Implantation choices, fusion preferences and implant removal after fixation in C1-C2 fractures: An AO Spine Knowledge Forum expert survey.

Authors

• Rishi Mugesh Kanna
• Mitchell Ng
• Andrei F Joaquim
• Gregory D Schroeder
• Mohammad El-Sharkawi
• Alfredo Guiroy
• Ratko Yurac
• Brian A Karamian
• Charlotte Dandurand
• Alexander R Vaccaro
• Grace Xiong
• Richard Bransford
• Martin Holas
• Klaus Schnake

Publication/Presentation Date

8-1-2026

Abstract

PURPOSE: The management of upper cervical spine (UCS) fractures is unclear concerning the role of fusion versus non-fusion fixation and the need for implant removal following fracture healing. This international AO Spine expert survey (Level IV study) evaluated the current trends, and practice preferences among experienced surgeons in the management of UCS fractures.

METHODS: A structured questionnaire was answered by AO Spine Knowledge Forum Trauma and Infection (KF T&I) members (n = 24). The survey collected data regarding demographics, classification use, fixation vs. fusion preferences, and implant removal practices for UCS fractures (C1, C2 odontoid, and Hangman's fractures). Descriptive statistics were analysed.

RESULTS: Majority were from North America and Europe (54%), orthopedic spine surgeons (87.5%), university-affiliated (88%), and well experienced (> 20 years: 58.3%). For C1 fractures, 79% used the AO UCS classification and 75% relied on MRI to assess transverse atlantal ligament integrity. Fixation ± fusion techniques dominated (C1-2 fusion: 62.5%; occipitocervical fixation: 45.9%), and implant removal was rarely performed (29.2% never, 70.8% only for symptoms). For odontoid fractures, 83.3% surgeons preferred posterior fixation in more than 60% fractures, while anterior odontoid screws were used infrequently (37.5%). 50% never removed implants. For Hangman's fractures, both anterior (41.7%) and posterior fixation/ fusion (45.8%) were equally preferred. In posterior fixations, fusion was added by 75%, while 25% favored only fixation without fusion. Implant removal was rare (16.7%).

CONCLUSIONS: This survey reveals that even among experienced surgeons, management strategies for UCS remain diverse. Segmental fixation procedures, particularly C1-C2 and C2-3 constructs, are commonly performed for both C1 and C2 fracture treatment while planned implant removal after fracture healing is rarely implemented. It highlights the need for prospective studies and randomized trials for formulating guidelines and indications for motion-preserving techniques and implant removal.

Volume

35

Issue

8

First Page

5157

Last Page

5164

ISSN

1432-0932

Published In/Presented At

Kanna, R. M., Ng, M., Joaquim, A. F., Schroeder, G. D., El-Sharkawi, M., Guiroy, A., Yurac, R., Karamian, B. A., Dandurand, C., Vaccaro, A. R., Xiong, G., Bransford, R., Holas, M., & Schnake, K. (2026). Implantation choices, fusion preferences and implant removal after fixation in C1-C2 fractures: An AO Spine Knowledge Forum expert survey. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society, 35(8), 5157–5164. https://doi.org/10.1007/s00586-026-09996-w

Disciplines

Business Administration, Management, and Operations | Health and Medical Administration | Management Sciences and Quantitative Methods

PubMedID

42133038

Department(s)

Administration and Leadership

Document Type

Article