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25 January 2025: Articles  China

Preserving Cervical Mobility: A Novel Robot-Assisted Approach for Atlas Fracture Fixation

Unusual or unexpected effect of treatment

Han Yi12ABCDEFG, Fei Wang12ADEF, Seng-Lin Zhang12BEF, Jiang Hu12ADEG, Wei Zhang12ACDEFG*

DOI: 10.12659/AJCR.945718

Am J Case Rep 2025; 26:e945718

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Abstract

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BACKGROUND: The management of unstable atlas fractures remains a subject of ongoing debate and controversy. The conservative surgical treatment commonly involves fusion, resulting in severe loss of cervical spine mobility, and a large incisions and extensive tissue dissection are required. We aim to introduce a novel concept and surgical approach for treating atlas fracture, one that involves minimizing trauma while maintaining mobility of the upper cervical spine without resorting to fusion.

CASE REPORT: We present the case of a 48-year-old woman with an atlas fracture who underwent robot-assisted pedicle screw placement via biportal endoscopy technique. We seek to introduce a novel concept and surgical approach for treating atlas fracture, one that involves minimizing trauma while maintaining mobility of the upper cervical spine without resorting to fusion. The patient’s preoperative VAS score for neck pain was 7, which improved to 3 postoperatively. The right and left cervical rotation improved from 15° preoperatively to 50° postoperatively. Preoperative CT and MRI scans demonstrated satisfactory reduction of the anterior and posterior arch fractures and satisfactory fixation position of the pedicle screws. She was discharged 4 days later, and she had good range of flexion, extension, and rotation of the cervical spine 2 months after surgery.

CONCLUSIONS: Robot-assisted percutaneous atlas pedicle screw placement via biportal endoscopy is a beneficial surgical treatment for atlas fractures. This technique offers satisfactory alignment and union of the fractures and preservation of atlanto-axial joint motion while having the advantages of minimal invasiveness, rapid postoperative recovery, and fewer complications.

Keywords: Cervical Plexus, endoscopy, Fractures, Bone, Osteoarthritis, RNA, Transfer, Arg, Robotic Surgical Procedures, Spinal Fusion

Introduction

Atlas fractures account for 25% of all craniocervical injuries, 2–13% of all cervical spine injuries, and 1–3% of all spinal injuries [1,2] The management of unstable atlas fractures remains a subject of ongoing debate and controversy. The traditional surgical treatment commonly involves occipital-cervical or atlanto-axial fusion, resulting in severe loss of cervical spine mobility [3]. The placement of C1 pedicle screws poses a significant risk of harm to the vertebral artery and spinal cord. Use of an orthopedic surgery robot can enhance the accuracy and reliability of pedicle screw placement [4], increasing the safety of C1 pedicle screw fixation. Unilateral biportal endoscopic (UBE) technology can effectively prevent the screws from slipping on the bone surface during placement. The UBE system offers a wide and clear field of vision, with large operation space and less surgical trauma [5]. We report a case of robot-assisted pedicle screw placement via biportal endoscopy for the treatment for a middle-aged woman with an atlas fracture. This technique involves the direct fixation of pedicle screws for atlas fractures, assisted by the orthopedic surgery robot, minimizing the complexity of pedicle screw implantation while enhancing the precision and safety of screw placement.

Case Report

The patient was a middle-aged woman who sustained an atlas fracture in a car accident. After being injured, she had neck pain and limited range of motion, with normal sensation and motor function in the extremities. Her VAS score was 7 and the right and left cervical rotation was about 15° each. Preoperative imaging studies, including X-rays, CT scans, sagittal reconstruction, and MRI scans (Figure 1), revealed a fracture of the right anterior posterior arch of the atlas, with significant displacement and instability of the cervical spine. The absence of any clinical manifestations of vascular injury made carotid and vertebral artery CT angiograms unnecessary.

Taking into account the torn transverse ligament of the atlas, which is consistent with the diagnostic criteria for unstable Jefferson fractures, we decided to perform robot-assisted unilateral biportal endoscopic atlas pedicle screw placement and fixation surgery after thoroughly communicating with the patient, explaining the necessity and risks of the surgery. After making all necessary preoperative preparations, the surgery was scheduled to take place 3 days after the initial injury.

The Robot Navigation and Positioning System utilizes a third-generation surgical robot. The intraoperative data collection was conducted using the German Siemens ARCADIS Orbit 3D C-arm X-ray machine.

After satisfactory anesthesia, the patient was placed in a prone position on a specialized robotic spine surgery table with the head stabilized in a head-holder, and soft pads were placed on both sides of the chest for protection. The head was maintained in a slightly extended position, being sure that the eyes and genitals were not compressed. C-arm fluoroscopy was performed to locate the position of the responsibility segment. Two 2 trans-verse incisions, approximately 2.0 cm long, were made on the left side of the posterior neck at the C1 level – one for inserting an observation endoscope and continuously flushing with saline, and the other for instrument operation and outflow of saline. We used bipolar radiofrequency ablation to expand the muscle and clean soft tissues. Subsequently, fracture reduction was performed under endoscopy to ensure proper alignment of the fracture and to expose the entry points for the pedicle screws at C1. C-arm fluoroscopy was used to localize the position of the tracer for 3D imaging, and the information was recorded into the robot system. Based on the collected information, the entry point, direction, and length for the screws were determined, and the cortical surface of the pedicle was removed using a high-speed grinding drill. Guide wires were placed with assistance of the robotic arm, and C-arm fluoroscopy confirmed correct positioning of the pins. Pedicle screws were then inserted into the pedicle of C1, and a second C-arm fluoroscopy confirmed the correct position of the internal fixation. Rods were connected to the pedicle screws, and the screws were tightened. A plasma drainage tube was placed, and the incision was sutured in layers, completing the surgery (Figure 2).

The surgical procedure lasted for a total of 225 minutes. The total radiation dose during surgery was the sum of the dose continuously scanned by the robot during data acquisition and the single C-arm fluoroscopy dose. The average fluoroscopy dose during a single continuous scan is 65.3 cGy/cm2, and the fluoroscopy dose data was directly collected on the main screen of the C-arm X-ray machine. The amount of radiation delivered for fluoroscopy of this surgery was 156 cGy/cm2.

Following successful completion of the operation, the patient was safely extubated and transferred to the ward. She patient was encouraged to ambulate early, and was able to walk around wearing the cervicothoracic brace for additional protection on the second day after surgery. The surgical drain was removed on the third postoperative day and the patient was discharged home on postoperative day 4. She was instructed to minimize movements of the cervical spine and was advised to gradually resume gentle range of motion exercises for the neck starting 1 month after surgery. Her postoperative neck pain was significantly relieved, and her range of motion gradually returned (the VAS score was 3 and the right and left cervical rotation was about 50° each). Follow-up examinations showed continued improvement in clinical symptoms, and imaging studies confirmed good fracture healing and restoration of cervical stability (Figure 3). Notably, there were no intraoperative, peri-operative, or postoperative complications.

The range of flexion, extension, and rotation of the cervical spine had recovered well at 2 months after surgery (Figure 4). CT scans taken 4 months after surgery showed that the fracture site of the posterior arch of the atlas had achieved fusion, and callus had also formed at the fracture site of the anterior arch (Figure 5).

Discussion

The mechanism underlying atlas fractures involves the axial transmission of force from the skull to the cervical vertebrae. These fractures typically occur at the mechanically vulnerable point where the anterior and posterior arches of the atlas intersect with its lateral masses [6]. The traditional atlanto-axial or occipital-cervical fusion for treatment of atlas fractures sacrifices the motor function of the upper cervical vertebrae. The ideal treatment for atlas fractures with transverse ligament rupture is to retain the occipital-atlas axis joint function, while achieving fracture reduction and stable fixation [7].

In recent years, an increasing number of scholars have reported that the treatment of unstable atlas fractures with C1 direct posterior internal fixation has achieved satisfactory effects [8–10]. This method can maximize the stability of the occipital-atlas axis complex, preserve the range of motion of the atlas occipital and atlas axis joints, and greatly shorten treatment time. However, owing to the deep anatomical position of the atlas pedicle, large incisions and extensive tissue dissection are required to expose it, and local blood vessels are densely distributed near the atlas, which can easily cause massive bleeding, resulting in a blurred surgical field and difficulty in screw placement [11]. Additionally, the atlas pedicle is composed primarily of rigid cortical bone, and the screw can slide on the bone surface, leading to screw placement failure and even damaging the vertebral artery and venous plexuses [12]. These shortcomings have limited the development of this fixation technology.

Therefore, we used biportal endoscopic dissection combined with robot-assisted screw placement. Compared with the traditional surgical method, this combined approach can provide better visualization and precise anatomical dissection while enhancing the accuracy and safety of C1 pedicle screw placement and reducing the risk of spinal cord and vertebral artery injury.

Minimally invasive endoscopic techniques have emerged as a new approach for the treatment of upper cervical spine injuries, which allows for a clearer and wider visualization of the surgical field. Using endoscopes, surgeons can gain a more precise and comprehensive understanding of the anatomy and pathology involved, making surgical procedures more accurate and efficient. Additionally, endoscopic techniques can significantly reduce tissue trauma, minimizing collateral damage to surrounding structures and accelerating postoperative recovery. Moreover, combined with use of a high-speed drill, surgeons can grind away the cortical bone at the pre-set screw entry point under endoscopic visualization, effectively addressing the issue of slipping during the placement of C1 pedicle screws.

Robot-assisted technology plays a crucial role in improving surgical precision and safety. Previous studies have shown that robotic systems can accurately calculate the surgical path and angle, ensuring that screws are placed precisely in the desired location. This precision not only improves the overall surgical outcome but also significantly reduces the risk of screw loosening or displacement and minimizing the potential for human errors, as it relies on precise algorithms and data to guide the surgical process [13–15].

We have described a novel approach for the treatment of C1 fractures, and this case report confirms the feasibility of this new technique. However, retrospective studies with larger sample sizes are needed to thoroughly validate the effectiveness and reliability of this surgical method.

Conclusions

Robot-assisted percutaneous atlas pedicle screw placement via biportal endoscopy is a safe, minimally invasive, and effective new approach for treatment of anterior and posterior arch fractures of the atlas. This technique combines the advantages of robotic navigation, minimally invasive endoscopy, and pedicle screw fixation, offering a novel idea for individualized treatment of complex fractures in the upper cervical spine. However, further validation of the long-term outcomes and complication profiles in a larger patient population is necessary.

References:

1.. Matthiessen C, Robinson Y, Epidemiology of atlas fractures – a national registry-based cohort study of 1,537 cases: Spine J, 2015; 15(11); 2332-37

2.. Fiedler N, Spiegl UJA, Jarvers JS, Epidemiology and management of atlas fractures: Eur Spine J, 2020; 29(10); 2477-83

3.. Mohile NV, Kuczmarski AS, Minaie A, Management of combined atlas and axis fractures: A systematic review: N Am Spine Soc J, 2023; 14; 100224

4.. Matur AV, Palmisciano P, Duah HO, Robotic and navigated pedicle screws are safer and more accurate than fluoroscopic freehand screws: A systematic review and meta-analysis: Spine J, 2023; 23(2); 197-208

5.. Yang H, Cheng F, Hai Y, Unilateral biportal endoscopic lumbar inter-body fusion enhanced the recovery of patients with the lumbar degenerative disease compared with the conventional posterior procedures: A systematic review and meta-analysis: Front Neurol, 2023; 13; 1089981

6.. Ivancic PC, Atlas injury mechanisms during head-first impact.: Spine (Phila Pa 1976), 2012; 37(12); 1022-29

7.. Li L, Teng H, Pan J, Direct posterior c1 lateral mass screws compression reduction and osteosynthesis in the treatment of unstable Jefferson fractures: Spine (Phila Pa 1976), 2011; 36(15); E1046-51

8.. Dean Q, Jiefu S, Jie W, Minimally invasive technique of triple anterior screw fixation for an acute combination atlas-axis fracture: Case report and literature review: Spinal Cord, 2010; 48(2); 174-77

9.. Kumar A, Onggo J, Fon LH, Direct fixation of C1 Jefferson fracture using C1 lateral mass screws: A case report: Int J Spine Surg, 2019; 13(4); 345-49

10.. Zou X, Ouyang B, Wang B, Motion-preserving treatment of unstable atlas fracture: transoral anterior C1-ring osteosynthesis using a laminoplasty plate: BMC Musculoskelet Disord, 2020; 21(1); 538

11.. Goldberg JL, Carnevale JA, Xia J, Variation in cervical pedicle morphology: Important considerations for posterior cervical procedures: Oper Neurosurg (Hagerstown), 2023; 24(2); e85-e91

12.. Qian LX, Hao DJ, He BR, Morphology of the atlas pedicle revisited: A morphometric CT-based study on 120 patients: Eur Spine J, 2013; 22(5); 1142-46

13.. Han X, Tian W, Liu Y, Safety and accuracy of robot-assisted versus fluoroscopy-assisted pedicle screw insertion in thoracolumbar spinal surgery: A prospective randomized controlled trial: J Neurosurg Spine, 2019; 30(5); 615-22

14.. Soliman MAR, Pollina J, Poelstra K, Can a spine robot be more efficient and less expensive while maintaining accuracy?: Int J Spine Surg, 2022; 16(S2); S50-S54

15.. Naik A, Smith AD, Shaffer A, Evaluating robotic pedicle screw placement against conventional modalities: A systematic review and network meta-analysis: Neurosurg Focus, 2022; 52(1); E10

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American Journal of Case Reports eISSN: 1941-5923
American Journal of Case Reports eISSN: 1941-5923