Resolution of traumatic vertebral artery dissection and occlusion after repositioning and posterior C1-ring osteosynthesis of a displaced Jefferson burst fracture.

A 70-year-old male sustained a Jefferson burst fracture with unilateral vertebral artery dissection and occlusion by displaced fragments. We performed reduction and posterior C1-ring osteosynthesis. We present a description of the intraoperative manual assessment of atlantoaxial stability. The vertebral artery was found with a good anterograde flow posteroperatively, and MRA showed reperfusion of the vessel. The patient was free of pain with preserved C1-C2 rotation after 6 weeks. Function-preserving posterior C1-ring osteosynthesis after reduction in a displaced Jefferson burst fracture complicated by vertebral artery dissection and occlusion may restore blood flow.

Modified anterior transarticular C1/2 fixation for odontoid fractures: An approach with high complication rate in geriatric population.

Background: In patients over 75 years of age, we applied a modified anterior transarticular C1/2 fixation with reduced pharyngeal mobilization versus the standard anterior triple/quadruple osteosynthesis procedures. Methods: From 2010 to 2018, 29 patients underwent a modified anterior transarticular C1/2 fixation utilizing single odontoid screw fixation through a right-sided Smith-Robinson - (i.e., short and steep screw trajectory for the right and long trajectory for the left side) approach. All the patients were 75 years of age or older (mean age 82.6) and had sustained odontoid Type II fractures. In addition, a subset exhibited further ligamentous injuries and/or atlas fractures. Their Mean Age-adjusted Charlson Comorbidity Index was 5.3 points (range 3-12), while mean American Society of Anesthesiologists scores averaged 2.9 (range 2-4). Results: The mean operating time was 55.8 min, there were no intraoperative complications, and there was minimal blood loss in all cases. The most common medical complications included aspiration pneumonia (24.1%, n = 7), altered mental status (17.2%, n = 5), and cardiac decompensation (6.9%, n = 2). One patient with delayed dysphagia and an infected implant resulting in loosening/dislocation required implant removal and long-term antibiotic therapy. The 30-day mortality rate was 13.8% (four patients) and the 1-year mortality rate was 27.6% (eight patients). Conclusion: Anterior transarticular C1/2/odontoid fixation with reduced pharyngeal mobilization and shorter operative times was associated with high morbidity/mortality rates. Dysphagia/aspiration was the major postoperative complications leading to some deaths especially in patients with dementia/Parkinsonism.

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

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 â€‹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.