Two-stage surgical approach for type III odontoid fracture with C1-C2 fracture dislocation: a case report and management overview

Abstract

Introduction and importance: Odontoid fractures of the second cervical vertebra (C2) are categorized into three types, with type III extending into the body of the axis. These fractures, often resulting from high-energy trauma, can cause significant instability and neurological issues. This case report discusses a 43-year-old male with a type III odontoid fracture and C1-C2 fracture dislocation, demonstrating the effectiveness of traditional neurosurgical techniques in managing such complex injuries.

Case presentation: A 43-year-old male presented with upper cervical pain and right upper limb weakness following a road traffic accident. Imaging revealed a type III odontoid fracture with posterior displacement and atlanto-axial (C1-C2) joint dislocation. The patient underwent a two-stage surgical procedure. The first stage involved transoral decompression to address the retropulsed odontoid fragment and relieve spinal cord compression. The second stage involved posterior craniocervical fixation using an autologous iliac bone graft for stabilization. The patient showed postoperative improvement and was discharged on the third day, with a stable condition at a one-month follow-up.

Clinical discussion: Managing type III odontoid fractures with C1-C2 dislocation is challenging, requiring a strategic approach to ensure spinal stability and neurological recovery. Transoral decompression provides direct access for effective decompression, while posterior fixation ensures robust stabilization. The use of an autologous iliac bone graft enhances fusion and long-term stability. This case illustrates the successful integration of traditional neurosurgical techniques with modern surgical principles.

Conclusion: This case underscores the importance of traditional neurosurgical techniques in managing complex odontoid fractures. The two-stage approach of transoral decompression followed by posterior craniocervical fixation proved effective, highlighting the relevance of these techniques in achieving positive outcomes in contemporary neurosurgical practice.

Keywords: C1–C2 fracture dislocation; odontoid fracture; posterior craniocervical fixation; traditional neurosurgical techniques; transoral decompression.

Figure 1

(A) Sagittal view of the cervical spine computed tomography scan with craniocervical junction showing a fracture of the odontoid process (red arrow) with retropulsion. (B) Axial view of the atlas vertebra (red arrow) with the odontoid (yellow arrow) showing the odontoid process in place in relation to the C2 vertebral arch.

Figure 2

Sagittal view of the computed tomography scan showing dislocation of the atlanto-axial joint on the right side (A) and on the left side (B). The red arrow indicates the axis, while the yellow arrow indicates the atlas, both displaying the dislocation of the joint.

Figure 3

Coronal view of the computed tomography scan showing fracture of the body of the axis indicated by the red arrow (A) and retropulsion of the odontoid fracture indicated by the red arrow (B).

Figure 4

Sagittal view of the cervical spine MRI with the craniocervical junction, T2-weighted image (T2WI) (A), and T1-weighted image (T1WI) (B) showing compression of the spinal cord (red arrows) at the level of C1 and C2 vertebrae.

Figure 5

Intraoperative image depicting fixation of the C2 spinous process (blue arrow) to the occipital bone (green arrow) achieved through the utilization of an autologous iliac bone graft (white arrow) and surgical wire.

Figure 6

Postoperative X-ray, lateral view (A) and anterior-posterior view (B), displaying the iliac bone graft (red arrow) and the surgical wire in place.

Figure 7

One-month postoperative follow-up computed tomography scan of the cervical spine with craniocervical junction (A, B), along with axial views (C, D), revealing an autologous iliac bone graft (yellow arrows) and demonstrating complete decompression of the spinal canal.