Surgical Versus Conservative Management for Treating Unstable Atlas Fractures: A Multicenter Study

Abstract

Objective: This multicenter study compared radiological parameters and clinical outcomes between surgical and non-surgical management and investigated treatment characteristics associated with the successful management of unstable atlas fractures. Methods:We retrospectively evaluated 53 consecutive patients with unstable atlas fracture who underwent halo-vest immobilization (HVI) or surgical fixation. Clinical outcomes were assessed using neck visual analog scale and disability index. The radiological assessment included total lateral mass displacement (LMD) and the anterior atlantodental interval (AADI).Results: Thirty-two patients underwent surgical fixation and 21 received HVI (mean follow-up, 24.9 months). In the surgical fixation, but not in the HVI, LMD and AADI showed statistically significant improvements at the last follow-up. The osseous healing rate and time-to-healing were 100% and 14.3 weeks with surgical fixation, compared with 71.43% and 20.0 weeks with HVI, respectively. Patients treated with HVI showed poorer neck pain and neck disability outcomes than those who received surgical treatment. LMD showed an association with osseous healing outcomes in non-operative management. Clinical outcomes and osseous healing showed no significant differences according to Dickman's classification of TAL injuries.Conclusion: Surgical internal fixation had a higher fusion rate, shorter fracture healing time, more favorable clinical outcomes, and a more significant reduction in LMD and AADI compared to nonoperative management. The pitfalls of external immobilization are inadequate maintenance and a lower probability of reducing fractured lateral masses. Stabilization by surgical reduction with interconnected fixation proved to be a more practical management strategy than non-operative treatment for unstable atlas fractures.

Design of a novel lateral mass screw–plate system for the treatment of unstable atlas fractures: a finite element analysis

“…In the past, skull traction, external fixation of the Halo-vest head frame, and other non-surgical treatment methods were mostly used, but the treatment time was long, the patients were difficult to tolerate, and the clinical results were poor [ 5 , 6 ]. Therefore, for better fracture healing and restoration of stability in the occipitocervical junction, it has been suggested by a majority of surgeons that patients with unstable atlas fractures should undergo surgical treatment at an early stage [ 6 – 8 ].…”

Commentary on “Surgical Versus Conservative Management for Treating Unstable Atlas Fractures: A Multicenter Study”

“…Therefore, ideal and comprehensive treatment should be changed according to modest concept.Based on these perspectives, the authors have reported clinical outcomes of multicenter comparative study between conservative and surgical management for isolated atlas fracture, which have a high potential for instability. 5 The authors have also evaluated preoperative radiological parameters that associated with faster osseous fusion and better clinical outcome after treatment in both groups. All patients enrolled in the study had atlas fracture with lateral mass displacement (LMD) following "rule of Spence" and disfunction of TAL including either type I or type II injury.…”

“…Based on these perspectives, the authors have reported clinical outcomes of multicenter comparative study between conservative and surgical management for isolated atlas fracture, which have a high potential for instability [ 5 ]. The authors have also evaluated preoperative radiological parameters that associated with faster osseous fusion and better clinical outcome after treatment in both groups.…”