Clinical and Radiological Clues of Traumatic Craniocervical Junction Injuries Requiring Occipitocervical Fusion to Early Diagnosis

다국어 초록 (Multilingual Abstract)

Objective: The purpose of this study is to find the clinical and radiographic characteristics of traumatic craniocervical junction (CCJ) injuries requiring occipitocervical fusion (OC fusion) for early diagnosis and surgical intervention.
Methods: We retrospectively reviewed 12 patients with CCJ injuries presenting to St. Michaels Hospital in Toronto who underwent OC fusion and looked into the following variables; (1) initial trauma data on emergency room arrival, (2) associated injuries, (3) imaging characteristics of computed tomography (CT) scan and magnetic resonance imaging (MRI), (4) surgical procedures, surgical complications, and neurological outcome.
Results: All patients were treated as acute spinal injuries and underwent OC fusion on an emergency basis. Patients consisted of 10 males and 2 females with an average age of 47 years (range, 18–82 years). All patients sustained high-energy injuries. Three patients out of 6 patients with normal BAI (basion-axial interval) and BDI (basion-dens interval) values showed visible CCJ injuries on CT scans. However, the remaining 3 patients had no clear evidence of occipitoatlantal instability on CT scans. MRI clearly described several findings indicating occipitoatlantal instability. The 8 patients with normal values of ADI (atlanto-dens interval interval) demonstrated atlantoaxial instability on CT scan, however, all MRI more clearly and reliably demonstrated C1/2 facet injury and/or cruciate ligament injury.
Conclusion: We advocate measures to help recognize CCJ injury at an early stage in the present study. Occipitoatlantal instability needs to be carefully investigated on MRI in addition to CT scan with special attention to facet joint and ligament integrity.

참고문헌 (Reference)

1 Debernardi A, "Traumatic injuries to the craniovertebral junction : a review of rare events" 37 : 203-216, 2014

2 Tobert DG, "Traumatic atlantooccipital dissociation and atlantoaxial instability : concomitant ligamentous injuries without neurologic deficit : a case report" 8 : e62-, 2018

3 Guigui P, "Traumatic atlantooccipital dislocation with survival : case report and review of the literature" 4 : 242-247, 1995

4 Mendenhall SK, "Traumatic atlantooccipital dislocation : comprehensive assessment of mortality, neurologic improvement, and patient-reported outcomes at a Level 1 trauma center over 15 years" 15 : 2385-2395, 2015

5 DiBenedetto T, "Traumatic atlanto-occipital instability. A case report with follow-up and a new diagnostic technique" 15 : 595-597, 1990

6 Collalto PM, "Traumatic atlanto-occipital dislocation. Case report" 65 : 863-870, 1986

7 Siddiqui J, "The spectrum of traumatic injuries at the craniocervical junction : a review of imaging findings and management" 24 : 377-385, 2017

8 Bucholz RW, "The pathological anatomy of fatal atlanto-occipital dislocations" 61 : 248-250, 1979

9 Davis JW, "The etiology of missed cervical spine injuries" 34 : 342-346, 1993

10 Theodore N, "The diagnosis and management of traumatic atlanto-occipital dislocation injuries" 72 (72): 114-126, 2013

11 Debernardi A, "The craniovertebral junction area and the role of the ligaments and membranes" 76 (76): S22-S32, 2015

12 Ali J, "The Advanced Trauma Life Support course for senior medical students" 35 : 541-545, 1992

13 Horn EM, "Survivors of occipitoatlantal dislocation injuries : imaging and clinical correlates" 6 : 113-120, 2007

14 Fisher CG, "Recognition and management of atlanto-occipital dislocation : improving survival from an often fatal condition" 44 : 412-420, 2001

15 Garrido BJ, "Occipitocervical fusion using contoured rods and medial offset connectors:description of a new technique" 32 (32): 2009

16 Kasliwal MK, "Occipitocervical dissociation-incidence, evaluation, and treatment" 9 : 247-254, 2016

17 Lu DC, "Nuances of occipitocervical fixation" 66 (66): 141-146, 2010

18 Ryken TC, "Management of isolated fractures of the atlas in adults" 72 (72): 127-131, 2013

19 Roy AK, "Magnetic resonance imaging of traumatic injury to the craniovertebral junction : a case-based review" 38 : E3-, 2015

20 Nidecker AE, "Magnetic resonance imaging of the craniovertebral junction ligaments : normal anatomy and traumatic injury" 77 : 388-395, 2016

21 Stassen NA, "Magnetic resonance imaging in combination with helical computed tomography provides a safe and efficient method of cervical spine clearance in the obtunded trauma patient" 60 : 171-177, 2006

22 Tubbs RS, "Ligaments of the craniocervical junction" 14 : 697-709, 2011

23 Dickman CA, "Injuries involving the transverse atlantal ligament : classification and treatment guidelines based upon experience with 39 injuries" 38 : 44-50, 1996

24 Havrda JB, "Imaging atlantooccipital and atlantoaxial traumatic injuries" 89 : 27-41, 2017

25 Jonsson H Jr, "Hidden cervical spine injuries in traffic accident victims with skull fractures" 4 : 251-263, 1991

26 Chan RN, "Diagnostic failures in the multiple injured" 20 : 684-687, 1980

27 Bellabarba C, "Diagnosis and treatment of craniocervical dislocation in a series of 17 consecutive survivors during an 8-year period" 4 : 429-440, 2006

28 Schmidt P, "Delineation of alar ligament : morphology : comparison of magnetic resonance imaging at 1. 5 and 3 tesla" 35 : e1635-e1639, 2012

29 Gerrelts BD, "Delayed diagnosis of cervical spine injuries" 31 : 1622-1626, 1991

30 Campo EMD, "Computed tomography parameters for atlantooccipital dislocation in adult patients : the occipital condyle-C1 interval" 24 : 535-545, 2016

31 Martinez-Del-Campo E, "Computed tomography parameters for atlantooccipital dislocation in adult patients : the occipital condyle-C1 interval" 24 : 535-545, 2016

32 Radcliff K, "CT and MRI-based diagnosis of craniocervical dislocations : the role of the occipitoatlantal ligament" 470 : 1602-1613, 2012

33 Souslian FG, "Atlanto-occipital dissociation in the setting of relatively normal radiologic findings" 143 : 405-411, 2020

34 Siccardi D, "Analysis of three-dimensional facet joint displacement during two passive upper cervical mobilizations" 50 : 102218-, 2020

35 Jung MK, "Analysis of diagnostics, therapy and outcome of patients with traumatic atlantooccipital dislocation" 21 : 1513-1519, 2021

36 Dyas AR, "Ability of magnetic resonance imaging to accurately determine alar ligament integrity in patients with atlanto-occipital injuries" 9 : 241-245, 2018

37 Menaker J, "40-slice multidetector CT : is MRI still necessary for cervical spine clearance after blunt trauma" 76 : 157-163, 2010