Treatment of Axis Body Fractures: A Systematic Review

The AO Spine Upper Cervical Injury Classification System (AO UCIC) - An Umbrella Review of Traumatic Axis Injuries Factors that May Affect Treatment Decision

Study designAn umbrella systematic review.ObjectiveTo identify historically recognized injury characteristics that may affect treatment decisions of traumatic C2 injuries and help improve the description of the "modifiers" presented in the AO Upper Cervical Injury Classification (UCIC).MethodsWe performed an umbrella review of systematic reviews evaluating studies about the management of axis fractures that identify potential modifiers in the treatment of these injuries. These modifiers were grouped according to the new AO UCIC.ResultsEight systematic reviews were included. They were divided into three groups: (1) Axis body fractures - one study, (2) Hangman´s fractures - one study, and (3) Odontoid fractures, six studies. For axis body fractures, most injuries were treated non-operatively, except some Benzel type 3 fractures (AO Type A) with displacement or severe comminution (M1). Hangman´s fractures classified as Effendi I and Levine-Edwards I and II were treated non-operatively with success, with no modifiers identified for non-union or instability. For Levine-Edwards type IIA and III surgery was generally recommended, but these should be classified as AO type B and C respectively without a need for modifiers. For odontoid fractures, fractures in the dens base, with displacement, or in elderly patients were associated with non-union (M1) and patients' specific factors (surgical condition) seem to affect the decision of treatment (M3) for considering surgery.ConclusionsWe identified from the literature some axis injury characteristics that seem to affect the treatment decision in historical series. Knowledge of these modifiers may further enhance the system's clinical utility.

Surgical Management of Extradural Tumors at the Craniovertebral Junction - Insights from a Tertiary Care Center

BACKGROUND

Craniovertebral junction (CVJ) tumors are challenging due to their unique anatomical location. This study aimed to evaluate the complexities in dealing with such precarious CVJ extradural lesions over the decade.

METHODS

Twenty-seven patients of extradural CVJ tumors operated between 2009 and 2018 were included. The demographic details, neurological status, surgical approach, extent of resection, type of fixation, complications, and outcome at final follow-up were recorded for each patient.

RESULTS

The mean age of the patients was 39.5 ± 20 years. Most (17/27) of the patients had involvement of a single level. Clivus was the most common (9/17) involved region followed by atlas (7/17) vertebrae. Majority of the patients (13/27) were operated through the posterior-only approach. About 15 patients (55.5%) had instability or extensive lesions that necessitated posterior fixation. None of the patients underwent anterior fixation. Gross and near total excision were achieved in 10 patients (37%) and 3 patients (11%) respectively while 14 patients underwent subtotal excision of tumor. On histopathological analysis, clival chordoma (8/27) was found to be the most common pathology followed by giant cell tumor (6/27), plasmacytoma (4/27), and multiple myeloma (2/27). Most patients (13 out of 27) had the same neurological status after the surgery. Six patients (22%) improved post-operatively with decreased weakness and spasticity. Thirteen (48%) patients underwent adjuvant radiotherapy.

CONCLUSIONS

This retrospective study provides valuable insights into managing extradural CVJ tumors and highlights the importance of individualized approaches for optimal outcome.

Diagnostic and Treatment of Spinal Fracture and Luxation in Italian Wolves (Canis lupus italicus)

The medical records of 14 Italian wolves (Canis lupus italicus) with a vertebral fracture or luxation (SFL) between C1 and L7 treated at Ospedale Veterinario San Michele from 2017 and 2022 were reviewed. The most common cause of SFL was “road traffic accident”. Neurological signs were graded from 0 to 6 using a modified Frankel scale. Spinal fractures occurred in C1–C5 in 1 case, in T3–L3 in 11 cases and in L4–L7 in 2 cases. Six wolves were euthanized without treatment because they presented paraplegia without deep pain perception (DPP). Two animals with motor function were treated conservatively, and later on one of them was euthanized because of neurological impairment. Six wolves were surgically treated. Seven wolves had good neurological recovery, and six of them were released into the wild. Our results suggest that wolves with DPP before surgery may have a good functional recovery.

Clinical Behavior of General Practitioners for Patients who Underwent an Operative or Conservative Treatment for a Craniocervical Fracture

Craniocervical fractures are socially important pathology. They represent one-third of the fractures in the cervical region. It is typical that elderly patients suffer from low-energy traumas such as falls, while younger patients suffer from high-energy traumas such as motor vehicle accidents, sport falls and etc. Craniocervical fractures are associated with an increased risk of craniocervical instability or neurological deficit. Primary therapeutic options depend on the type of fracture. Predictors of nonunions are the displacement of fractures, patients’ age, and comorbidities. The observership of the general practitioner in the postoperative period or the period of cervical immobilization could recognize possible malpositioning of the instrumentation, nonunion of the fracture, malsanation of the wound, and possible complications in case of the external immobilization. There is a lack of information on that topic. The goal of the paper is to summarise the most common fractures of the craniocervical region, their etiology, and treatment options and to present the results of our study of patients who underwent operative treatment for craniocervical fracture(s). Mastering the details, the treatment options, and the possible complication of the fractures in the craniocervical region, general practitioners could play an important role in the treatment of patients. 

Anterior Dens Screw Fixation for Traumatic C1-2 Lateral Subluxation With 3-Part Fractures of the C2 Axis (Dens, Lateral Mass, and Hangman Fractures): A Case Report

To report the first case of traumatic C1-2 lateral subluxation with three-part fractures of the C2 axis (dens, lateral mass, and hangman fractures) that was successfully treated with only anterior dens screw fixation.

Proposal of Treatment Strategy for Pedicle Fractures of the C2: An Analysis of 49 Cases

Spine surgeons often confuse C2 pedicle fractures (PFs) with pars interarticularis fractures. In addition, little information is available about the characteristics and treatment strategies for C2 PFs. We sought to investigate the characteristics of C2 PFs and to propose an appropriate treatment strategy. A total of forty-nine patients with C2 PFs were included in this study. We divided these patients into unilateral and bilateral C2 PF groups. The incidence rates and characteristics of other associated C2 and C2-3 injuries, and other cervical injuries, were evaluated. In addition, treatment methods and outcomes were analyzed. Twenty-two patients had unilateral C2 PFs and twenty-seven patients had bilateral C2 PFs. Among the cases of unilateral C2 PFs, all patients had one or more other C2 fractures, and twenty patients (90.9%) had one or two C2 body fractures. Meanwhile, among the cases of bilateral C2 PF, all patients had two or more other C2 fractures and one or two C2 body fractures. In unilateral C2 PFs, three patients with C2-3 anterior slip or adjacent cervical spine (C1-3) injury underwent surgery and nineteen patients (86.4%) were treated with conservative methods. In bilateral C2 PFs, three patients with C2-3 anterior slip or SCI at C2-3 underwent surgery and twenty-four patients (88.9%) were treated with conservative methods. Our results showed that C2 PFs do not occur alone and are always accompanied by other associated C2 injuries. C2 PFs should, generally, be thought of as a more complex fracture type than hangman's fracture or dens fracture. Despite the complex fracture characteristics, most C2 PFs can be managed with conservative treatment. However, surgical treatments should be considered if the C2 PFs are accompanied by the C2-3 anterior slip and adjacent cervical spine injury.