[Are there therapy algorithms in isolated and combined atlas fractures?]

Abstract

Aim: Injuries of the atlas are always a challenge in diagnostics and therapy. Different clinical manifestations, inconspicuous neurological results, uncertain findings of radiological diagnostics and possible accompanying injuries require individual therapeutic concepts.

Methods: Patients with injuries of C1 and C2 seen between 2001-2007 were evaluated and especially the morbidity and treatment of the C1-injured patients were verified. To systematise the injuries, a subdivision in isolated and combined trauma took place. Furthermore, the post-traumatic as well as post-therapeutic accompanying neurological deficits were evaluated.

Results: Altogether 121 fractures/injuries of the upper cervical spine (C1/C2) were counted, 22 (18.2 %) concerning the atlas. There were 11 fractures of type Gehweiler I, 9 of type III and 1 each of types II and IV. Isolated fractures of type I (5/11) were treated conservatively, combined injuries (6/11), depending on the stability and location of the attendant injuries, were treated with semi-rigid collars, anterior or posterior fusions. Stable fractures of type III (2/9) were primarily treated in Halo extension. Because of an attending dens fracture type Anderson II in 1 case, a spondylodesis of the dens was additionally performed in the conservative treatment of the atlas. The therapy of isolated unstable atlas fractures of type III (4/9) ranged, depending on the general conditions, from Halo extension, transoral C1 stabilisation, anterior transarticular C1/C2 fusion to posterior occipitocervical fusions. The therapeutic regime of combined unstable type III injuries (2/9) depended on the additional trauma: anterior fusion in C6/7 luxation fracture combined with Halo extension for C1, posterior C0/C3 fusion in unstable dens fractures of type Anderson II.

Conclusion: The therapy for atlas fractures orientates on the type of the C1 fracture, the accompanying injuries and the general condition of the patient. Isolated stable C1 fractures without dislocation can be treated conservatively (cervical collar), unstable fractures, depending on the general condition, should be referred to surgical therapy or halo extension. In combined atlas fractures the strategy of treatment has to take the stability of the C1 fractures into consideration, but also the additional injuries of the rest of the cervical spine and the attendant circumstances.