Management of combination fractures of the atlas and axis in adults

The establishment of a novel upper cervical complex fracture classification system

BACKGROUND CONTEXT

Upper cervical complex fractures are associated with high rates of neurological damage and mortality. The Dickman's classification is widely used in the diagnosis of upper cervical complex fractures. However, it falls short of covering the full spectrum of complex fractures. This limitation hinders effective diagnosis and treatment of these injuries.

PURPOSE

To address the diagnostic gap in upper cervical complex fractures, the study introduces a novel classification system for these injuries, assessing its reliability and usability.

STUDY DESIGN

Proposal of a new classification system for upper cervical complex fractures.

PATIENT SAMPLE

The study comprised the clinical data of 242 patients with upper cervical complex fractures, including 32 patients treated at our hospital, along with an additional 210 cases from the literature.

OUTCOME MEASURES

The inter-observer and intra-observer reliability (kappa coefficient, κ) of this classification system were investigated by 3 spine surgeons. The 3 researchers independently re-evaluated the upper cervical complex fracture classification system 3 months later.

METHODS

The proposed classification categorizes upper cervical complex fractures into 3 main types: Type I combines odontoid and Hangman's fractures into 2 subtypes; Type II merges C1 with odontoid/Hangman's fractures into 3 subtypes; and Type III encompasses a combination of C1, odontoid, and Hangman's fractures, divided into 2 subtypes. Meanwhile, a questionnaire was administered in 15 assessors to evaluate the system's ease of use and clinical applicability.

RESULTS

A total of 45 cases (18.6%) unclassifiable by Dickman's classification were successfully categorized using our system. The mean κ value of inter-observer reliability was 0.783, indicating substantial reliability. The mean κ value of intra-observer reliability was 0.862, indicating almost perfect reliability. Meanwhile, thirteen assessors (87.7%) stated that the classification system is easy to remember, easy to apply, and they expressed intentions to apply it in clinical practice in the future.

CONCLUSIONS

This system not only offers high confidence and reproducibility but also serves as a precise guide for clinicians in formulating treatment plans. Future prospective applications are warranted to further evaluate this classification system.

Mortality From Combined Fractures of the Atlas (C1) and Axis (C2) in Adults

Study design

A retrospective case report of all upper cervical spine fractures diagnosed by CT imaging between 01/01/2013 and 31/12/2015 in NHS Greater Glasgow and Clyde, Scotland.

Objective

To compare the mortality following combined fractures of the atlas and axis to that of isolated fractures of either vertebra.

Background

The mortality from axis fractures is well documented in the literature. However, a combined fracture of the atlas and axis is seldom reported, leading to relatively unknown outcomes and mortality.

Methods

A total of 171 patients with atlas and/or axis fractures. Thirty-three presented with concurrent lower cervical spine fractures and were excluded from further analysis. Kaplan-Meier curves were used to compare survivorship between 108 patients with isolated and 30 with combined fractures. Similar analysis adjusted for comorbidities, including dementia and previous fragility fractures.

Results

Patients were followed up for 47.3±10.3 months (SD). Patients with isolated atlas fractures were significantly younger than those with an axis or combined fracture. Nearly half (8/17) of combined fracture mortalities occurred within the first 120 days. The mortality at 120 days was 26.7% in the combined fractures group and 18.5% in the isolated fracture group. There was no significant difference in the 120-day and overall mortality between these injury patterns. Furthermore, cognitive impairment and previous fragility fractures bore no significant impact on mortality. Nevertheless, mortality in the combined fracture group with previous fragility fractures did trend to shorter survivorship.

Conclusions

Patients with combined fractures are older and with the ever-increasing elderly population, the incidence of these injuries is expected to rise. While our data show that the 120-day mortality is proportionally higher in the combined fractures group, no long-term statistically significant difference is demonstrated. This evidence contests the notion that combined fractures of the atlas and axis have higher mortality than isolated injuries of either cervical vertebra.

Upper Cervical Spine Trauma: WFNS Spine Committee Recommendations

Craniovertebral junction (CVJ) trauma is a challenging clinical condition. Being a highly mobile functional unit at the junction of the skull and the vertebral column, traumatic events in this area may produce devastating neurological complications and death. Additionally, many of the CVJ traumatic injuries can be left undiagnosed or even raise difficult treatment dilemmas. We present a literature review in the format of recommendations on the diagnosis and management of different scenarios for upper cervical trauma and produce recommendations, which can be applicable to various areas of the globe.

The Decision-Making Process in Traumatic Lesions of the Craniovertebral Junction: An Evidence-Based Approach? Part II

This paper is Part II of a two-part report. Part I of the report covered atlanto-occipital dislocation or dissociation, and isolated condylar fractures. This part of the report covers isolated and combination fractures of the atlas and axis.

Treatment of Axis Body Fractures: A Systematic Review

STUDY DESIGN

Evidence-based systematic review.

OBJECTIVES

To define the optimal treatment of fractures involving the C2 body, including those with concomitant injuries, based upon a systematic review of the literature.

SUMMARY OF BACKGROUND DATA

Axis body fractures have customarily been treated nonoperatively, but there are some injuries that may require operative intervention. High-quality literature is sparse and there are few class I or class II studies to guide treatment decisions.

MATERIALS AND METHODS

A literature search was conducted using PubMed (MEDLINE), Cochrane Central Register of Controlled Trials, and Scopus (EMBASE, MEDLINE, COMPENDEX). The quality of literature was rated according to a grading tool developed by the Center for Evidence-based Medicine. Operative and nonoperative treatment of axis body fractures were compared using fracture bony union as the primary outcome measure. As risk factors for nonunion were not consistently reported, cases were analyzed individually.

RESULTS

The literature search identified 62 studies, of which 10 were case reports which were excluded from the analysis. A total of 920 patients from 52 studies were included. The overall bony union rate for all axis body fractures was 91%. Although the majority of fractures were treated nonoperatively, there has been an increasing trend toward operative intervention for Benzel type III (transverse) axis body fractures. Nearly 76% of axis body fractures were classified as type III fractures, of which 88% united successfully. Nearly all Benzel type I and type II axis body fractures were successfully treated nonoperatively. The risk factors for nonunion included: a higher degree of subluxation, fracture displacement, comminution, concurrent injuries, delay in treatment, and older age.

CONCLUSIONS

High rates for fracture union are reported in the literature for axis body fractures with nonoperative treatment. High-quality prospective studies are required to develop consensus as to which C2 body fractures require operative fixation.

Craniovertebral junction injuries in children. A Review

The craniovertebral junction (CVJ) is the most complex and dynamic region of the cervical spine. The wide range of movements possible at this region makes it vulnerable to injury and instability. The special anatomical features make children more prone to injuries of CVJ than adults where lower cervical spine is involved more frequently. The classical clinical manifestation in CVJ injury patients are pyramidal signs including weakness and spasticity, stigmata of CVJ anomalies (short neck, low hair line, facial or hand asymmetry, high arched palate, ), torticolis and neck movement restriction. The history of transient loss of consciousness or sudden neurological deterioration following minor trauma may be elicited. Most authors advocate conservative management (in form of immobilization) of CVJ injuries in children as is true in adults. Halo vest provides superior immobilization in upper cervical and CVJ injuries and can be used in a child as young as 1 year of age with minimal difficulty. Early surgical intervention, i.e. within 2 weeks of injury include is indicated in injuries that cannot be reduced and stabilized by external means, partial spinal cord injury with progressive neurological deficit and in children with extradural hematoma.

Posterior pedicle screw fixation for complex atlantoaxial fractures with atlanto-dental interval of ≥ 5 mm or C2-C3 angulation of ≥ 11°

Objective

Previous studies have demonstrated that the posterior pedicle screw fixation is an effective and safe method to treat atlantoaxial fractures. However, no report focuses on only the complex atlantoaxial fractures with atlanto-dental interval (ADI) of ≥5 mm or C2-C3 angulation of ≥11°.

Methods

This study was to retrospectively evaluate the outcome of 15 patients (six females and nine males; age, 27–55 years) who underwent posterior pedicle screw fixation for the above complex atlantoaxial fractures between July 2006 and March 2011. Fracture combinations included three Jefferson-type II odontoid, four anterior ring-type II odontoid, two posterior ring-type II odontoid, one lateral mass-type II odontoid, one Jefferson-hangman’s fracture, three anterior ring-hangman’s fracture, and one lateral mass-hangman’s fracture. Fracture healing and bone fusion were determined on X-ray scan. Upper limbs, lower limbs, and sphincter functions were assessed using the Japanese Orthopaedic Association (JOA) score. The Frankel grading system was used to determine the neurological situation.

Results

The mean operative time, blood loss, and hospital stays were 108.9 ± 25.8 min, 508.0 ± 209.6 ml, and 13.3 ± 2.0 days. Fracture healing and graft fusion were obtained in all patients within 9 months. The ADI or C2-C3 angulation was reduced to ≤5 mm or ≤11°. The JOA score was significantly improved from 7.27 ± 1.10 preoperatively to 15.7 ± 2.1 postoperatively (P <0.001), with 88.1 ± 18.3% recovery rate and 93.3% excellent and good rate. The neurological situation was improved in all patients by at least 1 grade in the Frankel scale. After a mean of 36.5 months of follow-up (range, 18 to 58 months), no operative complications (spinal cord injury, vertebral artery injury, or cerebrospinal fluid leakage) were observed.

Conclusion

Posterior pedicle screw fixation is a reliable, effective, and minimally invasive procedure for patients suffering from complex atlantoaxial fractures.

The role of neurosciences intensive care in trauma and neurosurgical conditions

The creation of neurosciences intensive care units was born out of the awareness that a group of neurological and neurosurgical patients required specialized intensive medical and nursing care. This first of two articles describes the role of neurosciences intensive care in the management of trauma and neurosurgical conditions.

Double hangman's fracture

STUDY DESIGN

Clinical case report and review of the literature.

OBJECTIVE

To report a very rare case of bipedicular fracture of C2, C3 along with traumatic spondylolisthesis of the C2, C3 vertebral bodies together over C4 without any neurological deficits.

SUMMARY OF BACKGROUND DATA

Cervical spine injury is a potentially fatal and debilitating incident because of the risk of damage of the cervical spinal cord. Hangman's fracture comprises 4% to 7% of all traumatic cervical spine fractures. Attempting closed reduction in a neurologically intact patient may cause the development of new deficits during time of traction, especially in the case of compromised neural canal. The management should be aimed at providing a stable well-aligned spine without causing any new neurological deficits.

METHODS

A 35-year-old female had a motor vehicle accident and her forehead collided against the ground, causing hyperextension-compression type injury of the cervical spine that resulted in complaints of neck pain on movement. Cervical spine plain radiographs revealed spondylolisthesis of C2, C3 vertebral bodies together over C4 with bipedicular fracture of C2, C3. A computed tomographic scan confirmed these fractures. Magnetic resonance imaging further demonstrated spondylolisthesis without any spinal cord compression or signal abnormality. An anterior C2, C3 and C3-C4 cervical fusion was performed with iliac crest tricortical strut grafting and anterior cervical plating. The patient was turned to a prone position on the striker bed and posterior fixation was performed with lateral mass screws of C1 and C5.

RESULTS

Reduction of the spondylolisthesis was achieved with gradual cervical traction in an awake intubation followed by 360º of fusion with both anterior and posterior fixation.

CONCLUSION

Bipedicular fracture of C2, C3 along with traumatic spondylolisthesis of the C2, C3 vertebral bodies together over C4 without any neurological deficits is very rare injury and needs methodical 360º fixation.

Inception of an Australian spine trauma registry: the minimum dataset

Background The establishment of a spine trauma registry collecting both spine column and spinal cord data should improve the evidential basis for clinical decisions. This is a report on the pilot of a spine trauma registry including development of a minimum dataset. Methods A minimum dataset consisting of 56 data items was created using the modified Delphi technique. A pilot study was performed on 104 consecutive spine trauma patients recruited by the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR). Data analysis and collection methodology were reviewed to determine its feasibility. Results Minimum dataset collection aided by a dataset dictionary was uncomplicated (average of 5 minutes per patient). Data analysis revealed three significant findings: (1) a peak in the 40 to 60 years age group; (2) premorbid functional independence in the majority of patients; and (3) significant proportion being on antiplatelet or anticoagulation medications. Of the 141 traumatic spine fractures, the thoracolumbar segment was the most frequent site of injury. Most were neurologically intact (89%). Our study group had satisfactory 6-month patient-reported outcomes. Conclusion The minimum dataset had high completion rates, was practical and feasible to collect. This pilot study is the basis for the development of a spine trauma registry at the Level 1 trauma center.

Posterior osteosynthesis of the atlas for nonconsolidated Jefferson fractures: a new surgical technique

STUDY DESIGN

Case report and surgical technique.

OBJECTIVE

To describe a new technique to treat atlas burst fractures by selectively reconstructing the atlas from a posterior approach.

SUMMARY OF BACKGROUND DATA

The two surgical techniques reported until now for stabilizing atlas burst fractures are associated with some drawbacks. Posterior C0-C2 or C1-C2 fixations significantly reduce head rotation, while the transoral C1 lateral masses osteosynthesis can be associated with oropharyngeal and neurological complications. We propose a new surgical technique for the treatment of unstable Jefferson fractures aimed at avoiding these problems.

METHODS

A 25-year-old man presented with a Jefferson type III atlas fracture after a traffic accident. The fracture failed to consolidate after 3 months of halo brace immobilization. Surgery consisted in inserting bilateral posterior C1 lateral mass screws interconnected by a transversal rod, thereby creating a second C1 posterior arch under the fractured one.

RESULTS

Postoperative course was uneventful. Immediate postoperative stability was confirmed on dynamic X-ray films and head rotation was preserved. Delayed computed tomography scan demonstrated fracture consolidation.

CONCLUSION

The surgical technique described is new and effective for treating atlas burst fractures. This posterior procedure allows mobility preservation, with a low morbidity rate.

Atlas Fractures

OBJECTIVE

To provide a comprehensive review of the biomechanics, pathophysiology, and clinical management of atlas fractures.

METHODS

Selected literature review.

RESULTS

Atlas fractures account for 25% of craniocervical injuries, 3% to 13% of cervical spine injuries, and 1% to 3% of all spinal injuries. Motor vehicle accidents account for 80% to 85% of atlas fractures, and the mechanism of injury is axial loading. Isolated atlas fractures are more common; however, 40% to 44% of atlas fractures have concomitant axis fractures. Fractures of isolated anterior or posterior arches are more common and typically seen with concomitant spine fractures. Isolated burst fractures are the second most common type and rarely cause neurological injury. Treatment of atlas fractures is based on whether they occur in isolation or in combination with other cervical spine injuries and on the integrity of the transverse ligament, which is best assessed with high-resolution magnetic resonance imaging. Isolated atlas fractures without injury of the transverse ligament or associated with bony avulsion of the transverse ligament can be treated with halo-brace immobilization and should be followed for instability with flexion-extension radiography. Surgical fixation is recommended for nonbony avulsion of the transverse ligament or if instability is present. The type of surgical fixation is determined by the concomitant craniocervical injuries if present.

CONCLUSION

Atlas fractures can be treated with halo-brace immobilization with acceptable outcomes. The role of surgical fixation, especially for atlas burst fractures, requires further study for clarification.

Assessment of two measurement techniques of cervical spine and C1-C2 rotation in the outcome research of axis fractures: a morphometrical analysis using dynamic computed tomography scanning

STUDY DESIGN

In vivo study on cervical spine motion.

OBJECTIVE

To estimate the accuracy of clinical measurements, using a handheld goniometer for the assessment of total cervical neck rotation in outcome research of patients with C2 fractures and particularly odontoid fractures. Investigation on whether functional computed tomography (CT)-scanning is decisive in the investigation of functional outcome after C2 fractures.

SUMMARY OF BACKGROUND DATA

Pertinent literature exists concerning indications, techniques, complications of treatment, and risk factors for nonunion in C2 fractures; however, there are scarce data regarding the functional outcome in C2 fractures. Only a few studies assess functional outcome in terms of clinical outcome vehicles and clinical investigation of axial neck rotation, using a handheld goniometer. Measurements of axial neck rotation using a handheld goniometer are assumed not sufficient to compare the results of treatment strategies for C2-fractures or elucidate the ability for posttreatment rotation of C1-C2.

METHODS

The authors selected a homogenous group of 35 patients treated for C2 fractures using nonsurgical and surgical techniques. 69% of patients had odontoid fractures. Mean age of patients was 52 years. Patients were subjected to clinical assessment of axial cervical range of motion for rotation, using a handheld goniometer. Patients were also subjected to functional CT-scanning and measurements of total neck and atlantoaxial rotation were performed according to an established protocol.

RESULTS

With clinical measurements mean range of motion for left and right axial neck rotation was both 56 degrees. According to the functional CT scans, the mean left-sided and right-sided axial neck rotation was 48.6 degrees and 52.0 degrees. The mean for left- and right-sided atlantoaxial rotation was 20.2 degrees and 20.6 degrees. Total axial atlantoaxial rotation on CT scans was 40.3 degrees and total axial neck rotation was 103.3 degrees. In comparison to age and gender matched normal individuals total cervical neck rotation was reduced to a mean of 69.5%. The differences between total axial neck rotation assessed using a handheld goniometer and with functional CT-scanning were strongly significant (P < 0.0001). In addition, there was no statistically significant correlation between the clinically assessed total neck rotation to either the left or the right side and the ipsilateral percentage atlantoaxial rotation of total head neck rotation.

CONCLUSION

The current study demonstrated that for the comparison of functional outcome after different therapies of C2 fractures clinical measurements do not serve for reliable data on total neck rotation and particularly atlantoaxial rotation and the percentage of C1-C2 rotation of total neck rotation. The use of dynamic CT-scans in the analysis of functional outcome after C2 fractures is strongly recommended.

Surgical management of a combined fracture of the odontoid process with an atlas posterior arch disruption: a review of four cases

Four cases of operated odontoid process fractures associated with a fracture of the posterior arch of the atlas are presented. Three types of surgery were performed: atlas-axis fusion, occipitocervical fusion, and odontoid process screw fixation. Based on a literature review and our experience, the therapeutic management is discussed according to the type of odontoid fracture and the presence of neurological involvement, with a reminder that wiring is not indicated when C1 posterior arch continuity is compromised.

In vivo analysis of atlantoaxial motion in individuals immobilized with the halo thoracic vest or Philadelphia collar

STUDY DESIGN

In vivo biomechanical comparison of the halo thoracic vest (HTV) and the Philadelphia collar (PC).

OBJECTIVE

To delineate the capacity of both orthoses for immobilization of the atlantoaxial complex (AAC), e.g., for their use in odontoid fracture care.

SUMMARY OF BACKGROUND DATA

Stable odontoid fractures can be treated with external immobilization using, e.g., a PC or a HTV. Although the HTV confers higher morbidity, particularly in elderly patients, with a similar union-rate in odontoid fracture care compared with the PC, many surgeons are still prone to use the HTV instead of the PC because the former is thought to accomplish increased rigidity at the AAC. Because application of the HTV using pins is an invasive procedure, there is a lack of biomechanical in vivo data on the "real" rigidity conferred by a HTV in comparison with a PC.

METHODS

Twenty volunteers were subjected to flexion/extension radiographs immobilized in a modified HTV or a PC. The radiographs were performed in extreme position of flexion in sitting position and extension in standing position. The PC was fitted as usual. The 4 cortical pins of a normal clinically used HTV were replaced by 12 modified distance pins. The halo-ring was fixed to the head by tightening of the 12 pins in an alternating fashion, thus yielding a hexapod-like strong fixation between the head and the HTV. The procedure was uncomfortable but there were no adverse events from the HTV placement. Radiographs were analyzed for the segmental rotation angle of C1-C2 in sagittal plane (SRA C1-C2) and the absolute rotation angle of C2-C7 (ARA C2-C7) using the Harrison tangent method. Separation angles (rSRA C1-C2 and rARA C2-C7) were calculated from flexion/extension views. Two observers measured all angles. The means of the measurements were used for statistical analysis. The interobserver reliability was expressed by calculating intraclass correlation coefficients (ICCs). RESULTS.: Mean age of 20 volunteers was 30.9 +/- 4.2 years. Calculation of the ICCs showed good to excellent interobserver reliability for all angular measurements (ICC = 0.95-0.98). Concerning restriction of subaxial sagittal plane motion, the HTV was more effective than the PC. The difference for the rARA C2-C7 between the PC (mean 20.7 degrees) and HTV (mean 9.2 degrees) yielded significance (P = 0.01). But, concerning restriction of flexion/extension at the AAC, there was no statistical significant difference for the rSRA C1-C2 between the PC and HTV (P = 0.3). The PC (mean 1.3 degrees) was even superior to the HTV (mean, 3.3 degrees) in restricting sagittal motion at C1-C2. In comparison to normal atlantoaxial motion was restricted by 88.5% with the PC and 70.8% with the HTV. In light of the results and a selected review of literature, a treatment algorithm for the elderly patient with odontoid fracture is presented.

CONCLUSION

Under the extremes of flexion and extension bendings, the current study demonstrated that there was no significant difference in restriction of sagittal motion at C1-C2 when using the PC instead of the HTV in a group of 20 young normal adults. In light of the current biomechanical data and a selected review of literature, it is concluded that the use of a PC is sufficient for the treatment of stable odontoid fractures.

Posterior Instrumentation Surgery for Craniocervical Junction Instabilities: an Update

The surgical treatment of craniocervical junction (CCJ) instability has recently undergone significant development and change. Posterior instrumentation surgery has been the mainstay of treatment of CCJ instability, and is the focus of this review. For the treatment of atlantoaxial instability, C1-2 transarticular screw fixation has shown good stability, and has been regarded as the "gold standard" procedure. Because of potentially hazardous complications including vertebral artery injury, however, C-1 lateral mass-C-2 pedicle screw fixation is gaining popularity. For treatment of atlantooccipital instability, occipitocervical fixation using screw constructs (combined with either rods or plates) has shown more stability than sublaminar wiring techniques, and has been utilized more frequently. Both innovation in material engineering and in vitro biomechanical studies have contributed significantly to the development of more rigid internal fixation devices, and as a result, many patients who would have been treated conservatively with external orthosis are treated nowadays with instrumentation surgery, resulting in earlier ambulation, shortened hospital stay, and earlier recovery into social activities. New surgical techniques and instruments, however, need to stand the test of time to see whether they are free from long-term adverse events. The rapid turnover of new surgical techniques and hardware has made it difficult for less experienced surgeons to keep up with the latest developments. Conventional techniques can be safer and less technically demanding than newer techniques for those who are not familiar with them.