JOURNAL ARTICLE
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[Combined atlantoaxial fractures].

PURPOSE OF THE STUDY: Combined fractures of the atlas and epistropheus account for 3 % of all acute injuries to the cervical spine. In relation to all C1 and C2 injuries this is 43 % and 16 %, respectively. The aim of this study is to evaluate a group of patients with combined C1-C2 fractures and to suggest an effective therapeutic procedure.

MATERIAL: In the years 1996 to 2003, a total of 16 patients with trauma to the atlantoaxial complex were treated at the Orthopedic Department of the Third Faculty of Medicine, Charles University, Prague (1996-2001) and the Department of Spinal Surgery of the University Hospital in Motol, Prague (2001-2003). These injuries included a combined fracture of the dens (Anderson and D'Alonzo type II) and of the atlas posterior arch in six patients, a type II dens fracture combined with Jefferson fracture in two patients, a type III fracture of the dens with a lateral mass fracture in two patients, hangman's fracture with posterior arch fracture in three patients, a type II fracture of the dens with anterior arch fracture in one patient, a fracture of the C2 body with Jefferson fracture in one patient and a fracture of the C2 body with fracture of the lateral mass in one patient. Two patients were treated conservatively and 14 underwent surgery. On admission neurological deficit was found in five patients.

METHODS: Fourteen patients were operated on. Direct osteosynthesis of the dens, with motion in the atlantoaxial complex preserved, was performed in five patients. Seven patients underwent C1-C2 fixation that, in one, involved the C1-C3 segments; five patients were treated by Harms fixation with polyaxial screws from the posterior approach, two by the Magerl or Gallie techniques and one patient required occipito-cervical fixation of C0-C2. The patient with a hangman's fracture combined with fracture of the atlas posterior arch was treated by discectomy of C2-C3, tricortical graft from the iliac crest and plate application. The patients used Philadelphia collars for 6 to 12 weeks according to the type of injury and their bone quality.

RESULTS: Three patients (two undergoing direct osteosynthesis of the dens and one with occipito-cervical fixation) reported intermittent upper neck pain that required taking analgesics. The patient treated by occipito-cervical fixation repeatedly complained of restriction of rotational head movement by about 50 %. Radiograms of the cervical spine in both flexion and extension taken at 12- to 14-week follow-up all showed stable C0-C1 and C1-C2 segments. In the five patients undergoing direct osteosynthesis of the dens, complete bony union was found on X-ray and CT examination by 6 to 24 weeks postoperatively. Similarly, full instrumented fusion was achieved by 12 to 24 weeks postoperatively in the seven patients treated by dorsal fixation. The patient with anterior C2-C3 fixation showed, on X-ray images, a completely remodeled segment at 24 weeks after surgery. There was one intraoperative complication involving management of profuse bleeding from the venous plexus along the greater occipital nerve. No other complications related to the surgical procedure were recorded and no injury to the spinal cord, nerve roots or the vertebral artery was observed. None of the patients experienced any deterioration of neurological findings during the early postoperative period. One patient had to undergo resuturing of the operative wound from the posterior approach, because of subcutaneous necrosis that had failed to heal. No instrumentation failure or infection, regarded as late complications, were recorded.

DISCUSSION: At our Department we prefer early operative treatment involving spondylodesis in the shortest segment possible, with special emphasis on preserving rotational C1-C2 movement. Therefore, in some cases, we use only temporary stabilization with removal of instrumentation after 3 to 4 months. In this group the most frequent fractures were those combined with type II fractures of the dens. In such cases we always prefer direct osteosynthesis of the dens or, if this is not possible, the Harms technique of C1-C2 fixation, possibly only temporary. We believe, in agreement with Guilot and Fesser, that a potential failure of conservative therapy may result in a longer convalescent period and that patients should always be informed about these issues. In contrast to Guilot and Fesser we treat combined hangman's fractures from the anterior approach, by discectomy, tricortical graft and plate application.

CONCLUSIONS: Combined atlantoaxial fractures are serious, life-threatening injuries which, because of their diversity, require an individual approach to each patient. Early surgery is recommended with increasing frequency, particularly in the cases with persisting dislocation or instability. At the same time it is necessary to ensure that motion restriction of the cervical spine be minimal.

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