eMedicine Specialties > Orthopedic Surgery > Spine

C1 Fractures: Follow-up

Author: Mark R Foster, MD, PhD, FACS, President and Orthopaedic Surgeon, Orthopaedic Spine Specialists of Western Pennsylvania, PC
Contributor Information and Disclosures

Updated: Nov 6, 2009

Outcome and Prognosis

Patients with Jefferson fractures are expected to heal and have an excellent prognosis for resumption of activity in the absence of associated injuries. Any surgical stabilization severely restricts the motion of the head, because the occipitoatlantoaxial complex represents over 50% of the motion of the head on the trunk.

Future and Controversies

Disruption of the ring of C1 makes stabilization by a C1-2 fusion in the customary posterior fashion impossible; however, a C1-2 direct fixation with Magerl screws may stabilize the anterior ring to the body of C2. The role of this C1-2 fusion is not yet universally accepted, but with experience, the indications and role will be more clearly defined. A transoral resection of C1 may be preferred to an alternative technique, decompression posteriorly to the foramen magnum, particularly for a migrating odontoid fragment from an associated type 2 Anderson and D'Alonzo odontoid fracture with a Jefferson fracture. The significant amount of rotation of the atlas on the axis would be lost with this fusion, but the fusion would preserve the flexion and extension of the occipital condyle and head on the lateral masses, which would also be lost in an occipital C2 fusion, which is the traditional approach.

With regard to C1-to-C2 fixation, wires have been used for a significant time with excellent results. Gallie described fusion where wires are passed onto the arch of C1 and into the spinous process of C2.9 In 1978, Brooks and Jenkins then presented a more stable construct10 : Rather than placing the bone graft over the posterior elements, grafts are wedged between the posterior arch of C1 and C2, and the wires are passed under both C1 and C2, so they can more effectively stabilize the bone grafts in their respective positions and increase the area for fusion. However, this procedure requires passing the wires more laterally, with careful attention to the vascular structures.

In 2002, Richter et al presented 6 different techniques for biomechanical comparison, preferring transarticular screws but considering isthmic screws with a claw or lateral mass screws and isthmic screws as an alternative with somewhat less immediate stability.11 A 2003 report by Cornefjord et al on a series of patients with Olerud cervical fixation has also been presented12 : odontoid fracture occurred in 18 patients, rheumatoid instability in 6, and odontoid nonunion and os odontoideum in 1 patient each, with clinical follow-up (20 patients followed for 6-27 months) suggesting no serious complications and a high frequency of fusion healing.

The posterior arch at C1 has minimal bone for the fusion to heal, and claw techniques to avoid passing sublaminar wires over the brain stem had some early discouraging results, leading to refinements and further investigation. Various techniques will continue to be compared and studied because this is clearly a challenging area.

 


More on C1 Fractures

Overview: C1 Fractures
Workup: C1 Fractures
Treatment: C1 Fractures
Follow-up: C1 Fractures
Multimedia: C1 Fractures
References
Further Reading
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References

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Keywords

C1 fracture, C-1 fractures, cervical fracture, Jefferson's fracture, Jefferson fracture, axial burst fracture of the atlas, spine fracture, broken neck

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Contributor Information and Disclosures

Author

Mark R Foster, MD, PhD, FACS, President and Orthopaedic Surgeon, Orthopaedic Spine Specialists of Western Pennsylvania, PC
Mark R Foster, MD, PhD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Physical Society, Christian Medical & Dental Society, Eastern Orthopaedic Association, North American Spine Society, Orthopaedic Research Society, and Pennsylvania Orthopaedic Society
Disclosure: Nothing to disclose.

Medical Editor

James F Kellam, MD, Vice-Chair, Department of Orthopedic Surgery, Director of Orthopedic Trauma and Education, Carolinas Medical Center
James F Kellam, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Orthopaedic Trauma Association, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

William O Shaffer, MD, Professor, Vice-Chairman and Residency Program Director, Department of Orthopedic Surgery, University of Kentucky at Lexington
William O Shaffer, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, International Society for the Study of the Lumbar Spine, Kentucky Medical Association, Kentucky Orthopaedic Society, North American Spine Society, Southern Medical Association, and Southern Orthopaedic Association
Disclosure: DePuySpine 1997-2007 (not presently) Royalty Consulting; DePuySpine 2002-2007 (closed) Grant/research funds SacroPelvic Instrumentation Biomechanical Study; DePuyBiologics 2005-2008 (closed) Grant/research funds Healos study just closed; No present Industry grants or funds. None None

CME Editor

Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital
Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Physicians of Indian Origin, American College of International Physicians, and American College of Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Mary Ann E Keenan, MD, Professor, Vice Chair for Graduate Medical Education, Department of Orthopedic Surgery, University of Pennsylvania School of Medicine; Chief of Neuro-Orthopedics Program, Department of Orthopedic Surgery, Hospital of the University of Pennsylvania
Mary Ann E Keenan, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, American Society for Surgery of the Hand, and Orthopaedic Rehabilitation Association
Disclosure: Nothing to disclose.

 
 
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