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|LETTER TO EDITOR
|Year : 2014 | Volume
| Issue : 2 | Page : 203-204
Intra-operative K-wire breakage during odontoid screw fixation
Saquib Azad Siddiqui, Pankaj Kumar Singh, Kanwaljeet Garg, Deepak Agrawal, Bhawani S. Sharma
Department of Neurosurgery, All Indian Institute of Medical Sciences, New Delhi, India
|Date of Submission||02-Feb-2014|
|Date of Decision||08-Feb-2014|
|Date of Acceptance||08-Apr-2014|
|Date of Web Publication||14-May-2014|
Pankaj Kumar Singh
Department of Neurosurgery, All Indian Institute of Medical Sciences, New Delhi
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Siddiqui SA, Singh PK, Garg K, Agrawal D, Sharma BS. Intra-operative K-wire breakage during odontoid screw fixation. Neurol India 2014;62:203-4
Traumatic spine injuries involve the cervical spine in about 60% of patients and a quarter of these involve the C2 or axis level. , Odontoid screw fixation is considered the most elegant technique for type II odontoid fractures as it preserves the full range of movements of the cervical spine. We present a case of traumatic type II odontoid fracture with an uncommon complication of K-wire breakage during the odontoid screw fixation, which was managed without incurring any additional morbidity.
A 50-year-old lady presented to the emergency department with a history of motor vehicle accident 10 days before and neck pain since then. The neurological examination was within normal limits. Computed tomography (CT) of the cervical spine showed a type II odontoid fracture. Awake intubation was done with nonreinforced tube using fiberoptic bronchoscope to prevent any motion at the neck. The patient was then positioned on Allen's spine table (Allen Medical Systems, A Hill-Rom Company, MA, USA) with the neck placed in extension under traction. The O-arm® Intra-operative Imaging System (Medtronic, Inc., Minneapolis, MN, USA) was used for the procedure. Head was positioned (under O-arm imaging) so as to achieve proper alignment of the odontoid and a satisfactory screw trajectory. A vertical 5 cm incision was given on the right side of the neck along the anterior border of the sternocleidomastoid muscle at C5-6 disc space with dissection carried up to C2 body. Using a pneumatic drill under O-arm guidance, the K-wire was drilled into the body of the odontoid, through the fracture line and into the distal fragment being careful not to breach the distal cortex of the fragment (the distal cortex is not breached to prevent K-wire migration during reaming). A reamer was used over the guide-wire to make threads for the screw. While reaming a significant length of the K-wire broke off which was traversing the length from the C2 body into the fracture fragment [Figure 1]. Fluoroscopy showed no part of the K-wire breaching the cortex of the distal fragment. A second K-wire was then drilled into the fracture fragment adjacent to the previous one being careful not to displace the first K-wire. The drill hole was tapped and a 36 mm partially threaded titanium cannulated lag screw was inserted gradually over the guide-wire under O-arm guidance. The screw was satisfactorily placed and no migration of the broken K-wire was seen. Postoperatively, there were no neurological deficits. Follow-up CT scans 3 months later showed fusion of the fragment and no migration of the broken K-wire [Figure 2]. Another CT scan at 12 months showed good fusion with no migration of broken K-wire and no neurological deficit.
|Figure 1: Intra-operative O-arm images. (a) Lateral view showing type II odontoid fracture; (b) lateral view showing the broken K-wire seen traversing the fracture line into the distal fragment; (c) anteroposterior view, a new K-wire drilled adjacent to the broken wire; (d) lateral view, odontoid screw being placed|
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|Figure 2: (a-d) The adontoid screw placed satisfactorily beside the retained K-wire|
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In this patient, we speculate that the guide-wire broke due to the friction from the reamer's serrated teeth. In addition, there might have been an element of metal fatigue as the K-wire had been previously used. No attempt was made to retrieve the broken wire, as it would have led to additional dissection and possible severe morbidity. In the literature, there has been only one report documenting similar problem  where no attempt was made to retrieve the broken wire citing similar apprehensions. Wire migration leading to brainstem injury is another potential complication. Due to the rarity of this complication in neurosurgical practice, there are no recommendations in place for the management of this problem.
Galvanic corrosion seems to be of concern due to the use of dissimilar metals. However, there have been studies , that refute this concern and show that no adverse in vivo effects were detected with the use of dissimilar materials in a model of stainless steel wire and titanium screw. The bone healing with the implants at 3 months suggest that despite the use of dissimilar medical grade metals (stainless steel wire and titanium screw), the local environment provided stable implant anchorage and acceptable biotolerance.
Preventing the guide-wire from bending and withdrawing the guide-wire once the odontoid screw has engaged, the distal odontoid fragment should prevent this complication. To prevent the devastating complication of K-wire migration and brainstem injury, we never let the K-wire breach the distal cortex. Instead, we do it with the reamer. Finally, a new guide-wire used in each surgical case would enable the K-wire to better handle the stress of this surgery.
| » References|| |
|1.||Ersmark H, Löwenhielm P. Factors influencing the outcome of cervical spine injuries. J Trauma 1988;28:407-10. |
|2.||Huelke DF, O′Day J, Mendelsohn RA. Cervical injuries suffered in automobile crashes. J Neurosurg 1981;54:316-22. |
|3.||Orief T, Bin-Nafisah S, Almusrea K, Alfawareh M. Guidewire breakage: An unusual complication of anterior odontoid cannulated screw fixation. Asian Spine J 2011;5:258-61. |
|4.||Devine DM, Leitner M, Perren SM, Boure LP, Pearce SG. Tissue reaction to implants of different metals: A study using guide wires in cannulated screws. Eur Cell Mater 2009;18:40-8. |
|5.||Serhan H, Slivka M, Albert T, Kwak SD. Is galvanic corrosion between titanium alloy and stainless steel spinal implants a clinical concern? Spine J 2004;4:379-87. |
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