Odontoid screw fixation of the С2 vertebra fractures in children and adolescents: initial experience using the technique

Objective. To study the primary outcomes of surgical treatment of C2 odontoid fractures in children using the odontoid screw.

Material and Methods. The data of the anamnesis, physical examination, radiography and CT of the cervical spine of 5 children with a median age of 15 years (min – 5, max – 17) who underwent odontoid screw fixation for a C2 odontoid fracture were analyzed. Own data were compared with literature data.

Results. Four patients were diagnosed with a displaced odontoid fracture, and one developed a pseudoarthrosis despite conservative treatment. No neurological disorders were detected. The patients’ primary complaint was neck pain with movement. The median surgical time was 175 minutes with blood loss of 10 ml. No intra- or postoperative complications were recorded. Three months after surgery, pain relief and CT-confirmed consolidation of the odontoid process were noted.

Conclusion. Odontoid screw fixation of the C2 vertebra is suitable for use even in young children. The low complication rate and high percentage of primary consolidation with preserved rotational motion make it the method of choice for treating fractures and post-traumatic pseudoarthrosis of the odontoid process.

1. Kokoska ER, Keller MS, Rallo MC, Weber TR. Characteristics of pediatric cervical spine injuries. J Pediatr Surg. 2001;36:100–105. DOI: 10.1053/jpsu.2001.20022

2. Patel JC, Tepas JJ 3rd, Mollitt DL, Pieper P. Pediatric cervical spine injuries: defining the disease. J Pediatr Surg. 2001;36:373–376. DOI: 10.1053/jpsu.2001.20720

3. Viccellio P, Simon H, Pressman BD, Shah MN, Mower WR, Hoffman JR; NEXUS Group. A prospective multicenter study of cervical spine injury in children. Pediatrics. 2001;108:E20. DOI: 10.1542/peds.108.2.e20

4. Kim W, Ahn N, Ata A, Adamo MA, Entezami P, Edwards M. Pediatric cervical spine injury in the United States: Defining the burden of injury, need for operative intervention, and disparities in imaging across trauma centers. J Pediatr Surg. 2021;56:293–296. DOI: 10.1016/j.jpedsurg.2020.05.009

5. Cirak B, Ziegfeld S, Knight VM, Chang D, Avellino AM, Paidas CN. Spinal injuries in children. J Pediatr Surg. 2004;39:607–612. DOI: 10.1016/j.jpedsurg.2003.12.011

6. Leonard JR, Jaffe DM, Kuppermann N, Olsen CS, Leonard JC. Cervical spine injury patterns in children. Pediatrics. 2014;133:e1179–e1188. DOI: 10.1542/peds.2013-3505

7. Offiah CE, Day E. The craniocervical junction: embryology, anatomy, biomechanics and imaging in blunt trauma. Insights Imaging. 2016;8:29–47. DOI: 10.1007/s13244-016-0530-5

8. Lustrin ES, Karakas SP, Ortiz AO, Cinnamon J, Castillo M, Vaheesan K, Brown JH, Diamond AS, Black K, Singh S. Pediatric cervical spine: normal anatomy, variants, and trauma. Radiographics. 2003;23:539–560. DOI: 10.1148/rg.233025121

9. Gebauer M, Lohse C, Barvencik F, Pogoda P, Rueger JM, Püschel K, Amling M. Subdental synchondrosis and anatomy of the axis in aging: a histomorphometric study on 30 autopsy cases. Eur Spine J. 2006;15:292–298. DOI: 10.1007/s00586-005-0990-7

10. Karwacki GM, Schneider JF. Normal ossification patterns of atlas and axis: a CT study. AJNR Am J Neuroradiol. 2012;33:1882–1887. DOI: 10.3174/ajnr.A3105

11. Rusin JA, Ruess L, Daulton RS. New C2 synchondrosal fracture classification system. Pediatr Radiol. 2015;45:872–881. DOI: 10.1007/s00247-014-3224-5

12. Nalla S, Blanco-Perez E, Mata-Escolano F, Llido S, Sanchis-Gimeno JA. Unexpected persistent dentocentral synchondrosis of C2. World Neurosurg. 2018;111:26–27. DOI: 10.1016/j.wneu.2017.12.017

13. Anderson LD, D’Alonzo RT. Fractures of the odontoid process of the axis. J Bone Joint Surg Am. 1974;56:1663–1674.

14. Goel A, Laheri V. Plate and screw fixation for atlanto-axial subluxation. Acta Neurochir (Wien). 1994;129:47–53. DOI: 10.1007/BF01400872

15. Harms J, Melcher RP. Posterior C1–C2 fusion with polyaxial screw and rod fixation. Spine (Phila Pa 1976). 2001;26:2467–2471. DOI: 10.1097/00007632-200111150-00014

16. Jeanneret B, Magerl F. Primary posterior fusion C1/2 in odontoid fractures: indications, technique, and results of transarticular screw fixation. J Spinal Disord. 1992;5:464–475. DOI: 10.1097/00002517-199212000-00012

17. Böhler J. Anterior stabilization for acute fractures and non-unions of the dens. J Bone Joint Surg Am. 1982;64:18–27.

18. Junge A, Gotzen L, Wiemers F. [Surgical management of a dens fracture in a 3-year-old child. Clinical case report and discussion with reference to the literature]. Unfallchirurg. 1994;97:410–412. In German.

19. Blauth M, Schmidt U, Otte D, Krettek C. Fractures of the odontoid process in small children: biomechanical analysis and report of three cases. Eur Spine J. 1996;5:63–70. DOI: 10.1007/BF00307830

20. Godard J, Hadji M, Raul JS. Odontoid fractures in the child with neurological injury. Direct anterior osteosynthesis with a cortico-spongious screw and literature review. Child’s Nerv Syst. 1997;13:105–107. DOI: 10.1007/s003810050054

21. Meyer B, Vieweg U, Rao JG, Stoffel M, Schramm J. Surgery for upper cervical spine instabilities in children. Acta Neurochir (Wien). 2001;143:759–765; discussion 765–766. DOI: 10.1007/s007010170029

22. Zapałowicz K, Radek M, Radek A. [Direct fixation of the odontoid fracture in a child]. Neurol Neurochir Pol. 2004;38:317–321. In Polish.

23. Jones A, Mehta J, Fagan D, Ahuja S, Grant A, Davies P. Anterior screw fixation for a pediatric odontoid nonunion: a case report. Spine (Phila Pa 1976). 2005; 30:E28–E30. DOI: 10.1097/01.brs.0000149078.11647.80

24. Özkan N, Wrede K, Ardeshiri A, Sariaslan Z, Stein KP, Dammann P, Müller O, Ringelstein A, Sure U, Sandalcioglu IE. Management of traumatic spinal injuries in children and young adults. Child’s Nerv Syst. 2015;31:1139–1148. DOI: 10.1007/s00381-015-2698-2

25. Farrokhi MR, Rezaei H, Farrokhi F. Anterior screw fixation in type II odontoid fracture in an 18-month-old girl: a case report and review of the literature. Br J Neurosurg. 2019;33:699–702. DOI: 10.1080/02688697.2017.1409881

26. Wang J, Vokshoor A, Kim S, Elton S, Kosnik E, Bartkowski H. Pediatric atlantoaxial instability: management with screw fixation. Pediatr Neurosurg. 1999;30:70–78. DOI: 10.1159/000028766

27. Stulík J, Nesnídal P, Kryl J, Vyskočil T, Barna M. [Unstable injuries to the upper cervical spine in children and adolescents]. Acta Chir Orthop Traumatol Cech. 2013;80:106–113. In Czech. DOI: 10.55095/achot2013/016

28. Sawarkar DP, Singh PK, Agrawal D, Gupta DK, Satyarthee GD, Doddamani R, Verma S, Meena R, Tandon V, Gurjar HK, Jagdevan A, Kumar R, Chandra PS, Kale SS. Anterior odontoid screw fixation for pediatric and adolescent odontoid fractures: single-center experience over a decade. World Neurosurg. 2021;153:e153–e167. DOI: 10.1016/j.wneu.2021.06.075

29. Lin J, Ji W, Huang Z, Huang Z, Zhu Q, Liu J. Feasibility of anterior fixation with single screw for odontoid fractures in pediatrics: a computed tomographic study. Orthop Surg. 2023;15:2566–2573. DOI: 10.1111/os.13834

30. Fernandes LG, Cristante AF, Marcon RM, de Barros Filho TEP, Letaif OB. Feasibility of anterior screw fixation in children: a tomographic study. Eur Spine J. 2018;27:1388–1392. DOI: 10.1007/s00586-018-5504-5

31. Dou H, Xie C, Wang X, Huang Q. Image measurements of os odontoideum in child-ren. Transl Pediatr. 2021;10:388–393. DOI: 10.21037/tp-20-416

32. Štulík J, Geri G, Salavcová L, Barna M, Fojtík P, Naňka O. Pediatric dens anatomy and its implications for fracture treatment: an anatomical and radiological study. Eur Spine J. 2021;30:416–424. DOI: 10.1007/s00586-020-06490-9

33. Sha ZJ, Fu SY, Wang ZR, Hang HF, Huang AB. Sagittal changes in the dens significantly slowed after 12 years of age. Brain Spine. 2025;5:104233. DOI: 10.1016/j.bas.2025.104233

34. Sasso R, Doherty BJ, Crawford MJ, Heggeness MH. Biomechanics of odontoid fracture fixation. Comparison of the one- and two-screw technique. Spine (Phila Pa 1976). 1993;18:1950–1953. DOI: 10.1097/00007632-199310001-00004

35. McBride AD, Mukherjee DP, Kruse RN, Albright JA, McBride A. Anterior screw fixation of type II odontoid fractures: a biomechanical study. Spine. 1995;20(17):1855.

36. Wang J, Zhou Y, Zhang ZF, Li CQ, Zheng WJ, Liu J. Comparison of percutaneous and open anterior screw fixation in the treatment of type II and rostral type III odontoid fractures. Spine (Phila Pa 1976). 2011;36:1459–1463. DOI: 10.1097/BRS.0b013e3181f46ee8

37. Dou H, Xie C, Zhu S, Wang X, Huang Q, Zhou F. Feasibility analysis of the use of anterior screw fixation in the treatment of pediatric odontoid fracture. Transl Pediatr. 2021;10:967–972. DOI: 10.21037/tp-21-101

38. Prabhat AM, Liu DS, Cohen L, Gabriel D, Hines KE, Hogue GD. Odontoid fractures in the pediatric population: a systematic review and management algorithm. J Child Orthop. 2024;18:486–494. DOI: 10.1177/18632521241283232