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Cai M, Wu Y, Ma R, Chen J, Chen Z, Deng C, Huang X, Ma X, Zou X. Comparison of Transoral Anterior Jefferson-Fracture Reduction Plate and Posterior Screw-Rod Fixation in C1-Ring Osteosynthesis for Unstable Atlas Fractures. Neurospine 2024; 21:544-554. [PMID: 38317544 PMCID: PMC11224759 DOI: 10.14245/ns.2347230.615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 01/14/2024] [Accepted: 01/14/2024] [Indexed: 02/07/2024] Open
Abstract
OBJECTIVE To compare the clinical outcomes of transoral anterior Jefferson-fracture reduction plate (JeRP) and posterior screw rod (PSR) surgery for unstable atlas fractures via C1-ring osteosynthesis. METHODS From June 2009 to June 2022, 49 consecutive patients with unstable atlas fractures were treated by transoral anterior JeRP fixation (JeRP group) or PSR fixation (PSR group) and followed up at General Hospital of Southern Theatre Command of PLA; 30 males and 19 females were included. The visual analogue scale (VAS) score, Neck Disability Index (NDI), distance to anterior arch fracture (DAAF), distance to posterior arch fracture (DPAF), lateral mass displacement (LMD), Redlund-Johnell value, postoperative complications, and fracture healing rate were retrospectively collected and statistically analyzed. RESULTS Compared with that in the PSR group, the bleeding volume in the JeRP group was lower, and the length of hospital stay was longer. The VAS scores and NDIs of both groups were significantly improved after surgery. The postoperative DAAF and DPAF were significantly smaller after surgery in both groups. Compared with the significantly shorter DPAF in the PSR group, the JeRP group had a smaller DAAF, shorter LMDs and larger Redlund-Johnell value postoperatively and at the final follow-up. The fracture healing rate at 3 months after surgery was significantly greater in the JeRP group (p < 0.05). CONCLUSION Both C1-ring osteosynthesis procedures for treating unstable atlas fractures yield satisfactory clinical outcomes. Transoral anterior JeRP fixation is more effective than PSR fixation for holistic fracture reduction and short-term fracture healing, but the hospital stay is longer.
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Affiliation(s)
- Mandi Cai
- The First School of Clinical Medicine, Southern Medical University, Guangzhou, China
- Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, Guangzhou, China
| | - Yifeng Wu
- The First School of Clinical Medicine, Southern Medical University, Guangzhou, China
- Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, Guangzhou, China
| | - Rencai Ma
- Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, Guangzhou, China
| | - Junlin Chen
- The First School of Clinical Medicine, Southern Medical University, Guangzhou, China
- Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, Guangzhou, China
| | - Zexing Chen
- The First School of Clinical Medicine, Southern Medical University, Guangzhou, China
- Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, Guangzhou, China
| | - Chenfu Deng
- Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, Guangzhou, China
| | - Xinzhao Huang
- The First School of Clinical Medicine, Southern Medical University, Guangzhou, China
- Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, Guangzhou, China
| | - Xiangyang Ma
- The First School of Clinical Medicine, Southern Medical University, Guangzhou, China
- Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, Guangzhou, China
| | - Xiaobao Zou
- Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, Guangzhou, China
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Niu HG, Zhang JJ, Yan YZ, Zhao CK, Yang K, Zhang YS. Design of a novel lateral mass screw-plate system for the treatment of unstable atlas fractures: a finite element analysis. J Orthop Surg Res 2024; 19:120. [PMID: 38317156 PMCID: PMC10840214 DOI: 10.1186/s13018-024-04582-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 01/25/2024] [Indexed: 02/07/2024] Open
Abstract
BACKGROUND Osteosynthesis of unstable atlas fractures preserves joint motion and therefore has a distinct advantage over a range of treatment procedures. To prevent the potential disadvantages associated with osteosynthesis, a new atlas lateral mass screw-plate (LMSP) system has been designed. However, the biomechanical role of using the LMSP system in atlas internal fixation is not known. The aim of this study was to compare the biomechanical stability of a new LMSP with traditional posterior screw and rod (PSR) fixation techniques on the occipitocervical junction (C0-C2) through finite element analysis. METHODS A nonlinear C0-C2 finite element model of the intact upper cervical spine was developed and validated. The unstable model using the PSR system was then compared with the model using the LMSP system for fixation. A vertical load of 40 N was applied to the C0 to simulate head weight, while a torque of 1.5 Nm was applied to the C0 to simulate flexion, extension, lateral bending, and axial rotation. RESULTS The range of motion of both systems was close to the intact model. Compared with the LMSP system model, the PSR system model increased flexion, extension, lateral bending, and axial rotation by 4.9%, 3.0%, 5.0%, and 29.5% in the C0-C1 segments, and 4.9%, 2.7%, 2.4%, and 22.6% in the C1-C2, respectively. In flexion, extension, and lateral bending motion, the LMSP system model exhibited similar stress to the PSR system model, while in axial rotation, the PSR system model exhibited higher stress. CONCLUSIONS The findings of our study indicate that the two tested system models provide comparable stability. However, better stability was achieved during axial rotation with the LMSP system, and in this system, the maximum von Mises stress was less than that of the PSR one. As the atlantoaxial joint functions primarily as a rotational joint, the use of the LMSP system may provide a more stable environment for the joint that has become unstable due to fracture.
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Affiliation(s)
- He-Gang Niu
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, No.218 Jixi Road, Hefei, 230022, Anhui Province, People's Republic of China
| | - Jing-Jing Zhang
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, No.218 Jixi Road, Hefei, 230022, Anhui Province, People's Republic of China
| | - Yi-Zhu Yan
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, No.218 Jixi Road, Hefei, 230022, Anhui Province, People's Republic of China
| | - Cheng-Kun Zhao
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, No.218 Jixi Road, Hefei, 230022, Anhui Province, People's Republic of China
| | - Kun Yang
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, No.218 Jixi Road, Hefei, 230022, Anhui Province, People's Republic of China.
| | - Yin-Shun Zhang
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, No.218 Jixi Road, Hefei, 230022, Anhui Province, People's Republic of China.
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Ismail R, Manganaro M, Schartz D, Worley L, Kessler A. A pictorial review of imaging findings associated with upper cervical trauma. Emerg Radiol 2023:10.1007/s10140-023-02141-w. [PMID: 37254028 DOI: 10.1007/s10140-023-02141-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 05/02/2023] [Indexed: 06/01/2023]
Abstract
The diagnosis of cervical spine injury in the emergency department remains a critical skill of emergency room physicians as well as radiologists. Such diagnoses are often associated with high morbidity and mortality unless readily identified and treated appropriately. Both computed tomography (CT) and magnetic resonance imaging (MRI) often are crucial in the workup of spinal injury and play a key role in arriving at a diagnosis. Unfortunately, missed cervical spine injuries are not necessarily uncommon and often precede detrimental neurologic sequalae. With the increase in whole-body imaging ordered from the emergency department, it is critical for radiologists to be acutely aware of key imaging features associated with upper cervical trauma, possible mimics, and radiographic clues suggesting potential high-risk patient populations. This pictorial review will cover key imaging features from several different imaging modalities associated with upper cervical spine trauma, explore patient epidemiology, mechanism, and presentation, as well as identify confounding radiographic signs to aid in confident and accurate diagnoses.
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Affiliation(s)
- Rahim Ismail
- Department of Imaging Science, University of Rochester, 601 Elmwood Ave, Rochester, NY, 14642, USA
| | - Mark Manganaro
- Department of Imaging Science, University of Rochester, 601 Elmwood Ave, Rochester, NY, 14642, USA
| | - Derrek Schartz
- Department of Imaging Science, University of Rochester, 601 Elmwood Ave, Rochester, NY, 14642, USA
| | - Logan Worley
- Department of Imaging Science, University of Rochester, 601 Elmwood Ave, Rochester, NY, 14642, USA.
| | - Alexander Kessler
- Department of Imaging Science, University of Rochester, 601 Elmwood Ave, Rochester, NY, 14642, USA
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Spiegl UJA, Keil H, Krause J, Osterhoff G, Scheyerer MJ, Schnake KJ, Perl M. Combined Odontoid (C2) and Atlas (C1) Fractures in Geriatric Patients: A Systematic Review and Treatment Recommendation. Global Spine J 2023; 13:22S-28S. [PMID: 37084349 PMCID: PMC10177310 DOI: 10.1177/21925682221127951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/23/2023] Open
Abstract
STUDY DESIGN Systematic review. OBJECTIVE The aim of this study was to conduct a systematic overview of the pathogenesis and the treatment options of combined odontoid and atlas fractures in geriatric patients. METHODS This review is based on articles retrieved by a systematic search in the PubMed and Web of Science databases for articles published until February 2021 dealing with combination fractures of C1 and C2 in geriatric patients. RESULTS Altogether, 438 articles were retrieved from the literature search. A total of 430 articles were excluded. The remaining eight original articles were included in this systematic review depicting the topics pathogenesis, non-operative treatment, posterior approach, and anterior approach. The overall level of evidence of the studies is low. CONCLUSION Combined odontoid and atlas fractures in the geriatric population are commonly caused by simple falls and seem to be associated with atlanto-odontoid osteoarthritis. Non-operative treatment with a cervical orthosis is a feasible treatment option in the majority of patients with stable C2 fractures. In case of surgery posterior C1 and C 2 stabilization and anterior triple or quadruple screw fixation are possible techniques. Some patients may also deserve an occipito-cervical fusion. A possible treatment algorithm is proposed.
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Affiliation(s)
- Ulrich J A Spiegl
- Department of Orthopaedics, Trauma Surgery and Plastic Surgery, University of Leipzig, Leipzig, Germany
| | - Holger Keil
- Department of Trauma and Orthopedic Surgery, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - Johannes Krause
- Department of Trauma and Orthopedic Surgery, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - Georg Osterhoff
- Department of Orthopaedics, Trauma Surgery and Plastic Surgery, University of Leipzig, Leipzig, Germany
| | - Max J Scheyerer
- Department of Orthopedics and Trauma Surgery, University hospital, Duesseldorf, Germany
| | - Klaus John Schnake
- Center for Spinal and Scoliosis Surgery, Malteser Waldkrankenhaus St. Marien gGmbH, Erlangen, Germany
- Department of Orthopedics and Traumatology, Paracelsus Private Medical University Nuremberg, Nuremberg, Germany
| | - Mario Perl
- Department of Trauma and Orthopedic Surgery, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
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Niu HG, Zhang JJ, Tao H, Liu C, Zhou LP, Yang K, Cao Y, Li W, Shen CL, Zhang YS. Robot-Assisted Percutaneous Lag Screw Osteosynthesis for C1 Lateral Mass Fractures: Case Series and Technical Note. World Neurosurg 2023; 172:66-70. [PMID: 36739898 DOI: 10.1016/j.wneu.2023.01.106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 01/25/2023] [Accepted: 01/27/2023] [Indexed: 02/05/2023]
Abstract
BACKGROUND C1 lateral mass fractures (LMF) cause abnormal alignment of the upper cervical joints. Conservatively treated cases can develop into late cock-robin junction, requiring a reconstructive surgical procedure of the occipitocervical junction. Partial coronal C1 LMF could be effectively fixed with lag screws. Navigation and robot-assisted techniques have made percutaneous fixation possible and are gradually being used in the upper cervical spine. METHODS Five consecutive patients with C1 LMF who underwent percutaneous lag screw osteosynthesis under the guidance of a new robotic system were reviewed retrospectively. Preoperative and postoperative computed tomography scans were used to specify the fracture types and to assess the efficacy of fracture reduction. The medical records were reviewed. RESULTS Among the 5 patients, 4 underwent percutaneous lag screw reduction and fixation with the assistance of the robotic system through a posterior approach and 1 patient underwent a transoral approach. No intraoperative complications, such as screw malposition, neurologic deficit, and vertebral artery injury, occurred. Satisfactory fracture reduction and bone healing were achieved at postoperative follow-up. CONCLUSIONS Robot-assisted percutaneous lag screw osteosynthesis is a viable option for C1 LMF. Different approaches can be selected according to the distribution of the fracture lines. With the posterior approach, the guidewire tends to deviate from the entry point because of skiving, and the technical problems need to be further solved. Screw implant by a transoral approach is comparatively easy to achieve, but the possibly of infection exists and should be monitored.
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Affiliation(s)
- He-Gang Niu
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, Hefei, P. R. China
| | - Jing-Jing Zhang
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, Hefei, P. R. China
| | - Hui Tao
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, Hefei, P. R. China
| | - Chang Liu
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, Hefei, P. R. China
| | - Lu-Ping Zhou
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, Hefei, P. R. China
| | - Kun Yang
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, Hefei, P. R. China
| | - Yun Cao
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, Hefei, P. R. China
| | - Wei Li
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, Hefei, P. R. China
| | - Cai-Liang Shen
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, Hefei, P. R. China
| | - Yin-Shun Zhang
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, Hefei, P. R. China.
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C1 anatomy and dimensions relative to pedicle screw placement. J Clin Neurosci 2023; 111:22-25. [PMID: 36921553 DOI: 10.1016/j.jocn.2023.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 03/05/2023] [Indexed: 03/14/2023]
Abstract
The recent C1 pedicle screw technique for upper cervical vertebral stabilization allows longer screws to be implanted by setting the screw entry point through the posterior arch of C1, which could provide better biomechanics. However, there is controversy regarding the placement of C1 pedicle screws at different angles. We retrospectively reviewed the computed tomography (CT) scans of 300 patients. The trajectories of medial inclination of 0°, 5°, 10°, and 15° and trajectory of the maximum medial inclination angle were designed for each C1 pedicle on CT images. Screw track length at each angle, the angle of maximum medial inclination, pedicle height, distance from the screw entry point to the midpoint of the C1 posterior tubercle, and screw perforation rate at each angle were measured. The average maximum inclination angle was 17.01°, the maximum inclination angle screw track length was 31.05 mm, and the distance from the screw entry point to the midpoint of the C1 posterior nodule was 21.65 mm. The screw perforation rate was 46.73% at 15° of medial inclination, but only 5.61% at 10°, and no screw perforation at 5°. 26.47% C1 pedicle height < 4 mm. There was no significant difference between the measured data on the left and right sides(P > 0.05), and the measurement of female patients was usually smaller and significantly different from that of male patients(p < 0.05). Our data indicate that a reasonable screw inclination angle of 10° and the safety zone of screw angle can provide safety and avoid screw perforation. However, personalized measurement before surgery is essential.
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Yang K, Niu HG, Tao H, Liu C, Cao Y, Li W, Zhang JJ, Shen CL, Zhang YS. Posterior osteosynthesis with a new self-designed lateral mass screw-plate system for unstable atlas burst fractures. BMC Musculoskelet Disord 2023; 24:108. [PMID: 36759784 PMCID: PMC9909890 DOI: 10.1186/s12891-023-06209-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 01/30/2023] [Indexed: 02/11/2023] Open
Abstract
BACKGROUND In the treatment of unstable atlas fractures using the combined anterior-posterior approach or the posterior monoaxial screw-rod system, factors such as severe trauma or complex surgical procedures still need to be improved despite the favourable reduction effect. This research described and evaluated a new technique for the treatment of unstable atlas fracture using a self-designed lateral mass screw-plate system. METHODS A total of 10 patients with unstable atlas fractures using this new screw-plate system from January 2019 to December 2021 were retrospectively reviewed. All patients underwent posterior open reduction and internal fixation (ORIF) with a self-designed screw-plate system. The medical records and radiographs before and after surgery were noted. Preoperative and postoperative CT scans were used to determine the type of fracture and evaluate the reduction of fracture. RESULTS All 10 patients were successfully operated with this new system, with an average follow-up of 16.7 ± 9.6 months. A total of 10 plates were placed, and all 20 screws were inserted into the atlas lateral masses. The mean operating time was 108.7 ± 20.1 min and the average estimated blood loss was 98.0 ± 41.3 ml. The lateral mass displacement (LMD) averaged 7.1 ± 1.9 mm before surgery and almost achieved satisfactory reduction after surgery. All the fractures achieved bony healing without reduction loss or implant failure. No complications (vertebral artery injury, neurologic deficit, or wound infection) occurred in these 10 patients. At the final follow-up, the anterior atlantodens interval (AADI) was 2.3 ± 0.8 mm and the visual analog scale (VAS) was 0.6 ± 0.7 on average. All patients preserved almost full range of motion of the upper cervical spine and achieved a good clinical outcome at the last follow-up. CONCLUSIONS Posterior osteosynthesis with this new screw-plate system can provide a new therapeutic strategy for unstable atlas fractures with simple and almost satisfactory reduction.
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Affiliation(s)
- Kun Yang
- grid.412679.f0000 0004 1771 3402Department of Orthopedics, the First Affiliated Hospital of Anhui Medical University, No.218 Jixi Road, Hefei, 230022 Anhui Province China
| | - He-gang Niu
- grid.412679.f0000 0004 1771 3402Department of Orthopedics, the First Affiliated Hospital of Anhui Medical University, No.218 Jixi Road, Hefei, 230022 Anhui Province China
| | - Hui Tao
- grid.412679.f0000 0004 1771 3402Department of Orthopedics, the First Affiliated Hospital of Anhui Medical University, No.218 Jixi Road, Hefei, 230022 Anhui Province China
| | - Chang Liu
- grid.412679.f0000 0004 1771 3402Department of Orthopedics, the First Affiliated Hospital of Anhui Medical University, No.218 Jixi Road, Hefei, 230022 Anhui Province China
| | - Yun Cao
- grid.412679.f0000 0004 1771 3402Department of Orthopedics, the First Affiliated Hospital of Anhui Medical University, No.218 Jixi Road, Hefei, 230022 Anhui Province China
| | - Wei Li
- grid.412679.f0000 0004 1771 3402Department of Orthopedics, the First Affiliated Hospital of Anhui Medical University, No.218 Jixi Road, Hefei, 230022 Anhui Province China
| | - Jing-jing Zhang
- grid.412679.f0000 0004 1771 3402Department of Orthopedics, the First Affiliated Hospital of Anhui Medical University, No.218 Jixi Road, Hefei, 230022 Anhui Province China
| | - Cai-liang Shen
- grid.412679.f0000 0004 1771 3402Department of Orthopedics, the First Affiliated Hospital of Anhui Medical University, No.218 Jixi Road, Hefei, 230022 Anhui Province China
| | - Yin-shun Zhang
- grid.412679.f0000 0004 1771 3402Department of Orthopedics, the First Affiliated Hospital of Anhui Medical University, No.218 Jixi Road, Hefei, 230022 Anhui Province China
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Cloney MB, Kim HS, Dahdaleh NS. Risk Factors for Fracture Nonunion and Transverse Atlantal Ligament Injury After Isolated Atlas Fractures: A Case Series of 97 Patients. Neurosurgery 2022; 91:900-905. [PMID: 36083183 DOI: 10.1227/neu.0000000000002124] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 06/28/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The management of atlas fractures is controversial and hinges on the integrity of transverse atlantal ligament (TAL). OBJECTIVE To identify risk factors for atlas fracture nonunion, with and without TAL injury. METHODS All isolated, traumatic atlas fractures treated at our institution between 1999 and 2016 were analyzed. Multivariable logistic regression was used to identify variables associated with TAL injury confirmed on MRI, occult TAL injury seen on MRI but not suspected on computed tomography (CT), and with fracture nonunion on follow-up CT at 12 weeks. RESULTS Lateral mass displacement (LMD) ≥ 7 mm had a 48.2% sensitivity, 98.3% specificity, and 82.6% accuracy for identifying TAL injury. MRI-confirmed TAL injury was independently associated with LMD > 7 mm ( P = .004) and atlanto-dental interval ( P = .039), and occult TAL injury was associated with atlanto-dental interval ( P = .019). Halo immobilization was associated with having a Gehweiler type 3 fracture ( P = .020), a high-risk injury mechanism ( P = .023), and an 18.1% complication rate. Thirteen patients with TAL injury on MRI and/or LMD ≥ 7 mm were treated with a cervical collar only, and 11 patients (84.6%) healed at 12 weeks. Nonunion rates at 12 weeks were equivalent between halo (11.1%) and cervical collar (12.5%). Only age independently predicted nonunion at 12 weeks ( P = .026). CONCLUSION LMD > 7 mm on CT is not sensitive for TAL injury. Some atlas fractures with TAL injury can be managed with a cervical collar. Nonunion rates are not different between halo immobilization and cervical collar, but a strong selection bias precludes directly comparing the efficacy of these modalities. Age independently predicts nonunion.
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Affiliation(s)
- Michael Brendan Cloney
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Hyun Su Kim
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Nader S Dahdaleh
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Vaccaro AR, Lambrechts MJ, Karamian BA, Canseco JA, Oner C, Benneker LM, Bransford R, Kandziora F, Shanmuganathan R, El-Sharkawi M, Kanna R, Joaquim A, Schnake K, Kepler CK, Schroeder GD. Global Validation of the AO Spine Upper Cervical Injury Classification. Spine (Phila Pa 1976) 2022; 47:1541-1548. [PMID: 35877555 PMCID: PMC9612701 DOI: 10.1097/brs.0000000000004429] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 05/17/2022] [Accepted: 06/02/2022] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Global cross-sectional survey. OBJECTIVE To determine the classification accuracy, interobserver reliability, and intraobserver reproducibility of the AO Spine Upper Cervical Injury Classification System based on an international group of AO Spine members. SUMMARY OF BACKGROUND DATA Previous upper cervical spine injury classifications have primarily been descriptive without incorporating a hierarchical injury progression within the classification system. Further, upper cervical spine injury classifications have focused on distinct anatomical segments within the upper cervical spine. The AO Spine Upper Cervical Injury Classification System incorporates all injuries of the upper cervical spine into a single classification system focused on a hierarchical progression from isolated bony injuries (type A) to fracture dislocations (type C). METHODS A total of 275 AO Spine members participated in a validation aimed at classifying 25 upper cervical spine injuries through computed tomography scans according to the AO Spine Upper Cervical Classification System. The validation occurred on two separate occasions, three weeks apart. Descriptive statistics for percent agreement with the gold-standard were calculated and the Pearson χ 2 test evaluated significance between validation groups. Kappa coefficients (κ) determined the interobserver reliability and intraobserver reproducibility. RESULTS The accuracy of AO Spine members to appropriately classify upper cervical spine injuries was 79.7% on assessment 1 (AS1) and 78.7% on assessment 2 (AS2). The overall intraobserver reproducibility was substantial (κ=0.70), while the overall interobserver reliability for AS1 and AS2 was substantial (κ=0.63 and κ=0.61, respectively). Injury location had higher interobserver reliability (AS1: κ = 0.85 and AS2: κ=0.83) than the injury type (AS1: κ=0.59 and AS2: 0.57) on both assessments. CONCLUSION The global validation of the AO Spine Upper Cervical Injury Classification System demonstrated substantial interobserver agreement and intraobserver reproducibility. These results support the universal applicability of the AO Spine Upper Cervical Injury Classification System. LEVEL OF EVIDENCE 4.
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Affiliation(s)
| | | | | | - Jose A. Canseco
- Rothman Institute at Thomas Jefferson University, Philadelphia, PA
| | - Cumhur Oner
- Department of Orthopedic Surgery, University Medical Center, University of Utrecht, Utrecht, the Netherlands
| | | | - Richard Bransford
- Department of Orthopaedic Surgery, Harborview Medical Center, University of Washington, Seattle, WA
| | | | | | | | - Rishi Kanna
- Department of Orthopedics and Spine Surgery, Ganga Hospital, Coimbatore, Tamil Nadu, India
| | - Andrei Joaquim
- Department of Neurology, Neurosurgery Division, State University of Campinas, Campinas, Sao Paulo, Brazil
| | - Klaus Schnake
- Center for Spinal and Scoliosis Surgery, Malteser Waldkrankenhaus St. Marien, Erlangen, Germany
- Department of Orthopedics and Traumatology, Paracelsus Private Medical University Nuremberg, Nuremberg, Germany
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10
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Cloney MB, El-Tecle N, Dahdaleh NS. Traumatic atlas fracture patients comprise two subpopulations with distinct demographics and mechanisms of injury. Clin Neurol Neurosurg 2022; 221:107414. [PMID: 35987045 DOI: 10.1016/j.clineuro.2022.107414] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 08/10/2022] [Accepted: 08/13/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Atlas fractures account for as much as 13% of cervical fractures, yet their epidemiology and its implications remain under-examined. METHODS We retrospectively analyzed 97 consecutive cases of isolated, traumatic atlas fractures at our institution over a 17-year period with respect to demographic, clinical, and outcomes data. Unique patient subsets were identified and compared across these parameters. RESULTS The age of atlas fracture patients showed a bimodal distribution and strong goodness of fit, with one mean centered at an age of 30 years for patients age< 50 (R=0.9409) and mean age of 74 among patients age≥ 50 (R=0.8584). Young patients were more likely to have a high-risk mechanism of injury (57.8% vs. 11.5%, OR=10.49 [3.59, 29.65], p < 0.0001) and injuries while intoxicated (13.3% vs. 0%, OR ∞ [1.704, ∞], p = 0.0082). A greater portion of young patients were managed with halo (33.3% vs. 13.5%, OR=3.21 [1.20, 8.13, p = 0.0281]). Among patients who were managed with halo, a greater proportion had halo-related complications among patients age≥ 50 (57.1% vs. 6.7%, OR=18.67 [1.55, 239.1], p = 0.0207). The median age of atlas fractures increased by ~2.6 years annually (slope 2.637, p < 0.0001, R=0.8079). CONCLUSIONS The atlas fracture patient population may comprise two distinct subpopulations, distinguished by differences in age and mechanism of injury that lead to divergent management decisions. While halo immobilization has a low rate of complications among patients age< 50, the complication among patients age≥ 50 was significantly higher. The median age of atlas fracture patients increased linearly during the study period, highlighting the importance of age-related differences in management.
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Affiliation(s)
- Michael Brendan Cloney
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, United States.
| | - Najib El-Tecle
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Nader S Dahdaleh
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
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11
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Yan L, Du J, Yang J, He B, Hao D, Zheng B, Yang X, Hui H, Liu T, Wang X, Guo H, Chen J, Wang S, Ma S, Dong S. C1-ring osteosynthesis versus C1-2 fixation fusion in the treatment of unstable atlas fractures: a multicenter, prospective, randomized controlled study with 5-year follow-up. J Neurosurg Spine 2022; 37:157-165. [PMID: 35148517 DOI: 10.3171/2021.12.spine211063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 12/20/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim of the present study was to compare the long-term effects of posterior C1-ring osteosynthesis and C1-2 fixation fusion in the treatment of unstable atlas fractures. METHODS A multicenter, prospective, randomized controlled trial was conducted to analyze 73 patients with atlas fractures who underwent posterior fixation. The intervention group was treated with C1-ring osteosynthesis, and the control group was treated with C1-2 fixation fusion. The patients were followed up for 6 months, 1 year, 2 years, and 5 years after the operation. RESULTS Fifty-two patients had complete data at the last follow-up. The visual analog scale (VAS) score for neck pain in the intervention group was lower than that in the control group (p < 0.001). The operation time, intraoperative blood loss, radiation dose, bedridden period, hospital stay, and cost in the intervention group were significantly lower than those in the control group (p < 0.001). At the last follow-up, the Neck Disability Index in the intervention group was higher than that of the control group, and the angle of flexion-extension and axial rotation in the intervention group were greater than those in the control group (p < 0.001). CONCLUSIONS In this study, the authors found that posterior C1-ring osteosynthesis is superior to C1-2 fixation fusion in terms of long-term relief of neck pain and preservation of the physiological function of the cervical vertebrae. This technique is a reliable choice for the treatment of unstable C1 fractures.
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Affiliation(s)
- Liang Yan
- 1Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Jinpeng Du
- 1Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Junsong Yang
- 1Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Baorong He
- 1Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Dingjun Hao
- 1Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Bolong Zheng
- 1Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Xiaobin Yang
- 1Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Hua Hui
- 1Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Tuanjiang Liu
- 1Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Xiaodong Wang
- 1Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Hua Guo
- 2Department of Orthopaedics Surgery, Xi'an Central Hospital, Xi'an, China
| | - Jian Chen
- 3Department of Spine Surgery, Yingchuan Guolong Hospital, Yingchuan, China
| | - Shaofei Wang
- 4Department of Spine Surgery, Baoji Traditional Chinese Medicine Hospital, Baoji, China
| | - Shengzhong Ma
- 5Department of Spine Surgery, The Second Hospital of Shandong University, Jinan, China; and
| | - Shengli Dong
- 6Department of Spine Surgery, General Hospital of Pingmei Shenma Group, Pingdingshan, China
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12
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Wick J, Le H, Wick K, Peddada K, Bacon A, Han G, Carroll T, Swinford S, Javidan Y, Roberto R, Martin A, Ebinu J, Kim K, Klineberg E. Patient Characteristics, Injury Types, and Costs Associated with Secondary Over-Triage of Isolated Cervical Spine Fractures. Spine (Phila Pa 1976) 2022; 47:414-422. [PMID: 34366413 DOI: 10.1097/brs.0000000000004190] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort. OBJECTIVE To aim of this study was to identify patient variables, injury characteristics, and costs associated with operative and non-operative treatment following inter-facility transfer of patients with isolated cervical spine fractures. SUMMARY OF BACKGROUND DATA Patients with isolated cervical spine fractures are subject to inter-facility transfer for surgical assessment, yet are often treated nonoperatively. The American College of Surgeons' benchmark rate of "secondary over-triage" is <50%. Identifying patient and injury characteristics as well as costs associated with treatment following transfer of patients with isolated cervical spine fractures may help reduce rates of secondary over-triage and healthcare expenditures. METHODS Patients transferred to a Level-1 trauma center with isolated cervical spine fractures between January 2015 and September 2020 were identified. Patient demographics, comorbidities, insurance data, injury characteristics, imaging workup, treatment, and financial data were collected for all patients. Multivariable logistic regression models were constructed to identify patient and injury characteristics associated with surgical treatment. RESULTS Nearly 75% of patients were treated non-operatively. Over 97% of transfers were accepted by the general surgery trauma service. Multivariable modeling found that higher BMI, presence of any neurologic deficit including spinal cord or isolated spinal nerve root injuries, present smoking status, or cervical spine magnetic resonance imaging obtained post-transfer, were associated with surgical treatment for isolated cervical spine fractures. Among patients with type II dens fractures, increased fracture displacement was associated with surgical treatment. Median charges to patients treated operatively and nonoperatively were $380,890 and $90,734, respectively. Median hospital expenditures for patients treated operatively and nonoperatively were $55,115 and $12,131, respectively. CONCLUSION A large proportion of patients with isolated cervical spine fractures are subject to over-triage. Injury characteristics are important for determining need for surgical treatment, and therefore interfacility transfer. Improving communication with spine surgeons when deciding to transfer patients may significantly reduce health care costs and resource use.Level of Evidence: 4.
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Affiliation(s)
- Joseph Wick
- Department of Orthopaedic Surgery, University of California Davis Medical Center, Sacramento, CA
| | - Hai Le
- Department of Orthopaedic Surgery, University of California Davis Medical Center, Sacramento, CA
| | - Katherine Wick
- Department of Internal Medicine, University of California Davis Medical Center, Sacramento, CA
| | - Kranti Peddada
- Department of Orthopaedic Surgery, University of California Davis Medical Center, Sacramento, CA
| | - Adam Bacon
- University of California Davis School of Medicine, Sacramento, CA
| | - Gloria Han
- University of California Davis School of Medicine, Sacramento, CA
| | - Trevor Carroll
- Department of Orthopaedic Surgery, University of California Davis Medical Center, Sacramento, CA
| | - Steven Swinford
- Department of Orthopaedic Surgery, University of California Davis Medical Center, Sacramento, CA
| | - Yashar Javidan
- Department of Orthopaedic Surgery, University of California Davis Medical Center, Sacramento, CA
| | - Rolando Roberto
- Department of Orthopaedic Surgery, University of California Davis Medical Center, Sacramento, CA
| | - Allan Martin
- Department of Neurological Surgery, University of California Davis Medical Center, Sacramento, CA
| | - Julius Ebinu
- Department of Neurological Surgery, University of California Davis Medical Center, Sacramento, CA
| | - Kee Kim
- Department of Neurological Surgery, University of California Davis Medical Center, Sacramento, CA
| | - Eric Klineberg
- Department of Orthopaedic Surgery, University of California Davis Medical Center, Sacramento, CA
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13
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Lyons J, Mian H. Epidemiology of atlas fractures in the United States: A 20-year analysis. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2022; 13:85-93. [PMID: 35386248 PMCID: PMC8978844 DOI: 10.4103/jcvjs.jcvjs_164_21] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 01/09/2022] [Indexed: 11/06/2022] Open
Abstract
Introduction: Fractures of the atlas represent a large portion of cervical spine trauma in the geriatric population. With an aging and more active population, it is expected that the number of patients sustaining atlas fractures is increasing. However, epidemiologic data regarding the incidence of atlas fractures in large populations are scarce. The aim of this study was to investigate the incidence and demographic characteristics of patients with fractures of the atlas in the United States (US) over the last 20 years. Materials and Methods: This descriptive epidemiology study retrospectively analyzed the National Electronic Injury Surveillance System database to identify cases of atlas fractures presenting to US Emergency Departments (EDs) from 2001 to 2020. Annual and overall numbers of fractures and fracture incidence rates, patient demographics (age, gender, race), and injury characteristics (mechanism, associated injuries) were analyzed. Incidence rates are expressed as the number of fractures per million at-risk person-years. Patients were split into four different age groups for comparisons (<18, 18–64, 65–79, 80+ years). Results: An estimated 38,092 cases of acute atlas fractures were identified, representing 11.1% of all cervical fractures and corresponding to an overall incidence rate of 6.2. Slightly more than half (54%) occurred in females and the mean age was 71 years. Overall, a majority (64%) of cases occurred in patients > 70 years old. There was substantial increase in incidence rate with age (<18 years: 0.7; 18–64 years: 2.6; 65–79 years: 17.1; 80 + years: 71.8). The most common injury mechanism was a low-energy fall (74%). Overall, only 42% of atlas fractures were isolated injuries, with 58% of patients sustaining at least one concomitant injury and 48% sustaining at least one additional fracture. Accounting for population growth yielded a significantly increasing incidence over the study period from 1.7 in 2001 to 13.4 in 2020 (annual percent increase = 11, P < 0.00001). Disproportionately large increases in incidence rates were observed in the oldest patient groups. Conclusions: Atlas fractures occur in older patients and are often associated with concomitant injuries to the head and spine. These types of fractures are increasing in the US, especially among the elderly. The annual incidence increased nearly 700% over the course of the study period and in 2020 was over 13 per million overall. In elderly patients >80 years old, the most recent annual incidence rate was over 157 per million.
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14
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Abstract
Craniocervical injuries (CCJs) account for 10% to 30% of all cervical spine trauma. An increasing number of patients are surviving these injuries due to advancements in automobile technology, resuscitation techniques, and diagnostic modalities. The leading injury mechanisms are motor vehicle crashes, falls from height, and sports-related events. Current treatment with urgent rigid posterior fixation of the occiput to the cervical spine has resulted in a substantial reduction in management delays expedites treatment of CCJ injuries. Within CCJ injuries, there is a spectrum of instability, ranging from isolated nondisplaced occipital condyle fractures treated nonoperatively to highly unstable injuries with severely distracted craniocervical dissociation. Despite the evolution of understanding and improvement in the management of cases regarding catastrophic failure to diagnose, subsequent neurologic deterioration still occurs even in experienced trauma centers. The purpose of this article is to review the injuries that occur at the CCJ with the accompanying anatomy, presentation, imaging, classification, management, and outcomes.
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Affiliation(s)
- Catherine Olinger
- Harborview Medical Center, University of Washington Department of Orthopaedics and Sports Medicine, 908 Jefferson Street, Fifth Floor, Seattle, WA, USA.
| | - Richard Bransford
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, WA, USA; Department of Neurological Surgery, University of Washington, Seattle, WA, USA; Spine Fellowship Program, University of Washington Department of Orthopaedics and Sports Medicine, 908 Jefferson Street, Fifth Floor, Seattle, WA, USA
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15
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Tu Q, Chen H, Li Z, Chen Y, Xu A, Zhu C, Huang X, Ma X, Wang J, Zhang K, Yin Q, Xu J, Xia H. Anterior reduction and C1-ring osteosynthesis with Jefferson-fracture reduction plate (JeRP) via transoral approach for unstable atlas fractures. BMC Musculoskelet Disord 2021; 22:745. [PMID: 34461878 PMCID: PMC8406960 DOI: 10.1186/s12891-021-04628-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 08/18/2021] [Indexed: 11/14/2022] Open
Abstract
Background To introduce a novel transoral instrumentation in the treatment of unstable fractures of the atlas. Methods From January 2008 to May 2018, 22 patients with unstable C1 fractures who received Jefferson-fracture reduction plate (JeRP) via transoral approach were retrospectively analyzed. The case history and the radiographs before and after surgery were noted. The type of fracture, the reduction of the fracture, and position of the internal fixation were assessed through preoperative and postoperative CT scans. Results All 22 patients successfully underwent anterior C1-ring osteosynthesis using the JeRP system, with a follow-up of 26.84 ± 9.23 months. Among them, 9 patients had transverse atlantal ligament (TAL) injury, including 3 in Dickman type I and 6 in type II. The preoperative lateral mass displacement (LMD) decreased from 7.13 ± 1.46 mm to 1.02 ± 0.65 mm after the operation. Bone union was achieved in all patients without implant failure or loss of reduction. There were no surgery-related complications, such as wound infection, neurological deficit, or vertebral artery injury. However, atlantoaxial dislocation occurred in 3 patients with Dickman type I TAL injury 3 months postoperatively without any neurological symptoms or neck pain. Conclusions Transoral C1-ring osteosynthesis with JeRP is an effective surgical strategy to treat unstable atlas fractures with a safe, direct, and satisfactory reduction. The primary indication for the JeRP system is an unstable fracture (Gehweiler type I/III) or/ and TAL injury (Dickman type II). Supplementary Information The online version contains supplementary material available at 10.1186/s12891-021-04628-4.
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Affiliation(s)
- Qiang Tu
- Department of Orthopaedics, PLA General Hospital of Southern Theatre Command: People's Liberation Army General Hospital of Southern Theatre Command, Guangzhou, 510010, Guangdong, China.,Department of Orthopaedics, Southwest Hospital, Third Military Medical University, Chongqing, 400038, China.,The First School of Clinical Medicine, Southern Medical University, Guangzhou, 510010, Guangdong, China
| | - Hu Chen
- Department of Orthopaedics, PLA General Hospital of Southern Theatre Command: People's Liberation Army General Hospital of Southern Theatre Command, Guangzhou, 510010, Guangdong, China.,The First School of Clinical Medicine, Southern Medical University, Guangzhou, 510010, Guangdong, China
| | - Zhan Li
- Guangzhou University of Chinese Medicine, Guangzhou, 510006, Guangdong, China
| | - Yuyue Chen
- Department of Orthopaedics, PLA General Hospital of Southern Theatre Command: People's Liberation Army General Hospital of Southern Theatre Command, Guangzhou, 510010, Guangdong, China
| | - Aihong Xu
- Department of Orthopaedics, PLA General Hospital of Southern Theatre Command: People's Liberation Army General Hospital of Southern Theatre Command, Guangzhou, 510010, Guangdong, China
| | - Changrong Zhu
- Department of Orthopaedics, PLA General Hospital of Southern Theatre Command: People's Liberation Army General Hospital of Southern Theatre Command, Guangzhou, 510010, Guangdong, China
| | - Xianhua Huang
- Department of Orthopaedics, PLA General Hospital of Southern Theatre Command: People's Liberation Army General Hospital of Southern Theatre Command, Guangzhou, 510010, Guangdong, China
| | - Xiangyang Ma
- Department of Orthopaedics, PLA General Hospital of Southern Theatre Command: People's Liberation Army General Hospital of Southern Theatre Command, Guangzhou, 510010, Guangdong, China
| | - Jianhua Wang
- Department of Orthopaedics, PLA General Hospital of Southern Theatre Command: People's Liberation Army General Hospital of Southern Theatre Command, Guangzhou, 510010, Guangdong, China
| | - Kai Zhang
- Department of Orthopaedics, PLA General Hospital of Southern Theatre Command: People's Liberation Army General Hospital of Southern Theatre Command, Guangzhou, 510010, Guangdong, China
| | - Qingshui Yin
- Department of Orthopaedics, PLA General Hospital of Southern Theatre Command: People's Liberation Army General Hospital of Southern Theatre Command, Guangzhou, 510010, Guangdong, China
| | - Jianzhong Xu
- Department of Orthopaedics, Southwest Hospital, Third Military Medical University, Chongqing, 400038, China
| | - Hong Xia
- Department of Orthopaedics, PLA General Hospital of Southern Theatre Command: People's Liberation Army General Hospital of Southern Theatre Command, Guangzhou, 510010, Guangdong, China. .,The First School of Clinical Medicine, Southern Medical University, Guangzhou, 510010, Guangdong, China.
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16
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Ylönen H, Danner N, Jyrkkänen HK, Kämäräinen OP, Leinonen V, Huttunen J. Surgically Treated C1 Fractures: A Population-Based Study. World Neurosurg 2021; 154:e333-e342. [PMID: 34284160 DOI: 10.1016/j.wneu.2021.07.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 07/07/2021] [Accepted: 07/08/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To characterize surgical treatment and outcomes of C1 fractures in a population-based setup. METHODS Patients with C1 fracture treated at Kuopio University Hospital Neurosurgery were retrospectively identified from January 1996 to June 2017. C1 fractures were classified according to the AO Spine Upper Cervical and Gehweiler classification systems. Patients were divided into 4 groups based on their treatment: group 1 (underwent C1 surgery as a primary option), group 2 (underwent C1 surgery as a secondary option after initial nonoperative treatment), group 3 (underwent surgery involving the C1 level with main indication being a concomitant cervical spine fracture), and group 4 (C1 fracture treatment was nonoperative). RESULTS We identified 47 patients with C1 fracture (mean age, 60.3 ± 18.2 years; 83.0% men; American Society of Anesthesiologists score, 2.3 ± 0.8). Concomitant cervical spine fractures were present in 89.4% of cases, most commonly in the C2 vertebra (75.4%). In group 2, 3 of 5 fractures changed from AO Spine type A to B in control imaging after nonoperative treatment, indicating fracture instability and requiring secondary surgery. Good C1 fracture alignment was achieved for 10 of 10 followed-up patients in groups 1 and 2, and for 10 of 11 followed-up patients in group 3. Residual neck pain and stiffness were present in all groups. Neurologic symptoms were rare and mild. CONCLUSIONS For unstable C1 fractures, surgery is safe treatment with good outcomes. Fractures initially determined as stable may require surgery if alignment is worsened in follow-up imaging. Magnetic resonance imaging is recommended to better detect unstable C1 fractures in diagnostic imaging.
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Affiliation(s)
- Henri Ylönen
- Faculty of Health Sciences, School of Medicine, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, North Savo, Finland.
| | - Nils Danner
- Neurosurgery of KUH NeuroCenter, Kuopio University Hospital, Kuopio, Finland
| | | | - Olli-Pekka Kämäräinen
- Faculty of Health Sciences, School of Medicine, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, North Savo, Finland
| | - Ville Leinonen
- Faculty of Health Sciences, School of Medicine, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, North Savo, Finland
| | - Jukka Huttunen
- Neurosurgery of KUH NeuroCenter, Kuopio University Hospital, Kuopio, Finland
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