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

Abstract

Background In the absence of frank craniocervical dissociation, there is a lack of consensus regarding what patterns of craniocervical junction ligamentous injuries require occipital-cervical fusion. This study was undertaken to examine the integrity of the craniocervical junction ligaments and analyze clinical outcomes in patients who underwent occipital-cervical fusion for craniocervical junction injury. Methods Adult patients requiring occipital-cervical fusion were identified retrospectively utilizing keyword searches in cervical computed tomography and magnetic resonance imaging reports between 2012 and 2020 using Nuance mPower software (Nuance, Burlington, MA). The cervical magnetic resonance imaging examinations for these patients were reviewed for craniocervical ligamentous injury by two neuroradiologists. Descriptions of craniocervical junction injuries, demographic information, clinical history, surgical management, and global outcomes were recorded. Results Nine adult patients were identified with an acute, post-traumatic craniocervical junction injury requiring occipital-cervical fusion. All nine patients demonstrated a ligamentous tear in at least one of the four major craniocervical junction ligaments - the occipital condylar-C1 capsular ligaments, alar ligaments, tectorial membrane, and posterior atlantooccipital membrane. The tectorial membrane was the most commonly torn ligament followed by the alar ligament(s), posterior atlantooccipital membrane, and capsular ligament(s). There was wide variability in the number of major craniocervical junction ligaments torn, ranging from one ligament to all four ligaments. Four patients suffered persistent neurologic deficits following surgery. Conclusion Craniocervical injury is best evaluated by cervical magnetic resonance imaging. In the absence of overt craniocervical dissociation, we propose that an injury of the tectorial membrane in the adult population may indicate patients with significant craniocervical instability, possibly necessitating occipital-cervical fusion.

Interrelationship Between Craniocervical Dissociation Spectrum Injuries and Atlantoaxial Instability on Trauma Cervical MRI Examinations

“…Injuries to one or more of these major ligaments imply a greater risk for craniocervical instability and higher likelihood for occipital cervical fusion (Figure 4A-4D). Fiester et al identified nine patients who underwent emergent occipital cervical fusion for acute CDSI and found that all nine patients demonstrated a tear in the tectorial membrane and five patients sustained an alar ligament tear [20]. The importance of the major CCJ ligaments is supported from cadaveric studies that have investigated the in vitro biomechanical function of these three ligaments [21].…”

“…However, the patient’s age and comorbidities play a major role in the overall morbidity and mortality of craniocervical and atlantoaxial trauma [ 11 ]. One recent study demonstrated wide variability in the types of osteoligamentous trauma and the number of torn CCJ ligaments in patients who underwent occipital cervical fusion for CDSI [ 20 ]. Furthermore, there has been wide variability in the surgical techniques and clinical management of patients with CDSI implying that further research and/or a more nuanced understanding of CDSI is warranted to improve patient care.…”

An anatomical and radiological study of the tectorial membrane and supradental venous plexus: its clinical significance in traumatic craniovertebral dislocation

“…In recent literature, intact TM appears to be an important favorable prognostic factor in atlantooccipital dislocation which is considered to be a frequently fatal injury 12 . Fiester et al have proposed that the alteration of the supradental space (fat-lled space superior to the atlantoaxial joint, inferior to the basion of the clivus, and anterior to the TM) followed by injury of the TM may indicate a patient with signi cant CVJ instability [13][14][15][16] .…”

The Feasibility of Anterior Occipital Condyle Screw for the Reconstruction of Craniovertebral Junction: A Digital Anatomical and Cadaveric Study of a Novel Technique

“…7,8 Whereas, adverse events of posterior occipitocervical fusion were also reported including vascular injury, cerebrospinal fluid leakage, tectorial membrane injury even fixation failure. 9,10 As for the anterior approach treatments of occipitocervical fusion, the total en bloc spondylectomy using a combined approach 11 and reconstruction using a clival plate with titanium mesh cage have been reported. 12 Although these two methods can guarantee immediate immobility and achieve satisfactory bone fusion, lots of complications were reported including new neurologic deficit, implant failure, cerebrospinal fluid leakage and cervical nerve root injury.…”

“… 7 , 8 Whereas, adverse events of posterior occipitocervical fusion were also reported including vascular injury, cerebrospinal fluid leakage, tectorial membrane injury even fixation failure. 9 , 10 …”