Recommendations for the Diagnostic Testing and Therapy of Atlas Fractures

Abstract

In a consensus process with four sessions in 2017, the working group on “the upper cervical spine” of the German Society for Orthopaedic and Trauma Surgery (DGOU) formulated “Therapeutic Recommendations for the Diagnosis and Treatment of Fractures to the Upper Cervical Spine”, incorporating their own experience and current literature. The following article describes the recommendations for the atlas vertebra. About 10% of all cervical spine injuries include the axis vertebra. The diagnostic process primarily aims to detect the injury and to determine joint incongruency and integrity of the atlas ring. For classification purposes, the Gehweiler classification and the Dickman classification are suitable. The Canadian c-spine rule is recommended for clinical screening for c-spine injuries. CT is the preferred imaging modality; MRI is needed to determine the integrity of the Lig. transversum atlantis in complete atlas ring fractures. Conservative treatment is appropriate in very many atlas fractures. Surgical treatment is recommended in existing or potential joint incongruity or instability, which are frequently seen in Gehweiler IIIB or Gehweiler IV fractures. Posterior atlanto-axial stabilisation and fusion using transarticular screws or an internal fixator are regarded as a gold standard in the majority of surgical cases. Especially in young patients, the possibility of isolated atlas osteosynthesis should be checked. A possible option for Gehweiler IV fractures is halo-fixation with mild distraction for ligamentotaxis. Secondary dislocation should be checked for frequently. Involvement of the occipito-atlantal joint complex requires stabilisation of the occiput as well.

Key words

atlas fracture - upper cervical spine - Gehweiler - Dickman

• References/Literatur

• 1 Verheyden AP, Hölzl A, Ekkerlein H. et al. Therapieempfehlungen zur Versorgung von Verletzungen der Brust- und Lendenwirbelsäule. Unfallchirurg 2011; 114: 9-16
• 2 Riesner H, Blattert T, Katscher S. et al. Gibt es Therapiealgorithmen bei isolierten und kombinierten Atlas-Frakturen?. Z Orthop Unfall 2009; 147: 472-480 doi:10.1055/s-0029-1185621
• 3 Hadley MN, Dickman CA, Browner CM. et al. Acute traumatic atlas fractures: management and long term outcome. Neurosurgery 1988; 23: 31-35
• 4 Zielinski CJ, Gunther SF, Deeb Z. Cranial-nerve palsies complicating Jefferson fracture. A case report. J Bone Joint Surg Am 1982; 64: 1382-1384
• 5 Jefferson G. Report of four cases, and a review of those previously recorded. Br J Surg 1919; 7: 407-422 doi:10.1002/bjs.1800072713
• 6 Gehweiler JA, Osborne RL, Becker RF. The Radiology of vertebral Trauma. Philadelphia: W.B. Saunders Company; 1980
• 7 Dickman CA, Greene KA, Sonntag VK. Injuries involving the transverse atlantal ligament: classification and treatment guidelines based upon experience with 39 injuries. Neurosurgery 1996; 38: 44-50
• 8 Kandziora F, Schnake K, Hoffmann R. [Injuries to the upper cervical spine. Part 2: osseous injuries]. Unfallchirurg 2010; 113: 1023-1039 doi:10.1007/s00113-010-1896-3
• 9 Hoffman JR, Mower WR, Wolfson AB. et al. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group. N Engl J Med 2000; 343: 94-99 doi:10.1056/NEJM200007133430203
• 10 Stiell IG, Clement CM, McKnight RD. et al. The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J Med 2003; 349: 2510-2518 doi:10.1056/NEJMoa031375
• 11 Perez-Orribo L, Snyder LA, Kalb S. et al. Comparison of CT versus MRI measurements of transverse atlantal ligament integrity in craniovertebral junction injuries. Part 1: a clinical study. J Neurosurg Spine 2016; 24: 897-902 doi:10.3171/2015.9.SPINE13808
• 12 Biffl WL, Ray CE, Moore EE. et al. Noninvasive diagnosis of blunt cerebrovascular injuries: a preliminary report. J Trauma 2002; 53: 850-856 doi:10.1097/01.TA.0000027419.40682.49
• 13 Miller PR, Fabian TC, Croce MA. et al. Prospective screening for blunt cerebrovascular injuries: analysis of diagnostic modalities and outcomes. Ann Surg 2002; 236: 386-393 doi:10.1097/01.SLA.0000027174.01008.A0
• 14 Fowler JL, Sandhu A, Fraser RD. A review of fractures of the atlas vertebra. J Spinal Disord 1990; 3: 19-24
• 15 Spence KF, Decker S, Sell KW. Bursting atlantal fracture associated with rupture of the transverse ligament. J Bone Joint Surg Am 1970; 52: 543-549
• 16 Woods RO, Inceoglu S, Akpolat YT. et al. C1 lateral mass displacement and transverse atlantal ligament failure in Jeffersonʼs fracture: a biomechanical study of the „Rule of Spence“. Neurosurgery 2018; 82: 226-231 doi:10.1093/neuros/nyx194
• 17 Goel A. C1–C2 pedicle screw fixation with rigid cantilever beam construct: case report and technical note. Neurosurgery 2002; 51: 853-854
• 18 Harms J, Melcher RP. Posterior C1–C2 fusion with polyaxial screw and rod fixation. Spine (Phila Pa 1976) 2001; 26: 2467-2471
• 19 Jeanneret B, Magerl F. Primary posterior fusion C1/2 in odontoid fractures: indications, technique, and results of transarticular screw fixation. J Spinal Disord 1992; 5: 464-475
• 20 Abeloos L, De Witte O, Walsdorff M. et al. Posterior osteosynthesis of the atlas for nonconsolidated Jefferson fractures: a new surgical technique. Spine (Phila Pa 1976) 2011; 36: E1360-E1363 doi:10.1097/BRS.0b013e318206cf63
• 21 Böhm H, Kayser R, El Saghir H. et al. [Direct osteosynthesis of instable Gehweiler Type III atlas fractures. Presentation of a dorsoventral osteosynthesis of instable atlas fractures while maintaining function]. Unfallchirurg 2006; 109: 754-760 doi:10.1007/s00113-006-1081-x
• 22 He B, Yan L, Zhao Q. et al. Self-designed posterior atlas polyaxial lateral mass screw-plate fixation for unstable atlas fracture. Spine J 2014; 14: 2892-2896 doi:10.1016/j.spinee.2014.04.020
• 23 Hu Y, Ma W, Xu R. Transoral osteosynthesis C1 as a function-preserving option in the treatment of bipartite atlas deformity: a case report. Spine 2009; 34: E418-E421 doi:10.1097/BRS.0b013e3181a0ff2f
• 24 Hu Y, Xu RM, Albert TJ. et al. Function-preserving reduction and fixation of unstable Jefferson fractures using a C1 posterior limited construct. J Spinal Disord Tech 2014; 27: E219-E225 doi:10.1097/BSD.0b013e31829a36c5
• 25 Jo KW, Park IS, Hong JT. Motion-preserving reduction and fixation of C1 Jefferson fracture using a C1 lateral mass screw construct. J Clin Neurosci 2011; 18: 695-698 doi:10.1016/j.jocn.2010.08.033
• 26 Ma W, Xu N, Hu Y. et al. Unstable atlas fracture treatment by anterior plate C1-ring osteosynthesis using a transoral approach. Eur Spine J 2013; 22: 2232-2239 doi:10.1007/s00586-013-2870-x
• 27 Sun SH, Fang JL, Ma WH. et al. [Transoral plate internal fixation for treatment of instability atlas fracture]. Zhongguo Gu Shang 2013; 26: 81-84
• 28 Bednar DA, Almansoori KA. Solitary C1 posterior fixation for unstable isolated atlas fractures: case report and systematic review of the literature. Global Spine J 2016; 6: 375-382 doi:10.1055/s-0035-1564806
• 29 Kandziora F, Chapman JR, Vaccaro AR. et al. Atlas fractures and atlas osteosynthesis: a comprehensive narrative review. J Orthop Trauma 2017; 31 (Suppl. 04) S81-S89 doi:10.1097/BOT.0000000000000942
• 30 Bransford R, Chapman JR, Bellabarba C. Primary internal fixation of unilateral C1 lateral mass sagittal split fractures: a series of 3 cases. J Spinal Disord Tech 2011; 24: 157-163 doi:10.1097/BSD.0b013e3181e12419
• 31 Bromberg WJ, Collier BC, Diebel LN. et al. Blunt cerebrovascular injury practice management guidelines: the Eastern Association for the Surgery of Trauma. J Trauma 2010; 68: 471-477 doi:10.1097/TA.0b013e3181cb43da