C1-type II odontoid combination fractures considered to be unstable have been successfully managed with surgical stabilization and fusion. Techniques have included posterior C1-C2 fixation (with or without transarticular screws), anterior odontoid screw fixation, and occipitocervical fusion. Dickman et al,8 Andersson et al,13 Coyne et al,19 and Lee et al20 treated a total of 8 patients with C1-type II odontoid combination fractures with early surgical fusion based on an atlantoaxial interval of ≥ 6 mm. Six patients had posterior C1-C2 fusion, and 1 patient underwent occipital-cervical fusion for multiple fractures of the posterior atlantal arch. Occipitocervical fixation has been used to treat C1-C2 combination fractures by other authors in cases of C1 posterior arch incompetence or gross C1-C2 instability.8,13 Guiot and Fessler9 described 2 patients with this combination injury pattern treated posteriorly with C1-C2 transarticular screw fixation and fusion. Multiple authors have reported anterior odontoid fixation with fusion rates exceeding 90%. Montesano et al,21 Berlemann and Schwazenbach,55 Guiot and Fessler,9 Henry et al,22 and Apostolides et al23 have reported a combined total of 25 patients with C1-C2 combination fractures treated successfully with anterior odontoid fixation. Cases reported by Guiot and Fessler9 and Apostolides et al23 describe the use of anterior transarticular fixation for combination C1-C2 fracture injuries.
In summary, treatment options for C1-type II odontoid combination fractures include external orthoses (both nonrigid and rigid) and surgical fixation with fusion. C1-C2 instability defined by an atlantal-dens interval of ≥ 5 mm or the failure of external immobilization warrants consideration for surgical treatment by one of several acceptable means.
The combination of C1-Hangman fractures has been successfully treated with external immobilization in the majority of reported cases. Successful treatment with immobilization has been reported with a cervical collar,28 the halo device, and the sterno-occipital mandibular immobilizer-type orthosis.4,8,29-31 The report by Fielding et al32 included 15 patients with combination C1-Hangman fractures. They reported that when the combination Hangman fracture was associated with C2-3 angulation > 11°, they considered these C1-C2 combination injuries unstable. Surgical stabilization and fusion were recommended.
The recommended initial treatment of C1-C2 body fractures as reported in the literature is nonoperative. Both rigid immobilization and nonrigid immobilization have been described with nearly universal success.6,20,33-35 The Dickman et al8 series, which included 7 patients with combination C1-C2 body fractures were all successfully treated with either halo or sterno-occipital mandibular immobilizer immobilization.
Combination fractures of the atlas and axis occur relatively frequently and are associated with an increased incidence of neurological deficit compared with either isolated C1 or isolated C2 fractures. C1-type II odontoid combination fractures are the most common C1-C2 combination fracture injury pattern, followed by C1-miscellaneous axis body fractures, C1-type III odontoid fractures, and C1-Hangman combination fractures. Class III medical evidence addressing the management of patients with acute traumatic combination atlas and axis fractures describes a variety of treatment strategies for these unique fracture injuries based primarily on the specific characteristics of the axis fracture injury subtype.
The type of axis fracture present generally dictates the management strategy for the C1-C2 combination fracture injury. Rigid external immobilization is typically recommended as the initial management for the majority of patients with these injuries. Combination atlas-axis fractures with an atlantoaxial interval of ≥ 5 mm or angulation of C2 on C3 of ≥ 11° have been considered for and successfully treated with surgical stabilization and fusion. Surgical options in the treatment of combination C1-C2 fractures include posterior C1-2 internal fixation and fusion or combination anterior odontoid and C1-2 transarticular screw fixation with fusion. Fractures of the posterior ring of the atlas can complicate the surgical treatment of unstable C1-C2 combination fracture injuries. If the posterior arch of C1 is incompetent and a dorsal operative procedure is indicated, occipitocervical internal fixation and fusion, posterior C1-C2 transarticular screw fixation and fusion, and C1 lateral mass-C2 pars/pedicle screw fixation and fusion techniques have been reported to be successful.
Review of the available literature highlights the lack of prospective data and comparison studies to help guide appropriate treatment of combination atlas-axis fractures. Although immobilization has been recommended as the initial management of choice, the increased morbidity and mortality of halo use in the elderly, the increased rate of nonunion of type II odontoid fractures, and patient preferences all raise the question of the benefit of early surgical fixation and fusion for these injuries. Prospective data derived from appropriately designed comparative studies would assist in determining the most favorable outcome strategies and would provide Class II medical evidence on this topic.
The authors have no personal financial or institutional interest in any of the drugs, materials, or devices described in this article.
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