Treatment of Jefferson fracture with a halo apparatus. Report of two cases

Jefferson fracture as sport injury in weight-lifting athlete: A rare case report and literature review

INTRODUCTION AND IMPORTANCE

Cervical spine fractures are rare in sports, but their potentially grave consequences mean that they must be given special attention. The aim of this study was to present the case of a recreational athlete with a fracture of C1 resulting from weightlifting.

CASE PRESENTATION

Young, recreational athlete came with severe neck pain right after weightlifting. There was no neurologic deficits occurred. X ray and CT scan examination showed complete fracture of the right posterior and anterior arch of C1 and disruptions of the right transverse foramen and ligament. MRI revealed no sign of impingement or compromised canal. Patient was then treated conservatively with sternal occipital mandibular immobilizer (SOMI) brace for 4 weeks. Thereafter, the neck pain resolved gradually. No neurologic deterioration occurred. At time of brace removal, patient was free of pain with normal motoric and sensory function.

CLINICAL DISCUSSION

Our case was the first report of a Jefferson fracture caused by a direct injury mechanism due to the weightlifting sport. The type III Jefferson fracture produced by this contrary injury mechanism showed that with adequate force, another spectrum of injury mechanisms may be created.

CONCLUSION

With adequate assessment and proper patient selection, Jefferson fracture can be treated effectively by SOMI brace with excellent functional outcomes.

The effect of C1 bursting fracture on comparative anatomical relationship between the internal carotid artery and the atlas

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.

C1 fracture in a patient with a congenital cleft in the posterior arch: report on a failed conservative treatment

Unstable burst fractures of the atlas require sufficient immobilisation either with an external device or by surgical fusion. In patients with pre-existing congenital atlantal defects the decision whether to recommend non-operative or operative therapy is difficult. Treatment options are controversially discussed and standardised guidelines are not available. Although most surgeons advise operative fusion or osteosynthesis in atlanto-axial instability, non-operative immobilisation can be successful. We report on a patient with an unstable C1 burst fracture with a congenital posterior cleft in the atlantal arch who was treated with cervical extension and halovest immobilisation. Although callus bridging was initially observed, 9 months after the injury there was no sufficient fracture consolidation and surgical fusion had to be advised. While non-operative treatment may work in patients without congenital defects of the C1 arch, such is not recommended in patients who present with this anomaly.

Upper cervical spine injuries: indications and limits of the conservative management in Halo vest. A systematic review of efficacy and safety

INTRODUCTION

The integrity of the upper cervical spine is essential for survival and function, because of the neurovascular structures contained within its bony elements. Fractures of the upper cervical spine (C1-C2) are frequent. This systematic review assesses the efficacy and safety of the conservative management in Halo vest for patients with upper cervical spine fractures.

MATERIALS AND METHODS

Two reviewers independently identified studies in English, by a systematic search of CINAHL, Embase, Medline, HealthSTAR, and the Cochrane Central Registry of Controlled Trials, from inception of each database to 28 January 2010, using various combinations of the keywords terms "odontoid fractures", hangman's fractures", "axis fractures", "axis", "atlas", "Jefferson fractures", "C1 arch fractures", "C1 fractures", "C2 fractures", "cervical spine", "injuries", "fracture", "trauma", "neck injury", "surgery".

RESULTS

A total of 43 citations were obtained. An additional 4 papers were obtained from the reference list of the studies included. The 47 studies that were included described a total of 1078 patients with C1-C2 fractures managed by halo fixator.

CONCLUSIONS

The halo fixator has a well defined place in the management of fractures of the cervical spine. Clearly, studies of higher level of evidence, for instance large randomised trials, should be conducted, even though the available evidences suggest that management of upper cervical spine fracture with halo fixator is safe and effective.

Unilateral C-1 lateral mass sagittal split fracture: an unstable Jefferson fracture variant

Object

The object of this study was to describe an unusual fracture subtype within C-1 injuries with a propensity to result in late deformity and pain. Most patients with C-1 injuries are nonsurgically treated using external immobilization unless there is an injury of the transverse atlantal ligament. The authors describe an unusual variant involving a unilateral sagittal split with a high tendency to late deformity and pain. They also review the literature and treatment of C-1 fractures.

Methods

A retrospective review of 12,671 CT scans from a Level I trauma center over a 6-year period yielded 54 patients with C-1 fractures. Among these patients, 6 had an unusual unilateral lateral mass sagittal split, which resulted in a late cock-robin deformity in all survivors and thus a surgical deformity correction with occipital-cervical instrumented fusions. Patient charts and radiographs were reviewed, this fracture subtype is described, and its treatment discussed.

Results

Radiographic studies in 6 patients with C-1 fractures demonstrated a unilateral sagittal split of the lateral mass but an intact transverse atlantal ligament. In the 3 surviving patients, a late cock-robin deformity, significant loss of neck rotation, and severe neck pain developed. Vertebral artery occlusion, as revealed on CT angiography, occurred in 1 patient. All patients were placed in traction and underwent successful occipital-cervical fusion and deformity correction. At the final follow-up, all patients had satisfactory pain relief and improved head alignment.

Conclusions

Patients with a unilateral sagittal split of the C-1 lateral mass have unstable injuries and must be carefully monitored, with a low threshold for surgical reconstruction or prolonged traction. Patients with late deformity can be successfully treated with occipital-cervical instrumented fusions.

Case report: nonoperative treatment of an unstable Jefferson fracture using a cervical collar

The treatment of unstable burst fractures of the atlas (Jefferson fractures) is controversial. Unstable Jefferson fractures have been managed successfully with either immobilization, typically halo traction or halo vest, or surgery. We report a patient with an unstable Jefferson fracture treated nonoperatively with a cervical collar, frequent clinical examinations, and flexion-extension radiographs. Twelve months after treatment, the patient achieved painless union of his fracture. The successful treatment confirms prior studies reporting unstable Jefferson fractures have been treated nonoperatively. The outcome challenges the clinical relevance of treatment algorithms that rely on the "rules of Spence" to guide treatment of unstable Jefferson fractures and illustrates instability may not necessarily be present in patients with considerable lateral mass widening. Additionally, it emphasizes a more reliable way of assessing C1-C2 stability in unstable Jefferson fractures is by measuring the presence and extent of anterior subluxation on lateral flexion and extension views.

Long-term health-related quality of life outcomes following Jefferson-type burst fractures of the atlas

OBJECT

The primary goal of this study was to describe the long-term health-related quality of life (HRQOL) outcomes in patients who have suffered Jefferson-type fractures. These outcomes were compared with matched normative HRQOL data and with the patient's perceptions of their HRQOL prior to the injury. Variables that potentially influence these HRQOL outcomes were analyzed. No standardized outcome assessments have been published for patients who suffer these fractures; their outcomes have long thought to be excellent following treatment. Determining the optimal surrogate measure to represent preinjury HRQOL in trauma patients is difficult.

METHODS

A retrospective review, radiographic analysis, and cross-sectional outcome assessment were performed. The Short Form (SF)-36 and the American Academy of Orthopaedic Surgeons/North American Spine Society (AAOS/NASS) outcome instruments were filled out by patients at final follow-up examination (follow-up period 75 months, range 19-198 months) to represent their current status as well as their perceptions of preinjury status. In 34 patients, the SF-36 physical component score and the AAOS/NASS pain values were significantly lower than normative values. There was no significant difference between normative and preinjury values. Spence criteria greater than 7 mm and the presence of associated injuries predicted poorer outcome scores during the follow-up period.

CONCLUSIONS

Long-term follow-up examination of patients with Jefferson fractures indicated that patients' status does not return to the level of their perceived preinjury health status or that of normative population controls. Those with other injuries and significant osseous displacement (> or = 7 mm total) may experience poorer long-term outcomes. Limitations of the study included a relatively low (60%) response rate and the difficulties of identifying an appropriate baseline outcome in a trauma population with which the follow-up outcomes can be compared.

Isolated fractures of the atlas in adults

STANDARDS

There is insufficient evidence to support treatment standards.

GUIDELINES

There is insufficient evidence to support treatment guidelines.

OPTIONS

Treatment options in the management of isolated fractures of the atlas are based on the specific atlas fracture type. It is recommended that isolated fractures of the atlas with an intact transverse atlantal ligament be treated with cervical immobilization alone. It is recommended that isolated fractures of the atlas with disruption of the transverse atlantal ligament be treated with either cervical immobilization alone or surgical fixation and fusion.

Treatment of stable burst fracture of the atlas (Jefferson fracture) with rigid cervical collar

STUDY DESIGN

A retrospective review of a clinical series.

OBJECTIVE

To evaluate the use of a rigid cervical collar alone as the treatment for stable Jefferson fracture, and to devise an algorithm for treatment of Jefferson fracture with or without an associated cervical injury.

SUMMARY OF BACKGROUND DATA

The traditional treatment for Jefferson fracture, if there is no indication for surgery, is immobilization by halo vest. Because halo vest placement is associated with intracranial infection and a significant degree of patient discomfort, slightly less rigid forms of external immobilization may be useful for the treatment of stable Jefferson fractures. No standard protocol calling for the use of one form of stabilization device has been reported.

MATERIALS

The medical records and radiographs of 16 consecutive patients with Jefferson fracture during a 2-year period were reviewed. Each patient underwent a complete cervical radiograph series and a computed tomographic scan. The mean C1 lateral mass displacement was 1.8 mm. Cervical spine radiographs, including lateral flexion-extension views were obtained 10 to 12 weeks after injury before the removal of an external immobilization device.

RESULTS

Of these 16 patients, 1 sustained a complete injury, and 7 sustained an incomplete injury. Eight patients were neurologically intact. Twelve patients sustained a stable Jefferson fracture and were treated with a rigid cervical collar (Miami-J collar [Jerome Medical, Moorestown, NJ]) alone from 10 to 12 weeks. The patient sustaining the complete neurologic injury died of multisystem trauma. All 15 live patients showed no instability on their follow-up plain radiographs before the removal of an external stabilization device. Six patients underwent further plain radiographs approximately 1 year after the fracture and similarly demonstrated no instability.

CONCLUSIONS

Isolated stable burst fracture of the atlas can be treated effectively with a rigid cervical collar alone for 10 to 12 weeks with good neurologic recovery and segmental stability. Unstable Jefferson fractures with concurrent unstable fracture of other cervical vertebrae, especially C2, requires surgical stabilization.

Evaluation and treatment of atlas burst fractures (Jefferson fractures)

Although several large series of atlas fractures have been reported recently, none has concentrated on the evaluation and treatment of atlas burst fractures (Jefferson fractures). The treatment of this fracture is challenging. Its diagnosis may easily be missed due to concerns about associated trauma and absence of neurological signs. In addition, the open-mouth anteroposterior x-ray study, which is usually pathognomonic for the diagnosis, is often inadequate or not obtained. In order to clarify the diagnosis and treatment of this disorder, 17 cases of Jefferson fracture treated between 1982 and 1989 at the Louisiana State University Affiliated Hospitals are presented. The diagnosis was delayed in three patients because of a low index of suspicion and inadequate x-ray films. Four patients were noted to have unstable Jefferson fractures, all of these had an associated Type II odontoid fracture and were treated with occiput-C-2 wiring and fusion. The remainder of the patients had stable Jefferson fractures and were managed with Minerva jackets or rigid collar stabilization. No significant complications related to the treatment of the Jefferson fracture occurred in this series. One patient died from associated injuries; however, the remaining patients enjoyed an excellent long-term result with the acquisition of spinal stability and the resolution of subjective complaints.

Complications associated with the halo-vest. A review of 245 cases

The cases of all patients treated with halo-vests for cervical trauma at the University of Virginia since 1977 were analyzed retrospectively. A standardized chart and radiographic review protocol were used to identify complications associated with the use of the orthosis. Two hundred and forty-five patients satisfied the criteria for inclusion in the study. No patient developed or suffered progression of a neurological deficit while immobilized. Complications included: pneumonia causing death (one patient); loss of reduction or progression of the spinal deformity (23 patients); spinal instability following orthotic immobilization for 3 months (24 patients); pin-track infection (13 patients); migration of anteriorly placed iliac-strut grafts (two patients); cerebrospinal fluid leakage from a halo pinhole (one patient); and miscellaneous (seven patients). The findings indicate several conclusions. The halo-vest protects patients with cervical instability from neurological injury. It does not absolutely immobilize the cervical spine nor does it prevent progressive deformity of malpositioned strut grafts. Even after a 3-month orthotic treatment period, surgery may be required on ligamentous and osseous injuries to provide spinal stability. Elderly kyphotic patients may require custom-made vests. A small subset of patients exists for whom the confining nature of the halo-vest is intolerable for 3 months.

[Fractures of the atlas]

The authors present details of 22 fractures of the atlas treated at the Orthopaedic Clinic of the University of Athens between 1970 and 1982. After a brief survey of the basis of classification of the four types of fracture, the mechanism of injury, the clinical and radiological presentation and the treatment of these injuries, the authors analyse their own cases and examine their results. Such fractures may go unrecognised because of more obvious associated injuries at other levels in the cervical spine. Neurological signs are uncommon. Treatment has always been orthopaedic and the results are usually excellent.

Halo-thoracic brace immobilization in 188 patients with acute cervical spine injuries

The authors report 188 patients with acute cervical spine injury with fracture who underwent Halo-thoracic brace immobilization. The majority of the fractures were considered unstable. Early neurological assessment revealed 24 patients without neurological deficit. There were 164 patients with associated cervical cord injury; 84 patients with incomplete, and 80 patients with complete tetraplegia. Management consisted of skull traction and application of the Halo-thoracic brace about 1.3 weeks after admission. The average radiological union time was 11.5 weeks following a mean of 10.2 weeks of immobilization in a Halo apparatus. Satisfactory restoration of bone and ligament stability, with no significant posttreatment neck pain, was obtained in 168 cases (89%). This is comparable to the fusion rate achieved for cervical fractures in the literature. The follow-up periods range from 1 month to 6 years, with a mean of 10.8 months. The management and results in 73 patients with unilaterally and bilaterally locked facets with or without fractures are discussed. Complete tetraplegia is not considered a contraindication to Halo apparatus immobilization. The multiple factors responsible for overcoming the barrier of anesthetic skin are elucidated. Use of the Halo apparatus offers early mobilization and rehabilitation without neurological deterioration. Complications are few and insignificant.

Halo immobilization of cervical spine fractures. Indications and results

Thirty-three patients with a spectrum of cervical spine fractures or subluxations were treated with immobilization by a halo apparatus. All spines were assumed to be unstable because of the nature of the fracture or because of a subluxation noted on spine films. Treatment consisted of immobilization and fracture reduction followed by application of a halo plaster cast or molded halo plastic vest. Patient acceptance was high. Complications were few and minor. No patient experienced neurological deterioration during treatment. Reduction was well maintained during an average halo immobilization period of over 3 months. Use of the halo resulted in healing of bone and ligament and restoration of stability in 85% of the patients. Halo immobilization was efficacious in the treatment of odontoid and hangman's fractures as well as complex fractures involving multiple areas of a single vertebra. It was also used successfully as an adjunct to posterior cervical fusion. Although several patients with subluxations or angulation without bone injury were treated successfully, two of the four therapy failures occurred in this group of patients, and the halo must be used with caution in this clinical setting. Contraindications to the use of the halo include complete cervical spinal cord injury with anesthetic skin, tomographic and/or myelographic evidence of disc or bone within the spinal canal, and unsatisfactorily reduced subluxations. The halo has provided more effective and reliable immobilization than other orthoses. It is an acceptable alternative to cervical fusion for the achievement of stability in a wide variety of cervical spine fractures and dislocations avoiding both the short-term and perhaps long-term complications of spinal fusion.