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Purpose: The objective of this study is to characterize the occurrence of odontoid fractures within a Swedish population. Methods: Prospective data of adults diagnosed with an odontoid fracture between 2015 and 2021 were retrieved from the Swedish Fracture Register (SFR). Epidemiologic data including age, sex, injury mechanism, injury type, fracture type (Anderson and D'Alonzo classification), neurological status and treatment type were requested from the SFR. Data pertinent to osteoporosis was retrieved from the Swedish National Patient Register. Results: A total of 1,154 odontoid fractures were identified, of which 30 were type I fractures, 583 type II fractures, and 541 type III fractures. The mean (Standard Deviation [SD]) age was 77.2 (13.8) years. The prevalence of osteoporosis and neurological deficits did not differ between the fracture types. The majority of patients were treated non-surgically (81%). Male sex and patient age 18–30 years were commonly associated with a high-injury mechanism, especially motor vehicle accidents. In the type II fracture group, significantly more patients had fallen from standing height or less than in the type III group (66% vs. 58%, p = 0.01) while in contrast, motor vehicle accidents were more common in the type III fracture group (12% vs. type II: 8%, p = 0.04). Conclusion: Based on the SFR, the typical odontoid fracture patient is older and suffers a type II fracture. Most injuries were caused by low-energy trauma although in younger patients and males, they were associated with motor vehicle accidents. Across the patient population, odontoid fractures were usually treated non-surgically. [ABSTRACT FROM AUTHOR]

Aim: Surgical treatment options for upper cervical trauma are few and have a very high risk. We aimed to present our experiences on the cases in which we performed surgery by eliminating the flexion restriction in the postoperative period by not including the occipital region in surgery. Materials and Method: 16 cases who underwent atlantoaxial fixation with C1 mass-C2 pedicle screwing due to atlantoaxial instability after the year 2008 were retrospectively examined. Results: 16 patients were included in the study. While the median surgical procedure time of the patients was calculated as 107.5 (range, 60-150) minutes; Intraoperative blood loss was measured as median 350 (range, 200-550) mL. Postoperative complications were observed in 2 patients (12.5%). 1 (6.3%) of the complications was screw revision and 1 (6.3%) was superficial infection. It was observed that the VAS scores of the patients decreased significantly in the postoperative period. Conclusion: In cases where surgery is planned due to atlantoaxial instability, internal fixation with C1 lateral mass C2 pedicular screws and rod system from the posterior is recommended as an appropriate surgical method due to early and high solid fusion and no restriction in neck flexion movements. [ABSTRACT FROM AUTHOR]

An odontoid process fracture is a serious type of cervical spine injury. This injury is categorized into three types based on the location of the fracture. Severe or even fatal neurological deficits can occur due to associated cord injury, which can result in complete quadriplegia. Computed tomography is the primary diagnostic tool, while magnetic resonance imaging is used to evaluate any associated cord injuries. These injuries can occur either directly from the injury or during transportation to the hospital if mishandled. There are two main treatment approaches: surgical fixation or external nonsurgical fixation, with various types and models of fixation devices available. In this case study, computed tomography follow-up confirmed that external fixation can yield successful results in terms of complete healing, even in cases complicated by other factors that may impede healing, such as pregnancy.

Background: Simultaneous fractures of C1 and C2 are increasingly common, but contemporary series are limited in their evaluation., Methods: All patients with traumatic fractures of both C1 and C2 admitted to an academic trauma center from 2012 to 2022 were retrospectively analyzed. Multivariable regression was used to identify characteristics relevant to management and outcomes., Results: 103 patients were identified, most of whom (52.4%) were age ≥80 years, suffered ground-level falls (80.6%), and had minor associated injuries (median Injury Severity Score 1), but had a 28.2% 1-year mortality rate. Landells Type 1 fractures were the most common C1 fracture (50.5%), and dens fractures were the most common C2 fracture (74.8%). Most patients did not undergo MRI, but ligamentous injury was seen in 54.8% of those who did. Fourteen patients (13.6%) had surgery upfront, and 7 (6.8%) had surgery after a trial of nonoperative management. Selection for upfront surgery was associated with neurologic deficits (p=0.010) and age (p=0.026). Dens fracture patients tended to have C2 as their lower instrumented vertebra (p=0.0902), and hangman's fracture patients tended to have C3 as theirs (p=0.0714). Upfront surgery decreased the odds of bony nonunion (p=0.0281). 91.7% of patients with bony nonunion with flexion-extension films had fibrous nonunion., Conclusion: Simultaneous atlantoaxial fractures commonly occur in elderly patients after ground level falls with minor associated injuries. Surgical selection is driven by neurologic deficits and age, and C2 fracture type may influence procedure choice. Surgery decreases the odds of bony nonunion, and fibrous nonunion is common in its absence., (Copyright © 2024. Published by Elsevier Inc.)

Purpose: The purpose of our study was to determine common acute traumatic cervical spine fracture patterns on CT cervical spine (CTCS). Methods: We retrospectively reviewed 1091 CTCS positive for traumatic fractures performed over a 10-year period at a level 1 trauma center. Fractures were classified by vertebral level, laterality, and anatomic location (anterior/posterior arch, body, odontoid, pedicle, facet, lateral mass, lamina, spinous process, transverse foramina, and transverse processes). Results: C2 was the most commonly fractured vertebra (38% of all studies), followed by C7 (32.4%). 48.7% of studies had upper cervical spine (C1 and/or C2) fractures. 39.7% of positive studies involved > 1 vertebral level. Conditioned on fractures at one cervical level, the probability of fracture was greatest at adjacent levels with a 50% chance of sustaining a C7 fracture with C6 fracture. However, 31.3% (136) of studies with multi-level fractures had non-contiguous fractures. The most common isolated vertebral process fracture was of the transverse process, seen in 89 (8.2%) studies at a single level, 27 (2.5%) studies at multiple levels. Subaxial spine vertebral process fractures outnumbered body fractures with progressive dominance of vertebral process fracture down the spine. Conclusion: C2 was the most commonly fractured vertebral level. Multi-level traumatic cervical spine fractures constituted 40% of our cohort, most commonly at C6/C7 and C1/C2. Although the conditional probability of concurrent fracture in studies with multi-level fractures was greatest in contiguous levels, nearly one-third of multi-level fractures involved non-contiguous fractures. [ABSTRACT FROM AUTHOR]

Type II odontoid fractures are the commonest C2 fractures. The management of dens fractures remains controversial with various radiological and fracture morphological factors affecting the approach and outcomes. All cases of anterior odontoid screw fixation between 2010 and 2020 were retrospectively analyzed. Patients' clinical, radiological (type of fracture, orientation, displacement, and diastasis), operative (single vs. double screw) and follow-up records were documented. The postoperative imaging findings were classified into grades I (excellent), II (good), and III (poor) based on the anatomical alignment with the screw. Follow-up cervical computed tomography was reviewed for fracture union. A total of 49 patients with a mean age of 37.3 ± 13.8 years were included in the study. The average time from injury to surgery was 23.1 ± 22.2 days. The bicortical screw purchase and superoposterior odontoid tip breach significantly affected the postoperative alignment (P = 0.035 each). Fracture union was noted in 41 (83.7%) patients. The horizontal fracture displacement ≥2.5 mm (P = 0.02) and poor postoperative fracture alignment (P < 0.001) resulted in worse fracture union rates. Transient dysphagia was the commonest complication (n = 12), whereas screw breakout (n = 2) and pullout (n = 2) were other hardware-related complications. One patient underwent re-exploration for screw readjustment and 2 underwent posterior instrumentation. Anterior odontoid screw fixation is technically straightforward, less morbid, and preserves biomechanical cervical mobility, when compared with the posterior instrumentation. With careful patient selection, meticulous surgical planning, and intraoperative image-guided screw insertion, good fracture union outcomes can be obtained. In the current study, we were able to achieve stable fracture union in 83.7% patients. [ABSTRACT FROM AUTHOR]

Objective: Second cervical vertebrae (C2) fractures are a common traumatic spinal injury in the elderly population. Surgical fusion and nonoperative bracing are two primary treatments for cervical instability, but the former is often withheld in the elderly due to concerns for poor postoperative outcomes arising from patient frailty. This study sought to evaluate the in-hospital differences in mortality, outcomes, and discharge disposition in elderly patients with C2 fractures undergoing surgical intervention compared with conservative therapy., Methods: The National Trauma Data Bank was queried from 2017 to 2019 for all patients aged ≥ 65 years with C2 fractures undergoing either surgical stabilization or conservative therapy. Propensity score matching was performed using k-nearest neighbors with replacement based on patient demographics, comorbidities, insurance type, injury severity, and fracture type. Group differences were compared using Student t-tests and Pearson's chi-square tests with Benjamini-Hochberg multiple comparisons correction. Subgroup analyses were performed in the 65-74, 75-79, and 80+ year age subgroups., Results: Six thousand forty-nine patients were identified, of whom 2156 underwent surgery and 3893 received conservative treatment. Following matching, the surgery group had significantly lower mortality rates (5.52% vs 9.6%, p < 0.001), a longer mean hospital length of stay (LOS; 12.64 vs 7.49 days p < 0.001), and slightly higher rates of several complications (< 3% difference), as well as lower rates of discharge home (14.56% vs 23.52%, p < 0.001) and to hospice (1.07% vs 2.09%, p = 0.02) and a higher rate of discharge to intermediate care (68.83% vs 48.28%, p < 0.001). Similar trends in mortality and LOS were noted in all 3 subgroups., Conclusions: In elderly patients with C2 fractures, surgical stabilization confers a small survival advantage with a slightly higher in-hospital complication rate compared to conservative therapy. The increased rate of discharge to rehabilitation may represent better long-term prognosis following surgery. The increased risk of short-term complications is present but relatively small, thus surgery should not be withheld in patients with good long-term prognosis.

The fractures of the craniocervical junction and upper cervical spine are connected with a high risk of neurological deterioration, severe neurological deficit, and a significant risk of life. Dens fractures are the most common cervical fracture for the population above 65 years. In elderly patients, the fractures are associated with low-energy traumas and low bone density. We summarize the operative techniques for odontoid fractures and present a case of a seventy-year-old female who underwent an operation for odontoid screw fixation after a fall from a tree. Six days after the operation an instrumentation failure was established and revision with occipitospinodesis was performed. [ABSTRACT FROM AUTHOR]

Background Context: The prevalence of C2 fractures has increased in recent years. The treatment of these fractures include halo-vest immobilization (HVI), rigid cervical collar, or spinal fusion. There is controversy regarding the management of these fractures with different institutions having their own protocols based on individualized experience. The volume-outcome relationship of HVI use for C2 fractures has not been studied. Evaluation of such relationships are important as they suggest that patients may benefit from referral to and treatment at high-volume institutions.Purpose: To evaluate the volume-outcome relationship in HVI use for C2 fractures in New York State.Study Design: Retrospective analysis of a statewide database.Patient Sample: We queried the New York Statewide Planning and Research Cooperative System database for the International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code 805.02 (closed fracture of second cervical vertebra) and procedure code 029.4 (insertion or replacement of skull tongs or halo traction device) to identify all patients who received HVI for a fracture of the second cervical vertebra between the years 2001 and 2014. Those who had isolated C2 fractures were selected.Outcome Measures: Outcomes of interest included resource utilization characteristics (hospitalization charges and length of stay), perioperative complications, comorbidities, 30-day mortality, any readmission, and any future cervical fusion surgery.Methods: The 2001 to 2014 Statewide Planning and Research Cooperative System database was used to identify patients with C2 fractures who received HVI. Our key independent variable was institution volume modeled as high- (>25 halos/year), medium-, (10-25 halos/year), or low-volume (<10 halos/year) based on the total number of HVI procedures reported by hospitals during the study period. We compared outcomes with respect to hospital volume. We also compared patients by age groups: <40, 40 to 60, 60 to 80, and >80. Multivariate logistic regressions were performed for the binary variables any complication and any readmission while controlling for covariates hospital volume, age, sex, race, insurance status, and Elixhauser comorbidity mean. Statistical significance was set at a value of p<.05 for all analyses.Results: In all, 625 patients with C2 fractures managed with HVI were included. Most patients were male (53%) and Caucasian (76%) with a mean age of 57. Patients at high-volume hospitals were younger (52 vs. 59 and 60 for medium- and low-volume, respectively; p<.01) and had fewer future readmissions (40% vs. 54% and 84% for medium- and low-volume, respectively; p<.01). On multivariable analysis, those with private insurance and worker's compensation had lower likelihood of future readmission compared to Medicaid patients. Patients >80 had higher rates of major in-hospital complications (52% vs. 40%, 18%, and 19% for groups 60-79, 40-59, and <40, respectively; p<.01), mortality (14% vs. 5%, 1%, and 1% for groups 60-79, 40-59, and <40, respectively; p<.01), and readmissions after the initial HVI (62% vs. 50%, 54%, and 37% for groups 60-79, 40-59, and <40, respectively; p<.01). The annual rate of HVI use for C2 fractures decreased significantly from 2001 to 2014 (0.32 to 0.06 HVI procedures per 100,000 people; p<.01) with the rate of decline being less pronounced in high-volume institutions (70% decrease vs. 85% and 90% for medium- and low-volume, respectively).Conclusions: Halo vest utilization for C2 fractures in New York State has been declining over the past decade, with the decline being less pronounced in high-volume hospitals. Our hospital volume analysis suggests that HVI use in high-volume institutions is associated with a lower rate of future readmissions. This finding suggests that patients with C2 fractures may benefit from treatment at high-volume institutions. Further research to help improve referral of appropriate patients and increase access to such institutions is warranted. [ABSTRACT FROM AUTHOR]

Background: Metastatic cervical spine disease can cause compression fractures, cervical spine instability, and pain. Vertebroplasty can stabilize a fracture, reduce the pain associated with a compression fracture, prevent or stop the progression of a fracture, thus avoiding cervical spine fixation, and decreased mobility. Transoral C2 vertebroplasty is less invasive than open fusion surgery, but it poses its own risk of infection and cement leak in this highly sensitive area. Methods: The image guidance setup consisted of the Stryker NAV3i navigation system, Stryker CranialMask tracker, and the CranialMap 3.0 software combined with biplanar fluoroscopy. Results: The patient's neck pain has completely resolved immediately after the surgery. There were no complications. Conclusion: Quality of life preservation is paramount in the management of metastatic spine disease. Vertebroplasty of osteolytic lesions can both relieve pain and restore stability, thus avoiding permanent stiff cervical collar, halo vest, or upfront occipitocervical fusion. With the increasing availability of surgical navigation systems, its use combined with biplanar fluoroscopy for performing transoral C2 vertebroplasty seems to be an adequate treatment in selected cases for pain relief, stabilization, and maintaining quality of life in the complex cancer population with C2 pathological fractures. The article describes as well vertebroplasty of the subaxial spine through a conventional anterior approach which again seems to be adequate in the treatment of spinal pathological fractures. [ABSTRACT FROM AUTHOR]

Background: Transarticular C1–C2 screw fixation, first described by Magerl, is a widely accepted used technique for C1–C2 instability with a good biomechanical stability and fusion rate. Method: We present a 69-year-old woman, who was diagnosed with a C2 Odontoid fracture type III and primarily treated with conservative treatment and collar. During first 2 weeks of follow-up, the patient developed cervical pain associated with C1–C2 instability. A minimally invasive posterior C1–C2 transarticular screw instrumentation with a percutaneus approach was performed. Results and conclusion: Minimally invasive approach with tubular transmuscular approach for C1–C2 transarticular screws instrumentation is safe and effective for C1–C2 instability. [ABSTRACT FROM AUTHOR]

Purpose: The most common injuries to the upper cervical spine are fractures of the dens axis. Therefore, the purpose of our study was to answer three questions, namely (1) whether the size of the dens is adequate at all levels to accommodate two screws, (2) what the angle of the posterior tilt of the dens is in a healthy individual and (3) compare the measured variables between the sexes.Methods: The cohort comprised 50 males and 50 females CT examination of the craniocervical junction. We measured the five diameters of the dens and posterior dens angulation angle (PDAA) and screw insertion angle (SIA). The same dimensions were measured in a control group, consisting of 40 non-pathological second cervical vertebrae specimens.Results: On CT scans, the mean PDAA was 162.7 degrees in males and 160.26 degrees in females; the mean SIA was 62.0 degrees in males and 60.2 degrees in females. On specimens, the mean PDAA was 169.47 degrees in males and 166.95 degrees in females; the mean SIA was 65.42 degrees in males and 64.47 degrees in females. All obtained values were higher in males; regardless of their measuring on either CT scans or specimens, differences between males and females were statistically significant (p < 0.05) in a, c, d and e values.Conclusions: The values of our measurements correlate with the dimensions identified previously in other studies. Based on our clinical experience and measurements, we presume that two 3.5-mm screws can be inserted into the dens of all adult patients, except for those with pronounced anatomical anomalies. Posterior dens angulation angle is slightly larger than we expected. The dens is significantly larger in males almost in all measurement. These slides can be retrieved under Electronic Supplementary Material. [ABSTRACT FROM AUTHOR]

Aims Evaluation of clinical profile, mode of injury, and clinical outcome in patients of traumatic atlantoaxial dislocation (AAD) who underwent posterior C1 and C2 screw and rod fixation by using Harms and Goel technique. Materials and Methods It is a retrospective study involving all traumatic AAD patients of all age groups admitted at Department of Neurosurgery, RMLIMS, Lucknow, during the last two years. Inclusion criteria was all cases having traumatic AAD with or without C2 fracture and underwent posterior C1 and C2 screw and rod fixation by Harms and Goel technique. Clinical profile, age, sex, mode of injury, types of injury (detected in MRI and CT of cranio-vertebral junction), preoperative and postoperative (after one month of surgery) neurological status were evaluated and outcome analyzed. Results Over all, out of 14 patients, 12 (85.7%) patients improved in the form of either reduced spasticity, improved sensation, increased power of one or more limbs, or bladder and bowel control. One (7.1%) patient retained preoperative status, neither improved nor deteriorated. However, one (7.1%) patient deteriorated, lost all sensations, motor functions below the lesion, bladder and bowel control, and died due to respiratory failure after one and half month of the surgery. Conclusion We concluded that Harms and Goel technique is a safe and effective system for achieving C1–C2 fusion in traumatic AAD. Although this study is very small, does not provide Class 1 data, and is subject to the bias of any retrospective series, we believe our findings to be a useful addition to the body of literature on the surgical treatment of C1–C2 instability. [ABSTRACT FROM AUTHOR]

Purpose: In surgery of C1-C2 fractures, standard navigation for screw placement based on preoperative image data was compared with intraoperative imaging guidance applying intraoperative computed tomography (iCT) with a special focus on accuracy of screw placement, workflow, and radiation exposure. Methods: A single surgeon series of 16 consecutive patients with C1-C2 trauma was retrospectively analyzed. Seven patients were operated with standard navigation; preoperative image data were registered by a 20-point surface-matching process for each vertebra. Nine patients were operated with iCT guidance, allowing automatic navigation registration. Screw placement was examined and graded with either iCT or postoperative CT. Dose length product of CT and dose area products of fluoroscopy scans were assessed; effective radiation doses were estimated based on conversion factors. Radiation doses of intraoperative and postoperative X-ray and/or CT diagnostics for each group were summarized to compare the total effective doses.Results: A total number of 72 screws were placed, 26 in the standard navigation group including 24 screws in C1 and C2, and 46 screws in the iCT group including 34 screws in C1 and C2. 15.38% (n = 4) of the C2 screws showed a grade 1 deviation and 3.8% (n = 1) a grade 2 deviation applying standard navigation. There was no misplacement of screws in the iCT group. Mean operating time in the standard navigation group was 186.57 min versus 157.11 min in the iCT group, while the mean summarized effective dose was 1.129 mSv in the standard navigation and 2.129 mSv in the iCT group.Conclusion: iCT navigated surgery can lead to higher accuracy and shorter operating time compared to standard navigated operations. iCT is a safe and straightforward procedure allowing reduction in radiation exposure of the medical staff, while modified scan protocols resulted in a radiation exposure that is lower than in standard diagnostic neck CT. [ABSTRACT FROM AUTHOR]

There are various types of C2 fractures, including odontoid fractures, hangman fractures, and complex fractures, which involve the vertebral body or multiple fracture types. The published literature on C2 complex fractures is limited, and treatment strategies have not yet been established. An 80-year-old woman with a history of osteoporosis, brain stroke, and cervical spondylosis fell and sustained a C2 complex fracture. Initial treatment with a cervical collar was unsuccessful and a C2 direct screw osteosynthesis surgery was performed under an image-guided three-dimensional navigation system. The surgical procedure was successfully performed with a surgical time of 83 minutes and a blood loss of 31 ml. Her neck pain improved after surgery. Follow-up CT scans revealed acceptable healing of the fracture four months later. C2 direct screw osteosynthesis is a viable treatment option for C2 complex fractures, particularly in elderly patients who may benefit from early stabilization of the fracture to prevent complications associated with long-term conservative treatment., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Nagashima et al.)

Background Context: There are limited data available on the impact of associated spinal (other spinal injuries [OSIs]) and extra-spinal injuries (ESIs) occurring in conjunction with fractures of the axis vertebra (C2) on clinical outcomes.Purpose: This study aimed to compare outcomes in patients with isolated C2 fractures versus patients with associated injuries in conjunction with C2 fractures.Study Design/setting: A retrospective cohort study.Patient Sample: A total of 30,472 adult patients with C2 fractures (International Classification of Diseases, Ninth Revision, Clinical Modification code 805.02) registered in the Nationwide Inpatient Sample (NIS) database (2002-2011) comprised the patient sample.Outcome Measures: Inpatient mortality, unfavorable discharge, prolonged length of stay (LOS) and high-end hospital charges in the non-operative and operative cohorts, and postoperative complications (deep venous thrombosis [DVT]; acute renal failure [ARF]; respiratory complications and wound infections) for the operative cohort were the outcome measures.Methods: Patients were stratified into four categories based on injury type: (1) isolated C2 fracture (n=10,135; 33.3%); (2) C2 fracture+OSI (8.7%); (3) C2 fracture+ESI (37.2%); and (4) C2 fracture+OSI+ESI (20.8%). Multivariable logistic regression fitted with generalized estimating equations using the sandwich variance-covariance matrix estimator to account for clustering of similar outcomes within hospitals was used to examine the association of primary endpoints for each of the associated injury categories with reference to isolated C2 fractures.Results: Mean age of the cohort was 66.27±21.67 years and 52% were female. Of the cohort, 52% underwent surgical intervention for C2 fracture. In a pooled regression analysis involving the operative cohort, the risks for inpatient mortality (odds ratio [OR]: 3.77; 95% confidence interval [CI]: 3.02-4.70; p<.001), unfavorable discharge (OR: 1.83; 95% CI: 1.66-2.01; p<.001), prolonged LOS (OR: 1.33; 95% CI: 1.18-1.50; p<.001), high hospital charges (OR: 1.49; 95% CI: 1.31-2.69; p<.001), DVT (OR: 2.08; 95% CI: 1.61-2.68; p<.001), and ARF (OR: 1.46; 95% CI: 1.16-1.83; p=.001) were significantly higher in patients with additional injuries when compared with patients with C2 fractures alone. Likewise, increased chances of inpatient mortality (OR: 1.40; 95% CI: 1.21-1.62; p<.001), unfavorable discharge (OR: 1.24; 95% CI: 1.15-1.34; p<.001) and high hospital charges (OR: 1.31; 95% CI: 1.21-1.43; p<.001) were observed in a pooled analysis of patients with concomitant associated injuries in the non-operative cohort.Conclusions: Associated injuries occurring concomitantly with C2 fractures adversely influence postoperative outcomes. In comparison to isolated C2 fractures, patients with associated injuries tend to have a greater propensity for higher health-care resource use because of more complicated and longer hospital inpatient stay. [ABSTRACT FROM AUTHOR]

Objectives: We report a case of isolated pharyngeal plexus injury following posterior plating of a C2 fracture in an 84-year-old white male. Methods: Methods include a case report with literature review. Results: The patient presented with dense pharyngeal paralysis and inability to initiate swallowing but maintained true vocal cord movement. The patient required gastrostomy tube feeding for 3 months but eventually recovered his swallowing function. Prior literature on acute pharyngeal paralysis following upper cervical spine fracture repairs is reviewed with recommendations for care of this unique patient population. Conclusions: Traumatic C2 fracture repair can lead to isolated dense pharyngeal paralysis due to pharyngeal plexus injury with subsequent severe dysphagia. Observation may be appropriate in this population, with consideration of tracheotomy for recurrent aspiration. [ABSTRACT FROM AUTHOR]

Study Design. Retrospective database analysis. Objective. To examine the incidence of hospitalization, treatment, and cost of caring for patients with axis (C2) fractures. Summary of Background Data. The incidence of C2 fractures in the elderly seems to be increasing, however, a comprehensive analysis of the incidence, treatment, and cost of treating C2 fractures has not been previously reported. Methods. The Nationwide Inpatient Sample from 2000 to 2010 was used to identify patients with C2 fracture without neurological injury (International Classification of Disease, Ninth Revision, Clinical Modification code 805.02). Examined variables included age, International Classification of Disease, Ninth Revision, Clinical Modification injury severity score, comorbidities, mortality, hospital length of stay, treatments, and total inpatient hospitalization charge. Charges were adjusted for inflation to 2010 US dollars as well as for cost-to-charge ratios. Results. In total, 31,129 patients with C2 fracture were identified. From 2000 to 2010 the incidence of C2 fracture hospitalization increased in all age groups (P < 0.0001). The most rapid increase was in patients older than 84 years, who experienced a 3-fold increase from 3.18 to 9.77 hospitalizations per 10,000 individuals per year (P < 0.0001). From 2000 to 2010, the rate of halo vest placement decreased from 25.2% to 10.4% (P < 0.0001), whereas the rate of surgical intervention increased from 13.1% to 16.5% (P = 0.029). For nonoperatively treated patients, the mean hospitalization charge per patient increased from $39,346 in 2000 to $63,222 in 2010, and for surgically treated patients, it increased from $70,784 in 2000 to $133,064 in 2010 (P < 0.0001). During the decade, the estimated charges for annual inpatient care for patients with C2 fracture in the United States increased 4.7-fold from $334,138,919 to $1,577,254,958 (P < 0.0001). Conclusion. The incidence of C2 fracture hospitalizations increased dramatically from 2000 to 2010, with the most rapid increase in the elderly represented by a greater than 3-fold increase for patients older than 84 years. The inpatient charges for treating C2 fractures have risen faster than the increased incidence, with a 4.7-fold increase in hospital charges resulting in estimated annual charges of more than $1.5 billion in 2010. [ABSTRACT FROM AUTHOR]

The article discusses a study on a cohort of patients with acute C2 fractures who had halo fixation or spinal fusion. It aims to perform a retrospective matched cohort comparison of inhospital major complication rates and assess the impact of age, comorbidities and injury score within each cohort. It indicates that fusion patients had higher in-hospital complication rate, increased length of stay and higher charges due to age, comorbidities and injury severity regardless of treatment modality.

Background: Acute traumatic axis fractures are common cervical spine injuries often caused by road accidents or falls. They are usually classified into three different types, namely, odontoid fractures, Hangman's fractures, and miscellaneous fractures. Congenital malformations of the craniovertebral junction (CVJ), although typically asymptomatic, may result in neural compression or instability, especially following trauma. Here, the authors present an unusual oblique axis fracture occurring in conjunction with several malformations of the upper cervical spine. Case Description: Following a motor vehicle accident, a 25-year-old female's radiographic studies showed an oblique axis fracture involving both the anterior and posterior elements along with an anterior and posterior Klippel-Feil syndrome (KFS) anomaly. Following treatment in a halo vest, the patient maintained alignment, and ultimately the fracture was fused. Conclusions: True oblique fractures of the axis are rare, as in the case presented, and may occasionally occur in conjunction with KFS of the upper cervical spine. [ABSTRACT FROM AUTHOR]

Abstract: The National Automotive Sampling System (NASS) and Crash Injury Research and Engineering Network (CIREN) databases were used in an analysis of odontoid fracture in motor vehicle crashes. NASS data were evaluated for the years 1996–2002, and CIREN from 1996 to 2003. Out of 58 fractures, 38 were identified in the NASS and 20 in the CIREN databases. There were 3108 weighted cases in the NASS database. Frontal impacts (11:00 to 1:00h) were most commonly associated with the injury in both databases. Although male and female occupants sustained the injury, females were shorter in stature, older in age, lighter in weight, and crashes were less severe (lower change in velocity) when female occupants were involved in trauma. In both databases, pure odontoid fracture and facet/lamina fracture accounted for approximately one-third of the cases, and a majority of impacts were associated with changes in velocity less than 56km/h. Although vehicle model years ranged from 1976 to 2002, recent model years were more frequently associated with CIREN data. In the CIREN database, type II odontoid fracture was the most common, but no particular mechanism of injury dominated; such information was not available in the NASS database. To ameliorate odontoid fracture, focus should be on frontal impacts. Because different types of odontoid fracture are not included in the current Abbreviated Injury Scale, appropriate coding schemes should be developed to classify this injury. The CIREN database is unique because it provides important clinical information, i.e., fracture type, and the associated mechanism of injury. The mechanism component in any epidemiologically based injury analyses is valuable to advance improvements in vehicle crashworthiness. [Copyright &y& Elsevier]

Background: Management of avulsion fractures in the upper cervical spine remains the subject of debate. Currently, most experts favor nonoperative management of an isolated injury. However, these injuries can be complicated by soft-tissue trauma, which may require a different clinical approach to management. Accurate diagnosis of soft-tissue injuries depends on the choice of imaging modality and consideration of unique patient-specific factors. Case Description: A morbidly obese 34-year-old woman was involved in a low-velocity motor vehicle collision that caused a forceful extension of the cervical spine. Initial computed tomographic imaging demonstrated a displaced avulsion fracture of the C2 body and widening of the C2-C3 facet. However, subsequent imaging using magnetic resonance demonstrated more extensive injuries. Because bracing was not feasible due to cervical instability, the injury was treated with posterior C2-4 fusion and bone grafting. Conclusions: Even in low-velocity collisions and limited injury on imaging, patient-specific factors should be considered in management decisions. Magnetic resonance imaging showed significant ligamentous compromise and marked cervical instability, revealing potential damage to vulnerable neural structures. Magnetic resonance imaging should be considered in the initial approach to any patient with these injuries. [ABSTRACT FROM AUTHOR]

The aim of the study was to assess the efficacy and safety of direct posterior transpedicular osteosynthesis in traumatic spondylolisthesis of C 2 vertebra., Materials and Methods: The present study is an observational retrospective analysis of the results of surgical treatment of 19 patients operated on in 2014-2020 using the posterior transpedicular osteosynthesis technique with Herbert's compression screws for a Hangman's fracture type II according to Levine-Edwards classification. After the operation, the follow-up period lasted for 22 [10; 36] months., Results: The study group of patients (n=19) made 2.48% of all patients operated on for traumatic injury of the cervical spine (n=766) in the period from 2014 to 2020. In all cases, the surgical treatment was successful; there were no intraoperative complications in the form of damage to the vascular and nerve structures. The average duration of surgery was 70.8±24.5 min, and intraoperative blood loss was 92.9±41.8 ml. The length of hospitalization stay was 7 [5; 17] days. On the postoperative CT scans, no significant screw malposition (>2 mm) was found., Conclusion: Transpedicular osteosynthesis with compression screws in C 2 traumatic spondylolisthesis is a safe and sparing operation with a short duration and insignificant blood loss. Thorough preoperative planning and knowledge of the anatomic landmarks make it possible to perform this operation effectively under the C-arm X-ray system control without any navigation system., Competing Interests: Conflicts of interest. The authors have no conflicts of interest to declare.

Metastases to the upper cervical spine are uncommon, and subsequent instability is rare. We report the details of a patient with metastatic breast cancer to the axis manifesting as a pathologic fracture and C1/C2 instability. This was treated by preoperative reduction to appropriate alignment with use of crown halo traction, followed by posterior occipitocervical fusion and postoperative radiation therapy., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2020, Thirunavu et al.)

Background: Anterior transarticular screw fixation (ATSF) of C1/C2 can be used for the treatment of unstable dens fractures. Here, we evaluated the feasibility of an anterior C1/C2 fixation in elderly patients with unstable dens fractures. Furthermore, we tried to analyze safe entry zones for ATSF surgery., Methods: A consecutive cohort of 13 patients with unstable dens fractures were treated with ATSF of C1/C2 between January 2015 and October 2016. If necessary, an additional screw was placed into the odontoid process. The placement was radiographically analyzed using the 3D Arcadis Orbic (Siemens, Erlangen, Germany). Additionally, computed tomography scans of the cervical spine from 50 trauma patients were analyzed to evaluate safe entry zones for anterior odontoid screw fixation and for ATSF., Results: ATSF was performed in 13 cases (7 female, 6 male; mean age 81.80 years). One screw had to be corrected intraoperatively due to initial malplacement. Neurological deficits or an injury of the vertebral artery were not observed. All patients suffered from swallowing difficulties during the postoperative course, without lesions of the esophagus or the trachea. In 4 patients (30.8%), an additional posterior fixation was offered to the patients due to progressive loosening of the screws.The anatomical-radiographic analyzes revealed a significantly shallower angle of trajectory for anterior odontoid screw fixation (24.9° ± 5.85°) than for ATSF (39.1° ± 6.44° (left); 40.5° ± 6.79° (right) P = 0.02)., Conclusions: The ATSF of C1/C2 might be a valuable option in the treatment of instable C1/C2 fractures, especially in the elderly or in patients with short necks and/or high body mass index due to the steeper trajectory compared with odontoid screw placement. Yet available screws seem to be of inferior resistance compared with the biomechanical properties of a dorsal fixation. Further studies should focus on screws with better mechanical properties and probably additional cement augmentation., Level of Evidence: 4., Competing Interests: Disclosures and COI: The authors received no funding for this study. The study has been carried out in accordance with the Code of Ethics of the World Medical Association (Declaration of Helsinki) and was approved by the Institutional Review Board (Medical Faculty, University of Duisburg-Essen, Registration number 18-8049-BO). The authors declare that they have no competing interests., (©International Society for the Advancement of Spine Surgery 2020.)

Study Design: Retrospective database review., Objectives: To determine factors associated with unplanned readmission, complications, and mortality in patients undergoing operative management for C2 fractures., Methods: The American College of Surgeons-National Surgical Quality Improvement Program (ACS NSQIP) was queried between 2007 and 2014. Unplanned readmission, any complication, and mortality were the outcomes of interest. Bivariate statistics were calculated, and multivariate regression models were estimated., Results: A total of 285 patients were enrolled. Readmission data was available for 199 patients and 11 patients (5.5% of 199 patients) had an unplanned readmission. Overall, 60 patients (21% of 285 patients) had at least 1 complication and 15 patients (5.3% of 285 patients) died. Five factors were associated with complications: transferred from another facility (odds ratio [OR] 3.00, 95% confidence interval [CI]1.51-5.98; P < .01); operative time ≥180 minutes (OR 2.43, 95% CI 1.11-5.36; P = .03); at least 1 patient comorbidity (OR 2.50, 95% CI 1.01-6.18; P < .05); American Society of Anesthesiologists (ASA) class 3 (OR 4.86, 95% CI 1.19-19.88; P = .03); and ASA class 4 (OR 7.24, 95% CI 1.66-31.66; P = .01). The only factor associated with unplanned readmission was having at least one postoperative complication (OR 7.10, 95% CI 1.04-48.59; P < .05), while patients who were partially or totally dependent from a functional standpoint were at increased odds of death (OR 3.98, 95% CI 1.12-14.08; P = .03)., Conclusions: Patients with functional limitations have increased odds of death, while patients with postoperative complications have increased odds of unplanned readmission. Being transferred from an outside facility, having an operative time ≥180 minutes, having at least one comorbidity, and being classified as ASA class 3 or 4 increase patient odds of complication., Competing Interests: Declaration of Conflicting Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: DNB reports grants from Alpha Omega Alpha (AOA), outside the submitted work. ENM reports personal fees from Evolution Spine, personal fees from Globus Medical, outside the submitted work. AM reports grants from Globus, grants from LES Society, grants from Corelink, grants from AO Spine, grants from OMeGA, outside the submitted work. All other authors (CT, BR, RWM) have no disclosures., (© The Author(s) 2019.)

Background: We report a case of an elderly patient who was diagnosed with lateral atlantoaxial subluxation with type II odontoid fracture, an extremely uncommon upper cervical spine injury that has not been previously reported in the literature to the knowledge of the authors., Methods: An 87-year-old male reported to the emergency room following a syncopal episode after sustaining a fall. He complained of dizziness, fatigue, disruption of vision and audition, and worsening neck pain. Computed tomographic scans were positive of partial dislocation of the C1 relative to C2 and chronic fracture of dens classified as type II according to the Anderson and D'Alonzo classification system. Magnetic resonance imaging further revealed large fracture pannus tissue at the level of the dens, reducing the space in the spinal cord. There was no evidence of spinal cord injury. Atlas-axis fusion with instrumentation was performed to manage the injury. A review of the classification, occurrence, and management of upper cervical spine surgeries was performed., Results: An acute injury to a previously unrecognized type II odontoid fracture with partial C1-C2 dislocation was identified as a rare upper cervical spine injury and classified based on the Anderson and D'Alonzo and Fielding and Hawkins classification systems. The decision was made to perform instrumented spinal fusion by inserting mass screws into C1, pars screws into C2, and locking rods to realign the vertebral bodies and address the atlantoaxial instability. Follow-up scans indicated good postsurgical reduction and fixation, including resolution of the pannus overgrowth without direct intervention., Conclusions: Lateral atlantoaxial subluxation with chronic type II fracture of the dens constitutes a rare injury of the upper cervical vertebrae. Posterior instrumented spinal fusion was used to effectively manage the injury, leading to reabsorption of retro-odontoid pannus tissue., Competing Interests: Disclosures and COI: The authors declare no conflicts of interest. The institutional review board (IRB) of the University of California, Irvine, deemed this study to constitute a nonresearch endeavor, which therefore did not require IRB approval. Patient confidentiality has been protected according to the US Health Insurance Portability and Accountability Act (HIPAA) and in accordance to the tenets established by the Declaration of Helsinki for human subjects. The patient provided verbal consent after being asked if the material in this case report may be published.

Background Predictors of surgical outcomes following traumatic axis (C2) fractures in octogenarians remain undercharacterized. Methods Patients age ≥80 years undergoing cervical spine surgery following traumatic C2 fractures were extracted from the National Sample Program of the National Trauma Data Bank (2003-2012). Outcomes include overall inpatient complications, individual complications with an incidence >1%, hospital length of stay (HLOS), discharge disposition, and mortality. Demographics, comorbidities, and injury predictors were analyzed using multivariable regression. Odds ratios (OR), mean differences, and 95% confidence intervals (CIs) were calculated. Statistical significance was assessed at P < 0.05. Results The cohort of 442 patients was 48.6% male and had a mean age of 84.3 ± 2.7 years. The distribution of admissions was 42.3% to the hospital floor, 40.3% to the intensive care unit (ICU), 7.7% to telemetry, 2.0% to the operating room, and 7.7% to other/unknown. Mortality was 9.7%, mean HLOS was 13.1 ± 9.2 days, the rate of complications was 38.5%, and 81.5% of survivors were discharged to a nonhome facility. Injury severity was predictive of mortality and overall complications. History of bleeding disorder/coagulopathy predicted mortality (OR, 4.02; 95% CI, 1.07–15.05), overall complications (OR, 3.01; 95% CI, 1.09–8.32), cardiac arrest (OR, 8.19; 95% CI, 1.06–63.54), and renal complications (OR, 10.36; 95% CI, 2.13–50.38). History of congestive heart failure predicted mortality (OR, 3.10; 95% CI, 1.10–8.69). ICU admission (vs. floor) predicted overall complications (OR, 2.01; 95% CI, 1.23–3.27) and pneumonia (OR, 4.65; 95% CI, 1.91–11.30). Telemetry admission (vs. floor) predicted unplanned intubation (OR, 7.76; 95% CI, 1.24–48.49). Conclusions In this cohort of octogenarians undergoing surgery for traumatic C2 fracture, injury severity and a history of bleeding disorder/coagulopathy were identified as risk factors for inpatient complications and mortality. Heightened surveillance should be considered for ICU and/or telemetry admissions for the development of complications. These findings warrant consideration by the clinician, patient, and family to inform clinical decisions and goals of care. [ABSTRACT FROM AUTHOR]

Background The optimal form of treatment for C2 spine fractures is controversial. This investigation analyzed the variations in treatment of C2 fractures over time, by age group, and by geographic location. Methods The Nationwide Emergency Department Sample database was queried to identify patients 18 years and older who sustained C2 fracture without neurologic injury from 2006 to 2012. Subsequently, patients were further filtered based on the intervention they received: collar, halo, and surgery. Regions of hospital used in analysis were defined as Northeast, Midwest, South, and West. Linear regression models were used to analyze trends for C2 incidence rates and treatment type. Analysis of variance tests were used to determine differences among procedure groups when stratified by regions and age groups. Results Surgical intervention for C2 fracture increased from 36.5% in 2006 to 55.7% in 2012 ( r = 0.116, P < 0.001). In contrast, the rate of halo use decreased from 57.8% in 2006 to 37.1% in 2012 ( r = −0.139, P < 0.001). Surgery displayed increasing trend across all age groups. A greater proportion of patients in the Northeast were treated by collar compared with all other regions ( P < 0.001). In contrast, halo use was significantly lower in the Northeast than the other 3 regions ( P < 0.001). Conclusions This investigation demonstrated that surgical management of C2 fractures is increasing in frequency over time and at all age groups. Furthermore, the treatment of these fractures varies by region—the Northeast had the highest incidence of collar use and lowest rate of halo use. [ABSTRACT FROM AUTHOR]

Compression of the caudal medulla oblongata and ventral portions of the spinal cord is the most dangerous complication of atlanto-axial dislocation (AAD)., Aim: The study objective was to improve surgical management of patients with ventral compression of the spinal cord in the setting of AAD of various genesis., Material and Methods: We analyzed treatment outcomes in 250 patients with C1 and C2 injuries and diseases for the period between 2002 and 2016. Persistent ventral compression of the neural structures in the setting of AAD was detected in 34 (13.6%) patients. Anterior or posterior dislocation was in 21 patients, vertical dislocation occurred in 7 patients, and mixed (anterior and vertical) occurred in 6 cases. The causes of AAD included odontoid fractures (21 patients, 61.8%), Jefferson fractures (6 patients, 17.6%), atlas transverse ligament rupture (1 patient, 2.9%), rheumatoid arthritis (4 patients, 11.8%), and nonspecific spondylitis (2 patients, 5.9%)., Results: All dislocations were divided into Halo-tractable and Halo-intractable ones. In 24 cases, ventral decompression was achieved due to Halo reposition. Additional resection of a compressing substrate was performed through the submandibular approach in 4 patients, through the transoral approach in 5 patients, and through the transnasal approach in 1 case. In the postoperative period, complications in the form of pharyngeal edema developed in 1 patient after transoral decompression. In the other cases, there were no postoperative complications. All patients had improvement in their condition in the form of regression of a neurological deficit., Conclusion: Halo reposition is a technique eliminating, completely or partially, ventral compression in certain traumatic and non-traumatic dislocations. The choice of a surgical corridor should be performed after preliminary Halo correction. If the nasopalatine line runs in the odontoid neck projection, the submandibular approach may be used in the case of a Halo-tractable dislocation, and the endonasal approach may be used in the case of a Halo-intractable dislocation.

Fractures of the odontoid are the most common cervical spine injury in the geriatric population. The relationship between odontoid fracture displacement and postural change has not been previously described. We present the first described case of an elderly female patient with thoracic kyphosis and a type II odontoid fracture demonstrating significant fracture displacement with a postural change from sitting to standing. Various radiographic parameters are assessed and discussed in an attempt to characterize and explain this finding. We highlight the importance of regional and global spinal alignment and quantify physiologic odontoid fracture behavior with postural changes in this growing demographic. Upright radiographs in both sitting and standing positions may be considered when concern for odontoid fracture stability is questioned., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Background: Injuries to the craniovertebral junction (CVJ) are not uncommon, and are among the few skeletal injuries that carry a high mortality rate. Successful management of these injuries depends on familiarity with the normal anatomic relationships of this region, as well as prudent decision making regarding surgical versus conservative management alternatives., Methods: The purpose of this study was to analyze the indications for conservative treatment of CVJ trauma and to analyze the outcomes., Results: Eighty-eight patients admitted with CVJ injuries were managed conservatively. More than half were nearly neurologically intact on admission; 91% improved whereas 80% (excluding deaths/lost to follow) ultimately achieved bony union without surgical intervention., Conclusion: This study documents that conservative management of CVJ injuries in a select population can yield good clinical results., Competing Interests: There are no conflicts of interest.