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. 2022 Nov 8:2:101668.
doi: 10.1016/j.bas.2022.101668. eCollection 2022.

Unstable jefferson burst fractures (JBF): Intraoperative stability testing after posterior atlas ring osteosynthesis (C1-RO) allows determination of surgical procedure extent

Andy Ottenbacher  1 , Ahmed R Rizk  1 , Marcus Mehlitz  1 , Martin Bettag  1
Affiliations

Unstable jefferson burst fractures (JBF): Intraoperative stability testing after posterior atlas ring osteosynthesis (C1-RO) allows determination of surgical procedure extent

Andy Ottenbacher et al. Brain Spine. .

Abstract

Introduction: Motion preserving atlas ring osteosynthesis (C1-RO) for unstable Jefferson burst fractures (JBF) with insufficiency of the transverse atlantal ligament (TAL) is under debate. There is controversy about when to apply C1-RO and when further stabilization is needed.

Research question: Is intraoperative stability testing after C1-RO with restoration of secondary stabilizers feasible, and what are mid-to long-term results of posterior C1-RO vs. C1-C2 ORIF in unstable Jefferson burst fractures with Dickman type I or II transverse atlantal ligament lesions based on intraoperative decision using this stability testing?

Material and methods: Five consecutive patients with unstable JBF were treated with posterior C1-RO or C1-C2 ORIF based on the findings after intraoperative reduction and posterior C1-RO and stability testing. This newly developed intraoperative stability test based on the findings of biomechanical studies is a fluoroscopically controlled manual C1-C2 test with a force of approximately 50 ​N posterior-anterior stress and a tilting maneuver after C1-RO with repositioning. Clinical and radiological results of the cases with C1-RO were analyzed 3.5-21 months postoperatively.

Results: Posterior C1-RO was performed in four patients. One case required C1-C2 fixation due to significant instability. In cases of C1-RO, stable bony fusions of the atlas ring were observed within a year. In flexion-extension views, the anterior atlanto-dental interval (AADI) did not increase until the latest follow-up. No complications were observed.

Discussion and conclusion: The described intraoperative stability test after posterior C1-RO in unstable JBF enables the determination if C1-RO is sufficient or C1-C2 ORIF is necessary for treatment.

Keywords: C1-RO; C1-ring osteosynthesis; Intraoperative stability test; Motion preserving; Unstable jefferson burst fracture.

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Conflict of interest statement

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Figures

Graphic 1
Graphic 1
Algorithm of intraoperative stability testing in the treatment of unstable JBF.
Fig. 1
Fig. 1
Translational intraoperative stability test C1–C2 in patient #4 (screenshots of dynamic fluoroscopy). Minimum anterior atlanto-dental interval (AADI).
Fig. 2
Fig. 2
Translational intraoperative stability test C1–C2 in patient #4 (screenshots of dynamic fluoroscopy). Maximum AADI.
Fig. 3
Fig. 3
Translational intraoperative stability test C1–C2 in patient #3 (screenshots of dynamic fluoroscopy). Minimum AADI.
Fig. 4
Fig. 4
Translational intraoperative stability test C1–C2 in patient #3 (screenshots of dynamic fluoroscopy). Maximum AADI.
Fig. 5
Fig. 5
Tilting intraoperative stability test C1–C2 in patient #3. Minimum tilt.
Fig. 6
Fig. 6
Tilting intraoperative stability test C1–C2 in patient #3. Maximum tilt.
Fig. 7
Fig. 7
C1–C2 open reduction and internal fixation (ORIF) with a cross connector.
See this image and copyright information in PMC

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