Literature Review

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Original Article 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 www.ijcem.com /ISSN:1940-5901/IJCEM0001212 Original Article Management of combination fractures of the atlas and axis: a report of four cases and literature review Chao Liu1*, Linghao Kuang2*, Lei Wang3, Jiwei Tian3 1Shanghai Jiaotong University Affiliated First People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China; 2Department of Orthopedic Surgery, Zaozhuang Hosptial of Zaozhuang Mining Corporation, Zaozhuang, China; 3Department of Orthopaedics, Shanghai Jiaotong University Affiliated First People’s Hospital, Shanghai, China. *Co-first authors. Received June 25, 2014; Accepted July 27, 2014; Epub August 15, 2014; Published August 30, 2014 Abstract: Four cases of combination fractures of the atlas and axis are presented. Three types of management were performed: plaster immobilization, odontoid screw fixation combined with atlantoaxial pedicle screw fixation, occipito-cervical fusion with anterior operation by staged. Based on a literature review and our experience, treat- ment strategies is discussed according to the stability of the upper cervical spine and neurological involvement, with a reminder that combined injuries in the upper cervical spine should be sought in any patient with a cervical injury and early surgical solution may bring benefits once injury attack. Keywords: Cervical spine fracture, atlas, axis, plaster immobilization, cervical spine surgery Introduction Observations Although concomitant injuries of atlas and axis Case No. 1 are relatively common which account for nearly 3% of cervical spine lesions and 12% of upper Patient No. 1, male, 38 years old, presented cervical spine fractures [1-3], they are rarely minor head injury and severe neck after being reported in the literature, and their characteris- ejected during a low-speed motor vehicle colli- tics and treatment strategies are not well sion (Table 1, Figure 1). X-ray and cervical CT known with a higher incidence of neurological demonstrated a type II odontoid fracture morbidity than isolated C1 and C2 fractures [3]. according to Anderson and D’Alonzo [7], back- These combinations most often caused by ward sloping according to Roy-Camille [8], asso- motor vehicle accidents in young adults [4] and ciated with a fracture of posterior C1 arch. The occur with significantly higher incidence in the JOA score was 16, VAS score was 8 pro-opera- aged for whom falls are most likely the mecha- tion. A cervical collar was put to preserve the nism of injury in contrast [5, 6]. In particular, neck. The patient remained with no neurologi- while cervical immobilization has long been cal deficit but couldn’t stand a long time exter- recommended for the treatment of majority of nal immobilization therapy period. To simplify isolated atlas and axis fractures, today it seems nursing care and minimal the inconvenience of that surgical treatment is often proposed due cervical collar, the patient underwent odontoid to the occurrence of the two fractures in combi- screw fixation combined with atlantoaxial pedi- nation often implies a more significant struc- cle screw fixation surgery without fusion fol- tural and complex mechanical injury. The pur- lowed by a neck collar for 6 week. The JOA score pose of this retrospective study on a series of was 17, VAS score was 2 post-operation. After a four cases is to discuss the management 9 month follow-up, the fracture got healing and issues for C1-C2 combination fractures with the VAS score was 0. Then the patient was fol- our experience and a review of the literature. lowed via telephone interview and was asymp- Combination fractures of the atlas and axis Table 1. Summary of the four observations Case Age (years), Circumstances Follow-up Type of lesion Other Combination injury Management No. sex of the accident (months) 1 38, M Traffic accident Type II odontoid + C1 / odontoid screw 9 posterior arch fracture fixation combined with atlantoaxial pedicle screw fixation 2 18, F High fall injury Type II odontoid + Jefferson left humeral fractures, plaster immobilization 1 from 5m fracture left fronto-temporal bone fractures, subdural hematomas 3 59, M Traffic accident C1 posterior arcs, Hangman Rib + anterior cranial fossa Occipito-cervical 6 fracture and miscellaneous fractures, craniocerebral fusion with anterior fractures, dislocation of trauma operation by staged C2/3 4 56, M High fall injury Type II odontoid + Jefferson / odontoid screw 30 from 2m fracture fixation combined with atlantoaxial pedicle screw fixation Figure 1. A, B: X-ray and CT scan showed a type II odon- toid fracture combined with C2 posterior arch fracture. C-E: Odontoid screw fixation combined with atlantoaxial pedicle screw fixation with- out fusion. F, G: 3 months follow-up. tomatic but refused to return to clinic for evalu- VAS score was 9 pro-operation. A cranial halo ation though we wanted to remove the internal device was put in place with bed traction to instruments in 6 month after the surgery. reduce anterior displacement. The patient was engaged in special industries and her relatives Case No. 2 refused to choose operation, so plaster immo- Patient No. 2, female, 18 years old, presented bilization was performed and after 1 month head and cervical spine injury with no neuro- fellow-up, we lost contact with her. logical impairment resulting from a high falling Case No. 3 about 5 m (Figure 2). X-rays and 3D-CT scan showed a type II backward sloping odontoid Patient No. 3, male, 59 years old, presented fracture with anterior displacement associated with left upper extremity weakness suffered a with a Jefferson fracture. This patient also suf- car accident resulting in several fractures: frac- fering from left humeral fractures combined ture of the 2th right rib, frontal, right temporal with left fronto-temporal bone fractures and parietal bone and multiple fractures of the subdural hematomas. The JOA score was 16, anterior cranial fossa, frontal epidural hemato- 2075 Int J Clin Exp Med 2014;7(8):2074-2080 Combination fractures of the atlas and axis Figure 2. A-E: X-ray, CT scan and MRI showed a type II odontoid fracture combined with Jefferson fracture. F, G: Plaster immobilization. H: 1 month follow-up. mas on the right frontal and parietal temporal 3D-CT scan and MRI showed a type II backward mild subdural hematomas, subarachnoid sloping odontoid fracture with mild displace- hematomas. X-rays and 3D-CT scan showed ment associated with a Jefferson fracture, and bilateral posterior arch fractures of C1, trau- showed instability of C1/2. The JOA score was matic spondylolisthesis of the axis fractures, 16, VAS score was 6 pro-operation. A cervical miscellaneous fractures of the axis body, dislo- collar was put to preserve the neck. Surgery cation of C2/3 and hematoma formation of the was performed on the tenth day after injury spinal canal (Figure 3). The GCS score was 7, with odontoid screw fixation combined with Frankel in grade C, JOA score was 9 pre-opera- atlantoaxial pedicle screw fixation followed by a tion. He was performed craniocerebral opera- neck collar for 6 week. The JOA score was 17, tion emergency and a cervical collar was pro- VAS score was 2 post-operation. Postoperative vided. The patient remained tracheotomy with follow-up achieved healing at 3 months with no no neurological improvement and rapidly pre- pain at 2.5 years. sented pulmonary infection. After a 3 weeks’ supporting treatment in ICU, occipito-cervical Discussion fusion was decided. The GCS score was 15, Frankel in grade E, JOA score was 17 after 6 Although the first report of combination C1-2 weeks. An anterior operation was performed fracture injuries was compiled by Sir Geoffery due to the patient suffered from dysphagia. Jefferson in 1920 [9], combined injuries are Postoperative follow-up was simple with con- seldom reported in the literature. This type of solidation achieved with no secondary dis- fractures represent about 3% of all cervical placement at 3 months and satisfactory spinal spine injuries [4], 43% and 16% of C1 or C2 function with mild pain in neck. fractures, respectively [2, 10, 11]. In reports focusing primarily on C2 fracture, the occur- Case No. 4 rence of C1 fracture has been identified in 5% Patient No. 4, male, 56 years old, presented to 53% of odontoid fractures [5, 10, 12, 13], 6% with progressive neck pain after a high fall inju- to 26% of Hangman’s fracture [13-17]. Similarly, ry from about 2m (Figure 4). 8 days before odontoid fractures have been reported in 24% going to our clinic for evaluation he had taken a to 53% of patients with C1 fracture [13, 18, X-ray plain which just showed some mild cervi- 19]. That is to say any fracture of C1 can be cal degeneration without any fracture traces. accompanied by C2 and vice versa. The mecha- 2076 Int J Clin Exp Med 2014;7(8):2074-2080 Combination fractures of the atlas and axis Figure 3. A: CT scan showed craniocerebral trauma. B-E: 3D-CT scan showed bilateral posterior arch fractures of C1, Hangman fractures, miscellaneous fractures, dislocation of C2/3. F: Craniocerebral operation. G-K: Occipito- cervical fusion. L: 6 weeks after craniocerebral operation. M-P: Anterior operation. Q-S: 3 months follow-up. nism of injury seems to be reasonable that a report in ours (3 in 4). When a combined injury sudden axial load producing the C1 fracture [3, is recognized, management difficulties arise 20] coupled with a flexion force that result in C2 due to the unique anatomy and biomechanics injury (most commonly type II odontoid frac- of the atlantoaxial complex with the goals of ture) [21]. Acute combination fractures of atlas reduction of fracture, alignment of spine, stabil- and axis are more frequently associated with ity, and protection of spinal cord.
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