Treatment
Medical Therapy
Patients with C1 fractures customarily have some form of trauma; thus, they need to be immediately stabilized at the scene, which requires the customary attention to the ABCs (airway, breathing, and circulation). If the airway is compromised or air exchange is inadequate, intubation without moving the head is crucial (C-spine protection). Careful evaluation and frequent reassessment is needed because the patient may have sustained a concussion with the impact to the head (the common injury that produces the C1 fracture) and, because of a clouded sensorium, may not be able to be fully evaluated or to report neck pain. Patients with a diminished alertness and orientation should carefully undergo imaging studies to exclude underlying pathology.
Surgical Therapy
Treatment of the C1 fracture consists of stabilization or immobilization in a satisfactorily reduced position to allow reliable healing. This illustrates the necessity of identifying associated injuries; for example, if a Jefferson fracture is identified but an associated odontoid fracture, transverse ligament fracture, or other problem is present, then halo treatment may be modified or less successful. The transverse ligament is not necessarily expected to heal tightly or reliably, although a bony fracture would be expected to have mechanical integrity restored when healed.
With a C1 fracture, the posterior aspect of the ring becomes disconnected from the anterior aspect, which is stabilized around the odontoid; thus, a posterior fusion of the occiput to C1 would be inadequate to stabilize the spine and, consequently, would extend at a minimum to C2. Customarily, instrumentation attaches a type of contoured rod or plate from the occiput down to C2 to stabilize the area and facilitate healing.
A fractured odontoid fragment cannot be removed from the posterior approach; if a neurologic deficit or threat to the brain stem is present (the alar ligament may have an attached portion of the odontoid migrate superiorly into the foramen magnum to compress the brain stem at the pontomedullary junction), neurosurgical posterior decompression of the foramen magnum could be performed in a halo.
Alternative consideration may be given to a transoral approach or an anterior retropharyngeal approach for the combination of the Jefferson fracture and a fracture of the odontoid. The traditional treatment is a halo vest or cast until the Jefferson fracture is healed. Then, additionally, if the odontoid fracture healing has become delayed or a nonunion is present, this can be treated by a C1-2 arthrodesis, but the procedure must be delayed for the ring of C1 to heal.
For this combined fracture, an anterior open reduction and internal fixation of the odontoid may be performed, with 2 screws placed in an oblique fashion starting at the inferior anterior edge of C2 and directed cephalad to engage the odontoid. With a C1 fracture, this is done in conjunction with a halo vest. An alternative would be a Magerl approach of a posterior open reduction, accompanied by internal fixation of C1-2. For this procedure, 2 screws are placed in an oblique fashion starting at the inferior edge of the C2 lamina, and then they cross the C1-2 facet joint between the vertebral artery, which is lateral, and the spinal cord and brain stem, which are medial.
Preoperative Details
The patient must be maintained in protective immobilization—more than a soft collar for adults. Presumably, the patient is in a halo from the point of initial treatment. The reduction of an atlas fracture may be achieved by a ligamentotaxis with mild traction; however, traction is very risky, and such very unstable injuries have to be monitored extremely closely. Associated fractures must be identified expeditiously to direct subsequent treatment. Congenital abnormalities of the arch, such as an agenesis of the posterior ring, must be identified and taken into account in the treatment plan.
Intraoperative Details
If the patient is awake and has a halo and vest applied, then the conversation and discussion with the patient during the procedure demonstrates the maintained safety and neurologic status of the patient. Patients who undergo surgical correction, particularly posterior arthrodesis, may be monitored with somatosensory evoked potentials.
Postoperative Details
After application of a halo, close follow-up is required with radiographs to demonstrate that the fracture is maintained in a satisfactory position for healing. If surgical stabilization is appropriate, then monitoring the healing of the bone fusion with radiographs is also crucial postoperatively.
Follow-up
Patients in the halo require at least 8 weeks, or likely 12 or more weeks, of immobilization until healing is documented on radiographs. This period is followed by one in which the patient is placed in a collar to protect the neck while he or she is being weaned from the halo and while the neck is gradually being rehabilitated in terms of intrinsic muscle stability and range of motion.
Complications
Patients with upper cervical instability are at risk of death; this risk is increased if the injury is not identified and recognized. Neurologic damage at this level could make the patient dependent on a ventilator; thus, extreme care is necessary in handling these patients during fracture healing.
Associated injuries to the occipitoatlantoaxial complex must be considered and included in the treatment plan. Devastating neurologic injuries may result from vascular embarrassment resulting from the instability of these injuries.
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 Treatment: C1 Fractures |
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Further Reading
Related eMedicine topics
Fracture, Cervical Spine
Cervical Spine Injuries in Sports
Upper Cervical Spine, Trauma
Keywords
C1 fracture, C-1 fractures, cervical fracture, Jefferson's fracture, Jefferson fracture, axial burst fracture of the atlas, spine fracture, broken neck
