Management of occipitocervical junction and upper cervical trauma

Abstract

Objective:The treatment modality of occipitocervical junction (OCJ) and upper cervical traumas carries great importance because of unique form of bone, complex ligamentous, and neurovascular structure.Materials and Methods:Eighty-eight patients were admitted to Mersin University Department of Neurosurgery between January 2007 and January 2017 for injuries of the OCJ and upper cervical spine and evaluated retrospectively. In the group, there were 60 male, 28 female patients in the mean age of 42.9 (18–87) years. Among those, 2 occipital condyle fractures, 28 C1 fractures (26 isolated and 2 with transverse ligament injury), 9 combined C1/C2 fractures, 6 rotatory C1/C2 dislocations, and 43 C2 fractures (32 odontoid, 5 Hangman's, and 6 miscellaneous fractures) were diagnosed. In addition to clinical cases, ten cadavers were used to study the OCJ in a step-wise manner.Results:Occipital condyle fractures, isolated C1 fractures, and rotatory C1/C2 dislocations were treated conservatively. Two patients with C1 fracture including transverse ligament injury were operated in one of the methods of C1–C2 fusion which is posterior sublaminar wiring. Five patients having Type II odontoid fracture were treated surgically. One instable Hangman's fracture patient was treated as anterior cervical discectomy and fusion.Conclusions:Cases with isolated C1 fracture with intact transverse ligament should be conservatively treated without surgical approach. Atlas fractures with transverse ligament rupture, odontoid Type II fractures with dislocation >6 mm, and unstable Hangman's fractures required surgical treatment. Vital neurovascular, ligamentous, and accompanying bone structures should be evaluated for diagnosis and treatment modality. In addition, patient's health status, patient's treatment preference, and surgical team experience are the affecting factors for the decision of surgery.

Tectorial Membrane Injury, Frequently Identified in Adult Trauma Patients Who Undergo Occipital-Cervical Fusion for Craniocervical Instability

“…Of note, only one-third of our patient cohort who underwent occipital cervical fusion for acute, post-traumatic CCJ instability demonstrated an atlantooccipital capsular ligament disruption with subsequent widening of the atlantooccipital joint greater than 2.5 mm. The atlantooccipital capsular ligament is a tough ligament that envelops and reinforces the integrity of the atlantooccipital joint - a mildly mobile, synovial joint that allows approximately 25 degrees of flexion/extension and five degrees of rotation [ 22 - 25 ]. It is a primary CCJ stabilizing structure.…”

Minimalistic reconstruction of exposed skull in a complex craniovertebral polytrauma

“…[8] Meticulous assessment of associated transverse ligament injury is crucial. [4] Surgical fixation is preferred if the transverse ligament is avulsed or grossly injured, making the fracture unstable; and if the atlas and axis are fractured simultaneously. [11] Otherwise, stable non-displaced traumatic occipital condylar fractures usually heal well without complications after strict neck immobilization in a Philadelphia collar.…”

“…[11] Otherwise, stable non-displaced traumatic occipital condylar fractures usually heal well without complications after strict neck immobilization in a Philadelphia collar. [4] Any laxity in neck immobilization during the next few months may cause significant lifelong disability or even death. [5,8] Reconstructing large (>20 cm 2 ) forehead defects usually require sizeable loco-regional flaps or free tissue transfers.…”

“…Complicated anatomy of the skull base and cervical spine significantly challenge proper diagnosis and treatment of craniovertebral injuries. [4] Even in stable occipitocervical injuries, adequate neuroprotection becomes difficult with associated polytrauma involving other anatomical areas. [8] General anesthesia in such cases requires extreme caution, as even small and momentary lapses may have catastrophic consequences.…”

Anatomical Parameters for Occipital Condyle Screws: An Analysis of 500 Condyles Using CT Scans

“…The primary indication for occipitocervical fixation is instability. In general, acute instability occurs secondary to trauma, 1 - 3 while chronic instability occurs typically secondary to neoplasms, 4 , 5 inflammatory processes (e.g., rheumatologic disease), 4 or congenital malformations. 5 - 7 Despite careful preoperative planning, complications are relatively common from surgery and can often lead to debilitating or fatal consequences.…”