Remote Type II Odontoid Fracture

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goldfinch
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October 12, 2013 at 9:41 am

Post count: 3

#9566

Good Evening Dr. Corenman,

When I was 17 (now 50) I was in a terrible car accident and spent 4 days in the hospital. I was misdiagnosed with a sprained neck and concussion. I lived a very active life since that time without any major problems.

Due to apparent occipital neuralgia, I was diagnosed with a non-union fracture of the odontoid about 5 years ago. X-Rays and an MRI showed some minor instability at that time. The treating orthopedic surgeon ordered PT which corrected the headaches.

Recently the headaches reoccurred. Follow up X-Rays and a CT Scan indicated that the instability has gotten worse. Extension (head back) indicates a gap of approximately 1.0 mm. Flexion (head forward) indicates a gap of approximately 2.25 mm. The fracture is oriented to the front (anterior). There is partial fusion (arthritic) on one side.

I have received 4 opinions thus far:

1) An orthopedic surgeon said that he could do C1-C2 posterior fusion or I could continue to live with it but I had to keep in mind that a blow to the head could kill me. He ordered PT which failed this time.

2) A chiropractor has been successful at eliminating the headaches. He said that he did not see any instability and urged me not to get surgery under any circumstances.

3) A neurosurgeon said that surgery was imperative to stabilize the fracture whether it was anterior direct screw fixation (which he did not perform) or C1-C2 posterior fusion.

4) Another neurosurgeon informed me that I am not a candidate for anterior direct screw fixation because the screws usually break when this surgery is attempted on remote fractures. He also indicated that surgery was imperative and recommended C1-C2 posterior fusion.

I can live with the headaches and don’t have any symptoms of myelopathy. I don’t like the thought of losing the mobility of my head or becoming paralyzed. I don’t know who to trust. The chiropractor and the surgeons seem to be pitching their own book.

I’m kind of scared and feel under duress. Thus, I am concerned that I can not make a rational, objective decision.

I’m particularly impressed that you are both an M.D. and a D.C. so I would consider your opinion unbiased.

Your thoughts would be greatly appreciated. Have a great weekend.

Thanks,

Donald Corenman, MD, DC
Moderator

October 12, 2013 at 10:31 pm

Post count: 8660

#9569

One of the questions I have is where the fracture is located. Is the fracture at the base of the dens (called a type two fracture), at the tip (upper 1/3) or at the base through the body of the C2 vertebra?

The chiropractor does not understand the mechanics of this injury and his advice is probably not accurate.

If this fractures is a type II (the most common type that does not heal), there is some risk of living with this injury. You however have lived with this disorder for 33 years without a catastrophic injury.

Fixing a type II nonunion with an anterior dens screw has a high chance of not healing. The ends of the broken bone have healed years ago with scar. Stopping the motion with a screw probably will not allow healing.

A posterior fusion of C1-2 will make this nonunion safe but at a cost to you of range of motion. 50% of rotational motion (looking over your shoulder) derives from the C1-2 level and fusion will cost you one-half of your rotation.

Much depends upon the findings of the X-rays and CT scan. You note a “partial fusion” on one side. Is that between C1 and C2?

Dr. Corenman

PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.

Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books.

goldfinch
Member

October 17, 2013 at 6:45 am

Post count: 3

#9593

Good Evening Dr. Corenman,

Thank you for your prompt and courteous response.

This is most definitely a Type II odontoid fracture as the break is across the base of the dens and confirmed by the radiologist’s report of CT scans taken on 11/10/2008 and again on 8/15/13. It was also referred to as a “chronic non-united fracture of the odontoid” in the X-ray report.

The “partial fusion” that I mentioned were the chiropractor’s words. The radiologist’s report of 8/15/13 indicates that “A tiny calcification within the defect is unchanged since the previous study.” Further the report states that “Mild bony irregularity of the posterior wall of the dens is unchanged.” I think that is what the chiropractor was referring to.

Discussion yesterday with a neurosurgeon indicates that “functionally” the dens is fractured completely through as the tiny calcification and bony irregularity contributes nothing of consequence.

The gap that I referred to (1mm to 2.2mm)is the vertical distance between the base of the dens and the body of the C2 which increases with flexion. The neurosurgeon has indicated that the instability will most likely increase as I get older and that the risk of the C1 moving forward and compressing the spinal cord exists. I am neurologically intact at this time.

The neurosurgeon indicated that the normal distance (posterior) between the C1-C2 has decreased (sagging in the back) which is why the occipital nerve is pinched. However, the radiologist’s report of the CT scan states ” There is no loss of vertebral body height.”

The occipital headaches only occur when my head is upright and diminish when I lie flat (like when I got the CT scan). It seems lately that no matter what I do it aggravates this condition and although the headaches are under control I do have a persistent pain at the right rear base of my skull.

Have a great evening!

Thanks,

Goldfinch

Donald Corenman, MD, DC
Moderator

October 20, 2013 at 2:28 am

Post count: 8660

#9625

You have a typical un-united type II odontoid fracture. “Sagging” of the C1-2 level occurs whens the odontoid does not keep the alignment of C1 on C2 and the posterior ring of C1 “sags” on C2. The nerve root of C2 (greater occipital nerve) can be affected. Vertebral body height has no affect on this sagging and would be expected to be normal in the radiologist’s report.

There is a risk of neurological injury with this fracture. Obviously, you have lived with it for many years but there always has been a risk present. To fix it requires a fusion of C1-2 but at the price of reduced rotation of your neck.

Care of the headaches without dealing with the fracture instability can possibly be performed by facet or occipital nerve blocks (see website).

Dr. Corenman

PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.

Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books.

goldfinch
Member

November 8, 2013 at 4:04 pm

Post count: 3

#9767

Thank you Dr. Corenman. Your response helped me to make the decision to have the surgery (C1-C2 Posterior Fusion) which is scheduled for 7:30 A.M. this morning.

Thanks Again!

Goldfinch

Donald Corenman, MD, DC
Moderator

November 10, 2013 at 10:27 pm

Post count: 8660

#9768

Great! Please let us know how you do postoperatively.

Dr. Corenman

PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.

Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books.
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Donald Corenman, MD, DC

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Eric S

Sep 26, 2021

by Eric S on Donald Corenman, MD, DC

Successful pars repair at 46 years old

Back in November of 2018 (at 46 years old) I came from Vancouver BC to have a pars repair done with Dr. Donald Corenman at the Steadman Clinic in Vail Colorado. I'm finally posting this review nearly three years later in late 2021. The reason I waited so long was I wanted to know the final result before I posted my review. Unfortunately in that time Dr. Corenman has retired. Nevertheless, I want to post this review of Dr. Corenman and his staff at the Steadman Clinic in their excellent treatment of my L5 pars interarticularis.

I fractured my pars at age 42 back in 2014 when rolling on the gym floor, and was denied treatment by the Canadian healthcare system, probably due to my age. First my GP told me there was no surgical option for a pars defect, which was quite incorrect! I tried to live with it, but the symptoms worsened (periodic random spine slippage and weeks of resultant pain after just bending over to tie my shoe, so I eventually learned to mostly squat and hardly bend). When I finally consulted with Canadian spine surgeons, I was told they believed my pars defect had been congenital (since birth). This was absurd, considering I had done extreme martial arts (including jiu jitsu) for years prior, as well as 5 years of reinforcing steel full time in my 20s, probably the hardest job on the back you can find. No pars defect like mine would possibly have allowed this--ergo it was impossible that I had had the defect since birth. I did however have an asymptomatic congenital spina bifida occulta that made me more susceptible to a pars fracture. In 2014 in one instant, I went from having the strongest back people I knew said they'd ever seen, to being unable to safely bend over and tie my shoe without a non-negligible risk of my spine slipping randomly (which would lead to weeks of pain after each occurrence). This was due to the unilateral L5 pars defect, otherwise known as spondylolysis. It was when lying in pain on the floor 4 years later after maybe the 6th spine slippage event post injury, that I had had enough, and resolved to have surgery. If Canada's "universal health care" said no, I would make lemonade from lemons, and find the very best surgeon in the world at pars repairs. That was Dr. Donald Corenman. Dr. Corenman back in 2018 ran a website https://neckandback.com/ that dedicated many pages to the science of every aspect of pars repairs, from eligibility (good discs on MRI), to best surgical techniques (minimal open compared to minimally invasive), best imaging to use (i.e., O-Arm with Stealth imaging vs. older fluoroscopy), the ideal amount of BMP to use and why not use too much or too little, and much more, all to do with pars repairs, pages upon pages of his site just on the pars, with scientific references and his own extensive expert opinion. As a health research statistician, I was very impressed with this. It was in stark contrast to the websites of other spine surgeons which barely gave the pars a word or two, focusing almost exclusively on fusions. I had found the best surgeon in the world for pars repairs, and so after Dr. Corenman personally screened my MRI to ensure my discs were healthy, I booked the surgery.

Being 46 years old at the time of surgery in 2018, with a 4-year-old pars fracture from 2014 combined with a congenital SBO meant my pars fragment was somewhat atrophied, but it was "very solid", said Dr. Corenman in the operative report. Nevertheless, it was challenging with two things to fix, the pars and SBO, and OR time was around 4 hours. Recovery over the following months was guided by a very clear "Spine binder" from the Steadman Clinic with strict rules of "no BLT" (no bending, lifting or twisting), and illustrated physiotherapy guidelines. They even warned patients to avoid fish oil supplements, which could excessively dampen inflammation and hence slow bone healing. They answered many questions I had during months of recovery, with responses coming from the very supportive Lori Fugate (then director of Dr. Corenman's practice), and Ehrich Bean (then physician's assistant at the practice), as well as a couple calls with Dr. Corenman himself after two of the CT scans. Ehrich Bean offered great advice for taking the spine binder conservatively due to the nature of pars repairs vs. fusions. The final post-op CT scan I had was a couple weeks ago at 34 months post-op, and Dr. Corenman had retired, but I got a very positive and informative call from Eric Strauch (current PA at the Steadman Clinic under Dr. Corenman's replacement there, and who had also worked with Dr. Corenman previously). The staff at the Steadman Clinic were extremely supportive all the way through the process. I should mention, the local Canadian spine surgeon did offer me very good post-operative support including antibiotics as needed to deal with a mild surface incision-site infection early on, booking numerous x-rays when I felt something was amiss, as well as booking all four of my post-op CT scans. I am very grateful for that support also.

My final result shows plenty of solid bone across the pars and a healed SBO, with my vertebral body now a solid bone ring instead of being broken at two places as it was pre-op. Does my spine hold up in the real world? You bet! I have recently dug and moved several yards of dirt and sand and gravel by myself (shovel and wheelbarrow!) to fix our water main, pulled roots from the yard, moved several "portable" (these are HUGE) air conditioners up several flights of stairs my myself, and lifted weights. I now run 2 miles (3.2 KM) several times weekly with a hard 100 meter dash in the middle. I bend deeply before each run I go on, with no spine slippage. My spine feels amazing. I can bend over to do exercise, or real word tasks, with no risk of spine slippage.

My sincere thanks to God, Dr. Donald Corenman, Lori Fugate, Ehrich Bean, Eric Strauch, and the Steadman Clinic, as well as the Canadian spine surgeon who offered me excellent post-operative care back in Canada. You have all given me a new lease on life.

Sincerely,
Eric S

Robert S

May 11, 2021

by Robert S on Donald Corenman, MD, DC

Back Fusion Surgery

I had my entire lumbar spine fused in November of 2018. I had scoliosis , with pinched nerves that were so painful I could hardly walk - and standing for more than a few minutes was impossible. Even sitting was painful.
The fusion surgery produced immediate relief! And the recovery was much easier than I expected.
To this day I can do all the activities I love from hiking, to standing in a stream fly fishing to riding my bike long distances - or just walking down the street with my wife.
Kudos to Dr. Corenman and his staff, (including the two Erics) for taking such good care of me!

Leslie R

Jul 9, 2020

by Leslie R on Donald Corenman, MD, DC

TLIF

I had my TLIF surgery on 6/24/2020 by Dr. Corenman, I can not say enough good things about the Dr or his staff. I was always treated with respect and explained everything throughly, that made it easy for everyone to understand. I highly recommend Dr. Corenman and the Steadman Clinic.

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