Management of acute combined fractures of the atlas and axis: A retrospective study of two trauma centers

Abstract

Background:Management of combination fractures of the atlas and axis varies from nonoperative immobilization to selective early surgical intervention. In this study, we present our experience in managing these injuries.Materials and Methods:Electronic databases from two level 1 trauma centers were queried to identify all patients diagnosed with C1-C2 combination fractures from 2009 to present. Patient demographics, fracture characteristics, treatment modality, complications, Frankel scores, and fusion status were collected. Patients were separated into operative and nonoperative cohorts, and comparisons were made between the two groups.Results:Forty-eight patients were included, of which 19 received operative management and 29 were treated nonoperatively. The mean age was 76.1 and 75.3 years, respectively (P = 0.877). Frankel grade distribution was similar on presentation in both groups, with most being neurologically intact. C1 fractures of both the anterior and posterior arch were present in 41.2% patients undergoing fusions compared to 27.6% of patients treated nonoperatively. No significant differences in comorbidities, neurologic deficits, or radiographic measurements were observed across the two groups.Conclusions:This study demonstrates the variety of treatment strategies used for the management of combined C1-C2 fractures. Patients managed operatively tend to have both anterior and posterior C1 arch fractures, while patients managed nonoperatively tend to have either anterior or posterior arch fractures. In general, treatments should be tailored to patients’ needs depending on the stability of the fractures, neurological state, and medical comorbidities.

Management of combined atlas and axis fractures: a systematic review

“…The 22 articles identified during our literature review were published from 1977 to 2022, totaling 230 patients. A description of each article is presented in Table 1 [ 1 , 4 , 8 , 9 , [11] , [12] , [13] , [14] , [15] , [16] , [17] , [18] , [19] , [20] , [21] , [22] , [23] , [24] , [25] , [26] , [27] , [28] ]. There were 12 case series, 7 case reports, and 3 retrospective reviews.…”

“…The mean age of 221 patients with reported data was 58 years. Only 2 studies reported on comorbidities, which included hypertension, myocardiopathy, diabetes, cerebrovascular accident, hypothyroidism, and smoking [ 8 , 22 ]. Thirty-seven of the 213 patients (17%) presented with neurologic deficits, which is consistent with previously reported data [4] , [5] , [6] .…”

“… [23] , International Orthopaedics, 2016 41 50.9 (24–78 years) 28/41 (68%) Not Reported 7/41 (17%) MVC 23/41 (56%), Fall 14/41 (34%), Miscellaneous 4/41 (10%) DiDomenico et al. [8] , Journal of Craniovertebral Junction and Spine, 2017 48 75.6 16/48 (33%) HTN 24/48 (50%), Hypothyroidism 10/48 (20.8%), Type II DM 5/48 (10.4%), Smoking 10/48 (10.4%) 6/48 (12.5%) Fall 41/48 (84.5%), MVC 5/48 (10.4%), Miscellaneous 2/48 (4.2%) Josten et al. [24] , Archives of Orthopaedic and Trauma Surgery, 2018 23 84.6 (73–94) *Inclusion criteria age >70* 9/23 (34.8%) Not Reported 0/23 (0%) Fall 23/23 (100%) Dagtekin et al.…”

“… [23] , International Orthopaedics, 2016 Not Reported Type II Odontoid 19/41 (46%) Type III Odontoid 7/41 (17%) Hangman 4/41 (10%) Miscellaneous C2 11/41 (27%) Nonoperative 22/41 (53.7%): Halo Vest 19/22 (86.3%), C-Collar 3/22 (13.6%) Operative 19/41 (46.3%): C1-C2 PSF 12/19 (63.2%), C1-C3 PSF 4/19 (21.1%), C2-C3 PSF 1/19 (5.2%), OCF 2/19 (10.5%) All Type II/ III Odontoid fractures with ADI >5 mm or LMD >7 mm 16/26 (61.5%) managed operatively All fractures with C2-C3 angulation >11° 5/41 (12.2%) managed operatively Not Reported Nonoperative 2/22 (9%): 1 nonunion, 1 pinsite infection Operative 3/19 (7%): 1 wound infection, 1 hematoma, 1 screw malposition 19.3 (12–45) Operative management based on C2 fracture type, atlantoaxial instability (ADI >5 mm, LMD >7 mm) and C2-C3 angulation >11° DiDomenico et al. [8] , Journal of Craniovertebral Junction and Spine, 2017 Anterior Arch 15/48 (31.3%) Posterior Arch 17/48 (35.4%) Anterior + Posterior Arch 16/48 (33.3%) Type II Odontoid 35/48 (72.9%) Type III Odontoid 4/48 (8.3%) Hangman 2/48 (4.2%) Miscellaneous C2 1/48 (2.1%) Nonoperative 29/48 (60.4%): C-Collar, Halo Vest Operative 19/48 (39.6%): C1-C2 PSF 10 Nonoperative: 1.78 mm Operative: 1.94 mm (p=.58) Nonoperative: 6.06° Operative: 7.81° (p=.28) Nonoperative: 7.2 Operative: 13.5 (p=.001) Operative 3/19 (15.8%): 1 vertebral artery injury, 1 intra-op pneumothorax, 1 aspiration pneumonia 10 Operative management performed more frequently in the setting of Jefferson fractures Josten et al. [24] , Archives of Orthopaedic and Trauma Surgery, 2018 Anterior Arch 13/23 (56.5%) Posterior Arch 5/23 (21.7%) Anterior + Posterior Arch 5/23 (21.7%) Type II Odontoid 23/23 (100%) *Inclusion criteria* Operative 23/23 (100%): Odontoid and anterior transarticular C1-C2 screws *Inclusion criteria* Not Reported Not Reported 15.7 Operative 13/23 (56.5%): 6 dysphagia, 3 pneumonia, 3 screw loosening, 1 pleura effusion Not Reported Anterior odontoid and transarticular C1-C2 fixation is a valid treatment option in elderly patients but with high rates of dysphagia Dagtekin et al.…”

“…While prior literature advocates that management strategies are generally based on axis fracture characteristics, more recent studies have described additional injury patterns that denote instability and warrant surgery [ 3 , 4 , [7] , [8] , [9] , [10] ]. Furthermore, there are a multitude of patient factors that surgeons must consider, including age, activity level, and comorbidities, which may further complicate management decisions [ 3 , 4 , 7 , 8 , 11 ]. Additionally, there is no consensus in regards to specific surgical treatments, which include posterior cervical instrumented fusion, anterior/ posterior C1-C2 transarticular fixation and anterior odontoid fixation.…”