Flat panel detector-CT with endovenous injection. Description of a novel technique for obtaining cerebral arteries imaging: Technical note Romanian Neurosurgery (2016) XXX 3: 391 - 396 | 391 Re-alignment of operated anterior odontoid screw displaced Odontoid type 3 without resurgery: an unusual case report with a brief review of literature Ahmed Ansari Department of Neurosurgery, Hamdard Institute, Jamia Hamdard, New Delhi, INDIA Abstract: Odontoid fractures are particularly dangerous variety of cervical injury, due primarily to spinal cord trauma. In this article, we describe the re alignment of displaced operated type 3 odontoid # with anterior screw fixation with cervical traction. Key words: odontoid fracture, anterior odontoid screw, traction. Introduction Odontoid fractures comprise 9-20% of all cervical spine fractures. (1, 2, 3, 4) Many patients succumb to their injury at the time of accident due to spinal cord trauma, due to the strategic location of these fractures. (5) Pain is the most common symptom, followed by neurological deficits in surviving patients. (6) Nonunion and delayed myelopathy are the main problems associated with conservative management of these fractures. (7, 8) In this case report, we discuss about re- alignment of operated anterior odontoid screw displaced #type 3 with traction. Case report A 56 year old man presented following road traffic accident after twenty-five days to us with nape of neck pain and qaudriparesis. Bilateral increased tone in upper and lower limbs was noted. Power in bilateral upper limbs was 3/5 and lower limbs was 4/5. A CT craniovertebral junction (Figures 1 and 2) and MRI CVJ and cervical spine (Figure 3) revealed displaced Type 3 odontoid # with hyperintense signals at CVJ cord with cord compression. The patient was placed on traction, which improved power in his limbs and aligned the displaced odontoid segment. Anterior Odontoid screw (OS) fixation was performedand patient was given Philadelphia collar. The patient being highly non- compliant removed his collar on post-op day 1, moving his neck violently. Post-op CT CVJ (Figures 4, 5) revealed displaced odontoid segment. The patient reported a reduction in his limb power. He was again placed on traction, which resulted in an increase in his limb power, signifying instability. Repeat radiology (Figure 6) revealed alignment of # odontoid segment. He was advised posterior fixation but due to financial constraints, the patient party refused for surgery. He was given four post cervical collar for the stabilisation of # odontoid, after a few days of traction. 392 | Ansari - Re-alignment of operated anterior odontoid screw displaced Figure 1 - Sagittal CT images showing displaced odontoid # type 3 Figure 2 - Coronal CT images showing type 3 odontoid Figure 3 - Sagittal MRI image showing cord hyperintense signals with compression Figure 4 - Sagittal CT image showing displaced odontoid segment following anterior OS fixation Figure 5 - Coronal CT image following anterior OS fixation Romanian Neurosurgery (2016) XXX 3: 391 - 396 | 393 Figure 6 - X-ray CVJ with aligned odontoid # segment following anterior OS fixation with post OP traction Discussion Goel A., (9) compared odontoid with a typical Kolkata hand rickshaw puller. 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. Anderson and D'Alonzo (1974) (10) have classified odontoid fractures into type I, II and III. Based on this universally accepted classification, the type II and III odontoid fractures often require some form of stabilization. (11, 12) However the optimum treatment strategy on whether to perform surgery or to continue the patient on conservative management is still mired in controversy. (6, 13, 14) The surgical approaches prevalent for dealing with acute odontoid fractures include either an anterior odontoid screw (OS) placement or a posterior fixation (PF). (15, 16, 17, 18, 19) Conservative management using a halo brace is associated with variable fusion rates between 53-93%. The associated morbidity is related to its prolonged usage in a recumbent patient. (1, 20, 21) We gave the patient four post cervical collar, as he was highly irritable and non-compliant with halo brace. Shetty et al. (22) demonstrated an 84.2% fusion rate with conservative management in stable type II fractures. Literature shows that there is a growing trend towards surgical fixation of these fractures as fusion rates are better and 394 | Ansari - Re-alignment of operated anterior odontoid screw displaced the patients may be mobilized early. (23, 24) Anterior OS fixation was initially described by Nakanishi (17) and Bohler (1982). (18) This procedure allows for a more physiological fusion by direct osteosynthesis of the fracture lines and has the advantage of preserving normal rotation at the atlanto-axial joint. Many authors have recommended PF as the procedure of choice for the surgical approach in type IIA and type III fractures due to a slightly higher non-union rate associated with OS fixation. Moon et al., (25) Fountas et al., (26) and Lee et al. (27) in their series showed fusion rates of 100%, 87%, and 96%, respectively. Bhanot et al. (28) reported a 94% fusion rate with one case of non-union and one screw pull-out in their series of 17 type II odontoid fractures after an anterior screw fixation. Shrinivasan et al. (29) could successfully place OS in 84.6% type II fractures with an 82% fusion rate. Apfelbaum (2000) (16) and Dantas (2002) (30) have advised against the placement of anterior OS in fractures with an anterior oblique fracture line due to the high non- union rates. Whenever the angle of the odontoid fracture line is less oblique and screw trajectory across the fractured segments is achievable, OS fixation should be the first line management option as it provides for better functional results. Sawarkar DP et al, (31) reported a 100% fusion rate with Magerl`s technique. This technique may be used as a stand-alone procedure or may be supplemented with a C1- C2 sub-laminar wiring. Addition of sub- laminar wiring, however, did not change results of this technique in our series. This procedure is technically difficult and requires a steep upward trajectory. The three-point rigid fixation and cost-effectiveness of the procedure is responsible for its popularity. The Goel/Harms technique of C1-C2 fixation is more versatile when compared to the former procedure. They reported fusion rates of 100% in the 14 patients who underwent this form of fixation. There is, however, a risk of 1.3-5.8% (more with Magerl technique) of vertebral artery injury in posterior fusion procedures. (32) The biomechanical strength of this fixation is also less than ideal as compared to the Magerl or Goel/Harms procedure (that provides a strong rotational stability). (20) Therefore, the C1-C2 sublaminar wiring technique should be used as the last resort. Goel et al (33, 34, 35, 36, 37) prefers posterior lateral mass fixation in all cases where surgical treatment for fractured odontoid process is contemplated. 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, he resorts to fixation-arthrodesis of the atlantoaxial joint and settle the score once and for all. Romanian Neurosurgery (2016) XXX 3: 391 - 396 | 395 Correspondence Dr. Ahmed Ansari Assistant Professor, Department of Neurosurgery, Hamdard Institute, Jamia Hamdard, New Delhi, India. E-mail: ahmed.ansari2@gmail.com Phone: +91-9997456045 References 1. Hadley MN, Browner C, Sonntag VK. Axis fractures: A comprehensive review of management and treatment in 107 cases. Neurosurgery 1985;17:281-90. 2. Ryan MD, Henderson JJ. The epidemiology of fractures and fracture dislocations of the cervical spine. Injury 1992;23:38-40. 3. Grauer JN, Shafi B, Hilibrand AS, Harrop JS, Kwon BK, Beiner JM, et al. Proposal of a modified, treatment- oriented classification of odontoid fractures. Spine J 2005;5:123-9. 4. Rao G, Apfelbaum RI. Odontoid screw fixation for fresh and remote fractures. Neurol India 2005;53:416-23. 5. Bucholz RW, Burkhead WZ, Graham W, Petty C. Occult cervical spine injuries in fatal traffic accidents. J Trauma 1979;19:768-71. 6. Rizvi SA, Fredø HL, Lied B, Nakstad PH, Rønning P, Helseth E. Surgical management of acute odontoid fractures: Surgery-related complications and long-term outcomes in a consecutive series of 97 patients. J Trauma Acute Care 2012;72:682-90. 7. Moskovich R, Crockard HA. Myelopathy due to hypertrophic nonunion of the dens: Case report. J Trauma 1990;30:222-5. 8. Crockard HA, Heilman AE, Stevens JM. Progressive myelopathy secondary to odontoid fractures: Clinical, radiological, and surgical features. J Neurosurg 1993;78:579-86 9. Goel A. Treatment of odontoid fractures. Neurol India 2015 ;63:7-8 10. Anderson LD, D'Alonzo RT. Fractures of the odontoid process of the axis. J Bone Joint Surg Am 1974;56:1663-74. 11. Hadley MN, Browner CM, Liu SS, Sonntag VK. New subtype of acute odontoid fractures (type IIA). Neurosurgery 1988;22:67-71. 12. Roy-Camille R, Saillant G, Judet T, de Botton G, Michel G. Factors of severity in the fractures of the odontoid process (author's transl). Rev Chir Orthop Reparatrice Appar Mot 1980;66:183-6. 13. Shears E, Armitstead CP. Surgical versus conservative management for odontoid fractures. Cochrane Database Syst Rev 2008:CD005078. 14. Ryken T, Hadley M, Aarabi B, Dhall S, Gelb D, Hurlbert J, et al. Management of isolated fractures of the axis in adults. Neurosurgery 2013;72:132-50. 15. Aebi M, Etter C, Coscia M. Fractures of the odontoid process. Treatment with anterior screw fixation. Spine (Phila Pa 1976) 1989;14:1065-70. 16. Apfelbaum RI, Lonser RR, Veres R, Casey A. Direct anterior screw fixation for recent and remote odontoid fractures. J Neurosurg 2000;93:227-36. 17. Nakanishi T. Internal fixation of the odontoid fracture. Cent Jpn J Orthop Trauma Surg 1980;23:399- 406. 18. Bohler J. Screw-osteosynthesis of fractures of the dens axis (author's transl). Unfallheilkunde 1981;84:221-3. 19. Bohler J. Anterior stabilization for acute fractures and non-unions of the dens. J Bone Joint Surg Am 1982;64:18- 27. 20. Julien TD, Frankel B, Traynelis VC, Ryken TC. Evidence-based analysis of odontoid fracture management. Neurosurg Focus 2000;8:e1. 21. Polin RS, Szabo T, Bogaev CA, Replogle RE, Jane JA. Nonoperative management of types II and III odontoid fractures: The Philadelphia collar versus the halo vest. Neurosurgery 1996;38:450-6. 22. Shetty A, Kini AR, Prabhu J. Odontoid fractures: A retrospective analysis of 53 cases. Indian J Orthop 2009;43:352-60. 23. Smith HE, Vaccaro AR, Maltenfort M, Albert TJ, Hilibrand AS, Anderson DG, et al. Trends in surgical management for type II odontoid fracture: 20 years of experience at a regional spinal cord injury center. Orthopedics 2008;31:650. 24. Nourbakhsh A, Shi R, Vannemreddy P, Nanda A. Operative versus nonoperative management of acute odontoid type II fractures: A meta-analysis. J Neurosurg Spine 2009;11:651-8 25. Moon MS, Moon JL, Sun DH, Moon YW. Treatment of dens fracture in adults: A report of thirty-two cases. Bull Hosp Jt Dis 2006;63:108-12. 396 | Ansari - Re-alignment of operated anterior odontoid screw displaced 26. Fountas KN, Kapsalaki EZ, Karampelas I, Feltes CH, Dimopoulos VG, Machinis TG, et al. Results of long-term follow-up in patients undergoing anterior screw fixation for type II and rostral type III odontoid fractures. Spine (Phila Pa 1976) 2005;30:661-9. 27. Lee SC, Chen JF, Lee ST. Management of acute odontoid fractures with single anterior screw fixation. J Clin Neurosci 2004;11:890-5. 28. Bhanot A, Sawhney G, Kaushal R, Aggarwal AK, Bahadur R. Management of odontoid fractures with anterior screw fixation. J Surg Orthop Adv 2006;15:38-42. 29. Srinivasan US, Dhillon CS, Mahesha K, Kumar V. Anterior single lag screw fixation in Type II Dens fracture -Indian experience. Int J Neurotrauma (IJNT) 2008;5:87- 91. 30.Dantas FL, Prandini MN, Caires AC, Fonseca GA, Raso JL. Management of odontoid fractures using anterior screw fixation: Analysis of 15 cases. Arq Neuropsiquiatr 2002;60:823-9. 31. 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. 32. Steltzlen C, Lazennec JY, Catonné Y, Rousseau MA. Unstable odontoid fracture: Surgical strategy in a 22-case series, and literature review. Orthop Traumatol Surg Res 2013;99:615-23. 33. Goel A, Laheri V. Plate and screw fixation for atlanto- axial dislocation. (Technical report). Acta Neurochir (Wien) 1994;129:47-53. 34. Goel A, Desai K, Muzumdar DP. Atlantoaxial fixation using plate and screw method: A report of 160 treated patients. Neurosurgery 2002;51:1351-7. 35. Goel A. Treatment of basilar invagination by atlantoaxial joint distraction and direct lateral mass fixation. J Neurosurg Spine 2004;1:281-6. 36. Goel A, Shah A. Reversal of longstanding musculoskeletal changes in basilar invagination after surgical decompression and stabilization. J Neurosurg Spine 2009;10:220-7. 37.Goel A. Screws, facets and atlantoaxial instability. World Neurosurg 2013;80:514-5.