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Journal of Craniovertebral Junction and Spine
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Year : 2021  |  Volume : 12  |  Issue : 1  |  Page : 10-14  

Temporary spanning internal fixation for management of complex upper cervical spine fractures

Department of Orthopedics College of Medicine, King Saud University, Riyadh, Saudi Arabia

Date of Submission23-Jul-2020
Date of Acceptance22-Nov-2020
Date of Web Publication4-Mar-2021

Correspondence Address:
Khalid AlSaleh
Department of Orthopedics, College of Medicine, King Saud University, Riyadh 12372
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcvjs.JCVJS_118_20

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Introduction: Fractures of the upper cervical spine are often but not always amenable to either internal fixation or conservative management using a rigid cervical collar. For all other fractures in this area, management with a halo-vest orthosis is indicated, but it also has limitations. Here, we present an operative alternative to the halo-vest orthosis that provides more secure stability and less complications.
Methods: Three patients presented to our hospital with atypical fractures of C1 and C2 and were given the choice of either a halo-vest orthosis or secure internal fixation without fusion and accepted the latter. Internal fixation without fusion from occiput to the subaxial spine was performed for all three and then removed-6 months later -after radiologic confirmation of healing.
Results: All three patients underwent the procedure successfully and achieved and maintained acceptable alignment. Range of motion was preserved, and no intermediate-term issues were observed.
Conclusion: Spanning internal fixation provides a safe and effective technique in the management of complex upper cervical spine injuries without the drawbacks of using a halo-vest orthosis.

Keywords: Cervical spine, spine fractures, internal fixation

How to cite this article:
AlSaleh K, Abulras M, Alrehaili O. Temporary spanning internal fixation for management of complex upper cervical spine fractures. J Craniovert Jun Spine 2021;12:10-4

How to cite this URL:
AlSaleh K, Abulras M, Alrehaili O. Temporary spanning internal fixation for management of complex upper cervical spine fractures. J Craniovert Jun Spine [serial online] 2021 [cited 2022 Aug 19];12:10-4. Available from: https://www.jcvjs.com/text.asp?2021/12/1/10/310732

   Introduction Top

Fractures of the upper cervical spine account for over 45%–50% of all cervical spine trauma.[1],[2] Most of these injuries are treated conservatively using a halo-vest orthosis, but the trend toward operative fixation is growing internationally.[3] The rationale behind that global trend is the high complication rates and the questionable efficacy of halo-vest treatment.[4],[5],[6] Furthermore, the surgeon is occasionally faced with a complex fracture of the Atlas or Axis that neither fusion nor halo-vest immobilization is a good option. The ideal solution would provide better stabilization and less complications-than a halo-vest and would not eliminate motion from the adjacent segments. In this study, we present three cases of upper cervical spine injury where internal fixation was executed as a temporary stabilization measure, achieving the goals mentioned above.

   Methods Top

Three patients presented to our institution with fractures of C1 or C2 which would normally be managed with a halo-vest orthosis. The benefits and risks of halo-vest immobilization were explained to all patients. All patients were offered surgical treatment as an alternative, and all three accepted surgical treatment and preferred it to halo-vest immobilization.

Surgical technique

The patients were taken to the operating room where general anesthesia was administered. Mayfield frame immobilization was performed in the supine position and the patient was then rolled carefully into the prone position using the Jackson frame. A routine posterior cervical approach from the occiput to C4 followed, limiting the sub-periosteal dissection of the injured vertebrae. Specifically, the insertions of the rectus capitis and the longissimus muscles to C1 and C2 were preserved. Routine subperiosteal dissection of the occiput and subaxial spine allowed for instrumentation occipital plates and lateral mass screws bilaterally. A rod was then placed on each side and fixed to the plates/screws from the occiput to C3/C4 spanning the soft-tissue envelope over C1/C2. Closure was then done in layers, and a rigid cervical collar was applied for further external stabilization. The patient was mobilized the next day and discharged shortly thereafter. The cervical collar was removed at 12 weeks and a computerized tomography (CT) was performed at 6 months. Once healing of the fractures was established, a second operation was done to remove the implants and physical therapy was started 6 weeks following the second operation to regain range of motion and strengthen the cervical musculature.

   Results Top

All patients underwent the procedure successfully without complication. Radiological fusion was obtained in all three, and all had the implants removed 6 months postoperative [Figure 1],[Figure 2],[Figure 3]. A focused physical therapy program-6 weeks after implant removal was mandated with two objectives: Regain cervical motion first, and then strengthen the weak cervical paraspinal musculature. Details of each patient's clinical course are presented in [Table 1].
Figure 1: (a) Patient 1 radiologic presentation: plain roentgenograms and CT. (b) Patient 1 postoperative images. (c) Patient 1 final flexion extension films after removal of implants

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Figure 2: (a) Patient 2 radiologic presentation: CT. (b) Patient 2 postoperative images. (c) Patient 2 final images after removal of implants

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Figure 3: (a) Patient 3 radiologic presentation: CT. (b) Patient 3 postoperative images. (c) Patient 3 CT showing complete healing of the C2 fracture. (d) Patient 3 flexion-extension radiographs following removal of implants

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Table: Clinical course of the patients in the study

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   Discussion Top

Modern operative management of spine fractures evolved from the management of extremity fractures. In the second half of the twentieth century, internal fixation slowly took over the conservative treatment of extremity fractures. This was mostly due to better outcomes and less complications compared with plaster cast or traction immobilization associated with direct reduction and stable fixation.[7],[8] This effect made its way into spine surgery with the introduction of modern spinal implants. With certain fractures, internal fixation was not possible, and spanning external and later internal fixation methods were developed as definitive treatment or as temporary measures until the patient's condition allowed internal fixation.[9] Spanning internal fixation, however, has less complications than external fixation and provides better stability biomechanically.[10]

The halo-vest orthosis was first introduced in the 1950s for the treatment of children with poliomyelitis, cases of cervical spine trauma in addition to other conditions.[11] Although a revolutionary device when first introduced, even in their initial report the authors discussed the issues of inadequate fixation, pin site infections, and discomfort reported by the patients. At the time, modern implants were decades away from development and widespread use. Nowadays the halo-vest is still utilized in many centers across the globe, although less frequently than in previous decades. The complications associated with its use have been well described in the literature.[11],[12],[13],[14],[15],[16] Particularly in the elderly, its use is associated with increased incidence of pneumonia and increased mortality.[4],[17],[18] More recent reports have challenged this,[3],[16],[19] but it remains a concern for the clinician. From a biomechanical perspective, the halo-vest orthosis confers little stability to the fractured cervical spine,[20],[21] and a non-invasive halo maybe just as good.[22] Reports directly comparing internal fixation with halo-vest immobilization have been shown superior fusion rates, better alignment, less pain, and earlier return to work for both Atlas and Axis fractures.[23],[24]

There have been a few similar studies in the literature recently reporting for temporary internal fixation for upper cervical spine fractures.[25],[26],[27] These initial reports prove that certain fractures of the Atlas and Axis are better served with internal fixation without biologic fusion. The technique we report in our series confirms that and opens the door for further larger comparative series.

   Conclusion Top

Temporary spanning occipitalcervical fixation is a viable alternative to either operative fusion or halo-vest immobilization for the management of upper cervical spine fractures. It provides instant, maintained rigid stability not possible with halo-vest immobilization to these fractures with the complete loss of motion associated with definitive fusion surgery.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Passias PG, Poorman GW, Segreto FA, Jalai CM, Horn SR, Bortz CA, et al. Traumatic Fractures of the Cervical Spine: Analysis of Changes in Incidence, Cause, Concurrent Injuries, and Complications Among 488,262 Patients from 2005 to 2013. World Neurosurg 2018;110:e427-e437.  Back to cited text no. 1
Pal D, Sell P, Grevitt M. Type II odontoid fractures in the elderly: An evidence-based narrative review of management. Europ Spine J 2011;20:195-204.  Back to cited text no. 2
DePasse JM, Palumbo MA, Ahmed AK, Adams CA Jr., Daniels AH. Halo-vest immobilization in elderly odontoid fracture patients: Evolution in treatment modality and in-hospital outcomes. Clin Spine Surg 2017;30:E1206-10.  Back to cited text no. 3
Tashjian RZ, Majercik S, Biffl WL, Palumbo MA, Cioffi WG. Halo-vest immobilization increases early morbidity and mortality in elderly odontoid fractures. J Trauma 2006;60:199-203.  Back to cited text no. 4
Shin JJ, Kim SJ, Kim TH, Shin HS, Hwang YS, Park SK. Optimal use of the halo-vest orthosis for upper cervical spine injuries. Yonsei Med J 2010;51:648-52.  Back to cited text no. 5
Fan L, Ou D, Huang X, Pang M, Chen XX, Yang B, et al. Surgery vs. conservative treatment for type II and III odontoid fractures in a geriatric population: A meta-analysis. Medicine 2019;98:e10281.  Back to cited text no. 6
Perren SM, Russenberger M, Steinemann S, Müller ME, Allgöwer M. A dynamic compression plate. Acta Orthop Scand Suppl 1969;125:31-41.  Back to cited text no. 7
Glenn JN, Miner ME, Peltier LF. The treatment of fractures of the femur in patients with head injuries. J Trauma 1973;13:958-61.  Back to cited text no. 8
Egol KA, Tejwani NC, Capla EL, Wolinsky PL, Koval KJ. Staged management of high-energy proximal tibia fractures (OTA types 41): The results of a prospective, standardized protocol. J Orthop Trauma 2005;19:448-55.  Back to cited text no. 9
Wolf JC, Weil WM, Hanel DP, Trumble TE. A biomechanic comparison of an internal radiocarpal-spanning 2.4-mm locking plate and external fixation in a model of distal radius fractures. J Hand Surg Am 2006;31:1578-86.  Back to cited text no. 10
Nickel VL, Perry J, Garrett A, Heppenstall M. The halo. A spinal skeletal traction fixation device. J Bone Joint Surg Am 1968;50:1400-9.  Back to cited text no. 11
Baum JA, Hanley EN Jr., Pullekines J. Comparison of halo complications in adults and children. Spine 1989;14:251-2.  Back to cited text no. 12
Dormans JP, Criscitiello AA, Drummond DS, Davidson RS. Complications in children managed with immobilization in a halo vest. J Bone Joint Surg Am 1995;77:1370-3.  Back to cited text no. 13
Glover AW, Zakaria R, May P, Barrett C. Overtightening of halo pins resulting in intracranial penetration, pneumocephalus, and epileptic seizure. Int J Spine Surg 2013;7:e42-4.  Back to cited text no. 14
Menon KV, Al Rawi AE, Taif S, Al Ghafri K, Mollahalli KK. Orbital roof fracture and orbital cellulitis secondary to halo pin penetration: Case report. Global Spine J 2015;5:63-8.  Back to cited text no. 15
van Middendorp JJ, Slooff WB, Nellestein WR, Oner FC. Incidence of and risk factors for complications associated with halo-vest immobilization: A prospective, descriptive cohort study of 239 patients. J Bone Joint Surg Am 2009;91:71-9.  Back to cited text no. 16
Horn EM, Theodore N, Feiz-Erfan I, Lekovic GP, Dickman CA, Sonntag VK. Complications of halo fixation in the elderly. J Neurosurg Spine 2006;5:46-9.  Back to cited text no. 17
Majercik S, Tashjian RZ, Biffl WL, Harrington DT, Cioffi WG. Halo vest immobilization in the elderly: A death sentence? J Trauma 2005;59:350-6.  Back to cited text no. 18
Isidro S, Molinari R, Ikpeze T, Hernandez C, Mahmoudi MS, Mesfin A. Outcomes of halo immobilization for cervical spine fractures. Global Spine J 2019;9:521-6.  Back to cited text no. 19
Koch RA, Nickel VL. The halo vest: An evaluation of motion and forces across the neck. Spine (Phila Pa 1976) 1978;3:103-7.  Back to cited text no. 20
Glaser JA, Myers MA, McComis GP, Simons MP, Butler VH, Rust PF. Cervical motion after adding a posterior pad to the halo vest. Am J Orthop (Belle Mead NJ) 2000;29:557-62.  Back to cited text no. 21
DiPaola CP, Sawers A, Conrad BP, Horodyski M, DiPaola MJ, Del Rossi G, et al. Comparing cervical spine motion with different halo devices in a cadaveric cervical instability model. Spine 2009;34:149-55.  Back to cited text no. 22
Kim MK, Shin JJ. Comparison of radiological and clinical outcomes after surgical reduction with fixation or halo-vest immobilization for treating unstable atlas fractures. Acta Neurochir (Wien) 2019;161:685-93.  Back to cited text no. 23
Kim SK, Shin JJ, Kim TH, Shin HS, Hwang YS, Park SK. Clinical outcomes of halo-vest immobilization and surgical fusion of odontoid fractures. J Korean Neurosurg Soc 2011;50:17-22.  Back to cited text no. 24
Theologis AA, Deviren V, Tay B. Temporary fusionless posterior occipitocervical fixation for a proximal junctional type II odontoid fracture after previous C2-pelvis fusion: Case report, description of a new surgical technique, and review of the literature. Europ Spine J 2017;26 Suppl 1:243-8.  Back to cited text no. 25
Yuan S, Wei B, Tian Y, Yan J, Xu W, Wang L, et al. Posterior temporary C1-2 fixation for 3-part fractures of the axis (odontoid dens and Hangman fractures). Medicine (Baltimore) 2018;97:e12957.  Back to cited text no. 26
Guo Q, Deng Y, Wang J, Wang L, Lu X, Guo X, et al. Comparison of clinical outcomes of posterior C1-C2 temporary fixation without fusion and C1-C2 fusion for fresh odontoid fractures. Neurosurgery 2016;78:77-83.  Back to cited text no. 27


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1]


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