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Evidence-based Spine-care Journal May 2010Os odontoideum is a rare condition with a controversial pathogenesis and poorly understood natural history. As a result, it is difficult for clinicians to predict...
INTRODUCTION
Os odontoideum is a rare condition with a controversial pathogenesis and poorly understood natural history. As a result, it is difficult for clinicians to predict which patients require surgical fusion to prevent symptomatic progression and potentially devastating neurologic injury.
METHODS
We undertook a systematic review of the literature to evaluate the clinical outcomes in the treatment of asymptomatic and symptomatic cases of os odontoideum. Pubmed, EMBASE, Cochrane, National Guideline Clearinghouse Databases as well as bibliographies of key articles were searched. Articles were reviewed by two independently working reviewers. Inclusion and exclusion criteria were set and each article was subject to a predefined quality rating scheme.
RESULTS
We identified eleven articles meeting our inclusion criteria. Seven studies included patients with asymptomatic os odontoideum discovered incidentally from which it was possible to examine data on 18 individuals. Six studies were identified containing more than 15 patients with symptomatic os odontoideum.
CONCLUSION
The existing literature regarding both asymptomatic or symptomatic os odontoideum and its treatment is very limited. No definitive conclusions can be drawn from these studies. A basic approach to the management of os odontoideum is offered based on the findings of this study.
PubMed: 23544027
DOI: 10.1055/s-0028-1100896 -
Clinical Neurology and Neurosurgery Sep 2016The craniovertebral junction (CVJ) is a complex region of the spine with unique anatomical and functional relationships. To alleviate symptoms associated with... (Meta-Analysis)
Meta-Analysis Review
OBJECT
The craniovertebral junction (CVJ) is a complex region of the spine with unique anatomical and functional relationships. To alleviate symptoms associated with pathological processes involving the odontoid process, decompression is often required, including odontoidectomy. Accurate knowledge of the complication rates following the transoral and transnasal techniques is essential for both patients and surgeons.
METHODS
We conducted MEDLINE, Scopus and Web of Science database searches for studies reporting complications associated with the transoral and transnasal techniques for odontoidectomy. Case series presenting data for less than three patients were excluded. Rates of complication and clinical outcomes were calculated and subsequently analyzed using a fixed-effects model to assess statistical significance.
RESULTS
Of 1288 articles retrieved from MEDLINE, Scopus, and Web of Science, twenty-six met inclusion criteria. Transoral and transnasal procedures resulted in the following respective complication rates: arterial injury 1.9% and 0.0%, intraoperative CSF leak 0.3% and 30.0%, postoperative CSF leak 0.8% and 5.2%, 30-day mortality 2.9% and 4.4%, medical complications 13.9% and 28.6%, meningitis 1.0% and 4.0%, pharyngeal wound dehiscence 1.7% (transnasal not reported), pneumonia 10.3% (transnasal not reported), prolonged or re-intubation 5.6% and 6.0%, reoperation 2.5% and 5.1%, sepsis 1.9% and 7.7%, tracheostomy 10.8% and 3.4%, velopharyngeal insufficiency 3.3% and 6.4% and wound infection 3.3% and 1.9%. None of these differences were statistically significant, except for postoperative tracheostomy, which was significantly higher after transoral odontoidectomy 8.4% (95% CI 4.9% -11.9%) compared to transnasal odontoidectomy 0.8% (95% CI -1.0% -2.9%). Neurologic outcome was improved in 90.0% and worse in 0.9% of patients after transoral compared to 94.0% and 0.0% after transnasal odontoidectomy (p=0.30).
CONCLUSIONS
This work presents a systematic review of complications reported for transoral or transnasal odontoidectomy across a heterogeneous group of surgeons and patients. Due to inconsistent reporting, statistical significance was only achieved for postoperative tracheostomy, which was significantly higher in the transoral group. This investigation sets the framework for further discussions regarding odontoidectomy approach options and their associated complications during the informed consent process.
Topics: Humans; Intraoperative Complications; Mouth; Natural Orifice Endoscopic Surgery; Odontoid Process; Postoperative Complications; Transanal Endoscopic Surgery
PubMed: 27442001
DOI: 10.1016/j.clineuro.2016.07.019 -
North American Spine Society Journal Jun 2023Combined atlas-axis fractures are rare occurrences with substantially higher rates of neurologic deficits compared with isolated injuries. Given the intricate anatomic... (Review)
Review
BACKGROUND
Combined atlas-axis fractures are rare occurrences with substantially higher rates of neurologic deficits compared with isolated injuries. Given the intricate anatomic relationship between the atlas and axis vertebra, variable fracture patterns may occur, warranting special considerations from surgeons.
METHODS
A systematic search of PubMed and EMBASE was performed following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. Relevant studies on acute combined atlas-axis fractures that provided data on patient demographics, presentation (injury mechanism, neurologic deficits, fracture type), management, complications, and study conclusions were reviewed.
RESULTS
A total of 22 articles published from 1977 to 2022, comprising 230 patients, were included in the final analysis. Thirty-seven of the 213 patients (17%) presented with neurologic deficits. The most common atlas injuries were posterior arch fractures (54/169 patients; 32%), combined posterior arch/anterior arch fractures (44/169 patients; 26%), and anterior arch fractures (43/169 patients; 25%). The most common axis injuries were type II odontoid fractures (115/175 patients; 66%). Of the 127 patients managed operatively (127/230 patients; 55%), 45 patients (35%) were treated with C1-C2 posterior spinal fusion, 33 patients (26%) were treated with odontoid screw fixation and anterior/posterior C1-C2 trans-articular screws, 16 patients (13%) were treated with occiputocervical fusion and 12 patients (9%) were treated with odontoid screw fixation alone.
CONCLUSIONS
Management strategies are generally based on the type of axis fracture as well as the condition of the transverse ligament. Patients with stable fractures can be successfully managed nonoperatively with a cervical collar or halo immobilization. Combined atlas-axis fractures with an atlantodental interval >5 mm, C1 lateral mass displacement >7 mm, C2-C3 angulation >11° or an MRI demonstrating a disrupted transverse ligament are suggestive of instability and are often successfully managed with surgical intervention. There is no consensus regarding surgical technique.
PubMed: 37440984
DOI: 10.1016/j.xnsj.2023.100224 -
Journal of Neurosurgical Sciences Dec 2016Odontoid fractures (OF) are the most frequent cervical spine fracture type in the elderly, often following low-velocity falls. The rise in life expectancies has led to... (Meta-Analysis)
Meta-Analysis Review
INTRODUCTION
Odontoid fractures (OF) are the most frequent cervical spine fracture type in the elderly, often following low-velocity falls. The rise in life expectancies has led to an increase in octogenarians suffering OF, for which the optimal treatment remains undetermined.
EVIDENCE ACQUISITION
A comprehensive search was conducted (National Library of Medicine MEDLINE, Cochrane Central Register of Controlled Trials) for all articles through 03/2016. Articles were included if the study population evaluated treatment modalities in OF patients aged ≥80-years. Outcomes assessed were mortality, complications, osseous union, and fracture stability. Pooled odds ratios (OR) and 95% confidence intervals (CI) are reported.
EVIDENCE SYNTHESIS
Across 22 case series/retrospective studies, attributable mortality for surgery was 5.4% (8/149) vs. 10.1% (10/99) for nonsurgery (P=0.159). Surgery patients suffered higher complications rates (38.9%, 58/149; vs. 24.5%, 26/106); OR 1.96 ([1.13-3.40], P=0.016). Osseous union was better achieved with surgery (68.5%, 37/54; vs. 43.2%, 16/37); OR 2.86 ([1.20-6.80]; P=0.016). Fracture stability was better achieved with surgery (86.0%, 49/57; vs. 63.6%, 28/44); OR 3.50 ([1.33-9.21], P=0.009).
CONCLUSIONS
In general, octogenarians undergoing surgery for OF showed higher fusion and stability rates compared to nonsurgery, which may be due in part to surgical selection criteria, surgeon preference and patient comorbidities. Higher complications were observed for surgery patients, while no differences were observed for mortality. Prospective trials are greatly needed to identify the optional treatment modality and predictors of clinical outcome in octogenarians suffering OF.
Topics: Aged, 80 and over; Aging; Cervical Cord; Humans; Odontoid Process; Retrospective Studies; Spinal Fractures; Treatment Outcome
PubMed: 27163167
DOI: No ID Found -
European Spine Journal : Official... Feb 2021The primary goal of this study was to conduct a systematic review and meta-analysis of articles focused on odontoid screw fixation (OSF) and screw-related complications... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
The primary goal of this study was to conduct a systematic review and meta-analysis of articles focused on odontoid screw fixation (OSF) and screw-related complications or non-union rates.
METHODS
We conducted a systematic review of the PubMed and Crossref databases between January 1982 and December 2019. Inclusion criteria comprised detailed descriptions of the surgical technique and screw-related complications (screw cut-out, loosening, breakage, malposition) or fusion rates.
RESULTS
The initial selection consisted of 683 abstracts. A total of 150 full texts were chosen for detailed study, and 83 articles were included in the analysis. The point estimates for screw-related complications were as follows: 1. screw malposition frequency-4.8%; 2. screw cut-out rate-5.0%; 3. screw loosening/pull-out-3.8%; and 4. screw fracture rate-3.1%. The point estimate for the non-union rate was 9.7%. Statistical analysis of the screw-related complications rate based on surgical technique details was also performed CONCLUSIONS: Double-screw OSF performance in elder patients resulted in a higher risk of post-operative screw cut-out. In other cases, the development of screw-related complications did not depend on the method of intraoperative head fixation, selection of the implant entry point for OSF, type of the used screws, or cannulated instruments application. The outcomes of single-screw fixation through the anterior lip of the C2 vertebra were comparable to other techniques of OSF. Further, statistically reliable studies should be carried out to identify the optimal technique of OSF.
Topics: Aged; Bone Screws; Fracture Fixation, Internal; Fractures, Bone; Humans; Odontoid Process; Spinal Fractures
PubMed: 32556628
DOI: 10.1007/s00586-020-06501-9 -
Spine Oct 2010Clinically based systematic review. (Review)
Review
STUDY DESIGN
Clinically based systematic review.
OBJECTIVE
To define optimal clinical care for elderly patients with Type II and III odontoid fractures using a systematic review with expert opinion.
SUMMARY OF BACKGROUND DATA
Numerous manuscripts have been written about treatment strategies of odontoid fractures in the elderly. However, these articles are of low quality and optimal treatment algorithms do not exist.
METHODS
Focused questions on the treatment of elderly patients with Type II and III odontoid fractures were refined by a panel of spine traumologists surgeons, consisting of fellowship trained neurologic and orthopedic surgeons. MeSH keywords were searched through MEDLINE, EMBASE, and the Cochrane Database of Systematic reviews, and pertinent abstracts and manuscripts obtained. The quality of literature was rated as high, moderate, low, or very low. Using the GRADE evidence-based review system, the proposed questions were answered using the literature review and expert opinion. These treatment recommendations were then rated as either strong or weak based on the quality of evidence and clinical expertise.
RESULTS
The literature searches revealed low and very low quality evidence with no prospective or randomized studies. The MEDLINE search engine returned 1759 articles, which were further limited to "all aged (65 and over)," human subjects and the English language. The subsequent search resulted in a return of 377 manuscripts. These abstracts where then reviewed in detail and 117 manuscripts were selected, which were obtained and supplemented with additional manuscripts to form an evidentiary table.
CONCLUSION
Odontoid fractures have a significant morbidity in the elderly (>65 years) population. Type II fractures in this population are recommended to be treated operatively with a weak recommendation, and if treated nonoperatively using a hard collar immobilization device. Type III odontoid fractures in the elderly optimal treatment with a strong recommendation is immobilization in a hard collar.
Topics: Age Factors; Aged; Aged, 80 and over; Bone Screws; Braces; Delphi Technique; Evidence-Based Medicine; Fracture Fixation; Fracture Healing; Humans; Immobilization; Odontoid Process; Practice Guidelines as Topic; Spinal Fractures; Spinal Fusion; Treatment Outcome
PubMed: 20881465
DOI: 10.1097/BRS.0b013e3181f32716 -
Clinical Spine Surgery Dec 2017Evidence-based systematic review. (Review)
Review
STUDY DESIGN
Evidence-based systematic review.
OBJECTIVES
To define the optimal treatment of fractures involving the C2 body, including those with concomitant injuries, based upon a systematic review of the literature.
SUMMARY OF BACKGROUND DATA
Axis body fractures have customarily been treated nonoperatively, but there are some injuries that may require operative intervention. High-quality literature is sparse and there are few class I or class II studies to guide treatment decisions.
MATERIALS AND METHODS
A literature search was conducted using PubMed (MEDLINE), Cochrane Central Register of Controlled Trials, and Scopus (EMBASE, MEDLINE, COMPENDEX). The quality of literature was rated according to a grading tool developed by the Center for Evidence-based Medicine. Operative and nonoperative treatment of axis body fractures were compared using fracture bony union as the primary outcome measure. As risk factors for nonunion were not consistently reported, cases were analyzed individually.
RESULTS
The literature search identified 62 studies, of which 10 were case reports which were excluded from the analysis. A total of 920 patients from 52 studies were included. The overall bony union rate for all axis body fractures was 91%. Although the majority of fractures were treated nonoperatively, there has been an increasing trend toward operative intervention for Benzel type III (transverse) axis body fractures. Nearly 76% of axis body fractures were classified as type III fractures, of which 88% united successfully. Nearly all Benzel type I and type II axis body fractures were successfully treated nonoperatively. The risk factors for nonunion included: a higher degree of subluxation, fracture displacement, comminution, concurrent injuries, delay in treatment, and older age.
CONCLUSIONS
High rates for fracture union are reported in the literature for axis body fractures with nonoperative treatment. High-quality prospective studies are required to develop consensus as to which C2 body fractures require operative fixation.
Topics: Axis, Cervical Vertebra; Databases, Bibliographic; Fracture Fixation; Fractures, Bone; Humans; Longitudinal Studies
PubMed: 29176489
DOI: 10.1097/BSD.0000000000000309 -
European Spine Journal : Official... Oct 2023Odontoid fractures are the most common cervical spine fractures in the elderly, with a controversial optimal treatment. The objective of this review was to compare the... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
Odontoid fractures are the most common cervical spine fractures in the elderly, with a controversial optimal treatment. The objective of this review was to compare the outcome of surgical and conservative treatments in elderly (≥ 65 years), by updating a systematic review published by the authors in 2013.
METHODS
A comprehensive search was conducted in seven databases. Clinical outcome was the primary outcome. Fracture union- and stability were secondary outcomes. Pooled point estimates and their respective 95% confidence intervals (CIs) were derived using the random-effects model. A random-effects multivariable meta-regression model was used to correct for baseline co-variates when sufficiently reported.
RESULTS
Forty-one studies met the inclusion criteria, of which forty were case series and one a cohort study. No clinical differences in outcomes including the Neck Disability Index (NDI, 700 patients), Visual Analogue Scale pain (VAS, 180 patients), and Smiley-Webster Scale (SWS, 231 patients) scores were identified between surgical and conservative treatments. However, fracture union was higher in surgically treated patients (pooled incidence 72.7%, 95% CI 66.1%, 78.5%, 31 studies, 988 patients) than in conservatively treated patients (40.2%, 95% CI 32.0%, 49.0%, 22 studies, 912 patients). This difference remained after correcting for age and fracture type. Fracture stability (41 studies, 1917 patients), although numerically favoring surgery, did not appear to differ between treatment groups.
CONCLUSION
While surgically treated patients showed higher union rates than conservatively treated patients, no clinically relevant differences were observed in NDI, VAS pain, and SWS scores and stability rates. These results need to be further confirmed in well-designed comparative studies with proper adjustment for confounding, such as age, fracture characteristics, and osteoporosis degree.
Topics: Humans; Aged; Cohort Studies; Spinal Fractures; Odontoid Process; Fractures, Bone; Pain; Treatment Outcome
PubMed: 37439865
DOI: 10.1007/s00586-023-07779-1 -
Spine Oct 2010Systematic review of literature. (Review)
Review
STUDY DESIGN
Systematic review of literature.
OBJECTIVE
To determine the optimal indications and methods of surgical treatment for unstable type II odontoid fractures in skeletally mature individuals.
SUMMARY OF BACKGROUND DATA
Odontoid fractures are a frequently encountered injury pattern in the cervical spine. The surgical treatment of type II odontoid fractures varies among spinal surgeons. The optimal surgical indications and treatment for type II odontoid fractures remains unclear.
METHODS
Five primary research questions, based on safety and efficacy, were determined by consensus of a panel of spine trauma surgeons consisting of fellowship trained orthopedic and neurologic surgeons. A comprehensive review of the literature was performed using MeSH search terms in MEDLINE, PubMed, EMBASE, CINAHL, and the Cochrane Database of Systematic reviews. The quality of literature was rated as high, moderate, low, or very low. Using the GRADE evidence-based review system, the primary questions were answered using the literature review and expert opinion. These treatment recommendations were then rated as either strong or weak based on the quality of evidence and clinical expertise.
RESULTS
The initial search resulted in over 1300 results. After initial application of all inclusion and exclusion criteria, 458 abstracts were reviewed from which 22 manuscripts were found to meet all criteria. These were obtained, reviewed, and used to create an evidentiary table. All articles were of either low or very low quality.
CONCLUSION
There is no moderate or high quality literature on the surgical management of acute type II odontoid fractures. Optimal indications for either anterior or posterior treatment of fractures are described but with no comparative data. A single anterior odontoid screw is the recommended technique for anterior treatment. Posterior internal fixation (C1-C2 transarticular screw, C1-C2 segmental fixation) is the recommended technique for posterior treatment. In equivocally indicated instances, anterior or posterior treatment can be safely used with good outcome. In this scenario, surgical management decision should be influenced by surgeon and patient preference as well as cost considerations.
Topics: Adult; Aged; Aged, 80 and over; Bone Screws; Evidence-Based Medicine; Fracture Fixation; Fracture Healing; Humans; Internal Fixators; Joint Instability; Middle Aged; Odontoid Process; Patient Selection; Radiography; Spinal Fractures; Treatment Outcome; Young Adult
PubMed: 20881464
DOI: 10.1097/BRS.0b013e3181f32ca5 -
World Neurosurgery Jan 2017The aim of this systematic review was to compare the halo and hard collar in the management of adult odontoid fractures. (Review)
Review
BACKGROUND
The aim of this systematic review was to compare the halo and hard collar in the management of adult odontoid fractures.
METHODS
Systematic and independent searches on MEDLINE (PubMed) and the Cochrane Database of Systematic Reviews. Inclusion criteria included studies 1) with clinical outcomes, 2) in adults (18 years of age or order), 3) with odontoid fractures, 4) with patients immobilized using a halo or hard collar, and 5) in multiple (more than 5) patients. Treatment failure rates were calculated as the proportion requiring operative intervention.
RESULTS
There were 714 cases included, who were managed in a halo (60%) or collar (40%). The mean age was 66 years (range, 18-96 years). Type 2 odontoid fractures were the most common (83%). There was no significant difference in failure rates between the halo and collar in patients with type 2 odontoid fractures (P = 0.111). This was also true in elderly (older than 65 years of age) patients (P = 0.802). The collar had a higher failure rate in type 3 odontoid fractures, though numbers were small (P = 0.035). Fibrous malunion occurred in 56 patients, and only 7% failed. There was only 1 case of neurological deterioration. Although mortality rates were similar between the collar and halo (P = 0.173), the halo was associated with a significantly higher complication rate (P < 0.001).
CONCLUSIONS
For the most common clinical scenario, the halo and collar have similar failure rates, such that the higher morbidity associated with the halo may not be justified, especially in elderly patients. Malunion usually represents a stable clinical outcome, and surgery is rarely required. Prospective randomized studies are needed to more definitively compare the devices.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Humans; Middle Aged; Odontoid Process; Prospective Studies; Retrospective Studies; Spinal Fractures; Treatment Outcome; Young Adult
PubMed: 27756660
DOI: 10.1016/j.wneu.2016.10.035