To characterize surgical treatment and outcomes of C1 fractures in a population-based setup.
Consecutive C1 fracture patients treated at Kuopio University Hospital (KUH) Neurosurgery were retrospectively identified from January 1996 to June 2017. C1 fractures were classified according to the AOSpine Upper Cervical and Gehweiler classification systems. Patients were divided into four groups based on their treatment: Group 1, underwent C1 surgery as a primary option; Group 2, underwent C1 surgery as a secondary option after initial nonoperative treatment; Group 3, underwent surgery involving the C1 level with main indication being a concomitant cervical spine fracture; and Group 4, C1 fracture treatment was nonoperative.
We identified 47 C1 fracture patients (mean age 60.3 ± 18.2 years; ASA score 2.3 ± 0.8; 83.0% male). Concomitant cervical spine fractures were present in 89.4% of cases, most commonly in the C2 vertebra (75.4%). In Group 2, 3/5 fractures changed from AOSpine type A to B in control imaging after nonoperative treatment, indicating fracture instability and requiring secondary surgery. Good C1 fracture alignment was achieved for 10/10 followed-up patients in Groups 1 and 2, and for 10/11 followed-up patients in Group 3. Residual neck pain and stiffness were present in all groups. Neurological symptoms were rare and mild.
For unstable C1 fractures, surgery is safe treatment with good outcomes. Fractures initially determined as stable may require surgery if alignment is worsened in follow-up imaging. MRI is recommended to better detect unstable C1 fractures in diagnostic imaging.

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