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Ronald I. Apfelbaum, Russell R. Lonser, Robert Veres, and Adrian Casey

F ractures of the odontoid process of the C-2 VB are common cervical spine injuries, accounting for 10 to 20% of all cervical spine fractures. 9, 16, 20 These fractures most often occur at the junction of the odontoid process and the body of C-2 (Type II) or in the body of C-2 (Type III) and result in atlantoaxial instability. Because of the instability associated with these lesions, patients are at significant risk for immediate or delayed catastrophic spinal cord compromise 12 and achieving spinal stabilization is imperative. Current methods for

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Justin Slavin, Marcello DiStasio, Paul F. Dellaripa, and Michael Groff

, particularly an odontoid lesion, presents unique challenges. Imaging findings tend to be nonspecific, with possible enhancing regions. The disease presentation and symptoms can mimic other causes of arthropathy and spondylosis including infection, metastasis, and rheumatoid arthritis affecting the disk spaces, vertebral bodies, facet joints, or the posterior ligaments of the spine. Obtaining a pathologic specimen of the odontoid can be difficult as the lesion is difficult to reach from a posterior approach due to the spinal cord overlying the dens, and anterior approaches

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Jared M. Pisapia, Nikhil R. Nayak, Ryan D. Salinas, Luke Macyszyn, John Y. K. Lee, Timothy H. Lucas, Neil R. Malhotra, H. Isaac Chen, and James M. Schuster

O dontoid process fractures comprise 10%–20% of all cervical spine fractures, 18 , 22 of which Type II fractures, as described by Anderson and D'Alonso, 2 are the most common. These fractures through the base of the odontoid process are unstable and unlikely to heal without intervention, especially in patients with the following risk factors: age over 50 years, displacement of the dens greater than 5 mm relative to the C-2 body, angulation greater than 10°, translation greater than 4 mm, and failure to maintain alignment with external mobilization. 12

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Nathan T. Zwagerman, Matthew J. Tormenti, Zachary J. Tempel, Eric W. Wang, Carl H. Snyderman, Juan C. Fernandez-Miranda, and Paul A. Gardner

sagittal plane, lesions from the crista galli to the craniocervical junction can be directly accessed. The extension of these techniques to odontoid pathology is a further evolution of these techniques. 1 Since the first case report of endonasal odontoid decompression, 24 it has gained popularity with increasing case reports in the literature. 26 , 27 , 32 , 36 We present our experience with the fully endoscopic endonasal transodontoid approach including indications and complications. Methods We performed a retrospective review of all patients from 2004 to 2013 in

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William Fuell, Lucas Bradley, Gresham T. Richter, Noojan Kazemi, Gregory Albert, Richard McCarthy, and Eylem Ocal

T ranslational atlanto-axial subluxation (tAAS) is an uncommon entity in the pediatric population. It is commonly the result of a ligamentous defect, bony abnormality (os odontoideum), or trauma. 3 Some of the more common ligamentous or joint abnormalities associated with tAAS include rheumatoid arthritis, Down syndrome, Morquio syndrome, Marfan disease, Grisel syndrome, and Reiter syndrome. 5 Abnormalities of the bone, which include os odontoideum, synchondrosis, and subdental epiphysiolysis, often involve the odontoid process. Traumatic tAAS often involves a

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Terrence D. Julien, Bruce Frankel, Vincent C. Traynelis, and Timothy C. Ryken

Object

The management of odontoid fractures remains controversial. Evidence-based methodology was used to review the published data on odontoid fracture management to determine the state of the current practices reported in the literature.

Methods

The Medline literature (1966–1999) was searched using the keywords “odontoid,” “odontoid fracture,” and “cervical fracture” and graded using a four-tiered system. Those articles meeting selection criteria were divided in an attempt to formulate practice guidelines and standards or options for each fracture type. Evidentiary tables were constructed by treatment type.

Ninety-five articles were reviewed. Five articles for Type I, 16 for Type II, and 14 for Type III odontoid fractures met selection criteria. All studies reviewed contained Class III data (American Medical Association data classification).

Conclusions

There is insufficient evidence to establish a standard or guideline for odontoid fracture management. Given the extent of Class III evidence and outcomes reported on Type I and Type III fractures, a well-designed case-controlled study would appear to provide sufficient evidence to establish a practice guideline, suggesting that cervical immobilization for 6 to 8 weeks is appropriate management. In cases of Type II fracture, analysis of the Class III evidence suggests that both operative and nonoperative management remain treatment options. A randomized trial or serial case-controlled studies will be required to establish either a guideline or treatment standard for this fracture type.

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Luca Ricciardi, Sokol Trungu, Alba Scerrati, Pasquale De Bonis, Oriela Rustemi, Mauro Mazzetto, Giorgio Lofrese, Francesco Cultrera, Cédric Y. Barrey, Alessandro Di Bartolomeo, Amedeo Piazza, Massimo Miscusi, and Antonino Raco

T he craniovertebral junction (CVJ) is involved in as many as 20% of cervical spine traumatic injuries. 1–3 Odontoid fractures are mostly reported in the elderly, and they were classified by Anderson and D’Alonzo into 3 types. Odontoid type II fractures are those involving the base of the odontoid process, which may be displaced and/or angulated backward or forward. 4 These fractures result in C1–2 segmental instability, which may provide bulbar-medullary compression and segmental deformity. 4 , 5 Both conservative and surgical management have been proposed

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Tony Goldschlager, Roger Härtl, Jeffrey P. Greenfield, Vijay K. Anand, and Theodore H. Schwartz

A recent paper by Choi and Crockard compared transoral odontoid surgery to the crocodile; it has persisted from prehistoric times but still has a place today. 5 Indeed, the transoral approach is considered the gold-standard approach to surgically address periodontoid pathology. 16 However, the evolution of endoscopic endonasal surgery has led to the development of a minimally invasive alternative approach to the odontoid. While both the transoral and endonasal approaches are “natural orifice” surgery, the biggest advantage of the endonasal endoscopic

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Harminder Singh, Sarang Rote, Ajit Jada, Evan D. Bander, Gustavo J. Almodovar-Mercado, Walid I. Essayed, Roger Härtl, Vijay K. Anand, Theodore H. Schwartz, and Jeffrey P. Greenfield

endoscopic endonasal approach (EEA) to the CVJ and odontoid process using cadaveric dissection in 2002. 1 Later, Kassam et al. provided a description of EEA for resection of the odontoid process and rheumatoid pannus in a patient with symptomatic cervicomedullary compression. 8 Since then, EEA for odontoid resection has been more widely used, and several studies have evaluated the inferior anatomical extent of odontoidectomy through an endonasal approach, 3 , 10 , 18 , 20 reporting that this procedure allows for more rapid extubation and earlier time to feeding. 6 , 9

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James S. Harrop, Ashwini D. Sharan, and Gregory J. Przybylski

Object

Cervical spinal cord injury (SCI) after odontoid fracture is unusual. To identify predisposing factors, the authors evaluated a consecutive series of patients who sustained SCI from odontoid fractures.

Methods

A consecutive series of 5096 admissions to the Delaware Valley Regional Spinal Cord Injury Center were reviewed, and 126 patients with neurological impairment at the C1–3 levels were identified. Seventeen patients had acute closed odontoid fractures with neurological deficit. Various parameters including demographics, mechanisms of injury, associated injuries, fracture types/displacements, and radiographic cervical canal dimensions were compared between “complete” and “incomplete” spinal cord injured–patients as well as with neurologically intact patients who had suffered odontoid fractures. There were similar demographics, mechanisms of injury, associated injuries, fracture type/displacement, and canal dimensions in patients with complete and incomplete SCIs. However, only patients with complete injury were ventilator dependent. In comparison with patients with intact spinal cords, spinal cord–injured patients were more commonly males (p = 0.011) who had sustained higher velocity injuries (p = 0.027). The computerized tomography scans of 11 of 17 neurologically impaired patients were compared with those of a random sample of 11 patients with intact spinal cords. Although the anteroposterior diameter (p = 0.028) and cross-sectional area (p = 0.0004) of the cervical spinal canal at the C–2 level were smaller in impaired patients, the displacement of the fragment was not different.

Conclusions

Odontoid fractures are an infrequent cause of SCI. Patients with these injuries typically are males who have smaller spinal canals and have sustained high velocity injuries.