A retrospective review of fixation of C1 ring XXXX -does the transverse atlantal ligament (TAL) really matter?

@entity1 @entity174 @entity4040 @entity158 @entity1317 @entity130
BACKGROUND CONTEXT: In contrast to the majority of outcome data, many consider C1 @entity174 to be benign injuries and so have advocated for conservative management, except in the case of concomitant transverse atlantal ligament (TAL) injury where C1-C2 or occiput-C2 fusions are recommended. PURPOSE: Our goal was to evaluate a series of unstable C1 @entity174 treated with C1 open reduction and internal fixation (ORIF) to assess clinical and radiographic outcomes by determining the success of reduction and @entity158 relief. STUDY DESIGN/SETTING: This is a retrospective cohort review. @entity1 SAMPLE: The sample includes adult @entity1 with unstable C1 @entity174 treated with open reduction and primary internal fixation. OUTCOME MEASURES: Primary outcome measures included visual analog @entity158 scale (VAS), radiographic reduction (lateral mass displacement), maintenance of reduction, C1-C2 instability, and complications. METHODS: A retrospective review of all @entity1 with C1 @entity174 between September 2002 and September 2013 identified 12 consecutive @entity1 from a level I @entity130 center who were treated with primary internal fixation without fusion. Electronic medical records and preoperative and postoperative radiographs were reviewed. The surgical technique consisted of a posterior cervical approach to the C1 arch and open reduction using bilateral C1 lateral mass screws connected transversely with a rod. Pre- and postoperative computed tomography scans were used to assess reduction. Long-term follow-up flexion and extension radiographs were used to assess C1-C2 stability. The authors did not receive relevant funding in relation to this research. RESULTS: Twelve @entity1 underwent C1 ORIF, with a mean age of 43 (9 males and 3 females) and a mean follow-up of 17 months. Transverse atlantal ligament was found to be disrupted with type I or @entity130 in 11 of the 12 @entity1 : 5 type I and 6 type II. Preoperative lateral mass displacement averaged 7.1   mm, with postoperative displacement after reduction averaging 2.4   mm (p-value <.001). The VAS score averaged 0.7 at latest follow-up. No @entity1 went on to develop C1-C2 instability on final flexion-extension films. No @entity1 had a complication that resulted in neurologic @entity1317 associated with the procedure. No @entity1 were found to have late sequelae of malunion or loss of reduction. Two surgically related complications occurred, namely one @entity1 with errant screw requiring return to the operating room (OR) and one with @entity4040 of the occipital-C1 joint. CONCLUSIONS: Although a small series, early evidence suggests that @entity1 with unstable C1 ring @entity174 can be successfully managed with primary ORIF. Open reduction and internal fixation results in a stable construct that maintains reduction, results in excellent @entity158 control, and does not lead to C1-C2 instability. In our series, we have not observed the presence of TAL injury to adversely affect outcomes, and thus do not believe it is a contraindication to ORIF. Comparative studies comparing internal fixation with non-operative, C1-C2, or occiput-C2 fusions would yield more insight into optimal treatment options for these @entity174 .
