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1、Odontoid Fracture and Delayed Odontoid Fracture and Delayed Atlantoaxial DislocationAtlantoaxial DislocationChang Zheng Hospital ShanghaiJia LianshunPrefacePrefacelDens axis Atlantoaxial stability Most important axial bone structurelOdontoid fracture Atlantoaxial instability Secondary SCIOdontoid fr
2、acture Odontoid fracture 710%of cervical spine fracturecause SCI instantly Respiratory dysfunction Even deathSpecial structures and functionHigh ununion rate after fractureClinical informationClinical informationMale 41 cases Female 15 casesAge range 1558 yrs Average 37.5 yrs 1120 yrs 5 cases 2131yr
3、s 16 cases 31 40yrs 23 cases 4150yrs 7 cases 5058yrs 5 casesInjury causesInjury causesAccidental falls 15 cases building work accident 12 cases drop from bed 3 cases Motor vehicle accident 11 casesSports-related injury 13 cases water dive 7 casesTumble on ground 7 casesWeight hurt 10 casesCourse of
4、diseasesCourse of diseasesTime from injury to treatment shortest 4 weeks longest 26 months 13M 23 cases 4 6M 15 cases 79M 11 cases 1012M 4 cases 1 yrs 3 casesTreatment courseTreatment coursenot treated after injury 12 casesno diagnosis when admitted 7 casesskull traction 23W stabilized by collars 16
5、 casesonly collars stabilization 21 casesMotor functionMotor functionNormal gait,no motor limitation work properly 16 casesWeakness of legs,clumsy action,but can walk weakness of hands grasping function not affected 21 casesunstable gait need support,weakness of upper limbs,capable of grasping,13 ca
6、sesincapable of standing and walking stay in bed 6 casesRadiological examinationRadiological examinationRoutine X-ray programhead-neck AP lateraldynamic lateral filmsopen mouth viewAll case showed odontoid fractureAccording to Anderson-D扐扐lonzo classificatonType 47 cases Type 9 casesMRI examination
7、MRI examination 41 cases41 casesNo significant abnormal 8 casesSpinal cord compression 33 casesl l SC signals increasing 5casesTreatmentTreatment All received operationAll received operationBefore operation Skull traction routinely1W later X rays observe reduction trend possible reductionkeep tracti
8、on until restored impossible reductiongive up tractionl lReducible dislocation need no continuous traction receive operation directlyAtlanoaxial Atlanoaxial posterior posterior structure structure bone graft and wire fixation bone graft and wire fixationModified Gallie method 17 cases Modified Brook
9、s method 14 casesl lAutogenous iliac bone Autogenous iliac bone clip to be clip to be 揟揟揟揟?shape?shapel lThe convex of bone graft is inserted into the gap The convex of bone graft is inserted into the gap between between the posterior arch of atlas and the base of C2 lamina and spinous Distance=810
10、mm Inter-arches&Over-surface bone graft+Wire fixationAtlas Atlas posterior posterior arch arch resection resection +Occipital-cervical fusion +Occipital-cervical fusionResect each side of the dislocated atlas posterior arch 10mm beside the posterior tubercleAutogenous iliac grafts between the occipi
11、tal and the base of C2 spinous processes Total 25 casesResultsResultsNo death caseNo death caseAll be followed-upAll be followed-upAverage follow-up time 3yrs and 6MShortest 11M Longest 10yrs and 8MBetter:symptoms and signs improved Limbs motor deficit,unstable gaitno-change:no change of symptoms an
12、d signs or feelings Bone grafts un-union Results of treatmentResults of treatmentAtlantoaxial fusionAtlantoaxial fusionExcellent 14 cases Good 11 casesBetter 4 cases No change 2 cases*1 case bone graft ununion and displacedOccipitocervical fusion Occipitocervical fusion Excellent 12 cases Good 8 cas
13、esBetter 3 cases No change 2 cases*bone graft ununion and displacedMain causes of early mis-diagnosisMain causes of early mis-diagnosisSurvivals of odontoid fracture only complicated with mild dislocation or no dislocation of atlasclinical symptoms are mild not enough to take patient抯抯 attentionthe
14、illegible radiography show overlapping of bone structure between atlas and axisPathological changesPathological changesIntensive related factorsIntensive related factorsTraumatic force formTraumatic force strengthAnatomic structureAnatomy about odontoidAnatomy about odontoidSagittal diameter of C1 c
15、anal=30 mmDiameter of cord=10 mmDiameter of dens=10 mmSafe space for cord=10 mmConsiderable buffering space is availableMechanism of odontoid fractureMechanism of odontoid fractureSkull flexion injury is one of the major causesTraumatic forces head bended suddenlyTraumatic forces head bended suddenl
16、yOdontoid Odontoid Anterior arch of C1 Anterior arch of C1 Transverse ligamentTransverse ligamentImpacting forward togetherImpacting forward togetherTransverse shear force Vertical compress forceTransverse shear force Vertical compress forceSeparate the connection between odontoid and C2 bodySeparat
17、e the connection between odontoid and C2 bodyOdontoid fractureOdontoid fractureOutside shear force Outside tear forceOutside shear force Outside tear forceMechanism of delayed atlas dislocationMechanism of delayed atlas dislocationUnstable status caused by odontoid fractureUnstable status caused by
18、odontoid fractureSkull has trends of inclining forward and moving continuouslySkull has trends of inclining forward and moving continuouslyAtlas move forward progressively with dens axisAtlas move forward progressively with dens axisDelayed atlas dislocation Delayed atlas dislocation Direct operativ
19、e decompression Direct operative decompression Moving forward equably or Moving forward rotatelyMoving forward equably or Moving forward rotately Potential risks of SCI Potential risks of SCI Contributed factors Contributed factors odontoid odontoid ligaments around ligaments around articular capsul
20、e articular capsuleDiagnosis of Diagnosis of Diagnosis of odontoid fracture&atlas dislocationodontoid fracture&atlas dislocationHistoryinjury,treatment courselocal and neurologic examinationimage examination routine X-rays films routine X-rays filmsSkull-neck AP films Open-mouth films Lateral flexio
21、n and extension filmsSkull-neck AP films Open-mouth films Lateral flexion and extension filmsX-ray tomography CT MRIX-ray tomography CT MRIDifferentiate with the odontoid dysplasia and its deformity complicationDifferentiate with the odontoid dysplasia and its deformity complicationFacilitate choosi
22、ng the treatment plan and assessing prognosisFacilitate choosing the treatment plan and assessing prognosisDiscussion Discussion Discussion Treatment TreatmentOdontoid fracture self-healing difficultCan hardly heal at the displaced siteNon-operation treatments are ineffectiveSurgical treatment is th
23、e first choiceOperative procedure choice according to pathologic changes and clinical featuresAtlantoaxial fusionAtlantoaxial fusion an ideal methodan ideal methodConditionsReduction completely or almost restored after skull tractionAtlas is not dislocated or can restore while extensionOccipital-cer
24、vical arthrodesisOccipital-cervical arthrodesis a common operative procedurea common operative procedureRestricting the skull-neck motor function in some extent Indications those who needs posterior arch resection those who needs posterior arch resection obvious atlantoaxial dislocationposterior arc
25、h of atlas is the chief compressorposterior arch of atlas is the chief compressoratlas anterior dislocation is smallsevere symptoms of SCI existsevere symptoms of SCI existMethods of rebuilding the stabilityMethods of rebuilding the stabilityModified Gallie and Brooks techniqueProcedures of wire tec
26、hnicalProcedures of wire technicalRevising and placing of bone graftsRevising and placing of bone graftsl lDistance between the posterior arch Distance between the posterior arch and laminae and spinous of C2 is and laminae and spinous of C2 is 8mmwhen atlas is at neutral position under normal when
27、atlas is at neutral position under normal physical conditionphysical conditionl lRelatively constant keeping the ligament tension between Relatively constant keeping the ligament tension between atlas and axis and the stability of joints related to dens axisatlas and axis and the stability of joints
28、 related to dens axisAdvantages Advantages of the posterior structure fusion of the posterior structure fusion inter-arches bone grafting over-surface bone graftinginter-arches bone grafting over-surface bone graftingThe posterior arch of atlas the surface of posterior archThe posterior arch of atla
29、s the surface of posterior archThe base of spinous processes the C2 laminas The base of spinous processes the C2 laminas Increasing the contact area of bone graftsIncreasing the stability of fixationPrinciples Principles of fusion and fixation procedures of fusion and fixation proceduresDistinguish
30、anatomic structures carefullyDetach the atlas which sink in the canal Sufficient exposure for the posterior arch tubercleDo not push with a periosteum separatorDetach the upper and lower posterior arch clearlyPrinciples Principles of fusion and fixation procedures of fusion and fixation proceduresOperate carefully to avoid SCIIf dislocation remained do not reduce with instrument fusion at original place to avoid SCIOccipital-cervical fusion procedure make intensive attachment of bone grafts assure the healing of bone grafts