SpineUniverse Case Study Library

Traumatic C1 Fracture

History

A 30-year-old male was involved in a motor vehicle accident, where he sustained a C1 fracture. The patient was neurologically intact but complaining of neck pain.

Examination

The CT scan at the time of presentation showed that the fracture involved the anterior and posterior arch. There was no overhang of C1 on C2 lateral masses. The atlanto-dental interval showed a 2mm displacement, as shown in Figure 1 below.

Initial Treatment

At the time of presentation, the patient was treated conservatively with a rigid cervical collar.

Three weeks after discharge from the hospital, the patient returned to the clinic with increased and constant severe neck and suboccipital pain (VAS 9).

Images (x-ray and CT) revealed occipito-cervical instability (C1-C2) with increased atlanto-dental interval, significant overhang of C1 lateral mass over C2 and cranial settling, as shown in Figure 2 below.

Pre-treatment Images

 Initial Presentation

fig1 Cardona Uribe Occipital Condyle Screw Initial Pre-op CT

Figure 1: CT scan images showing craniocervical junction and C1 fracture

 

Presentation after Treatment with Rigid Cervical Collar

fig2 Cardona Uribe Occipital Condyle Screw After Rigid Collar CT

Figure 2: CT scan images showing cranial settling, and C1 displacement

Diagnosis

The patient was diagnosed with occipito-cervical instability.

Suggest Treatment

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Selected Treatment

The patient was placed under GETA, and SSEP/MEP monitoring was established, including hypoglossal EMG nerve monitoring. Proper alignment was confirmed with fluoroscopy and intraoperative CT navigation.

The patient underwent posterior occipito-C2 fusion instrumentation utilizing the occipital condyle screws as cranial fixation points (polyaxial screw rod construct). This technique was described by Uribe et al.1 You can see this in Figure 3, which is immediate post-op.

Post-treatment Images


fig3 Cardona Uribe Occipital Condyle Screw Immediate Post-op X-ray and CT

Figure 3: Immediate post-operative x-ray and CT scan images showing occipital condyle screws and C2 pedicle screws and rod construct.
 

fig4 Cardona Uribe Occipital Condyle Screw 1-year Post-op X-rays

Figure 4: Cervical lateral, flexion, and extension x-rays demonstrating adequate fusion at 1-year follow-up.

Outcome

At 1-year follow-up, the patient had clinical improvement (VAS 1), a stable occipital cervical junction, and evidence of solid fusion, as shown in Figure 4 above.

Reference

  1. Uribe JS, Ramos E, Baaj A. Occipital Cervical Stabilization Using Occipital Condyles For Cranial Fixation: Technical Case Report. Neurosurgery 65:E1216-E1217, 2009.

 

Case Discussion

The authors present a case of a patient with significant post-traumatic occipitocervical instability requiring stabilization. There are several options for adequate internal fixation when managing such patients. The use of the occipital condyles for this purpose, as described by Uribe et al, is certainly a reasonable consideration. One must keep in mind the course of the hypoglossal nerves when carrying out occipital condyle screw fixation.

Community Case Discussion (6 comments)

SpineUniverse invites spine professionals to share their thoughts on this case.


I have had experience with such injuries in the past. Ideally he should have been treated with either a halo or primary C1-2 fusion initially, depending on what the patient elected after being informed of the options, and risks/benefits. Given the elapsed time from injury and the displacement, non-operative treatment with a halo would not be out of the question. But is would be less likely to succeed. Given his youth, one should seek to treat this without sacrificing joints that are not essential to success. I would recommend 2-5 days of preop traction to reduce the displacement, then perform a Magerl style fusion with iliac crest graft. One could also undertake a Goel/Harms style C1-2 procedure. But this is far less cost-effective while being equally successful. It is not necessary to sacrifice the Occ-C1 joint.

Bear in mind that Harms & Melcher reported acute cases in which they internally fixed the fracture like this, then removed the fixation after the fracture had healed. C1-2 motion was preserved.

Initial tx was appropriate (rigid collar). No one should have a primary fusion for Jefferson fracture (C1 Lateral Mass fx(s)) with <7 mm widening on OMO = transverse ligament is intact. The halo vs. rigid collar is a reasonable discussion.

I typically do weekly x-rays until some callous is noted....if can get ahold of the trauma patient.

I voted for the procedure that was ultimately performed. I am a neuropathologist by trade. I like your approach and concern about sacrificing the Occ-C1 joint. I believe your recommended pre-op traction followed with Mageri style fusion was the best for this patient.

Etela

In reviewing the follow up images, it is clear that the fracture has become unstable. The C1 lateral masses are sliding off of C2 and there is a fracture in the anterior and posterior arch of C1 with widening. Suggesting a C1-2 fusion in this setting is more than likely to result in failure. C1 in this situation provides no structural support and is not an adequate endpoint to the construct. This stabilization procedure requires fixation to the occiput ; whether it is to the condyles or suboccipital bone is personal preference.

Thus far, I do strongly feel that there is a gap in adequate treatment options for C1 fracture. Occipito-C2 fusion is an option, however, it permantly eliminates significant motion of upper C spine. I have submitted an article for publication.
It will be out in SPINE in next few weeks. It is titled
"Open Posterior Reduction and
Stabilization of a C1 Burst Fracture Using Mono-axial Screws". It is basically a motion preserving surgical stabilization of C1 fracture such as this case.

Jon Park MD
Stanford, CA

Criteria proposed to determine transverse atlantal ligament injury with associated C1-C2 instability include :
i) Sum of the displacement of the lateral masses of C1 on C2 of greater than 8.1 mm on plain films (“rules of Spence” corrected for magnification),
ii) a predental space of greater than 3.0 mm in adults, and magnetic resonance imaging evidence of ligamentous disruption or avulsion.

i think since there is instability so i would consider occipital or suboccipital fusion of c1 and c2. However there is very little evidence based medicine over management of c1 injuries.

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