Commentary on “Surgical Versus Conservative Management for Treating Unstable Atlas Fractures: A Multicenter Study”

Traumatic atlantoaxial instability caused by atlas fracture has been a well-known lesion for a long time, however, surgical indication and appropriate operation based on injury type are still controversial. It must be a clue that preoperative radiological evaluation wheth-er a tensive structure of the transverse atlantal ligament (TAL), which is composed primary of collagen fibers with very few elastic fibers, 1 is intact or not as well as a complexity of atlas fracture. Instability related to the TAL is divided to 2 types using magnetic resonance imaging by Dickman’s classification: a TAL type I injury, characterized by a direct rupture of the ligament, whereas a TAL type II injury, involving an avulsion fracture at the attached site of the ligament. 2 Several previous reports have described surgical indication should be differ-entiated considering this classification. 2-4 Recently, more precise information about radiological findings can be helpful to make a decision for optimal management, and innovative development of spinal fixation has improved quality and safety of spinal fusion even in this complicated area. Therefore, ideal and comprehensive treatment should be changed accord-ing to modest concept. Based on these perspectives, the authors have reported clinical outcomes of multicenter comparative study between conservative and surgical management for isolated atlas fracture, which have a high potential for instability. 5 The authors have also evaluated preoperative radiological parameters that associated with faster osseous fusion and better clinical outcome after treatment in both groups. All patients enrolled in the study had atlas fracture with lateral mass displacement (LMD) following “rule of Spence” and disfunction of TAL including either type I or type II injury. Surgical treatment provided more rapid bone healing with significantly better clinical and radiological outcomes compared to those in conservative management with halo-vest immobilization (HVI). Specifically, total LMD and the anterior atlantodental interval were significantly improved in the surgical group indi-cating satisfactory restoration was maintained anatomically