FINAL COVER LETTER

Dear Dr. Horton

We are submitting “Fractures of the Odontoid Process and their surgical aproaches” to The Lancet Neurology for possible consideration of publication. The authors are Juan E. Vásquez, MD, Franco Ravera, MD and Chief Department and Carlos Wilson, MD, all members of the Neurosurgical Department of the Rancagua Regional Hospital. Our study was performed to provide an important guideline for this specific upper cervical fracture and its therapeutical options.

This study provides longuitudinal evidence of 97 cases followed up during ten years, with low rates of complications and excellent surgical output. It may serve as a guideline to enhance surgical outcomes at the different neurosurgical departments.

Finally, the article has not been submitted for publication nor has it been published in whole or in part elsewhere, and that there is no conflict of interests.

Sincerely,

Juan Enrique Vásquez, MD

Student of the Neurosurgical internship program, University of Chile

Correspondance to: JE Vásquez j.e.vasquez@uchile.cl

COVER LETTER DRAFT 1

Dear Dr. Horton

We are submitting “Fractures of the Odontoid Process and their surgical aproaches” to The Lancet Neurology because is the leading specialist neurology journal in the world with the highest impact factor. The authors are Juan E. Vásquez, MD, Franco Ravera, MD and Chief Department and Carlos Wilson, MD, all members of the Neurosurgical Department of the Rancagua Regional Hospital. Our study was performed to deliver a powerful guide of the different therapeutical options for this upper cervical fracture.

Although is a retrospective study we have an exceptional high number of cases (ten years follow up, 97 cases), low rates of complications and an excellent surgical output.

As it was mentioned previously this study provides the most clear therapeutic guide ever and it will enhance the surgical outcomes of the different neurosurgical departments.

Finally, the article has not been submitted for publication nor has it been published in whole or in part elsewhere and that there is no conflict of interests.

Sincerely,

Juan Enrique Vásquez, MD

Student of the Neurosurgical internship program, University of Chile

Correspondance to: JE Vásquez j.e.vasquez@uchile.cl

HOW MISTAKEN THEY ARE

The first thing we have to mention is the importance of the talker: Sir Ken Robinson was from 1998 a member of the British government advisory commitee on creative and cultural education and was knighted in 2003 for his achievements, besides that, he has written several book about education, the last one published in January 2009.

One important issue is that education not only in the UK but in the whole world tries to teach us dogmas and how to work with parameters, in other words society thwarts us and shape us into its own benefit. In a way we are like a squadron of soldiers whose has been teached to be (or tried to be) good in math, language and the other “major” subjects because otherwise we are not going to be able to be someone in life, raise a family, buy our own house, etc.

How mistaken they are!!! society needs (i say need not only the basic for its survival) entertainment, poetry, drama, arts, comedy, sports, etc. etc. etc. and if you want to became an entertainer, a poet, an artist, a comedian, an athlete you are stigmatized and treated as an outlaw.

Here mental illness comes into play. Because of the mental impairment inherent in the condition, the mentally ill are not susceptible to the requirements of society, they are as free as they desire.

FINAL ABSTRACT

"Fractures of the Odontoid Process and their surgical approaches"

JE Vásquez et al.

Abstract

Fractures of the Odontoid are the most common type of C2 fractures but do not have a consensus treatment, therefore we performed a retrospective study which compares the anterior and posterior approach in the Odontoid Process fracture including type of fracture, neurological involvement, surgical technique, postoperative management and early patient follow up. The data were obtained of the Neurosurgical Department of the Rancagua Regional Hospital database and includes 97 patients with dens fracture between June 1998 and August 2009. According to the Anderson and D' Alonzo classification the prevalence of type I and type II was 32,9% and 62,8% respectively. Is also important to show that four patients (4,1%) had a combination of a type II fracture plus a fracture of the Atlas. The data shown that only 6% of patients with a cervical fracture was neurologically impaired before the surgery and only one patient had neurological secuelae after the procedure because of the severity of the spine injury. For the resolution of the type II fracture we performed an anterior surgical approach with a cannulated screw, for the combination of fractures a posterior C1-2 transarticular screw fixation with supplemental tension-band fixation and a conservative management for the rest of the patients (type I). The postoperative management consisted in the use of a cervical brase for 6 weeks in all cases, at least two controls made by a neurosurgeon and the use of analgesics. We conclude that the anterior approach is the first choice when a surgical resolution is needed because it has a low rate of complications, is easier to perform and is a cheap procedure, thus the most important suggestion of our study is that an accurate classification of the fracture has to be done because it provides important information about the prognosis and in a major percentage will decide whether a surgical resolution is needed and which approach is suitable for every case.

Key Words: Odontoid Process, Atlas, Anderson and D' Alonzo classification, canulated screw, cervical brase

Abstract II

"Fractures of the Odontoid Process and its surgical approaches"

Key Words: Odontoid Process, Atlas, Anderson and D' Alonzo classification, canulated screw, cervical brase

JE Vásquez et al.

Abstract

Fractures of the Odontoid are the most common type of C2 fractures but do not have a consensus treatment, therefore we performed a retrospective study which compares the anterior and posterior approach in the Odontoid Process fracture including: type of fracture, neurological involvement, surgical technique, postoperative management and early patient follow up. The data were obtained of the Neurosurgical Department of the Rancagua Regional Hospital database and includes 97 patients with dens fracture between June 1998 and August 2009. According to the Anderson and D' Alonzo classification the prevalence of type I and type II was 32,9% and 62,8% respectively. Is important to show that four patients (4,1%) had a combination of a type II fracture plus a fracture of the Atlas. For the resolution of the type II fracture we performed an anterior surgical approach with a cannulated screw, posterior C1-2 transarticular screw fixation with supplemental tension-band fixation was used for the combination of fractures and a conservative management for the rest of the patients. The data shown that only 6% of patients with a cervical fracture was neurologically impaired before the surgery. The postoperative management consisted in the use of a cervical brase for at least 6 weeks in all cases. Only one patient had neurological secuelae after surgery because of the severity of the spine injury. A conclusion of our study is that an accurate classification of the fracture has to be done because it provides important information about the prognosis and in a major percentage will decide whether a surgical resolution is needed and which approach is suitable for every case.

Abstract I

"Fractures of the Odontoid Process and its surgical approach"

JE Vásquez et al.

Abstract

Fractures of the Odontoid are the most common type of C2 fractures and do not have a consensus treatment, because of that we performed a retrospective study which compares the anterior and posterior approach in the Odontoid Process fracture including: type of fracture, neurological involvement, surgical technique, postoperative management and early follow up of the patients. The data was obtained of the Neurosurgical Department of the Rancagua Regional Hospital database and includes ninety seven patients with dens fracture between June 1998 and August 2009. According to the Anderson and D' Alonzo classification, sixty one of the ninety seven patients had a type II fracture (62,8%), thirthy two (32,9%) a type I and four (4,1%) patients had a combination of a type II fracture plus a fracture of the Atlas. An anterior surgical approach with a cannulated screw was performed for the resolution of the type II fracture, posterior C1-2 transarticular screw fixation with supplemental tension-band fixation was used for the combination of fractures and a conservative management for the rest of them. Only 6% from the total was neurologically impaired before the surgery. The postoperative management consisted in the use of a cervical brase for at least 6 weeks in all cases. Is very important to make an accurate classification of the fracture because in a mayor percentage will decide whether a surgical resolution is needed and which approach is suitable for every case.

Key Words: Odontoid Process, Atlas, Anderson and D' Alonzo classification, canulated screw, cervical brase

Introduction II

Hello everybody, my name is Juan Enrique Vásquez Pedraza, my nickname is kike and I am 27 years old.

I studied medicine at the University of Santiago, i got my degree in December of 2007, since then I am working in a family heathcare center as a general physician in Rancagua. In 2008 I made an intern medicine diploma and a surgery internship for five months, last year I took a postgraduate course about Neurosciences and clinical managment, I also pushished two posters in the Chilean Neurosurgery Congress and one was elected in the first place, the "Spinal Cord injury, comparison of early and late treatment" poster.

Next year i´m gonna apply to neurosurgery internship in this university and I really hope to be selected because I am eager to start my specialization.

In my spare time, i try to do a lot of things because I don`t have much time to waste, that`s why i play tennis at least once a week, specially in summer and squash or racquetball in winter, I also go very often to the cinema.

I think that`s all, good bye.