C1 and C2 Fractures Above a Previous Fusion Treated with Internal Fixation without Fusion

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.

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.…”

“… [9] , Indian Journal of Orthopaedics, 2019 23 52.4 (24–72) 16/23 (69.6 %) Not Reported 9/23 (39.1%) MVC 12/23 (52.2%), Fall 8/23 (34.8%), Miscellaneous 3/23 (13%) Kolz et al. [27] , The Journal of Bone and Joint Surgery Case Connector, 2021 1 71 0/1 (0%) Not Reported 0/1 (0%) Not Reported Verma et al. [28] , Neurology India, 2022 10 47.7 (23–81) 10/10 (100%) Not Reported 4/10 (40%) Fall 7/10 (70%), MVC 3/10 (30%) MVC, motor vehicle collision; MCC, motorcycle collision; HTN, hypertension; CVA, cerebrovascular attack; DM, diabetes.…”

“… [9] , Indian Journal of Orthopaedics, 2019 Anterior Arch 8/23 (34.8%) Posterior Arch 8/23 (34.8%) Anterior + Posterior Arch 3/23 (13.0%) Lateral mass 4/23 (17.4%) Type II Odontoid 23/23 (100%) *Inclusion criteria* Nonoperative 13/23 (56.5%): Halo Vest 10/13 (76.9%), C-Collar 3/13(23.1%) Operative 10/23 (43.5%): C1-C2 PSF 8/10 (80%), OCF 2/10 (20%) Not Reported Not Reported Not Reported Nonoperative 2/13 (9%): 1 nonunion, 1 pinsite infection Operative 2/10 (20%): 1 occipital cervical pain, 1 CSF leak 23.9 (1542) Operative management based on C1 fracture type and atlantoaxial instability (ADI >5 mm, LMD >7 mm) Kolz et al. [27] , The Journal of Bone and Joint Surgery Case Connector, 2021 Lateral Mass 1/1 (100%) Type II Odontoid 1/1 (100%) Operative 1/1 (100%): C1-C4 temporary internal fixation Not Reported Not Reported Not Reported None 0/1 (0%) Not reported Temporary internal fixation is a valid treatment option in elderly patients with a prior cervical fusion Verma et al. [28] , Neurology India, 2022 Anterior Arch 2/10 (20%) Posterior Arch 4/10 (40%) Anterior + Posterior Arch 3/10 (30%) Lateral Mass 1/10 (10%) Type II Odontoid 9/10 (90%) Type I Odontoid 1/10 (10%) Nonoperative 1/10 (10%): C-Collar Operative 9/10 (90%): C2 pedicle + C3 lateral mass screws 5/9 (55.6%) OCF 3/9 (33.3%), Posterior transarticular C1-C2 screws 1/9 (11.1%) Not Reported Not Reported Not Reported None 0/10 (0%) 28.7 Intraoperative CT navigation systems allows for more accurate C2 pedicle screw placement and can preserve C1-C2 rotation by avoiding C1 instrumentation in certain fracture patterns ADI, atlantodental interval; OCF, occiputocervical fusion; SOMI, sternal occipital mandibular immobilizer; PSF, posterior spinal fusion; LMD, lateral mass displacement.…”

“…As a motion-preserving alternative, Pawar and O'Leary [11] and Kolz et al. [27] reported 2 respective cases in which combined C1-type II odontoid fractures were managed with temporary internal fixation followed by hardware removal. The former study involved an 18-year-old male, while the latter was a 71-year-old female who previously underwent a C2-T2 anterior-posterior fusion for cervical spondylosis [ 11 , 27 ].…”

“… [27] reported 2 respective cases in which combined C1-type II odontoid fractures were managed with temporary internal fixation followed by hardware removal. The former study involved an 18-year-old male, while the latter was a 71-year-old female who previously underwent a C2-T2 anterior-posterior fusion for cervical spondylosis [ 11 , 27 ]. The authors advocate that in the setting of an intact transverse ligament, temporary internal fixation is a viable alternative in certain patient populations in order to preserve postoperative motion [ 11 , 27 ].…”