Fracture of the Dens Axis Due to Spinal Manifestation of Sarcoidosis: Treatment Option and Review of the Literature

Study design: Case report and literature review.

Objective: We present a case of a pathologic unstable fracture of the odontoid process due to vertebral osseous sarcoidosis. The surgical management of this unreported pathology is described and a review of the literature is given.

Summary of background data: Sarcoidosis is a chronic inflammatory systemic disease of unknown etiology, characterized by multiorgan noncaseating granulomatous infiltrations. It affects primarily the lungs, lymphatic system, eyes, skin, heart, and nervous system. Osseous sarcoidosis is usually clinically asymptomatic and therefore frequently under-diagnosed. When it does affect the skull or vertebral column, specific surgical therapy is only necessary in cases with nonmanageable pain or where structural integrity is threatened.

Methods: Our patient underwent a so-called semiconservative approach, consisting of a minimally invasive transoral-transpharyngeal approach, surgical debridement of the lytic bony lesion, transplantation of cancellous homologous bone, and carbon chest halo-immobilization. Halo-immobilization was left for 8 weeks, followed by a further 6 weeks with a hard cervical collar.

Results: Routine computed tomography scans 3 days, 6, 12, 18 weeks, and 1 year after surgery showed good filling of the original defect with cancellous bone, correct alignment of the upper cervical spine, and progressive fracture consolidation and stability. Surgical site infection (SSI) was not observed. The patient had no neurological postoperative deficits. After initial dysphagia, swallowing was not permanently impaired.

Conclusion: Sarcoidosis-induced odontoid fractures can be managed successfully using a semiconservative approach, consisting of transoral-transmucosal, minimally invasive surgical procedure for debridement of the lesion and transplantation of cancellous bone with additional halo-immobilization. Permanent fusion of C1-2 with loss of the cervical range of motion is avoided. Despite performing bone surgery in a potentially markedly contaminated site, bacterial infection was not an issue, possibly supported by the temporary discontinuation of immunosuppressive agents and the prudent use of antibiotics.Level of Evidence: 4.