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  • Guideline Summary
  • NGC:009763
  • 2013 Mar

Management of acute combination fractures of the atlas and axis in adult. In: Guidelines for the management of acute cervical spine and spinal cord injuries.

Ryken TC, Hadley MN, Aarabi B, Dhall SS, Gelb DE, Hurlbert RJ, Rozzelle CJ, Theodore N, Walters BC. Management of acute combination fractures of the atlas and axis in adults. In: Guidelines for the management of acute cervical spine and spinal cord injuries. Neurosurgery. 2013 Mar;72(Suppl 2):151-8. [56 references] PubMed External Web Site Policy

View the original guideline documentation External Web Site Policy

This is the current release of the guideline.

Age Group

UMLS Concepts (what is this?)

SNOMEDCT_US
Bone structure of atlas (14806007), Bone structure of axis (39976000), Brace (360316004), Cervical arthrodesis (81099000), Cervical collar (63562005), Closed fracture of first cervical vertebra (269063003), Closed fracture of second cervical vertebra (269064009), External fixation device (118383002), Fracture (125605004), Fracture (72704001), Fracture of odontoid process (281910003), Fracture of vertebral column (50448004), Halo brace (183187001), Hangman's fracture (263070009), Immobilization - action (257884004), Injury of cervical spine (262522002), Open fracture atlas (269071004), Open fracture axis (269072006), Spinal arthrodesis (55705006), Spinal injury (262521009)

Major Recommendations

The rating schemes used for the strength of the evidence (Class I-III) and the levels of recommendations (Level I-III) are defined at the end of the "Major Recommendations" field.

Recommendations

Level III

The treatment of combination atlas-axis fractures based primarily on the specific characteristics of the axis fracture is recommended.

  • External immobilization of most C1-C2 combination fractures is recommended.
  • C1-type II odontoid combination fractures with an atlanto-dental ratio of ≥5 mm and C1-Hangman combination fractures with C2-C3 angulation of ≥11 should be considered for surgical stabilization and fusion.

Summary

Combination fractures of the atlas and axis occur relatively frequently and are associated with an increased incidence of neurological deficit compared with either isolated C1 or isolated C2 fractures. C1-type II odontoid combination fractures are the most common C1-C2 combination fracture injury pattern, followed by C1-miscellaneous axis body fractures, C1-type III odontoid fractures, and C1-Hangman combination fractures. Class III medical evidence addressing the management of patients with acute traumatic combination atlas and axis fractures describes a variety of treatment strategies for these unique fracture injuries based primarily on the specific characteristics of the axis fracture injury subtype.

The type of axis fracture present generally dictates the management strategy for the C1-C2 combination fracture injury. Rigid external immobilization is typically recommended as the initial management for the majority of patients with these injuries. Combination atlas-axis fractures with an atlanto-axial interval of ≥5 mm or angulation of C2 on C3 of ≥11° have been considered for and successfully treated with surgical stabilization and fusion. Surgical options in the treatment of combination C1-C2 fractures include posterior C1-C2 internal fixation and fusion or combination anterior odontoid and C1-C2 transarticular screw fixation with fusion. Fractures of the posterior ring of the atlas can complicate the surgical treatment of unstable C1-C2 combination fracture injuries. If the posterior arch of C1 is incompetent and a dorsal operative procedure is indicated, occipitocervical internal fixation and fusion, posterior C1-C2 transarticular screw fixation and fusion, and C1 lateral mass-C2 pars/pedicle screw fixation and fusion techniques have been reported to be successful.

Definitions:

Rating Scheme for the Strength of the Evidence: Modified North American Spine Society Schema to Conform to Neurosurgical Criteria as Previously Published and for Ease of Understanding and Implementation: Levels of Evidence for Primary Research Questiona

Class Therapeutic Studies: Investigating the Results of Treatment Diagnostic Studies: Investigating a Diagnostic Test Clinical Assessment: Studies of Reliability and Validity of Observations, Including Clinical Examination, Imaging Results, and Classifications
I High-quality randomized controlled trial with statistically significant difference or no statistically significant difference but narrow confidence intervals Testing of previously developed diagnostic criteria on consecutive patients (with universally applied reference "gold" standard) Evidence provided by 1 or more well-designed clinical studies in which interobserver and intraobserver reliability is represented by a ĸ statistic ≥0.60 or an intraclass correlation coefficient of ≥0.70
Systematic reviewb of Class I randomized controlled trials (and study results were homogeneousc) Systematic reviewb of Class I studies  
II Lesser-quality randomized controlled trial (e.g., <80% follow-up, no blinding, or improper randomization) Development of diagnostic criteria on consecutive patients (with universally applied reference "gold" standard) Evidence provided by 1 or more well-designed clinical studies in which interobserver and intraobserver reliability is represented by a ĸ statistic of 0.40–0.60 or an intraclass correlation coefficient of 0.50–0.70
Prospectived comparative studye Systematic reviewb of Class II studies  
Systematic reviewb of Class II studies or Class I studies with inconsistent results Study of nonconsecutive patients; without consistently applied reference "gold" standard  
Case-control studyg Systematic reviewb of Class III studies  
Retrospectivef comparative studye Case-control study  
Systematic reviewb of Class II studies    
III Case seriesh Poor reference standard Evidence provided by 1 or more well-designed clinical studies in which interobserver and intraobserver reliability is represented by a ĸ statistic of <0.40 or an intraclass correlation coefficient of <0.50
Expert opinion Expert opinion  

aA complete assessment of quality of individual studies requires critical appraisal of all aspects of the study design.

bA combination of results from 2 or more prior studies.

cStudies provided consistent results.

dStudy was started before the first patient enrolled.

ePatients treated 1 way (e.g., halo vest orthosis) compared with a group of patients treated in another way (e.g., internal fixation) at the same institution.

fThe study was started after the first patient was enrolled.

gPatients identified for the study on the basis of their outcome, called "cases" (e.g., failed fusion), are compared with those who did not have outcome, called "controls" (e.g., successful fusion).

hPatients treated 1 way with no comparison group of patients treated in another way.

Levels of Recommendation

Level I Generally accepted principles for patient management, which reflect a high degree of clinical certainty (usually this requires Class I evidence which directly addresses the clinical questions or overwhelming Class II evidence when circumstances preclude randomized clinical trials)
Level II Recommendations for patient management which reflect moderate clinical certainty (usually this requires Class II evidence or a strong consensus of Class III evidence)
Level III Other strategies for patient management for which the clinical utility is uncertain (inconclusive or conflicting evidence or opinion)

Clinical Algorithm(s)

None provided

Disease/Condition(s)

Acute combination fractures of the atlas and axis, including:

  • C1-type II odontoid fractures
  • C1-type III odontoid fractures
  • C1-Hangman fractures
  • C1-miscellaneous C2 body fractures

Guideline Category

Management

Treatment

Clinical Specialty

Neurological Surgery

Orthopedic Surgery

Intended Users

Advanced Practice Nurses

Hospitals

Nurses

Physician Assistants

Physicians

Guideline Objective(s)

To update the medical evidence on the management of acute combination fractures of the atlas and axis in adults

Target Population

Adult patients with acute combination fractures of the atlas and axis

Interventions and Practices Considered

  1. Management strategy based on the specific characteristics of the axis fracture
  2. External immobilization (collar, halo)
  3. Surgical stabilization and fusion (anterior and posterior approaches)

Major Outcomes Considered

  • Fusion (success) rate
  • Morbidity and mortality

Methods Used to Collect/Select the Evidence

Hand-searches of Published Literature (Primary Sources)

Hand-searches of Published Literature (Secondary Sources)

Searches of Electronic Databases

Description of Methods Used to Collect/Select the Evidence

Search Criteria

A National Library of Medicine (PubMed) computerized literature search from 1966 to 2011 was undertaken using Medical Subject Headings in combination with "vertebral fracture": "atlas," "axis," and "human." This strategy yielded 202 references. The abstracts were reviewed, and articles focusing on clinical management and follow-up of combination fractures of the atlas and axis were selected for inclusion. The relative infrequency of these fractures, the small number of case series, and the numerous case reports with pertinent information required rather broad inclusion criteria. The bibliographies of the selected papers were reviewed to provide additional references.

Number of Source Documents

Forty-seven manuscripts describing the clinical features and the management of acute traumatic atlas and axis combination fractures are summarized in Evidentiary Table format (see Table 2 in the original guideline document).

Methods Used to Assess the Quality and Strength of the Evidence

Weighting According to a Rating Scheme (Scheme Given)

Rating Scheme for the Strength of the Evidence

Rating Scheme for the Strength of the Evidence: Modified North American Spine Society Schema to Conform to Neurosurgical Criteria as Previously Published and for Ease of Understanding and Implementation: Levels of Evidence for Primary Research Questiona

Class Therapeutic Studies: Investigating the Results of Treatment Diagnostic Studies: Investigating a Diagnostic Test Clinical Assessment: Studies of Reliability and Validity of Observations, Including Clinical Examination, Imaging Results, and Classifications
I High-quality randomized controlled trial with statistically significant difference or no statistically significant difference but narrow confidence intervals Testing of previously developed diagnostic criteria on consecutive patients (with universally applied reference "gold" standard) Evidence provided by 1 or more well-designed clinical studies in which interobserver and intraobserver reliability is represented by a ĸ statistic ≥0.60 or an intraclass correlation coefficient of ≥0.70
Systematic reviewb of Class I randomized controlled trials (and study results were homogeneousc) Systematic reviewb of Class I studies  
II Lesser-quality randomized controlled trial (e.g., <80% follow-up, no blinding, or improper randomization) Development of diagnostic criteria on consecutive patients (with universally applied reference "gold" standard) Evidence provided by 1 or more well-designed clinical studies in which interobserver and intraobserver reliability is represented by a ĸ statistic of 0.40–0.60 or an intraclass correlation coefficient of 0.50–0.70
Prospectived comparative studye Systematic reviewb of Class II studies  
Systematic reviewb of Class II studies or Class I studies with inconsistent results Study of nonconsecutive patients; without consistently applied reference "gold" standard  
Case-control studyg Systematic reviewb of Class III studies  
Retrospectivef comparative studye Case-control study  
Systematic reviewb of Class II studies    
III Case seriesh Poor reference standard Evidence provided by 1 or more well-designed clinical studies in which interobserver and intraobserver reliability is represented by a ĸ statistic of <0.40 or an intraclass correlation coefficient of <0.50
Expert opinion Expert opinion  

aA complete assessment of quality of individual studies requires critical appraisal of all aspects of the study design.

bA combination of results from 2 or more prior studies.

cStudies provided consistent results.

dStudy was started before the first patient enrolled.

ePatients treated 1 way (e.g., halo vest orthosis) compared with a group of patients treated in another way (e.g., internal fixation) at the same institution.

fThe study was started after the first patient was enrolled.

gPatients identified for the study on the basis of their outcome, called "cases" (e.g., failed fusion), are compared with those who did not have outcome, called "controls" (e.g., successful fusion).

hPatients treated 1 way with no comparison group of patients treated in another way.

Methods Used to Analyze the Evidence

Systematic Review with Evidence Tables

Description of the Methods Used to Analyze the Evidence

Selected articles were carefully reviewed by the authors. An evidentiary table was created (refer to Table 2 in the original guideline document) that reflected the strengths and weaknesses of each article.

On occasion, the assessed quality of the study design was so contentious and the conclusions so uncertain that the guideline authors assigned a lower medical evidence classification than might have been expected without such a detailed review. In every way, adherence to the Institute of Medicine's criteria for searching, assembling, evaluating, and weighing the available medical evidence and linking it to the strength of the recommendations presented in this document was carried out.

Articles that did not achieve immediate consensus among the author group were discussed extensively until a consensus was reached. Very few contributions required extensive discussion. Most articles were easily designated as containing Class I, II, or III medical evidence using the criteria set forth by the author group at the initiation of the literature evaluation process (see the "Rating Scheme for the Strength of the Evidence" field).

Methods Used to Formulate the Recommendations

Expert Consensus

Description of Methods Used to Formulate the Recommendations

The current author group was selected for its expertise in spinal surgery (both neurosurgical and orthopedic), neurotrauma, clinical epidemiology, and, in several cases, prior experience with guideline development. The topics chosen for inclusion in this iteration of these guidelines are contemporary and pertinent to the assessment, evaluation, care, and treatment of patients with acute cervical spine and/or spinal cord injuries.

Rating Scheme for the Strength of the Recommendations

Levels of Recommendation

Level I Generally accepted principles for patient management, which reflect a high degree of clinical certainty (usually this requires Class I evidence which directly addresses the clinical questions or overwhelming Class II evidence when circumstances preclude randomized clinical trials)
Level II Recommendations for patient management which reflect moderate clinical certainty (usually this requires Class II evidence or a strong consensus of Class III evidence)
Level III Other strategies for patient management for which the clinical utility is uncertain (inconclusive or conflicting evidence or opinion)

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation

Not stated

Description of Method of Guideline Validation

Not applicable

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field). All articles provided Class III medical evidence.

Potential Benefits

Appropriate management of acute combination fractures of the atlas and axis in adults

Potential Harms

The authors of one study concluded that odontoid fractures in the elderly are associated with significant morbidity and mortality and appear to be magnified with the use of a halo immobilization device.

Qualifying Statements

  • Medical evidence-based guidelines are not meant to be restrictive or to limit a clinician's practice. They chronicle multiple successful treatment options (for example) and stratify the more successful and the less successful strategies based on scientific merit. They are not absolute, "must be followed" rules. This process may identify the most valid and reliable imaging strategy for a given injury, for example, but because of regional or institutional resources, or patient co-morbidity, that particular imaging strategy may not be possible for a patient with that injury. Alternative acceptable imaging options may be more practical or applicable in this hypothetical circumstance.
  • Guidelines documents are not tools to be used by external agencies to measure or control the care provided by clinicians. They are not medical-legal instruments or a "set of certainties" that must be followed in the assessment or treatment of the individual pathology in the individual patients we treat. While a powerful and comprehensive resource tool, guidelines and the recommendations contained therein do not necessarily represent "the answer" for the medical and surgical dilemmas faced with many patients.

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools

Mobile Device Resources

For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

IOM Care Need

Getting Better

IOM Domain

Effectiveness

Bibliographic Source(s)

Ryken TC, Hadley MN, Aarabi B, Dhall SS, Gelb DE, Hurlbert RJ, Rozzelle CJ, Theodore N, Walters BC. Management of acute combination fractures of the atlas and axis in adults. In: Guidelines for the management of acute cervical spine and spinal cord injuries. Neurosurgery. 2013 Mar;72(Suppl 2):151-8. [56 references] PubMed External Web Site Policy

Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released

2013 Mar

Guideline Developer(s)

American Association of Neurological Surgeons - Medical Specialty Society

Congress of Neurological Surgeons - Professional Association

Source(s) of Funding

Congress of Neurological Surgeons

Guideline Committee

Guidelines Author Group of the Joint Section of Disorders of the Spine and Peripheral Nerves of the American Association of Neurological Surgeons and the Congress of Neurological Surgeons

Composition of Group That Authored the Guideline

Authors: Timothy C. Ryken, MD, MS, Iowa Spine & Brain Institute, University of Iowa, Waterloo/Iowa City, Iowa; Mark N. Hadley, MD (Lead Author), Division of Neurological Surgery, University of Alabama at Birmingham, Birmingham, Alabama; Bizhan Aarabi, MD, FRCSC, Department of Neurosurgery, University of Maryland, Baltimore, Maryland; Sanjay S. Dhall, MD, Department of Neurosurgery, Emory University, Atlanta, Georgia; Daniel E. Gelb, MD, Department of Orthopaedics, University of Maryland, Baltimore, Maryland; R. John Hurlbert, MD, PhD, FRCSC, Department of Clinical Neurosciences, University of Calgary Spine Program, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada; Curtis J. Rozzelle, MD, Division of Neurological Surgery, Children's Hospital of Alabama, University of Alabama at Birmingham, Birmingham, Alabama; Nicholas Theodore, MD, Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona; Beverly C. Walters, MD, MSc, FRCSC (Lead Author), Division of Neurological Surgery, University of Alabama at Birmingham, Birmingham, Alabama, Department of Neurosciences, Inova Health System, Falls Church, Virginia

Financial Disclosures/Conflicts of Interest

The authors have no personal financial or institutional interest in any of the drugs, materials, or devices described in this guideline.

Guideline Status

This is the current release of the guideline.

Guideline Availability

Available from the Neurosurgery Web site External Web Site Policy.

Availability of Companion Documents

The following are available:

  • Foreword. Guidelines for the management of acute cervical spine and spinal cord injuries. Neurosurgery 2013;72(3):1. Available from the Neurosurgery Web site External Web Site Policy.
  • Commentary. Guidelines for the management of acute cervical spine and spinal cord injuries. Neurosurgery 2013;72(3):2-3. Available from the Neurosurgery Web site External Web Site Policy.
  • Introduction to the guidelines for the management of acute cervical spine and spinal cord injuries. Neurosurgery 2013;72(3):5-16. Available from the Neurosurgery Web site External Web Site Policy.
  • Methodology of the guidelines for management of acute cervical spine and spinal cord injuries. Neurosurgery 2013;72(3):17-21. Available from the Neurosurgery Web site External Web Site Policy.

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on July 9, 2013. The information was verified by the guideline developer on October 3, 2013.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

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