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C1 fracture


Introduction

Cervical spinal cord injury is a devastating complication most commonly caused by motor vehicle collisions and falls from heights. Upper cervical spinal cord injuries may result in neurogenic shock, respiratory failure, and loss of motor in the upper and lower extremities, often leaving patients bed bound and connected to a ventilator for life. For this reason, injuries of the upper cervical spine must be managed with extreme care and urgency. The craniocervical junction (CVJ) is the most mobile portion of the spine, with complex associations between numerous ligaments and joints. Isolated fractures of the axis are known as Jefferson fractures, named after Sir Geoffrey Jefferson who described them in 1920. These fractures are typically stable and rarely result in neurological injury, but the primary concern is whether the transverse ligament remains intact, as this will guide the treatment of these patients. The most commonly used classification system for Jefferson fractures was described by Landells and Van Peteghem. In this system, type I fractures involve only a single arch of C1, type II fractures involve both the anterior and posterior arch, and type III fractures are fractures of the C1 lateral mass. Type I and III fractures are typically managed with external orthosis for 8 to 12 weeks with fusion rates nearing 100%. Type II fractures can be managed conservatively as well with orthosis as long as the transverse ligament is intact. One method for determining stability of the transverse ligament is with the rule of Spence, which states that the ligament is likely disrupted if an open mouth odontoid x-ray shows combined lateral displacement of C1 on C2 of 7 mm or greater. Disruption of the transverse ligament should prompt consideration for surgical stabilization of the fracture. In this chapter, we will discuss the presentation and management of a patient with an isolated fracture of C1 and discuss the relevant anatomy and surgical approaches.

Example case

  • Chief complaint: neck pain after fall

  • History of present illness: A 56-year-old male who presents to the emergency room after a fall from a ladder, approximately 10 ft in height. He has arm paresthesias but no weakness. He has a spinal cord stimulator and cannot undergo magnetic resonance imaging (MRI). Computed tomography (CT) imaging revealed evidence of a C1 fracture ( Fig. 30.1 ).

    Fig. 30.1, Preoperative computed tomography (CT) image of the cervical spine. (A) Axial image at the rostral aspect of the dens. (B) Axial image at the level of the midbody of the dens. (C) Axial image at the level of the C2 vertebral body. (D) Sagittal image demonstrating multiple fractures of the C1 arch. The C1 neural arch is fractured in two places anteriorly and two places posterolaterally. A fracture also runs through the anterior aspect of the left C1 articular process. There is a small defect in the medial aspect of the right C1 articular pillar and a very small ossific fragment at the right lateral aspect of the dens, which likely represents an avulsion fracture of the right transverse ligament.

  • Medications: Dilaudid, Advil, acetaminophen

  • Allergies: no known drug allergies

  • Past medical history: chronic pain

  • Past surgical history: multiple lumbar laminectomies, spinal cord stimulator

  • Family history: noncontributory

  • Social history: daily alcohol consumption

  • Physical examination: awake, alert, and oriented to person, place, and time; cranial nerves II–XII intact; bilateral deltoids/biceps/triceps 5/5; interossei 5/5; iliopsoas/knee flexion/knee extension/dorsi, and plantar flexion 5/5

  • Reflexes: 2+ in bilateral biceps/triceps/brachioradialis; 3+ in bilateral patella/ankle; positive Babinski; positive Hoffman’s bilaterally; diffuse allodynia present in bilateral upper extremities

  • Laboratories: all within normal limits

  • Ciaran Bolger, MD

  • Royal College of Surgeons

  • Catherine Moran, MD

  • Neurosurgery

  • Tallaght University Hospital

  • Dublin, Ireland

  • Gordon Deen, MD

  • Neurosurgery

  • Mayo Clinic

  • Jacksonville, Florida, United States

  • K. Daniel Riew, MD

  • Orthopaedic Surgery

  • Columbia University

  • New York, New York, United States

  • Baron Zarate Kalfopulos, MD

  • Orthopaedic Surgery

  • Instituto Nacional de Rehabilitacion

  • Medica Sur

  • Mexico City, Mexico

Preoperative
Additional tests requested CT myelogram None

  • CT myelogram

  • CTA

  • MRI C-spine

  • C-spine AP/lateral x-ray

  • Open-mouth x-ray

Surgical approach selected Posterior C1-2 fusion Miami J collar, no surgery offered Halo vest and no surgery unless instability and lack of healing; if instability after immobilization, then posterior C1-2 fusion Posterior C1-2 fusion

  • Surgical approach if 21 years old

  • Surgical approach if 80 years old

  • Same approach

  • Same approach

  • Same approach

  • Same approach

  • C1 lateral mass screws and rods

  • Hard collar

  • Same

  • Minerva jacket

Goal of surgery Stabilize spine, maintain joint integrity, promote healing, reduce pain, prevent neurological deterioration Stabilize spine Stabilize spine, early mobilization
Perioperative
Positioning Prone, with pins Prone Prone, no pins
Surgical equipment

  • Fluoroscopy

  • Surgical navigation

  • Fluoroscopy

  • Surgical microscope

  • Fluoroscopy

  • IOM

Medications MAP>80 Steroids None
Anatomical considerations Spinal cord, vertebral artery, C2-3 joint, C2 nerve root Vertebral artery, C2 nerve, venous plexus, spinal cord Vertebral artery, C2 nerve, thecal sac, spinous process
Complications feared with approach chosen Instability Hematoma, displacement of screws, medical complications Vertebral artery injury, durotomy, C1 lateral mass fracture, C2 nerve root injury, venous plexus bleeding
Intraoperative
Anesthesia General General General
Exposure Occiput-C2 Occiput-C2 C1-3
Levels decompressed None None None
Levels fused C1-2 C1-2 C1-2
Surgical narrative Position prone with neck flexion, midline incision occiput to C2, expose C1 arch and posterior elements of C2, subperiosteal dissection medial border of C2 to expose pedicle and C1-2 joint bilaterally, dissect lateral to vertebral foramen, insert C2 pedicle screws with fluoroscopy/PediGuard/surgical navigation if available, dissect C1 arch laterally and stay inferior to arch to expose C1 lateral mass, insert lag screw with preservation of C2 nerve root if possible, maintain venous hemostasis with bipolar/hemostatic agents, secure screws to rods bilaterally, confirm with x-ray, closure in layers If halo did not work, position prone in neutral head position, expose C1-2, leave muscles attach to caudal edge of C2, place C1 lateral mass screws and C2 pedicle screws, alternatively can use C1-2 transarticular screws, bone graft with allograft iliac crest wired in to directly compress it into C1 posterior arch and C2 lamina/spinous process, intraoperative CT to confirm position of hardware Position prone, midline incision, expose C1-3 spinous process, expose posterior arch of C1 (<10 mm on each side) and lamina of C2 until lateral mass, make an entry point for C2 pedicle screw with polish drill that is 25–30 degrees cephalad and 30–35 degrees medial, drill C1 lateral mass with 15 degrees cephalad and 5–10 degrees medially, connect screws with longitudinal rods with transverse connector, decorticate C2 lamina and lateral mass and inferior edge of C1 posterior arch, use demineralized bone matrix, layered closure
Complication avoidance Insert C2 pedicle screw with PediGuard or stealth navigation, preserve C2 root if possible, stay on the underside of the C1 arch Leave muscles attach to caudal edge of C2, structural allograft at C1 posterior arch, intraoperative CT Limit posterior arch of C1 exposure, respect muscular insertions on C1 and C2 spinous process, use transverse connector
Postoperative
Admission Floor Floor Floor Floor
Postoperative complications feared Malunion, infection Hematoma, displacement of screws, medical complications Vertebral artery injury, wound infection, CSF leak
Anticipated length of stay 3–5 days 2–3 days 1–2 days 2 days
Follow-up testing

  • C-spine x-ray prior to discharge

  • CT C-spine 3 months and 6 months after surgery if necessary

  • Possibly remove screws 6 months after surgery

  • C-spine x-rays 1 month after discharge

  • CT C-spine 2 months after discharge

  • C-spine flexion-extension x-rays 4–6 weeks after halo vest placement if no surgery

  • C-spine standing AP/lateral x-rays at 6 weeks, 6 months, 1 year after surgery

  • C-spine x-rays 6 weeks and every 3 months for first year after surgery

  • CT C-spine 12 months after surgery

Bracing None Hard collar for 2 months None None
Follow-up visits 2 weeks, 3 months, 6 months after surgery 6 weeks after discharge 6 weeks, 6 months,1 year after surgery 2 weeks, 6 weeks, every 3 months for first year after surgery
AP , Anteroposterior; CSF , cerebrospinal fluid; CT , computed tomography; CTA , computed tomography angiography; IOM , intraoperative monitoring; MAP , mean arterial pressure; MRI , magnetic resonance imaging.

Differential diagnosis

  • ▪

    C1 fracture

  • ▪

    Cervical muscle strain

  • ▪

    Normal synchondrosis (pediatrics)

  • ▪

    Spinal cord injury

  • ▪

    Chiari malformation

  • ▪

    Syringomyelia

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