title: [The Anterior "Triple-/Quadruple" Technique for C1/C2 Trauma in the Elderly: First Experience with 16 Patients].
abstract: BACKGROUND
  In geriatric patients the management of odontoid type II fractures is complicated by osteoporosis and atlantoaxial arthritis (spondylarthritis C1/C2) with an increased lever arm. Furthermore, a few of the odontoid fractures are accompanied by an atlas fracture resulting in the "atlantoaxial unhappy triad". Posterior C1/C2 spondylodesis with bilateral Magerl screws and C1 hooks is a strong biomechanical construct, however, the posterior approach is associated with several drawbacks such as increased risk of infection and increased blood loss. In contrast, the anterior bilateral C1/C2 transarticular screw fixation with additional odontoid screw fixation is also a known technique. Advantages of the anterior approach are shorter surgery time, lower intraoperative blood loss and lower risk of infection.
  
  
  METHODS
  In this retrospective study, all geriatric patients with an atlantoaxial arthritis and odontoid or combined atlantoaxial fracture treated at our institution between 01/2012 and 12/2014 with an anterior screw fixation were included. Following closed reduction, the surgical management was performed over a standard right anterior approach. At the end of surgery, operation time and blood loss were documented. During the hospital stay radiological follow-up of the upper cervical spine were performed to analyse the screw position. We also report the length of stay on intensive care unit, the hospital course and demographic data of the patients. Follow-up was planned after 6 weeks, 6, 12 and 18 months. During follow-up COMI evaluation and X-rays of the cervical spine were made.
  
  
  CONCLUSIONS
  This study included 16 patients who underwent surgery for C1-C2 lesions. There were 9 females and 7 males. Median age at the time of operation was 76 years. At the time of surgery, fractures were classified as follows: 8 patients showed an "atlantoaxial unhappy triad", 8 patients had a type II odontoid fracture complicated by osteoporosis and atlantoaxial arthritis (spondylarthritis C1/C2). Average time for operative treatment was 100 ± 36.35 minutes with a median intraoperative fluoroscopy time of 161 seconds. The intraoperative blood loss was minimal (45 ± 22.80 ml). Length of stay was documented with 10 (± 4.60) days whereby the patients spent on average 0.8 days in the intensive care unit postoperatively. No serious morbidities, such as esophageal perforation, carotid artery laceration, neurological deterioration, and airway obstruction were reported. All cases of transient dysphagia resolved gradually and spontaneously without therapy. In 4 cases (25 %) we detected a penetration of the atlantooccipital joint without functional impairment. In one case we have seen an implant failure. The technique of anterior screw fixation of odontoid and bilateral transarticular C1-C2 anterior screw fixation provides a fast surgery without higher morbidity. Based on our findings, this technique and its feasibility is an alternative to known posterior C1/C2 spondylodesis in the elderly.
authors.affiliation: Klinik für Unfall- und Wiederherstellungschirurgie, Uniklinik RWTH Aachen.
authors.forename: C
authors.initials: C
authors.lastname: Herren
authors.affiliation: Klinik für Unfall- und Wiederherstellungschirurgie, Uniklinik RWTH Aachen.
authors.forename: M
authors.initials: M
authors.lastname: Pishnamaz
authors.affiliation: Klinik für Unfall- und Wiederherstellungschirurgie, Uniklinik RWTH Aachen.
authors.forename: P
authors.initials: P
authors.lastname: Lichte
authors.affiliation: Klinik für Unfall- und Wiederherstellungschirurgie, Uniklinik RWTH Aachen.
authors.forename: F
authors.initials: F
authors.lastname: Hildebrand
authors.affiliation: Unfallchirurgie und Orthopädische Chirurgie, Sana Klinikum Offenbach.
authors.forename: R M
authors.initials: RM
authors.lastname: Sellei
authors.affiliation: Klinik für Unfall- und Wiederherstellungschirurgie, Uniklinik RWTH Aachen.
authors.forename: H-C
authors.initials: HC
authors.lastname: Pape
authors.affiliation: Klinik für Unfall- und Wiederherstellungschirurgie, Uniklinik RWTH Aachen.
authors.forename: P
authors.initials: P
authors.lastname: Kobbe
mesh_terms: D000368:Aged; D001863:Bone Screws; D002574:Cervical Vertebrae / Q000000981:diagnostic imaging / Q000293:injuries* / Q000601:surgery*; D005260:Female; D005593:Fracture Fixation, Internal / Q000295:instrumentation* / Q000379:methods; D017102:Fracture Healing; D006801:Humans; D008297:Male; D010865:Pilot Projects; D011859:Radiography; D020127:Recovery of Function; D016103:Spinal Fractures / Q000150:complications / Q000175:diagnosis / Q000601:surgery*; D013123:Spinal Fusion / Q000295:instrumentation* / Q000379:methods; D025241:Spondylarthritis / Q000150:complications / Q000175:diagnosis / Q000601:surgery*; D016896:Treatment Outcome