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A case of cervical myelopathy following chronic hypertrophic non-union type 2 odontoid fracture managed with posterior C1 decompression and C1-3 instrumentation: Case report and brief review of literature
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How to cite this article: Shaaban AT, Doomi A, Belkheir S. A case of cervical myelopathy following chronic hypertrophic non-union type 2 odontoid fracture managed with posterior C1 decompression and C1-3 instrumentation: Case report and brief review of literature. Surg Neurol Int 2020;11:132.
Abstract
Background:
Type 2 odontoid fractures are the most common type of fracture of the axis. In rare cases, nonunion of a type 2 odontoid fracture can be hypertrophic resulting in myelopathy due to cervical cord compression.
Case Description:
A 48-year-old male presented with hypertrophic nonunion of a chronic type 2 odontoid fracture resulting in cord compression/myelopathy. This was adequately treated utilizing a C1 decompression and C1-3 instrumented fusion; no anterior procedure was necessary.
Conclusion:
Here, we successfully treated a patient with a hypertrophic nonunion of a chronic type 2 odontoid fracture utilizing a posterior only approach consisting of a C1 laminectomy with C1-C3 fusion.
INTRODUCTION
Type 2 odontoid fracture is the most common type of fracture of axis and most common cervical spine fractures in elderly population. Incidence in the USA is estimated 21.4/100,000 inpatient.[4,7] In rare cases, chronic nonunion of type 2 odontoid fractures can become hypertrophied resulting in ventral cord compression/myelopathy.[9] Nonunion type 2 odontoid fractures are usually managed with combined anterior/posterior decompressions/fusions.[2,6,8] Here, we present a 48-year-old male with a chronic nonunion of a type 2 odontoid fracture resulting in cord compression/myelopathy adequately managed with a posterior surgery alone (i.e., C1 decompression and C1-C3 instrumented fusion).
CASE DESCRIPTION
Clinical presentation
A 48-year-old male presented with chronic neck pain and 4 months of progressive myelopathy (i.e., unsteady gait and clumsiness). Two years ago, he had fallen from 2 m height, hitting his head and neck on the ground. Since then, he continued to experience Lhermitte’s signs. On examination, he had no motor or sensory deficits, but exhibited a spastic gait, bilateral Hoffman’s sign, diffuse upper and lower extremity hyperreflexia, and bilateral ankle clonus.
Diagnostic studies
Cervical spine X-ray and computed tomography (CT) studies confirmed an old nonunited displaced fracture at the base of the odontoid process of the C2 vertebra narrowing the spinal canal at the C1-2 level due to displacement of C1 [Figures 1 and 2]. The magnetic resonance imaging of cervical spine showed severe canal stenosis and T2 hyperintense cord signal changes at level of C1 [Figure 3].
Surgery
The patient underwent awake fiber-optic endotracheal intubation. Intraoperative neurophysiological monitoring included somatosensory evoked and motor evoked potentials.
A C1 decompressive laminectomy was performed and all were placed under CT neuronavigation guidance. These included lateral mass screws at C1 applied (32 × 3.5 mm partially threaded), bilateral C2 pars articularis screws (18 × 3.5 mm), and C3 lateral mass screws (16 × 3.5 mm). After the rods were applied, the intraoperative CT showed reduction of the C1/2 malalignment. Routine completion of the Instrumentation and closure followed [Figures 4 and 5].
DISCUSSION
Frequency of type 2 odontoid fractures resulting in nonunion
Odontoid fractures are the most common fractures involving axis and are the most frequently encountered cervical spine fractures seen in adults over 65 years of age. Nonoperative management is associated with a high risk of nonunion (i.e., 36.3%).[7]
Incidence of hypertrophic nonunion of type 2 odontoid fractures
Hypertrophic nonunion of type 2 odontoid fracture is rare. Of five such cases found in the literature, four were managed with anterior decompression/posterior fusion, while one was treated nonsurgically [Table 1].[1,3,5,9] We believe that the combined anterior/posterior approach is not always needed and increases the risks/complications for older patients. As we found here, a posterior only alternative procedure proved effective. In our case, we successfully utilized a posterior-only approach consisting of a C1 decompression with a C1-C3 posterior fusion.
CONCLUSION
We recommend a posterior only approach consisting of a C1 laminectomy with C1-C3 posterior fusion for managing a hypertrophic chronic nonunion of a type 2 odontoid fracture.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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