Function-preserving reduction and fixation of unstable Jefferson fractures using a C1 posterior limited construct

This is a retrospective, clinical, and radiologic study of posterior reduction and fusion of the C1 arch in the treatment of unstable Jefferson fractures.

The aim of the study was to describe a new motion-preserving surgical technique in the treatment of unstable Jefferson fracture.

The management of unstable Jefferson fractures remains controversial. The majority of C1 fractures can be effectively treated nonoperatively with external immobilization unless there is an injury to the transverse atlantal ligament (TAL). Conservative treatment usually involves immobilization for a long time in Halo vest, whereas surgical intervention generally involves C1-C2 fusion, eliminating the range of motion of the upper cervical spine. We propose a novel method for the treatment of unstable Jefferson fractures without restricting the range of motion.

A retrospective review of 12 patients with unstable C1 fractures between April 2008 and October 2011 was performed. They were treated by inserting bilateral posterior C1 pedicle screws or lateral mass screws interconnected by a transversal rod to achieve internal fixation. There were 8 men and 4 women, with an average age of 35.6 years (range, 20-60 y). Presenting symptoms included neck pain, stiffness, and decreased range of motion but none had neurological injury. Seven patients had bilateral posterior arch fractures associated with unilateral anterior arch fractures (posterior 3/4 Jefferson fracture, Landells type II), and 5 had unilateral anterior and posterior arch fractures (half-ring Jefferson fracture, Landells type II). Seven patients had intact TAL, and 5 patients had fractures and avulsion of the attachment of TAL (Dickman type II).

A total of 24 screws were inserted. Five cases had screws placed in the lateral mass: 3 because of posterior arch breakage, and 2 because the height of the posterior arch at the entry point was <4 mm. The remaining 7 cases had pedicle screw fixation. One patient had venous plexus injury during exposure of lower margin of the posterior arch; however, successful hemostasis was achieved with Gelfoam. Postoperative x-ray and computed tomography scan showed partial breach of the transverse foramen caused by a screw in 1 case, and breach of the inner cortex of the pedicle caused by screw displacement in 1 case; however, no spinal cord injury or vertebral artery injury was found. The remaining screws were in good position. Patients were followed up for 6-40 months (average, 22 mo). All cases had recovery of range of motion of the cervical spine to the preinjury level by 3-6 months after surgery, with resolution of pain. At 6 months follow-up, plain radiographs and computed tomography scans revealed satisfactory cervical alignment, no implant failure, and satisfactory bony fusion of the fractures; no C1-C2 instability was observed on the flexion-extension radiographs.

C1 posterior limited construct is a valid technique and a feasible method for treating unstable Jefferson fractures, which allows preservation of the function of the craniocervical junction, without significant morbidity.