Combined Injury of the Atlas and Axis Vertebrae

Česká verzia

Authors: J. Kočiš; P. Wendsche; V. Mužík; R. Veselý; I. Černohousová
Authors place of work: Klinika traumatologie LF MU, Úrazová nemocnice v Brně
Published in the journal: Cesk Slov Neurol N 2008; 71/104(5): 576-582
Category: Short Communication

Summary

Objective of study:
The article presents the authors’ retrospective assessment of a sample of patients with a finding of combined injury of the atlas and axis vertebrae and their experience in treating this type of combined injury.

Methods:
In the years 1999–2006 we treated 35 patients in our clinic for combined injury of the atlas and axis vertebrae. Patients’ ages ranged from 13 to 94 years with an average of 49.4 years. The sample included 21 men and 14 women. The most frequent cause of injury was a car/motorcycle accident (16 cases in total), a fall while walking in 9 cases, a fall from a height in 6 cases and jumping into shallow water in 4 cases. Fractures were classified according to Aebi and Nazarian. The breakdown of types of injuries was as follows: type C1.2 20 cases, type C1.3 5 cases, type C1.1 4 cases, type C2.3 3 cases, type C3.1 2 cases and type C2.1 1 case. The neurological condition of 32 patients received was assessed as Frankel E, two patients were classified as Frankel A and one patient as Frankel B. The dominant therapeutic approach was conservative, in 28 cases. We operated on seven patients. We carried out compression osteosynthesis of the axis vertebra in two cases and in two cases we used the Gallie technique. Magerl’s rear transarticular stabilization technique was used in the treatment of three patients.

Results:
The monitoring period for patients is at least six months to four years. We categorised all patients’ wounds as healed six months after injury. X‑ray pictures, functional x-ray pictures and the scope of movement of the cervical spinal column were assessed. Two patients with a neurological deficit improved; one patient with a neurological Frankel A damage died without a direct causal relationship to the injury or its treatment. We did not observe any complications in relation to the treatment of patients.

Conclusion:
Combined injury of the atlas and axis vertebrae is relatively frequent. It is always necessary to look for a simultaneous injury of the other vertebra when a fracture of one of these vertebrae is identified. In our sample, patients experienced neurological handicaps in the event of combined ligament and bone‑ligament injuries type C1–C2. Treatment is guided by an assessment of the instability of the injury. Treatment strategy is dominated by the aim of achieving stable osteosynthesis in unstable injuries if the patient’s health condition permits this.

Key words:
atlas – axis – combined injury of the atlas and axis

Zdroje

1. Jefferson G. Fractures of the atlas vertebra: Report of four cases and a review of those previously recorded. Br J Surg 1920; 7: 407–422.

2. Levine AM, Edwards CC. Treatment of Injuries in the C1–C2 complex. Orthop Clin North Am 1986; 17(1): 31–44.

3. Aebi M, Nazarian S. Classification of injuries of the cervical spine. Orthopade 1987; 16(1): 27–36.

4. Gehweiler JA jr, Duff DE, Martinez S, Miller MD, Clark WM. Fractures of the atlas vertebra. Skeletal Radiology 1976, 1: 97–102.

5. Gleizes V, Jacquot FP, Signoret F, Feron JM. Combined injuries in the upper cervical spine: clinical and epidemiological data over a 14–year period. Eur Spine J 2000; 9(5): 386–392.

6. Berlemann U, Schwarzenbach O. Dens fractures in the elderly. Results of anterior screw fixation in 19 elderly patients. Acta Orthop Scand 1997; 68(4): 319–324.

7. Dickman CA, Hadley MN, Browner C, Sonntag VKH. Neurosurgical management of acute atlas–axis combination fractures: A review of 25 cases. J Neurosurg 1989; 70(1): 45–49.

8. Fowler JL, Sandhu A, Fraser RD. A review of fractures of the atlas vertebra. J Spinal Disord 1990; 3(1): 19–24.

9. McGuire RA jr, Harkey HL. Modification of technique and results of atlantoaxial transfacet stabilization. Orthopedics 1995; 18(10): 1029–1032.

10. Fujimura Y, Nishi Y, Chiba K, Kobayashi K. Prognosis of neurological deficits associated with upper cervical spine injuries. Paraplegia 1995; 33(4): 195–202.

11. Kesterson L, Benzel EC, Orrison W, Coleman J. Evaluation and treatment of atlas burst fractures (Jefferson fractures). J Neurosurg 1991; 75(2): 213–220.

12. Fujimura Y, Nishi Y, Kobayashi K. Classification and treatment of axis body fractures. J Orthop Trauma 1996; 10(8): 536–540.

13. Hanigan WC, Powell FC, Elwood PW, Henderson JP. Odontoid fractures in elderly patients. J Neurosurg 1993; 78(1): 32–35.

14. Hanssen AD, Cabanela ME. Fractures of the dens in adult patients. J Trauma 1987; 27(8): 928–934.

15. Zavanone M, Guerra P, Rampini P, Crotti F, Vaccari U. Traumatic fractures of the craniovertebral junction: Management of 23 cases. J Neurosurg Sci 1991; 35(1): 17–22.

16. 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(4): 464–475.

17. Castillo M, Mukherji SK. Vertical fractures of the dens. AJNR Am J Neuroradiol 1996; 17(9): 1627–1630.

18. Coric D, Wilson JA, Kelly DL jr. Treatment of traumatic spondylolisthesis of the axis with nonrigid immobilization: a review of 64 cases. J Neurosurg 1996; 85(4): 550–554.

19. Lind B, Nordwall A, Sihlbom H. Odontoid fractures treated with halo-vest. Spine 1987; 12(2): 173–177.

20. Polin RS, Szabo T, Bogaev CA, Replogle RE, Jane JA. Nonoperative management of types II and III odontoid fractures: the Philadelphia collar versus the halo vest. Neurosurgery 1996; 38(3): 450–457.

21. Segal LS, Grimm JO, Stauffer ES. Non-union of fractures of the atlas. J Bone Joint Surg Am 1987; 69(9): 1423–1434.

22. Lipson SJ. Fractures of the atlas associated with fractures of the odontoid process and transverse ligament ruptures. J Bone Joint Surg Am 1977; 59(7): 940–943.

23. Grob D, Magerl F. Operative Stabilisierung bei Frakturen von C1 und C2. Orthopade 1987; 16(1): 46–54.

24. Magerl F, Seemann PS. Stable Posterior Vision of the Atlas and Axis by Transarticular Screw Fixation. In: Kehr P, Weidner A(eds). Cervical Spine I. Berlin: Springer Verlag1986: 322–327.

25. Suchomel P, Štulík J, Klézl Z, Chrobok J, Lukáš R, Krbec M, Magerl F. Magerlova fixace C1–2. Multicentrická retrospektivní studie. Acta Chir Orthop Traumatol Čech 2004; 71(1): 6–12.

26. Coyne TJ, Fehlings MG, Wallace MC, Bernstein M, Tator CH. C1–C2 posterior cervical fusion: long‑term evaluation of results and efficacy. Neurosurgery 1995; 37(4): 688–693.

27. Harms J, Melcher PR. Posterior C1–C2 fusion with polyaxial screw and rod fixation. Spine 2001; 26(22): 2467–2471.

28. Štulík J, Vyskočil T, Šebesta P, Kryl J. Komplexní atlantoaxiální zlomeniny. Acta Chir Orthop Traumatol Čech 2005; 72: 105–110.

29. Anderson LD, D‘Alonzo RT. Fractures of the odontoid process of the axis. J Bone Joint Surg Am 1974; 56(8): 1663–1674.

30. Andersson S, Rodrigues M, Olerud C. Odontoid fractures: high complication rate associated with anterior screw fixation in the elderly. Eur Spine J 2000; 9(1): 56–59.

31. Hays MB, Bernhang AM. Fractures of the atlas vertebra. A three-part fracture not previously classified. Spine 1992; 17(2): 240–242.

32. Pedersen AK, Kostuik JP. Complete fracture‑dislocation of the atlantoaxial complex: case report and recommendations for a new classification of dens fractures. J Spinal Disord 1994; 7(4): 350–355.

33. Guiot B, Fessler RG. Complex atlantoaxial fractures. J Neurosurg 1999; 91 (Suppl 2): 139–143.

34. Montesano PX, Anderson PA, Schlehr F,Thalgott JS, Lowrey G. Odontoid fractures treated by anterior odontoid screw fixation. Spine 1991; 16 (Suppl 3): S33–S37.

35. Apostolides PJ, Theodore N, Karahalios DG, Sonntag VKH. Triple anterior screw fixation of an acute combination atlas-axis fracture. Case report. J Neurosurg 1997; 87(1): 96–99.

36. Vaccaro AR, Lehman AP, Ahlgren BD, Garfin SR. Anterior C1–C2 screw fixation and bony fusion through an anterior retropharyngeal approach. Orthopedics 1999; 22(12): 1165–1170.

37. Ekong CE, Schwartz ML, Tator CH, Rowed DW, Edmonds VE. Odontoid fracture: management with early mobilization using the halo device. Neurosurgery 1981; 9(6): 631–637.

38. Brashear R jr, Venters G, Preston ET. Fractures of the neural arch of the axis. A report of twenty-nine cases. J Bone Joint Surg Am 1975; 57(7): 879–887.

39. Elliott JM jr, Rogers LF, Wissinger JP, Lee JF. The hangman‘s fracture. Fractures of the neural arch of the axis. Radiology 1972; 104(2): 303–307.

40. Lee TT, Green BA, Petrin DR. Treatment of stable burst fracture of the atlas (Jefferson fracture) with rigid cervical collar. Spine 1998; 23(18): 1963–1967.

41. Fielding JW, Francis WR jr, Hawkins RJ, Pepin J, Hensinger R. Traumatic spondylolisthesis of the axis. Clin Orthop Relat Res 1989; 239: 47–52.

42. Bohay D, Gosselin RA, Contreras DM. The vertical axis fracture: a report on three cases. J Orthop Trauma 1992; 6(4): 416–419.

43. Craig JB, Hodgson BF. Superior facet fractures of the axis vertebra. Spine 1991; 16(8): 875–877.