Implantation choices, fusion preferences and implant removal after fixation in C1-C2 fractures: An AO Spine Knowledge Forum expert survey

Rishi Mugesh Kanna; Mitchell Ng; Andrei F Joaquim; Gregory D Schroeder; Mohammad El-Sharkawi; Alfredo Guiroy; Ratko Yurac; Brian A Karamian; Charlotte Dandurand; Alexander R Vaccaro; Grace Xiong; Richard Bransford; Martin Holas; Klaus Schnake

doi:10.1007/s00586-026-09996-w

Implantation choices, fusion preferences and implant removal after fixation in C1-C2 fractures: An AO Spine Knowledge Forum expert survey

Eur Spine J. 2026 May 14. doi: 10.1007/s00586-026-09996-w. Online ahead of print.

Authors

Affiliations

¹ Ganga Hospital, Coimbatore, India. rishiortho@gmail.com.
² Rothman Institute, Philadelphia, USA.
³ State University of Campinas, Campinas, Brazil.
⁴ Assiut University, Assiut, Egypt.
⁵ Clinica de Cuyo, Mendoza, Argentina.
⁶ Universidad del Desarrollo, Santiago, Chile.
⁷ University of Utah, Salt Lake City, USA.
⁸ University of British Columbia, Vancouver, Canada.
⁹ Stanford University, Stanford, USA.
¹⁰ Harborview Medical Center, Seattle, USA.
¹¹ Slovak Medical University, Bratislava, Slovakia.
¹² Malteser Waldkrankenhaus Erlangen, Erlangen, Germany.

PMID: 42133038
DOI: 10.1007/s00586-026-09996-w

Abstract

Purpose: The management of upper cervical spine (UCS) fractures is unclear concerning the role of fusion versus non-fusion fixation and the need for implant removal following fracture healing. This international AO Spine expert survey (Level IV study) evaluated the current trends, and practice preferences among experienced surgeons in the management of UCS fractures.

Methods: A structured questionnaire was answered by AO Spine Knowledge Forum Trauma and Infection (KF T&I) members (n = 24). The survey collected data regarding demographics, classification use, fixation vs. fusion preferences, and implant removal practices for UCS fractures (C1, C2 odontoid, and Hangman's fractures). Descriptive statistics were analysed.

Results: Majority were from North America and Europe (54%), orthopedic spine surgeons (87.5%), university-affiliated (88%), and well experienced (> 20 years: 58.3%). For C1 fractures, 79% used the AO UCS classification and 75% relied on MRI to assess transverse atlantal ligament integrity. Fixation ± fusion techniques dominated (C1-2 fusion: 62.5%; occipitocervical fixation: 45.9%), and implant removal was rarely performed (29.2% never, 70.8% only for symptoms). For odontoid fractures, 83.3% surgeons preferred posterior fixation in more than 60% fractures, while anterior odontoid screws were used infrequently (37.5%). 50% never removed implants. For Hangman's fractures, both anterior (41.7%) and posterior fixation/ fusion (45.8%) were equally preferred. In posterior fixations, fusion was added by 75%, while 25% favored only fixation without fusion. Implant removal was rare (16.7%).

Conclusions: This survey reveals that even among experienced surgeons, management strategies for UCS remain diverse. Segmental fixation procedures, particularly C1-C2 and C2-3 constructs, are commonly performed for both C1 and C2 fracture treatment while planned implant removal after fracture healing is rarely implemented. It highlights the need for prospective studies and randomized trials for formulating guidelines and indications for motion-preserving techniques and implant removal.

Keywords: AO Spine survey; C1 fracture; Fusion; Hangman’s fracture; Implant removal; Non-fusion; Odontoid fracture; Upper cervical spine.