Fracture « tear-drop » en extension de l’axis

Analysis of Nonunion in Conservatively Managed Anterior Tear Drop Fractures of C2 Vertebra

Many anterior C2 (2nd cervical vertebra) tear drop (TD) fractures can be successfully managed with conservative treatment. However, due to the occurrence of nonunion, large-sized or complex anterior C2 TD fractures undergo surgical treatment. To date, no surgical treatment guidelines are available about anterior C2 TD fractures. Therefore, we performed this study to investigate the factors that may affect nonunion for anterior C2 TD fractures and to suggest surgical treatment guidelines. Thirty-three patients with anterior C2 TD fractures, who underwent conservative treatment and had a minimum 1-year follow-up, were divided into union (N = 26) and nonunion (N = 7) groups. Their radiological and clinical data were analyzed retrospectively and compared between the two groups. The avulsion fracture ratio (29.5% vs. 43.3%, p < 0.05) and fracture displacement (3.6 mm vs. 5.1 mm, p < 0.05) were higher in the nonunion group compared to the union group. Incidence of associated C2 injury was higher in the nonunion group compared to the union group (15.4% vs. 57.1%, p < 0.05). Union status was negatively correlated with associated C2 injury (correlation coefficient, CC = -0.398, p < 0.05). Our results suggest that surgical treatment could be considered for anterior C2 TD fractures with an avulsion fracture ratio > 43%, fracture displacement > 5 mm, or associated C2 injury.

Anterior Hollow Screw Fixation Combined with Posterior Lateral Mass Screws Fixation to Treat A Huge Tear Drop Fracture of The Axis

Teardrop fracture of axis is rarely seen, especially the huge type. The surgical approach is controversial and individualized in the literature. We reported a special case to share our experience of anterior hollow screw fixation combined with posterior unilateral lateral mass screws fixation to treat a huge teardrop fracture of the axis (HTDFA). A 42-year-old male was referred to our department; he presented neck pain after a vehicle accident. Neck movement was limited with no neurological compromise. Cervical x-rays showed a huge tear drop fracture of the anterior–inferior corner of the axis，the lower cervical spine degeneration and poor cervical curvature. Cervical CT confirmed the avulsed ratio of inferior endplate of axis up to 62%. Cervical MRI showed the anterior longitudinal ligament disruption associated with disk injury and instability of C2-3. In order to save the motion segment of C2-3 and decrease the possibility of lower cervical degeneration if C2-3 fusion occurs, a surgical plan involving anterior reduction, hollow screw fixation combined with posterior unilateral mass screws fixation was performed. The 3 months postoperative x-ray and CT scan showed the tear drop fragment had completely healed. The internal fixations were removed timely for 6 months after surgery. The patient had an excellent function of cervical spine without any clinical symptoms. The 12 months postoperative X-ray showed radiographic union of the bony fragment and a good motion range without any instability. We conclude that anterior hollow screw fixation combined with posterior unilateral lateral mass screws fixation can be the treatment of choice for HTDFA

Anterior reduction and fusion for treatment of massive tear drop fracture of axis combining with inferior endplate serious traversed lesion: A retrospective study

BACKGROUND

Tear drop fracture of axis represents a very small percentage of injuries of the cervical spine, but there is controversy about the treatment method for tear drop fracture of axis, especially when a large avulsed fragment is significant displacement, which combined with the inferior endplate serious traversed lesion of axis.

OBJECTIVE

To evaluate the clinical outcome of anterior reduction, graft fusion of C2-3 and plate fixation in the management of massive tear drop fracture of axis combining with inferior endplate serious traversed lesion of axis.

METHODS

There were 7 patients with a massive tear drop fracture of axis combining with inferior endplate serious traversed lesion. The avulsed ratio of inferior endplate of axis was 46.8 ± 13.4%, the average angle of rotation of the avulsed fragment was 30.4 ± 11.7, and the average displacement was 7.7 ± 2.8 mm. The posterior displacement of axis body was observed with three patients. All patients underwent anterior reduction, graft fusion of C2-3 and plate fixation with high anterior cervical retropharyngeal approach. The follow-up ranges from 2 years to 5 years.

RESULTS

In all cases, tear drop fracture was reduced completely, avulsed fragment got bony healing, and bone graft achieved bony fusion at C2-3. There were no local angle deformity and rotated deformity in all patients, and there were normal physiological lordosis and good stabilization of upper cervical spine. The neurological function of one patient with American Spine Injury Association (ASIA) impairment scale type D was improved to type E postoperatively. Six patients without neurological lesion had no neurological syndrome after operation.

CONCLUSIONS

Anterior surgical procedures would be an effective treatment of massive tear drop fracture of axis combining with inferior endplate serious traversed lesion. Complete reduction, sufficient stabilization and normal physiological lordosis of upper cervical spine could be achieved postoperatively.

Anterior Reduction, Discectomy, and Three Cortical Iliac Bone Grafting With Instrumentation to Treat A Huge Tear Drop Fracture of the Axis: A Case Report and Literature Review

Fractures of the axis body have been little reported and treatment strategies remain controversial and individualized. Not more than 10 cases of huge tear drop fracture of the axis (HTDFA) have been reported in previous studies and the treatment method varies from conservative treatment to an anterior, or posterior, approach surgery. Considering the sparse knowledge of HTDFA, we present a special case report to share our experience and to explore the safety and effectiveness of anterior reduction and fusion to treat HTDFA. A 24-year-old man was referred to our department; he presented with neck pain lasting for 12 h since being involved in a roll-over motor vehicle accident. His neck movement was limited but there was no neurological compromise. Physical examination of the patient showed myodynamia of four limbs Grade 5, Hoffmann sign (-), and Babinski sign (-). Three-dimensional reconstruction computed tomography (CT) confirmed a huge tear drop fracture of the anterior-inferior corner of the axis and discontinuity of the cortex of the axis. After discussion with the spinal surgeon team in the department and an effective conversation with the patient, surgery involving anterior reduction, discectomy, and three cortical iliac bone grafts with instrumentation after transnasal induction of general anesthesia was performed. The patient was instructed to wear a cervical collar until he returned to our department for a follow-up examination some 3 months after surgery. The 3-month postoperative x-ray and CT scan showed a good position of the implant and bony fusion at the C2/3 segment. Anterior reduction, discectomy, and three cortical iliac bone grafts with instrumentation to treat HTDFA are effective, safe, and simple. Of course, longer follow-up duration and more cases are warranted to verify this procedure. Anterior reduction, discectomy, and bone grafting with instrumentation are warranted for most HTDFA cases. However, if HTDFA incorporates other complex fractures, such as fracture of the posterior structure, an anterior and posterior union surgery is recommended.

Treating Huge Tear-Drop Fracture of Axis With Trapezoidal Bone: A Case Report and Literature Review

STUDY DESIGN

Case report and review of relevant literature.

OBJECTIVE

To discuss the surgical strategies and clinical outcome of managing huge tear drop fracture of axis.

SUMMARY OF BACKGROUND DATA

Teardrop fracture of axis is rarely seen, especially the huge type. The surgical technique is demanding because of the special anatomical structure and difficulty with bone grafting. Moreover, the surgical approach is controversial in the literature.

METHODS

A 51-year-old male patient suffered from neck pain after falling from the bicycle, neck movement was limited with no neurological compromise. X-ray suggested huge tear-drop fracture of anterior-inferior corner of axis, narrowing of C2/3 intervertebral disc. Fusion with self-designed tricortical trapezoidal iliac bone was performed.

RESULTS

Treating huge teardrop fracture of axis by anterior bone grafting with self-designed tricortical trapezoidal iliac bone is effective and stable. A 3-month follow-up showed fusion was achieved, upper cervical curvature was restored, and neck pain disappeared.

CONCLUSION

Self-designed tricortical trapezoidal iliac bone provided adequate fusion area of bone grafting, restoring the normal intervertebral height and cervical alignment, and the midterm outcome is satisfactory.

LEVEL OF EVIDENCE

5.

Tear-drop fracture of the axis in a child with an 8-year follow-up: a case report

We reported a 12-year-old boy with neck pain and dysphagia 6 days after his neck being tied by another boy's arms from the back. The boy was found to have a tear-drop fracture of the axis in both radiograph and MRI, which was a rare case in children. He was placed in a cervical traction with Glisson belt and received transfusion for 2 weeks until his neck pain and dysphagia were released. Thereafter, an operation of anterior fusion and fixation was chosen to ensure further stability of the cervical spine and replacement of the fracture fragment. An 8-year follow-up examination showed a satisfactory range of motion of the cervical spine, fusion at C2-3 intervertebral space, and normal signal of C3-4 intervertebral disk. We conclude that tear-drop fractures of the axis in children may be caused by extension injury without a high-energy trauma, and operation of anterior fusion and fixation can be the treatment of choice.

Clinical features of the extension teardrop fracture of the axis: review of 13 cases

Object

Extension teardrop fracture of the axis is an extremely rare cervical spinal injury. The classic clinical features, which have mainly been described by radiologists rather than spine surgeons, include its occurrence in elderly patients with osteoporosis, an association with minimal or no prevertebral soft-tissue swelling, and an absence of associated neurological deficit. However, recent case studies indicate notable exceptions to these clinical features, although few studies have investigated osteoporosis in these patients. The purpose of the present study was to clarify the clinical features of extension teardrop fracture of the axis.

Methods

The authors retrospectively reviewed data obtained in 13 patients with regard to their injury etiology, neurological deficit, treatment and outcome (residual neck pain), and imaging findings (size and displacement of the fragment, C2–3 subluxation, disc injury, and osteoporosis of the axis).

Results

Extension teardrop fracture of the axis constituted 11.6% of upper cervical spinal injuries at the authors' institute. The mean age of the patients was 49.5 years and distinct osteoporosis was identified in only 1 patient. A C2–3 subluxation was observed in 2 patients, in whom the displacement of the fragment was significant, although its size did not appear to have an effect. Magnetic resonance imaging, undertaken in 7 patients within 48 hours of injury, showed no disc injuries. Instability of the cervical spine was absent in all patient at follow-up. Only one patient underwent surgery for the presenting symptoms of dysphagia. The other patients were treated conservatively. The authors examined 9 patients directly; these patients had bony fusion and did not complain of neck pain, except for a patient with traumatic spondylolisthesis.

Conclusions

Extension teardrop fracture of the axis is generally caused by hyperextension of the cervical spine caused by a direct high-energy blow to the forehead or mandible. Based on the present case study, the authors believe that osteopenia and older age should not be considered risk factors. Most patients with an extension teardrop fracture of the axis can be treated conservatively, and surgical intervention may only be indicated for specific cases, such as those in which a patient presents with dysphagia or with other complicated fractures.

Nonoperative Management of Vertical C2 Body Fractures

OBJECTIVE:

To estimate the incidence and to describe the clinical results of the nonoperative management of vertical C2 body fractures.

METHODS:

An 8-year retrospective review of upper cervical spine injuries from the registry of a level I trauma center identified 21 patients with a vertical C2 body fracture.

RESULTS:

Sixteen coronally oriented Type 1 vertical C2 body fractures and 5 sagittally oriented Type 2 vertical C2 body fractures were identified. These fractures account for approximately 10% of the upper cervical spine fractures identified over this period of time. One elderly patient with a Type 1 fracture died as a result of pneumonia, and two patients with Type 2 fractures died from severe closed-head injuries. One patient had evidence of spinal cord injury. This was not related to the C2 body fracture but rather to a subaxial cervical spine injury. Of the surviving 18 patients, all were managed nonoperatively (with external orthoses) and showed evidence of fusion (union of fracture fragments) at the time of the last follow-up.

CONCLUSION:

Vertical C2 body fractures are not rare injuries and can account for up to 10% of upper cervical spine injuries. In general, vertical C2 body fractures are amenable to nonoperative treatment with external orthoses.