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Abstract
Objective:
The purpose of this study is to identify risk factors related to the fusion failure after halo-vest immobilization of odontoid fracture type III.
Methods:
We retrospectively analyzed ten patients who underwent halo-vest immobilization for acute traumatic odontoid fracture between October 2002 and December 2011. All patients had type III odontoid fracture using the Anderson and D’Alonzo classification. We reviewed digital radiographs and analyzed the images during conservative treatment with halo-vest immobilization.
Results:
The patients consisted of nine men and one woman, with mean age of 40.2 years (range: 25-56), who had no history of medical comorbidity and significant neurologic deficit. The mean follow-up period was 6 months (range: 4-11). All patients were initially treated by halo-vest immobilization. Seven patients showed union of fractured site on radiologic findings after halo-vest immobilization only. However, other 3 patients underwent surgery for fixation due to fusion failure. Among the factors we analyzed such as, radiographic characteristics and clinical feature, presence of comminuted fracture, instability of fractured fragment and failed reduction of misalignment were the factors related to fusion failure.
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FIGURE 1.
Measurement of radiographic findings. A: A tangent line is drawn along the anterior aspect of the odontoid fragment and the anterior aspect of the C2 body. A transverse line is drawn connecting these two lines. This distance is measured as the displacement of fractured odontoid process. B: A tangent line is drawn along the posterior aspect of the odontoid fragment and the posterior aspect of the C2 body. The angle subtended by these lines is the degree of angulation of fractured odontoid process. C: The gap between fractured odontoid process and dens body was determined as measured distance between inferior border of fractured odontoid process and superior border of fractured C2 body. D: The type of fracture line of odontoid process was determined in the computed tomography lateral reconstruction image. E: Overall lordosis was determined as measured angle between inferior endplate of C2 and inferior endplate of C7 in the lateral view of cervical plain radiograph.
FIGURE 2.
Magnetic resonance imaging showed disruption of the transverse ligament of atlantoaxial joint (arrow).
FIGURE 3.
Imaging studies from case 1. A: Computed tomography (CT) scans of the patient showed a type III odontoid fracture and there was ossification of posterior longitudinal ligament at the level of C3-C4. The fractured odontoid process was slightly displaced anteroinferiorly. B: A coronal reconstruction image revealed the comminuted fracture. C: The plain radiograph after 1 day of halo-vest immobilization. D: The plain radiograph on 3 weeks follow up showing the change of cervical lordotic curve. E: After 14 weeks, on the CT lateral reconstruction image, we found that the fracture site had not completely healed.
FIGURE 4.
Imaging studies from case 2. A, B: Computed tomography (CT) scans of the patient showed a type III odontoid fracture with horizontal line and the fractured odontoid process was not displaced. C: The plain radiograph on 1day after halo-vest immobilization. D: The plain radiograph on 5 weeks follow up showing the redisplacement of fractured odontoid process. E: The CT lateral reconstruction image on 10 weeks follow up showing the osteosclerotic margin of fractured site.
FIGURE 5.
Imaging studies from case 3. A, B: Computed tomography scans of the patient showed a type III odontoid fracture with irregular fracture line and the fractured odontoid process was displaced anteroinferiorly. C: The patient underwent the conservative treatment with halo-vest immobilization at his request, (D) but the displaced odontoid process was not corrected in alignment. E: Postoperative plain radiograph. Note that posterior interspinous fusion combined with sustained halo-vest immobilization.
TABLE 1.
The clinical characteristics of 10 cases
| Case no. | Age (years)/ Sex | Trauma | Time from injury to HVI (days) | Periods of HVI (weeks) | Neurologic symptoms | Associated injury | F/U duration (months) | Result of HVI |
|---|---|---|---|---|---|---|---|---|
| 1 | 54/M | In-car TA | 1 | 14 | Both knee tingling sense | (-) | 4 | Failure |
| 2 | 49/M | In-car TA | 3 | 10 | (-) | (-) | 4 | Failure |
| 3 | 25/M | In-car TA | 2 | 3 day+postop 3 m† | (-) | (-) | 4 | Failure |
| 4 | 30/M | Fall down | 5 | 12 | (-) | (-) | 5 | Success |
| 5 | 49/M | In-car TA | 2 | 13 | Decreased sense on Rt. occiput | Compression fracture,T12& L1 | 5 | Success |
| 6 | 42/M | In-car TA | 5 | 12 | (-) | (-) | 10 | Success |
| 7 | 31/M | In-car TA | 7 | 25 | Delirium&transient memory impairment | Traumatic SAH | 7 | Success |
| 8 | 35/M | In-car TA | 4 | 14 | Paresthesia on Lt. arm | (-) | 4 | Success |
| 9 | 31/F | In-car TA | 9 | 8∗ | (-) | Fractures of Lt. femur & humerus | 7 | Success |
| 10 | 56/M | In-car TA | 6 | 14 | (-) | C5-6 ligamentous subluxation | 11 | Success |
TABLE 2.
The radiological characteristics of 10 cases
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