Case Study Series: Odontoid Fracture
This patient is a 19 year-old young woman who was involved in a high-speed motor vehicle crash. She suffered multiple fractures, including her leg and and her cervical spine (neck).
Fortunately, the fractures of her neck did not result in any neurological injury. The fracture pattern, however, was complex.
She had fractures of the first (C1), second (C2), sixth (C6), and seventh (C7) cervical vertebrae. The C1 fracture was a burst fracture of the C1 ring also known as a Jefferson’s fracture. These fractures have complete disruption of the ring of the C1.
The C2 fracture was a specific fracture of the base of the odontoid process. The odontoid process is a bony protusion upwards off the vertebral body of C2. These are called odontoid fractures and this particular one is the more difficult type to treat. It is called a type 2 odontoid fracture.
The C6 and C7 fractures were simple fractures of the back of the canal. They are called laminar fractures and are of no significant clinical consequence.
The treatment of the Jefferson’s fracture in association with the type 2 odontoid fracture is complicated. We reviewed the imaging in conference and had multiple different opinions from various spine surgeons. There were two treatment options that were recommended by several spine surgeons.
One was a posterior cervical surgery to place screws and rods from the base of the skull to the C2 level (or from C1 to C2) to stabilize the fractures. This was an extensive surgery and would also significantly limit the range of motion of her cervical spine.
The other approach was placement of a halo-vest (external ring attached to skull and to a vest that stabilizes the head and cervical spine) that she would have to be in for 3 months. This device has significant discomfort and alters patient’s quality of life while they are in it.
After discussing the options and the different risks with the patient and her family, we decided on the surgery that I felt would given her the most benefit with the least risk.
My recommendation was to place an odontoid screw from the anterior approach to fixate the type 2 odontoid fracture because she was young and had a good chance of fusing the fractured segment. It also gave her a good chance of maintaining movement between C1 and C2.
The odontoid screw placement was only feasible if the Jefferson’s fracture was stable enough to treat with a rigid collar. If it was not stable then she would need a posterior instrumented fusion. I checked an MRI of the cervical spine and the ligaments holding together the C1 ring were partially torn.
I felt the tears were not significant enough to lead to instability. So we could proceed with the odontoid screw placement and then treat the Jefferson’s fracture with a rigid collar.
She underwent an anterior approach for placement of an odontoid screw through the body of C2 to capture the fractured odontoid and allow it to fuse to the body of C2.
We then kept her in a rigid collar for 3 months. She had minimal post-operative pain. She has fully recovered with good active range of motion of her cervical spine.
And all the fractures healed.