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Three Part Question

In [patients with Jefferson fracture] would [surgical intervention or conservative management] lead to [complete alignment of the cervical fracture]?

Clinical Scenario

A 20-Year-old female front seat passenger with the seat belt on sustained a neck injury from a frontal collision car Accident that left her with a fronto-parietal scalp laceration; presented to the Emergency Room with cervical spine precautions. Primary survey demonstrated a non-disabling local neck pain and tenderness. The neurologic examination was normal with no disabilities, and no cranial nerve involvement. Glasgow coma scale was 15/15. Past medical history is unremarkable with no previous incident.
An X-Ray, Computed Tomography (CT) scan and MRI of the neck revealed only a Jefferson fracture with a 12 mm widening of the lateral mass of C1. The Anterior Atlanto-Dens Interval (ADI) was normal (2mm) and the Space Available for the Cord was 17mm.

Search Strategy

A National Library of Medicine (PubMed), OVID, Cochrane Library, and google scholar computerized literature search from 1984 to 2019 was undertaken using Medical Subject Headings in combination with “Jefferson’s fracture”, “Lateral Mass”, “atlas” and “human”.
The relative infrequency of these fractures, the small number of case series, and numerous case reports with pertinent information required rather broad inclusion and exclusion criteria. The bibliographies of selected articles were reviewed to provide additional references and to assess the completeness of the literature review.
These efforts resulted in more than 20 contemporary articles describing acute traumatic atlas fractures not included in the previous version of this literature review. One of these reports provided no new data and was excluded. Although case reports were included in the previous search because of the paucity of clinical material on this subject, no new case reports were identified that would affect the aim of the study. More than 15 contemporary Class III medical evidence case series are summarized in Evidentiary Table format and are described in an excel sheet. This in turn organized our resources into a table that made it easier for us to work through this project and identify what sources to implement throughout our study. Selected supporting articles are included in the bibliography and contribute to the scientific foundation.

Search Outcome

This strategy yielded more than 30 references. The abstracts were reviewed, and articles addressing clinical management and follow-up of atlas fractures were selected for inclusion. The relative infrequency of these fractures, the small number of case series, and numerous case reports with pertinent information required rather broad inclusion and exclusion criteria. The bibliographies of selected articles were reviewed to provide additional references and to assess the completeness of the literature review.

Clinical Bottom Line

Compared with Halo Vest Immobilization (HVI), surgical reduction with fixation reduces fractured lateral mass displacements, increases fusion rate, and reduces time-to-fusion while maintaining cervical curvature and improving neck pain and daily activities.