Unstable Jefferson variant atlas fractures: an unrecognized cervical injury

We retrospectively reviewed the plain films and CT scans of 11 unstable atlas fractures from a series of 72 atlas fractures to better characterize these injuries and to determine if the correct diagnosis could have been made. These 11 atlas fractures were unstable because either the anterior bony ring was disrupted (six cases), the posterior longitudinal ligament was torn (one case), or both the anterior bony ring and the posterior longitudinal ligament were disrupted (four cases), allowing C1-C2 subluxation to occur. Although all the fractures were potentially unstable, only eight demonstrated subluxation on the lateral radiography. Despite the abnormal open mouth view in all cases, the plain films showed minimal abnormalities, requiring CT for definitive diagnosis. Less than half (five of 11) of the patients had other levels of spine injury or associated transverse ligament tear. Three of the 11 patients were quadriplegic, and two died as a result of their spinal cord injury. These unstable atlas fractures were similar to the classical Jefferson fracture in appearance and mechanism, except that they had fewer than four breaks in the atlas ring and were associated with severe neurologic injury and lower level spine injuries. The pattern of bilateral anterior arch fractures was associated more often with neurologic injury. Because of these differences, we chose to refer to them as Jefferson variant fractures to distinguish them from the classical Jefferson fracture and to emphasize the seriousness of this injury.