Temporary Occiput–C2 Fixation for Unstable Atlas Fractures: A Reliable Alternative to Halo-Vest? Minimum Two-Year Clinical Outcomes

Abstract

Study Design

Retrospective study.

Objectives

This study aimed to assess clinical and radiological outcomes of temporary occiput–C2 fixation(TOC2F) as an alternative to halo-vest immobilization in unstable atlas fractures.

Methods

After ethics approval, 43 patients treated for C1 fractures between 2011-2018 were reviewed.Inclusion criteria were acute traumatic C1 fractures managed with TOC2F and at least two years of follow-up after implant removal. Exclusion criteria were polytrauma affecting follow-up, pathological fractures, prior cervical surgery, congenital anomalies, and incomplete data. Preoperative imaging included MRI, CT, MR angiography, and X-ray. Union was evaluated with CT at 3 and 6 months. Functional outcomes were assessed using NDI, SF-36 (MCS/PCS), and goniometric cervical rotation.

Results

The cohort consisted of 23 patients(16 male,7 female).According to Landells classification,78.2% had type II and 21.7% type III fractures. Radiological union was achieved in all patients by 6 months, with hardware removal at a mean of 6.3 months. Cervical rotation significantly improved from 103.78° ± 12.02 at day 4 to 153.78° ± 9.29 at two years(P < .05).NDI scores improved from 12.21 ± 3.66 to 2.14 ± 0.94(P < .05).Final SF-36 MCS/PCS scores were favorable 56.33/56.09).No neurological deterioration occurred; one superficial wound complication was documented.

Conclusion

TOC2F demonstrates potential as a viable and effective alternative for the management of unstable C1 burst fractures.This technique provides immediate postoperative stability, facilitates reliable fracture union, and allows restoration of physiological cervical motion following implant removal.The favorable functional outcomes, low complication rate, and preserved long-term mobility observed in this study suggest that temporary fixation may offer substantial advantages over halo-vest immobilization and permanent fusion in appropriately selected patients.

Keywords

Jefforsan fractures cervical vertebrae surgery temparary internal fixation

Introduction

Fractures of the atlas (C1) account for approximately 2-13% of all cervical spine injuries and commonly result from high-energy axial loading or low-energy trauma in the elderly population.^1,2 Although most isolated C1 fractures are stable and respond well to external immobilization, instability associated with transverse atlantal ligament (TAL) disruption, combined C1–C2 injuries, or marked lateral mass displacement carries a substantial risk of nonunion and late deformity if not adequately stabilized.³ In recent years, a more nuanced understanding of C1 fracture patterns and TAL integrity has led to an increased tendency toward surgical fixation in unstable atlas fractures, while the role of purely conservative management has progressively diminished.⁴

Traditionally, halo-vest immobilization has been considered the primary nonoperative treatment option for unstable atlas fractures because it provides more rigid immobilization than cervical collars or Minerva braces.⁵ However, numerous series and systematic reviews have highlighted important limitations of halo-vest therapy, including loss of reduction, pin-related complications, dysphagia, pulmonary issues, skin problems, and poor tolerance, particularly among elderly or comorbid patients.^6,7 Reported failure rates and complication profiles have raised concerns regarding the reliability and safety of halo-vest immobilization in this context, thereby increasing interest in surgical alternatives.

Several contemporary studies suggest that surgical stabilization yields superior radiographic and clinical outcomes compared with halo-vest immobilization in patients with unstable atlas fractures. Accordingly, posterior C1–C2 fusion and occipitocervical fusion have become widely accepted components of the treatment algorithm for these injuries.⁸ Nevertheless, permanent posterior fusion across the upper cervical spine inevitably sacrifices motion. The atlanto-occipital and atlantoaxial joints account for the majority of cervical flexion–extension and axial rotation, and occipitocervical fusion in particular has been associated with loss of lordosis, increased cervical sagittal vertical axis, and potential long-term detrimental effects on quality of life.⁹

The concept of a temporary “internal halo,” achieved by spanning constructs across the upper cervical spine, has emerged as a strategy to provide rigid internal stabilization while avoiding the external complications associated with halo-vest immobilization. Case series of temporary occipitocervical or upper cervical spanning fixation have reported successful fracture healing, maintenance of alignment, and preservation of postoperative range of motion following implant removal.^10,11

The aim of the present study was to evaluate the minimum two-year radiological and clinical outcomes of patients with unstable atlas fractures treated with temporary occiput–C2 fixation (TOC2F) followed by implant removal, and to assess whether this internal halo approach may serve as a reliable alternative to halo-vest immobilization in carefully selected cases.

Materials and Methods

Study Design

This retrospective study was conducted in accordance with the ethical principles of the Declaration of Helsinki. Following approval from the institutional ethics committee, 43 patients who were treated for C1 fractures between 2011 and 2018 were retrospectively reviewed. The inclusion criteria comprised patients aged ≥18 years with acute traumatic unstable C1 fractures who underwent treatment with temporary occiput–C2 fixation (TOC2F) and had a minimum follow-up period of two years after implant removal.

Patients were excluded if they had a history of prior cervical spine surgery or congenital cervical spine anomalies; pathological fractures secondary to infection, malignancy, or metabolic bone disease; transverse ligament injury; fractures with facet joint step-off; severe osteoporosis; incomplete clinical or radiological records; or if they were lost to follow-up before the two-year evaluation. These refined inclusion and exclusion criteria constituted the surgical indications applied in the present study. Additionally, patients with severe polytrauma that could interfere with standardized treatment protocols or follow-up were excluded. Based on these criteria, a total of 23 patients (16 males and 7 females) were ultimately included in the analysis. (Figure 1).

Figure 1.

Study flow diagram showing the inclusion and exclusion of patients

Demographic data (age and sex), mechanism of injury, associated injuries, Neck Disability Index (NDI) scores, cervical rotation range of motion, postoperative complications, and total follow-up duration were recorded. Preoperative evaluation included cervical magnetic resonance imaging (MRI), computed tomography (CT), and anteroposterior radiographs. Vertebral artery anatomy was assessed preoperatively using magnetic resonance angiography, and the presence of high-riding vertebral arteries was documented. Fracture union was evaluated using cervical CT scans at the 3rd and 6th postoperative months. Union was defined as the presence of trabeculation across the fracture lines on both cervical plain radiographs and CT scans. Bone union was further confirmed postoperatively with CT imaging, including systematic evaluation of the sagittal, coronal, and axial planes according to the fracture location. After solid union was confirmed in all patients, the temporary fixation hardware was removed, and patients were promptly enrolled in a structured physical therapy program. Dynamic cervical radiographs were obtained following removal of the TOC2F instrumentation. Cervical rotation was measured at the two-year follow-up. Functional outcomes were assessed using the Short Form–36 Health Survey (SF-36), including the Mental Component Summary (MCS) and Physical Component Summary (PCS), as well as the Neck Disability Index (NDI) scores.^12,13

Preoperative Diagnostic Evaluations

Preoperative diagnostic evaluations included cervical magnetic resonance imaging, computed tomography, and anteroposterior X-rays to determine the extent and localization of the fractures. The integrity of the vertebral arteries was assessed using magnetic resonance angiography, with high-riding vertebral arteries noted preoperatively.

Surgical Technique

All patients underwent surgery under total intravenous anesthesia. After baseline motor evoked potential (MEP) and somatosensory evoked potential (SSEP) values were obtained using multimodal neuromonitoring, the patients were positioned prone with the Mayfield skull clamp.^14,15 The operating table was then adjusted to the Trendelenburg position to minimize venous bleeding. A midline skin incision was made beginning 2 cm caudal to the external occipital protuberance and extended inferiorly as needed. The occiput was exposed using electrocautery, and the ligamentous structures were retracted laterally. Screw lengths for the occipital plate were determined intraoperatively, and all screws were inserted bicortically. C1-C2 facet joint and capsule were retained throughout the surgery. In C2 instrumentation, intralaminar screws were chosen for 4 patients due to the presence of high-riding vertebral artery and pedicle screws for 19 patients. Bilateral C1 lateral mass screws were used to achieve reduction of the lateral mass displacement. These two screws were attached with a transverse rod to compress and reduce C1 lateral masses (Figure 2). All screws were placed under fluoroscopic guidance. C2 screws and occipital plate were fixed with 2 rods. For patients presenting with associated Type II odontoid fractures, anterior odontoid fixation with a Böhler screw was carried out before TOC2F (Figure 3).

Figure 2.

A 19-year-old male patient who underwent surgery due to C1 burst (Jefferson) fracture. Displacement of the lateral mass is clearly demonstrated on coronal plane CT images. (A) Preoperative CT images. (B) Postoperative CT images. Evidence of lateral mass reduction and C1 fracture consolidation is demonstrated (C) Six-month follow-up computed tomography scans, with regions of bone union highlighted by arrows. (D) X-ray after TOC2F surgery. (E) X-ray after removal of temporary fixation materials

Figure 3.

A 36-year-old male patient who underwent surgery due to type 3 C1 and type 2 C2 odontoid fracture. (A)Preoperative CT images. (B) Postoperative X-ray. (D) X-ray after removal of temporary fixation materials

Postoperative Rehabilitation

Drain removal was performed when the daily drainage volume declined to <50 cc. Patients didn’t use a neck collar after surgery and were followed up with plain radiographs in the early postoperative period at 6-week intervals. The union was evaluated with computed tomography. TOC2F materials were removed after the solid union was achieved. Postoperative mobility was evaluated with dynamic cervical radiographs. All patients were admitted to a physical therapy program for 6 weeks after the removal of TOC2F implants. NDI scores and degrees of neck rotation were recorded 4 days after removal of implants and at the postoperative 2^nd-year follow-up. Cervical rotational range of motion was assessed with a goniometer.¹⁶ Physical therapy aimed to provide neck range of motion and strengthen the paraspinal neck muscles.

Results

The mean age of the 23 patients (16 males and 7 females) was 41.9 years (range 18-72). The etiologies of the patients included 14 falls from height, 8 motor vehicle accidents, and 1 firearm injury. No preoperative neurologic deficit was present in any of the patients (American Spinal Injury Association: grade ASIA E). All patients had a C1 fracture. Eighteen patients (78.2%) had type 2 (Jefferson), 5 patients had (21.7%) type 3 (unstable unilateral mass fracture) fracture according to Landells classification.¹⁷ Three patients (13%) had type 2 odontoid fracture according to Anderson classification and 2 patients (8.6%) had occipital condyle fracture in addition to C1 fracture (Table 1).^18,19 In 3 patients with odontoid fractures, primarily an anterior approach was used for screw fixation. The mean follow-up duration of the patients was 43.5 (range 28-63) months. All patients had a complete union at the 6th-month follow-up. The implants were removed at a mean of 6.3 (range 6-7) months (Figure 2).

Table 1.

Descriptive Characteristics of Patients

Descriptive characteristics	Number (n)	Percentage (%)
Age (Mean ± SD: 42.2 ± 13.40, min:18, max:72)
Sex
Female	7	42.9
Male	16	57.1
Etiology
MVA	8	34.7
FAI	1	4.3
Fall from height	14	60.8
Fractured vertebra
Isolated C1 fracture	18	64.2
C1 + Occipital condyle	2	14.2
C1 + Odontoid	3	21.4
Asia grade
E	23	100.0
Follow-up time (Mean ± SD: 46.21 ± 18.38, min:24, max:84 months)
Time of implant removal (Mean ± SD: 6.42 ± 0.64, min:6, max:8 months)

SD: Standard Deviation. MVA: motor vehicle accident. FAI: Firearm Injury.

The mean degrees of neck rotation of the patients were 103.78 ± 12.02 and 153.78 ± 9.29 on the 4th day and in the 2nd year after removal of the TOC2F implants, respectively. The mean NDI score on the 4th day after the removal of the implant was 12.21 ± 3.66. According to the score ranges of the NDI, 71.4% of the patients had mild disability, and 28.6% had moderate disability on the 4th day, while all the patients (100.0%) had no disability at the 2nd year follow-up. The mean NDI score of the patients in the 2nd year after the removal of the implant was 2.14 ± 0. 94 (Table 2). There was a statistically significant difference between the NDI scores and degrees of neck rotation on the 4th day and 2nd year after the removal of the implant (P < 0.05). The SF36 score of the patients at the last follow-up was 56.33/56.09 for MCS/PCS. Postoperative complications were assessed under the categories of vascular injury, neurological deficit, implant-related failure (including screw loosening and rod–screw dissociation), and infection. A postoperative superficial soft tissue infection was identified in only one patient and was successfully managed with regular wound care and systemic antibiotic therapy. Furthermore, dynamic radiographs obtained following implant removal were used to evaluate spinal stability, and all patients demonstrated stable healing without evidence of instability. No additional surgery was necessary for any patient at the treated levels.

Table 2.

Degrees of Neck Rotation and NDI Scores of Patients

Variables	Mean ± SD	Min-Max
Degree of neck rotation
4th day	103.78 ± 12.02	85-122
2nd year	153.78 ± 9.29	138-168
NDI
4th day	12.21 ± 3.66	8-19
Scoring intervals	%(n)
0-4 no disability	0.0(0)
5-14 mild	69.5(16)
15-24 moderate	30.4(7)
25-34 severe	0.0(0)
>34 complete	0.0(0)
2nd year	2.14 ± 0.94	1-4
Scoring intervals	%(n)
0-4 no disability	100.0(23)
5-14 mild	0.0(0)
15-24 moderate	0.0(0)
25-34 severe	0.0(0)
>34 complete	0.0(0)

NDI: Neck disability index.

Statistical Analysis

The data were analyzed in the SPSS 23.0 statistical package program. Number, percentage, mean, and standard deviation were used as descriptive statistics in data analysis. The fitness of the variables of the degree of neck rotation and NDI score to normal distribution was evaluated with the Shapiro-Wilk test. Wilcoxon Signed Ranks Test was used for the comparison of the degree of neck rotation and NDI scores on the 4th day and 2 years after implant removal. The level of significance for statistical tests was set at P < 0.05.

Discussion

The findings of this study indicate that TOC2F provides a reliable and effective treatment strategy for unstable C1 burst fractures, resulting in favorable radiological and functional outcomes while preserving upper cervical mobility. All patients in our cohort achieved complete osseous union within six months, and no neurological deficits were observed during the follow-up period. The substantial improvement in cervical rotation—from a mean of 103.8° shortly after implant removal to 153.8° at the two-year follow-up—highlights the effectiveness of this technique in restoring physiological motion at the craniovertebral junction. According to the literature, an average cervical rotation of approximately 160° in healthy individuals is considered physiological.²⁰ In our study, assessments performed at the two-year follow-up demonstrated that the measured values closely approximated physiological cervical rotation ranges. Similarly, the progressive reduction in Neck Disability Index (NDI) scores, with all patients demonstrating full functional recovery by the second year, underscores the long-term benefits of temporary fixation. Favorable SF-36 Mental Component Summary (MCS) and Physical Component Summary (PCS) scores further support the notion that this approach not only stabilizes the fracture but also maintains an acceptable health-related quality of life. In the present study, odontoid fractures accompanied C1 fractures in three patients, while occipital condyle fractures were identified in two patients. Due to the limited sample size, the impact of these associated injuries on clinical and radiological outcomes could not be statistically evaluated.

Atlas fractures are known to result in atlantoaxial instability and may pose life-threatening risks. Consequently, the surgical management of fractures involving this region remains technically challenging. Over the past decades, a variety of surgical techniques have been developed to address instability at the craniovertebral junction. The technique originally described by Gallie in 1939 provided satisfactory stability; however, it resulted in a significant restriction of cervical rotation.²¹ Subsequent modifications of this technique were proposed by various surgeons in an effort to improve clinical outcomes. The transarticular screw fixation technique introduced by Magerl in 1979 represented a major advancement in atlantoaxial stabilization. Nevertheless, this approach carries an inherent risk of vertebral artery injury. More recently, the Harms technique, which involves C1 lateral mass and C2 pedicle screw fixation, has been widely adopted due to its biomechanical strength and reliability. Despite these advantages, this method—similar to other rigid fixation techniques—inevitably sacrifices cervical rotation. Given the functional importance of cervical rotation, particularly in activities of daily living, temporary fixation techniques that preserve motion while providing sufficient stability have gained increasing popularity worldwide. These approaches offer a balance between maintaining physiological cervical motion and achieving reliable stabilization, thereby representing an attractive therapeutic alternative in appropriately selected patients.^11,22-24

The management of atlantoaxial injuries traditionally includes rigid cervical collars, halo-vest immobilization, and various internal fixation techniques.^25-27Although cervical collars are easy to use and well-tolerated, their limited stabilizing capacity often results in high nonunion rates, particularly in unstable C1 fractures. Halo-vest immobilization, introduced in the mid-20th century, offers superior rigidity compared with collars²⁸; however, its clinical utility is counterbalanced by substantial discomfort, high complication rates, and specific contraindications such as scalp lacerations and skull fractures.²⁹ Numerous studies have documented complications including pin-site infections, brain abscesses, dysphagia, pulmonary issues, and pin loosening—many of which necessitate early conversion to surgical treatment.³⁰ Given these limitations, internal fixation techniques, including C1–C2 fusion and occipitocervical fusion, have gained prominence as more reliable alternatives. Over the past decades, spine trauma management has increasingly mirrored advancements in extremity fracture care, with a paradigm shift from external immobilization toward internal fixation, early mobilization, and improved patient-reported outcomes.³¹ Despite the robust stability offered by fusion procedures, the loss of motion at the atlantoaxial complex—which contributes to more than 50% of cervical rotation—poses a major functional drawback.³² To balance stability with motion preservation, temporary fixation strategies have emerged as an appealing alternative. In this context, TOC2F was used in our series to avoid the long-term morbidity associated with permanent fusion and the high complication rates of halo-vest treatment. Our findings demonstrated consistent radiological union, excellent functional recovery, and substantial preservation of cervical rotation, supporting the viability of this technique in managing unstable C1 fractures.

The results of the present study are consistent with the existing body of literature on occipitocervical fixation and motion-preserving strategies for upper cervical spine injuries. Joaquim et al provided a comprehensive review of occipitocervical fixation techniques, emphasizing the importance of achieving biomechanical stability while preserving upper cervical motion whenever feasible.³³ In another study, patients who underwent temporary C1–C2 fixation for unstable C1–C2 fractures were evaluated. Biomechanical analyses demonstrated that temporary C1–C2 cervical fixation provided sufficient rigidity and stability when compared with transarticular screw fixation. Following implant removal, patients were followed for approximately one year, and a mean cervical rotation of 149° was reported.²² In our study, patients were followed for two years after implant removal, and in line with the literature, similarly favorable clinical and functional outcomes were achieved. Additionally, previous studies evaluating temporary occipitocervical fixation for upper cervical fractures have reported comparable positive results^10,11 . One of the distinguishing features of our study is the use of an additional transverse rod technique in displaced C1 lateral mass fractures, which enabled anatomical reduction of the lateral masses through compression. We believe that one of the most important advantages of the TOC2F technique, compared with other temporary fixation methods, is its ability to facilitate anatomical reduction in displaced C1 lateral mass fractures (Figure 2). As with all temporary fixation techniques, the need for a second surgical procedure for implant removal in the TOC2F technique may cause concern for patients. Nevertheless, the preservation of cervical range of motion—particularly in young and physically active individuals—renders this method a valuable therapeutic alternative.

Our findings support this principle, as TOC2F resulted in complete radiographic union by six months and substantial improvements in cervical mobility, with mean rotational range increasing from 103.78° to 153.78° over the two-year follow-up. These outcomes reinforce the concept that temporary fixation may serve as an effective alternative to permanent occipitocervical fusion, mitigating long-term motion restriction without compromising stability. Rispoli et al questioned the ongoing role of halo-vest immobilization for atlantoaxial fractures, citing its limited capacity to achieve stable fixation and its well-documented issues regarding patient tolerance and compliance.³⁴ The present study further substantiates this shift away from nonoperative immobilization toward surgical stabilization, as all patients achieved solid bone union with a secure construct and demonstrated meaningful functional recovery. Moreover, the absence of neurological deterioration and the low complication rate observed in our cohort underscore the safety and effectiveness of surgical management compared with conventional conservative treatment options.

Yang et al described the application of temporary bridge occipitocervical fixation for comminuted atlantoaxial fractures, reporting successful fracture healing and favorable functional outcomes following implant removal.¹¹ Consistent with their results, the present study demonstrates that TOC2F provides adequate stabilization during the healing phase while allowing substantial restoration of cervical mobility once the hardware is removed. The continuous improvement observed in NDI scores—culminating in complete functional recovery in all patients by the two-year follow-up—further aligns with the findings of Yang et al and reinforces the value of a temporary fixation strategy. These results suggest that, in appropriately selected patients, temporary constructs may deliver sufficient biomechanical stability to support fracture union while avoiding the long-term morbidity inherent to permanent occipitocervical fusion. Collectively, the present findings add to the growing body of literature supporting temporary fixation techniques in the management of C1 fractures. When compared with traditional occipitocervical fusion or halo-vest immobilization, TOC2F appears to strike an optimal balance between achieving immediate postoperative stability and preserving long-term cervical motion, thereby enhancing both structural and functional outcomes.

Previous studies have documented cases of unintended arthrodesis in patients whose temporary C1–C2 fixation constructs were retained for longer than one year.²⁴ To minimize this risk, patients in the present cohort were monitored closely with serial radiographic evaluations, and implants were removed promptly once solid osseous union was confirmed. The mean duration of implant retention was 6.4 months. Following hardware removal, all patients participated in a structured physiotherapy program aimed at restoring cervical mobility and preventing postoperative stiffness. Several reports in the literature have explored the use of temporary C1–C2 fixation for fractures involving C1 or C2.³⁵Among these, Guo et al compared outcomes between patients with odontoid fractures treated with temporary C1–C2 fixation and those managed with permanent fusion, demonstrating superior preservation of motion and comparable union rates in the temporary fixation group. Similarly, Han et al evaluated temporary C1–C2 fixation for type II odontoid fractures and reported outcomes equivalent to permanent fusion but with the added advantage of maintaining atlantoaxial rotation following implant removal.²³ In the present study, three patients presented with concomitant type II odontoid fractures coexisting with C1 fractures. In these cases, anterior odontoid screw fixation was performed to restore dens stability, followed by temporary posterior occiput–C2 fixation within the same surgical session to stabilize the C1 fracture. This combined anterior–posterior approach ensured adequate stabilization across both injury levels while preserving the potential for physiological motion recovery after hardware removal.

This study has several limitations that should be acknowledged. First, its single-center retrospective design inherently restricts the generalizability of the findings and introduces the possibility of selection and information biases. Second, the relatively small sample size limits the statistical power to detect infrequent complications or subtle differences in clinical outcomes associated with TOC2F. Third, the absence of a direct comparison group—such as patients treated with permanent occipitocervical fusion or halo-vest immobilization—precludes a more rigorous evaluation of the relative efficacy and safety of this technique. Furthermore, cost-effectiveness and health-economic implications were not assessed, despite their growing importance in treatment decision-making and resource allocation. Future research should include prospective, multicenter studies with larger cohorts and well-designed comparative analyses to validate these findings, clarify patient selection criteria, and further define the role of temporary fixation within the management algorithm for upper cervical spine injuries.

Conclusion

TOC2F demonstrates potential as a viable and effective alternative for the management of unstable C1 burst fractures. This technique provides immediate postoperative stability, facilitates reliable fracture union, and allows restoration of physiological cervical motion following implant removal. The favorable functional outcomes, low complication rate, and preserved long-term mobility observed in this study suggest that temporary fixation may offer substantial advantages over halo-vest immobilization and permanent fusion in appropriately selected patients.

Footnotes

ORCID iDs

Muhammed Fatih Serttaş

Tuna Pehli̇vanoğlu

Ethical Considerations

This study was approved by the committee on ethics. Aproval number: E-67961857-050.04-167912

Consent to Participate

This retrospective study was approved by the institutional review board, and informed consent was obtained from all participating patients for the use of their clinical data and images.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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