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A 35-year-old patient sustains a bilateral anterior and posterior arch (C1) injury with an intact transverse ligament. Which of the following treatment options is most appropriate?
Soft collar orthosis for 4-6 weeks
Rigid collar orthosis for 6-12 weeks
Posterior C1-C2 fusion
Select Answer to see Preferred Response
The patient has sustained a Jefferson fracture of the C1 arch. Given that the transverse ligament is intact, of the options listed, a rigid collar orthosis for 6-12 weeks would be the most appropriate treatment.
Fractures of the atlas are often the result of hyperextension, lateral compression and axial compression. Type 2 atlas fractures (Jefferson burst) involve the anterior and posterior arches as a result of axial loading. The stability and treatment of these fractures depends on the integrity of the transverse ligament.
Dickman et al. reviewed 39 patients with injury to the transverse ligament or its bony origins. They recommend that ligamentous (Type 1) injuries be treated with early surgery where as bony ligamentous avulsion (Type 2) injuries be treated initially with a hard cervical orthosis. Type 2 injuries had a 74% success rate of healing with conservative measures.
Spence et al. report a case of an atlas fracture with an associated injury to the transverse ligament. They indicate that lateral mass displacement greater than 6.9 mm is likely indicative of a tear in the transverse ligament. They recommend use of radiographs to delineate the integrity of the transverse ligament, as this will help guide treatment.
Illustration A shows an axial CT cut of a Jefferson fracture. The posterior arches are bilaterally fractured with unilateral involvement of the anterior arch.
Answer 1: Observation is not indicated in this situation.
Answers 2, 3: In a Jefferson type injury, a soft collar orthosis is not indicated
Answer 5: Given the integrity of the transverse ligament, a posterior cervical fusion is not indicated at this time.
Dickman CA, Greene KA, Sonntag VK
Neurosurgery. 1996 Jan;38(1):44-50. PMID: 8747950 (Link to Abstract)
Spence KF Jr, Decker S, Sell KW.
J Bone Joint Surg Am. 1970 Apr;52(3):543-9. PMID: 5425648 (Link to Abstract)
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Figure A shows the coronal and axial CT images of a 27-year-old male that suffered a fall from a significant height. Which of the following radiographic measurements would best indicate disruption of the transverse ligament?
Atlantodental interval (ADI) of 2mm
Posterior atlanto-dens interval (PADI) of 16mm
C2 pars horizontal displacement of 3 mm
Combined lateral mass displacement of 8.2mm
A Power's ratio of 1.2
The clinical presentation is consistent with a Jefferson fracture. A combined lateral mass displacement of 8.2mm or greater would indicate injury to the tranverse ligament.
A Jefferson fracture (Type II Atlas Fracture) is characterized by bilateral fractures of both the anterior and posterior arch. They are considered unstable when the transverse ligament is no longer intact. Radiographically, an atlanto-dens-interval (ADI) of >3mm or a sum of lateral mass displacement of >8.2mm both indicate a ruptured transverse ligament. Treatment of Jefferson fractures remain controversial. A stable injury (intact transverse ligament) can be treated with a cervical orthosis.
Spence et al., in a historic anatomic study, showed that lateral mass separation of > 6.9 mm implied rupture of the transverse ligament.
Heller et al. built radiographic magnification into Spence's findings, and argues that a transverse ligament rupture should not be inferred unless lateral mass separation is > 8.1 mm on open mouth odontoid views.
Haus et al. published a case report of a single patient with a lateral mass displacement of 14mm that was treated successfully with a cervical orthosis only.
Illustration A shows. Illustration shows the radiographic parameters that indicated a rupture of the transverse ligament.
Answer 1: An Atlantodental interval (ADI) of 2mm is normal and would not indicated an injury to the transverse ligament. An ADI of >3mm indicates injury to the transverse ligament.
Answer 2. A Posterior atlanto-dens interval (PADI) of 16mm is a normal finding. A Posterior atlanto-dens interval (PADI) of < 14mm would indicated a injury to the tranverse ligament. Keep in mind diameter of the spinal canal at C1 = PADI + diameter of dens + ADI.
Answer 3: C2 pars horizontal displacement is used to evaluate traumatic spondylolithesis of axis (Hangman's fracture).
Answer 4: The Power's ratio is used to evaluate occipitocervical instability.
Heller JG, Viroslav S, Hudson T
J Spinal Disord. 1993 Oct;6(5):392-6. PMID: 8274806 (Link to Abstract)
Haus BM, Harris MB
Clin. Orthop. Relat. Res.. 2008 May;466(5):1257-61. PMID: 18259828 (Link to Abstract)
Average 4.0 of 32 Ratings
A Gallie C1-2 fusion with sublaminar wiring of C1 to the spinous process of C2 is a valid treatment option for which of the following injury patterns?
comminuted C1 burst fracture
type I odontoid fracture
type III odontoid fracture
transverse ligament disruption
A C1-2 fusion with sublaminar wiring or modern screw-rod constructs is indicated in transverse ligament injuries.
Gallie et al reports “Recurrence of the [atlanto-axial] displacement following disruption of the transverse ligament can be prevented by fastening the two vertebrae together by fine steel wire passed around the laminae or spines. And the risk of late recurrence can be eliminated by bone grafts laid in the spines or on the laminae and articular facets."
Of note, this technique is somewhat dated, although one can still use it with successful results. Other C1-C2 fusion technique currently used include C1/2 transarticular screws or C1 lateral mass/C2 pedicle screw-rod construct.
Illustration A shows the anatomy of the tranverse ligament, which is an important stabilizer of the C1-2 motion segment.
Answer 1: C1-2 fusion is not valid for occipital-cervical dissociation because fusion to the occiput is needed and not addressed.
Answer 2: Comminuted C1 burst fracture also needs fusion to the occiput because comminution will compromise your fixation at C1.
Answer 3 & 4: Types I and III odontoid fractures are treated nonoperatively.
Ann Surg. 1937 Oct;106(4):770-6. PMID: 17857077 (Link to Abstract)
Brooks AL, Jenkins EB.
J Bone Joint Surg Am. 1978 Apr;60(3):279-84. PMID: 348703 (Link to Abstract)
Average 4.0 of 23 Ratings
Biomechanical studies have shown that an atlanto-dens interval of >7mm is likely associated with?
an intact transverse ligament, with ruptured alar and apical ligaments
a ruptured transverse ligament, with intact alar and apical ligaments
a ruptured transverse and apical ligament, with an intact alar ligaments
a ruptured transverse and alar ligament, with an intact apical ligaments
a ruptured transverse and alar ligament, and a ruptured tectorial membrane
The intrinsic ligaments, located within the spinal canal, provide most of the ligamentous stability. These ligaments form three layers anterior to the dura. From dorsal to ventral, they include the tectorial membrane, the cruciate ligament, and the odontoid ligaments. The tectorial membrane connects the posterior body of the axis to the anterior foramen magnum and is the cephalad continuation of the posterior longitudinal ligament. The cruciate ligament lies anterior to the tectorial membrane, behind the odontoid process. The transverse atlantal ligament is the strongest component, connecting the posterior odontoid to the anterior atlas arch, inserting laterally on bony tubercles. The odontoid ligaments (alar and apical ligaments) are the most ventral ligamentous structures. The paired alar ligaments connect the odontoid to the occipital condyles. They measure 5 to 6 mm in diameter and are relatively strong, in contrast with the small apical ligament that runs vertically between the odontoid and foramen magnum. In normal adults the ADI is < 3mm and < 5mm in children. Experimentally produced transverse ligament insufficiency with intact alar and apical ligaments results in a maximal translation of 5 mm, as shown by Fielding et al. Displacement >7 mm was associated with loss of integrity of the alar ligament and tectorial membrane.
Jackson RS, Banit DM, Rhyne AL 3rd, Darden BV 2nd.
J Am Acad Orthop Surg. 2002 Jul-Aug;10(4):271-80. PMID: 15089076 (Link to Abstract)
Fielding JW, Cochran Gv, Lawsing JF 3rd, Hohl M.
J Bone Joint Surg Am. 1974 Dec;56(8):1683-91. PMID: 4434037 (Link to Abstract)
Average 3.0 of 32 Ratings
HPI - Patient was riding a motor bike in South East Asia when a car pulled out in front. Patient then swerved to miss the car and ended up going head first into a metal pole on the side of the road. He was wearing a helmet and traveling at 40 km/hr.
At hospital MRI showed no ligament damage but CT showed fracture of the right anterior arch and left posterior arch right behind the left lateral mass. CT also showed a clay shovelers fracture attributed to the patient holding on tightly to the handlebars. The patient was then airlifted to Singapore.
Time frame and Planning:
Week 1: Fitted with halo (discharged from hospital after 10 days)
Week 8: Halo removed Aspen Vista applied, no union
Week 12: New Scans, no improvement, gap widened.
Week 14: Soft Collar used during sleeping and on and off during day.
Week 16: Sleeping without brace, no brace for 50% of day. Return to work part time
Week 18: No brace.
Week 22: Return to work full time.
Currently the patient is a
Many patients have non-union. Is this a cause for concern?
HPI - The patient is 43 year old gentleman, who was assaulted and placed in a head lock 2 months ago. He said he heard something "crack" in his neck. He immediately had severe neck pain, and difficulty swallowing over the first few days, but denied any weakness. Over the following weeks he developed weakness in his upper and lower extremities that evolved to the point that he lost his ability to ambulate, and was admitted to the public hospital in Managua, Nicaragua.
How would you treat this patients? Keep in mind we are in Nicaragua, and there are very few implants available.
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