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

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. 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? 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 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. 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. 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.