NON-OPERATIVE MANAGEMENT OF ATLANTO-AXIAL FRACTURES: MAINTAINING RIGID IMMOBILIZATION UNTIL CT SCANNING CONFIRMS FRACTURE UNION IMPROVES OUTCOMES AND REDUCES THE NEED FOR SUBSEQUENT SURGERY

Abstract

Introduction: The management atlanto-axial fractures, particularly those of the odontoid peg, remains controversial. We managed patients with C1/C2 fractures non-operatively in rigid immobilization until CT-scanning confirmed bony union, rather than for the standard 3-month period. We examined whether this improved outcomes and reduced the need for surgery.

Method: All patients admitted to our unit with atlanto-axial fractures between 2001–2007 were retrospectively analyzed. All fractures had the ‘intention-to-treat’ conservatively in either halothoracic vest (85%) or Aspen collar (15%). Rigid immobilization was maintained until CT-scanning demonstrated bony fusion. Functional stability was subsequently assessed with flexion-extension radiographs after removal of rigid immobilization.

Results: Twenty-seven patients were studied. Nineteen had odontoid peg fractures (10 type II; 9 type III). The remainder consisted of 3 Hangman’s, 3 lateral mass and 2 atlas ring fractures. 83% of patients progressed to union at an average of 13.2 weeks (range 5–22). Six complications related to halo immobilization were observed (three skull perforations/pin-site infections). All of these patients progressed to union non-operatively.

Failure of non-operative management was deemed as non-union or poor patient tolerance of halo, and occurred in 4 patients (17%). All four had type II odontoid peg fractures, and had transarticular screw fixation. One postoperative complication of screw fracture was recorded.

Conclusion: Non-union rates of conservatively managed atlanto-axial fractures with standard 3-month rigid immobilization have been reported as high as 35%. In our series, CT-imaging to confirm bony union prior to removal of the rigid immobilization (prolonging immobilization where necessary) significantly lowered the rate of non-union and therefore the need for subsequent surgery.

Ethics approval: None Audit

Interest Statement: None