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1
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Kolz JM, Christensen TC, Diehn FE, Sebastian AS, Currier BL, Nassr AN. Nonsurgical Management of Combined Occipitocervical and Atlantoaxial Distraction Injuries: A Case Report. JBJS Case Connect 2021; 11:e20.00228. [PMID: 33502138 DOI: 10.2106/jbjs.cc.20.00228] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE A 41-year-old man sustained occipitocervical dislocation (OCD) and atlantoaxial dislocation (AAD) injuries in a motor vehicle collision. These injuries were treated nonoperatively with a hard cervical collar and activity restrictions with an excellent result at 4-year follow-up. CONCLUSION OCD and AAD injuries require prompt diagnosis and immobilization. Standard of care for coexisting injuries is occipitocervical fusion; however, some patients have coexisting injuries which may prevent operative treatment. These polytrauma patients require a creative nonoperative approach with close follow-up to avoid neurologic decline.
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Affiliation(s)
- Joshua M Kolz
- Department of Orthopaedic Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Felix E Diehn
- Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | - Arjun S Sebastian
- Department of Orthopaedic Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Ahmad N Nassr
- Department of Orthopaedic Surgery, Mayo Clinic, Rochester, Minnesota
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2
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Tobert DG, Ferrone ML, Czuczman GJ. Traumatic Atlanto-Occipital Dissociation and Atlantoaxial Instability: Concomitant Ligamentous Injuries without Neurologic Deficit: A Case Report. JBJS Case Connect 2019; 8:e62. [PMID: 30095471 DOI: 10.2106/jbjs.cc.18.00021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE A 35-year-old man was involved in a motor-vehicle collision and sustained multiple thoracoabdominal and extremity injuries. A high injury burden and a normal neurologic examination contributed to a delay in diagnosing a ligamentous, combined atlanto-occipital dissociation (AOD) and vertical atlantoaxial injury (AAI). Additional imaging revealed the combined injury, and the patient underwent an occipitocervical fusion. CONCLUSION To our knowledge, this is the first case of a simultaneous traumatic AOD and AAI without fracture in a neurologically intact patient. Knowledge of reliable and easily applied radiographic relationships is important to expeditiously diagnose potentially lethal yet easily overlooked occipitocervical injuries.
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Affiliation(s)
- Daniel G Tobert
- Harvard Combined Orthopaedic Residency Program, Massachusetts General Hospital, Boston, Massachusetts
| | - Marco L Ferrone
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
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Luan Q, Ban Y, Liu K, Sun B, Wang X, Lin X. The relationship between density variations of transverse ligament tubercles on multidetector computed tomography (MDCT) and age, gender, or laterality in a large cohort. Surg Radiol Anat 2019; 42:137-141. [PMID: 31486863 DOI: 10.1007/s00276-019-02324-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Accepted: 08/30/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Transverse ligament tubercles are unique structures that maintain the stability of the upper cervical spine. However, the density variations of tubercles in different clinical contexts or populations have not been carefully studied through multidetector computed tomography (MDCT). PURPOSE This study aimed to evaluate the relationship between density variations in the transverse ligament tubercles, as measured through multidetector computed tomography (MDCT), with age, gender, or laterality. METHODS A cohort of 339 Chinese patients that underwent MDCT in the head or neck were recruited. The patients were divided into eight age groups. The densities of the bilateral transverse ligament tubercles were classified through MDCT, and the potential relationship between the density of the tubercles and the age, gender, or laterality was analyzed. RESULTS Based on MDCT findings, four different density types of tubercles were identified (type 0-III). Our data suggest that the density of tubercles increased with age (χ2 = 637.7, p < 0.05). However, the density of tubercles did not correlate with laterality (male: t = 0.217, p > 0.05, female: t = 1.448, p > 0.05) or gender (χ2 = 5.706, p > 0.05). CONCLUSIONS The density of the transverse ligament tubercles, as measured through MDCT, shows a stereotyped dynamic pattern, i.e., it apparently increases with age, but neither gender nor laterality significantly contribute to these changes.
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Affiliation(s)
- Qinhua Luan
- Shandong Provincial Hospital Affiliated to Shandong University, No. 324, Jing-wu Road, Jinan, 250021, People's Republic of China.,Shandong Medical Imaging Research Institute Affiliated to Shandong University, No. 324, Jing-wu Road, Jinan, 250021, People's Republic of China
| | - Yongguang Ban
- Shandong Medical Imaging Research Institute Affiliated to Shandong University, No. 324, Jing-wu Road, Jinan, 250021, People's Republic of China.
| | - Kai Liu
- Shandong Medical Imaging Research Institute Affiliated to Shandong University, No. 324, Jing-wu Road, Jinan, 250021, People's Republic of China
| | - Bo Sun
- Shandong Medical Imaging Research Institute Affiliated to Shandong University, No. 324, Jing-wu Road, Jinan, 250021, People's Republic of China
| | - Ximing Wang
- Shandong Provincial Hospital Affiliated to Shandong University, No. 324, Jing-wu Road, Jinan, 250021, People's Republic of China
| | - Xiangtao Lin
- Shandong Provincial Hospital Affiliated to Shandong University, No. 324, Jing-wu Road, Jinan, 250021, People's Republic of China
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4
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Rief M, Zoidl P, Zajic P, Heschl S, Orlob S, Silbernagel G, Metnitz P, Puchwein P, Prause G. Atlanto-occipital dislocation in a patient presenting with out-of-hospital cardiac arrest: a case report and literature review. J Med Case Rep 2019; 13:44. [PMID: 30803441 PMCID: PMC6390378 DOI: 10.1186/s13256-018-1926-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 11/13/2018] [Indexed: 12/18/2022] Open
Abstract
Background Atlanto-occipital dislocation is a rare and severe injury of the upper spine associated with a very poor prognosis. Case presentation We report the case of a 59-year-old European man who suffered from out-of-hospital cardiac arrest following a motor vehicle accident. Cardiopulmonary resuscitation was initiated immediately by bystanders and continued by emergency medical services. After 30 minutes of cardiopulmonary resuscitation with a total of five shocks following initial ventricular fibrillation, return of spontaneous circulation was achieved. An electrocardiogram recorded after return of spontaneous circulation at the scene showed signs of myocardial ischemia as a possible cause for the cardiac arrest. No visible signs of injury were found. He was transferred to the regional academic trauma center. Following an extended diagnostic and therapeutic workup in the emergency room, including extended focused assessment with sonography for trauma ultrasound, whole-body computed tomography, and magnetic resonance imaging (of his head and neck), a diagnosis of major trauma (atlanto-occipital dislocation, bilateral serial rip fractures and pneumothoraces, several severe intracranial bleedings, and other injuries) was made. An unfavorable outcome was initially expected due to suspected tetraplegia and his inability to breathe following atlanto-occipital dislocation. Contrary to initial prognostication, after 22 days of intensive care treatment and four surgical interventions (halo fixation, tracheostomy, intracranial pressure probe, chest drains) he was awake and oriented, spontaneously breathing, and moving his arms and legs. Six weeks after the event he was able to walk without aid. After 2 months of clinical treatment he was able to manage all the activities of daily life on his own. It remains unclear, whether cardiac arrest due to a cardiac cause resulted in complete atony of the paravertebral muscles and caused this extremely severe lesion (atlanto-occipital dislocation) or whether cardiac arrest was caused by apnea due the paraplegia following the spinal injury of the trauma. Conclusions A plausible cause for the trauma was myocardial infarction which led to the car accident and the major trauma in relation to the obviously minor trauma mechanism. With this case report we aim to familiarize clinicians with the mechanism of injury that will assist in the diagnosis of atlanto-occipital dislocation. Furthermore, we seek to emphasize that patients presenting with electrocardiographic signs of myocardial ischemia after high-energy trauma should primarily be transported to a trauma facility in a percutaneous coronary intervention-capable center rather than the catheterization laboratory directly.
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Affiliation(s)
- Martin Rief
- Division of General Anaesthesiology, Emergency and Intensive Care Medicine, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria. .,Department of Anaesthesiology and Intensive Care Medicine, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria.
| | - Philipp Zoidl
- Division of General Anaesthesiology, Emergency and Intensive Care Medicine, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria.,Department of Anaesthesiology and Intensive Care Medicine, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria
| | - Paul Zajic
- Division of General Anaesthesiology, Emergency and Intensive Care Medicine, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria.,Department of Anaesthesiology and Intensive Care Medicine, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria
| | - Stefan Heschl
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria.,Division of Cardiac, Thoracic and Vascular Anaesthesiology and Intensive Care Medicine, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria
| | - Simon Orlob
- Division of General Anaesthesiology, Emergency and Intensive Care Medicine, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria.,Department of Anaesthesiology and Intensive Care Medicine, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria
| | - Günther Silbernagel
- Division of Angiology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria
| | - Philipp Metnitz
- Division of General Anaesthesiology, Emergency and Intensive Care Medicine, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria.,Department of Anaesthesiology and Intensive Care Medicine, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria
| | - Paul Puchwein
- Department of Orthopedics and Trauma Surgery, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria
| | - Gerhard Prause
- Division of General Anaesthesiology, Emergency and Intensive Care Medicine, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria.,Department of Anaesthesiology and Intensive Care Medicine, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria
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5
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Dyas AR, Niemeier TE, Mcgwin G, Theiss SM. Ability of magnetic resonance imaging to accurately determine alar ligament integrity in patients with atlanto-occipital injuries. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2018; 9:241-245. [PMID: 30783347 PMCID: PMC6364359 DOI: 10.4103/jcvjs.jcvjs_81_18] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Objective: The objective of this study is to evaluate the the reliability of magnetic resonance imaging (MRI) in diagnosing alar ligament disruption in patients with potential atlanto-occipital dissociation (AOD). Materials and Methods: Three-blinded readers performed retrospective review on 6 patients with intra-operative confirmed atlanto-occipital dissocation in addition to a comparison cohort of patients with other cervical injuries that did not involve the atlanto-occipital articulation. Ligament integrity was graded from 1 to 3 as described by Krakenes et al. The right and left ligaments were assessed separately. Inter-observer agreement by patient, by group (AOD vs. non-AOD), and intra-observer agreement was calculated using weighted Cohen's kappa. Results: Interobserver agreement of alar ligament grade for individual patients ranged from slight to fair (κ = 0.05–0.30). Interobserver agreement of alar ligament grade for each group (AOD vs. non-AOD) ranged from fair to substantial (κ = 0.37–0.66). No statistically significant difference in categorical analysis of groups (AOD vs. non-AOD) and grade (0–1 vs. 2–3) was observed. Intraobserver agreement of individual patient's alar ligament grade ranged from moderate to substantial (κ = 0.50–0.62). Conclusion: The use of MRI to detect upper cervical ligament injuries in AOD is imperfect. Our results show inconsistent and unsatisfactory interobserver and intraobserver reliability in evaluation of alar ligament injuries. While MRI has immense potential for detection of ligamentous injury at the craniovertebral junction, standardized algorithms for its use and interpretation need to be developed.
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Affiliation(s)
- Adam R Dyas
- Department of Orthopedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Thomas E Niemeier
- Department of Orthopedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Gerald Mcgwin
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Steven M Theiss
- Department of Orthopedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Chowdhury FH, Haque MR, Alam SM, Khaled Chowdhury SMN, Khan SI, Goel A. Condylar Joint Fusion and Stabilization (by Screws and Plates) in Nontraumatic Atlanto-Occipital Dislocation: Technical Report of 2 Cases. World Neurosurg 2017; 107:54-62. [PMID: 28765028 DOI: 10.1016/j.wneu.2017.07.127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 07/19/2017] [Accepted: 07/20/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Nontraumatic spontaneous atlanto-occipital dislocation (AOD) is rare. In this report, we discuss the technical steps of condylar joint fusion and stabilization (by screws and plates) in nontraumatic AOD. To the best of our knowledge, it is the first report of such techniques. MATERIAL AND METHODS A young girl and a young man with progressive quadriparesis due to nontraumatic spontaneous atlanto-occipital dislocation were managed by microsurgical reduction, fusion, and stabilization of the joint by occipital condylar and C1 lateral mass screw and plate fixation after mobilization of vertebral artery. RESULT In both cases, condylar joints fixation and fusion were done successfully. CONCLUSION Condylar joint stabilization and fusion may be a good or alternative option for AOD.
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Affiliation(s)
- Forhad H Chowdhury
- Department of Neurosurgery, National Institute of Neurosciences and Hospital, Shere-e-bangla nagar, Dhaka, Bangladesh.
| | | | - Sarwar Murshed Alam
- Department of Neurosurgery, National Institute of Neurosciences and Hospital, Shere-e-bangla nagar, Dhaka, Bangladesh
| | - S M Noman Khaled Chowdhury
- Department of Neurosurgery, National Institute of Neurosciences and Hospital, Shere-e-bangla nagar, Dhaka, Bangladesh
| | - Shamsul Islam Khan
- Department of Neurosurgery, National Institute of Neurosciences and Hospital, Shere-e-bangla nagar, Dhaka, Bangladesh
| | - Atul Goel
- Seth GS Medical College and KEM Hospital, Mumbai, India
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7
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Theodore N. In Reply: Occipitocervical fixation: A single surgeon's experience with 120 patients. Neurosurgery 2017; 80:E265. [PMID: 28402569 DOI: 10.1093/neuros/nyx037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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8
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Hallgren RC. Injury Threshold of Rectus Capitis Muscles at the Atlanto-occipital Joint. J Manipulative Physiol Ther 2017; 40:71-76. [DOI: 10.1016/j.jmpt.2016.11.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 04/30/2016] [Accepted: 06/15/2016] [Indexed: 12/25/2022]
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Child Z, Rau D, Lee MJ, Ching R, Bransford R, Chapman J, Bellabarba C. The provocative radiographic traction test for diagnosing craniocervical dissociation: a cadaveric biomechanical study and reappraisal of the pathogenesis of instability. Spine J 2016; 16:1116-23. [PMID: 27283520 DOI: 10.1016/j.spinee.2016.03.057] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2015] [Revised: 02/24/2016] [Accepted: 03/04/2016] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Craniocervical dissociation is a rare but serious condition, and missed injuries have been associated with poor neurologic outcomes and deterioration. A fluoroscopic traction test is employed to interrogate the craniocervical ligaments when clinical and imaging findings are equivocal. However, no specific protocol or known parameters with respect to traction or force applied have been established. PURPOSE This study sought to define the parameters of the radiographic traction test with sequential sectioning of the primary ligamentous restraints under controlled distraction of the craniocervical junction in a biomechanical model. STUDY DESIGN This is a cadaveric biomechanical study. METHODS A custom loading apparatus applied traction forces in six specimens (O-C3) and the following ligaments were sectioned: alar, tectorial membrane, and occiput-C1 capsules to simulate varying degrees of craniocervical dissociation. Traction was applied 0 to 20 lb with fluoroscopy. Digital image analysis quantified the relative displacements of C0-C1, average craniocervical excursion, and under what load could a 2-mm craniocervical displacement be reproducibly recorded. RESULTS A weight-distance table was produced and showed a marked loss of stability with sectioning of the ligaments and across all specimens in a similar pattern. Minimal translation was noted with sectioning of two of three ligaments in any order (<1-2 mm). All specimens exhibited a firm restraint to dissociation until the last of the three stabilizers was sectioned. Thus an "all-or-none" restraint to instability is present. All specimens failed at a weight of 5-10 lb (>2 mm). CONCLUSIONS The current knowledge base of craniocervical injuries is very limited. This study shows that the key restraints to craniocervical instability are the alar ligaments, tectorial membrane, and the atlantooccipital joint capsules. Dissociation requires the complete incompetence of all three. The craniocervical traction test reliably demonstrates instability and requires no more than 5-10 lb of traction to perform.
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Affiliation(s)
- Zachary Child
- University of Texas Health Science Center San Antonio, Department of Orthopaedics, 7703 Floyd Curl Dr, Mail code 7774, San Antonio, TX 78229-3900.
| | - Daniel Rau
- University of Washington/Harborview Medical Center, Department of Orthopedics and Sports Medicine, Seattle, Washington, USA
| | - Michael J Lee
- University of Washington/Harborview Medical Center, Department of Orthopedics and Sports Medicine, Seattle, Washington, USA
| | - Randall Ching
- University of Washington/Harborview Medical Center, Department of Orthopedics and Sports Medicine, Seattle, Washington, USA
| | - Richard Bransford
- University of Washington/Harborview Medical Center, Department of Orthopedics and Sports Medicine, Seattle, Washington, USA
| | - Jens Chapman
- University of Washington/Harborview Medical Center, Department of Orthopedics and Sports Medicine, Seattle, Washington, USA
| | - Carlo Bellabarba
- University of Washington/Harborview Medical Center, Department of Orthopedics and Sports Medicine, Seattle, Washington, USA
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10
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Ban Y, Luan Q, Liu K, Wang X, Sun B, Zhao B, Chhabra A. Variation of bilateral transverse ligament tubercles with age and gender in a large series of subjects on multidetector computed tomography. Acta Radiol 2016; 57:721-5. [PMID: 26377261 DOI: 10.1177/0284185115604513] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Accepted: 08/12/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND The transverse ligament tubercles play an important role in maintaining the stability of upper cervical spine, but the variation of these tubercles with aging has not been studied systematically. PURPOSE To evaluate the variation of the height of the transverse ligament tubercles with respect to age and gender, and assess side-to-side differences on multidetector computed tomography (MDCT). MATERIAL AND METHODS A consecutive series of 291 Chinese patients undergoing a head or neck MDCT were divided into eight age groups. The bony anatomy of the atlas was displayed symmetrically by aligning the axial plane and the mean height of bilateral transverse ligament tubercles was measured. The height was correlated with age and gender and side-to-side differences were analyzed. Finally, the inter-observer performance was assessed. RESULTS No transverse ligament tubercles were seen in 51 cases (17.5%, 51/291) and unilateral transverse ligament tubercles were seen in two cases (0.7%, 2/291). Bilateral transverse ligament tubercles were observed in 238 cases (81.8%, 238/291). The average height of the left and right tubercles were 2.68 ± 1.58 mm and 2.68 ± 1.54 mm, respectively, with no significant side-to-side differences (t = 0.061, P > 0.05). The height was also similar in both genders (left: t = 0.497, P > 0.05, right: t = 0.730, P > 0.05). The height increased linearly with age (left: r = 0.513, P < 0.05, right: r = 0.516, P < 0.05). The inter-observer reliability was excellent. CONCLUSION The height of the transverse ligament tubercles on MDCT linearly increases with increasing age with no significant differences among the genders or the side measured.
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Affiliation(s)
- Yongguang Ban
- Shandong Medical Imaging Research Institute, Shandong University, Jinan, PR China
| | - Qinhua Luan
- Shandong Medical Imaging Research Institute, Shandong University, Jinan, PR China
| | - Kai Liu
- Shandong Medical Imaging Research Institute, Shandong University, Jinan, PR China
| | - Ximing Wang
- Shandong Medical Imaging Research Institute, Shandong University, Jinan, PR China
| | - Bo Sun
- Shandong Medical Imaging Research Institute, Shandong University, Jinan, PR China
| | - Bin Zhao
- Shandong Medical Imaging Research Institute, Shandong University, Jinan, PR China
| | - Avneesh Chhabra
- Musculoskeletal Radiology UT Southwestern Medical Center, Dallas, TX, USA
- Johns Hopkins University, Baltimore, MD, USA
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Mendenhall SK, Sivaganesan A, Mistry A, Sivasubramaniam P, McGirt MJ, Devin CJ. Traumatic atlantooccipital dislocation: comprehensive assessment of mortality, neurologic improvement, and patient-reported outcomes at a Level 1 trauma center over 15 years. Spine J 2015; 15:2385-95. [PMID: 26165481 DOI: 10.1016/j.spinee.2015.07.003] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Revised: 05/28/2015] [Accepted: 07/01/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Only Level 3 evidence exists for the diagnosis and treatment of atlantooccipital dislocation (AOD) with few studies examining mortality, neurologic improvement, and patient-reported outcomes (PROs). PURPOSE First, the aim was to determine: the incidence of AOD, 90-day surgical morbidity and mortality after AOD, patient factors that may be associated with delayed or missed diagnosis, and factors that were associated with mortality and neurologic improvement after AOD. Secondly, the aim was to quantify the pain, disability, and quality of life experienced by patients surviving AOD. STUDY DESIGN/SETTING This was a retrospective cohort study. PATIENT SAMPLE A total of 5,337 consecutive spine computed tomography traumagrams from 1997 to 2012 were included. OUTCOME MEASURES Mortality, neurologic improvement, complications, EuroQol five dimensions (EQ-5D), Neck Disability Index (NDI), Numeric Rating Scale (NRS)-neck, NRS-arm, and return-to-work were the outcome measures. METHODS Patients were considered to have AOD if they met one of the following radiographic criteria: basion-dens interval greater than 10 mm; basion-axial interval: anterior displacement greater than 12 mm or posterior displacement greater than 4 mm between the basion and posterior C2 line; and condyle to C1 interval greater than 1.4 mm. Linear regression analysis was performed to identify factors associated with 90-day mortality, neurologic improvement, and missed diagnosis. Patient-reported outcomes were assessed via phone interview. RESULTS Thirty-one patients met radiographic criteria for AOD; an incidence of 0.6% over 15 years. Twenty-one (68%) patients were treated with occipital cervical fusion. At 90 days postoperatively, there were no new neurologic deficits or reoperations. Eight (26%) patients died within 90 days. All patients who died had no documented AOD diagnosis and were not treated surgically. Missed AOD diagnosis was the strongest predictor of mortality. Younger age, lower Glasgow Coma Score, lower Injury Severity Score (ISS) score, and worse initial American Spinal Injury Association (ASIA) score were significantly associated with greater neurologic improvement. Higher ISS score and better ASIA score were significantly associated with missed AOD diagnosis. The average PROs metrics at time of telephone follow-up were as follows: EQ-5D=0.73±0.19, NDI=30.89±18.57, NRS-neck=2.33±2.21, NRS-arm=2.00±2.54. Of the patients with follow-up data, four were employed full-time, and five were receiving disability. CONCLUSIONS Our work suggests that failure to diagnose AOD is a powerful predictor of mortality. Higher ISS scores and better neurologic presentation were significantly associated with missed diagnosis. Craniocervical arthrodesis preserved neurologic function with low complication rate and unexpectedly high PROs and return-to-work. These results must be carefully interpreted because it is unclear whether missed AOD diagnosis accompanies another death-causing injury (eg, traumatic brain injury) or if failure to treat AOD contributes to mortality in a multifactorial manner.
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Affiliation(s)
- Stephen K Mendenhall
- Department of Neurological Surgery, Vanderbilt University Medical Center, T-4224 Medical Center N., 1611 21st Ave. S., Nashville, TN 37232, USA
| | - Ahilan Sivaganesan
- Department of Neurological Surgery, Vanderbilt University Medical Center, T-4224 Medical Center N., 1611 21st Ave. S., Nashville, TN 37232, USA
| | - Akshitkumar Mistry
- Department of Neurological Surgery, Vanderbilt University Medical Center, T-4224 Medical Center N., 1611 21st Ave. S., Nashville, TN 37232, USA
| | - Priya Sivasubramaniam
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, 1215 21st Ave. S. #4200, Nashville, TN 37232, USA
| | - Matthew J McGirt
- Department of Neurological Surgery, Vanderbilt University Medical Center, T-4224 Medical Center N., 1611 21st Ave. S., Nashville, TN 37232, USA; Carolina Neurosurgery and Spine Associates, 225 Baldwin Ave., Charlotte, NC 28204, USA
| | - Clinton J Devin
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, 1215 21st Ave. S. #4200, Nashville, TN 37232, USA.
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Liu K, Xie F, Wang D, Guo L, Qi Y, Tian J, Zhao B, Chhabra A. Reference ranges for atlantodental interval in adults and its variation with age and gender in a large series of subjects on multidetector computed tomography. Acta Radiol 2015; 56:465-70. [PMID: 24782570 DOI: 10.1177/0284185114530284] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The atlanto-dental interval measurement in the cervical spine in young adults has been reported on multidetector computed tomography (MDCT), but has not been systematically assessed in all ages. PURPOSE To evaluate the reference ranges for the atlanto-dental interval (ADI) in a large sample of adult patients on MDCT and to analyze the relationships of these measurements with gender and age of the patients as well as inter-observer performance. MATERIAL AND METHODS First, a consecutive series of 700 Chinese patients aged over 18 years undergoing an upper cervical MDCT scan were divided equally into seven age groups. Second, the mid-sagittal image of the atlanto-dental joint was chosen for measurement and ADI was defined as the distance intercepted from the segment line linking the center of anterior atlas tubercle with that of posterior tubercle. Third, the correlation of ADI with age and gender was analyzed using linear regression analysis. Finally, the inter-observer performance was assessed using Bland and Altman's limits of agreement. RESULTS The ADI was 1.77 ± 0.39 mm, 1.61 ± 0.37 mm, 1.58 ± 0.36 mm, 1.41 ± 0.29 mm, 1.31 ± 0.29 mm, 1.34 ± 0.28 mm, and 1.06 ± 0.47 mm in the age groups 18-24 years, 25-29 years, 30-39 years, 40-49 years, 50-59 years, 60-69 years, and older than 70 years, respectively. The range of ADI was 0.85-3.12 mm in the age group 18-39 years, 0.71-2.55 mm in the age group 40-59 years, and 0.00-2.37 mm in the age group older than 60 years. There was no difference between gender and ADI (r = 0.00, P = 1.000). ADI decreased linearly with age (r = -0.511, P = 0.000). The inter-observer performance was reliable. CONCLUSION ADI measurements on MDCT linearly decrease with increasing age, and these are not affected by gender in adult patients. Different reference values might be used at different ages when diagnosing atlantoaxial anterior dislocation or subluxation.
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Affiliation(s)
- Kai Liu
- Shandong Medical Imaging Research Institute, Shandong University, Jinan, PR China
| | - Fubo Xie
- Department of Radiology, Qilu Hospital, Shandong University, Jinan, PR China
| | - Daocai Wang
- Shandong Medical Imaging Research Institute, Shandong University, Jinan, PR China
| | - Lingfei Guo
- Shandong Medical Imaging Research Institute, Shandong University, Jinan, PR China
| | - Yuangang Qi
- Department of Radiotherapy, Shandong Tumor Hospital, Jinan, PR China
| | - Jun Tian
- Shandong Medical Imaging Research Institute, Shandong University, Jinan, PR China
| | - Bin Zhao
- Shandong Medical Imaging Research Institute, Shandong University, Jinan, PR China
| | - Avneesh Chhabra
- Department of Musculoskeletal Radiology & Orthopedic Surgery, UT Southwestern Medical Center, Johns Hopkins University, Dallas, TX, USA
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Hall GC, Kinsman MJ, Nazar RG, Hruska RT, Mansfield KJ, Boakye M, Rahme R. Atlanto-occipital dislocation. World J Orthop 2015; 6:236-243. [PMID: 25793163 PMCID: PMC4363805 DOI: 10.5312/wjo.v6.i2.236] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Revised: 05/02/2014] [Accepted: 10/27/2014] [Indexed: 02/06/2023] Open
Abstract
Atlanto-occipital dislocation (AOD) is being increasingly recognized as a potentially survivable injury as a result of improved prehospital management of polytrauma patients and increased awareness of this entity, leading to earlier diagnosis and more aggressive treatment. However, despite overall improved outcomes, AOD is still associated with significant morbidity and mortality. The purpose of this paper is to review the biomechanical aspects, clinical features, radiologic criteria, and treatment strategies of AOD. Given that the diagnosis of AOD can be very challenging, a high degree of clinical suspicion is essential to ensure timely recognition and treatment, thus preventing neurological decline or death.
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14
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Li-jun L, Ying-chao H, Ming-jie Y, Jie P, Jun T, Dong-sheng Z. Biomechanical analysis of the longitudinal ligament of upper cervical spine in maintaining atlantoaxial stability. Spinal Cord 2014; 52:342-7. [DOI: 10.1038/sc.2014.8] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2013] [Revised: 01/07/2014] [Accepted: 01/13/2014] [Indexed: 11/09/2022]
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Dengler BA, Bartanusz V. Bilateral abducens nerve palsy following ligamentous C1-C2 distraction. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2013; 23 Suppl 2:248-52. [PMID: 24311020 DOI: 10.1007/s00586-013-3121-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Revised: 11/24/2013] [Accepted: 11/24/2013] [Indexed: 11/26/2022]
Abstract
PURPOSE Posttraumatic abducens nerve palsy is well documented following head injury, but only few case reports exist on sixth nerve palsy after cervical spine trauma. Bilateral abducens palsy following vertical C1-C2 ligamentous distraction has not been described yet. METHODS We report two patients who sustained motor vehicle accident-related C1-C2 distraction injury and were diagnosed with posttraumatic bilateral abducens nerve palsy. RESULTS Patients underwent surgical stabilization of the upper cervical spine and demonstrated a remarkable recovery of the sixth nerve deficit up to 1 year after injury. CONCLUSION We hypothesize that ligamentous C1-C2 distraction leads to caudal displacement of the brainstem in relation to the cranial base causing traction injury to the abducens nerve at its entry into Dorello's canal in the cavernous sinus.
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Affiliation(s)
- Bradley A Dengler
- Department of Neurosurgery, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, 78229-3900, USA
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Gutiérrez-Crespo B, Kircher PR, Carrera I. 3 TESLA MAGNETIC RESONANCE IMAGING OF THE OCCIPITOATLANTOAXIAL REGION IN THE NORMAL HORSE. Vet Radiol Ultrasound 2013; 55:278-85. [DOI: 10.1111/vru.12121] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Accepted: 08/09/2013] [Indexed: 11/26/2022] Open
Affiliation(s)
- Beatriz Gutiérrez-Crespo
- Section of Diagnostic Imaging; Vetsuisse Faculty; University of Zürich; Winterthurerstrasse 260 8057 Zurich Switzerland
| | - Patrick R. Kircher
- Section of Diagnostic Imaging; Vetsuisse Faculty; University of Zürich; Winterthurerstrasse 260 8057 Zurich Switzerland
| | - Ines Carrera
- Section of Diagnostic Imaging; Vetsuisse Faculty; University of Zürich; Winterthurerstrasse 260 8057 Zurich Switzerland
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Debernardi A, D'Aliberti G, Talamonti G, Villa F, Piparo M, Ligarotti G, Cenzato M. Traumatic injuries to the craniovertebral junction: a review of rare events. Neurosurg Rev 2013; 37:203-16; discussion 216. [PMID: 23928657 DOI: 10.1007/s10143-013-0492-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2012] [Revised: 01/25/2013] [Accepted: 03/10/2013] [Indexed: 01/08/2023]
Abstract
The craniovertebral junction is a specific region of the spine with unique anatomical and biomechanical properties that yields a wide variety of injury patterns. Junctional traumatic fractures and/or dislocations are widely reported in clinical practice, but we could identify only a subgroup of upper cervical spine traumatic injuries with very few cases reported in the literature, and for this reason may be considered rare. In some of these cases, the absence of spinal biomechanical instability, in association with moderate clinical symptoms (neck stiffness and pain) and the difficulty in fracture identification through standard cervical radiographs, leads to a high percentage of missed injuries. In other cases, traumatic events have been commonly described only in autopsy series due to the high degree of spinal biomechanical instability. Herein, we have summarized all the relevant literature concerning this issue and also included our cases, with the aim of emphasizing prompt diagnosis and correct management. We provide a guide for correctly identifying "rare" craniovertebral junction traumatic injuries.
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Affiliation(s)
- Alberto Debernardi
- Department of Neurosurgery, Niguarda Cà Granda Hospital, P.zza Ospedale Maggiore, 3, 20162, Milan, Italy,
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Pissonnier ML, Lazennec JY, Renoux J, Rousseau MA. Trauma of the upper cervical spine: focus on vertical atlantoaxial dislocation. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2013; 22:2167-75. [PMID: 23838700 DOI: 10.1007/s00586-013-2841-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Revised: 05/07/2013] [Accepted: 05/16/2013] [Indexed: 12/13/2022]
Abstract
PURPOSE Traumatic ligament injuries of the craniovertebral junction, either isolated or associated with bone avulsion or fracture, often lead to death. These injuries are rare and underrated but are increasingly seen in emergency departments due to the improvement in initial on-scene management of accidents. Vertical atlantoaxial dislocation (AAD) is a specific lesion that was barely reported. Based on our experience, our goal was to systematically investigate the prevalence and prognosis of traumatic vertical AAD and discuss its management. METHODS All cervical CT scans performed at our institution between 2006 and 2010 for cervical trauma in adults were retrospectively reviewed. Based on the measurement of lateral mass index (LMI), defined as the gap between C1 and C2 articular facets, we identified three cases of traumatic vertical AAD in 300 CT scans. Their medical records were investigated. RESULTS The incidence of vertical AAD was 1% in the exposed population. One case was an isolated vertical AAD and two were associated with a type II odontoid fracture. We report the first case in the literature of unilateral vertical AAD. Two patients died rapidly; the survivor was treated with occipitocervical fixation. Specific maneuvers were used for immobilization and reduction. CONCLUSIONS This study found a not insignificant incidence of vertical AAD and a high lethality rate. LMI appears to be a relevant radiological criterion for this diagnosis, for which traction is contraindicated. Associated neurological or vascular damage should be suspected and investigated. In our experience, spinal surgical fixation is required because of major instability.
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Affiliation(s)
- M L Pissonnier
- Department of Orthopaedic and Trauma Surgery, Hôpital Pitié Salpétrière (Assistance Publique - Hopitaux de Paris), Université Paris 6, Paris, France
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Perez-Orribo L, Little AS, Lefevre RD, Reyes PR, Newcomb AG, Prevedello DM, Roldan H, Nakaji P, Dickman CA, Crawford NR. Biomechanical Evaluation of the Craniovertebral Junction After Anterior Unilateral Condylectomy: Implications for Endoscopic Endonasal Approaches to the Cranial Base. Neurosurgery 2013; 72:1021-29; discussion 1029-30. [DOI: 10.1227/neu.0b013e31828d6231] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Endoscopic endonasal approaches to the craniovertebral junction and clivus, which are increasingly performed for ventral skull base pathology, may require disruption of the occipitocondylar joint.
OBJECTIVE:
To study the biomechanical implications at the craniovertebral junction of progressive unilateral condylectomy as would be performed through an endonasal exposure.
METHODS:
Seven upper cervical human cadaveric specimens (C0-C2) underwent nondestructive biomechanical flexibility testing during flexion-extension, axial rotation, and lateral bending at C0-C1 and C1-C2. Each specimen was tested intact, after an inferior one-third clivectomy, and after stepwise unilateral condylectomy with an anterior approach. Angular range of motion (ROM), lax zone, and stiff zone were determined and compared with the intact state.
RESULTS:
At C0-C1, mobility during flexion-extension and axial rotation increased significantly with progressive condylectomy. ROM increased from 14.3 ± 2.7° to 20.4 ± 5.2° during flexion and from 6.7 ± 3.5° to 10.8 ± 3.0° during right axial rotation after 75% condyle resection (P < .01). At C1-C2, condylectomy had less effect, with ROM increasing from 10.7 ± 2.0° to 11.7 ± 2.0° during flexion, 36.9 ± 4.8° to 37.1 ± 5.1° during right axial rotation, and 4.3 ± 1.9° to 4.8 ± 3.3° during right lateral bending (P = NS). Because of marked instability, the 100% condylectomy condition was untestable. Changes in ROM were a result of changes more in the lax zone than in the stiff zone.
CONCLUSION:
Lower-third clivectomy and unilateral anterior condylectomy as would be performed in an endonasal approach cause progressive hypermobility at the craniovertebral junction. On the basis of biomechanical criteria, craniocervical fusion is indicated for patients who undergo > 75% anterior condylectomy.
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Affiliation(s)
- Luis Perez-Orribo
- Spinal Biomechanics Research Laboratory
- Department of Neurosurgery, Hospital Universitario de Canarias, Canary Islands, Spain
| | - Andrew S. Little
- Barrow Pituitary and Cranial Base Center, Division of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | | | | | | | | | - Hector Roldan
- Department of Neurosurgery, Hospital Universitario de Canarias, Canary Islands, Spain
| | - Peter Nakaji
- Barrow Pituitary and Cranial Base Center, Division of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Curtis A. Dickman
- Barrow Pituitary and Cranial Base Center, Division of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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Effect of magnetic resonance imaging field strength on delineation and signal intensity of alar ligaments in healthy volunteers. Spine (Phila Pa 1976) 2012; 37:E1062-7. [PMID: 22498994 DOI: 10.1097/brs.0b013e31825831ca] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A prospective study of healthy volunteers. OBJECTIVE To evaluate the influence of magnetic resonance imaging (MRI) field strength on the delineation and signal intensity of alar ligaments (AL) in healthy volunteers. SUMMARY OF BACKGROUND DATA The fact that AL physiologically show morphologic variabilities is well established. However, presence and etiology of high-signal intensities within the AL as well as the influence of the MRI field strength on the signal characteristics of AL are still not completely understood. METHODS.: Coronal and sagittal 2-mm proton-density weighted sequences were acquired in 50 healthy volunteers using different MRI field strengths (1 T, 1.5 T, 3 T). Delineation and signal characteristics of AL were evaluated by 2 neuroradiologists independently. Differences concerning delineation and signal intensity between the MRI scanners, inter rater reliability between the 2 readers, and intrarater reliability at different time points were calculated. RESULTS Delineation of AL was significantly better both on 3 T and 1.5 T than on 1 T (P = 0.05) in sagittal as well as in coronal view. In coronal view delineation was significantly better on 3 T than on 1.5 T, whereas in sagittal view no significant difference was evident when comparing 1.5 T and 3 T. Concerning signal intensity of AL in sagittal view, there was no significant difference between the 3 different field strengths. Inter-rater and intrarater agreements were fair to moderate with respect to delineation as well as signal intensity of AL. CONCLUSION 1.5 T and 3 T significantly improve the delineation of AL when compared with lower field strength (1 T), but signal intensity of the AL in healthy volunteers is not influenced by the field strength. Increased signal is present in asymptomatic subjects on both low- and high-field magnetic resonance systems. Accordingly, the pathologic relevance of increased signal intensity of the AL, regardless of field strength, may not be indicative of traumatic AL injury.
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Survival of Atlanto-Occipital Dissociation Correlates With Atlanto-Occipital Distraction, Injury Severity Score, and Neurologic Status. ACTA ACUST UNITED AC 2011; 71:393-5. [PMID: 21206289 DOI: 10.1097/ta.0b013e3181eb6a31] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Direct posterior c1 lateral mass screws compression reduction and osteosynthesis in the treatment of unstable jefferson fractures. Spine (Phila Pa 1976) 2011; 36:E1046-51. [PMID: 21289552 DOI: 10.1097/brs.0b013e3181fef78c] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Technical case report. OBJECTIVE To investigate a new concept and surgical technique in the treatment of unstable Jefferson fractures, which preserves the motion of upper cervical spine, avoiding fusion. SUMMARY OF BACKGROUND DATA The management of unstable Jefferson fractures remains controversial. Conservative treatment usually involves a long time of immobilization in halo vest, whereas surgical intervention generally performs fusion, eliminating the range of motion of upper cervical spine. METHODS Two patients with unstable Jefferson fractures were surgically treated via direct posterior C1 lateral mass screws compression reduction and osteosynthesis technique, aiming at restoring the C0-C2 height and maintaining the vertical ligamentous tension for C0-C1-C2 complex stability despite the incompetent transverse ligament, achieving physiologic repair instead of traditional fusion. The clinical and radiographic results were documented. RESULTS The postoperative CT showed that C1 lateral mass screws were well positioned. At 1-year follow-up, plain radiographs, and CT scan revealed no implant failure, good cervical alignment, and bony healing of the fractures; no C1-C2 instability was observed on the flexion-extension radiographs. The patients were completely pain-free, with full range of motion of the cervical spine. CONCLUSION The ideal treatment of unstable Jefferson fractures is expected to preserve the function of C0-C1-C2. Unstable Jefferson fractures involve the concomitant failure of the vertical ligamentous tension because of the loss of C0-C2 height. Reduction of the displaced lateral masses to restore the C0-C2 height and maintain the ligamentous tension is the key to the surgery. Direct posterior C1 lateral mass screws compression reduction and osteosynthesis is a valid technique, avoiding fusion of upper cervical spine.
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Koller H, Resch H, Tauber M, Zenner J, Augat P, Penzkofer R, Acosta F, Kolb K, Kathrein A, Hitzl W. A biomechanical rationale for C1-ring osteosynthesis as treatment for displaced Jefferson burst fractures with incompetency of the transverse atlantal ligament. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2010; 19:1288-98. [PMID: 20386935 PMCID: PMC2989204 DOI: 10.1007/s00586-010-1380-3] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2010] [Revised: 01/23/2010] [Accepted: 03/13/2010] [Indexed: 01/07/2023]
Abstract
Nonsurgical treatment of Jefferson burst fractures (JBF) confers increased rates of C1-2 malunion with potential for cranial settling and neurologic sequels. Hence, fusion C1-2 was recognized as the superior treatment for displaced JBF, but sacrifies C1-2 motion. Ruf et al. introduced the C1-ring osteosynthesis (C1-RO). First results were favorable, but C1-RO was not without criticism due to the lack of clinical and biomechanical data serving evidence that C1-RO is safe in displaced JBF with proven rupture of the transverse atlantal ligament (TAL). Therefore, our objectives were to perform a biomechanical analysis of C1-RO for the treatment of displaced Jefferson burst fractures (JBF) with incompetency of the TAL. Five specimens C0-2 were subjected to loading with posteroanterior force transmission in an electromechanical testing machine (ETM). With the TAL left intact, loads were applied posteriorly via the C1-RO ramping from 10 to 100 N. Atlantoaxial subluxation was measured radiographically in terms of the anterior antlantodental interval (AADI) with an image intensifier placed surrounding the ETM. Load-displacement data were also recorded by the ETM. After testing the TAL-intact state, the atlas was osteotomized yielding for a JBF, the TAL and left lateral joint capsule were cut and the C1-RO was accomplished. The C1-RO was subjected to cyclic loading, ramping from 20 to 100 N to simulate post-surgery in vivo loading. Afterwards incremental loading (10-100 N) was repeated with subsequent increase in loads until failure occurred. Small differences (1-1.5 mm) existed between the radiographic AADI under incremental loading (10-100 N) with the TAL-intact as compared to the TAL-disrupted state. Significant differences existed for the beginning of loading (10 N, P = 0.02). Under physiological loads, the increase in the AADI within the incremental steps (10-100 N) was not significantly different between TAL-disrupted and TAL-intact state. Analysis of failure load (FL) testing showed no significant differences among the radiologically assessed displacement data (AADI) and that of the ETM (P = 0.5). FL was Ø297.5 +/- 108.5 N (range 158.8-449.0 N). The related displacement assessed by the ETM was Ø5.8 +/- 2.8 mm (range 2.3-7.9). All specimens succeeded a FL >150 N, four of them >250 N and three of them >300 N. In the TAL-disrupted state loads up to 100 N were transferred to C1, but the radiographic AADI did not exceed 5 mm in any specimen. In conclusion, reconstruction after displaced JBF with TAL and one capsule disrupted using a C1-RO involves imparting an axial tensile force to lift C0 into proper alignment to the C1-2 complex. Simultaneous compressive forces on the C1-lateral masses and occipital condyles allow for the recreation of the functional C0-2 ligamentous tension band and height. We demonstrated that under physiological loads, the C1-RO restores sufficient stability at C1-2 preventing significant translation. C1-RO might be a valid alternative for the treatment of displaced JBF in comparison to fusion of C1-2.
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Affiliation(s)
- Heiko Koller
- Department for Traumatology and Sport Injuries, Paracelsus Medical University Salzburg, Müllner Hauptstrasse 48, 5020 Salzburg, Austria.
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Clival epidural hematoma in traumatic sixth cranial nerve palsies combined with cervical injuries. J Neuroophthalmol 2010; 30:18-25. [PMID: 20182201 DOI: 10.1097/wno.0b013e3181ce14ae] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Eight patients sustained a combination of clival epidural hematoma, traumatic sixth cranial nerve palsy (6 NP), and occipitocervical injury. This combination of features has been sparsely described. Whether the hematoma, which represents tectorial membrane injury, is merely a marker for 6 NP and occipitocervical injury or is causative is unresolved, but this imaging finding should alert examiners who note traumatic 6 NP to the need for detailed cervical imaging, as surgical stabilization of this region may be critical to prevent future spinal cord dysfunction.
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Radcliff KE, Ben-Galim P, Dreiangel N, Martin SB, Reitman CA, Lin JN, Hipp JA. Comprehensive computed tomography assessment of the upper cervical anatomy: what is normal? Spine J 2010; 10:219-29. [PMID: 20207332 DOI: 10.1016/j.spinee.2009.12.021] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2009] [Revised: 11/27/2009] [Accepted: 12/25/2009] [Indexed: 02/08/2023]
Abstract
BACKGROUND CONTEXT High-speed computed tomography (CT) exams have replaced traditional radiographs for assessment of cervical spine injuries in many emergency departments. Recent evidence demonstrates that even subtle displacements can indicate significant upper cervical spine injuries. Many different anatomical measurements have been described in the upper cervical spine to date, most of them based on X-ray. The range of anatomical relationships that exist in an uninjured population must be known to reliably detect abnormal relations. The measurements with the lowest normal variation are likely to be most useful in detecting injuries. PURPOSE The purpose of this study was to describe the normal quantitative anatomical relationships as well as the threshold measurements most likely to detect injury in the upper cervical spine. STUDY DESIGN/SETTING Retrospective anatomical case review. PATIENT SAMPLE Seventy-six thin-sliced cervical CT scans randomly selected from a trauma population, all negative for injury in the cervical spine. METHODS Forty-two different anatomical measurements were made of the upper cervical spine. These included traditional historical measurements and other detailed dimensions to characterize occipitocervical (OC) and atlantoaxial (AA) joint relationships. RESULTS After review of all the anatomical measurements performed in the upper cervical spine, direct measurements of the joint space had the least variation. The mean OC joint space was 0.6mm, with an upper 95% confidence interval (CI) of 1mm at the most anterior or posterior aspects of the joints. This was true for both sagittal and coronal measurements. The mean AA joint space was 0.6mm, with an upper 95% CI of 1.2mm at the lateral aspect of the joint on the coronal image only. The midsagittal structures demonstrated significantly higher standard deviation and variability. CONCLUSIONS These results revealed consistently narrow joint spaces and left-right symmetry in the upper cervical spine joints that do not vary according to demographics. There was distinctly greater consistency in the coronal plane, which enabled more precise diagnostic measurement and side-to-side comparison of measurements. This precision will enable more accurate identification of abnormal scans, which should prompt consideration for additional workup. Thus, better understanding of these relationships may enable earlier detection of subtle craniocervical dissociative injuries based on CT scan data. This is important, because the only evidence of a severe injury on CT can be subtle misalignment.
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Affiliation(s)
- Kristen E Radcliff
- Department of Orthopedic Surgery, Baylor College of Medicine, 6620 Main St., 11th Floor, Houston, TX 77030, USA
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Cervical external immobilization devices: evaluation of magnetic resonance imaging issues at 3.0 Tesla. Spine (Phila Pa 1976) 2010; 35:411-5. [PMID: 20110847 DOI: 10.1097/brs.0b013e3181b0e9f8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Laboratory investigation, ex vivo. OBJECTIVE Currently, no studies have addressed the magnetic resonance imaging (MRI) issues for cervical external immobilization devices at 3-Tesla. Under certain conditions significant heating may occur, resulting in patient burns. Furthermore, artifacts can be substantial and prevent the diagnostic use of MRI. Therefore, the objective of this investigation was to evaluate MRI issues for 4 different cervical external immobilization devices at 3-Tesla. SUMMARY OF BACKGROUND DATA Excessive heating and substantial artifacts are 2 potential complications associated with performing MRI at 3-Tesla in patients with cervical external immobilization devices. Using ex vivo testing techniques, MRI-related heating and artifacts were evaluated for 4 different cervical devices during MRI at 3-Tesla. METHODS Four cervical external immobilization devices (Generation 80, Resolve Ring and Superstructure, Resolve Ring and Jerome Vest/Jerome Superstructure, and the V1 Halo System; Ossur Americas, Aliso Viejo, CA) underwent MRI testing at 3-Tesla. All devices were made from nonmetallic or nonmagnetic materials. Heating was determined using a gelled-saline-filled skull phantom with fluoroptic thermometry probes attached to the skull pins. MRI was performed at 3-Tesla, using a high level of RF energy. Artifacts were assessed at 3-Tesla, using standard cervical imaging techniques. RESULTS The Generation 80 and V1 Halo devices exhibited substantial temperature rises (11.6 degrees C and 8.5 degrees C, respectively), with "sparking" evident for the Generation 80 during the MRI procedure. Artifacts were problematic for these devices, as well. By comparison, the 2 Resolve Ring-based cervical external immobilization devices showed little or no heating (< or = 0.6 degrees C) and the artifacts were acceptable for diagnostic MRI examinations. CONCLUSION The low degree of heating and minor artifacts associated with the Resolve-based cervical external immobilization devices indicated that these products are safe for patients undergoing MRI at 3-Tesla.
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Evaluation of the C1–C2 Articulation on MDCT in Healthy Children and Young Adults. AJR Am J Roentgenol 2009; 193:1388-92. [DOI: 10.2214/ajr.09.2688] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Rocha R, Sawa AGU, Baek S, Safavi-Abbasi S, Hattendorf F, Sonntag VKH, Crawford NR. Atlantoaxial rotatory subluxation with ligamentous disruption: a biomechanical comparison of current fusion methods. Neurosurgery 2009; 64:ons137-43; discussion ons143-4. [PMID: 19240563 DOI: 10.1227/01.neu.0000335778.31497.5b] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE We evaluated the biomechanical effects of 4 instrumented configurations after induced atlantoaxial rotatory subluxation: transarticular screw fixation (T/A) and polyaxial C1 lateral mass and C2 pedicle screw and rod fixation (LC1-PC2) for atlantoaxial arthrodesis with unilateral and bilateral instrumentation. METHODS Three-dimensional intervertebral motion was tracked stereophotogrammetrically while 14 human cadaveric spine specimens underwent nonconstraining pure moment loading. Nondestructive loads were applied quasi-statistically in 0.25-Nm increments to a maximum load of 1.5 Nm during flexion-extension, right and left axial rotation, and right and left lateral bending. Hyperrotation injuries were created using torsional loads applied during left axial rotation until visible failure occurred. RESULTS In the normal condition, the values for angular range of motion, lax zone (zone of ligamentous laxity), and stiff zone (zone of ligamentous stretching) were similar in both groups in all directions of loading, with no significant differences (P > 0.05) between groups at C0-C1 or C1-C2. Both instrumentation systems (bilateral configurations) substantially stabilized angular motion at C1-C2 (P < 0.05) during all loading modes for the T/A group, and during all but right lateral bending (P = 0.072) for the LC1-PC2 group. The mean failure load for both intact and instrumented specimens was slightly greater, but not significant for the LC1-PC2 group compared with the T/A group (P > 0.14). CONCLUSION Both methods fixated atlantoaxial subluxation equally well. Compared with unilateral instrumentation, a bilateral configuration with the LC1-PC2 technique significantly increased stability during extension (P < 0.05). During axial rotation, bilateral T/A screws significantly increased stability compared with unilateral fixation (P < 0.02).
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Affiliation(s)
- Rogério Rocha
- Spinal Biomechanics Laboratory, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
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