title: A retrospective review of fixation of C1 ring fractures--does the transverse atlantal ligament (TAL) really matter?
abstract: BACKGROUND
  In contrast to the majority of outcome data, many consider C1 fractures to be benign injuries and so have advocated for conservative management, except in the case of concomitant transverse atlantal ligament (TAL) injury where C1-C2 or occiput-C2 fusions are recommended.
  
  
  OBJECTIVE
  Our goal was to evaluate a series of unstable C1 fractures treated with C1 open reduction and internal fixation (ORIF) to assess clinical and radiographic outcomes by determining the success of reduction and pain relief.
  
  
  METHODS
  This is a retrospective cohort review.
  
  
  METHODS
  The sample includes adult patients with unstable C1 fractures treated with open reduction and primary internal fixation.
  
  
  METHODS
  Primary outcome measures included visual analog pain scale (VAS), radiographic reduction (lateral mass displacement), maintenance of reduction, C1-C2 instability, and complications.
  
  
  METHODS
  A retrospective review of all patients with C1 fractures between September 2002 and September 2013 identified 12 consecutive patients from a level I trauma center who were treated with primary internal fixation without fusion. Electronic medical records and preoperative and postoperative radiographs were reviewed. The surgical technique consisted of a posterior cervical approach to the C1 arch and open reduction using bilateral C1 lateral mass screws connected transversely with a rod. Pre- and postoperative computed tomography scans were used to assess reduction. Long-term follow-up flexion and extension radiographs were used to assess C1-C2 stability. The authors did not receive relevant funding in relation to this research.
  
  
  RESULTS
  Twelve patients underwent C1 ORIF, with a mean age of 43 (9 males and 3 females) and a mean follow-up of 17 months. Transverse atlantal ligament was found to be disrupted with type I or type II injury in 11 of the 12 patients: 5 type I and 6 type II. Preoperative lateral mass displacement averaged 7.1 mm, with postoperative displacement after reduction averaging 2.4 mm (p-value <.001). The VAS score averaged 0.7 at latest follow-up. No patients went on to develop C1-C2 instability on final flexion-extension films. No patients had a complication that resulted in neurologic deficit or vascular injury associated with the procedure. No patients were found to have late sequelae of malunion or loss of reduction. Two surgically related complications occurred, namely one patient with errant screw requiring return to the operating room (OR) and one with arthrosis of the occipital-C1 joint.
  
  
  CONCLUSIONS
  Although a small series, early evidence suggests that patients with unstable C1 ring fractures can be successfully managed with primary ORIF. Open reduction and internal fixation results in a stable construct that maintains reduction, results in excellent pain control, and does not lead to C1-C2 instability. In our series, we have not observed the presence of TAL injury to adversely affect outcomes, and thus do not believe it is a contraindication to ORIF. Comparative studies comparing internal fixation with non-operative, C1-C2, or occiput-C2 fusions would yield more insight into optimal treatment options for these fractures.
authors.affiliation: Department of Orthopedics and Sports Medicine, Harborview Medical Center, Box 359798, 325 Ninth Ave, Seattle, WA 98104-2499, USA. Electronic address: jshatsky@uw.edu.
authors.forename: Joshua
authors.initials: J
authors.lastname: Shatsky
authors.affiliation: Department of Orthopedics and Sports Medicine, Harborview Medical Center, Box 359798, 325 Ninth Ave, Seattle, WA 98104-2499, USA.
authors.forename: Carlo
authors.initials: C
authors.lastname: Bellabarba
authors.affiliation: Department of Orthopedics and Sports Medicine, Harborview Medical Center, Box 359798, 325 Ninth Ave, Seattle, WA 98104-2499, USA.
authors.forename: Quynh
authors.initials: Q
authors.lastname: Nguyen
authors.affiliation: Department of Orthopedics and Sports Medicine, Harborview Medical Center, Box 359798, 325 Ninth Ave, Seattle, WA 98104-2499, USA.
authors.forename: Richard J
authors.initials: RJ
authors.lastname: Bransford
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001269:Atlanto-Occipital Joint; D001863:Bone Screws; D001270:Cervical Atlas / Q000000981:diagnostic imaging / Q000293:injuries / Q000601:surgery*; D005260:Female; D005593:Fracture Fixation, Internal / Q000379:methods*; D006801:Humans; D007592:Joint Diseases; D008023:Ligaments, Articular / Q000000981:diagnostic imaging / Q000293:injuries / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D009333:Neck; D059408:Pain Management; D011183:Postoperative Complications; D016059:Range of Motion, Articular; D012189:Retrospective Studies; D016103:Spinal Fractures / Q000601:surgery*; D014057:Tomography, X-Ray Computed; D014193:Trauma Centers; D016896:Treatment Outcome; D055815:Young Adult
keywords: Atlas; C1 fracture; C1 open reduction and internal fixation (C1 ORIF); C1 osteosynthesis; C1–C2 articulation; C1–C2 instability; Cervical spine surgery; Jefferson fracture; Rule of Spence; Transverse atlantal ligament (TAL)