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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 -
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 -
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 -
Surgical Neurology Dec 2005Traumatic hypoglossal nerve palsy is a rare entity and has rarely been described in association with an odontoid fracture.
BACKGROUND
Traumatic hypoglossal nerve palsy is a rare entity and has rarely been described in association with an odontoid fracture.
CASE DESCRIPTION
We present a patient with a posttraumatic odontoid fracture who developed selective weakness of his arms and a unilateral hypoglossal nerve palsy. A systematic review of the literature is presented, and hypothetical causes for the injury are discussed.
CONCLUSION
Bell's cruciate paralysis and central cord syndrome are probably expressions of the same mechanism rather than 2 separate entities based on a preferential damage of pyramidal crossing arm fibers. C2 fractures with concomitant lower cranial nerve injury are relatively rare and have a reasonably good outcome, especially when unilateral.
Topics: Aged; Aged, 80 and over; Humans; Male; Atrophy; Cervical Vertebrae; Fractures, Closed; Hypoglossal Nerve Diseases; Odontoid Process; Syndrome; Tongue
PubMed: 16293473
DOI: 10.1016/j.surneu.2005.04.032 -
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