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Study Design Narrative Review. Objectives The premise of this review is to provide a review of the literature pertaining to studies describing outcomes of surgical cohorts when implementing C1 osteosynthesis for arch fractures with or without transverse atlantal ligamentous (TAL) injury. Methods A comprehensive search strategy was implemented across several search engines to identify studies which evaluate the outcomes of C1 osteosynthesis for patients with C1 arch fractures with and without TAL injury. Results Ten studies were identified. Parameters reported included osteosynthesis fusion rates, deformity correction, preservation of motion segments, patient reported outcome measures and overall complications. Overall, C1 osteosynthesis showed excellent fusion rates with complications comparable to traditional techniques denoted in literature. Furthermore, the osteosynthesis technique depicted good overall deformity correction and preservation of motion segments, in addition to good patient reported outcomes. Conclusion It appears C1 osteosynthesis offers a safe and efficacious alternative option for the surgical treatment of C1 fractures with TAL rupture. It has the potential to reduce deformity, increase ROM, improve PROMs and has complication rates comparable with those of fusion techniques. However more robust prospective evidence is required.

Background C1-ring osteosynthesis is a valid alternative to posterior C1–C2 or C0–C2 fusion to preserve important C1–C2 motion in the treatment of unstable atlas fractures. Nevertheless, the fixation instruments used in current studies for transoral anterior C1-ring osteosynthesis were not suitable for anterior anatomy of the atlas or did not have reduction mechanism. We therefore present this report to investigate preliminary clinical effects of transoral anterior C1-ring osteosynthesis using a laminoplasty plate in unstable atlas fractures. Methods From January 2014 to December 2017, 13 patients with unstable atlas fractures were retrospectively reviewed. All patients were treated with transoral anterior C1-ring osteosynthesis using a laminoplasty plate. Pre- and postoperative images were obtained to assess reduction of the fracture, internal fixation placement, and bone union. Neurological function, range of motion, and pain levels were evaluated clinically on follow-up. Results The surgeries were successfully performed in all cases. The average follow-up duration was 16.6 ± 4.4 months (range 12–24 months). One patient suffered screw loosening after operation and underwent replacement operation subsequently. Satisfactory clinical outcomes were achieved in all patients with ideal fracture reduction, reliable plate placement, well-preserved range of motion, and neck pain alleviation. All patients achieved bone union of fractures without loss of reduction or implant failure or C1–C2 instability during the follow-up. No vascular or neurological complication was noted during the operation and follow-up. Conclusions Transoral anterior C1-ring osteosynthesis using a laminoplasty plate is a effective surgical treatment for unstable atlas fractures. This technique has a ingenious reduction mechanism, and can provide satisfactory bone union and preservation of C1–C2 motion.

Combination atlas–axis fractures are less studied but relatively common with a higher incidence of neurological deficits than isolated C1 or C2 fractures. Several authors focused on the treatment strategies, but there is no study to compare the stability of different fixation methods; neither not yet clear which technique represents the best choice and whether stabilization devices can be efficient and beneficial for complex atlantoaxial fractures. The aim of this study was to compare the biomechanical properties of three fixation techniques: atlantoaxial pedicle screws fixation (PSF), occipital–cervical fusion (OCF) and transarticular screw fixation (TSF) based on combination factures model. Our results showed the range of motion (ROM) of fracture model increased obviously than intact model. The ROM in flexion/extension and rotation of C0–C1 in PSF and TSF models were increased. The ROM of C1–C2 in all conditions in PSF, OCF and TSF models were decreased. The ROM of C2–C3 was decreased in OCF, but remains the same stage in PSF and TSF. These suggested that three surgical methods are effective for the combination fractures of atlas and axis, which can ensure good stability. It can properly increase the ROM of C0–C1 when using PSF. These findings would aid in the treatment of this complex fractures.

Background In the treatment of unstable atlas fractures using the combined anterior–posterior approach or the posterior monoaxial screw-rod system, factors such as severe trauma or complex surgical procedures still need to be improved despite the favourable reduction effect. This research described and evaluated a new technique for the treatment of unstable atlas fracture using a self-designed lateral mass screw-plate system. Methods A total of 10 patients with unstable atlas fractures using this new screw-plate system from January 2019 to December 2021 were retrospectively reviewed. All patients underwent posterior open reduction and internal fixation (ORIF) with a self-designed screw-plate system. The medical records and radiographs before and after surgery were noted. Preoperative and postoperative CT scans were used to determine the type of fracture and evaluate the reduction of fracture. Results All 10 patients were successfully operated with this new system, with an average follow-up of 16.7 ± 9.6 months. A total of 10 plates were placed, and all 20 screws were inserted into the atlas lateral masses. The mean operating time was 108.7 ± 20.1 min and the average estimated blood loss was 98.0 ± 41.3 ml. The lateral mass displacement (LMD) averaged 7.1 ± 1.9 mm before surgery and almost achieved satisfactory reduction after surgery. All the fractures achieved bony healing without reduction loss or implant failure. No complications (vertebral artery injury, neurologic deficit, or wound infection) occurred in these 10 patients. At the final follow-up, the anterior atlantodens interval (AADI) was 2.3 ± 0.8 mm and the visual analog scale (VAS) was 0.6 ± 0.7 on average. All patients preserved almost full range of motion of the upper cervical spine and achieved a good clinical outcome at the last follow-up. Conclusions Posterior osteosynthesis with this new screw-plate system can provide a new therapeutic strategy for unstable atlas fractures with simple and almost satisfactory reduction.

Background This study aimed to compare the clinical outcomes of three distinct fixation systems— Jefferson Fracture Reduction Plate (JeRP), laminoplasty plates, and mini-reconstruction titanium plates—for treating atlas fractures via the transoral anterior approach. Methods A total of 76 patients who underwent single-segment transoral anterior fixation between January 2008 and June 2023 were retrospectively analyzed. Patients were stratified into three groups based on the fixation system used. Baseline characteristics, including fracture patterns, transverse ligament integrity, American Spinal Injury Association (ASIA) scores, and preoperative comorbidities, demonstrated no significant intergroup differences ( P  > 0.05), ensuring comparability. Outcomes evaluated included operative time, intraoperative blood loss, hospitalization duration, Visual Analog Scale (VAS) scores, Neck Disability Index (NDI), lateral mass displacement (LMD), and complications. Results All procedures were successfully completed. No wound dehiscence or surgical site infection was observed. At 1-year follow-up, all patients achieved bony union, near-complete pain resolution, and preserved cervical mobility. The JeRP plate group exhibited significantly longer operative duration and higher blood loss compared to the laminoplasty and mini-reconstruction titanium plate groups. Hospitalization durations were comparable across groups. Postoperative LMD, VAS and NDI reductions were significant in all groups ( P  < 0.05), with no intergroup differences. Complications included screw loosening and accidental screw placement into the occipitoatlantal joint (JeRP group, n  = 2) and transient pharyngeal discomfort (mini-reconstruction titanium plate group, n  = 1). Four patients with Dickman Type Ⅰ transverse ligament injuries exhibited asymptomatic atlantoaxial instability but required no intervention (JeRP group, n  = 2; mini-reconstruction titanium plate group, n  = 1; the laminoplasty plate group, n  = 1) . Conclusion Transoral anterior single-segment fixation effectively stabilizes atlas fractures while preserving occipital-atlas and atlantoaxial mobility. While all three systems achieved comparable clinical outcomes, laminoplasty and mini-reconstruction titanium plates demonstrated superior operative efficiency. Surgeons should prioritize low-profile implants to optimize visualization and simplify placement. Strict patient selection—particularly excluding Dickman Type I ligament injuries—is critical to ensuring long-term stability.

Objective To compare the clinic outcome of Jefferson-fracture reduction plate (JERP) or posterior pedicle screw-rod system in the treatment of Jefferson’s fracture and identify potential pre-operative risk factors for complications in patients treated with JERP system. Methods and materials A cohort of 68 patients with fresh Jefferson’s fracture who underwent reduction and fixation operation by our self-designed JERP plate or conventional posterior pedicle screw-rod system from June 2015 to June 2022 in our orthopedics center has been reviewed retrospectively. All the patients have been identified as Jefferson’s fracture (Gehweiler typeⅢa) by X-ray, CT and MR. Especially the transverse ligament remain intact and no dislocation of atlantoaxial junction has been found. All the patients presented with neck pain without neurological deficit. Forty-two patients underwent JERP system and twenty-six underwent posterior pedicle screw-rod system reduction and fixation. All the patients were followed up at least 12 months postoperatively. Parameters such as the operative time, blood loss, The visual analogue scale (VAS) score, distance to anterior arch fracture (DAAF), distance to posterior arch fracture (DPAF), lateral mass displacement (LMD) were retrospectively collected and statistically analyzed. Furthermore, we analyzed four preoperative characteristics for surgery-related complications, including age, gender, cause of injury and injury time. Results All 68 patients were followed up for 12 to 24 months. There was no significant difference in operation time, VAS scores and the incidence of postoperative complications between the two groups ( P  > 0.05). Compared with that in the control group, the blood loss in the JERP group was lower, and the length of hospital stay was longer. Furthermore, the JERP group had a smaller DAAF, shorter LMD and longer DPAF compared with the control group ( P  < 0.05). Furthermore, injury time (OR = 4.40; 95% CI, 1.05–20.69; P  = 0.04) were significant associated with complications, whereas other variables were not. Conclusion The JERP system achieves superior radiographic reduction of the atlas fracture (evidenced by improved postoperative DAAF, DPAF, and LMD) compared with the conventional posterior pedicle screw-rod system, but is associated with a longer hospital stay. Injury time may be associated with complications in patients treated with the JERP system, although this finding is based on univariate analysis and requires further validation.

Abstract OBJECTIVE To provide a comprehensive review of the biomechanics, pathophysiology, and clinical management of atlas fractures. METHODS Selected literature review. RESULTS Atlas fractures account for 25% of craniocervical injuries, 3% to 13% of cervical spine injuries, and 1% to 3% of all spinal injuries. Motor vehicle accidents account for 80% to 85% of atlas fractures, and the mechanism of injury is axial loading. Isolated atlas fractures are more common; however, 40% to 44% of atlas fractures have concomitant axis fractures. Fractures of isolated anterior or posterior arches are more common and typically seen with concomitant spine fractures. Isolated burst fractures are the second most common type and rarely cause neurological injury. Treatment of atlas fractures is based on whether they occur in isolation or in combination with other cervical spine injuries and on the integrity of the transverse ligament, which is best assessed with high-resolution magnetic resonance imaging. Isolated atlas fractures without injury of the transverse ligament or associated with bony avulsion of the transverse ligament can be treated with halo-brace immobilization and should be followed for instability with flexion-extension radiography. Surgical fixation is recommended for nonbony avulsion of the transverse ligament or if instability is present. The type of surgical fixation is determined by the concomitant craniocervical injuries if present. CONCLUSION Atlas fractures can be treated with halo-brace immobilization with acceptable outcomes. The role of surgical fixation, especially for atlas burst fractures, requires further study for clarification.