Management of Massively Displaced Type II Odontoid Fracture in an Obese Patient in a Resource-Challenged Facility: A Case Report of an Anterior Screw Osteosynthesis Technique

Abstract

The surgical management of a 22-year-old obese patient with a massively displaced type II odontoid fracture through anterior osteosynthesis (using a cannulated titanium screw of size 4.0 mm by 35 mm) in a resource-challenged facility is reported. The fracture was transverse at the waist of the dens with huge anterior–lateral displacement and overlapping. This fracture was unique in term of its displacement and overlapping nature of the fragment from routinely seen cases. The management was also challenged with the patient’s obesity, lack of a Mayfield device, and a nonadjustable operating table. The patient underwent the surgery and gradually and satisfactorily improved with full pre-injury functional status.

Introduction

The C2 vertebra (axis) is the second cervical vertebra and one of the three atypical cervical vertebrae. The axis has a peg-like protuberance or projection called odontoid process (dens) that projects itself cranially from the body of C2 vertebra. The odontoid process lies anterior to the spinal cord and functions as a pivot to provide upper cervical and head rotation through the atlas and stability to the upper cervical region.[1] Further stability of the cervical region is contributed by other structures such as the muscular attachments to the spinous process of the axis. Odontoid fracture can lead to a life-threatening condition following forces acting on it due to its proximity to the spinal cord and brainstem.[2] The odontoid process and anterior arch of the atlas are articulated and held together by alar, cruciform, and transverse ligaments that maintain the stability and prevent anterior displacement of C1 and posterior displacement of C2. Displacement by injury may lead to spinal cord compromise due to the narrowing of the vertebral canal and foramen. This compromise can affect cervical nerves and spinal cord at that particular level, leading to a spectrum of neurological deficits including nerve supply to respiratory muscles (diaphragm).[1,3]

Fractures of the odontoid pegs are not uncommon injuries in clinical practice. It accounts for 10%–20% of cervical fractures, and the fracture can follow low energy falls in elderly people, but usually of high energy traumatic injuries in younger individuals.[4,5,6] Odontoid injuries follow a bimodal pattern, especially in elderly and young patients. This fracture is relatively commoner in elderly, often missed, and usually caused by simple falls with risks from increased osteoporosis and associated with increased higher morbidity and mortality when compared to younger patients whose injuries are often from high-energy blunt trauma to the head, leading to cervical hyperflexion or hyperextension.[4,5,6] Odontoid injury is very rare in children, and it occurs usually at the site of basilar synchondros (like a traction injury).

The classification of odontoid fractures was first highly popularised in 1974 by Anderson and D’Alonzo,[7] which became widely accepted till date. This groups odontoid fractures into three main types: type I is an oblique fracture of the tip of the dens, type II is a fracture of the junction of the dens with the central body of the axis, and type III is a fracture in which the fracture line extends downward into the cancellous portion of the body of the axis.[7] The presentation varied widely depending on the severity of the injury. A conscious patient may present with neck pain, which becomes worse with motion, especially rotation, occipital head ache, and dysphagia, especially when there is associated large retro-pharyngeal haematoma. There could be a spectrum of neurological deficits, although this is not usual due to a large spinal canal at this level. Trauma patients should be properly evaluated, and attention should be paid to life-threatening and potentially life-threatening injuries using advanced trauma life support protocols. Imaging assessment includes radiographs, computed tomography (CT) scan, and magnetic resonance imaging (MRI). Odontoid fractures are best assessed by CT scan in sagittal and coronal views for identification of anatomical damage to each vertebra and displacement of bone fragments into the canal, especially with reconstructions. MRI is unique for its roles in identifying and displaying of intervertebral discs, ligamentous flavum, and neural structures. Even though CT scan is crucial for detailed assessment of bony injuries, MRI is considered very important for all patients with neurological indications and those who are considered for surgery.

Generally, appropriate management strategies of odontoid fracture are based on many influencing factors such as the type and nature of the fracture, quality or nature of the bone, pre-existing degenerative changes (arthrosis, myelopathy, spinal canal stenosis, and general quality of the cervical spine), and patient’s age.[8] Other important factors especially in a resource-poor setting like where the index case was managed includes but not limited to patient’s age and comorbidity, available facility, and surgeon’s skill and competency. Conservative nonoperative treatment is considered appropriate for stable non-displaced odontoid fractures, which can be achieved by the use of hard collars (like Philadelphia).[8] Halo fixator is another means of nonoperative treatment but should be used with caution due to possibilities of increased morbidity and mortality, especially in the elderly patients mainly because of soft tissue handling problems.[8,9,10,11] Hard collars may be used in the first phase for unstable fractures before further treatment or used for 6–8 weeks where nonoperative treatment is indicated.[8] Surgically, it can be fixed by anterior osteosynthesis with (1 or 2) screws in the classical unstable type II odontoid fracture in patients with good bone quality.[8,12] It can also be fixed by the anterior transarticular C1/2 stabilisation technique, which may be used in elderly patients to secure reduction by transarticular stabilisation of C1/2.[8,13] Also, posterior transarticular C1/2 stabilisation and fusion technique can be employed for surgery, which is the classical posterior fusion technique.[14,15,16] Other techniques include posterior instrumentation by Harms–Goel of C1/2 internal fixation using C1 lateral mass screws and C2 pedicle screws[17] and posterior occipito-cervical stabilisation and fusion (C0–C3/4).[8]

The outcome is usually good; however, complications varied widely depending on the severity of the injury, type of fracture, fracture pattern, bone quality and status, underlying pathology of the spine, age and comorbidity of the patient, competency of healthcare providers, and available facilities for care. The complication includes injury to vital structures, nonunion, and failed osteosynthesis. Morbidity and mortality are commoner in the elderly population.

We report the surgical management of a massively displaced type II odontoid fracture in an obese patient in a resource-challenged facility with the cannulated screw fixation technique via the anterior approach due partly to its uniqueness in and rarity of this procedure in this part of the world, with this case being the first of its kind our hospital.

Case Presentation

A case of a 22-year-old male university undergraduate who presented with a 3-day history of neck pain, dysphagia, severe occipital headache, weakness of both upper limbs, and neck deformity following road traffic crash is reported. He was an unrestrained middle rear sitter of a saloon car travelling on the inter-city road (Zamfara–Sokoto road). The car, while on speed, lost control when the driver was trying to avoid a motorbike and subsequently veered off road, eventually stopped by a tree. The patient sustained close injury to the neck and some minor abrasions to lower limbs. Other passengers also sustained varied injuries, but there was no life causality. The patient was taken to a peripheral hospital where he was given initial care and referred to our surgical out-patient department due to the persistence and progressive nature of the above symptoms. There was no other major injury and no difficulty with breathing.

His physical examination revealed an obesity characterized by a body mass index of 37.6 kg/m², was anxious and in moderate painful distress, and was found to use the right hand to support the head; lateral right eye conjunctiva haemorrhage was also observed. Other findings include right-sided torticoliosis, nuchal muscle spasm and tenderness, weakness of C4 and C5 motor (power of 4/5 on the right), and apprehension in moving the neck to any direction. Philadelphia collar was applied immediately, and the patient was admitted [Figure 1]. The radiographs and CT showed a type II odontoid fracture with massive anterior–lateral displacement and overlapping [Figures 2 and 3]. MRI revealed disruption of bony continuity of the odontoid process at the basilar part, occipito-cervical spinal canal stenosis, and some compression on the spinal cord [Figure 4].

Figure 1.

Patient on the operation table before surgery with Philadelphia collar

Figure 2.

Patient’s cervical spine plain radiographs with a pointer to the fracture site catheterised by the anterior displacement of the odontoid peg and C1 spinous process (a and b)

Figure 3.

Cervical computerised tomography (a and b) showing the fracture of the odontoid peg with huge anterior and left lateral displacement

Figure 4.

Patient’s cervical spine magnetic resonance imaging cervical canal stenosis at the occipito-cervical junction

The diagnosis of type II odontoid fracture with massive displacement and overlapping in an obese patient was made. The patient was worked up for surgery by doing the routine investigations, which were all within normal limits, and subsequently had single cannulated screw fixation of the fracture via the anterior approach with C-arm guide on the 6th day post-injury. He was in supine position after general anaesthesia with muscle-relaxant, and skull traction with 7 kg was applied, with a sand bag in between scapulae to give the neck maximum extension while maintaining the neck with skull traction. Anterior transverse incision was made anterior to the level of C4, which was developed to access the fracture site. Fracture fragments could not be adequately reduced by the traction even with gentle addition of human traction until a blunt instrument was used to push the proximal fragment superior-posteriorly from the wound while monitoring with C-arm images [Figure 5]. A guide wire was inserted after satisfactory reduction, and a cannulated screw (titanium, 4.0 mm by 35 mm) was used to maintain the reduction by screwing it over the guide wire with a cannulated screw driver [Figure 6]. Wound closure was done with subcuticlar vicryl 1/0 after satisfactory images were obtained from C-arm. After surgery, he was maintained on a cervical collar (Philadelphia), was advised bed rest, and postoperative analgesics and antibiotics as well as neuro-vitamins were prescribed. The patient’s symptoms significantly improved within 3 days post-surgery and eventually disappeared completely within a week. He was discharged on the 10th day post-operation with suggestion of a cervical collar and could resume gradually his daily activities. He resumed back to school 17th day after surgery to write his examinations and discontinued wearing the cervical collar on his own 4 weeks after surgery, claiming that he has fully recovered. He has not visited the clinic since then but always chats on WhatsApp to greet as well as occasional phone calls, and presently he and his uncle have become friends by always keeping in touch on phones on social grounds.

Figure 5.

Patient’s C-arm images after traction reduction with skull traction and during manipulation with a blunt instrument to reduce the fracture adequately due to challenges of reduction by the patient body physique and depth of the wound

Figure 6.

Stages of cannulated screw placement through guide wire (graduated wire)

The surgical procedure was challenged by the patient’s obesity owing to bulky neck soft tissue (short neck), lack of Mayfield, nonadjustable operating table, and difficulty in reducing the overlapped fracture fragment. We could have referred him to a facility where these were available, but the closer facilities to us are beyond the financial strength of the family, and the cheaper government facilities are too far from ours, with very high risks for secondary injuries along with possibility of worsened neurological status before getting there. Hence, we decided to manage him.

The figures below are the preoperative and intra-operative clinical photographs and images.

Discussion

Our patient is a young man (22 year old) who had high-impact injury from auto-crash. Auto-crash is the most common cause of odontoid fracture in young adults.[4,5,6] The injury is usually associated with high mortality, especially within 24 h, which could be as high as 25%–40% after the incident in high-impact injuries.[18] Our patient presented to the hospital 3 days after injury with the ability to walk but mild weakness of the upper limbs, severe neck pain, and occipital headache.

Generally, the neurological recovery is always good; however, complications include residual or persistent weakness in the upper limb and neck, which are the most common neurological symptoms that may warrant urgent intervention to prevent permanent deficits.[18] Our patient progressively improved with complete resolution of headache, neck pain, and upper limb weakness within a week of the surgery This surgical treatment outcome of this patient is highly encouraging despite the setbacks, and it is comparable to the outcome of many patients who had similar surgical intervention in more resourceful facilities unlike ours.[18,19,20] We chose surgical management due to type of fracture (type II) and massive displacement of the fracture in addition to the symptoms including the neurological symptoms. At presentation, we could have referred him to a facility where the needed resources and facilities were available, but the closer facilities are beyond the financial strength of his family, and the cheaper government facilities are too far from ours with very high risks for secondary injuries before getting there. Hence, we decided to manage him with available resources.

Many literature and clinical experiences have supported an anterior odontoid screw fixation (which could be one or two depending on the bone quality) which is relatively easier to retain reduction and prevent cervical rotation at the fracture site, immediate stability of the spine, higher fusion rate, early return of function and normal lifestyle, and shorter time of procedure, lesser risks of injury to vital structures, especially vertebral artery, less blood loss, less postoperative pain, hence less need for opioid use, less tissue damage, and shorter hospital stay as compared to posterior cervical laminectomy and fusion (PCIF).[18,19,20] Our patient benefited with the advantages of the anterior approach, even though the reduction and access was challenging due to the his obesity and body physique.

However, there are different posterior cervical approach and instrumentation for fusion, which may be the best option in older fracture (late presentation), especially when it is older than 6 months due to progressive increase in fusion failure rate and limited access for surgery unlike PCIF.[18,21]

Literature search revealed that surgical treatment of odontoid fracture is very rare in West African counties, especially Nigeria, as we only came across of two cases (type II fracture) as part of upper cervical spine injury managed by Adeolu et al.[22] with Rogers inter-spinous wiring. This paucity in literature evidence of surgical management of odontoid fracture in West Africa, especially in Nigeria, could be as a result of lack of expertise, paucity of spine surgeons, missed injury, or high pre-hospital mortality due to poor level of pre-hospital care following such injuries and inadequate diagnostic tools and pre-hospital care and poor transport of injured patients, especially in many small cities to the tertiary hospital where such services are possible.

Conclusion

Management of massively displaced and overlapped type II odontoid fracture of an obese patient in a resource-challenged facility is a unique experience. The uniqueness of the fracture pattern, patient’s obesity, and lack of Mayfield device for traction are important case emphasising values of adequate planning, patient’s safety, and making use of available resources to get the best clinical outcomes for the patient. This also underlies the importance of knowledge and skills in patients’ surgical care.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.