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Anterior screw osteosynthesis with single cannulated screw
11%
650/5670
Halo immobilization
15%
870/5670
Anterior screw osteosynthesis with two cannulated screws
10%
552/5670
C1-C2 transarticular screws
50%
2837/5670
Posterior C1-C2 wiring with autograft
12%
708/5670
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The clinical presentation is consistent with an odontoid fracture with an aberrant vertebral artery on the left. C1-C2 transarticular screws are an absolute contraindication in this scenario. The vertebral artery is an important consideration when performing posterior cervical spine surgery. Injury to this artery can lead to stroke and death. Normally the vertebral artery travels superiorly in the transverse foramen of C6 to C2. At C2 the artery deviates laterally to the pass through the transverse foramen of C1 and then wraps medially on the superior surface of the posterior arch of C1 before ascending into the foramen magnum. Anomalous variants of the vertebral arery may be present in up to 30% of individuals, and may be intraosseous or extraosseous. Intraosseous variants may be injured during posterior cervical stabilization techniques. In patients with an aberrant vertebral artery, C1-C2 transarticular screws are contraindicated due to the risk of injury to the aberrant vertebral artery. Patel et al. performed a literature review to investigate the optimal surgical treatment for unstable type II odontoid fractures in skeletally mature individuals. They found there is no moderate or high quality literature on the surgical management of acute type II odontoid fractures, and that there is no comparative data to objectively compare an anterior vs. posterior approach. They report that in equivocally indicated instances, anterior or posterior treatment can both be safely used with good outcome. Wright et al. performed a retrospective study to look at the incidence of vertebral arery injury and subsequent neurological deficit in patients where C1-C2 trans-articular screws are placed. They found of 2492 C1-2 transarticular screws in 1318 patients, thirty-one patients (2.4%) had known vertebral artery injuries and an additional 23 patients (1.7%) were suspected of having injuries. Of the patients with known or suspected vertebral artery injuries, 2 (3.7%) of the 54 patients exhibited subsequent neurological deficits and one (1.9%) died from a bilateral VA injury. Figure A is an open-mouth odontoid radiograph that shows a type 2 odontoid fracture. Figure B is a sagittal CT that shows a Type 2 odontoid fracture. Figure C is a CT angiogram that shows an anomalous vertebral artery on the left, with the absence of a normal vertebral foramen. Illustration A shows the anatomy of a normal vertebral artery and its relative position to a C1-C2 transarticular screw. Illustration B shows an anomalous extra-osseous vertebral artery. Illustration C shows a CT scan of an anomalous intra-osseous vertebral artery.
3.5
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