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British Medical Bulletin Sep 2015Ankylosing spondylitis (AS) can lead to an increased risk of cervical fractures. (Review)
Review
INTRODUCTION
Ankylosing spondylitis (AS) can lead to an increased risk of cervical fractures.
SOURCES OF DATA
A systematic review was undertaken using the keywords 'ankylosing spondylitis', 'spine fractures', 'cervical fractures', 'surgery' and 'postoperative outcomes' on Medline, Pubmed, Google Scholar, Ovid and Embase, and the quality of the studies included was evaluated according to the Coleman Methodology Score.
AREAS OF AGREEMENT
Surgery ameliorates neurological function in patients with unstable AS-related cervical fractures. The combined anterior/posterior and the posterior approaches are more effective than the anterior approach.
AREAS OF CONTROVERSY
The optimal approach, anterior, posterior or combined anterior/posterior, for the management of AS related cervical fractures has not been defined.
GROWING POINTS
Open reduction and internal fixation allows avoiding worsening and enhances neurological function in AS patients with cervical fractures.
AREAS TIMELY FOR DEVELOPING RESEARCH
Adequately powered randomized trials with appropriate subjective and objective outcome measures are necessary to reach definitive conclusions.
Topics: Axis, Cervical Vertebra; Fracture Fixation, Internal; Humans; Patient Selection; Postoperative Complications; Spinal Fractures; Spondylitis, Ankylosing; Treatment Outcome
PubMed: 25800241
DOI: 10.1093/bmb/ldv010 -
Neurosurgery Oct 2015Odontoid fractures are the most common cervical spine fracture in the geriatric population; however, the treatment of type II odontoid fractures in this age group is... (Review)
Review
BACKGROUND
Odontoid fractures are the most common cervical spine fracture in the geriatric population; however, the treatment of type II odontoid fractures in this age group is controversial.
OBJECTIVE
To compare the short-term (<3 months) mortality, long-term (≥12 months) mortality, and complication rates of patients >60 years of age with a type II odontoid fracture managed either operatively or nonoperatively.
METHODS
We performed a systematic review of literature published between January 1, 2000, and February 1, 2015, related to the treatment of type II odontoid fractures in patients >60 years of age. An analysis of short-term mortality, long-term mortality, and the occurrence of complications was performed.
RESULTS
A total of 452 articles were identified, of which 21 articles with 1233 patients met the inclusion criteria. Short-term mortality (odds ratio, 0.43; 95% confidence interval, 0.30-0.63) and long-term mortality (odds ratio, 0.47; 95% confidence interval, 0.34-0.64) were lower in patients who underwent surgical treatment than in those who had nonsurgical treatment, and there were no significant differences in the rate of complications (odds ratio, 1.01; 95% confidence interval, 0.63-1.63). Surgical approach (posterior vs anterior) showed no significant difference in mortality or complication rate. Similarly, no difference in mortality or complication rate was identified with hard collar or a halo orthosis immobilization.
CONCLUSION
The current literature suggests that well-selected patients >60 years of age undergoing surgical treatment for a type II odontoid fracture have a decreased risk of short-term and long-term mortality without an increase in the risk of complications.
Topics: Aged; Aged, 80 and over; Humans; Middle Aged; Odontoid Process; Spinal Fractures; Treatment Outcome
PubMed: 26378359
DOI: 10.1227/NEU.0000000000000942 -
World Neurosurgery Nov 2022Odontoidectomy for symptomatic irreducible ventral brainstem compression at the craniovertebral junction may result in spine instability requiring subsequent... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Odontoidectomy for symptomatic irreducible ventral brainstem compression at the craniovertebral junction may result in spine instability requiring subsequent instrumentation. There is no consensus on the importance of C1 anterior arch preservation in prevention of iatrogenic instability. We conducted a systematic review of the impact of C1 anterior arch preservation on postodontoidectomy spine stability.
METHODS
PubMed, Embase, Scopus, Web of Science, and Cochrane were searched following the PRISMA guidelines to include studies of patients undergoing odontoidectomy. Random-effect model meta-analyses were performed to compare spine stability between C1 anterior arch preservation versus removal and posttreatment outcomes between transoral approaches (TOAs) versus endoscopic endonasal approaches (EEAs).
RESULTS
We included 27 studies comprising 462 patients. The most common lesions were basilar invagination (73.3%) and degenerative arthritis (12.6%). Symptoms included myelopathy (72%) and neck pain (43.9%). Odontoidectomy was performed through TOA (56.1%) and EEA corridors (34.4%). The C1 anterior arch was preserved in 16.7% of cases. Postodontoidectomy stabilization was performed in 83.3% patients. Median follow-up was 27 months (range, 0.1-145). Rates of spine instability were significantly lower (P = 0.004) when the C1 anterior arch was preserved. Postoperative clinical improvement and pooled complications were reported in 78.8% and 12.6% of patients, respectively, with no significant differences between TOA and EEA (P = 0.892; P = 0.346). Patients undergoing EEA had significantly higher rates of intraoperative cerebrospinal fluid leaks (P = 0.002).
CONCLUSIONS
Odontoidectomy is safe and effective for treating craniovertebral junction lesions. Preservation of the C1 anterior arch seems to improve maintenance of spine stability. TOA and EEA show comparable outcomes and complication rates.
Topics: Humans; Spine; Nose; Decompression, Surgical; Spinal Cord Diseases; Spinal Diseases; Odontoid Process
PubMed: 36049722
DOI: 10.1016/j.wneu.2022.08.105 -
Rheumatology (Oxford, England) Jul 2016The aim was to evaluate whether anti-TNF discontinuation and tapering strategies are efficacious for maintaining remission or low disease activity (LDA) in patients with... (Review)
Review
OBJECTIVE
The aim was to evaluate whether anti-TNF discontinuation and tapering strategies are efficacious for maintaining remission or low disease activity (LDA) in patients with axial spondyloarthritis.
METHODS
A systematic literature review up to September 2014 was performed using Medline, EMBASE and Cochrane databases. Longitudinal studies evaluating the efficacy of discontinuation/tapering of anti-TNF therapy to maintain clinical response achieved after receiving a standard dose of the same drug were included. The results were grouped according to the type of strategy (discontinuation or tapering) evaluated.
RESULTS
Thirteen studies out of 763 retrieved citations were included. Overall, published data are scarce and the level of evidence of the studies is weak. Five studies provided evidence for assessing discontinuation strategy. The frequency of patients developing flare during the follow-up period ranged between 76 and 100%. The median (range) follow-up period was 52 (36-52) weeks and time to flare 16 (6-24) weeks. Additionally, eight studies evaluating tapering strategy were selected. The percentage of patients maintaining LDA or remission was reported in five studies and ranged between 53 and 100%. The remaining three studies reported the mean change in BASDAI and CRP after reducing the anti-TNF dose and did not observe any relevant increase in these parameters.
CONCLUSION
Published data indicate that a tapering strategy for anti-TNF therapy is successful in maintaining remission or LDA in most patients with axial spondyloarthritis. However, a discontinuation strategy is not recommended because it leads to flare in most cases. Further studies with an appropriate design covering the whole spectrum of the disease are required to confirm these results.
Topics: Adult; Antirheumatic Agents; Axis, Cervical Vertebra; Disease Progression; Female; Humans; Longitudinal Studies; Male; Spondylarthritis; Tumor Necrosis Factor-alpha; Withholding Treatment
PubMed: 26998860
DOI: 10.1093/rheumatology/kew033 -
European Spine Journal : Official... Jan 2013Odontoid fractures are the most common cervical spine fractures in the elderly. As the population ages, their incidence is expected to increase progressively. The... (Review)
Review
PURPOSE
Odontoid fractures are the most common cervical spine fractures in the elderly. As the population ages, their incidence is expected to increase progressively. The optimal treatment of this condition is still the subject of controversy. The objective of this review is to summarize and compare the outcome of surgical and conservative interventions in the elderly (≥ 65 years).
METHODS
A comprehensive search was conducted in nine databases of medical literature, supplemented by reference and citation tracking. Clinical status was considered the primary outcome. Fracture union and stability rates were considered secondary outcomes.
RESULTS
A total of nineteen studies met the inclusion criteria. All studies were performed retrospectively and were of limited quality. There was insufficient data, especially from direct comparisons, to determine the difference in clinical outcome between surgical and conservative interventions. Osseous union was achieved in 66-85 % of surgically treated patients and in 28-44 % of conservatively treated patients. Fracture stability was achieved in 82-97 % of surgically patients and in 53-79 % of conservatively treated patients.
CONCLUSIONS
There was insufficient data to determine a potential difference in clinical outcome between different treatment groups. Surgically treated patients showed higher osseous union rates compared to conservatively treated patients, possibly because of different selection mechanisms. The majority of patients appears to achieve fracture stability regardless of the applied treatment. A prospective trial with appropriate sample size is needed to identify the optimal treatment of odontoid fractures in the elderly and predictors for the success of either one of the available treatments.
Topics: Aged; Aged, 80 and over; Female; Fracture Fixation, Internal; Humans; Male; Odontoid Process; Spinal Fractures
PubMed: 22941218
DOI: 10.1007/s00586-012-2452-3 -
ANZ Journal of Surgery May 2014Non-surgical immobilization strategies for type 2 odontoid fractures vary considerably, with some surgeons preferring rigid collars, halothoracic bracing or the Minerva... (Review)
Review
BACKGROUND
Non-surgical immobilization strategies for type 2 odontoid fractures vary considerably, with some surgeons preferring rigid collars, halothoracic bracing or the Minerva brace. Choice of device should be informed by the effectiveness in achieving union, whilst minimizing mortality and complications.
OBJECTIVES
Perform a systematic review evaluating the efficacy of non-surgical interventions for type 2 odontoid fractures.
DATA SOURCES
MEDLINE (OvidSP), EMBASE (OvidSP) and The Cochrane Library, ClinicalTrials.gov, Current Controlled Trials.
METHODS
We conducted a systematic review of studies directly comparing the halothoracic brace and cervical collars or the Minerva brace for union, mortality and complications. Studies were appraised for quality and bias, and results were pooled for analysis.
RESULTS
Our search identified 1794 citations, 13 of which met inclusion criteria. There were no randomized or prospective studies. All studies were small, retrospective and observational. Our results demonstrate a greater likelihood of developing stable union (osseous and fibrous); relative risk (RR) 1.27 (95% confidence intervals (CI) 1.03 to 1.57; P = 0.03); and airway complications; RR 7.52 (95% CI 1.39 to 40.83; P = 0.02) with halothoracic bracing compared with cervical collar. In patients >65, there was a greater risk of airway complications; RR 7.50 (0.96-58.36; P = 0.05). No other significant differences were identified.
CONCLUSION
Evidence to support selection of non-surgical immobilization in type 2 odontoid fractures is poor. Osseous union has traditionally been the benchmark for 'successful' treatment; however, evidence of association between union and improved outcomes is lacking. We highlight the need for a randomized study to promote evidence-based decision-making in the non-surgical management of this injury.
Topics: Aged; Braces; Humans; Immobilization; Odontoid Process; Orthotic Devices; Spinal Fractures
PubMed: 24119021
DOI: 10.1111/ans.12401 -
European Spine Journal : Official... Mar 2006During the past 30 years various treatment protocols for hangman's fractures have been attempted. In order to guide the management of hangman's fractures, different... (Meta-Analysis)
Meta-Analysis Review
During the past 30 years various treatment protocols for hangman's fractures have been attempted. In order to guide the management of hangman's fractures, different classifications have been introduced. However, opinions on operative or nonoperative treatment have not yet been solidified. To evaluate both conservative and operative management of hangman's fractures in the published literature and to provide appropriate guidelines for treatment of hangman's fractures, a systematic review of the literature regarding the management of hangman's fractures was performed. An English literature search from January 1966 to January 2004 was completed with reference to treatment of hangman's fractures. The classification for treatment guidance from the literature was also reviewed. Regarding a primary therapy for hangman's fractures, there were 20 papers (62.5%) that advocated for a conservative treatment and 11 of the remaining 12 papers suggested that conservative treatment was suitable for some stable fractures. The classification of Effendi et al. modified by Levine and Edwards was used widely. Most hangman's fractures could be managed successfully with traction and external immobilization, especially in Effendi Type I, Type II and Levine-Edwards Type II fractures. It is necessary for Levine-Edwards Type IIa and III fractures to be treated with rigid immobilization. Only for some stable Type I and Levine-Edwards Type II injuries, nonrigid external fixation alone was sufficient. Rigid immobilization alone was necessary for most cases. Surgical stabilization is recommended in unstable cases when there is the possibility of later instability, such as Levine-Edwards Type IIa and III fractures with significant dislocation. The classification system proposed by Effendi et al. and modified by Levine and Edwards provided a clinically reasonable guideline for successful management of hangman's fractures.
Topics: Axis, Cervical Vertebra; Cervical Vertebrae; Evidence-Based Medicine; Fracture Fixation; Humans; Spinal Fractures; Spondylolisthesis
PubMed: 16235100
DOI: 10.1007/s00586-005-0918-2 -
The Cochrane Database of Systematic... Oct 2008Fractures of the odontoid process of the second cervical vertebra can result in instability, neurological damage and death. Treatment includes conservative management... (Review)
Review
BACKGROUND
Fractures of the odontoid process of the second cervical vertebra can result in instability, neurological damage and death. Treatment includes conservative management (external immobilisation devices) or surgical treatment (internal fixation by posterior fusion or anterior screw fixation).
OBJECTIVES
To compare surgical with conservative treatment for fractures of the odontoid process.
SEARCH STRATEGY
We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (February 2008), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2008, Issue 1), MEDLINE (1966 to February 2008), EMBASE (1988 to February 2008), LILACS (accessed February 2008), reference lists of articles and registries of ongoing trials.
SELECTION CRITERIA
Randomised and quasi-randomised controlled trials comparing surgical versus conservative management of odontoid fractures.
DATA COLLECTION AND ANALYSIS
Two review authors independently examined the search results to identify trials for inclusion.
MAIN RESULTS
We did not identify any studies that met our inclusion criteria. We excluded one ongoing and registered study that is comparing surgery versus conservative treatment because it does not involve randomisation of treatment allocation.
AUTHORS' CONCLUSIONS
There is no evidence available from adequately controlled trials to inform the decision on whether the surgical treatment of odontoid fractures gives a better outcome. A sufficiently powered good quality multicentre randomised controlled trial comparing surgery versus conservative treatment is warranted.
Topics: Fracture Fixation; Humans; Odontoid Process; Spinal Fractures
PubMed: 18843678
DOI: 10.1002/14651858.CD005078.pub2 -
World Neurosurgery Aug 2022Nonoperative management of odontoid fractures can result in solid fusion, unstable nonunion, and fibrous nonunion. Odontoid fractures with fibrous nonunion will not... (Review)
Review
OBJECTIVE
Nonoperative management of odontoid fractures can result in solid fusion, unstable nonunion, and fibrous nonunion. Odontoid fractures with fibrous nonunion will not demonstrate dynamic instability on imaging studies. However, the safety of accepting this outcome has been debated. We have provided, to the best of our knowledge, the first systematic review of the existing literature to explore the safety of allowing fibrous nonunion as an acceptable outcome for odontoid fractures.
METHODS
The PubMed and Embase databases were searched in January 2022. The outcomes were extracted and categorized according to the mortality, neurologic sequelae, pain, neck disability index, and satisfaction.
RESULTS
Of a total of 700 abstracts screened, the full text of 79 reports was assessed, with 13 studies included. Of the included patients, 141 had had a fibrous nonunion, all described in observational studies. The follow-up ranged from 0.6 to 5.8 years. None of the 141 patients had experienced a neurologic event. One patient had died of trauma-related issues; however, causality was not reported. Most of the studies had reported good to excellent pain scores. Most of the neck disabilities reported had ranged from mild to moderate in severity. However, 1 study of 5 patients had reported severe disability. All the patients reported good or excellent satisfaction.
CONCLUSIONS
The evidence we found supports that it is safe to forgo surgery for carefully selected patients with nonunited odontoid fractures when near-anatomic alignment is present, dynamic instability is lacking on imaging studies, the neurologic examination findings are normal, and the risk of neck injury is low. Further study is needed to define the full natural history of fibrous nonunion of odontoid fractures.
Topics: Fractures, Bone; Humans; Odontoid Process; Pseudarthrosis; Retrospective Studies; Spinal Fractures; Treatment Outcome
PubMed: 35659587
DOI: 10.1016/j.wneu.2022.05.116 -
Journal of Neurosurgery. Spine Aug 2023Odontoid fractures can be managed surgically when indicated. The most common approaches are anterior dens screw (ADS) fixation and posterior C1-C2 arthrodesis (PA). Each... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
Odontoid fractures can be managed surgically when indicated. The most common approaches are anterior dens screw (ADS) fixation and posterior C1-C2 arthrodesis (PA). Each approach has theoretical advantages, but the optimal surgical approach remains controversial. The goal in this study was to systematically review the literature and synthesize outcomes including fusion rates, technical failures, reoperation, and 30-day mortality associated with ADS versus PA for odontoid fractures.
METHODS
A systematic literature review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines by searching the PubMed, EMBASE, and Cochrane databases. A random-effects meta-analysis was performed and the I2 statistic was used to assess heterogeneity.
RESULTS
In total, 22 studies comprising 963 patients (ADS 527, PA 436) were included. The average age of the patients ranged from 28 to 81.2 years across the included studies. The majority of the odontoid fractures were type II based on the Anderson-D'Alonzo classification. The ADS group was associated with statistically significantly lower odds to achieve bony fusion at last follow-up compared to the PA group (ADS 84.1%; PA 92.3%; OR 0.46; 95% CI 0.23-0.91; I2 42.6%). The ADS group was associated with statistically significantly higher odds of reoperation compared to the PA group (ADS 12.4%; PA 5.2%; OR 2.56; 95% CI 1.50-4.35; I2 0%). The rates of technical failure (ADS 2.3%; PA 1.1%; OR 1.11; 95% CI 0.52-2.37; I2 0%) and all-cause mortality (ADS 6%; PA 4.8%; OR 1.35; 95% CI 0.67-2.74; I2 0%) were similar between the two groups. In the subgroup analysis of patients > 60 years old, the ADS was associated with statistically significantly lower odds of fusion compared to the PA group (ADS 72.4%; PA 89.9%; OR 0.24; 95% CI 0.06-0.91; I2 58.7%).
CONCLUSIONS
ADS fixation is associated with statistically significantly lower odds of fusion at last follow-up and higher odds of reoperation compared to PA. No differences were identified in the rates of technical failure and all-cause mortality. Patients receiving ADS fixation at > 60 years old had significantly higher and lower odds of reoperation and fusion, respectively, compared to the PA group. PA is preferred to ADS fixation for odontoid fractures, with a stronger effect size for patients > 60 years old.
Topics: Humans; Adult; Middle Aged; Aged; Aged, 80 and over; Spinal Fractures; Odontoid Process; Fracture Fixation, Internal; Arthrodesis; Fractures, Bone; Bone Screws; Treatment Outcome
PubMed: 37148232
DOI: 10.3171/2023.3.SPINE221001