|Year : 2021 | Volume
| Issue : 2 | Page : 234-239
Direct Anterior Screw Fixation for a Pediatric Odontoid Fracture with Associated Skull Fracture: A Case Report
Dilip Dutta, Arjun Shankar Dasgupta
Department of Neurosurgery, Park Clinic, Kolkata, West Bengal, India
|Date of Submission||01-Aug-2020|
|Date of Decision||09-Feb-2021|
|Date of Acceptance||15-Apr-2021|
|Date of Web Publication||16-Jul-2021|
Department of Neurosurgery, Park Clinic, 167, Sarat Chatterjee Road, P.O. Shibpur, District – Howrah, State – West Bengal.
Source of Support: None, Conflict of Interest: None
The upper cervical spine remains the most susceptible region for spinal trauma in children, with odontoid fractures being the most common ones in this age group. Concomitant traumatic brain injuries or skull fractures can pose therapeutic challenges in such cases. We report a case of an 11-year-old boy who presented in the semiconscious state with a deep scalp laceration in the left frontoparietal region. A computed tomography (CT) scan revealed a depressed skull fracture requiring an emergency left frontoparietal decompressive craniectomy and an associated fracture of the odontoid process at the base with anterior displacement. Odontoid fractures usually heal well after immobilization, and the use of instrumented fusion is still debated in view of skeletal immaturity. The usual management of Halo vest could not be instituted in his case owing to the skull fracture, and a single cannulated screw fixation was done under fluoroscopic guidance. Direct operative fusion of the odontoid process has been described in younger children with apophyseal fractures, but the evidence of such procedures is rare in elder children with a fused odontoid process. This case report, thus, confirms the anterior odontoid screw fixation as an effective mode of treatment in children of the 7- to 12-year age group.
Keywords: Direct anterior approach, odontoid fracture, pediatric, screw fixation
|How to cite this article:|
Dutta D, Dasgupta AS. Direct Anterior Screw Fixation for a Pediatric Odontoid Fracture with Associated Skull Fracture: A Case Report. Indian Spine J 2021;4:234-9
|How to cite this URL:|
Dutta D, Dasgupta AS. Direct Anterior Screw Fixation for a Pediatric Odontoid Fracture with Associated Skull Fracture: A Case Report. Indian Spine J [serial online] 2021 [cited 2021 Aug 4];4:234-9. Available from: https://www.isjonline.com/text.asp?2021/4/2/234/321563
| Introduction|| |
Spinal injuries after trauma are rare in children as compared with adults; they are mostly confined to the cervical spine and occur in the pediatric age group younger than 12 years of age. Cervical spine injuries (CSI) frequently involve the upper cervical spine, owing to the anatomical and biomechanical characteristics of the developing spine and large head size as compared with the body. Odontoid process fracture constitutes the most common type of CSI in the pediatric age group. The most common treatment option of odontoid fractures in children remains reduction and immobilization in Halo vest or Minerva cast. Though anterior screw fixation has a high fusion rate along with proper maintenance of range of neck movement, there is no consensus about the use of this technique in this age group. We report a case of a child younger than 12 years who was managed with anterior odontoid screw fixation (AOSF), as cranial halo was not an option owing to the concomitant depressed skull fracture.
| Case Report|| |
An 11-year-old boy presented in the semiconscious state after a fall from a height into a gutter, head first. On initial examination, he was confused, opening his eyes to loud sounds and obeying commands. He was moving all four limbs equally. His pupillary responses were normal, deep tendon reflexes were maintained, and plantar response was bilaterally down going. There was a deep scalp laceration in the left frontoparietal region. Other systemic examinations were normal. Initial X-ray of the cervical spine showed an indistinct fracture line through the base of the odontoid process [Figure 1]. A CT scan of the brain revealed a depressed fracture involving the left frontoparietal bones, with the fracture line extending to the orbital roof with underlying contusions and pneumocephalus [Figure 2]. An emergency left frontoparietal decompressive craniectomy was performed along with elevation of bone fragments and debridement. Postoperatively, on detailed evaluation, the patient complained of neck pain and there was midline neck tenderness on palpation. Further radiological evaluation revealed fracture of the odontoid process with anterior displacement without any significant angulation on the CT scan of the cervical spine [Figure 3]. Magnetic resonance imaging (MRI) of the cervical spine ruled out any ligamentous injury [Figure 4]. After explaining to the parents the radiological findings and the difficulty of nonoperative management in the boy’s case, we proceeded to perform surgical fusion. The boy was preoperatively shifted for Halter traction and positioned supine with his mouth opened with radiolucent gags for open mouth view. On fluoroscopic evaluation, there was a reduction of fracture displacement and we proceeded to perform AOSF. Two fluoroscopic machines were used at right angles. A right anterior neck skin crease incision was made at the level of C5,6. After exposure of the prevertebral space up to the inferior border of C2, the C2,3 disc space was confirmed under fluoroscopy. The anterior part of the lower endplate of C2 was exposed, and a long drill sleeve was introduced. A guide wire was introduced under fluoroscopic guidance and placed in the middle of the odontoid process, as we planned to use a single lag screw. After measurement of the screw length, a 32 mm cannulated cancellous bone screw was introduced under fluoroscopic guidance. Postoperative X-ray and CT scan confirmed proper positioning of the screw and the fracture fragment [Figure 5]. Postoperative external orthosis for cervical spine immobilization was not used in this case as rigid fixation was obtained surgically. Postoperative recovery was uneventful and neck pain diminished. The patient is currently on follow-up for two years without any pain, restriction of neck movement, or neurological deficit. The CT cervical spine showed adequate fusion at two years [Figure 6].
|Figure 1: X-ray of cervical spine. A. AP view and B. lateral view showed an indistinct fracture line through the base of the odontoid process without displacement or angulation|
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|Figure 2: CT scan of brain. A. bone window showing depressed fracture of skull involving the left frontal and parietal bone. B. bone window showing extension of fracture line to the orbital roof. C. brain window showing depressed fracture with underlying contused brain parenchyma. D. brain window showing depressed fracture with underlying contusions and pneumocephalus|
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|Figure 3: CT scan of cervical spine. A. axial section showing fracture line through the base of odontoid process. B. coronal reconstruction showing fracture through the odontoid base without any lateral displacement. C. sagittal reconstruction showing almost horizontal fracture line through the odontoid base with anterior displacement but without significant tilt|
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|Figure 4: MRI of cervical spine. A. Axial T2-weighted spin echo sequence image demonstrating an intact transverse ligament, appearing as a hypointense band dorsal to the odontoid process. There is no increased signal intensity within or at the attachment of the transverse ligament. B. Sagittal short tau inversion recovery (STIR) sequence of cervical spine also does not show any increased signal intensity at the level of the cruciate ligament, confirming ligamentous integrity. C. Axial T2-weighted gradient recall echo (GRE) sequence does not show any features of hemorrhage in the form of increased signal intensity in the ligamentous complex as well as the spinal cord|
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|Figure 5: A. Open mouth view of postoperative X-ray of cervical spine shows single odontoid screw in proper position. B. Lateral view of X-ray of cervical spine shows proper reduction of the odontoid fracture fragment with single screw in situ. C. Serial axial sections of CT scan of axis, bony window showing proper positioning of the odontoid screw|
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|Figure 6: Serial sagittal reconstructed images of the CT scan of the cervical spine done after two years show proper fusion of the odontoid process at the level of the fracture|
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| Discussion|| |
Fracture of the odontoid process in children has a different demography as compared with adults. Even in the pediatric population, two different age groups have different fracture pattern owing to the embryological development of the axis. Odontoid fractures mainly involve dento-central synchondrosis at the base of the dens in children from infancy to 5-7 years of age, when the fusion of the odontoid process is completed with the body of the axis. After 14 years of age, the spinal injury pattern attains adult proportions. In children between 8 and 14 years of age, odontoid fractures still follow a distinct pattern of non-apophyseal fracture and are very rare as compared with the younger age group.
Till date, there is no consensus about the classification and management of odontoid fractures in children. Different synchondrosal classification schemes have been suggested for children upto seven years, but no clear recommendations exist for the 8- to 14-year age group; Anderson and D’Alonzo classification is being used by some researchers.,, Odontoid fractures in children often go unnoticed, owing to the difficulty in communication in younger children and confusing radiographic features of unfused ossification centers and normal anatomic variants in this age group. The most consistent finding in pediatric CSI is midline cervical tenderness. In our patient also, midline tenderness led us to perform a CT scan of the cervical spine, which revealed a transverse fracture of the odontoid process at the base.
Odontoid process fractures are rarely associated with neurological injury, and the majority cases present with neck pain or torticolis. The management of this type of fracture aims at preventing the progression of deformity and subsequent neurological deficit. Pediatric odontoid process fractures are associated with significant morbidity and mortality. Most authors have advocated closed reduction and external stabilization with close radiographic follow-up as an initial treatment approach. A recent meta-analysis has reported a 93% fusion rate with external orthosis over a follow-up period of three to six months. The management of such injuries in this age group is difficult, owing to the greater head-to-body ratio and the difficulty in cooperating with the cranial halo or brace. Also, there is no consensus regarding the management in this age group; data regarding outcome after immobilization in external orthosis or surgical fusion are mostly extrapolated from series, including the adult population.
The most commonly accepted treatment strategy in this type of fracture remains to be immobilization of the cervical spine in the Halo vest; however, chances of malunion and nonunion are high, as it allows some flexion–extension movement at the injured spinal level. Also, it is difficult to maintain those devices in children. There remains apprehension regarding pin penetration, owing to decreased skull thickness and the presence of soft osseous tissue in younger children. Complications such as pin site infection, pin loosening, and skin breakdown have been reported in the pediatric age group. In our patient, halo application was not an option as the associated depressed fracture of the skull was extensive and extended into the orbital roof. Immobilization of the cervical spine in Minerva cast or a custom-made cervical collar can be an option in similar cases; however, whether this type of orthosis can provide adequate immobilization to the atlantoaxial complex is still debated. Prolonged immobilization of 3 to 13 weeks has been recommended post-reduction. Potential complication can arise in the form of infected sore formation on continuous, prolonged use of a cervico-thoracic cast or a rigid cervical collar.
Adequate and proper immobilization of the atlanto-axial complex is the key to achieve fusion in odontoid fractures in the pediatric age group. Although significant fusion rates have been reported with external orthosis, Fulkerson et. al. have reported an 11.4% failure or non-union rate along with a 43.3% complication rate in an analysis of patients of odontoid synchondrosis fracture treated with Halo fixation. Some studies have suggested a direct surgical approach and instrumented fusion of the odontoid process in children with concomitant traumatic brain injury in view of early and good fusion rates. Surgical fusion also allows freedom from a bracing or cervical collar in children. Direct surgical fusion has been reported in many cases in the age group from infancy to seven years, whereas there are very few reports of such fusion in the 8- to 14-year age group. There has been only one case report of direct anterior fixation of the odontoid fracture in a 12-year-old child with type III fracture. In their study, Brockmeyer et. al. have reported two patients with AOSF in the 14- to 16-year group with a good fusion rate. Also, in their study, they have commented that instrumented fusion does not hamper the ultimate height of the child as majority of the growth occurs in long bones after the first several years of life and no significant post-fusion spinal deformity is informed. So, the youngest age of fusion should depend on the adequacy of the bone to accept hardware. The bony cervical spine approaches adult composition by 8–10 years of age, and the odontoid tip also fuses by 12 years. A recent tomographic study conducted to assess the feasibility of AOSF in children also confirmed the morphometric adequacy of single 3.5–4.5 mm screw fixation in the age group of 6–12 years. Rigid screw fixation should always be preferred in the pediatric age group, owing to a higher degree of fusion rates as compared with the traditional bone graft and wire fixation techniques. Although initial studies of surgical odontoid fusion reported higher complication rates in the form of deep wound infections or failure of fusion, these series mostly included surgical fusion by onlay graft or wiring techniques. Recent direct rigid fixation techniques are associated with very less complication rates in the pediatric age group. These lower rates of complications are in distinct contrast to the adult series, reporting significant complication rates that are attributable to several associated medical comorbidities in elderly patients, in whom odontoid fractures are more prevalent.
In our patient, a single 32 mm cannulated screw could be introduced uneventfully after checking for proper reduction of the fracture fragments. Good fusion was established at a follow-up CT scan. Although odontoid fractures are rare in this age group, concomitant severe head injuries are not uncommon and create therapeutic challenges. Direct anterior screw fixation is an effective mode of management of odontoid fractures in 7- to 12-year-old children.
The authors acknowledge the guidance and academic support of Professor Manoj Kumar Bhattacharyya, Head of the Department, Neurosurgery and Professor Sandip Chatterjee, professor and academic coordinator, Department of Neurosurgery, Park Clinic, Kolkata.
Financial support and sponsorship
No financial support was received from anybody for the study.
Conflicts of interest
The authors have no conflicts of interest to disclose.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]