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Editorial
Treatment of odontoid fractures The odontoid process mimics a hand rickshaw puller. Such rickshaws are now seen mainly in Kolkata [Figure 1]. The weight of the entire rickshaw is on the two wheels, and the rickshaw puller primarily has to guide and direct the vehicle without bearing any weight on himself. He can run with the rickshaw for kilometers without feeling any weight on his shoulders. The rickshaw puller may be an old man or may even be injured, but can still carry on his work. This is essentially because the entire weight of the rickshaw is on the two wheels that are also the primary site of movement. Moreover, the rickshaw will lose its direction, movement, and even its stability if there is no rickshaw puller or if the rickshaw puller is unable to stand on his feet. On similar lines, the facets are the only true joints in the entire spine. The odontoid process and the intervertebral discs have similar roles of assisting or guiding and providing a purpose to the movements that are initiated and completed in the facets. The concept in the treatment of odontoid fracture is based on the premise that if the odontoid process is injured such that the spinal alignments have altered and dynamic images show evidence of instability, the surgery has to aim at providing stability to the region by fixation of the facets. If the fractured segments of the odontoid process are in alignment, a conservative nonsurgical treatment or an odontoid screw fixation may be an option. The treatment of the odontoid fracture will essentially depend on the site of fracture and the degree of altered movements that occur. The fracture of the odontoid process may be associated with a fracture of other parts of the vertebra. The fracture may result in an altered stability on dynamic images, or the instability may be obvious even on static images. The facets may be in alignment or might not be in alignment. There may or may not be an evidence of cord compression on imaging. The patient may be neurologically intact or affected. Pain as a symptom is common in such cases and signifies the presence of instability of the region.
I prefer posterior lateral mass fixation in all cases where surgical treatment for fractured odontoid process is contemplated.[1-5] The dictum should be that whenever one is in doubt about the stability, one should fix it. Any evidence of instability of the region should point at malfunctioning of the facets and the need for fixation. And when one attempts to fix the region, the most versatile and proven method of fixation should be employed. If the surgery is contemplated, it should not be a semifinal surgery; it should be of the type that will result in fixation and fusion of the region. Any surgery in the region is major and should be done with all preparedness and precautions. Although attempts to fuse the fractured odontoid process and to retain the movements at the facet joints can be successful in some cases, my observation is that one should resort to fixation-arthrodesis of the atlantoaxial joint and settle the score once and for all. Significant neck pain and presence of neurological deficits can be indications of surgery. Movement restriction at the neck following the fixation method described by us and also used by Sawarkar et al. is only marginal and may not be a contraindication for surgery that is aimed to provide stability to the region.[7] Sawarkar et al. present a large series of patients operated for odontoid fracture. They identify the usefulness and effectiveness of anterior odontoid screw fixation. The odontoid screw fixation procedure does have the advantage of being simple and if learnt adequately, is a safe surgical procedure. The success rate of fusion of the fractured
Access this article online Website:
Quick Response Code
www.neurologyindia.com DOI: 10.4103/0028-3886.152657 PMID: xxxxx
Figure 1: A typical Kolkata rickshaw
Neurology India / January 2015 / Volume 63 / Issue 1
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[Downloaded free from http://www.neurologyindia.com on Thursday, March 05, 2015, IP: 202.177.173.189] || Click here to download free Android application for this journal Goel: Treatment of odontoid fractures
segment of the odontoid process can be high, but the rate of stabilization of the region can be remarkably low.
References 1.
The treatment of odontoid fractures should be based on subtleties of an individual case. It appears that when the odontoid process fracture is in its distal half or third, and when there is no significant evidence of instability of the region, a conservative non-operative treatment or an anterior odontoid screw fixation can be a satisfactory method of treatment. However, whenever there is even a slight evidence of instability that is manifested by neck pain, presence of neurological deficits, cord signal intensity changes on imaging, facetal mal-alignment, and excessive and abnormal movements at the atlantoaxial joint, the patient should undergo a surgery that will aim at fixation and arthrodesis of the atlantoaxial joint. Atul Goel
2.
3. 4.
5. 6.
7.
Goel A, Laheri V. Plate and screw fixation for atlanto-axial dislocation. (Technical report). Acta Neurochir (Wien) 1994;129:47-53. Goel A, Desai K, Muzumdar DP. Atlantoaxial fixation using plate and screw method: A report of 160 treated patients. Neurosurgery 2002;51:1351-7. Goel A. Treatment of basilar invagination by atlantoaxial joint distraction and direct lateral mass fixation. J Neurosurg Spine 2004;1:281-6. Goel A, Shah A. Reversal of longstanding musculoskeletal changes in basilar invagination after surgical decompression and stabilization. J Neurosurg Spine 2009;10:220-7. Goel A. Screws, facets and atlantoaxial instability. World Neurosurg 2013;80:514-5. Goel A, Figueiredo A, Maheshwari S, Shah A. Atlantoaxial manual realignment in a case with post-traumatic atlantoaxial joint disruption. J Clin Neurosci 2010;17:672-3. Sawarkar D, Singh P, Siddique S, Agrawal D, Satyarthee G, Gupta D, et al. Surgical management of odontoid fracture at level one trauma center: A single-center surgical series of 142 cases. Neurol India 2015;63:40-8.
Department of Neurosurgery, King Edward Memorial Hospital, Seth Gordhandas Sunderdas Medical College, Parel, Mumbai, Maharashtra, India E-mail: [email protected]
8
How to cite this article: Goel A. Treatment of odontoid fractures. Neurol India 2015;63:7-8. Source of Support: Nil, Conflict of Interest: None declared.
Neurology India / January 2015 / Volume 63 / Issue 1
Copyright of Neurology India is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Editorial
Treatment of odontoid fractures The odontoid process mimics a hand rickshaw puller. Such rickshaws are now seen mainly in Kolkata [Figure 1]. The weight of the entire rickshaw is on the two wheels, and the rickshaw puller primarily has to guide and direct the vehicle without bearing any weight on himself. He can run with the rickshaw for kilometers without feeling any weight on his shoulders. The rickshaw puller may be an old man or may even be injured, but can still carry on his work. This is essentially because the entire weight of the rickshaw is on the two wheels that are also the primary site of movement. Moreover, the rickshaw will lose its direction, movement, and even its stability if there is no rickshaw puller or if the rickshaw puller is unable to stand on his feet. On similar lines, the facets are the only true joints in the entire spine. The odontoid process and the intervertebral discs have similar roles of assisting or guiding and providing a purpose to the movements that are initiated and completed in the facets. The concept in the treatment of odontoid fracture is based on the premise that if the odontoid process is injured such that the spinal alignments have altered and dynamic images show evidence of instability, the surgery has to aim at providing stability to the region by fixation of the facets. If the fractured segments of the odontoid process are in alignment, a conservative nonsurgical treatment or an odontoid screw fixation may be an option. The treatment of the odontoid fracture will essentially depend on the site of fracture and the degree of altered movements that occur. The fracture of the odontoid process may be associated with a fracture of other parts of the vertebra. The fracture may result in an altered stability on dynamic images, or the instability may be obvious even on static images. The facets may be in alignment or might not be in alignment. There may or may not be an evidence of cord compression on imaging. The patient may be neurologically intact or affected. Pain as a symptom is common in such cases and signifies the presence of instability of the region.
I prefer posterior lateral mass fixation in all cases where surgical treatment for fractured odontoid process is contemplated.[1-5] The dictum should be that whenever one is in doubt about the stability, one should fix it. Any evidence of instability of the region should point at malfunctioning of the facets and the need for fixation. And when one attempts to fix the region, the most versatile and proven method of fixation should be employed. If the surgery is contemplated, it should not be a semifinal surgery; it should be of the type that will result in fixation and fusion of the region. Any surgery in the region is major and should be done with all preparedness and precautions. Although attempts to fuse the fractured odontoid process and to retain the movements at the facet joints can be successful in some cases, my observation is that one should resort to fixation-arthrodesis of the atlantoaxial joint and settle the score once and for all. Significant neck pain and presence of neurological deficits can be indications of surgery. Movement restriction at the neck following the fixation method described by us and also used by Sawarkar et al. is only marginal and may not be a contraindication for surgery that is aimed to provide stability to the region.[7] Sawarkar et al. present a large series of patients operated for odontoid fracture. They identify the usefulness and effectiveness of anterior odontoid screw fixation. The odontoid screw fixation procedure does have the advantage of being simple and if learnt adequately, is a safe surgical procedure. The success rate of fusion of the fractured
Access this article online Website:
Quick Response Code
www.neurologyindia.com DOI: 10.4103/0028-3886.152657 PMID: xxxxx
Figure 1: A typical Kolkata rickshaw
Neurology India / January 2015 / Volume 63 / Issue 1
7
[Downloaded free from http://www.neurologyindia.com on Thursday, March 05, 2015, IP: 202.177.173.189] || Click here to download free Android application for this journal Goel: Treatment of odontoid fractures
segment of the odontoid process can be high, but the rate of stabilization of the region can be remarkably low.
References 1.
The treatment of odontoid fractures should be based on subtleties of an individual case. It appears that when the odontoid process fracture is in its distal half or third, and when there is no significant evidence of instability of the region, a conservative non-operative treatment or an anterior odontoid screw fixation can be a satisfactory method of treatment. However, whenever there is even a slight evidence of instability that is manifested by neck pain, presence of neurological deficits, cord signal intensity changes on imaging, facetal mal-alignment, and excessive and abnormal movements at the atlantoaxial joint, the patient should undergo a surgery that will aim at fixation and arthrodesis of the atlantoaxial joint. Atul Goel
2.
3. 4.
5. 6.
7.
Goel A, Laheri V. Plate and screw fixation for atlanto-axial dislocation. (Technical report). Acta Neurochir (Wien) 1994;129:47-53. Goel A, Desai K, Muzumdar DP. Atlantoaxial fixation using plate and screw method: A report of 160 treated patients. Neurosurgery 2002;51:1351-7. Goel A. Treatment of basilar invagination by atlantoaxial joint distraction and direct lateral mass fixation. J Neurosurg Spine 2004;1:281-6. Goel A, Shah A. Reversal of longstanding musculoskeletal changes in basilar invagination after surgical decompression and stabilization. J Neurosurg Spine 2009;10:220-7. Goel A. Screws, facets and atlantoaxial instability. World Neurosurg 2013;80:514-5. Goel A, Figueiredo A, Maheshwari S, Shah A. Atlantoaxial manual realignment in a case with post-traumatic atlantoaxial joint disruption. J Clin Neurosci 2010;17:672-3. Sawarkar D, Singh P, Siddique S, Agrawal D, Satyarthee G, Gupta D, et al. Surgical management of odontoid fracture at level one trauma center: A single-center surgical series of 142 cases. Neurol India 2015;63:40-8.
Department of Neurosurgery, King Edward Memorial Hospital, Seth Gordhandas Sunderdas Medical College, Parel, Mumbai, Maharashtra, India E-mail: [email protected]
8
How to cite this article: Goel A. Treatment of odontoid fractures. Neurol India 2015;63:7-8. Source of Support: Nil, Conflict of Interest: None declared.
Neurology India / January 2015 / Volume 63 / Issue 1
Copyright of Neurology India is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
