I'm going to talk about odontoid fractures. I walked across the street before this course. I live right here. Sadly, I have nothing to disclose. I'm going to talk about odontoid fractures, go over some quick overview, and then some cases. It's about 10% to 15% of cervical fractures. They are usually not fatal, but if they are, they're usually at the time of injury, and only about 10% have significant deficits. Usually associated with neck pain, worse with movement. Bimodal, it's either young patients or old patients. Young patients tend to have high velocity injuries. Older patients, very low energy trauma, like a ground level fall. And in the studies I read, 70 was considered old. Workup includes your normal x-ray, CT, MRIs. At our hospital, we no longer get x-rays. There's a trauma protocol, and they go straight to CT. They kind of CT from head to toe, but a lot of our community hospitals still do get x-rays, so sometimes you will see x-rays. Patient factors to consider when you're seeing a patient. Age is actually a very big one. Associated injuries, medical comorbidities, healing potential, tolerance for treatment. Older patients definitely do not tolerate halos, and patient wishes. So two mechanisms of injury. One is hyperflexion, which is the most common, which is of course your head leaning forward, as this fracture here shows, and that would occur. Second is hyperextension, which is less common. Classification, which we all know, are Anderson and DiAlonzo classification. Type 1, which is right here, is at the tip of the dens. It is considered a type 1 fracture if it is above the transverse ligament. Sometimes there's a bulge in the alar ligament. You have to be very careful with these fractures. It does indicate something like an AOD, which we just talked about, that you have to look for. Type 2, which is much, much more common, is right at the base. And again, this is a watershed blood supply area. The apex is from branches of the ICA, and the base is from branches of the vertebral artery, so this not only does not have a lot of surface area for contact for healing, but also has decreased blood supply as well. And then type 3, which is through the body. So moving on to type 1. There isn't much controversy on how to treat a type 1. Again, you worry about an AOD, or transverse ligament injury, when you do see these. We usually immobilize them anywhere from eight to 12 weeks. And recommendations are either collar or halo. We tend to use a collar more often, and there's near 100% infusion with these. And this is a CT scan. I've seen, I think I've been here six years, we see a lot of trauma, and I've seen one, type 1. They're really not that common. Ways to immobilize the cervical spine. We all know the halo, which most patients do not like, nor do they like the Minerva brace, or the CTO brace. We have our Philly collar, Miami-Jay, and Aspen collar, which they seem to tolerate a little better when you talk about cervical immobilization. So moving on to type 2. Type 2 remains controversial. There's a lot of papers about type 2, depending on age and mechanism of injury, and how we treat these. There's a wide range of non-union rates, depending what paper you read, anywhere from five to 76%. The overall quoted rate's about 30%. It does depend on certain factors, such as displacement. The bigger the displacement, such as greater than six millimeters, you have a higher non-union rate, closer to 70%. The most recent papers and recommendations use advanced age as age older than 50. Most people wouldn't consider that old, but in this paper it was. You have increased non-union rates, 21 times higher than those with similar fractures who were younger. Another controversy of the type 2 is a bony union versus a stable fibrous union, and this mostly occurs in the elderly population. So the union rates are based off of bony fusion, but there are a lot of people, such as myself, who believe as you get older, you can actually have a stable fibrous non-union in the elderly, where the fibrous tissue holds, they fracture together, even though it doesn't seem to be a complete bony fusion. The reason that we tolerate that sometimes in our older patients, because delayed myelopathy, which is what we worry about, if these fractures don't heal, takes 13 years or longer, and that's usually in younger patients, and these older patients who are 80, 85, 90, they're probably not gonna be around 13 years. So non-union risk factors. Again, age greater than 50, more than five millimeters of displacement, fracture comminution, or an angulated fracture of more than 10 degrees, or delay in treatment, meaning that they show up three to six months after the injury and don't realize it's there. So treatment options for type two. We have immobilization, which we showed before, they're halo or collar. Hedontoid screw, that does assume that the transverse ligament is intact in order to do an hedontoid screw. Both of those are motion-preserving options. And then the posterior C12 fusions. I have a few pictures, but I think Praveen's talking about this afterwards. C12 wiring, which you've already seen, transarticular screws, which we just saw, and a HARMS construct, C12 fusion, which I think we're gonna talk about a little bit more in depth next. Do remember that when you fuse C12, you lose 50 of your 100 degrees of rotation, so about 50%. So we'll kind of go through these. Hedontoid screw, so something we do not too often. We may do 18 to 20 of these a year, mostly in our elderly population at our institution. It takes more time to set up than it does to actually do. Either use biplanar fluoro, or we have an O-arm that we can just use biplanar fluoro on. Depends on patient morphology. It's an ACDF approach, it's a simple screw that goes right through the fracture site all the way to the end. There was a controversy at one time of one versus two screws. One is just as biomechanically stable as two, and a little bit easier to put in just one screw. About a 90% fusion rate, and that is if this is done within the first six months of a fracture. Some people say earlier than that, but that's what most of the papers say. Very high risk of non-union if you have this type of a fracture. It's difficult to line this back up and get a screw where you need to, so you may either miss when you go across the fracture line, or it just doesn't heal as well. So here I have a 69-year-old who had a four-foot fall, which isn't very far, I think it was a short ladder, and we have a type two hedontoid fracture here. So given the age that we talked about, he's a little older than 50 years old, so he has a very high non-union rate. We opted to put a hedontoid screw in him, and he did very well. This is our 71-year-old with a ground-level fall. Again, has a type two fracture. This one is posteriorly placed. MRI was done in this patient, which we would normally do MRIs if we're going to consider surgery, looking for a transverse ligament injury, or if they have, if they're difficult to examine, or if we don't have a good exam. We do not get MRIs on every hedontoid fracture that we see. This particular patient here, before they were discharged from the hospital, we do get an upright X-ray of them and their collar. This is the X-ray of the patient, and you'll see here is the base of the dens, and over here is the top of the dens. So this occurred three days after being in the hospital in a collar. So obviously this is not something we can send this patient home with. So what would you do? Our options are either do nothing or do something. We at our institution try not to put a 71-year-old in a halo. The reports are up to 86% morbidity and mortality for people over the age of 74 in a halo for various reasons. I mean, it's very, very high. There might be, I don't know any case you would stick an elderly person in a halo more than maybe just a day or two if you're trying to reduce something and hold them in place before you fix them possibly, even then it's a high risk for aspiration, pneumonia, and other things to happen in the hospital, but I would try not to put a halo on anyone this age. But we thought that the patient would make it through surgery, so we were able to reduce it, and we put in a dontoid screw in. Now, dontoid screws in the elderly, there's a lot of papers on this too, also have up to, I think, 26, 28% mortality, morbidity associated with a surgical procedure as well. Yes, sir? You said that if a patient failed a cholera audit, how long after an injury would you still consider a dontoid screw? So published reports say up to six months. I only do them the first six weeks, but that's my, I don't know anyone else's personal preference, but after six weeks, it is a little bit more difficult to get past the fracture site. There's already some healing or some fibrous union or non-union that I think is difficult to get across. People will do this, they do have, they're very successful with it, but in my practice, it's not something that I do. Yes, sir? Did you use a contraband contraption when you used that before? We did, we did. If you ever have problems with using that length screw, trying to pull out a fracture, bring it back and do the contraction, do you take the traction off once they're reduced? They usually will stay reduced. We usually, I mean, you can reduce them and keep them at maybe five pounds. We don't have to keep them a lot of weight. And we do take the traction off, though, before we put the actual screw in. Yes? Is there a reason why you prefer doing a dontoid screw in this case, versus C-linked, apart from preservation of motion? Because I always thought that the morbidity of swallowing issues and stuff is pretty high, and a 17-year-old is motion preservation a big factor. So, I would say you are correct. A C-1-2 fusion would have also been a very viable option. In our institution, we tend to do a lot of a dontoid screws in the elderly. Our patients tend to do well, although this is not in every institution, so this is something I would do. But I think a C-1-2 fusion is also a very good option with less associated morbidity and mortality. I think most people would agree that this is not a patient who really can't do the hospital or the college on the first time around. Even if they're refusing or adamant about it, you have to make it clear, because this is already slightly displaced when they left versus x-ray. So, it's either halo or OR. It's not the appropriate one to put in the college. Michelle, can you show with the cursor where the back of the DENS is? Yeah, it is. So, here's the body, and the DENS is over here. So, the posterior- There's C-1 and C-2's back here. So, that's C-1 that's lined up where the DENS used to be. That's C-1. That's the DENS in the canal. We have lots more fun. All right, transarticular screws, I think Praveen's gonna talk about these as well, but that's an option too for somebody with a dontoid fracture. These are not my pictures. I pulled these away from someone else. C-1-2 fusion, which we're gonna talk about as well. But C-1-2 fusions have extremely high rates of fusion. They're very good constructs when done correctly and fuse very well. So, back to our cases. So, we have a 70-year-old. I have a lot of old people at my institution. Status was a fall off a horse. He fell off a horse. He had some neck pain. His primary care doctor put him in a little collar for a while. His neck pain went away. Took it off. So, he's seeing us six months later. So, this is what we have. It's a pipe tube, a dontoid fracture, but now we're six months out. So, now what do we do? Neck pain. And he can't ride his horse. If he rides his horse, he gets this weird sensation. Maybe, probably, I don't remember if it was paresthesia or electrical shocks that kinda run down his body, down his hands. How much displacement is that? It doesn't look like much displacement at all. I think it did have six months before the convalescence. It's still actually under a dontoid screw. So, a dontoid screw. So, a dontoid screw at six months. That's towards the outer limits of when you would wanna do that. It would be very difficult to get across the, you can see these are well corticated. Very difficult to get across this fracture. And across this fibrous tissue that's in here as well. So, he, he's symptomatic when he rides his horse. Only when he rides his horse. This guy's a rancher. We're in Texas. He wants to ride his horse. He's not giving up his horse. So, what are we gonna do? I don't have my list. So, we'll pick, what do you two? What are you gonna do with him? I would flex-ax him. Okay, so you flex-ax him. He moves two millimeters. Given that he does have at least a little bit of motion and he does have symptoms, I think that offering him or recommending an operation to him would be what you'd go for. What do you want to do to him? I want to take a look at the course of the vertebral artery but I think a C1-2 transepticular screening would be decent. So, a C1-2 fusion of some type. Okay. So, that's what we did. I chose a little different option. I did a C1 lateral mass and a C2 PARs in this gentleman and I just supplemented that with a wiring in the back. He did well. Six months later, he rode his horses. He actually rode his horses three months later but in his collar. All right, type three. Yes? Why did you supplement with the Sontag wiring? So, the people in this room trained me. So, I kind of, I was trained to do this this way. It works very well. It increases your fusion rate and you can lay a bone graft on the side or in the gutters that you've already got a piece of bone that you can get. It's really easy to do a C1-2 wiring and it's a nice big solid piece of bone between C1 and C2 that I know is gonna fuse in addition to having instrumentation there. So, type three. Not much controversy with type three. 90% of them heal with just simple immobilization. One series had 100% healing rate in a halo and a rigid collar. They're reported anywhere from 50 to 70%. I think it's a little higher than that but I couldn't find that in the literature. Patient factors also matter. Age, medical comorbidities, things like that. Again, this is a type three here but some of these are real shallow. Yes, they go into the body but a shallow type three, I might still consider and treat that as a type two. If it has more than five millimeters of extraction or it cannot be maintained reduction after you reduce these, consider surgery. So, I've got another 72-year-old. Status post, a ground level fall. Again, this is a type three, you can see here. So, next guy over. How are you gonna treat this? Yeah, that's you. So, I think the guy's having neck pain at this point. Neck pain only. So, I think if you look at the extent of displacement of the C2, it's not much and I think I would probably try a collar first for this guy and then have him come back and see how his symptoms are, what the extent of fusion is. It turns out that it still hasn't fused and he's still having symptoms. I'd probably recommend a C1 tube just because of the center around that that's a pretty popular clinical collar, I think. So, we treated him with a cervical collar. We put him in Miami-Jay. He fell again, so we got a CT scan and he was about six weeks or so in his collar afterwards and you can see there's some evidence of healing in this area and then this is his X-ray, I think three or four months afterwards and it's completely healed. I couldn't find the CT, but he healed very well on a collar. So, this is a 34-year-old, status post and MVC. Again, we've got a type three. So, next guy over. What are we gonna do with our 34-year-old with a type three odontoid fracture? If you give it a chance to heal and it doesn't heal it, is there a transplant? So, you're gonna put him in a halo or a collar? Collar. Collar. Okay, so I got a Miami-Jay collar. So, we did that. We put him in a collar, but he's 34 and he's invincible and twice I walked into his room and he wasn't wearing his collar. So, now what are you gonna do? But if you give him more immunity, probably can heal. Well, two days. I mean, he's in the hospital, two days. Each day I walked in, not wearing his collar. Well, I did a... See, surgery is an option. Or I call it the penalty halo. So, I put him in a halo. And because, I mean, he's young. He wasn't a smoker. He could heal well with the mobilization as long as he kept his immobilization on. So, we put him in a halo, secondary to non-compliance. And in a halo, four weeks later, he came back with a neck tray, which looked alarming. And obviously, he's got a trach. So, he really isn't doing a lot of things going on, but this is what it looked like. So, now what are we gonna do? Next guy, over. Yeah. We've seen that too. Yeah, I mean, they can take him off if they want to. So, was he symptomatic? Was he symptomatic? No, I mean, he wasn't symptomatic. Well, you know, despite the fact that he's not symptomatic, he's obviously not stable, and he's obviously not complying as well. He's still conservative management. And, you know, he's, as you say, very forward-thinking. Well, he's extremely forward-thinking. So, we consider surgery. What do you... C1, well, it depends on what you're comfortable with. I'm C1, so that would work. C1, 2, fusion? Yeah. Are you going to reduce that somehow? Yeah, I'm gonna try to reduce. So, I would, you know, again, put the AO ring back on, try to reduce him in the lower, under the lower, and then do the C1, C2, similar to the C1, C2. So, we reduced him in the, I think it is ICU bed, or in the hospital. So, we reduced him. And, it reduces really well. And then, we did exactly what you suggested, and we went and did a C1, 2, fusion. And, it didn't un-reduce a millimeter or two, but it healed very well. Can I just ask, so, can you go back to that? Sure. So, when you're operative, how do you decide if you have a high-riding bird that you need there? What size could you get? Or, does that affect your, where you do a lot of trans-articular screwing? So, I'm not a big fan of the trans-articular screw. So, I do a C1, 2 fusion, either with a C2 pedicle, or a C2 PAR screw. And, it depends where the bird is. And, I actually measure. I mean, I teach other residents to measure how far you can go, how far you can drill, and so you know exactly where you're going. And, when you put in the C2 PAR screws, and we'll show you tomorrow, or the next day, whenever the lab is, it's real easy. You can see your PARs. I mean, you can literally take your Penfield 4, see the lateral and medial border, and you just go right down the hole. All right, so recommendations. In 2013, there was a supplement that was put out for spine injuries. There are level two and level three data. Recommendations, hopefully you can read this. Phaedontic fracture type one, collar mobilization, which we talked about. Type two, they recommend early surgery if you're greater than 50 years old, or halo if you're less than 50. Type 2A or 2C, early surgery, which is our common unit of fractures. Type 3, collar, halo, or surgery if it's a big angulation or if it doesn't reduce. What I kind of recommend for type one, again, is a collar. Type two, usually collars or surgery. We have the penalty halo, which we will use, or sometimes patients don't want to have surgery, and if it needs to be reduced, and it won't stay that way in a collar, we'll put a halo on. We do leave that up to the patients. Consider surgery if they're greater than 50 years old. The type 2A fracture, if there's a big displacement of five or six millimeters, they can't maintain alignment, or if the patient wishes to rather have an odontoid screw or some kind of effusion rather than wear a collar or halo. And type three, again, it recommends collar or halo, but we usually try a collar first unless they're not compliant or we do a penalty halo. And that's it.

odontoid fractures

cervical fractures

neck pain

X-rays

CT scans

MRIs