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Christopher P. Ames, Frank Acosta and Eric Nottmeier

F ractures of C-1 account for approximately 5% of acute cervical fractures. 7, 8 Pure axial loading forces are thought to compress the atlas between the occipital condyles and axial joint surface, usually resulting in a burst-type injury involving two or more fractures through the C-1 ring. Secondary bending forces may produce multiple different fracture patterns. 1 Severe compression injuries may also result in rupture or avulsion of the transverse ligament 3 which causes atlantoaxial instability and further disruption of the C-1 ring integrity. It has

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Christopher P. Ames, Neil R. Crawford, Robert H. Chamberlain, Vivek Deshmukh, Belma Sadikovic and Volker K. H. Sonntag

shallow Type III odontoid fractures. The advantages of this approach include the following: 1) preservation of motion at C1–2; 2) direct stabilization of the fracture; and 3) promotion of healing through fracture reduction and compression. The first advantage is particularly important because more than half of all cervical axial rotation occurs at the atlantoaxial level. Although some complications associated with the anterior odontoid screw fixation technique exist, they are relatively rare and include screw pullout (5%) and screw fracture (2% of all nonunions

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Henry E. Aryan, C. Benjamin Newman, Eric W. Nottmeier, Frank L. Acosta Jr., Vincent Y. Wang and Christopher P. Ames

S tabilization of a disrupted atlantoaxial complex presents a unique set of challenges. This junction is highly mobile, accounting for 50% (47°) of the rotational and 12% (10°) of the flexion and extension movements of the cervical spine. 35 , 36 , 40 , 44 , 45 This high degree of mobility makes adequate stabilization inherently problematic, and the rates of fusion at the C1–2 motion segment have been lower than in the subaxial spine. 2 , 4 , 8–10 , 12 The set of potential operative interventions is further limited by the anatomy of this region, which is

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Atul Goel

Object Stabilization of the atlantoaxial complex has proven to be very challenging. Because of the high mobility of the C1–2 motion segment, fusion rates at this level have been substantially lower than those at the subaxial spine. The set of potential surgical interventions is limited by the anatomy of this region. In 2001 Jürgen Harms described a novel technique for individual fixation of the C-1 lateral mass and the C-2 pedicle by using polyaxial screws and rods. This method has been shown to confer excellent stability in biomechanical studies. Cadaveric

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Christopher P. Ames, Vincent Y. Wang, Vedat Deviren and Frank D. Vrionis

, epidural decompression, and circumferential fusion of spinal metastases . Spine 25 : 2240 – 2250 , 2000 4 Bilsky MH , Shannon FJ , Sheppard S , Prabhu V , Boland PJ : Diagnosis and management of a metastatic tumor in the atlantoaxial spine . Spine 27 : 1062 – 1069 , 2002 5 Cahill DW , Kumar R : Palliative subtotal vertebrectomy with anterior and posterior reconstruction via a single posterior approach . J Neurosurg 90 : 42 – 47 , 1999 6 Cole JS , Patchell RA : Metastatic epidural spinal cord compression . Lancet Neurol 7

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Justin K. Scheer, Jessica Tang, Johnny Eguizabal, Azadeh Farin, Jenni M. Buckley, Vedat Deviren, R. Trigg McClellan and Christopher P. Ames

, Prabhu V , Boland PJ : Diagnosis and management of a metastatic tumor in the atlantoaxial spine . Spine 27 : 1062 – 1069 , 2002 5 Boriani S , Bandiera S , Biagini R , Bacchini P , Boriani L , Cappuccio M , : Chordoma of the mobile spine: fifty years of experience . Spine 31 : 493 – 503 , 2006 6 Boriani S , Chevalley F , Weinstein JN , Biagini R , Campanacci L , De Iure F , : Chordoma of the spine above the sacrum. Treatment and outcome in 21 cases . Spine 21 : 1569 – 1577 , 1996 7 Chou D , Acosta F Jr

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Jon Park, Justin K. Scheer, T. Jesse Lim, Vedat Deviren and Christopher P. Ames

T he atlantoaxial complex may become unstable due to congenital disease, an inflammatory disorder, trauma, or a neoplasm. 2 , 7 The instability can be surgically corrected with various options such as C1–2 transarticular screw fixation, wiring techniques, laminar hooks, and screw/rod constructs that require translaminar, pars, lateral mass, and pedicle screws. 33 Stabilization of the atlantoaxial complex is clinically challenging because of the high multiaxial ROM at this joint and the proximity of the vertebral artery. 22 , 25 , 26 , 35 Traditionally

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querying the Cochrane Collaboration, Educus journal search, PubMed, and Google Scholar databases using the following phrases: “spine injury return to play,” “cervical spine injury athletes,” and “return to play thoracolumbar.” Additionally relevant references from these articles were reviewed. Results: All recommendations represent level III evidence. Absolute contraindications for return to play include atlantoaxial fusions, occipitalcervical fusions, atlantodental interval >3mm adult (> 4mm child),acute herniated discs, discs with pain and neurologic deficits

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Justin K. Scheer, Jessica A. Tang, Justin S. Smith, Frank L. Acosta Jr., Themistocles S. Protopsaltis, Benjamin Blondel, Shay Bess, Christopher I. Shaffrey, Vedat Deviren, Virginie Lafage, Frank Schwab, Christopher P. Ames and the International Spine Study Group

, Guan Y , Pintar F : Importance of physical properties of the human head on head-neck injury metrics . Traffic Inj Prev 10 : 488 – 496 , 2009 112 Yoshida G , Kamiya M , Yoshihara H , Kanemura T , Kato F , Yukawa Y , : Subaxial sagittal alignment and adjacent-segment degeneration after atlantoaxial fixation performed using C-1 lateral mass and C-2 pedicle screws or transarticular screws. Clinical article . J Neurosurg Spine 13 : 443 – 450 , 2010 113 Yoshimoto H , Ito M , Abumi K , Kotani Y , Shono Y , Takada T

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Camilo A. Molina, Christopher P. Ames, Dean Chou, Laurence D. Rhines, Patrick C. Hsieh, Patricia L. Zadnik, Jean-Paul Wolinsky, Ziya L. Gokaslan and Daniel M. Sciubba

cervical atlantoaxial (C1–2) tumors present challenges that are different from those presented by subaxial (C3–7) tumors. For example, atlantoaxial chordomas frequently involve both the cervical roots and vertebral arteries. Although the C1–4 roots can generally be sacrificed without ensuing neurological deficit, vertebral artery sacrifice can result in significant neurological deficits, particularly if the dominant vertebral artery is sacrificed in the setting of insufficient collateral flow. Tumors that do not involve the vertebral arteries bilaterally are more