Reviewer’s comment concerning “Unstable atlas fracture treatment by anterior plate C1-ring osteosynthesis using a transoral approach” (10.1007/s00586-013-2870-x by Weihu Ma, Nanjian Xu, Yong Hu, Guoqing Li, Liujun Zhao, Shaohua Sun, Weiyu Jiang, Guanyi Liu, Yongjie Gu, Jiayong Liu and Liang Yu)

This short report is of interest in that it demonstrates the divergence of views in spinal surgery and even the difficulty in deciding the classification of a single fracture such as this. Is it stable or unstable given the CT appears to show a unilateral lateral mass fracture only? What is the age of the patient? Do they have co-morbidities? What is their employment? These are just some of the questions that might be posed.

There would be a body of opinion that would always treat a fracture such as this conservatively with external orthosis. Others would take the view that it should be fixed if we assume that it is unstable, with transverse ligament injury. Surgical fixation has been previously described by others including Ruf et al. [1] in 2004.

This suggests the need for registry data to try to answer some of the questions posed by this type of injury.