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Thread: Grandfather has C1 Fracture not healing

  1. #1

    Unhappy Grandfather has C1 Fracture not healing

    Hello!
    I am so glad I found this forum. My Grandfather fell about 6 weeks ago and fractured his C1 in 3 places about 1/4" in each place. He is 87 and was put in a collar, one of the hard ones, not a soft neck collar, this one was pretty big. He isn't a very good candidate for a Halo. Last week he had an MRI/CT scan and X'Ray and we found out that the 1/4" is now 1 1/4" in spaces and his head is basically "floating" held up by the collar he wears. The neurosurgeon is consulting with his peers to see if there is anything that can be done, but he isn't hopeful. My Grandfather can't handle a 9 hour surgery for a Halo and it isnt meant to be long term. They told he and my Mom that eventually the C1 will disintegrate and paralysis will set in, he already feels tingles in his neck. She has talked to him about hospice and comfort care, he told her he wants to die. Is there any hope? What will happen as the gaps in the C1 continue to widen? If it has gotten that much bigger in just over a month, how quickly will it progress to paralysis? Please...anyone's comments are welcome.
    Christine

  2. #2
    Yes, as you know this is serious and things aren't looking posiitive but it is still early in the game and you need to wait to see what the neurosurgeon comes up with. At his age, the bones do not fuse well and this is his problem. I am sure why the surgery to apply the halo would be 9 hours unles they were also going to try an internal fix his spine also.
    I am sure the neurosrugeron will come up with some options.

    CWO

  3. #3
    Quote Originally Posted by Christine0929 View Post
    Hello!
    I am so glad I found this forum. My Grandfather fell about 6 weeks ago and fractured his C1 in 3 places about 1/4" in each place. He is 87 and was put in a collar, one of the hard ones, not a soft neck collar, this one was pretty big. He isn't a very good candidate for a Halo. Last week he had an MRI/CT scan and X'Ray and we found out that the 1/4" is now 1 1/4" in spaces and his head is basically "floating" held up by the collar he wears. The neurosurgeon is consulting with his peers to see if there is anything that can be done, but he isn't hopeful. My Grandfather can't handle a 9 hour surgery for a Halo and it isnt meant to be long term. They told he and my Mom that eventually the C1 will disintegrate and paralysis will set in, he already feels tingles in his neck. She has talked to him about hospice and comfort care, he told her he wants to die. Is there any hope? What will happen as the gaps in the C1 continue to widen? If it has gotten that much bigger in just over a month, how quickly will it progress to paralysis? Please...anyone's comments are welcome.
    Christine
    Christine,

    Your grandfather is a very lucky man to have this injury without any spinal cord injury. Most atlanto-axial (C1/C2) fractures do heal if it can be immobilized for several months. This is often done with the halo device although, depending on the extent of the fracture, a halo device may not be sufficient to stabilize his head. I don't think that putting on a halo device would take 9 hours. They are probably referring to putting on a halo plus putting in screws and other devices to stabilize the site.

    In most cases, placement of one or two screws plus prolonged immobilization with a hard collar will lead to fusion, as the following abstract from a 1999 study from the University of Florida in Gainsville indicates [1]. Frequently, a single anterior screw may be sufficient to stabilize the C1/2 fracture sufficiently to attain fusion [2]. In Europe, they tend to treat these conditions conservatively [3] and the fusion rate, at least in young patients, occurs in about 85% of patients.

    One of the reasons that I cite these articles is because it will give you an idea who are the experts on this subject in the United States and Europe.

    Wise.

    1: J Neurosurg. 1999 Oct;91(2 Suppl):139-43.Links
    Complex atlantoaxial fractures.
    Guiot B, Fessler RG.
    Department of Neurosurgery, University of Florida, Gainesville 32610, USA.
    OBJECT: The authors conducted a retrospective study to evaluate the treatment of complex C1-2 fractures. METHODS: There were 10 cases of complex C1-2 fractures. Six patients were men (median age 58 years) and four patients were women (median age 55.5 years). Injuries resulted from seven falls, two motor vehicle accidents, and one diving incident. Three patients suffered from upper-extremity weakness. Neurological function in seven patients was intact preoperatively. Fracture combinations included six Jefferson/Type II odontoid, two anterior ring/Type II odontoid, one posterior ring/Type II odontoid, and one posterior ring/Type III odontoid/Type III hangman's fracture. All patients underwent surgery, five after halo immobilization for an average of 4 months failed to provide stability. Treatment included placement of six odontoid screws, one posterior C1-2 transarticular screw, one odontoid screw with anterior C1-2 transarticular screw fixation, one C1-2 transarticular screw with C1-2 Songer cable fusion, and one odontoid screw with bilateral C-2 pedicle screw fixation. Specific treatment was determined by the combination of fractures. Postoperatively, all patients were immobilized in a hard collar for 3 months. There were no intraoperative surgery-related complications. The mean follow-up period was 28.5 months. Neurological recovery was observed in one of three patients who presented with neurological deficits. Fusion occurred in all cases. CONCLUSIONS: The goals in treating these complex fractures are to achieve early maximum stability and minimum reduction in range of motion. These are often competing phenomena. Frequently in cases of atlas-axis fracture, odontoid screw fixation combined with hard collar immobilization is the best therapy, provided the transverse atlantal ligament is competent. If not, C1-2 stabilization with placement of transarticular screws is required for best results.

    2. Neurosurgery. 1999 Oct;45(4):812-9; discussion 819-20.
    Comment in:
    Neurosurgery. 2000 Sep;47(3):794.
    Management of acute odontoid fractures with single-screw anterior fixation.
    Subach BR, Morone MA, Haid RW Jr, McLaughlin MR, Rodts GR, Comey CH.
    Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pennsylvania, USA.
    OBJECTIVE: Accepted management strategies for odontoid fractures include external immobilization and surgical stabilization using anterior or posterior approaches. Displaced Type II fractures and rostral Type III fractures are at high risk for nonunion. Anterior fixation of odontoid fractures with a single cortical lag screw is a relatively new technique that combines rigid internal stabilization with preservation of intrinsic C1-C2 motion. We retrospectively reviewed our series of 26 consecutive patients who underwent odontoid screw fixation, to further define the safety and efficacy of the technique. METHODS: During a 5-year period, 26 patients presented with acute traumatic Type II odontoid fractures. Ten patients were female and 16 were male, with a mean age of 35 years. All patients underwent anterior odontoid screw fixation by the senior surgeon (RWH), within a mean of 3 days after injury. All patients were postoperatively maintained in external orthoses, for a mean of 7.2 weeks, and were monitored with serial clinical and radiographic examinations. RESULTS: With a mean follow-up period of 30 months, radiographic fusion was documented for 25 of 26 patients (96%). No complications related to the surgical approach were identified, and all patients remained in neurologically stable condition. Two complications (8%) were related to the instrumentation; one patient required external immobilization because of suboptimal screw placement, and one patient required posterior atlantoaxial arthrodesis because of inadequate fracture reduction. CONCLUSION: Single-screw anterior odontoid fixation was associated with a relatively low complication rate and a high fusion rate in this study. We think that this should be the preferred treatment method for acute Type II odontoid fractures.

    3. Chirurg. 1999 Nov;70(11):1225-38.Click here to read Links
    [Operative versus non operative treatment of odontoid non unions. How dangerous is it not to stabilize a non union of the dens?]
    [Article in German]
    Blauth M, Richter M, Kiesewetter B, Lange U.
    Unfallchirurgische Klinik, Medizinische Hochschule Hannover.
    INTRODUCTION: Injuries precede the vast majority of all odontoid pseudarthroses. Because of specific anatomic conditions type II injuries lead more often than other types to non unions. For its development insufficient internal or external fixation and a persisting fracture gap are crucial. METHODS AND RESULTS: In 71 patients after operative stabilization of odontoid fractures with two anterior lag-screws we detected 8 non unions. In 3 patients the interval between accident and operation amounted to more than 5 weeks, seven times we did not succeed in closing the fracture gap. Technical mistakes like insufficient reduction (n = 1) or screw misplacement (n = 3) were additional reasons. According to the literature and own observations an os odontoideum must be considered in most instances as a pseudarthrosis after a lesion of the subdental synchondrosis in childhood. The most important diagnostic tool in odontoid non unions is a dynamic examination of the upper cervical spine under fluoroscopic control in maximum flexion and extension. We propose a classification of posttraumatic dens non unions into 4 types. Type I corresponds to a stable "non union" in approximate anatomical position of the dens and without signs of instability in the former fracture zone. Type II describes a relatively stable grossly displaced non union that is not to be reduced by simple, closed means. Type III means an unstable non union and Type IV a posttraumatic os odontoideum. CONCLUSIONS: Therapeutical recommendations need to be differentiated. Unstable non unions are most often responsible for persistent pain, may result in acute or chronic myelopathy++ and therefore - as well as ossa odontoidea - need operative fixation. In considerably displaced non unions a closed reduction manoeuver with long term traction should be tried. The operative treatment of choice is the posterior transarticular screw fixation C1/C2 desirably in a percutaneous technique. Tight, "stable" pseudarthroses in the sense of a persisting fracture gap in painfree patients should first be controlled radiologically. If the odontoid position remains unchanged, non operative treatment may be continued.

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