The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 94, Issue 19

Scientific Articles | October 03, 2012

Treatment Algorithm for Dens Fractures: Non-Halo Immobilization, Anterior Screw Fixation, or Posterior Transarticular C1-C2 Fixation

Markus R. Konieczny, MD¹; Arnold Gstrein, MD¹; Ernst J. Müller, MD¹

¹ Department of Traumatology, General Hospital Klagenfurt, Academic Teaching Hospital of the University of Graz, Schlossmannstrasse 11, 40225 Düsseldorf, Germany. E-mail address for M.R. Konieczny: Markus@Konieczny.net. E-mail address for A. Gstrein: Arnold.Gstrein@lkh-klu.at. E-mail address for E.J. Müller: Ernst.Mueller@lkh-klu.at

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Investigation performed at the Department of Traumatology, General Hospital Klagenfurt, Academic Teaching Hospital of the University of Graz, Düsseldorf, Germany

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, no author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

J Bone Joint Surg Am, 2012 Oct 03;94(19):e144 1-6. doi: 10.2106/JBJS.K.01616

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Abstract

Background:

The appropriate treatment of dens fractures is unclear. We established a staged treatment protocol for dens fractures and conducted a prospective study to evaluate the outcome of treatment based on this protocol.

Methods:

We prospectively evaluated sixty-nine consecutive patients who presented to our institution with a dens fracture. The mean duration of follow-up was 9.7 months (range, six to fifty-eight months). Fractures were categorized as stable or unstable. Stable fractures were treated by immobilization in a rigid collar. Patients seventy-five years or older with unstable fractures, patients with a neurological deficit, and patients with Anderson and D’Alonzo type-III fractures underwent posterior transarticular C1-C2 stabilization. Unstable fractures in patients younger than seventy-five years were stabilized with direct anterior screw fixation. Thirty-one patients were treated with a Philadelphia collar, twenty-five with posterior transarticular fixation, and thirteen with direct anterior screw fixation.

Results:

Fracture-healing or solid fusion of C1-C2 was documented in sixty-eight of sixty-nine treated patients at final follow-up. The remaining patient had a stable nonunion of the dens. Secondary procedures were performed in five patients.

Conclusions:

Our treatment algorithm based on dens fracture type, fracture stability, and patient age was associated with a high success rate. Evaluating fracture stability is crucial when considering nonoperative treatment. External stabilization with a rigid cervical collar was adequate for stable fractures of the dens and was associated with a high healing rate. Posterior transarticular screw fixation of C1-C2 was associated with a high success rate, including in elderly patients.

Level of Evidence:

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Figures in this Article

Introduction

Introduction | Materials and Methods | Results | Discussion | Appendix

Fractures of the dens represent approximately 7% to 15% of all cervical spine fractures and 1% to 2% of all spine fractures^1,2. Despite numerous publications on this subject, with a trend toward primary operative stabilization^1,3-5, the appropriate treatment for this frequent and potentially life-threatening injury remains controversial.

Nonunion rates of 2.4% to 100%^2,4,6,7 have been reported for various types of dens fractures and treatment modalities. Important factors contributing to nonunion are the direction and magnitude of displacement as well as the magnitude of angulation of the dens fracture, direction of the fracture line, fracture type, fracture stability, patient age, and degree of neurological deficit^2,4,6,7.

A halo device is utilized in the majority of nonoperatively treated patients because it provides substantial reduction of motion in the upper cervical spine, but the number of associated complications is high^8-11. There have been several reports of a high healing rate and low complication rate with non-halo immobilization^12,13. Nonunion rates of 0% to 27% have been reported for operative stabilization^5,14,15, but several reports have indicated a high prevalence of major complications^5,8,16.

Anterior screw fixation is often used for operative treatment because C1-C2 rotation is preserved and healing rates ranging from 88% to 100% have been reported^3,17,18. However, there are reports of high complication rates associated with this technique, especially in elderly patients^{3,5,8,16,18,19}. Posterior transarticular fixation of C1-C2 has been associated with high fusion rates ranging from 96% to 100% and low complication rates in elderly patients, although neck rotation is substantially reduced^4,20,21.

We established a comprehensive treatment algorithm for dens fractures and conducted a prospective study by allocating each patient to a treatment group on the basis of age, fracture stability, and fracture type. Nonoperative treatment involved non-halo immobilization, and operative treatment involved either anterior screw fixation or posterior transarticular fixation.

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | Appendix

Patients

Seventy-one patients with an acute dens fracture presented to our institution between May 1, 2003, and December 31, 2009. Patient characteristics and concomitant injuries are summarized in the Appendix. Eleven (15%) of the patients presented with a neurological deficit (see Appendix). Two patients (eighty and eighty-four years old) with an unstable dens fracture died before they could be stabilized for surgery. One of these patients presented with an Injury Severity Score (ISS)²² of forty-eight, and the other patient had incomplete posttraumatic tetraplegia and a history of coronary artery disease.

Diagnostic Algorithm and Treatment Protocol

All patients were evaluated with use of radiography and computed tomography (CT). Fractures were classified as stable or unstable according to previously described criteria^2,6,8: fractures that had an initial displacement of <5 mm and initial angulation of <11° on the CT scans as well as anteroposterior displacement of <2 mm on lateral flexion-extension sagittal radiographs were classified as stable. Lateral flexion-extension cervical spine radiographs were made when neither a displacement of ≥5 mm nor an angulation of ≥11° was seen on the initial CT scans. If accurate interpretation of the lateral flexion-extension cervical spine radiographs was not possible, the examination was repeated with use of fluoroscopy. All fractures that did not fulfill the above criteria for stability were classified as unstable. All fractures were also classified according to the system of Anderson and D’Alonzo, with type II indicating a fracture within the dens and type III indicating a fracture through the C2 vertebral body²³. The treatment algorithm is summarized in the Appendix.

Stable fractures without a concomitant neurological deficit were treated nonoperatively with a Philadelphia collar (Philadelphia Cervical Collar Company, Thorofare, New Jersey) for twelve weeks (Fig. 1). Lateral flexion-extension cervical spine radiography was repeated at seven to fourteen days after the injury to confirm stability after any pain-related muscle spasms had subsided. If the fracture was classified as unstable (displacement of ≥2 mm) on these radiographs, secondary treatment consisting of posterior transarticular stabilization was performed.

Fig. 1

A seventy-eight-year-old woman sustained a stable fracture of the dens in a fall from an upright position and was treated nonoperatively. Fig. 1-A Sagittal CT scan immediately after the trauma. Fig. 1-B Sagittal CT scan six months after injury, showing fracture-healing.

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All patients with an unstable fracture or a concomitant neurological deficit underwent operative stabilization. Direct anterior screw fixation with a single cannulated screw was the method of choice for type-II fractures in patients younger than seventy-five years^17,18 (Fig. 2). A modified posterior transarticular screw fixation of C1-C2 with a modification of the technique of Magerl and Seemann was performed in patients who were seventy-five years and older or had a type-III fracture¹⁴ (Fig. 3). All operative procedures were performed by the same surgical team.

Fig. 2

A thirty-eight-year-old man sustained an unstable fracture in a bicycle accident and was treated with direct anterior screw fixation. Fig. 2-A Preoperative sagittal CT scan. Fig. 2-B Postoperative sagittal CT scan. Fig. 2-C Postoperative lateral cervical spine radiograph. Fig. 2-D Postoperative anteroposterior radiograph.

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Fig. 3

An eighty-nine-year-old woman sustained an unstable fracture of the dens in a fall and was treated with transarticular screw fixation with a modified Gallie fusion³⁵. Fig. 3-A Preoperative sagittal CT scan. Fig. 3-B Postoperative lateral radiograph. Fig. 3-C Postoperative anteroposterior radiograph.

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The distribution of patients according to treatment group is summarized in Table I. The mean duration of follow-up was 9.7 months (range, six to fifty-eight months). The clinical and radiographic follow-up of all patients included evaluations at six weeks, twelve weeks, and six months. A CT scan was performed at three months.

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TABLE I Treatment

	No. of Patients
Treatment	Total	Male	Female	Age*(yr)
Primary operative stabilization of an unstable fracture	38	22	16	64.5 (17-91)
Anterior screw fixation	13	8	5	47.8 (17-74)
Posterior transarticular C1-C2 fusion	25	14	11	72.1 (18-91)
Semirigid external stabilization of a stable fracture	31	18	13	68.0 (17-97)

*Values are given as the mean, with the range in parentheses.

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TABLE I Treatment

	No. of Patients
Treatment	Total	Male	Female	Age*(yr)
Primary operative stabilization of an unstable fracture	38	22	16	64.5 (17-91)
Anterior screw fixation	13	8	5	47.8 (17-74)
Posterior transarticular C1-C2 fusion	25	14	11	72.1 (18-91)
Semirigid external stabilization of a stable fracture	31	18	13	68.0 (17-97)

*Values are given as the mean, with the range in parentheses.

Diagnosis of a nonunion was made according to the criteria of Schatzker et al.²⁴: either (1) a defect in the dens with continuous sclerosis of both fragments (vascular pseudarthrosis) or (2) a defect in the dens with continuous resorption of both fragments (rarefying osteitis or atrophic pseudarthrosis), in association with (3) a defect in the dens with definite loss of cortical continuity and/or (4) demonstrable movement of the dens fragments during flexion and extension or on fluoroscopic views. Neurological impairment was classified according to the Frankel system²⁵ (grade A, a complete lesion; B, only sensory function preserved; C, some motor power preserved but useless; D, useful motor power preserved; and E, absence of neurological symptoms).

Source of Funding

There was no external source of funding.

Results

Introduction | Materials and Methods | Results | Discussion | Appendix

Twenty-eight (90%) of the thirty-one patients treated with Philadelphia collar immobilization had primary union of the dens. The nonunions occurred in two (11%) of the eighteen nonoperatively treated type-III fractures and one (8%) of the thirteen nonoperatively treated type-II fractures. Two of the three nonunions were treated with secondary posterior transarticular fixation; both patients had a successful fusion and had no neck pain or neurological symptoms at twelve months postoperatively. The third patient, an eighty-seven-year-old man, had a stable nonunion after a type-III fracture. He reported intermittent neck pain and had no neurological deficit, and secondary operative treatment was not performed.

A successful fusion was achieved in all twenty-five of the fractures stabilized with posterior transarticular fixation. Three (23%) of the thirteen patients who underwent direct anterior screw fixation had persistent instability and nonunion of the dens four months after surgery; all three subsequently underwent posterior transarticular stabilization that resulted in a successful fusion. One of these patients reported intermittent neck pain and the other two reported no neck pain twelve months after the second surgical procedure. None of the three patients had a neurological deficit.

Twelve of the thirteen stable type-II dens fractures healed after Philadelphia collar immobilization. The remaining fracture developed a nonunion that was successfully treated with posterior transarticular fixation. The twenty-one unstable type-II fractures in patients seventy-five years of age or older (mean, 79.5 years; range, seventy-five to ninety-one years) were stabilized by posterior transarticular fixation, and all fusions were successful. The eleven unstable type-II fractures in patients younger than seventy-five years (mean age, 56.5 years; range, thirty-one to seventy-four years) were treated with direct anterior screw fixation. All but one fracture healed; the patient with a nonunion underwent secondary posterior transarticular screw fixation four months after the first operation, and the fusion was successful.

Only one of the eighteen patients with a stable type-III fracture required secondary posterior transarticular screw fixation after initial treatment with semirigid external stabilization (a Philadelphia collar) because of persistent instability and nonunion after four months, and the fusion was successful. In addition, a stable nonunion was diagnosed in an eighty-seven-year-old patient at the time of final follow-up. Six type-III fractures were classified as unstable. Four of these patients underwent posterior transarticular stabilization, and all fusions were successful. The other two patients (seventeen and nineteen years old) underwent direct anterior screw fixation; both had a nonunion when evaluated four months after surgery and underwent successful secondary posterior transarticular fixation (Table II).

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TABLE II Treatment Outcome

		Outcome of Primary Treatment		Outcome of Secondary Operation	Final Outcome
	Patients	Union	Nonunion	Union	Union
All fractures
Posterior transarticular fixation	25	25	0	—	25
Anterior screw fixation	13	10	3	3	13
Conservative treatment	31	28	3	2	30
Type-II fractures
Posterior transarticular fixation	21	21	0	—	21
Anterior screw fixation	11	10	1	1	11
Conservative treatment	13	12	1	1	13
Type-III fractures
Posterior transarticular fixation	4	4	0	—	4
Anterior screw fixation	2	0	2	2	2
Conservative treatment	18	16	2	1	17

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TABLE II Treatment Outcome

		Outcome of Primary Treatment		Outcome of Secondary Operation	Final Outcome
	Patients	Union	Nonunion	Union	Union
All fractures
Posterior transarticular fixation	25	25	0	—	25
Anterior screw fixation	13	10	3	3	13
Conservative treatment	31	28	3	2	30
Type-II fractures
Posterior transarticular fixation	21	21	0	—	21
Anterior screw fixation	11	10	1	1	11
Conservative treatment	13	12	1	1	13
Type-III fractures
Posterior transarticular fixation	4	4	0	—	4
Anterior screw fixation	2	0	2	2	2
Conservative treatment	18	16	2	1	17

Seven deaths (10%) occurred during the study period. As noted, two patients (eighty and eighty-four years old) died because of multiple injuries and/or comorbidities before operative intervention could be performed. One patient (ninety-two years old) who had been treated successfully with a Philadelphia collar died at home of heart disease eight months after the injury. Two patients (sixty-two and seventy-four years old) treated with direct anterior screw fixation died four months after surgery of pulmonary complications; both had presented with posttraumatic tetraplegia. Two patients treated with transarticular fixation died. One of these patients (eighty-nine years old) had presented with posttraumatic tetraplegia and died of pulmonary complications four months after surgery. The other patient (ninety-one years old) had chronic obstructive pulmonary disease (GOLD stage 3²⁶) and died of pneumonia three months after surgery.

Eleven patients (15%) presented with a neurological disorder (see Appendix); all had initial posterior displacement of the fractured dens. The amount of displacement in three of these patients was at least equal to the sagittal width of the dens, and all three presented with tetraplegia resulting in a Frankel grade of A. The displacement was ≥50% of the sagittal width of the dens in another three patients; two of these patients presented with a Frankel grade of B and one with a dysesthesia of the upper extremities.

Four patients treated with posterior transarticular screw fixation developed mechanical complications. Two of these patients experienced breakage of one of the two screws at six months, and both screws in another patient broke after his son jumped on his head at four months postoperatively. The fourth patient required revision surgery because of a malpositioned screw. All four of these patients had a successful fusion.

Discussion

Introduction | Materials and Methods | Results | Discussion | Appendix

Fracture-healing or solid fusion of C1-C2 was documented at the time of final follow-up in sixty-eight of the sixty-nine patients treated for a dens fracture, and the remaining patient had a stable nonunion of the dens. The primary healing rate was 90% (twenty-eight of thirty-one) after nonoperative treatment, 100% (twenty-one of twenty-one) after posterior transarticular screw fixation, and 77% (ten of thirteen) after anterior screw fixation.

The healing rate after nonoperative treatment in the present series was higher than that reported in previous publications^4,12,27,28. Our data showed that a Philadelphia collar was an appropriate treatment method for stable type-II and type-III fractures of the dens, with a high healing rate and a low complication rate. Previous publications also demonstrated that, from a biomechanical standpoint, immobilization with a Philadelphia cervical collar is equivalent to halo-vest immobilization⁹ for stable fractures of the dens^2,6,7,12.

In contrast to previous publications, the prevalence of nonunion in this series was higher for type-III fractures than for type-II fractures, although this finding has to be interpreted with caution because of the relatively small numbers of patients. The rate of nonunion after direct anterior screw fixation in the present series was higher than that in previous reports. However, two of the three nonunions involved oblique type-III fractures with anterior comminution that were treated with direct anterior screw fixation rather than posterior transarticular screw fixation because of the young age of the patients (seventeen and nineteen years old). Hadley et al. described this fracture subtype as being highly unstable and difficult to treat²⁹, and a figure in the Appendix demonstrates why it is difficult to achieve stabilization of this type of fracture with anterior screw fixation.

Posterior transarticular screw fixation of C1-C2 had a high success rate with a low complication rate, especially in patients older than seventy-five years. Difficulty in placing the screws has been reported previously in up to 26% of patients³⁰ when screw insertion was performed as recommended in the guidelines¹⁴. We were able to perform this procedure in all patients, but we experienced two main problems in achieving correct screw placement: excessive thoracic kyphosis, which prevents adequate inclination of the screw during placement, and a so-called high-riding vertebral artery.

In patients with excessive thoracic kyphosis, C2 can be manipulated intraoperatively by applying a clamp to its spinous process even though the patient’s head is fixed in a Mayfield clamp and C1 is fixed quite rigidly to the head. During insertion of the Kirschner wire, the C2 body is flexed by manipulation of the clamp, allowing a steeper placement of the wire. Just before the Kirschner wire exits into the C1-C2 joint, the C2 position is corrected by extension so that proper anatomical positioning of the C1-C2 joint is achieved and the Kirschner wire enters the lateral mass of C1 in the middle third of the lower joint surface. In addition, we use drill guides that can be placed directly onto the entry point on the posterior lamina of C2. With these guides, the angulation of the Kirschner wire can be manipulated and steeper inclination is possible.

In elderly patients with a so-called high-riding vertebral artery, there is usually an osseous bridge that allows placement of a screw. We therefore used 2.7-mm screws, which we placed extremely close to the posterior edge of the cranial joint surface of C2, accepting perforation of the lamina of C2 before entering the lateral mass of C1.

With the described techniques, we were able to place two screws in all cases involving a traumatic fracture. However, different techniques had to be utilized for anatomical reasons in two patients with nontraumatic instability of the C1-C2 joint.

Fifteen percent of the patients in the present series presented with a neurological disorder, a rate that is consistent with those in other studies (3% to 25%)^3,16,31. The three tetraplegic patients were all at least sixty-nine years of age, and all three died, consistent with the previously described deleterious effect of initial neurological impairment in elderly patients with a dens fracture³². In agreement with a previous report³², we found an association between posterior displacement and neurological deficit; all eleven patients who sustained a posttraumatic neurological deficit had posterior displacement of the fractured dens. The three patients with the greatest degree of neurological impairment also had the greatest fracture displacement.

Radiography and CT scanning were performed as part of our diagnostic algorithm. If no parameters were indicative of instability, additional lateral flexion-extension cervical spine radiographs were made. The usefulness of flexion-extension views is controversial. Khan et al.³³ recently reported that 69% of such radiographs were inadequate (incomplete visualization, insufficient range of flexion-extension, or no evidence of rotational deformity). However, 11% of the patients in a study by Lewis et al.³⁴ demonstrated instability on flexion-extension views, and 36% of these patients had had no signs of instability in the routine imaging studies. Since early detection of instability increases patient comfort and shortens the hospital stay, we continue to use these views to increase the sensitivity of detecting instability of the upper cervical spine.

Appendix

Introduction | Materials and Methods | Results | Discussion | Appendix

Tables showing patient characteristics and concomitant injuries and neurological deficits as well as figures showing the treatment algorithm and schematic diagrams explaining why, from a biomechanical standpoint, direct anterior screw fixation of type-III fractures is not recommended are available with the online version of this article as a data supplement at jbjs.org.

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Topics

fracture ; bone screws ; immobilization ; odontoid fracture

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Markus R. Konieczny, Arnold Gstrein, Ernst J. Müller; Treatment Algorithm for Dens Fractures: Non-Halo Immobilization, Anterior Screw Fixation, or Posterior Transarticular C1-C2 Fixation. The Journal of Bone & Joint Surgery. 2012 Oct;94(19):e144 1-6.

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