Objective: The posterior minimally invasive approaches for odontoid fractures include the midline nuchal ligament approach (MNLA) and the paramedian muscle-splitting approach (PMSA). However comparative data on their anatomical characteristics and clinical efficacy remain scarce to date. The objective of this study is to determine the differences in anatomy and clinical outcomes between the MNLA and the PMSA for reduction and temporary internal fixation of odontoid fractures.
Methods: This retrospective analysis focused on 31 patients with odontoid fractures from February 2021 to December 2023. Among them,16 patients underwent PMSA and 15 patients underwent MNLA. Various parameters were compared between the two groups, including operation time, intraoperative blood loss, postoperative complications, edema rates of cervical posterior muscles, the range of motion in rotation of C1–C2, patient satisfaction, Visual Analogue Scale score for neck pain, axial symptom scores, and neck disability index. Additionally, an anatomical study was performed; the PMSA and the MNLA were simulated on six fresh cadaveric specimens to compare the anatomical differences in surgical exposure between the two approaches.
Results: In the clinical study, both groups successfully achieved fracture healing. Compared with the PMSA group, the MNLA group had several advantages, including shorter operative times, lower intraoperative blood loss, and a lower edema rate of posterior cervical muscles. However, similar results were observed between the two groups in terms of the range of motion in rotation of C1–C2, patient satisfaction, Visual Analogue Scale score for neck pain, axial symptom scores, and neck disability index at the last follow-up. In the cadaveric study, we found the trapezius-splenius capitis interface and the course of the greater occipital nerve (GON) varied significantly and the GON was present in the surgical field in 2 of 6 specimens in the PMSA, which brought difficulties for the surgical operation. In contrast, the MNLA, using the spinous process of C2 and the obliquus capitis inferior (OCI) as anatomical landmarks, provided a simpler surgical procedure and easier exposure.
Conclusion: Both the MNLA and the PMSA demonstrated favorable clinical outcomes for the treatment of odontoid fractures. However, compared with the PMSA, the MNLA, using the spinous process of C2 and the OCI as anatomical landmarks, offers advantages of the stability of the surgical procedure, easy exposure, and reduced iatrogenic damage to the cervical posterior muscles and GON.
| [1] |
A. Nourbakhsh and Z. C. Hanson, “Odontoid Fractures: A Standard Review of Current Concepts and Treatment Recommendations,” Journal of the American Academy of Orthopaedic Surgeons 30, no. 6 (2022): e561–e572, https://doi.org/10.5435/JAAOS-D-21-00165.
|
| [2] |
J. N. Grauer, B. Shafi, A. S. Hilibrand, et al., “Proposal of a Modified, Treatment-Oriented Classification of Odontoid Fractures,” Spine Journal 5, no. 2 (2005): 123–129, https://doi.org/10.1016/j.spinee.2004.09.014.
|
| [3] |
B. Ni, Q. Guo, X. Lu, et al., “Posterior Reduction and Temporary Fixation for Odontoid Fracture: A Salvage Maneuver to Anterior Screw Fixation,” Spine 40, no. 3 (2015): E168–E174, https://doi.org/10.1097/BRS.0000000000000709.
|
| [4] |
Q. Guo, Y. Deng, J. Wang, et al., “Comparison of Clinical Outcomes of Posterior C1–C2 Temporary Fixation Without Fusion and C1–C2 Fusion for Fresh Odontoid Fractures,” Neurosurgery 78, no. 1 (2016): 77–83, https://doi.org/10.1227/NEU.0000000000001006.
|
| [5] |
J. Su, Y. Hu, I. M. Djibo, et al., “Pivotal Role of Obliquus Capitis Inferior in Torticaput Revealed by Single-Photon Emission Computed Tomography,” Journal of Neural Transmission 129, no. 3 (2022): 311–317, https://doi.org/10.1007/s00702-022-02469-6.
|
| [6] |
R. Li, Y. Liu, Y. Zhang, C. Yang, Z. Zhang, and J. Huang, “The Effect of Suboccipital Muscle Dysfunction on the Biomechanics of the Upper Cervical Spine: A Study Based on Finite Element Analysis,” BMC Musculoskeletal Disorders 25, no. 1 (2024): 400, https://doi.org/10.1186/s12891-024-07401-5.
|
| [7] |
M. Holy, L. Szigethy, A. Joelson, and C. Olerud, “A Novel Treatment of Pediatric Atlanto-Occipital Dislocation With Nonfusion Using Muscle-Preserving Temporary Internal Fixation of C0-C2: Case Series and Technical Note,” Journal of Neurological Surgery Reports 84, no. 1 (2023): e11–e16, https://doi.org/10.1055/s-0043-1760830.
|
| [8] |
J. Liu, S. Liu, E. Jiang, et al., “Clinical and Radiographic Outcomes of Modified Posterior Atlantoaxial Temporary Fixation With Preservation of Semispinalis Cervicis: A Comparative Study,” Global Spine Journal 14, no. 1 (2024): 272–282, https://doi.org/10.1177/21925682221103832.
|
| [9] |
T. Shiraishi, M. Kato, Y. Yato, et al., “New Techniques for Exposure of Posterior Cervical Spine Through Intermuscular Planes and Their Surgical Application,” Spine 37, no. 5 (2012): E286–E296, https://doi.org/10.1097/BRS.0b013e318239cc7e.
|
| [10] |
P. Lian, H. Chen, W. Wang, et al., “Evaluation of the Anatomical Reference Point in Posterior Minimally Invasive Atlantoaxial Spine Surgery: A Cadaveric Anatomical Study,” Orthopaedic Surgery 16, no. 4 (2024): 943–952, https://doi.org/10.1111/os.14023.
|
| [11] |
Z. Xu, J. Wu, H. Wang, et al., “Posterior Reduction and Temporary Fixation Through Intermuscular Approach for Odontoid Fracture,” Operative Neurosurgery 28, no. 6 (2025): 772–778, https://doi.org/10.1227/ons.0000000000001399.
|
| [12] |
Y. Xu, W. Xiong, S. I. I. Han, Z. Fang, and F. Li, “Posterior Bilateral Intermuscular Approach for Upper Cervical Spine Injuries,” World Neurosurgery 104 (2017): 869–875, https://doi.org/10.1016/j.wneu.2017.05.051.
|
| [13] |
A. Spiessberger, A. Stauffer, F. Baumann, et al., “Splitting of the Semispinalis Capitis Muscle as a Less Invasive Approach for Atlantoaxial Fusion – A Technical Note,” Journal of Clinical Neuroscience 62 (2019): 260–263, https://doi.org/10.1016/j.jocn.2018.11.044.
|
| [14] |
J. Harms and R. P. Melcher, “ Posterior C1–C2 Fusion With Polyaxial Screw and Rod Fixation,” Spine. 2001; 26(22): 2467-2471, https://doi.org/10.1097/00007632-200111150-00014.
|
| [15] |
Q. Guo, M. Zhang, L. Wang, X. Lu, X. Guo, and B. Ni, “Comparison of Atlantoaxial Rotation and Functional Outcomes of Two Nonfusion Techniques in the Treatment of Anderson-D'alonzo Type II Odontoid Fractures,” Spine 41, no. 12 (2016): E751–E758, https://doi.org/10.1097/BRS.0000000000001370.
|
| [16] |
Z. Xu, J. Wu, F. Chen, et al., “Atlantoaxial Intra-Articular Cage Fusion by Posterior Intermuscular Approach for Treating Reducible Atlantoaxial Dislocation: A Technique Note With Case Series,” European Spine Journal 33, no. 8 (2024): 3060–3068, https://doi.org/10.1007/s00586-024-08318-2.
|
| [17] |
R. W. Molinari, O. A. Khera, W. L. Gruhn, and R. W. McAssey, “Rigid Cervical Collar Treatment for Geriatric Type II Odontoid Fractures,” European Spine Journal 21, no. 5 (2012): 855–862, https://doi.org/10.1007/s00586-011-2069-y.
|
| [18] |
E. C. Huskisson, “Measurement of pain,” Lancet 2, no. 7889 (1974): 1127–1131, https://doi.org/10.1016/s0140-6736(74)90884-8.
|
| [19] |
T. Tsuji, T. Asazuma, K. Masuoka, et al., “Retrospective Cohort Study Between Selective and Standard C3-7 Laminoplasty. Minimum 2-Year Follow-Up Study,” European Spine Journal 16, no. 12 (2007): 2072–2077, https://doi.org/10.1007/s00586-007-0428-5.
|
| [20] |
M. Sterling and T. Rebbeck, “The Neck Disability Index (NDI),” Australian Journal of Physiotherapy 51, no. 4 (2005): 271, https://doi.org/10.1016/S0004-9514(05)70017-9.
|
| [21] |
M. Wang, X. J. Luo, Q. X. Deng, J. H. Li, and N. Wang, “Prevalence of Axial Symptoms After Posterior Cervical Decompression: A Meta-Analysis,” European Spine Journal 25, no. 7 (2016): 2302–2310, https://doi.org/10.1007/s00586-016-4524-2.
|
| [22] |
K. L. Hung, Y. Lu, Y. Tian, et al., “Minimally Invasive Surgery for Posterior Atlantoaxial Lateral Mass Joint Fusion (MIS-PALF): A Muscle-Sparing Procedure for Atlantoaxial Instability or Dislocation,” Journal of Bone and Joint Surgery 106, no. 23 (2024): 2215–2222, https://doi.org/10.2106/JBJS.23.01464.
|
| [23] |
R. G. Fessler and L. T. Khoo, “Minimally Invasive Cervical Microendoscopic Foraminotomy: An Initial Clinical Experience,” Neurosurgery 51, no. 5 Suppl (2002): S37–S45.
|
| [24] |
F. Ma, Y. Fan, Y. Liao, et al., “Management of Fresh Odontoid Fractures Using Posterior C1–2 Fixation Without Fusion: A Long-Term Clinical Follow-Up Study,” Journal of Neurosurgery. Spine 36, no. 6 (2022): 968–978, https://doi.org/10.3171/2021.9.SPINE21822.
|
| [25] |
M. Meyer, K. Farah, T. Graillon, H. Dufour, B. Blondel, and S. Fuentes, “Minimally Invasive Percutaneous C1–C2 Fixation Using an Intraoperative Three-Dimensional Imaging-Based Navigation System for Management of Odontoid Fractures,” World Neurosurgery 137 (2020): 266–271, https://doi.org/10.1016/j.wneu.2019.12.054.
|
| [26] |
L. Gfrerer, M. A. Hansdorfer, R. O. Amador, C. Chartier, K. P. Nealon, and W. G. Austen, “Muscle Fascia Changes in Patients With Occipital Neuralgia, Headache, or Migraine,” Plastic and Reconstructive Surgery 147, no. 1 (2021): 176–180, https://doi.org/10.1097/PRS.0000000000007484.
|
| [27] |
B.-c. Son, D.-r. Kim, and S.-w. Lee, “Intractable Occipital Neuralgia Caused by an Entrapment in the Semispinalis Capitis,” Journal of the Korean Neurosurgical Society 54, no. 3 (2013): 268, https://doi.org/10.3340/jkns.2013.54.3.268.
|
| [28] |
N. Zheng, Y. Y. Chi, X. H. Yang, et al., “Orientation and Property of Fibers of the Myodural Bridge in Humans,” Spine Journal 18, no. 6 (2018): 1081–1087, https://doi.org/10.1016/j.spinee.2018.02.006.
|
| [29] |
W. B. Jiang, Z. H. Zhang, S. B. Yu, et al., “Scanning Electron Microscopic Observation of Myodural Bridge in the Human Suboccipital Region,” Spine 45, no. 20 (2020): E1296–E1301, https://doi.org/10.1097/BRS.0000000000003602.
|
| [30] |
J. E. Janis, D. A. Hatef, I. Ducic, et al., “The Anatomy of the Greater Occipital Nerve: Part II. Compression Point Topography,” Plastic and Reconstructive Surgery 126, no. 5 (2010): 1563–1572, https://doi.org/10.1097/PRS.0b013e3181ef7f0c.
|
| [31] |
S. S. Scherer, L. Schiraldi, G. Sapino, et al., “The Greater Occipital Nerve and Obliquus Capitis Inferior Muscle: Anatomical Interactions and Implications for Occipital Pain Syndromes,” Plastic and Reconstructive Surgery 144, no. 3 (2019): 730–736, https://doi.org/10.1097/PRS.0000000000005945.
|
| [32] |
K. T. Foley, S. K. Gupta, J. R. Justis, and M. C. Sherman, “Percutaneous Pedicle Screw Fixation of the Lumbar Spine,” Neurosurgical Focus 10, no. 4 (2001): 1–9, https://doi.org/10.3171/foc.2001.10.4.11.
|
| [33] |
K. T. Foley and S. K. Gupta, “Percutaneous Pedicle Screw Fixation of the Lumbar Spine: Preliminary Clinical Results,” Journal of Neurosurgery. Spine 97, no. 1 (2002): 7–12, https://doi.org/10.3171/spi.2002.97.1.0007.
|
| [34] |
G. M. Johnson, M. Zhang, and D. G. Jones, “The Fine Connective Tissue Architecture of the Human Ligamentum Nuchae,” Spine 25, no. 1 (2000): 5, https://doi.org/10.1097/00007632-200001010-00003.
|
| [35] |
M. Kato, H. Nakamura, S. Konishi, et al., “Effect of Preserving Paraspinal Muscles on Postoperative Axial Pain in the Selective Cervical Laminoplasty,” Spine 33, no. 14 (2008): E455–E459, https://doi.org/10.1097/BRS.0b013e318178e607.
|
| [36] |
D. H. Kim, J. T. Hong, J. W. Hur, I. S. Kim, H. J. Lee, and J. B. Lee, “Clinical and Radiological Outcomes in C2 Recapping Laminoplasty for the Pathologies in the Upper Cervical Spine,” Neurospine 21, no. 2 (2024): 565–574, https://doi.org/10.14245/ns.2347270.635.
|
| [37] |
P. M. M. Nyemb, “Review of the Literature on Anatomical Variations of the Trapezius Muscle,” MOJ Anatomy & Physiology 4, no. 5 (2017): 385–390, https://doi.org/10.15406/mojap.2017.04.00152.
|
| [38] |
R. Tubbs, K. Watanabe, M. Loukas, and A. Cohen-Gadol, “The Intramuscular Course of the Greater Occipital Nerve: Novel Findings With Potential Implications for Operative Interventions and Occipital Neuralgia,” Surgical Neurology International 5, no. 1 (2014): 155, https://doi.org/10.4103/2152-7806.143743.
|
| [39] |
M. Saad, I. V. Manzanera Esteve, A. G. Evans, et al., “Preoperative Visualization of the Greater Occipital Nerve With Magnetic Resonance Imaging in Candidates for Occipital Nerve Decompression for Headaches,” Scientific Reports 14, no. 1 (2024): 15248, https://doi.org/10.1038/s41598-024-65334-4.
|
RIGHTS & PERMISSIONS
2025 The Author(s). Orthopaedic Surgery published by Tianjin Hospital and John Wiley & Sons Australia, Ltd.
PDF
