- Department of Neurosurgery, Hopital Maisonneuve-Rosemont, Québec, Canada.
- Department ofNeurosurgery, Centre Hospitalier de l’Université de Montréal, Montréal, Québec, Canada.
- Department of Orthopedics, Centre Hospitalier de l’Université de Montréal, Montréal, Québec, Canada.
Department ofNeurosurgery, Centre Hospitalier de l’Université de Montréal, Montréal, Québec, Canada.
DOI:10.25259/SNI_479_2020Copyright: © 2020 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Sung-Joo Yuh1,2, Zhi Wang3, Ghassan Boubez3, Daniel Shedid2. Hemiparesis resulting from an unusual C1 fracture: A case report and literature review. 22-Dec-2020;11:449
How to cite this URL: Sung-Joo Yuh1,2, Zhi Wang3, Ghassan Boubez3, Daniel Shedid2. Hemiparesis resulting from an unusual C1 fracture: A case report and literature review. 22-Dec-2020;11:449. Available from: https://surgicalneurologyint.com/surgicalint-articles/10473/
Background: Jefferson fractures are burst fractures involving both the anterior and posterior arches of C1. They typically result from axial compression or hyperextension injuries. Most are stable, and neurological deficits are rare. They are often successfully treated with external immobilization, but require surgery (e.g., fusion/ stabilization).
Case Description: An 89-year-old male presented with a left-sided hemiplegia following a trivial fall. The cervical computed tomography scan revealed a left-sided displaced comminuted C1 fracture involving the arch and lateral mass. The MR revealed posterior cord compression and focal myelomalacia. Six months following an emergent C1–C3 decompression with occiput to C4 instrumented fusion, the patient was neurologically intact and pain-free.
Conclusion: An 89-year-old male presented with a left-sided hemiplegia due to a Type 3/4 C1 Jefferson fracture. Following posterior C1–C3 surgical decompression with C0–C4 instrumented fusion, the patient sustained a complete bilateral motor recovery.
Keywords: C1, Central cord syndrome, Cervical fracture, Jefferson fracture
Jefferson fractures are burst fractures involving both the anterior and posterior arches of C1; they account for 2–13% of all cervical fractures.[
The majority of C1 fractures are stable (e.g., with unruptured transverse ligaments) in neurologically intact patients and can be treated with external immobilization alone.[
Here, we present an 89-year-old male, who following trivial trauma, sustained a left-sided C1 Jefferson fracture, resulting in hemiplegia. This was successfully managed with a C1–C3 surgical decompression and C0–C4 instrumented fusion.
Following a trivial fall, an 89-year-old right handed male with hypertension, chronic renal failure, and orthostatic hypotension, acutely presented with a flaccid left-sided hemiplegia. He complained of severe neck pain, a limited range of cervical motion, and left lower extremity Lhermitte’s signs (e.g., “electric-like/lightening sensations”). On examination, he was hemiplegic in the left upper (0/5) and lower extremity (1/5) (e.g. the right sided weakness was mild (4/5) in these distributions) and had intact sensory and sphincter function. After 1 hour in the emergency room, his left upper extremity paralysis improved to a 1–2/5 strength level.
The cervical CT revealed a displaced comminuted C1 arch fracture on the left that involved the left lateral mass of C1 there was an accompanying diathesis of 10 mm [
The patient underwent an emergent C1–C3 laminectomy with occiput (CO)–C4 instrumented fusion. Under fluoroscopy, bilateral C1 lateral mass screws, bilateral C2 pars interarticular screws, and C4 lateral mass screws were applied; no C3 lateral mass screws could be placed due to technical interference from the C2 screw heads. Occipital plates/rods were placed bilaterally from C0-C4 [
Immediately postoperatively, the patient regained strength in both his upper and lower extremities (4/5). He was discharged to a rehabilitation facility 14 days later without any residual deficits. Six months postoperatively, his neck pain resolved, and X-rays showed no subsequent instrument-related complications.
C1 atlas factures can be divided into five different types based on the fracture location patterns[
Here, the initial CT scan showed a fracture of the left lateral mass involving the anterior arch, and a single fracture of the right-sided posterior arch. There was also an associated left occipital condyle fracture. This constituted a Type 3/4 C1 fracture [
Neck pain is the most common presentation for C1 Jefferson fractures, as these fractures typically do not present with neurological deficits; the large diameter of the spinal canal is further widened by the centrifugal displacement of the fragments.[
The integrity of the transverse ligament determines the stability of Jefferson fractures.[
After a fall, an 89-year-old male presented with a Type 3/4 C1 Jefferson fracture that resulted in an acute left-sided flaccid hemiplegia. Following a C1–C3 laminectomy and CO–C4 fusion, the patient fully recovered.
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