Horizontal C-1 fractures in association with unstable distraction injuries of the craniocervical junction

Clinical article

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Object

Horizontal fractures of the anterior arch of the atlas not associated with odontoid fractures have been regarded as stable fractures that can be simply treated with a cervical collar. The authors report that C-1 horizontal fractures also occur in association with severe distraction injuries of the craniocervical junction.

Methods

The authors retrospectively reviewed imaging studies obtained in all surviving patients in whom unstable distraction injuries of the craniocervical junction were diagnosed and in whom surgery was performed at their institution between 1995 and 2009. All patients who also had a C-1 horizontal fracture as a component of their spinal injury were included in the study.

Results

Of 47 patients with unstable craniocervical distraction injuries, 5 patients had a horizontal fracture through the anterior ring of C-1: 1 patient had a primarily C1–2 distractive injury whereas 4 others had a grossly unstable injury across the occipitoatlantal junction (occipitoatlantal dissociation).

Conclusions

The finding of a C-1 horizontal fracture does not always reflect a benign injury and its presence should heighten the concern of a more severe and unstable injury at the craniocervical junction.

Article Information

Address correspondence to: Marcelo D. Vilela, M.D., 2480 Aimores, 11 Andar, Belo Horizonte, Minas Gerais 30140-072, Brazil. email: mdvilela@u.washington.edu.

Please include this information when citing this paper: published online April 29, 2011; DOI: 10.3171/2011.3.SPINE10756.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    A: Cervical spine sagittal reformatted CT scan showing a horizontal fracture of the anterior arch of C-1, an increased basion–posterior axial line interval, and widened posterior C1–2 spinolaminar distance. B: Displaced left lateral mass of C-1 exerting compression on the cord. C and D: Postoperative images demonstrating normal alignment following open reduction and occiput–C3 instrumentation and fusion.

  • View in gallery

    A: Image obtained in a cervical spine trauma series showing extensive prevertebral swelling, a horizontal fracture through the anterior arch of C-1, and a fracture of the C-1 posterior ring. B: Cervical CT reformatted images showing the C-1 horizontal fracture, an increased basion-dens interval, and a more than 2-mm widening of the occipitoatlantal joint space. C: Sagittal T2-weighted MR image showing disruption of the tectorial membrane and apical ligament.

  • View in gallery

    A and B: Sagittal reformatted CT images showing a horizontal fracture through the anterior ring of C-1, less than a 2-mm widening of the occipitoatlantal joint spaces, and severe widening of the atlantoaxial joint spaces, along with an increase in the C1–2 spinolaminar distance. C: Coronal T2-weighed MR image demonstrating high signal in the occipitoatlantal and atlantoaxial joint spaces. D: Postoperative flexion lateral radiograph showing C1–3 posterior fusion and instrumentation and stable occipitoatlantal joints.

References

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