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Beucler N, Sellier A, Dagain A. Motion-preserving C1 lateral mass fixation with compression for unstable Jefferson fracture of the Atlas: technical note. Neurosurg Rev 2024; 47:650. [PMID: 39302548 DOI: 10.1007/s10143-024-02898-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2024] [Revised: 09/02/2024] [Accepted: 09/15/2024] [Indexed: 09/22/2024]
Affiliation(s)
- Nathan Beucler
- Neurosurgery Department, Sainte-Anne Military Teaching Hospital, 2 Boulevard Sainte-Anne, Cedex 9, 83800, Toulon, France.
| | - Aurore Sellier
- Neurosurgery Department, Sainte-Anne Military Teaching Hospital, 2 Boulevard Sainte-Anne, Cedex 9, 83800, Toulon, France
| | - Arnaud Dagain
- Neurosurgery Department, Sainte-Anne Military Teaching Hospital, 2 Boulevard Sainte-Anne, Cedex 9, 83800, Toulon, France
- Val de Grâce Military Academy, 1 Place Alphonse Laveran, Cedex 5, 75230, Paris, France
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Niu HG, Zhao CK, Yang K, Tao H, Liu C, Zhang JJ, Shen CL, Zhang YS. Monoaxial Screws Versus Polyaxial Screws Osteosynthesis for Unstable Atlas Fractures: A Retrospective, Comparative Study With a Minimum Follow-Up of 3 years. Global Spine J 2024:21925682241247489. [PMID: 38606957 DOI: 10.1177/21925682241247489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/13/2024] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE The study aimed to compare the radiological parameters, clinical outcomes, and long-term effects of the posterior osteosynthesis with polyaxial screw-rod system and the monoaxial screw-rod system in the treatment of unstable atlas fractures. METHODS We retrospectively analyzed the clinical data of 33 patients with posterior ORIF for unstable atlas fractures in our hospital from August 2013 to June 2020, with a minimum of 3 years of follow-up. Polyaxial screws (group A) were used in 12 patients and monoaxial screws (group B) in 21 patients. Perioperative data, radiological parameters, and clinical outcomes were collected and compared between the 2 surgical approaches. RESULTS The operative time, blood loss, time of screw-rod system placement, and hospital stay were significantly lower in group A than in group B. At the last follow-up, the visual analog scale (VAS) score and anterior arch reduction rate of the atlas in group A were lower than those in group B, while the lateral mass displacement (LMD) in group A was higher than that in group B. There was no significant difference between Group A and Group B in terms of the anterior atlantodental interval (AADI), posterior arch reduction rate of the atlas, range of motion (ROM), and neck disability index (NDI). CONCLUSIONS Monoaxial screws can achieve better reduction results for unstable atlas fractures, especially for the anterior arch of atlas. However, the surgical operation of monoaxial screws is more complicated than that of polyaxial screws and has more complications. Appropriate implants should be selected for the treatment of unstable atlas fractures based on the type of atlas fracture, the experience of surgeons, and the demands of patients.
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Affiliation(s)
- He-Gang Niu
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, Hefei, PR China
| | - Cheng-Kun Zhao
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, Hefei, PR China
| | - Kun Yang
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, Hefei, PR China
| | - Hui Tao
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, Hefei, PR China
| | - Chang Liu
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, Hefei, PR China
| | - Jing-Jing Zhang
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, Hefei, PR China
| | - Cai-Liang Shen
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, Hefei, PR China
| | - Yin-Shun Zhang
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, Hefei, PR China
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Niu HG, Zhang JJ, Yan YZ, Yang K, Zhang YS. Direct osteosynthesis in the treatment of atlas burst fractures: a systematic review. J Orthop Surg Res 2024; 19:129. [PMID: 38331873 PMCID: PMC10851607 DOI: 10.1186/s13018-024-04571-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 01/18/2024] [Indexed: 02/10/2024] Open
Abstract
PURPOSE The treatment of unstable atlas fractures remains a controversial topic. The study aims at assessing the prognosis and efficacy of osteosynthesis for unstable atlas fractures through a review of the current literature and additionally aims to compare outcomes between the transoral and posterior approaches. METHODS A systematic review of databases including PubMed, EMBASE, Cochrane, Web of Science, CNKI, and Wanfang was conducted. Titles and abstracts were screened by two reviewers to identify studies meeting pre-defined inclusion criteria for comprehensive analysis. RESULTS The systematic review included 28 articles, 19 employing the posterior approach and 9 utilizing the transoral approach. It covered osteosynthesis in 297 patients with unstable atlas fractures, comprising 169 treated via the posterior approach and 128 via the transoral approach. Analysis revealed high healing rates and clinical improvement in both approaches, evidenced by improvements in the visual analog scale, range of motion, atlantodens interval, and lateral displacement distance post-surgery. CONCLUSION Osteosynthesis offers effective treatment for unstable atlas fractures. Both transoral and posterior approaches can achieve good clinical outcomes for fracture, and biomechanical studies have confirmed that osteosynthesis can maintain the stability of the occipitocervical region, preserve the motor function of the atlantoaxial and occipito-atlantoaxial joints, and greatly improve the quality of life of patients. However, variations exist in the indications and surgical risks associated with each method, necessitating their selection based on a thorough clinical evaluation of the patient's condition.
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Affiliation(s)
- He-Gang Niu
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, No.218 Jixi Road, Hefei, 230022, Anhui Province, People's Republic of China
| | - Jing-Jing Zhang
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, No.218 Jixi Road, Hefei, 230022, Anhui Province, People's Republic of China
| | - Yi-Zhu Yan
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, No.218 Jixi Road, Hefei, 230022, Anhui Province, People's Republic of China
| | - Kun Yang
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, No.218 Jixi Road, Hefei, 230022, Anhui Province, People's Republic of China.
| | - Yin-Shun Zhang
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, No.218 Jixi Road, Hefei, 230022, Anhui Province, People's Republic of China.
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Niu HG, Zhang JJ, Yan YZ, Zhao CK, Yang K, Zhang YS. Design of a novel lateral mass screw-plate system for the treatment of unstable atlas fractures: a finite element analysis. J Orthop Surg Res 2024; 19:120. [PMID: 38317156 PMCID: PMC10840214 DOI: 10.1186/s13018-024-04582-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 01/25/2024] [Indexed: 02/07/2024] Open
Abstract
BACKGROUND Osteosynthesis of unstable atlas fractures preserves joint motion and therefore has a distinct advantage over a range of treatment procedures. To prevent the potential disadvantages associated with osteosynthesis, a new atlas lateral mass screw-plate (LMSP) system has been designed. However, the biomechanical role of using the LMSP system in atlas internal fixation is not known. The aim of this study was to compare the biomechanical stability of a new LMSP with traditional posterior screw and rod (PSR) fixation techniques on the occipitocervical junction (C0-C2) through finite element analysis. METHODS A nonlinear C0-C2 finite element model of the intact upper cervical spine was developed and validated. The unstable model using the PSR system was then compared with the model using the LMSP system for fixation. A vertical load of 40 N was applied to the C0 to simulate head weight, while a torque of 1.5 Nm was applied to the C0 to simulate flexion, extension, lateral bending, and axial rotation. RESULTS The range of motion of both systems was close to the intact model. Compared with the LMSP system model, the PSR system model increased flexion, extension, lateral bending, and axial rotation by 4.9%, 3.0%, 5.0%, and 29.5% in the C0-C1 segments, and 4.9%, 2.7%, 2.4%, and 22.6% in the C1-C2, respectively. In flexion, extension, and lateral bending motion, the LMSP system model exhibited similar stress to the PSR system model, while in axial rotation, the PSR system model exhibited higher stress. CONCLUSIONS The findings of our study indicate that the two tested system models provide comparable stability. However, better stability was achieved during axial rotation with the LMSP system, and in this system, the maximum von Mises stress was less than that of the PSR one. As the atlantoaxial joint functions primarily as a rotational joint, the use of the LMSP system may provide a more stable environment for the joint that has become unstable due to fracture.
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Affiliation(s)
- He-Gang Niu
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, No.218 Jixi Road, Hefei, 230022, Anhui Province, People's Republic of China
| | - Jing-Jing Zhang
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, No.218 Jixi Road, Hefei, 230022, Anhui Province, People's Republic of China
| | - Yi-Zhu Yan
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, No.218 Jixi Road, Hefei, 230022, Anhui Province, People's Republic of China
| | - Cheng-Kun Zhao
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, No.218 Jixi Road, Hefei, 230022, Anhui Province, People's Republic of China
| | - Kun Yang
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, No.218 Jixi Road, Hefei, 230022, Anhui Province, People's Republic of China.
| | - Yin-Shun Zhang
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, No.218 Jixi Road, Hefei, 230022, Anhui Province, People's Republic of China.
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Ibrahim Y, Li H, Zhao G, Yuan S, Zhao Y, Liu W, Tian Y, Wang L, Liu X. Posterior Temporary C1-2 Pedicle Screws Fixation for the Treatment of Unstable C1-2 Complex Fractures: Minimum of 2-Year Follow-Up. Global Spine J 2023; 13:1522-1532. [PMID: 34409875 PMCID: PMC10448083 DOI: 10.1177/21925682211039186] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
STUDY DESIGN Retrospective. OBJECTIVES To present rarely reported complex fractures of the upper cervical spine (C1-C2) and discuss the clinical results of the posterior temporary C1-2 pedicle screws fixation for C1-C2 stabilization. METHODS A total of 19 patients were included in the study (18 males and 1 female). Their age ranged from 23 to 66 years (mean age of 39.6 years). The patients were diagnosed with complex fractures of the atlas and the axis of the upper cervical spine and underwent posterior temporary C1-2 pedicle screws fixation. The patients underwent a serial postoperative clinical examination at approximately 3, 6, 9 months, and annually thereafter. The neck disability index (NDI) and the range of neck rotary motion were used to evaluate the postoperative clinical efficacy of the patients. RESULTS The average operation time and blood loss were 110 ± 25 min and 50 ± 12 ml, respectively. The mean follow-up was 38 ± 11 months (range 22 to 60 months). The neck rotary motion before removal, immediately after removal, and the last follow-up were 68.7 ± 7.1°, 115.1 ± 11.7°, and 149.3 ± 8.9° (P < 0.01). The NDI scores before and after the operation were 42.7 ± 4.3, 11.1 ± 4.0 (P < 0.01), and the NDI score 2 days after the internal fixation was removed was 7.3 ± 2.9, which was better than immediately after the operation (P < 0.01), and 2 years after the internal fixation was removed. The NDI score was 2.0 ± 0.8, which was significantly better than 2 days after the internal fixation was taken out (P < 0.001). CONCLUSIONS Posterior temporary screw fixation is a good alternative surgical treatment for unstable C1-C2 complex fractures.
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Affiliation(s)
- Yakubu Ibrahim
- Department of Orthopedics, Qilu Hospital of Shandong University, Jinan, Shandong, People’s Republic of China
- Cheeloo College of Medicine, Shandong University, Jinan, Shandong, People’s Republic of China
| | - Hao Li
- Department of Orthopedics, Qilu Hospital of Shandong University, Jinan, Shandong, People’s Republic of China
- Cheeloo College of Medicine, Shandong University, Jinan, Shandong, People’s Republic of China
| | - Geng Zhao
- Department of Orthopedics, Qilu Hospital of Shandong University, Jinan, Shandong, People’s Republic of China
- Cheeloo College of Medicine, Shandong University, Jinan, Shandong, People’s Republic of China
| | - Suomao Yuan
- Department of Orthopedics, Qilu Hospital of Shandong University, Jinan, Shandong, People’s Republic of China
- Cheeloo College of Medicine, Shandong University, Jinan, Shandong, People’s Republic of China
| | - Yiwei Zhao
- Department of Orthopedics, Qilu Hospital of Shandong University, Jinan, Shandong, People’s Republic of China
- Cheeloo College of Medicine, Shandong University, Jinan, Shandong, People’s Republic of China
| | - Wubo Liu
- Department of Orthopedics, Qilu Hospital of Shandong University, Jinan, Shandong, People’s Republic of China
- Cheeloo College of Medicine, Shandong University, Jinan, Shandong, People’s Republic of China
| | - Yonghao Tian
- Department of Orthopedics, Qilu Hospital of Shandong University, Jinan, Shandong, People’s Republic of China
- Cheeloo College of Medicine, Shandong University, Jinan, Shandong, People’s Republic of China
| | - Lianlei Wang
- Department of Orthopedics, Qilu Hospital of Shandong University, Jinan, Shandong, People’s Republic of China
- Cheeloo College of Medicine, Shandong University, Jinan, Shandong, People’s Republic of China
| | - Xinyu Liu
- Department of Orthopedics, Qilu Hospital of Shandong University, Jinan, Shandong, People’s Republic of China
- Cheeloo College of Medicine, Shandong University, Jinan, Shandong, People’s Republic of China
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Tinner C, Aregger FC, Deml MC. Transoral unilateral lag screw osteosynthesis for coronal split fracture of the lateral mass of the atlas - case report, operative technique and review of the literature. BRAIN & SPINE 2023; 3:101761. [PMID: 38020987 PMCID: PMC10668072 DOI: 10.1016/j.bas.2023.101761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 04/28/2023] [Accepted: 06/07/2023] [Indexed: 12/01/2023]
Abstract
Introduction Atlas ring fractures, which account for 1.3% of all spinal fractures, are predominantly managed conservatively. However, in certain cases, surgical treatment may be necessary depending on the type of fracture, degree of comminution, fracture location, and associated ligamentous injuries. Surgical stabilization frequently results in a posterior C1-2 or C0-2 fusion, which restricts movement, particularly craniocervical rotation. Coronal split fractures of the lateral mass need to be reduced and fixed due to dislocation, instability and secondary osteoarthritis. The preferred treatment approach involves internal fixation of the reduced fracture fragments, while avoiding restriction of the upper cervical spine's range of motion (ROM). Research question Is unilateral anterior transoral lag screw for treatment of unstable coronal split fracture of lateral mass of the atlas feasible and a safe treatment option? Case Report Material and Methods We report on a 55-year-old female suffering from polytrauma with multiple spinal and extremity injuries. Results A coronal split fracture of the lateral mass of the atlas was treated minimally invasive with a transoral lag screw technique to reduce and fix the fracture that has a tendency for fracture gap widening. Stable fixation and fracture union and thus restoration of function was achieved. Discussion and conclusion Transoral lag screw osteosynthesis for coronal split fracture of the lateral mass of the atlas is a potential treatment option in selected cases to preserve mobility in the upper cervical spine after spinal trauma.
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Affiliation(s)
- Christian Tinner
- Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Fabian Cedric Aregger
- Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Moritz Caspar Deml
- Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Switzerland
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Dong WX, Chu ZT, Hu Y. Treatment of unstable C1 semi-ring fractures with direct C1 pedicle screw fixation using a navigational template: A case report and literature review. Medicine (Baltimore) 2023; 102:e33800. [PMID: 37335724 DOI: 10.1097/md.0000000000033800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2023] Open
Abstract
RATIONALE Because of the risk of C1 to C2 instability, which would reduce the mobility of the occipito-atlanto-axis articulation, unstable C1 semi-ring fractures are typically treated with C1 to C2 or C0 to C2 fusion. The vertebral artery and spinal cord are at risk of harm during the installation of C1 pedicle screws. There is a need for a method that can maintain the occipito-atlanto-axis articulation's mobility and increase the safety of C1 pedicle screw fixation, particularly for surgeons who have less experience inserting C1 pedicle screws freehand. PATIENT CONCERNS A 45-year-old man who had suffered a severe fall from a height of 2.5 m presented with pain in his cervical spine. Magnetic resonance imaging and computed tomography were used to diagnose unstable atlas fractures. DIAGNOSIS According to radiographic studies, the patient had a unilateral anterior and posterior arch fracture (semi-ring fracture, Landells type II), as well as fractures and transverse ligament avulsion at the attachment site. INTERVENTIONS We fixed the C1 directly with a pedicle screw using a navigational template. OUTCOMES Both during and after the operation, there were no connected complications. Imaging at 12 months after surgery demonstrated that the fracture had united. The average visual analog scale score decreased from 8 before surgery to 2. LESSONS In particular for surgeons with less experience placing freehand C1 pedicle screws, direct C1 pedicle screw fixation with the aid of a navigational template was a good option because it can preserve the mobility of the occipito-atlanto-axis articulation and improve the safety of C1 pedicle screw.
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Affiliation(s)
- Wei-Xin Dong
- Department of Spinal Surgery, Ningbo No.6 Hospital, Ningbo, Zhejiang Province, China
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Yang K, Niu HG, Tao H, Liu C, Cao Y, Li W, Zhang JJ, Shen CL, Zhang YS. Posterior osteosynthesis with a new self-designed lateral mass screw-plate system for unstable atlas burst fractures. BMC Musculoskelet Disord 2023; 24:108. [PMID: 36759784 PMCID: PMC9909890 DOI: 10.1186/s12891-023-06209-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 01/30/2023] [Indexed: 02/11/2023] Open
Abstract
BACKGROUND In the treatment of unstable atlas fractures using the combined anterior-posterior approach or the posterior monoaxial screw-rod system, factors such as severe trauma or complex surgical procedures still need to be improved despite the favourable reduction effect. This research described and evaluated a new technique for the treatment of unstable atlas fracture using a self-designed lateral mass screw-plate system. METHODS A total of 10 patients with unstable atlas fractures using this new screw-plate system from January 2019 to December 2021 were retrospectively reviewed. All patients underwent posterior open reduction and internal fixation (ORIF) with a self-designed screw-plate system. The medical records and radiographs before and after surgery were noted. Preoperative and postoperative CT scans were used to determine the type of fracture and evaluate the reduction of fracture. RESULTS All 10 patients were successfully operated with this new system, with an average follow-up of 16.7 ± 9.6 months. A total of 10 plates were placed, and all 20 screws were inserted into the atlas lateral masses. The mean operating time was 108.7 ± 20.1 min and the average estimated blood loss was 98.0 ± 41.3 ml. The lateral mass displacement (LMD) averaged 7.1 ± 1.9 mm before surgery and almost achieved satisfactory reduction after surgery. All the fractures achieved bony healing without reduction loss or implant failure. No complications (vertebral artery injury, neurologic deficit, or wound infection) occurred in these 10 patients. At the final follow-up, the anterior atlantodens interval (AADI) was 2.3 ± 0.8 mm and the visual analog scale (VAS) was 0.6 ± 0.7 on average. All patients preserved almost full range of motion of the upper cervical spine and achieved a good clinical outcome at the last follow-up. CONCLUSIONS Posterior osteosynthesis with this new screw-plate system can provide a new therapeutic strategy for unstable atlas fractures with simple and almost satisfactory reduction.
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Affiliation(s)
- Kun Yang
- grid.412679.f0000 0004 1771 3402Department of Orthopedics, the First Affiliated Hospital of Anhui Medical University, No.218 Jixi Road, Hefei, 230022 Anhui Province China
| | - He-gang Niu
- grid.412679.f0000 0004 1771 3402Department of Orthopedics, the First Affiliated Hospital of Anhui Medical University, No.218 Jixi Road, Hefei, 230022 Anhui Province China
| | - Hui Tao
- grid.412679.f0000 0004 1771 3402Department of Orthopedics, the First Affiliated Hospital of Anhui Medical University, No.218 Jixi Road, Hefei, 230022 Anhui Province China
| | - Chang Liu
- grid.412679.f0000 0004 1771 3402Department of Orthopedics, the First Affiliated Hospital of Anhui Medical University, No.218 Jixi Road, Hefei, 230022 Anhui Province China
| | - Yun Cao
- grid.412679.f0000 0004 1771 3402Department of Orthopedics, the First Affiliated Hospital of Anhui Medical University, No.218 Jixi Road, Hefei, 230022 Anhui Province China
| | - Wei Li
- grid.412679.f0000 0004 1771 3402Department of Orthopedics, the First Affiliated Hospital of Anhui Medical University, No.218 Jixi Road, Hefei, 230022 Anhui Province China
| | - Jing-jing Zhang
- grid.412679.f0000 0004 1771 3402Department of Orthopedics, the First Affiliated Hospital of Anhui Medical University, No.218 Jixi Road, Hefei, 230022 Anhui Province China
| | - Cai-liang Shen
- grid.412679.f0000 0004 1771 3402Department of Orthopedics, the First Affiliated Hospital of Anhui Medical University, No.218 Jixi Road, Hefei, 230022 Anhui Province China
| | - Yin-shun Zhang
- grid.412679.f0000 0004 1771 3402Department of Orthopedics, the First Affiliated Hospital of Anhui Medical University, No.218 Jixi Road, Hefei, 230022 Anhui Province China
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Ottenbacher A, Rizk AR, Mehlitz M, Bettag M. Unstable jefferson burst fractures (JBF): Intraoperative stability testing after posterior atlas ring osteosynthesis (C1-RO) allows determination of surgical procedure extent. BRAIN & SPINE 2022; 2:101668. [PMID: 36506288 PMCID: PMC9729808 DOI: 10.1016/j.bas.2022.101668] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 08/03/2022] [Accepted: 10/28/2022] [Indexed: 11/11/2022]
Abstract
Introduction Motion preserving atlas ring osteosynthesis (C1-RO) for unstable Jefferson burst fractures (JBF) with insufficiency of the transverse atlantal ligament (TAL) is under debate. There is controversy about when to apply C1-RO and when further stabilization is needed. Research question Is intraoperative stability testing after C1-RO with restoration of secondary stabilizers feasible, and what are mid-to long-term results of posterior C1-RO vs. C1-C2 ORIF in unstable Jefferson burst fractures with Dickman type I or II transverse atlantal ligament lesions based on intraoperative decision using this stability testing? Material and methods Five consecutive patients with unstable JBF were treated with posterior C1-RO or C1-C2 ORIF based on the findings after intraoperative reduction and posterior C1-RO and stability testing. This newly developed intraoperative stability test based on the findings of biomechanical studies is a fluoroscopically controlled manual C1-C2 test with a force of approximately 50 N posterior-anterior stress and a tilting maneuver after C1-RO with repositioning. Clinical and radiological results of the cases with C1-RO were analyzed 3.5-21 months postoperatively. Results Posterior C1-RO was performed in four patients. One case required C1-C2 fixation due to significant instability. In cases of C1-RO, stable bony fusions of the atlas ring were observed within a year. In flexion-extension views, the anterior atlanto-dental interval (AADI) did not increase until the latest follow-up. No complications were observed. Discussion and conclusion The described intraoperative stability test after posterior C1-RO in unstable JBF enables the determination if C1-RO is sufficient or C1-C2 ORIF is necessary for treatment.
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Affiliation(s)
- Andy Ottenbacher
- Krankenhaus der Barmherzigen Brüder, Department of Neurosurgery, Trier, Germany
| | - Ahmed R. Rizk
- Krankenhaus der Barmherzigen Brüder, Department of Neurosurgery, Trier, Germany
| | - Marcus Mehlitz
- Krankenhaus der Barmherzigen Brüder, Department of Neurosurgery, Trier, Germany
| | - Martin Bettag
- Krankenhaus der Barmherzigen Brüder, Department of Neurosurgery, Trier, Germany
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10
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Yan L, Du J, Yang J, He B, Hao D, Zheng B, Yang X, Hui H, Liu T, Wang X, Guo H, Chen J, Wang S, Ma S, Dong S. C1-ring osteosynthesis versus C1-2 fixation fusion in the treatment of unstable atlas fractures: a multicenter, prospective, randomized controlled study with 5-year follow-up. J Neurosurg Spine 2022; 37:157-165. [PMID: 35148517 DOI: 10.3171/2021.12.spine211063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 12/20/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim of the present study was to compare the long-term effects of posterior C1-ring osteosynthesis and C1-2 fixation fusion in the treatment of unstable atlas fractures. METHODS A multicenter, prospective, randomized controlled trial was conducted to analyze 73 patients with atlas fractures who underwent posterior fixation. The intervention group was treated with C1-ring osteosynthesis, and the control group was treated with C1-2 fixation fusion. The patients were followed up for 6 months, 1 year, 2 years, and 5 years after the operation. RESULTS Fifty-two patients had complete data at the last follow-up. The visual analog scale (VAS) score for neck pain in the intervention group was lower than that in the control group (p < 0.001). The operation time, intraoperative blood loss, radiation dose, bedridden period, hospital stay, and cost in the intervention group were significantly lower than those in the control group (p < 0.001). At the last follow-up, the Neck Disability Index in the intervention group was higher than that of the control group, and the angle of flexion-extension and axial rotation in the intervention group were greater than those in the control group (p < 0.001). CONCLUSIONS In this study, the authors found that posterior C1-ring osteosynthesis is superior to C1-2 fixation fusion in terms of long-term relief of neck pain and preservation of the physiological function of the cervical vertebrae. This technique is a reliable choice for the treatment of unstable C1 fractures.
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Affiliation(s)
- Liang Yan
- 1Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Jinpeng Du
- 1Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Junsong Yang
- 1Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Baorong He
- 1Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Dingjun Hao
- 1Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Bolong Zheng
- 1Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Xiaobin Yang
- 1Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Hua Hui
- 1Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Tuanjiang Liu
- 1Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Xiaodong Wang
- 1Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Hua Guo
- 2Department of Orthopaedics Surgery, Xi'an Central Hospital, Xi'an, China
| | - Jian Chen
- 3Department of Spine Surgery, Yingchuan Guolong Hospital, Yingchuan, China
| | - Shaofei Wang
- 4Department of Spine Surgery, Baoji Traditional Chinese Medicine Hospital, Baoji, China
| | - Shengzhong Ma
- 5Department of Spine Surgery, The Second Hospital of Shandong University, Jinan, China; and
| | - Shengli Dong
- 6Department of Spine Surgery, General Hospital of Pingmei Shenma Group, Pingdingshan, China
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Shin JW, Suk KS, Kim HS, Yang JH, Kwon JW, Lee HM, Moon SH, Lee BH, Park SJ, Park SR, Kim SK. Direct Internal Fixation for Unstable Atlas Fractures. Yonsei Med J 2022; 63:265-271. [PMID: 35184429 PMCID: PMC8860933 DOI: 10.3349/ymj.2022.63.3.265] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 10/27/2021] [Accepted: 11/30/2021] [Indexed: 11/27/2022] Open
Abstract
PURPOSE To investigate the radiologic and clinical outcomes of direct internal fixation for unstable atlas fractures. MATERIALS AND METHODS This retrospective study included 12 patients with unstable atlas fractures surgically treated using C1 lateral mass screws, rods, and transverse connector constructs. Nine lateral mass fractures with transverse atlantal ligament (TAL) avulsion injury and three 4-part fractures with TAL injury (two avulsion injuries, one TAL substance tear) were treated. Radiologic outcomes included the anterior atlantodental interval (AADI) in flexion and extension cervical spine lateral radiographs at 6 months and 1 year after treatment. CT was also performed to visualize bony healing of the atlas at 6 months and 1 year. Visual Analog Scale (VAS) scores for neck pain, Neck Disability Index (NDI) values, and cervical range of motion (flexion, extension, and rotation) were recorded at 6 months after surgery. RESULTS The mean postoperative extension and flexion AADIs were 3.79±1.56 (mean±SD) and 3.13±1.01 mm, respectively. Then mean AADI was 3.42±1.34 and 3.33±1.24 mm at 6 months and 1 year after surgery, respectively. At 1 year after surgery, 11 patients showed bony healing of the atlas on CT images. Only one patient underwent revision surgery 8 months after primary surgery due to nonunion and instability findings. The mean VAS score for neck pain was 0.92±0.99, and the mean NDI value was 8.08±5.70. CONCLUSION C1 motion-preserving direct internal fixation technique results in good reduction and stabilization of unstable atlas fractures. This technique allows for the preservation of craniocervical and atlantoaxial motion.
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Affiliation(s)
- Jae-Won Shin
- Department of Orthopedic Surgery, National Health Insurance Service Ilsan Hospital, Goyang, Korea
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Kyung-Soo Suk
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Korea.
| | - Hak-Sun Kim
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Jae-Ho Yang
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Ji-Won Kwon
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Hwan-Mo Lee
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Sung-Hwan Moon
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Byung-Ho Lee
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Sang-Jun Park
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Sub-Ri Park
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Sun-Kyu Kim
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Korea
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De Iure F, Corghi A, Amendola L, Cappuccio M. Posterior Osteotomy and Osteosynthesis for Malunited Atlas Fracture: A Surgical Technique. Clin Spine Surg 2021; 34:342-346. [PMID: 34379612 DOI: 10.1097/bsd.0000000000001147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Accepted: 12/22/2020] [Indexed: 11/26/2022]
Abstract
Conservative treatment is commonly accepted and widely used for most atlas compression fractures. Malunion due to mismatching of the articular surfaces in C0-C1 and C1-C2 is therefore frequent even without associated instability. Such a result is considered acceptable in the elderly with low functional requests but should be avoided in young patients. Authors describe a new surgical technique to reduce and fix a nonunion and malunited fracture of the atlas through a posterior arch osteotomy followed by articular masses stabilization with polyaxial screws and precurved titanium rod. Rod prebending reduces lateral inclination of the screw heads during the reduction maneuver through compression applied between screw heads making it effective.
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Kolz JM, Hobson SL, Currier BL, Nassr AN. C1 and C2 Fractures Above a Previous Fusion Treated with Internal Fixation without Fusion: A Case Report. JBJS Case Connect 2021; 11:01709767-202106000-00028. [PMID: 33979831 DOI: 10.2106/jbjs.cc.20.00672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE A 71-year-old woman sustained C1 lateral mass and type 2 odontoid fractures 3 years after C2-T2 anterior-posterior fusion. She was treated with C1-C4 instrumentation without fusion for 9 months followed by instrumentation removal to restore atlantoaxial motion. After instrumentation removal, she maintained clinically relevant cervical lateral bending, rotation, and flexion and extension. CONCLUSION The loss of upper cervical motion after C1-C2 instrumented fusion may be debilitating for patients in the setting of previous subaxial cervical fusion. Temporary instrumentation without fusion may allow for preservation of upper cervical motion in patients with concomitant C1 and C2 fractures above a previous cervical fusion.
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Affiliation(s)
- Joshua M Kolz
- Department of Orthopaedic Surgery, Mayo Clinic, Rochester, Minnesota
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邹 小, 欧阳 北, 马 向, 陈 育, 葛 苏, 张 双, 倪 菱, 夏 虹, 吴 增. [Progress in treatment of unstable atlas fracture]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2020; 34:793-796. [PMID: 32538574 PMCID: PMC8171540 DOI: 10.7507/1002-1892.201909129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 04/07/2020] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To summarize the progress in treatment of unstable atlas fracture, the existing problems, and the research direction. METHODS Related literature at home and abroad was reviewed. The stability evaluation of atlas fracture and treatment methods were introduced, and the selection of surgical approach and fixation instruments in treatment of unstable atlas fracture were summarized and analyzed. RESULTS At present, atlas fractures are considered as unstable fractures except single anterior arch fractures with complete transverse ligament or simple posterior arch fractures. The treatment of unstable atlas fracture has been developed from nonsurgical treatment and traditional fusion surgery to single-segment fixation. Nonsurgical treatment is less effective, while traditional fusion surgery has a disadvantage of limited the motion of the upper cervical spine. Single-segment fixation can not only restore and fix the fracture, but also preserve the upper cervical motion function. Single-segment fixation approaches include posterior and transoral approaches, and the fixation instruments are being constantly improved, mainly including screw-rod system, screw-plate system, and plate system. CONCLUSION For unstable atlas fracture, single-segment fixation is an ideal surgical method, and has more advantages when compared with nonsurgical treatment and traditional fusion surgery. Single-segment fixation via transoral approach is more direct for atlas anterior arch fracture reduction, but there is a high risk of infection; and single-segment fixation via posterior approach is less effective for the reduction of atlas anterior arch fracture. Therefore, a better reduction method should be explored.
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Affiliation(s)
- 小宝 邹
- 南方医科大学第一临床医学院(广州 510515)The First School of Clinical Medicine, Southern Medical University, Guangzhou Guangdong, 510515, P.R.China
- 中国人民解放军南部战区总医院骨科(广州 510010)Department of Orthopedics, General Hospital of Southern Theatre Command of Chinese PLA, Guangzhou Guangdong, 510010, P.R.China
| | - 北平 欧阳
- 南方医科大学第一临床医学院(广州 510515)The First School of Clinical Medicine, Southern Medical University, Guangzhou Guangdong, 510515, P.R.China
- 中国人民解放军南部战区总医院骨科(广州 510010)Department of Orthopedics, General Hospital of Southern Theatre Command of Chinese PLA, Guangzhou Guangdong, 510010, P.R.China
| | - 向阳 马
- 南方医科大学第一临床医学院(广州 510515)The First School of Clinical Medicine, Southern Medical University, Guangzhou Guangdong, 510515, P.R.China
- 中国人民解放军南部战区总医院骨科(广州 510010)Department of Orthopedics, General Hospital of Southern Theatre Command of Chinese PLA, Guangzhou Guangdong, 510010, P.R.China
| | - 育岳 陈
- 南方医科大学第一临床医学院(广州 510515)The First School of Clinical Medicine, Southern Medical University, Guangzhou Guangdong, 510515, P.R.China
| | - 苏 葛
- 南方医科大学第一临床医学院(广州 510515)The First School of Clinical Medicine, Southern Medical University, Guangzhou Guangdong, 510515, P.R.China
| | - 双 张
- 南方医科大学第一临床医学院(广州 510515)The First School of Clinical Medicine, Southern Medical University, Guangzhou Guangdong, 510515, P.R.China
| | - 菱 倪
- 南方医科大学第一临床医学院(广州 510515)The First School of Clinical Medicine, Southern Medical University, Guangzhou Guangdong, 510515, P.R.China
| | - 虹 夏
- 南方医科大学第一临床医学院(广州 510515)The First School of Clinical Medicine, Southern Medical University, Guangzhou Guangdong, 510515, P.R.China
| | - 增晖 吴
- 南方医科大学第一临床医学院(广州 510515)The First School of Clinical Medicine, Southern Medical University, Guangzhou Guangdong, 510515, P.R.China
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Kim MK, Shin JJ. Comparison of radiological and clinical outcomes after surgical reduction with fixation or halo-vest immobilization for treating unstable atlas fractures. Acta Neurochir (Wien) 2019; 161:685-693. [PMID: 30710241 DOI: 10.1007/s00701-019-03824-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Accepted: 01/23/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND Unstable atlas fractures with concomitant transverse atlantal ligament (TAL) injury may be conservatively managed by halo-vest immobilization (HVI) or surgically treated by various fixation techniques. Many surgeons prefer surgical management due to complications, nonunion, and further dislocations with HVI. There are no comparative studies on surgical and nonsurgical management of unstable atlas fractures. We retrospectively assessed the radiological and clinical outcomes of surgical reduction with fixation vs. non-operative treatments for unstable atlas fractures with TAL rupture. METHODS We analyzed records of 24 patients (15 men, 9 women; mean age, 48.3 years) with at least 1 year of follow-up. They underwent HVI or surgical reduction with fixation for unstable atlas fracture combined with TAL injury. Clinical outcomes, including neck visual analog scale and neck disability index (NDI), and radiological measurements, including degree of fracture displacement, atlantodental interval (ADI), range of motion (ROM), cervical alignment, fusion rate, and time-to-fusion, were assessed. RESULTS Of the 24 patients, 13 were treated by surgical reduction with fixation (C1 lateral mass screw-C2 pedicle screw with a cross-link) and 11 by HVI. A significant reduction in lateral displacement of fractured lateral masses was identified in surgical reduction with fixation (3.21 ± 1.21 mm) compared with HVI (0.97 ± 2.69 mm). The mean reduction in ADI was 1.47 ± 1.08 mm with surgical fixation and 0.66 ± 1.02 mm with HVI. The bony rate and time-to-fusion were 100% and 14.91 ± 3.9 weeks with surgical reduction, and 72.7% and 22.31 ± 10.85 weeks with HVI. The postoperative neck pain relief and NDI after surgical fixation were higher than those after HVI. CONCLUSIONS Compared with HVI, surgical reduction with fixation reduces fractured lateral mass displacements, increases fusion rate, and reduces time-to-fusion while maintaining cervical curvature and improving neck pain and daily activities.
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Affiliation(s)
- Moon Kyu Kim
- Department of Neurosurgery, Sanggye Paik Hospital, Inje University College of Medicine, Dongil-ro 1342, Nowon-gu, Seoul, 01757, South Korea
| | - Jun Jae Shin
- Department of Neurosurgery, Sanggye Paik Hospital, Inje University College of Medicine, Dongil-ro 1342, Nowon-gu, Seoul, 01757, South Korea.
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Abstract
Fractures of the C1 vertebrae (atlas) are commonly the result of falls and other trauma, which cause hyperextension, or axial compression of the cervical spine. Although historically thought as a benign injury with lower neurological risks, current data suggests that this may not hold true for geriatric patients (aged 65 y and older) who may be predisposed to these fractures even after lower-energy trauma such as ground-level falls. Advancements in orthopedic trauma care has increased our diagnostic abilities to identify and manage patients with C1 fractures and other upper cervical spine trauma. However, there are no universal treatment guidelines based on level I trials. Current treatment ranges from nonoperative to operative management depending on fracture-pattern and integrity of the surrounding ligaments. Furthermore, in the elderly patients these fractures present a unique dilemma due to preexisting comorbidities and contraindications to various treatment modalities. C1 fractures warrant greater recognition to provide optimal treatment to patients and minimize the risk for developing complications. The goal of this review is to highlight the most updated treatment guidelines and to discuss the complications of both operative and nonoperative management of C1 fractures especially among the elderly patient population.
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Keskil S, Göksel M, Yüksel U. Transoral screw and wire fixation for unstable anterior ½ atlas fracture. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2018; 8:364-368. [PMID: 29403251 PMCID: PMC5763596 DOI: 10.4103/jcvjs.jcvjs_94_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Study Design: Atlas fractures are evaluated according to the fracture type and ligamentous injury. External immobilization may result in fracture nonunion. Objective: The ideal treatment method for non-stabilized atlas fractures is limited fixation without restricting the range of motion of the atlantoaxial and atlantooccipital joints. Summary of Background Data: Such a result can be established by using either anterior fixation or posterior lateral mass fixation. However, none of these techniques can fully address anterior 1/2 atlas fractures such as in this case. Materials and Methods: A transoral technique in which bilateral screws were placed intralaminarly and connected with wire was used to reduce and stabilize an anterior 1/2 fracture of C1. Result: Radiological studies after the surgery showed good cervical alignment, no screw or wire failure and good reduction with fusion of anterior arcus of C1. Conclusions: Internal immobilization by this screw and wire osteosynthesis technique protects the mobility of the atlanto-occipital and atlantoaxial joints. The main advantage is that neither the twisted wires inserted under the anterior lamina, nor the laterally placed screw heads interfere with midline wound closure; unlike the plate/cage and rod systems used together with anterior screws. A computer navigation system with intraoperative 3D imaging facilities will be of benefit for safe placement of the screw, however we preferred a free-hand technique, as the starting point was at the fracture line along the trajectory of the routinely accessible anterior lamina.
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Affiliation(s)
- Semih Keskil
- Department of Neurosurgery, Kırıkkale University Medical School, Kırıkkale, Turkey
| | - Murat Göksel
- Department of Neurosurgery, Kırıkkale University Medical School, Kırıkkale, Turkey
| | - Ulas Yüksel
- Department of Neurosurgery, Kırıkkale University Medical School, Kırıkkale, Turkey
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Zhang YS, Zhang JX, Yang QG, Li W, Tao H, Shen CL. Posterior osteosynthesis with monoaxial lateral mass screw-rod system for unstable C1 burst fractures. Spine J 2018; 18:107-114. [PMID: 28739475 DOI: 10.1016/j.spinee.2017.06.029] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 06/21/2017] [Accepted: 06/27/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Surgical treatment for unstable atlas fractures has evolved in recent decades from C1-C2 or C0-C2 fusion to motion-preservation techniques of open reduction and internal fixation (ORIF). However, regardless of a transoral or a posterior approach, the reduction is still not satisfactory. PURPOSE The article describes and evaluates a new technique for treating unstable atlas fractures by using a monoaxial screw-rod system. STUDY DESIGN This is a retrospective study. PATIENT SAMPLE The sample includes adult patients with unstable C1 fractures treated with a posterior monoaxial screw-rod system. OUTCOME MEASURES The outcome measures included a visual analog pain scale, radiographic reduction (lateral mass displacement [LMD]), maintenance of reduction, C1-C2 instability (anterior atlantodens interval), and complications. MATERIALS AND METHODS From August 2013 to May 2016, nine consecutive patients with unstable atlas fractures were retrospectively reviewed. All patients were treated with posterior ORIF by using a monoaxial screw-rod system. The medical records and the preoperative and postoperative radiographs were reviewed. Preoperative and postoperative computed tomography scans were used to specify the fracture types and to assess the reduction. RESULTS All nine patients with a mean age of 50.3 years successfully underwent surgery with this technique, and a follow-up of 17.4±9.3 months was performed. Transverse atlantal ligament (TAL) injury was found in eight of the nine patients: one of type I and seven of type II. The preoperative LMD averaged 7.0±2.2 mm and was restored completely after surgery; all the fractures achieved bony healing without loss of reduction or implant failure. None of the patients had complications of neurologic deficit, vertebral artery injury, or wound infection associated with the surgical procedure. Two patients complained of greater occipital nerve neuralgia after the operation, which gradually disappeared in 1 month. All patients had a well-preserved range of motion of the upper cervical spine at the final follow-up. CONCLUSIONS Posterior osteosynthesis with a monoaxial screw-rod system is capable of an almost anatomical reduction for the unstable atlas fractures. The TAL incompetence may not be a contraindication to ORIF for C1 fractures, but the long-term effect of C1-C2 instability remains to be further investigated.
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Affiliation(s)
- Yin-Shun Zhang
- Department of Orthopaedics, the First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Jian-Xiang Zhang
- Department of Orthopaedics, the First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Qing-Guo Yang
- Department of Orthopaedics, the First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Wei Li
- Department of Orthopaedics, the First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Hui Tao
- Department of Orthopaedics, the First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Cai-Liang Shen
- Department of Orthopaedics, the First Affiliated Hospital of Anhui Medical University, Hefei, China.
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Kim HS, Cloney MB, Koski TR, Smith ZA, Dahdaleh NS. Management of Isolated Atlas Fractures: A Retrospective Study of 65 Patients. World Neurosurg 2017; 111:e316-e322. [PMID: 29258944 DOI: 10.1016/j.wneu.2017.12.053] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 12/08/2017] [Accepted: 12/09/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Jefferson fractures, or burst fractures of the C1 vertebra, can be managed surgically or conservatively, depending on their stability. METHODS We identified all patients who were treated for a C1 fracture at our institution between 1999 and 2016 for retrospective analysis. Patients with any other concurrent cervical fractures or nontraumatic etiology of fracture were excluded. Stability was defined as either lateral mass displacement ≥7 mm on computed tomography or presence of transverse atlantal ligament disruption on magnetic resonance imaging. We collected data on patients' demographic, clinical, and radiographic presentation and identified variables independently associated with instability at presentation and failure to achieve fusion at follow-up. RESULTS We identified 65 patients. On multivariable regression, instability at presentation was independently associated with atlantodens interval (odds ratio [OR] 2.357, 95% confidence interval [CI] [0.0629-1.271], P = 0.099) and type 3 fracture (OR 6.081, 95% CI [1.068-34.612], P = 0.042). Failure to achieve fusion was independently associated with age (OR 1.226, 95% CI [1.007-1.495], P = 0.043), motor vehicle collision as mechanism of injury (OR 22834.3, 95% CI [3.135-1.66e8], P = 0.027), and type 2 fracture (OR 168.537, 95% CI [1.743-16292.92], P = 0.028). Type 3 fracture was positively associated with halo vest for management (OR 17.171, 95% CI [2.882-102.289], P = 0.002) and negatively associated with a rigid cervical collar for management (OR 0.0616, 95% CI [0.0104-0.3653], P = 0.002). All 4 patients who underwent surgery presented with unstable fracture (P = 0.0187). CONCLUSIONS Atlantodens interval, mechanism of injury, and fracture type affect Jefferson fracture management decisions and outcomes, including instability at presentation and fusion at follow-up. Most fractures were managed nonsurgically regardless of stability.
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Affiliation(s)
- Hyun Su Kim
- Department of Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Michael Brendan Cloney
- Department of Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Tyler R Koski
- Department of Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Zachary A Smith
- Department of Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Nader S Dahdaleh
- Department of Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA.
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Abstract
Most atlas fractures are the result of compression forces. They are often combined with fractures of the axis and especially with the odontoid process. Multiple classification systems for atlas fractures have been described. For an adequate diagnosis, a computed tomography is mandatory. To distinguish between stable and unstable atlas injury, it is necessary to evaluate the integrity of the transverse atlantal ligament (TAL) by magnetic resonance imaging and to classify the TAL lesion. Studies comparing conservative and operative management of unstable atlas fractures are unfortunately not available in the literature; neither are studies comparing different operative treatment strategies. Hence all treatment recommendations are based on low level evidence. Most of atlas fractures are stable and will be successfully managed by immobilization in a soft/hard collar. Unstable atlas fractures may be treated conservatively by halo-fixation, but nowadays more and more surgeons prefer surgery because of the potential discomfort and complications of halo-traction. Atlas fractures with a midsubstance ligamentous disruption of TAL or severe bony ligamentous avulsion can be treated by a C1/2 fusion. Unstable atlas fractures with moderate bony ligamentous avulsion may be treated by atlas osteosynthesis. Although the evidence for the different treatment strategies of atlas fractures is low, atlas osteosynthesis has the potential to change treatment philosophies. The reasons for this are described in this review.
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Krassnig R, Orlandi JA, Tackner E, Hohenberger G, Puchwein P. Computer-aided analysis for optimal screw insertion in lateral mass of C1: An anatomical study. Arch Orthop Trauma Surg 2017; 137:817-822. [PMID: 28357498 PMCID: PMC5432586 DOI: 10.1007/s00402-017-2678-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2016] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Motion preserving techniques in C1 ring fractures are increasingly used especially in young patients. Therefore, lateral mass screws are inserted in the first vertebra and connected by a rod. The purpose of this study was to determine safe zones regarding the vertebral arteries and the medulla oblongata for optimal lateral mass screw positioning when fusing the C1-ring. MATERIALS AND METHODS Images of the cervical spine of 50 patients (64-line CT scanner) were evaluated and virtual screws were positioned in both lateral masses of the first vertebra using 3D-reconstructions of CT scans. The length of the screws, the insertion angles in two planes, the distance to the vertebral artery, and the spinal canal was investigated. Descriptive statistics was used and gender-dependent differences were calculated using student t-test. A diameter of 4 mm was chosen for the screws. RESULTS The mean screw length was 30.0 ± 2.3 mm on the right and 30.1 ± 2.1 mm on the left side. The arithmetic mean for the transverse angle was 16.4 ± 5.6° on the right and 15.6 ± 6.3° on the left, the sagittal angle averaged 8.3 ± 3.8° on the right, and 11.0 ± 4.9° on the left side. The mean distance between screw and spinal canal has been determined on the right with 2.4 ± 0.7 mm and 2.2 ± 0.6 mm on the left side. The distance from the C1 lateral mass screw to the vertebral artery was on average 7.1 ± 1.5 mm on the right side (significant correlation with gender, p value: 0.03) and 7.4 ± 1.4 mm on the left side. CONCLUSIONS Screws should be positioned with a slightly converging angle of 16° and a slightly ascending angle of 10°. Due to the required high precision technique intraoperatively multiplanar 2 D or 3 D imaging is recommended to avoid harm to the vertebral artery or the spinal canal.
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Affiliation(s)
- Renate Krassnig
- Department of Orthopedics and Traumatology, Medical University Graz (MUG), Auenbruggerplatz 5, 8036 Graz, Austria
| | - Jakob Andrea Orlandi
- Department of Orthopedics and Traumatology, Medical University Graz (MUG), Auenbruggerplatz 5, 8036 Graz, Austria
| | - Ellen Tackner
- Department of Orthopedics and Traumatology, Medical University Graz (MUG), Auenbruggerplatz 5, 8036 Graz, Austria
| | - Gloria Hohenberger
- Department of Orthopedics and Traumatology, Medical University Graz (MUG), Auenbruggerplatz 5, 8036 Graz, Austria
| | - Paul Puchwein
- Department of Orthopedics and Traumatology, Medical University Graz (MUG), Auenbruggerplatz 5, 8036 Graz, Austria
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Abstract
INTRODUCTION Ring fixation of C1 can be performed using pedicle screws and a rod in case of unstable Jefferson or lateral mass fractures of C1. MATERIALS AND METHODS In a case series of three patients, we stabilized C1 fractures surgically using a modified technique of C1 ring fixation by using monoaxial instead of polyaxial screws. Functional outcome and pain was recorded postoperatively. RESULTS In this very small case series, we observed good results concerning pain and functional outcome. All fractures were bony healed within 13 weeks. In one case, a screw penetrated the spinal canal and had to be repositioned. A mild irritation of C2 nerve root occurred in two cases postoperatively. CONCLUSION C1 Ring fusion with monoaxial screws provides a good ability to reduce the fracture indirectly by the screws and the rod itself.
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Bednar DA, Almansoori KA. Solitary C1 Posterior Fixation for Unstable Isolated Atlas Fractures: Case Report and Systematic Review of the Literature. Global Spine J 2016; 6:375-82. [PMID: 27190741 PMCID: PMC4868582 DOI: 10.1055/s-0035-1564806] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Accepted: 08/19/2015] [Indexed: 11/11/2022] Open
Abstract
Study Design A systematic review of the literature. Objectives To review the published results to date of motion-preserving direct reconstruction of C1 ring fractures with combined coronal plane displacement of at least 7 mm (rule of Spence) and so at risk for Dickman type I or II disruption of the transverse atlantal ligament (TAL). Methods A structured literature review prompted by successful management of a typical case. Results To date only 65 such cases are reported and follow-up is almost uniformly short. Although reported clinical success is uniform, the case mix is heterogenous and confirmation/classification of ligamentous injury at baseline is often lacking. Conclusions Direct C1 stabilization shows promise as a "more selective" option in managing displaced atlas fractures with probable TAL disruption but cannot yet be recommended as a practice standard. Prospective clinical studies are indicated and should be structured so as to differentiate between Dickman type I and type II injuries of the TAL.
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Affiliation(s)
- Drew A. Bednar
- Division of Orthopedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Khaled A. Almansoori
- Division of Orthopedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
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Keskil S, Göksel M, Yüksel U. Unilateral lag-screw technique for an isolated anterior 1/4 atlas fracture. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2016; 7:50-4. [PMID: 27041886 PMCID: PMC4790149 DOI: 10.4103/0974-8237.176625] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
STUDY DESIGN Fractures of the atlas are classified based on the fracture location and associated ligamentous injury. Among patients with atlas fractures treated using external immobilization, nonunion of the fracture could be seen. OBJECTIVE Ideally, treatment strategy for an unstable atlas fracture would involve limited fixation to maintain the fracture fragments in a reduced position without restricting the range of motion (ROM) of the atlantoaxial and atlantooccipital joints. SUMMARY OF BACKGROUND DATA Such a result can be established using either transoral limited internal fixation or limited posterior lateral mass fixation. However, due to high infection risk and technical difficulty, posterior approaches are preferred but none of these techniques can fully address anterior 1/4 atlas fractures such as in this case. MATERIALS AND METHODS A novel open and direct technique in which a unilateral lag screw was placed to reduce and stabilize a progressively widening isolated right-sided anterior 1/4 single fracture of C1 that was initially treated with a rigid cervical collar is described. RESULTS Radiological studies made after the surgery showed no implant failure, good cervical alignment, and good reduction with fusion of C1. CONCLUSIONS It is suggested that isolated C1 fractures can be surgically reduced and immobilized using a lateral compression screw to allow union and maintain both C1-0 and C1-2 motions, and in our knowledge this is the first description of the use of a lag screw to achieve reduction of distracted anterior 1/4 fracture fragments of the C1 from a posterior approach. This technique has the potential to become a valuable adjunct to the surgeon's armamentarium, in our opinion, only for fractures with distracted or comminuted fragments whose alignment would not be expected to significantly change with classical lateral mass screw reduction.
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Affiliation(s)
- Semih Keskil
- Department of Neurosurgery, Medical School, Kırıkkale University, Kırıkkale, Turkey
| | - Murat Göksel
- Department of Neurosurgery, Medical School, Kırıkkale University, Kırıkkale, Turkey
| | - Ulaş Yüksel
- Department of Neurosurgery, Medical School, Kırıkkale University, Kırıkkale, Turkey
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Shatsky J, Bellabarba C, Nguyen Q, Bransford RJ. A retrospective review of fixation of C1 ring fractures--does the transverse atlantal ligament (TAL) really matter? Spine J 2016; 16:372-9. [PMID: 26656168 DOI: 10.1016/j.spinee.2015.11.041] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Revised: 09/10/2015] [Accepted: 11/18/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT In contrast to the majority of outcome data, many consider C1 fractures to be benign injuries and so have advocated for conservative management, except in the case of concomitant transverse atlantal ligament (TAL) injury where C1-C2 or occiput-C2 fusions are recommended. PURPOSE Our goal was to evaluate a series of unstable C1 fractures treated with C1 open reduction and internal fixation (ORIF) to assess clinical and radiographic outcomes by determining the success of reduction and pain relief. STUDY DESIGN/SETTING This is a retrospective cohort review. PATIENT SAMPLE The sample includes adult patients with unstable C1 fractures treated with open reduction and primary internal fixation. OUTCOME MEASURES Primary outcome measures included visual analog pain scale (VAS), radiographic reduction (lateral mass displacement), maintenance of reduction, C1-C2 instability, and complications. METHODS A retrospective review of all patients with C1 fractures between September 2002 and September 2013 identified 12 consecutive patients from a level I trauma center who were treated with primary internal fixation without fusion. Electronic medical records and preoperative and postoperative radiographs were reviewed. The surgical technique consisted of a posterior cervical approach to the C1 arch and open reduction using bilateral C1 lateral mass screws connected transversely with a rod. Pre- and postoperative computed tomography scans were used to assess reduction. Long-term follow-up flexion and extension radiographs were used to assess C1-C2 stability. The authors did not receive relevant funding in relation to this research. RESULTS Twelve patients underwent C1 ORIF, with a mean age of 43 (9 males and 3 females) and a mean follow-up of 17 months. Transverse atlantal ligament was found to be disrupted with type I or type II injury in 11 of the 12 patients: 5 type I and 6 type II. Preoperative lateral mass displacement averaged 7.1 mm, with postoperative displacement after reduction averaging 2.4 mm (p-value <.001). The VAS score averaged 0.7 at latest follow-up. No patients went on to develop C1-C2 instability on final flexion-extension films. No patients had a complication that resulted in neurologic deficit or vascular injury associated with the procedure. No patients were found to have late sequelae of malunion or loss of reduction. Two surgically related complications occurred, namely one patient with errant screw requiring return to the operating room (OR) and one with arthrosis of the occipital-C1 joint. CONCLUSIONS Although a small series, early evidence suggests that patients with unstable C1 ring fractures can be successfully managed with primary ORIF. Open reduction and internal fixation results in a stable construct that maintains reduction, results in excellent pain control, and does not lead to C1-C2 instability. In our series, we have not observed the presence of TAL injury to adversely affect outcomes, and thus do not believe it is a contraindication to ORIF. Comparative studies comparing internal fixation with non-operative, C1-C2, or occiput-C2 fusions would yield more insight into optimal treatment options for these fractures.
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Affiliation(s)
- Joshua Shatsky
- Department of Orthopedics and Sports Medicine, Harborview Medical Center, Box 359798, 325 Ninth Ave, Seattle, WA 98104-2499, USA.
| | - Carlo Bellabarba
- Department of Orthopedics and Sports Medicine, Harborview Medical Center, Box 359798, 325 Ninth Ave, Seattle, WA 98104-2499, USA
| | - Quynh Nguyen
- Department of Orthopedics and Sports Medicine, Harborview Medical Center, Box 359798, 325 Ninth Ave, Seattle, WA 98104-2499, USA
| | - Richard J Bransford
- Department of Orthopedics and Sports Medicine, Harborview Medical Center, Box 359798, 325 Ninth Ave, Seattle, WA 98104-2499, USA
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Han SH, Hyun SJ, Jahng TA, Kim KJ. Posterior osteosynthesis of a spontaneous bilateral pedicle fracture of the lumbar spine. J Neurosurg Spine 2015; 24:398-401. [PMID: 26588501 DOI: 10.3171/2015.7.spine141207] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Spontaneous bilateral pedicle fractures of the lumbar spine are rare, and an optimal surgical treatment has not been suggested. The authors report the case of a 50-year-old woman who presented with low-back pain and right leg radiating pain of 1 year's duration. Radiological studies revealed a spontaneous bilateral pedicle fracture of L-5. All efforts at conservative treatment failed, and the patient underwent surgery for osteosynthesis of the fractured pedicle using bilateral pedicle screws connected with a bent rod. Her low-back and right leg pain were relieved postoperatively. A CT scan performed 3 months postoperatively revealed the disappearance of the pedicle fracture gap and presence of newly formed bony trabeculation. In rare cases of spontaneous bilateral pedicle fracture of the lumbar spine, osteosynthesis of the fractured pedicle using bilateral pedicle screws and a bent rod is a motion-preserving technique that may be an effective option when conservative management has failed.
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Affiliation(s)
- Sang-Hyun Han
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Seung-Jae Hyun
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Tae-Ahn Jahng
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Ki-Jeong Kim
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
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Kim MS, Kim JY, Kim IS, Cho KS, Kim SD, Lee HJ, Kim JT, Hong JT. The effect of C1 bursting fracture on comparative anatomical relationship between the internal carotid artery and the atlas. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2015; 25:103-109. [PMID: 25753004 DOI: 10.1007/s00586-015-3848-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Revised: 12/30/2014] [Accepted: 02/26/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE To describe the effect of the C1 bursting fracture on the location of the internal carotid artery (ICA) around the atlas. METHODS The authors analyzed the morphology of the atlas and the ICA in 15 patients with C1 bursting fracture and compared with control group (77 patients) without any pathology. All patients were evaluated with CT angiography for the anatomical assessment. The laterality of the ICA, the distances of the ICA from the midline, anterior tubercle, and ventral surface of the C1 lateral mass were compared between two groups. The distance between the lateral margin of the longus capitis muscle and the inner edge of the transverse foramen was also measured. RESULTS Medially located ICA was more common in the C1 bursting fracture group than control group (76.7 vs 42.8 %). There were no significant differences between 2 groups for the distance from the midline, anterior tubercle, and ventral surface of the C1 lateral mass, respectively. The distance of the longus capitis muscle to transverse foramen was 2.52 ± 2.09 and 4.15 ± 3.09 mm in each group, and there was statistically significant difference (p < 0.01). CONCLUSIONS Lateral displacement of the bony structure of C1 bursting fracture changes the relative location of the ICA medially, which increase the injury risk during the bicortical C1 screw insertion. These data suggest that CT angiography or enhanced CT scans can give critical information to choose the ideal fixation technique and the proper trajectory of the screws for C1 bursting fracture.
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He B, Yan L, Zhao Q, Chang Z, Hao D. Self-designed posterior atlas polyaxial lateral mass screw-plate fixation for unstable atlas fracture. Spine J 2014; 14:2892-6. [PMID: 24768734 DOI: 10.1016/j.spinee.2014.04.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Revised: 03/16/2014] [Accepted: 04/15/2014] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Most atlas fractures can be effectively treated nonoperatively with external immobilization unless there is an injury to the transverse atlantal ligament. Surgical stabilization is most commonly achieved using a posterior approach with fixation of C1-C2 or C0-C2, but these treatments usually result in loss of the normal motion of the C1-C2 and C0-C1 joints. PURPOSE To clinically validate feasibility, safety, and value of open reduction and fixation using an atlas polyaxial lateral mass screw-plate construct in unstable atlas fractures. STUDY DESIGN Retrospective review of patients who sustained unstable atlas fractures treated with polyaxial lateral mass screw-plate construct. PATIENT SAMPLE Twenty-two patients with unstable atlas fractures who underwent posterior atlas polyaxial lateral mass screw-plate fixation were analyzed. OUTCOME MEASURES Visual analog scale, neurologic status, and radiographs for fusion. METHODS From January 2011 to September 2012, 22 patients with unstable atlas fractures were treated with this technique. Patients' charts and radiographs were reviewed. Bone fusion, internal fixation placement, and integrity of spinal cord and vertebral arteries were assessed via intraoperative and follow-up imaging. Neurologic function, range of motion, and pain levels were assessed clinically on follow-up. RESULTS All patients were followed up from 12 to 32 months, with an average of 22.5±18.0 months. A total of 22 plates were placed, and all 44 screws were inserted into the atlas lateral masses. The mean duration of the procedure was 86 minutes, and the average estimated blood loss was 120 mL. Computed tomography scans 9 months after surgery confirmed that fusion was achieved in all cases. There was no screw or plate loosening or breakage in any patient. All patients had well-preserved range of motion. No vascular or neurologic complication was noted, and all patients had a good clinical outcome. CONCLUSIONS An open reduction and posterior internal fixation with atlas polyaxial lateral mass screw-plate is a safe and effective surgical option in the treatment of unstable atlas fractures. This technique can provide immediate reduction and preserve C1-C2 motion.
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Affiliation(s)
- Baorong He
- Department of Spine Surgery, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, Friendship Road 555, Xi'an 710054, China
| | - Liang Yan
- Department of Spine Surgery, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, Friendship Road 555, Xi'an 710054, China
| | - Qinpeng Zhao
- Department of Spine Surgery, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, Friendship Road 555, Xi'an 710054, China
| | - Zhen Chang
- Department of Spine Surgery, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, Friendship Road 555, Xi'an 710054, China
| | - Dingjun Hao
- Department of Spine Surgery, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, Friendship Road 555, Xi'an 710054, China.
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Li-jun L, Ying-chao H, Ming-jie Y, Jie P, Jun T, Dong-sheng Z. Biomechanical analysis of the longitudinal ligament of upper cervical spine in maintaining atlantoaxial stability. Spinal Cord 2014; 52:342-7. [DOI: 10.1038/sc.2014.8] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2013] [Revised: 01/07/2014] [Accepted: 01/13/2014] [Indexed: 11/09/2022]
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Abstract
BACKGROUND Majority of C1 fractures can be effectively treated conservatively by immobilization or traction unless there is an injury to the transverse ligament. Conservative treatment usually involves a long period of immobilization in a halo-vest. Surgical intervention generally involves fusion, eliminating the motion of the upper cervical spine. We describe the treatment of unstable Jefferson fractures designed to avoid these problems of both conservative and invasive methods. MATERIALS AND METHODS A retrospective review of 12 patients with unstable Jefferson fractures treated with transoral osteosynthesis of C1 between July 2008 and December 2011 was performed. A steel plate and C1 lateral mass screw fixation were used to repair the unstable Jefferson fractures. Our study group included eight males and four females with an average age of 33 years (range 23-62 years). RESULTS Patients were followed up for an average of 16 months after surgery. Range of motion of the cervical spine was by and large physiologic: Average flexion 35° (range 28-40°), average extension 42° (range 30-48°). Lateral bending to the right and left averaged 30° and 28° respectively (range 12-36° and 14-32° respectively). The average postoperative rotation of the atlantoaxial joint, evaluated by functional computed tomography scan was 60° (range 35-72°). Total average lateral displacement of the lateral masses was 7.0 mm before surgery (range 5-12 mm), which improved to 3.5 mm after surgery (range 1-6.5 mm). The total average difference of the atlanto-dens interval in flexion and extension after surgery was 1.0 mm (range 1-3 mm). CONCLUSIONS Transoral osteosynthesis of the anterior ring using C1 lateral mass screws is a viable option for treating unstable Jefferson fractures, which allows maintenance of rotation at the C1-C2 joint and restoration of congruency of the atlanto-occipital and atlantoaxial joints.
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Affiliation(s)
- Yong Hu
- Department of Spinal Surgery, Ningbo No. 6 Hospital, Ningbo 315040, Zhejiang Province, People's Republic of China
| | - Todd J Albert
- Department of Orthopaedic Surgery, Thomas Jefferson University and Rothman Institute, Philadelphia, Pennsylvania 19107, USA
| | - Christopher K Kepler
- Department of Orthopaedic Surgery, Thomas Jefferson University and Rothman Institute, Philadelphia, Pennsylvania 19107, USA
| | - Wei-Hu Ma
- Department of Spinal Surgery, Ningbo No. 6 Hospital, Ningbo 315040, Zhejiang Province, People's Republic of China
| | - Zhen-Shan Yuan
- Department of Spinal Surgery, Ningbo No. 6 Hospital, Ningbo 315040, Zhejiang Province, People's Republic of China
| | - Wei-Xin Dong
- Department of Spinal Surgery, Ningbo No. 6 Hospital, Ningbo 315040, Zhejiang Province, People's Republic of China
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Ma W, Xu N, Hu Y, Li G, Zhao L, Sun S, Jiang W, Liu G, Gu Y, Liu J. Unstable atlas fracture treatment by anterior plate C1-ring osteosynthesis using a transoral approach. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2013; 22:2232-9. [PMID: 23775293 PMCID: PMC3804683 DOI: 10.1007/s00586-013-2870-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2012] [Revised: 03/14/2013] [Accepted: 06/07/2013] [Indexed: 10/26/2022]
Abstract
STUDY DESIGN A retrospective study was conducted to evaluate anterior plate fixation of unstable atlas fractures using a transoral approach. OBJECTIVE To further investigate the safety and efficacy of this surgical technique, as there is currently a paucity of available data. While most atlas fractures can be managed by external immobilization with favorable results, surgery is usually preferable in highly unstable cases. Surgical stabilization is most commonly achieved using a posterior approach with fixation of C1-C2 or C0-C2, but these techniques usually result in loss of joint function and cannot fully stabilize anterior arch fractures of the atlas. Although a transoral approach circumvents these issues, only nine cases were described in the literature to our knowledge. METHODS Twenty patients with unstable atlas fractures were treated with this technique during a 6-year period. Screw and plate placement, bone fusion, and integrity of spinal cord and vertebral arteries were assessed via intraoperative and follow-up imaging. Neurologic function, range of motion, strength, pain levels, and signs of infection were assessed clinically upon follow-up. RESULTS There were no incidents of screw loosening or breakage, plate displacement, spinal cord injury, or vertebral artery injury. A total of 20 plates were placed and all 40 screws were inserted into the atlas lateral masses. CT scans demonstrated that two screws were placed too close to the vertebral artery canal, but without clinical consequences. Imaging demonstrated that bone fusion was achieved in all cases by 6 months postoperatively, without intervertebral instability. No plate-related complications were observed in any patients during the follow-up period. CONCLUSIONS C1 anterior plate fixation using a transoral approach appears to be a safe, reliable, and function-preserving surgical method for the management of unstable atlas fractures. For this type of fracture, a transoral approach with anterior fixation should be considered as an alternative to posterior approaches or conservative treatments.
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Affiliation(s)
- Weihu Ma
- Department of Orthopedics, Sixth Hospital of Ningbo, 1059 Zhongshan East Road, Ningbo, 315040, People's Republic of China,
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