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Bohra H, Maalouly J, Neha C, Stewart C, Diwan AD, Petersingham G, Seex K, Rao PJ. Halo traction evaluation of craniocervical instability in hereditary connective tissue disorder patients: Case series. J Clin Neurosci 2025; 132:110957. [PMID: 39644519 DOI: 10.1016/j.jocn.2024.110957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2024] [Revised: 11/27/2024] [Accepted: 11/27/2024] [Indexed: 12/09/2024]
Abstract
INTRODUCTION Craniocervical instability (CCI) is a condition commonly found in patients with connective tissue disorders such as Ehlers-Danlos Syndrome (EDS), leading to various symptoms. Assessing patients for surgical fusion as a treatment for CCI is challenging due to the complex nature of EDS-related symptoms. This study aimed to evaluate the role of pre-fusion halo-vest traction in alleviating symptoms and determining suitable candidates for fusion surgeries. METHODS EDS patients (n = 21) with neurological symptoms underwent insertion of halo-vest traction between 2019 and 2024. Patients completed a CCI Questionnaire before and after the halo-vest traction, reporting symptoms related to headache, vision, hearing, equilibrium, and function. Symptom groups were assigned scores based on patient responses, with one point for each affirmative answer. Before and after scores were analyzed using paired Student's t-test. Patients experiencing over 50 % improvement in the majority of symptoms were considered for definitive fusion surgery. 16 out of 21 patients subsequently underwent fusion for CCI. RESULTS The average age of the patients was 35 years, with a female-to-male ratio of 20:1, consistent with existing literature. Significant improvements were observed in various symptom groups after halo-vest traction, including headache (57 % improvement, p < 0.001), brainstem functions (71 % improvement, p < 0.001), cerebellar functions (55 % improvement, p < 0.001), hearing (63 % improvement, p < 0.001), motor functions (51 % improvement,p < 0.001), vision (60 % improvement, p < 0.001), cardiovascular functions (46 % improvement, p < 0.05), sensory and pain (53 % improvement, p < 0.001), high cortical functions (54 % improvement, p < 0.001), GI functions (52 % improvement, p < 0.05), bladder functions (52 % improvement, p < 0.05), and Modified Karnofsky score (30 % improvement, p < 0.05). CONCLUSION Halo-vest traction proved to be a simple and effective method for evaluating patients for surgery while providing symptomatic relief in EDS-related CCI cases. It allows surgeons to monitor patients with a now post halo stable craniocervical junctions (CCJ) before committing to surgery.
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Affiliation(s)
- Hussain Bohra
- Spine Service, Department of Orthopaedic Surgery, St George and Sutherland Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Joseph Maalouly
- Brain and Spine Surgery, Bella Vista, NSW, Australia; Norwest Private Hospital, Dept of Neurosurgery, NSW, Australia
| | - Chopra Neha
- Spine Service, Department of Orthopaedic Surgery, St George and Sutherland Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Charmian Stewart
- Spine Service, Department of Orthopaedic Surgery, St George and Sutherland Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Ashish D Diwan
- Spine Service, Department of Orthopaedic Surgery, St George and Sutherland Clinical School, University of New South Wales, Sydney, NSW, Australia
| | | | - Kevin Seex
- Macquarie University Hospital, Dept of Neurosurgery, NSW, Australia
| | - Prashanth J Rao
- Brain and Spine Surgery, Bella Vista, NSW, Australia; Norwest Private Hospital, Dept of Neurosurgery, NSW, Australia; Macquarie University Hospital, Dept of Neurosurgery, NSW, Australia; University of New South Wales, Sydney, NSW, Australia.
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Kempeneers MA, Buis DR, Feller RE, Roosendaal SD, Slot KM, Wolf NI, Vandertop WP. Torticollis with Atlantoaxial Rotatory Subluxation in Children: A Clinical Review. Neuropediatrics 2024; 55:349-355. [PMID: 38657679 DOI: 10.1055/a-2312-9994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
A small proportion of children with a sudden onset torticollis ("wry neck") presents with an atlantoaxial rotatory subluxation, usually after mild trauma or recent head or neck infection. Torticollis is a clinical diagnosis and imaging is usually not indicated, though often performed in clinical practice. Atlantoaxial rotatory subluxation on imaging is often a physiological phenomenon in torticollis, and concomitant neurological symptoms are therefore rare. Treatment is primarily conservative, with analgesics, a rigid neck collar, and if needed benzodiazepines to counteract muscle spasms and anxiety. In case of treatment failure or chronic subluxation, cervical repositioning and fixation under general anesthesia may be considered. Surgical treatment is only indicated in a small percentage of patients with chronic refractory subluxation, concomitant cervical fractures, or congenital anomalies. Early diagnosis and treatment are important, since this is associated with a more successful conservative outcome than a prolonged approach.
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Affiliation(s)
| | - Dennis R Buis
- Department of Neurosurgery, Amsterdam UMC, Amsterdam, The Netherlands
| | - Ricardo E Feller
- Department of Neurosurgery, Amsterdam UMC, Amsterdam, The Netherlands
| | | | - K Mariam Slot
- Department of Neurosurgery, Amsterdam UMC, Amsterdam, The Netherlands
| | - Nicole I Wolf
- Department of Child Neurology, Emma Children's Hospital, Amsterdam UMC, Amsterdam, The Netherlands
| | - W Peter Vandertop
- Department of Neurosurgery, Amsterdam UMC, Amsterdam, The Netherlands
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Sheppard WL, Savage JW, Moore T. Atlanto-occipital Dissociation: A Review on Epidemiology, Recognition and Diagnosis, Management Options, Outcomes, and Future Directions. Clin Spine Surg 2024; 37:395-403. [PMID: 39356168 DOI: 10.1097/bsd.0000000000001701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2024] [Accepted: 09/07/2024] [Indexed: 10/03/2024]
Abstract
Atlanto-occipital dissociation (AOD) is an extremely common injury but often fatal. In a systematic review from 2010, AODs were present in almost 20% of blunt trauma fatalities. It is an injury many patients do not survive; therefore, few are treated, even at high volume trauma centers. In survivors, his injury is often missed or the diagnosis is often delayed. Mortality rates commonly reach beyond 60% when injury patterns go unrecognized. Approximately 50% of patients with AOD sustain blunt cerebrovascular injury and nearly 20% of patients present with traumatic brain injury (TBI) or stroke. This pathology was once considered uniformly fatal. However, over the last 20 years, significant advancements have been made both clinically and radiographically, to better identify and manage this injury pattern. Despite improvements in clinical comprehension and improved time to diagnosis, less than 75% of cases are currently recognized within 24 hours. Less than 40% of patients who suffer AOD are independent with functionality, without neurological impairment. This article reviews current literature regarding AOD in hopes to improve timing to diagnosis, subsequent prognosis, timing to fixation or stabilization, and postoperative recovery.
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Affiliation(s)
- William L Sheppard
- Cleveland Clinic Foundation, Neurological Institute, Cleveland, OH
- Department of Orthopaedic Surgery, Los Angeles, CA
| | - Jason W Savage
- Cleveland Clinic Foundation, Neurological Institute, Cleveland, OH
| | - Tim Moore
- Department of Orthopaedic Surgery, Case Western Reserve University School of Medicine, Cleveland, OH
- MetroHealth Medical Center, Cleveland, OH
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Charbonneau L, Watanabe K, Chaalala C, Bojanowski MW, Lavigne P, Labidi M. Anatomy of the craniocervical junction - A review. Neurochirurgie 2024; 70:101511. [PMID: 38277861 DOI: 10.1016/j.neuchi.2023.101511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 10/31/2023] [Indexed: 01/28/2024]
Abstract
An in-depth understanding of the anatomy of the craniocervical junction (CCJ) is indispensable in skull base neurosurgery. In this paper, we discuss the osteology of the occipital bone, the atlas (C1) and axis (C2), the ligaments and the muscle anatomy of the CCJ region and their relationships with the vertebral artery. We will also discuss the trajectory of the vertebral artery and review the anatomy of the jugular foramen and lower cranial nerves (IX to XII). The most important surgical approaches to the CCJ, including the far lateral approach, the anterolateral approach of Bernard George and the endoscopic endonasal approach, will be discussed to review the surgical anatomy.
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Affiliation(s)
- Laurence Charbonneau
- Division of Neurosurgery, Department of Surgery, University of Montreal, Quebec, Canada.
| | - Kentaro Watanabe
- Department of Neurosurgery, Tokyo Jikei University School of Medicine, Tokyo, Japan
| | - Chiraz Chaalala
- Division of Neurosurgery, Department of Surgery, University of Montreal, Quebec, Canada
| | - Michel W Bojanowski
- Division of Neurosurgery, Department of Surgery, University of Montreal, Quebec, Canada
| | - Philippe Lavigne
- Division of Oto-rhino-laryngology, Department of Surgery, University of Montreal, Quebec, Canada
| | - Moujahed Labidi
- Division of Neurosurgery, Department of Surgery, University of Montreal, Quebec, Canada
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Morimoto LR, Kase DT, Esmanhotto PG, Maciel MA, Augusto ACL, Catricala PF, Anaya JEC, Mukherjee S, Fernandes ARC, Aihara AY. Imaging Assessment of Nontraumatic Pathologic Conditions at the Craniovertebral Junction: A Comprehensive Review. Radiographics 2024; 44:e230137. [PMID: 38635454 DOI: 10.1148/rg.230137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2024]
Abstract
Nontraumatic pathologic conditions of the craniovertebral junction encompass a range of conditions affecting the complex anatomy of this region without direct physical injury. These conditions include congenital syndromes that predispose individuals to ligamentous laxity, potentially leading to instability. Additionally, rare but noteworthy cases such as Grisel syndrome, a cause of pediatric torticollis, may arise without a traumatic trigger. Inflammatory diseases, including rheumatoid arthritis, ankylosing spondylitis, and crystal deposition, can lead to cervical instability and spinal cord compression. Infections at the upper cervical spine are dominated by tuberculosis, typically transmitted through hematologic or lymphatic routes with characteristic imaging findings. On the other hand, purulent bacterial infections in this area are rare. Furthermore, although tumors involving the structures of the craniovertebral junction are infrequent, they can lead to significant complications, albeit less frequently through cord compression and more commonly via pathologic fractures or subluxation. The craniocervical junction is a complex anatomic region comprising ligaments, bones, joints, and muscles that support the head's weight and enable its wide range of motion. Accurate recognition and understanding of the complex anatomy and the various nontraumatic pathologic conditions at the craniovertebral junction are pivotal for initiating timely and appropriate treatment strategies. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.
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Affiliation(s)
- Letícia R Morimoto
- From the Department of Diagnostic Imaging, Universidade Federal de São Paulo (UNIFESP), Rua Napoleão de Barros 800, Vila Clementino, São Paulo, SP 04024-002, Brazil (L.R.M., D.T.K., P.G.E., A.C.L.A., P.F.C., A.R.C.F., A.Y.A.); Dasa Institute for Education and Research (IEPD), Rio de Janeiro, Brazil (D.T.K., P.G.E., M.A.M., A.C.L.A., P.F.C., J.E.C.A., A.Y.A.); Department of Radiology, A.C. Camargo Cancer Center, São Paulo, Brazil (M.A.M.); Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, Va (S.M.); and Group of Radiology and Diagnostic Imaging, Rede D'Or São Paulo, São Paulo, Brazil (A.R.C.F.)
| | - Daisy T Kase
- From the Department of Diagnostic Imaging, Universidade Federal de São Paulo (UNIFESP), Rua Napoleão de Barros 800, Vila Clementino, São Paulo, SP 04024-002, Brazil (L.R.M., D.T.K., P.G.E., A.C.L.A., P.F.C., A.R.C.F., A.Y.A.); Dasa Institute for Education and Research (IEPD), Rio de Janeiro, Brazil (D.T.K., P.G.E., M.A.M., A.C.L.A., P.F.C., J.E.C.A., A.Y.A.); Department of Radiology, A.C. Camargo Cancer Center, São Paulo, Brazil (M.A.M.); Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, Va (S.M.); and Group of Radiology and Diagnostic Imaging, Rede D'Or São Paulo, São Paulo, Brazil (A.R.C.F.)
| | - Paola G Esmanhotto
- From the Department of Diagnostic Imaging, Universidade Federal de São Paulo (UNIFESP), Rua Napoleão de Barros 800, Vila Clementino, São Paulo, SP 04024-002, Brazil (L.R.M., D.T.K., P.G.E., A.C.L.A., P.F.C., A.R.C.F., A.Y.A.); Dasa Institute for Education and Research (IEPD), Rio de Janeiro, Brazil (D.T.K., P.G.E., M.A.M., A.C.L.A., P.F.C., J.E.C.A., A.Y.A.); Department of Radiology, A.C. Camargo Cancer Center, São Paulo, Brazil (M.A.M.); Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, Va (S.M.); and Group of Radiology and Diagnostic Imaging, Rede D'Or São Paulo, São Paulo, Brazil (A.R.C.F.)
| | - Murilo A Maciel
- From the Department of Diagnostic Imaging, Universidade Federal de São Paulo (UNIFESP), Rua Napoleão de Barros 800, Vila Clementino, São Paulo, SP 04024-002, Brazil (L.R.M., D.T.K., P.G.E., A.C.L.A., P.F.C., A.R.C.F., A.Y.A.); Dasa Institute for Education and Research (IEPD), Rio de Janeiro, Brazil (D.T.K., P.G.E., M.A.M., A.C.L.A., P.F.C., J.E.C.A., A.Y.A.); Department of Radiology, A.C. Camargo Cancer Center, São Paulo, Brazil (M.A.M.); Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, Va (S.M.); and Group of Radiology and Diagnostic Imaging, Rede D'Or São Paulo, São Paulo, Brazil (A.R.C.F.)
| | - Ana C L Augusto
- From the Department of Diagnostic Imaging, Universidade Federal de São Paulo (UNIFESP), Rua Napoleão de Barros 800, Vila Clementino, São Paulo, SP 04024-002, Brazil (L.R.M., D.T.K., P.G.E., A.C.L.A., P.F.C., A.R.C.F., A.Y.A.); Dasa Institute for Education and Research (IEPD), Rio de Janeiro, Brazil (D.T.K., P.G.E., M.A.M., A.C.L.A., P.F.C., J.E.C.A., A.Y.A.); Department of Radiology, A.C. Camargo Cancer Center, São Paulo, Brazil (M.A.M.); Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, Va (S.M.); and Group of Radiology and Diagnostic Imaging, Rede D'Or São Paulo, São Paulo, Brazil (A.R.C.F.)
| | - Patrick F Catricala
- From the Department of Diagnostic Imaging, Universidade Federal de São Paulo (UNIFESP), Rua Napoleão de Barros 800, Vila Clementino, São Paulo, SP 04024-002, Brazil (L.R.M., D.T.K., P.G.E., A.C.L.A., P.F.C., A.R.C.F., A.Y.A.); Dasa Institute for Education and Research (IEPD), Rio de Janeiro, Brazil (D.T.K., P.G.E., M.A.M., A.C.L.A., P.F.C., J.E.C.A., A.Y.A.); Department of Radiology, A.C. Camargo Cancer Center, São Paulo, Brazil (M.A.M.); Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, Va (S.M.); and Group of Radiology and Diagnostic Imaging, Rede D'Or São Paulo, São Paulo, Brazil (A.R.C.F.)
| | - Julia E C Anaya
- From the Department of Diagnostic Imaging, Universidade Federal de São Paulo (UNIFESP), Rua Napoleão de Barros 800, Vila Clementino, São Paulo, SP 04024-002, Brazil (L.R.M., D.T.K., P.G.E., A.C.L.A., P.F.C., A.R.C.F., A.Y.A.); Dasa Institute for Education and Research (IEPD), Rio de Janeiro, Brazil (D.T.K., P.G.E., M.A.M., A.C.L.A., P.F.C., J.E.C.A., A.Y.A.); Department of Radiology, A.C. Camargo Cancer Center, São Paulo, Brazil (M.A.M.); Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, Va (S.M.); and Group of Radiology and Diagnostic Imaging, Rede D'Or São Paulo, São Paulo, Brazil (A.R.C.F.)
| | - Sugoto Mukherjee
- From the Department of Diagnostic Imaging, Universidade Federal de São Paulo (UNIFESP), Rua Napoleão de Barros 800, Vila Clementino, São Paulo, SP 04024-002, Brazil (L.R.M., D.T.K., P.G.E., A.C.L.A., P.F.C., A.R.C.F., A.Y.A.); Dasa Institute for Education and Research (IEPD), Rio de Janeiro, Brazil (D.T.K., P.G.E., M.A.M., A.C.L.A., P.F.C., J.E.C.A., A.Y.A.); Department of Radiology, A.C. Camargo Cancer Center, São Paulo, Brazil (M.A.M.); Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, Va (S.M.); and Group of Radiology and Diagnostic Imaging, Rede D'Or São Paulo, São Paulo, Brazil (A.R.C.F.)
| | - Artur R C Fernandes
- From the Department of Diagnostic Imaging, Universidade Federal de São Paulo (UNIFESP), Rua Napoleão de Barros 800, Vila Clementino, São Paulo, SP 04024-002, Brazil (L.R.M., D.T.K., P.G.E., A.C.L.A., P.F.C., A.R.C.F., A.Y.A.); Dasa Institute for Education and Research (IEPD), Rio de Janeiro, Brazil (D.T.K., P.G.E., M.A.M., A.C.L.A., P.F.C., J.E.C.A., A.Y.A.); Department of Radiology, A.C. Camargo Cancer Center, São Paulo, Brazil (M.A.M.); Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, Va (S.M.); and Group of Radiology and Diagnostic Imaging, Rede D'Or São Paulo, São Paulo, Brazil (A.R.C.F.)
| | - André Y Aihara
- From the Department of Diagnostic Imaging, Universidade Federal de São Paulo (UNIFESP), Rua Napoleão de Barros 800, Vila Clementino, São Paulo, SP 04024-002, Brazil (L.R.M., D.T.K., P.G.E., A.C.L.A., P.F.C., A.R.C.F., A.Y.A.); Dasa Institute for Education and Research (IEPD), Rio de Janeiro, Brazil (D.T.K., P.G.E., M.A.M., A.C.L.A., P.F.C., J.E.C.A., A.Y.A.); Department of Radiology, A.C. Camargo Cancer Center, São Paulo, Brazil (M.A.M.); Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, Va (S.M.); and Group of Radiology and Diagnostic Imaging, Rede D'Or São Paulo, São Paulo, Brazil (A.R.C.F.)
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Wan M, Zong R, Tong HY, Zhang ZZ, Zhao B, Yu XG. A morphometric study of the atlanto-occipital joint in adult patients with Chiari malformation type I. Br J Neurosurg 2024; 38:12-15. [PMID: 32969751 DOI: 10.1080/02688697.2020.1823940] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 09/11/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND There are many morphometric studies on Chiari malformation type I (CMI) patients, most of which focus on the posterior cranial fossa (PCF). Less attention has been paid to the atlanto-occipital joint. In this study, we aim to evaluate the morphological characteristics of the atlanto-occipital joint in CMI patients. MATERIALS AND METHODS The cervical CT imaging data of adult patients diagnosed with CMI but without any bony malformation in craniovertebral junction (CVJ) who were treated by the authors between January 2014 and December 2019 were retrospectively analyzed. The equal number of sex and age-matched healthy individuals were included as the control group. The morphometric analysis was performed by measuring the length and depth of the atlanto-occipital joint, and the depth/length ratio was calculated to evaluate the curvature of the joint. RESULTS A total of 47 patients (15 males and 32 females) were included. The mean age of patients was 47.49 ± 9.01 years (range 19-62 years). The mean depth/length ratio of the atlanto-occipital joint in CMI patients was 0.141 ± 0.065 (range 0.027 - 0.274), which was smaller than that of control individuals (0.228 ± 0.057, range 0.069 - 0.379). And the difference was statistically significant (p < .01). CONCLUSIONS The atlanto-occipital joints in CMI patients are significantly flatter compared with those in healthy controls. This morphological variation could lead to differences of the atlanto-occipital stability between CMI patients and normal population, which may be related to the pathogenesis of CMI.
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Affiliation(s)
- Ming Wan
- Department of Neurosurgery, Medical School of Chinese PLA, Beijing, PR China
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, PR China
| | - Rui Zong
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, PR China
| | - Huai-Yu Tong
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, PR China
| | - Zhi-Zhong Zhang
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, PR China
| | - Bo Zhao
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, PR China
| | - Xin-Guang Yu
- Department of Neurosurgery, Medical School of Chinese PLA, Beijing, PR China
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Fiester P, Orallo P, Soule E, Rao D, Tavanaiepour D. Utility of Anterior Atlantodens Interval Widening on Cervical Spine CT for Assessing Transverse Atlantal Ligament Injury. Global Spine J 2023; 13:2319-2326. [PMID: 35212239 PMCID: PMC10538329 DOI: 10.1177/21925682221081211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Retrospective, cross-sectional. OBJECTIVES To identify trauma patients with confirmed tears of the transverse atlantal ligament on cervical MRI and measure several parameters of atlanto-axial alignment on cervical CT, including the anterior atlantodens interval, to determine which method is most sensitive in predicting transverse atlantal ligament injury. METHODS Adult trauma patients who suffered a transverse atlantal ligament tear on cervical MRI were identified retrospectively. The cervical CT and MRI exams for these patients were reviewed for the following: anterior and lateral atlantodens interval widening, lateral C1 mass offset, C1-C2 rotatory subluxation, and transverse atlantal ligament injuries on cervical MRI. RESULTS Twenty-six patients were identified with a tear of the transverse atlantal ligament on cervical MRI. Twelve percent of these patients demonstrated an anterior dens interval measuring greater than 2 mm, 26% of patients demonstrated lateral mass offset of C1 on C2 (average offset of 2.4 mm), 18% of patients demonstrated an asymmetry greater than 1 mm between the left and right lateral atlantodens interval, and one patient demonstrated atlanto-axial rotation measuring greater than 20%. Ten patients had an accompanying C1 burst fracture and eight patients had a C2 fracture. One patient demonstrated widening of the atlanto-occipital joint space greater than 2 mm indicative of craniocervical dissociation injury. CONCLUSIONS An anterior atlantodens interval measuring greater than 2 mm is an unreliable methodology to screen trauma patients for transverse altantal ligament injuries and atlanto-axial instability. Moreover, C1 lateral mass offset, lateral atlantodens asymmetry, and atlanto-axial rotation were all poor predictors of transverse atlantal ligament tears.
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Affiliation(s)
- Peter Fiester
- Department of Neuroradiology, University of Florida Health - Jacksonville, Jacksonville, FL, USA
| | - Peaches Orallo
- Department of Anesthesiology, University of Florida Health - Jacksonville, Jacksonville, FL, USA
| | - Erik Soule
- Department of Neuroradiology, University of Florida Health - Jacksonville, Jacksonville, FL, USA
| | - Dinesh Rao
- Department of Neuroradiology, University of Florida Health - Jacksonville, Jacksonville, FL, USA
| | - Daryoush Tavanaiepour
- Department of Neurosurgery, University of Florida Health - Jacksonville, Jacksonville, FL, USA
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Schollaert J, Van Goethem JWM. Imaging in Whiplash-Associated Disorders. Semin Musculoskelet Radiol 2023; 27:512-521. [PMID: 37816359 DOI: 10.1055/s-0043-1772170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/12/2023]
Abstract
"Whiplash," a term describing the severe acceleration and deceleration forces applied to the head, craniocervical junction (CCJ), and cervical spine during trauma, is one of the most frequent mechanisms of injury to the CCJ. The CCJ is a complex region at the transition of the cranium and the cervical spine, essential for maintaining craniocervical stability. In whiplash injuries, the CCJ may be compromised due to underlying ligamentous or, less frequently, osseous, intravertebral disk and/or muscular lesions. Imaging is crucial in detecting acute lesions but may also play a role in the follow-up of chronic pathology because soft tissue lesions and progressive disk pathology could contribute to a whiplash-associated disorder.
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Affiliation(s)
- Joris Schollaert
- Department of Medical and Molecular Imaging, VITAZ, Sint-Niklaas, Belgium
- Department of Radiology, University Hospital of Antwerp, Antwerp, Belgium
| | - Johan W M Van Goethem
- Department of Medical and Molecular Imaging, VITAZ, Sint-Niklaas, Belgium
- Department of Radiology, University Hospital of Antwerp, Antwerp, Belgium
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Mertens K, Vanhoenacker FM. Imaging of the Craniocervical Junction: A Pictorial Review. Semin Musculoskelet Radiol 2023; 27:499-511. [PMID: 37816358 DOI: 10.1055/s-0043-1772190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/12/2023]
Abstract
The craniocervical junction (CCJ) is a complex anatomical structure comprising the occiput, the atlas, and the axis. The CCJ plays an important role in maintaining stability, providing protection, and supporting neurovascular structures. The CCJ can be affected by a wide range of congenital variants and traumatic, degenerative, inflammatory, and tumoral pathologies. This pictorial review the normal anatomy of the CCJ and presents the most common anatomical variants and pathologic conditions affecting the CCJ.
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Affiliation(s)
- Kris Mertens
- Department of Radiology, UZ Leuven, University of Leuven, Leuven, Belgium
- Department of Radiology, AZ Sint-Maarten, Mechelen, Belgium
| | - Filip M Vanhoenacker
- Department of Radiology, UZ Leuven, University of Leuven, Leuven, Belgium
- Department of Radiology, AZ Sint-Maarten, Mechelen, Belgium
- Department of Diagnostic Sciences, UZ Gent, Faculty of Medicine and Health Sciences, Ghent, Belgium
- Department of Radiology, UZ Antwerpen, University of Antwerp, Edegem, Belgium
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Lu C, Duan W, Zhang C, Du Y, Wang X, Ma L, Wang K, Wu H, Chen Z, Jian F. Correlation Among Syrinx Resolution, Cervical Sagittal Realignment, and Surgical Outcome After Posterior Reduction for Basilar Invagination, Atlantoaxial Dislocation, and Syringomyelia. Oper Neurosurg (Hagerstown) 2023; 25:125-135. [PMID: 37083634 DOI: 10.1227/ons.0000000000000719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 02/14/2023] [Indexed: 04/22/2023] Open
Abstract
BACKGROUND The correlation among syrinx resolution, occipitoaxial sagittal alignment, and surgical outcome in long-term follow-up seems to have not been clarified. OBJECTIVE To further explore the relationship between the syrinx resolution and occipitoaxial realignment after posterior reduction and fixation in basilar invagination (BI)-atlantoaxial dislocation (AAD) patients with syringomyelia. METHODS A continuous series of 32 patients with BI-AAD and syringomyelia who received direct posterior reduction met the inclusion criteria of this study. Their clinical and imaging data were analyzed retrospectively. Before surgery and at the last follow-up, we used the Japanese Orthopedic Association (JOA) score and the Neck Disability Index (NDI) to assess the neurological status, respectively. The Pearson correlation coefficient and multiple stepwise regression analysis were used to explore the relevant factors that may affect surgical outcomes. RESULTS There were significant differences in atlantodental interval, clivus-axial angle, occiput-C2 angle (Oc-C2A), cervicomedullary angle (CMA), subarachnoid space (SAS) at the foramen magnum (FM), syrinx size, NDI, and JOA score after surgery compared with those before surgery. ΔCMA and the resolution rate of syrinx/cord as relevant factors were correlated with the recovery rate of JOA (R 2 = 0.578, P < .001) and NDI (R 2 = 0.369, P < .01). What's more, ΔSAS/FMD (SAS/FM diameter) and ΔOc-C2A were positively correlated with the resolution rate of syrinx/cord (R 2 = 0.643, P < .001). CONCLUSION With medulla decompression and occipital-cervical sagittal realignment after posterior reduction and fusion for BI-AAD patients with syringomyelia, the structural remodeling of the craniovertebral junction and occipitoaxial realignment could contribute to syringomyelia resolution.
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Affiliation(s)
- Chunli Lu
- Division of Spine, Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Neurospine Center, China International Neuroscience Institute (CHINA-INI), Beijing, China
- Research Center of Spine and Spinal Cord, Beijing Institute for Brain Disorders, Capital Medical University, Beijing, China
- Lab of Spinal Cord Injury and Functional Reconstruction, CHINA-INI, Xuanwu Hospital, Capital Medical University, Beijing, China
- National Center for Neurological Disorders, Beijing, China
| | - Wanru Duan
- Division of Spine, Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Neurospine Center, China International Neuroscience Institute (CHINA-INI), Beijing, China
- Research Center of Spine and Spinal Cord, Beijing Institute for Brain Disorders, Capital Medical University, Beijing, China
- Lab of Spinal Cord Injury and Functional Reconstruction, CHINA-INI, Xuanwu Hospital, Capital Medical University, Beijing, China
- National Center for Neurological Disorders, Beijing, China
| | - Can Zhang
- Division of Spine, Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Neurospine Center, China International Neuroscience Institute (CHINA-INI), Beijing, China
- Research Center of Spine and Spinal Cord, Beijing Institute for Brain Disorders, Capital Medical University, Beijing, China
- Lab of Spinal Cord Injury and Functional Reconstruction, CHINA-INI, Xuanwu Hospital, Capital Medical University, Beijing, China
- National Center for Neurological Disorders, Beijing, China
| | - Yueqi Du
- Division of Spine, Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Neurospine Center, China International Neuroscience Institute (CHINA-INI), Beijing, China
- Research Center of Spine and Spinal Cord, Beijing Institute for Brain Disorders, Capital Medical University, Beijing, China
- Lab of Spinal Cord Injury and Functional Reconstruction, CHINA-INI, Xuanwu Hospital, Capital Medical University, Beijing, China
- National Center for Neurological Disorders, Beijing, China
| | - Xinyu Wang
- Division of Spine, Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Neurospine Center, China International Neuroscience Institute (CHINA-INI), Beijing, China
- Research Center of Spine and Spinal Cord, Beijing Institute for Brain Disorders, Capital Medical University, Beijing, China
- Lab of Spinal Cord Injury and Functional Reconstruction, CHINA-INI, Xuanwu Hospital, Capital Medical University, Beijing, China
- National Center for Neurological Disorders, Beijing, China
| | - Longbing Ma
- Division of Spine, Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Neurospine Center, China International Neuroscience Institute (CHINA-INI), Beijing, China
- Research Center of Spine and Spinal Cord, Beijing Institute for Brain Disorders, Capital Medical University, Beijing, China
- Lab of Spinal Cord Injury and Functional Reconstruction, CHINA-INI, Xuanwu Hospital, Capital Medical University, Beijing, China
- National Center for Neurological Disorders, Beijing, China
| | - Kai Wang
- Division of Spine, Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Neurospine Center, China International Neuroscience Institute (CHINA-INI), Beijing, China
- Research Center of Spine and Spinal Cord, Beijing Institute for Brain Disorders, Capital Medical University, Beijing, China
- Lab of Spinal Cord Injury and Functional Reconstruction, CHINA-INI, Xuanwu Hospital, Capital Medical University, Beijing, China
- National Center for Neurological Disorders, Beijing, China
| | - Hao Wu
- Division of Spine, Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Neurospine Center, China International Neuroscience Institute (CHINA-INI), Beijing, China
- Research Center of Spine and Spinal Cord, Beijing Institute for Brain Disorders, Capital Medical University, Beijing, China
- Lab of Spinal Cord Injury and Functional Reconstruction, CHINA-INI, Xuanwu Hospital, Capital Medical University, Beijing, China
- National Center for Neurological Disorders, Beijing, China
| | - Zan Chen
- Division of Spine, Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Neurospine Center, China International Neuroscience Institute (CHINA-INI), Beijing, China
- Research Center of Spine and Spinal Cord, Beijing Institute for Brain Disorders, Capital Medical University, Beijing, China
- Lab of Spinal Cord Injury and Functional Reconstruction, CHINA-INI, Xuanwu Hospital, Capital Medical University, Beijing, China
- National Center for Neurological Disorders, Beijing, China
| | - Fengzeng Jian
- Division of Spine, Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Neurospine Center, China International Neuroscience Institute (CHINA-INI), Beijing, China
- Research Center of Spine and Spinal Cord, Beijing Institute for Brain Disorders, Capital Medical University, Beijing, China
- Lab of Spinal Cord Injury and Functional Reconstruction, CHINA-INI, Xuanwu Hospital, Capital Medical University, Beijing, China
- National Center for Neurological Disorders, Beijing, China
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11
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Fiester P, Soule E, Reno D, Cosare M, Rao D, Supsupin E, Orallo P. Cervical MRI assessment of traumatic anterior atlanto-occipital membrane complex injuries with evaluation of ancillary findings. Emerg Radiol 2023; 30:333-342. [PMID: 37085742 DOI: 10.1007/s10140-023-02134-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 04/10/2023] [Indexed: 04/23/2023]
Abstract
BACKGROUND AND PURPOSE The purpose of this study was to identify and classify the different types of anterior atlanto-occipital membrane complex injuries on MRI and evaluate for the presence, size, and location of a prevertebral effusion on the preceding CT exams. MATERIALS AND METHODS Patients who suffered an anterior atlanto-occipital membrane complex injury were identified retrospectively utilizing Nuance mPower software. An anatomic-based description of the location of the anterior atlanto-occipital membrane complex injury was recorded along with any additional osteoligamentous trauma of the craniocervical junction. The preceding cervical CT exams for these patients were reviewed for the presence and location of a prevertebral effusion. RESULTS Fifty patients were identified with an acute, post-traumatic anterior atlanto-occipital membrane complex injury. Three distinct patterns of anterior atlanto-occipital membrane complex injury were observed. Nineteen patients demonstrated increased STIR signal with disruption of the anterior atlanto-occipital membrane, ten patients demonstrated increased STIR signal with disruption of the anterior atlanto-axial membrane, and twenty-one patients demonstrated increased STIR signal with disruption of both the anterior atlanto-occipital membrane and anterior atlanto-axial membrane. An effusion at the C1-C2 level was present in greater than 90% of patients with anterior atlanto-occipital membrane complex injury. CONCLUSIONS The presence of a craniocervical prevertebral effusion on CT in trauma patients may raise suspicion for an injury to the anterior atlanto-occipital membrane complex and potentially trigger additional investigation with cervical MRI.
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Affiliation(s)
- Peter Fiester
- Department of Radiology, Division of Neuroradiology, University of Florida College of Medicine - Jacksonville, Jacksonville, FL, USA.
| | - Erik Soule
- Department of Radiology, Division of Neuroradiology, University of Florida College of Medicine - Jacksonville, Jacksonville, FL, USA
| | - Dillon Reno
- Liberty University College of Osteopathic Medicine, Lynchburg, VA, USA
| | - Michael Cosare
- Lake Erie College of Osteopathic Medicine, Bradenton, FL, USA
| | - Dinesh Rao
- Department of Radiology, Division of Neuroradiology, University of Florida College of Medicine - Jacksonville, Jacksonville, FL, USA
| | - Emilio Supsupin
- Department of Radiology, Division of Neuroradiology, University of Florida College of Medicine - Jacksonville, Jacksonville, FL, USA
| | - Peaches Orallo
- Department of Anesthesiology, University of Florida College of Medicine - Jacksonville, Jacksonville, FL, USA
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12
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Nicholson LL, Rao PJ, Lee M, Wong TM, Cheng RHY, Chan C. Reference values of four measures of craniocervical stability using upright dynamic magnetic resonance imaging. LA RADIOLOGIA MEDICA 2023; 128:330-339. [PMID: 36715785 PMCID: PMC10020271 DOI: 10.1007/s11547-023-01588-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Accepted: 01/04/2023] [Indexed: 01/31/2023]
Abstract
PURPOSE To establish reference ranges for four most commonly used diagnostic measures of craniocervical instability (CCI) in three cervical sagittal positions. This necessitated development of a reliable measurement protocol using upright, dynamic MRI (udMRI), to determine differences in the extent of motion between positions, and whether age and sex correlate with these measures. MATERIALS AND METHODS Deidentified udMRIs of 50 adults, referred for reasons other than CCI, were captured at three positions (maximal flexion, maximal extension and neutral). Images were analyzed, providing measures of basion-axial interval, basion-axial angle, basion-dens interval (BDI) and the Grabb-Oakes line (GOL) for all three positions (12 measures per participant). All measures were independently recorded by a radiologist and neurosurgeon to determine their reliability. Descriptive statistics, correlations, paired and independent t-tests were used. Mean (± 2 SD) identified the reference range for all four measures at each craniocervical position. RESULTS The revised measurement protocol produced inter-rater reliability indices of 0.69-0.97 (moderate-excellent). Fifty adults' (50% male; mean age 41.2 years (± 9.7)) reference ranges for all twelve measures were reported. Except for the BDI and GOL when moving between neutral and full flexion, significant extents of movement were identified between the three craniocervical positions for all four measures (p ≤ 0.005). Only a minor effect of age was found. CONCLUSIONS This is the first study to provide a rigorous standardized protocol for four diagnostic measures of CCI. Reference ranges are established at mid and ends of sagittal cervical range corresponding to where exacerbations of signs and symptoms are commonly reported.
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Affiliation(s)
- Leslie L Nicholson
- School of Medical Sciences, The University of Sydney, Camperdown, NSW, Australia.
| | - Prashanth J Rao
- Macquarie University Hospital, Macquarie Park, NSW, Australia
- Faculty of Medicine and Health, Macquarie University, Macquarie Park, NSW, Australia
| | - Matthew Lee
- Radiology, Western Imaging Group, Blacktown, NSW, Australia
| | - Tsz Ming Wong
- Department of Rehabilitation Sciences, Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong
| | - Regen Hoi Yan Cheng
- Department of Rehabilitation Sciences, Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong
| | - Cliffton Chan
- School of Medical Sciences, The University of Sydney, Camperdown, NSW, Australia
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Wathen C, Ghenbot Y, Chauhan D, Schuster J, Petrov D. Management of Traumatic Atlantooccipital Dissociation at a Level 1 Trauma Center: A Retrospective Case Series. World Neurosurg 2023; 170:e264-e270. [PMID: 36336270 DOI: 10.1016/j.wneu.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 10/31/2022] [Accepted: 11/01/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Atlantooccipital dislocation (AOD) is a highly unstable and often neurologically devastating injury to the craniocervical junction that typically results from high-energy trauma. Management of these devastating injuries is complex, with prognostication difficult due to high rates of concomitant intracranial and systemic injuries. This report highlights advances in management of AOD and appropriate implementation of operative adjuncts including neuronavigation and the use of intraoperative neuromonitoring. METHODS All patients with AOD presenting to a high-volume, level 1 trauma center between January 2015 and August 2021 were retrospectively identified through a prospectively maintained database of patients presenting with traumatic spine injuries. Medical records, including imaging reports, clinical documentation, and intraoperative neurophysiological reports were reviewed. RESULTS A total of 11 patients were identified with patterns of injury consistent with AOD. Fifty-five percent of patients survived until discharge. 73% of patients underwent surgery for stabilization. All 4 patients with preoperative neurologic deficits who underwent surgery had monitorable transcranial motor evoked potentials and somatosensory evoked potentials. Two experienced significant motor recovery postoperatively, and 2 did not survive to discharge. Blunt cerebrovascular injuries were identified in 73% of patients. CONCLUSION AOD is encountered with increasing frequency. The identification and management of this specific injury is complicated by the volume and severity of associated injuries, especially concomitant traumatic brain injury. Timely recognition is critical and the use of surgical adjuncts including intraoperative neurophysiologic monitoring and surgical navigation can increase the safety and success of these procedures while also providing prognostic information on potential for motor recovery.
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Affiliation(s)
- Connor Wathen
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Yohannes Ghenbot
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Daksh Chauhan
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - James Schuster
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Dmitriy Petrov
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Comparison between 2D TSE and 3D SPACE in the evaluation of craniocervical ligaments. 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 2023; 32:361-367. [PMID: 36477892 DOI: 10.1007/s00586-022-07459-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 11/02/2022] [Accepted: 11/07/2022] [Indexed: 12/12/2022]
Abstract
PURPOSE To evaluate the MRI findings of the craniocervical junction ligaments and compare the 2D TSE sequence and 3D SPACE sequence on cervical spine MRI. METHODS Eighty cervical spine MRIs were retrospectively analyzed, including 2D TSE and 3D SPACE sequences. The visibility and morphology of the transverse ligament (TL) and alar ligament (AL) were evaluated by two readers using a five-point grading scale for visibility (1 = not visible, 2 = barely visible, 3 = adequately visible, 4 = good visibility, 5 = excellent visibility) and a four-point grading scale for morphology (0 = homogeneous low SI with normal thickness, 1 = high SI with normal thickness, 2 = reduced thickness, 3 = full-thickness rupture or indistinguishable from surrounding structures). The grades of the two sequences were compared. Reader agreements were measured using the percentage of exact agreement. RESULT The visibility grade of TL was significantly higher in 3D, indicating better visualization. The morphology grade of TL was significantly lower in the 3D, indicating more normal-appearing ligament. The exact agreements of visibility and morphology grade of TL tended to be higher in 3D. On the other hand, there was no significant difference in visibility grade of AL between the two sequences. The morphological grade of AL was significantly higher in 3D. The agreement of the morphological grade of AL tended to be lower in 3D. CONCLUSION The utilization of 3D sequences significantly improves the visibility of TL and could potentially reduce false-positive diagnoses of ligament injury.
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15
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Gurjar HK, Rai HIS, Mishra S, Garg K. Technical Considerations in Surgical Fixation of Jefferson Fracture. INDIAN JOURNAL OF NEUROTRAUMA 2022. [DOI: 10.1055/s-0042-1759854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
AbstractJefferson fracture is defined as the simultaneous disruption of the continuity of the anterior and posterior arches of the atlas vertebra. It generally results from an axial impact to the head. Most of these fractures are amenable to nonoperative management. Significant disruption of the transverse atlantal ligament that is the main stabilizing ligament of the atlantoaxial articulation and contiguous spinal injuries often form the indications for operative intervention in these fractures. The outward and caudal displacement of the C1 lateral masses observed in these fractures often requires significant deviation from the standard operative technique of atlantoaxial fixation when the osseous elements are intact. Accordingly, we have described the surgical nuances relevant to the exposure and instrumentation of the atlantoaxial region in the setting of Jefferson fracture, through our experience in two cases.
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Affiliation(s)
- Hitesh Kumar Gurjar
- Department of Neurosurgery & Gamma-Knife, All India Institute of Medical Sciences, New Delhi, India
| | - Hitesh Inder Singh Rai
- Department of Neurosurgery & Gamma-Knife, All India Institute of Medical Sciences, New Delhi, India
| | - Shashwat Mishra
- Department of Neurosurgery & Gamma-Knife, All India Institute of Medical Sciences, New Delhi, India
| | - Kanwaljeet Garg
- Department of Neurosurgery & Gamma-Knife, All India Institute of Medical Sciences, New Delhi, India
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16
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An anatomical and radiological study of the tectorial membrane and its clinical implications. Sci Rep 2022; 12:21480. [PMID: 36509799 PMCID: PMC9744818 DOI: 10.1038/s41598-022-25213-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 11/28/2022] [Indexed: 12/14/2022] Open
Abstract
The radiological image of an intact tectorial membrane (TM) became an important favorable prognostic factor for craniovertebral instability. This study visualized the fascial layers of the TM and adjacent connective tissues with clinical significance by micro-CT and histological analysis. The TM firmly attached to the bony surface of the clivus, traversed the atlantoaxial joint posteriorly, and was inserted to the body of the axis showing wide distribution on the craniovertebral junction. The supradental space between the clivus, dens of the axis, anterior atlantooccipital membrane, and the TM contained profound venous networks within the adipose tissues. At the body of the axis, the compact TM layer is gradually divided into multiple layers and the deeper TM layers reached the axis while the superficial layer continued to the posterior longitudinal ligament of the lower vertebrae. The consistent presence of the fat pad and venous plexus in the supradental space and firm stabilization of the TM on the craniovertebral junction was demonstrated by high-resolution radiologic images and histological analysis. The evaluation of the TM integrity is a promising diagnostic factor for traumatic craniovertebral dislocation.
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Wittig TM, Ziegeler K, Kreutzinger V, Golchev M, Ponsel S, Diekhoff T, Ulas ST. Dual-Energy Computed Tomography Collagen Density Mapping of the Cranio-Cervical Ligaments-A Retrospective Feasibility Study. Diagnostics (Basel) 2022; 12:diagnostics12122966. [PMID: 36552973 PMCID: PMC9776840 DOI: 10.3390/diagnostics12122966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 11/20/2022] [Accepted: 11/24/2022] [Indexed: 11/29/2022] Open
Abstract
The objectives of this study were to investigate the mean collagen content of the atlanto-axial joint (AAJ) ligaments in a cohort without inflammatory disease and to analyze clinical confounders such as age, sex, and presence of ligamentous calcifications. A total of 153 patients who underwent dual-energy computed tomography (DECT) due to various reasons (e.g., suspected cancer or infection) were included in this retrospective study. Reconstruction of collagen density maps from the DECT dataset was performed. Region of interest (ROI) analysis was performed to assess densities in the following regions: ligamentum transversum atlantis (LTA), ligamenta alaria, fasciculi longitudinales, ligamentum nuchae, and retro-odontoid soft tissue (RDS). Osteoarthritis (OA) and the presence of calcifications were assessed by two experienced readers blinded to clinical data. Subgroup comparisons were performed using unpaired t-tests. The correlation of collagen density and clinical factors was investigated using Pearson's correlation coefficient. Mean LTA collagen density was 141.7 (SD 35.7). Ligamentous calcifications were rare (14.4 %). OA of the AAJ was common (91.5 %). LTA collagen density was not associated with age (Pearson's r of 0.109; p = 0.180) and was not significantly higher in patients with OA (p = 0.070). No correlations between RDS thickness, collagen density or calcifications were found. Our results show collagen density mapping of the cranio-cervical joint ligaments to be feasible; collagen densities are not significantly associated with age, sex, AAJ degeneration, or asymptomatic ligamentous calcification.
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Affiliation(s)
- Thomas Matthias Wittig
- Department of Radiology, Charité-Universitätsmedizin Berlin, Campus Mitte, Humboldt-Universität zu Berlin, Freie Universität Berlin, 10117 Berlin, Germany
| | - Katharina Ziegeler
- Department of Radiology, Charité-Universitätsmedizin Berlin, Campus Mitte, Humboldt-Universität zu Berlin, Freie Universität Berlin, 10117 Berlin, Germany
| | - Virginie Kreutzinger
- Department of Radiology, Vivantes Klinikum im Friedrichshain, 10249 Berlin, Germany
| | - Milen Golchev
- Department of Radiology, Charité-Universitätsmedizin Berlin, Campus Mitte, Humboldt-Universität zu Berlin, Freie Universität Berlin, 10117 Berlin, Germany
| | - Simon Ponsel
- Department of Radiology, Charité-Universitätsmedizin Berlin, Campus Mitte, Humboldt-Universität zu Berlin, Freie Universität Berlin, 10117 Berlin, Germany
| | - Torsten Diekhoff
- Department of Radiology, Charité-Universitätsmedizin Berlin, Campus Mitte, Humboldt-Universität zu Berlin, Freie Universität Berlin, 10117 Berlin, Germany
| | - Sevtap Tugce Ulas
- Department of Radiology, Charité-Universitätsmedizin Berlin, Campus Mitte, Humboldt-Universität zu Berlin, Freie Universität Berlin, 10117 Berlin, Germany
- Berlin Institute of Health at Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany
- Correspondence: ; Tel.: +49-30-450-627044
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Muacevic A, Adler JR, Patel J, Jenson M, Rao D. Interrelationship Between Craniocervical Dissociation Spectrum Injuries and Atlantoaxial Instability on Trauma Cervical MRI Examinations. Cureus 2022; 14:e31238. [PMID: 36514650 PMCID: PMC9733797 DOI: 10.7759/cureus.31238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 11/08/2022] [Indexed: 11/09/2022] Open
Abstract
Background and purpose Craniocervical dissociation injuries encompass a spectrum of osteoligamentous injuries between the skull base and C1-C2 that may be treated via prolonged external immobilization versus occipital cervical fusion depending on the risk of persistent craniocervical instability. However, the presence of atlantoaxial instability (AAI) at C1-C2, as determined by transverse atlantal ligament (TAL) integrity with or without a C1 fracture, may guide the neurosurgical management of craniocervical dissociation spectrum injuries (CDSI) since it implies an overall greater degree of instability at the craniocervical junction (CCJ). Materials and methods Adult trauma patients who suffered a transverse atlantal ligament injury on cervical magnetic resonance imaging (MRI) were identified retrospectively. The cervical computed tomography (CT) and magnetic resonance imaging examinations for these patients were reviewed for additional traumatic findings. Demographic information, treatment, and outcome information were recorded. Results Twenty-nine trauma patients presented to the emergency department (ED) with an acute, midsubstance transverse atlantal ligament tear on cervical magnetic resonance imaging. Thirty-one percent of patients demonstrated a tear in at least one major craniocervical ligament (atlanto-occipital capsular ligaments, alar ligaments, and tectorial membrane {TM}) with 14% demonstrating a tear in two major craniocervical ligaments and no patients demonstrating a tear in all three major craniocervical ligaments. Minor craniocervical ligament injuries (anterior atlanto-occipital membrane complex {AAOMc} and posterior atlanto-occipital membrane complex {PAOMc}) were common and observed in 76% of patients. Conclusions Our study suggests that multiple major craniocervical junction ligamentous injuries on cervical magnetic resonance imaging are relatively uncommon in the setting of transverse atlantal ligament injury.
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Craniocervical Junction and Cervical Spine Anatomy. Neuroimaging Clin N Am 2022; 32:875-888. [DOI: 10.1016/j.nic.2022.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Fiester P, Soule E, Rao D, Patel J, Jenson M, Rahmathulla G, Orallo P. Appropriateness of Cervical Magnetic Resonance Imaging in the Evaluation and Management of C1 Jefferson Fractures. World Neurosurg 2022; 167:e137-e145. [PMID: 35948216 DOI: 10.1016/j.wneu.2022.07.117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 07/25/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Traditionally, C1 fractures have been designated as stable or unstable based on the inherent integrity of the transverse altantal ligament. The purpose of our study was to identify adult trauma patients with C1 fractures on cervical computed tomography and evaluate whether C1-C2 alignment differed in patients with and without an associated transverse atlantal ligament injury on follow-up cervical magnetic resonance imaging. METHODS Adult trauma patients who suffered a C1 fracture were identified retrospectively. The cervical computed tomography examinations for these patients were reviewed for the following: C1 fracture classification, anterior atlantodens interval (ADI) widening, asymmetry in the lateral atlantodens interval, C1 lateral mass offset, and atlantoaxial rotation. RESULTS Acute C1 fractures were grouped into those with an unequivocal transverse atlantal ligament injury (n = 12), and patients with an unequivocally intact transverse atlantal ligament (n = 20). Three patients were classified as indeterminate for transverse atlantal ligament injury. Statistically significant increases in lateral ADI asymmetry and combined C1 lateral mass offset were identified in patients with transverse atlantal ligament tears. CONCLUSIONS Lateral ADI asymmetry (using a cutoff of >3 mm), combined C1 lateral mass offset, and anterior ADI demonstrate robust specificity to "rule in" transverse atlantal ligament injury. Atlantoaxial alignment was overall relatively insensitive as a screening test although sensitivity can be improved using a cutoff of >2 mm for lateral ADI asymmetry. Our findings reinforce the role of cervical magnetic resonance imaging in the diagnostic workup and clinical management of trauma patients with an acute burst fracture of the C1 vertebra.
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Affiliation(s)
- Peter Fiester
- Department of Neuroradiology, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA.
| | - Erik Soule
- Department of Neuroradiology, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA
| | - Dinesh Rao
- Department of Neuroradiology, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA
| | - Jeet Patel
- Department of Neuroradiology, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA
| | - Matthew Jenson
- Department of Neuroradiology, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA
| | - Gazanfar Rahmathulla
- Department of Neurosurgery, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA
| | - Peaches Orallo
- Department of Anesthesiology, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA
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Fiester P, Rao D, Soule E, Jenson M, Patel J, Supsupin E, Rahmathulla G, Tavanaiepour D. Radiologic utility of the Gehweiler and AO spine classification systems for C1 Trauma: A retrospective review from a Level I trauma center. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2022; 13:432-438. [PMID: 36777912 PMCID: PMC9910133 DOI: 10.4103/jcvjs.jcvjs_133_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 10/30/2022] [Indexed: 12/12/2022] Open
Abstract
Objective The purpose of our study was to identify adult trauma patients with an acute C1 burst fracture, evaluate for concomitant transverse atlantal ligament (TAL) injury, and apply the modified Gehweiler and AO spine classification systems to determine the utility of these classification systems in accurately defining C1 trauma. Materials and Methods Adult trauma patients with an acute C1 fracture were identified retrospectively using Nuance mPower software. The C1 fracture was described based on whether the fracture involved the anterior arch, posterior arch, lateral mass, medial tubercle, and/or transverse process. If follow-up cervical magnetic resonance imaging (MRI) was performed, the presence and location of an associated TAL injury was recorded. The anatomic location of the C1 burst fracture and TAL injury, if present, were compared with the descriptive classification systems outlined by Gehweiler/Dickman (modified) and the AO Spine society. Any additional osseous trauma of the skull base and C1-C2 was also recorded along with relevant clinical history and management. Results Thirty-nine patients were identified with an acute C1 burst fracture on cervical computed tomography (CT) with seventy-seven percent of patients undergoing follow-up cervical MRI. Observed fracture patterns were divided into five distinct types based on CT findings and further subdivided based on the integrity of the transverse altantal ligament on MRI. TAL tears were observed exclusively in type 3 fractures (anterior and posterior arch fractures) and type 4 fractures (anterior arch, posterior arch, and lateral mass fractures). The modified Gehweiler classification system failed to accurately describe the anatomic location of the C1 fracture in forty-four percent of patients, whereas the AO spine was too broad and failed to accurately describe fracture location in our cohort. Conclusions The Gehweiler and AO spine classifications demonstrated significant shortcomings in the accurate description of patients with C1 trauma. Whereas the Gehweiler system did not accurately describe the anatomic location of the various C1 fractures, the AO spine system was too broad and failed to radiologically classify fracture location. Moreover, there was a high number of patients with AO spine type B injuries without atlantoaxial translation that nevertheless required C1-C2 fusion for atlantoaxial instability. We suggest the need for an updated classification system that takes into account both the CT (fracture location) and MRI (TAL integrity) appearance of C1 trauma. An updated classification strategy will offer a radiologic standardization of C1 trauma that will aid in future research studies and help optimize patient management.
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Affiliation(s)
- Peter Fiester
- Department of Radiology, University of Florida Health, Jacksonville, Florida, USA
| | - Dinesh Rao
- Department of Radiology, University of Florida Health, Jacksonville, Florida, USA
| | - Erik Soule
- Department of Radiology, University of Florida Health, Jacksonville, Florida, USA
| | - Matthew Jenson
- Department of Radiology, University of Florida Health, Jacksonville, Florida, USA
| | - Jeet Patel
- Department of Radiology, University of Florida Health, Jacksonville, Florida, USA
| | - Emilio Supsupin
- Department of Radiology, University of Florida Health, Jacksonville, Florida, USA
| | - Gazanfar Rahmathulla
- Department of Neurosurgery, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Daryoush Tavanaiepour
- Department of Neurosurgery, University of Florida College of Medicine, Jacksonville, Florida, USA
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22
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Pediatric craniocervical fusion: predictors of surgical outcomes, risk of recurrence, and re-operation. Childs Nerv Syst 2022; 38:1531-1539. [PMID: 35511272 DOI: 10.1007/s00381-022-05541-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 04/22/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE Craniocervical junction abnormalities include a wide variety of disorders and can be classified into congenital or acquired. This study aimed to review the surgical outcome of pediatric patients who underwent craniocervical and/or atlantoaxial fusion. METHODS This is a retrospective cohort study including all pediatric patients (≤ 18 years) who underwent craniocervical and/or atlantoaxial fusion between 2009 and 2019 at quaternary medical city. RESULTS A total of 25 patients met our criteria and were included in the study. The mean age was 9 years (range: 1-17 years). There was a slight female preponderance (N = 13; 52%). Most patients (N = 16; 64%) had non-trauamatic/chronic causes of craniocervical instability. Most patients presented with neck pain and/or stiffness (N = 14; 56%). Successful fusion of the craniocervical junction was achieved in most patients (N = 21; 84%). Intraoperative complications were encountered in 12% (N = 3) of the patients. Early postoperative complications were observed in five patients (20%). Five patients (20%) experienced long-term complications. Revision was needed in two patients (8%). Older age was significantly associated with higher fusion success rates (p = 0.003). The need for revision surgery rates was significantly higher among younger age group (3.75 ± 2, p = 0.01). CONCLUSIONS The study demonstrates the surgical outcome of craniocervical and/or atlantoaxial fusion in pediatric patients. Successful fusion of the craniocervical junction was achieved in most patients. Significant association was found between older age and successful fusion, and between younger age and need for revision surgery.
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23
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Kopparapu S, Mao G, Judy BF, Theodore N. Fifty years later: the "rule of Spence" is finally ready for retirement. J Neurosurg Spine 2022; 37:149-156. [PMID: 35148514 DOI: 10.3171/2021.12.spine211188] [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: 09/29/2021] [Accepted: 12/20/2021] [Indexed: 11/06/2022]
Abstract
Determination of the optimal approach to traumatic atlas fractures with or without transverse atlantal ligament (TAL) injury requires a nuanced understanding of the biomechanics of the atlantoaxial complex. The "rule of Spence" (ROS) was created in 1970 in a landmark effort to streamline management of burst-type atlas fractures. The ROS states that radiographic evidence of lateral mass displacement (LMD) (i.e., the distance that the C1 lateral masses extend beyond the C2 superior articular processes) greater than 6.9 mm may indicate both a torn TAL and need for surgical management. Since then, the ROS has become ubiquitous in the spine literature about atlas injuries. However, in the decades since the original paper by Spence et al., modern research efforts and imaging advancements have revealed that the ROS is inaccurate on both fronts: it neither accurately predicts a TAL injury nor does it inform surgical decision-making. The purpose of this review was to delineate the history of the ROS, demonstrate its limitations, present findings in the existing literature on ROS and LMD thresholds, and discuss the current landscape of management techniques for TAL injuries, including parameters such as the atlantodental interval and type of injury according to the Dickman classification system and AO Spine upper cervical injury classification system. The ROS was revolutionary for initially investigating and later propelling the biomechanical and clinical understanding of atlas fractures and TAL injuries; however, it is time to retire its legacy as a rule.
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24
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DeNunzio G, Evans T, Beebe ME, Browning J, Koivisto J. Craniocervical Junction Visualization and Radiation Dose Consideration Utilizing Cone Beam Computed Tomography for Upper Cervical Chiropractic Clinical Application a Literature Review. Dose Response 2022; 20:15593258221107515. [PMID: 35719850 PMCID: PMC9201332 DOI: 10.1177/15593258221107515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives To highlight the detail obtained on a Cone Beam Computed Tomography (CBCT) scan of the craniocervical junction and its usefulness to Chiropractors who specialize in the upper cervical spine. A review of the dose considerations to patients vs radiography in a chiropractic clinical setting and to review the effective radiation dose to the patient. Methods A review of studies discussing cervical biomechanics, neurovascular structures, and abnormal radiographic findings, was discussed in relation to chiropractic clinical relevance. Further studies were evaluated demonstrating radiation dose to the patient from radiographs compared to CBCT. Results Incidental and abnormal findings of the craniocervical junction were shown to have superior visualization with CBCT compared to radiography. The radiation dose to the patient for similar imaging protocols to the craniocervical junction and cervical spine was equal or less utilizing CBCT when compared to radiographs. Conclusions The use of CBCT for visualization of the craniocervical junction and cervical spine in the chiropractic clinical setting allows for adjunctive visualization of the osseous structures which is germane to clinical protocol. Further with CBCT the effective dose to the patient is equal or less than similar imaging protocols utilizing radiographs to evaluate the craniocervical junction.
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Affiliation(s)
- Greg DeNunzio
- Sweere Center for Clinical Biomechanics and Applied Ergonomics, Northwestern Health Sciences University, Bloomington, MI, USA
| | - Tyler Evans
- Private Practice, Arete Chiropractic, Portsmouth, NH, USA
| | - Mychal E Beebe
- Private Practice, Arete Chiropractic, Portsmouth, NH, USA
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25
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Odontoid Fractures: A Standard Review of Current Concepts and Treatment Recommendations. J Am Acad Orthop Surg 2022; 30:e561-e572. [PMID: 35266921 DOI: 10.5435/jaaos-d-21-00165] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 11/08/2021] [Indexed: 02/01/2023] Open
Abstract
Odontoid fractures represent the most common fractures involving C2 and the most common cervical spine fractures in patients older than 65 years. Despite their increasing frequency, optimal management of these injuries remain a subject to debate. Although types I and III injuries have relatively good healing potential with nonsurgical treatment, type II fractures carry a higher risk for nonunion. In particular, elderly patients are at risk for nonunion or fibrous malunion after nonsurgical treatment; however, increased medical comorbidities and poor bone quality also increase the risks of surgery in this cohort. The high morbidity and mortality associated with these injuries has made it an area of particular interest among spine surgeons. The purpose of this review was to summarize the pathophysiology, evaluation, and diagnosis of these injuries and to review controversies in management and considerations for treatment based on the most recent available literature.
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26
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Kikuta S, Iwanaga J, Ishak B, Dumont AS, Tubbs RS. A Comprehensive Review of the Superficial Anterior Atlanto-Occipital Ligament of the Craniocervical Junction. Kurume Med J 2022; 67:1-4. [PMID: 35095017 DOI: 10.2739/kurumemedj.ms671005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
This paper aimed to better describe the anatomy of the superficial anterior atlanto-occipital ligament of the craniocervical junction and discuss this ligament's potential function and clinical implications. A broad literature review on the anatomical features and findings of the superficial anterior atlanto-occipital ligament was performed. The superficial anterior atlanto-occipital ligament is located anterior to the anterior atlanto-occipital membrane. However, the physiological role of the superficial anterior atlanto-occipital ligament is still unclear due to a lack of anatomical and biomechanical studies although one study has suggested that this ligament is a secondary stabilizer of the craniocervical junction. Further studies are needed to clarify the function and anatomy of the superficial anterior atlanto-occipital ligament.
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Affiliation(s)
- Shogo Kikuta
- Dental and Oral Medical Center, Kurume University School of Medicine
| | - Joe Iwanaga
- Dental and Oral Medical Center, Kurume University School of Medicine.,Division of Gross and Clinical Anatomy, Department of Anatomy, Kurume University School of Medicine.,Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine
| | - Basem Ishak
- Department of Neurosurgery, Heidelberg University Hospital
| | - Aaron S Dumont
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine
| | - R Shane Tubbs
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine.,Department of Neurosurgery and Ochsner Neuroscience Institute, Ochsner Health System.,Department of Structural & Cellular Biology, Tulane University School of Medicine.,Department of Anatomical Sciences, St. George's University
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27
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Fiester P, Rao D, Soule E, Jenson M, Rahmathulla G. Occult craniocervical dissociation on cervical CT: an under-appreciated presentation of craniocervical trauma requiring occipital cervical fusion. Emerg Radiol 2022; 29:383-393. [PMID: 35029773 DOI: 10.1007/s10140-022-02018-4] [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: 11/01/2021] [Accepted: 01/05/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND PURPOSE Craniocervical dissociation is a rare and life-threatening injury that results from a significant hyperflexion-hyperextension force. Occult craniocervical dissociation is defined as an unstable craniocervical injury in the absence of atlanto-occipital joint space widening or other skull base line abnormality. The early and accurate diagnosis of craniocervical dissociation is crucial since the early diagnosis and subsequent stabilization with occipital-cervical fusion has been shown to reduce neurologic morbidity and mortality. Several normative skull base lines have been developed to predict craniocervical dissociation. The purpose of our study was to measure the atlanto-occipital joint space and four other common skull base lines in patients who underwent occipital-cervical fusion for post-traumatic craniocervical instability. MATERIALS AND METHODS Patients who underwent occipital-cervical fusion for craniocervical injury were identified retrospectively using a keyword search of radiology reports using Nuance mPower software. The cervical CT and MRI exams for these patients were reviewed and the atlanto-occipital joint space, Powers ratio, Wackenheim line, posterior axial line, and basion dens interval were measured. Detailed descriptions of craniocervical ligament injuries on MRI were recorded along with patient demographic information, clinical history, management, and outcome. RESULTS Nine adult patients who underwent occipital-cervical fusion for an acute craniocervical injury were identified. Six patients demonstrated an atlanto-occipital joint space measuring 2 mm or less on cervical spine CT with no additional abnormality in the Powers ratio, Wackenheim line, posterior axial line, or basion-dens interval. Three patients demonstrated widening of the atlanto-occipital joint space with two patients demonstrating an abnormality in at least two additional skull base lines. Clinical outcomes were variable with nearly half of the patients demonstrating persistent neurologic deficits, including one quadriplegic patient. CONCLUSIONS A normal atlanto-occipital joint space and skull base line measurements on cervical CT demonstrated a low predictive value for detecting unstable craniocervical injuries. Occult craniocervical dissociation was present in two-thirds of patients who underwent occipital cervical fusion for acute, craniocervical trauma. A high clinical and radiologic index of suspicion for craniocervical trauma with subsequent follow-up cervical MRI to directly evaluate ligamentous integrity is necessary to accurately diagnose and triage patients with high velocity trauma.
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Affiliation(s)
- Peter Fiester
- Department of Neuroradiology, University of Florida College of Medicine - Jacksonville, 655 West 8th Street, Jacksonville, FL, 32209, USA
| | - Dinesh Rao
- Department of Neuroradiology, University of Florida College of Medicine - Jacksonville, 655 West 8th Street, Jacksonville, FL, 32209, USA
| | - Erik Soule
- Department of Neuroradiology, University of Florida College of Medicine - Jacksonville, 655 West 8th Street, Jacksonville, FL, 32209, USA.
| | - Matthew Jenson
- Department of Neuroradiology, University of Florida College of Medicine - Jacksonville, 655 West 8th Street, Jacksonville, FL, 32209, USA
| | - Gazanfar Rahmathulla
- Department of Neurosurgery, University of Florida College of Medicine - Jacksonville, 655 West 8th Street, Jacksonville, FL, 32209, USA
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28
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Shiraishi D, Nishimura Y, Aguirre-Carreno I, Hara M, Yoshikawa S, Eguchi K, Nagashima Y, Ito H, Haimoto S, Yamamoto Y, Ginsberg HJ, Takayasu M, Saito R. Clinical and Radiological Clues of Traumatic Craniocervical Junction Injuries Requiring Occipitocervical Fusion to Early Diagnosis. Neurospine 2022; 18:741-748. [PMID: 35000327 PMCID: PMC8752707 DOI: 10.14245/ns.2142860.430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 10/16/2021] [Indexed: 11/19/2022] Open
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 (atlantodens 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.
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Affiliation(s)
- Daimon Shiraishi
- Department of Neurosurgery, Nagoya University Hospital, Nagoya, Japan.,Department of Neurosurgery, Inazawa Manucipal Hospital, Aichi, Japan
| | - Yusuke Nishimura
- Department of Neurosurgery, Nagoya University Hospital, Nagoya, Japan
| | - Isaac Aguirre-Carreno
- Division of Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Masahito Hara
- Department of Neurosurgery, Aichi Medical University Hospital, Aichi, Japan
| | - Satoshi Yoshikawa
- Department of Neurosurgery, Nagoya University Hospital, Nagoya, Japan
| | - Kaoru Eguchi
- Department of Neurosurgery, Nagoya University Hospital, Nagoya, Japan
| | | | - Hiroshi Ito
- Department of Neurosurgery, Nagoya University Hospital, Nagoya, Japan
| | - Shoichi Haimoto
- Department of Neurosurgery, Nagoya University Hospital, Nagoya, Japan
| | - Yu Yamamoto
- Department of Neurosurgery, Inazawa Manucipal Hospital, Aichi, Japan
| | - Howard J Ginsberg
- Department of Neurosurgery, Inazawa Manucipal Hospital, Aichi, Japan
| | - Masakazu Takayasu
- Department of Neurosurgery, Aichi Medical University Hospital, Aichi, Japan
| | - Ryuta Saito
- Department of Neurosurgery, Nagoya University Hospital, Nagoya, Japan
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29
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Lepard J, Reed L, Theiss S, Rajaram S. Unilateral atlanto-occipital injury: A case series and detailed radiographic description. J Craniovertebr Junction Spine 2022; 13:344-349. [PMID: 36263347 PMCID: PMC9574108 DOI: 10.4103/jcvjs.jcvjs_79_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 07/31/2022] [Indexed: 11/22/2022] Open
Abstract
Context Atlanto-occipital dissociation is a highly lethal ligamentous injury at the craniocervical junction (CCJ). Previous studies have described rare cases of milder forms of atlanto-occipital injury (AOI) which might be managed nonoperatively, but there is a paucity of literature on this subject. Aims: We retrospectively reviewed our institutional experience to characterize the injury patterns, treatments, and clinical courses of patients with unilateral AOI. Methods: We included patients with radiographic evidence of unilateral occipitocervical joint capsular disruption, distraction, or edema ± injury of the apical ligament, tectorial membrane, anterior atlanto-occipital membrane, posterior atlanto-occipital membrane, alar ligaments, or cruciate ligament. The long-term outcomes were gathered from medical records, and six patients were available for Neck Disability Index via phone call at the time of the study. Results: Eight patients were included in the study. The mean age was 45.1 years ± 26.5. Causes of trauma included motor vehicle collision for five patients (5/8, 62.5%), falls for two (2/8, 25), and assault for one (1/8, 12.5%). All patients had a widened condyle-C1 interval >2 mm. Three patients underwent occipitocervical fusion, one patient underwent atlantoaxial fusion, and another received subaxial fusions for other injuries. Three patients underwent no surgical intervention. All patients were seen at least once as an outpatient following hospital discharge. There were no delayed neurologic injuries or deaths. Conclusions: We propose that ligamentous injury at the CCJ functions more as a spectrum rather than dichotomous diagnosis, of which a subset can likely be safely managed nonoperatively.
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30
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Fiester P, Soule E, Rahmathulla G, Rao D. C1-C2 Dorsal Epidural Hematoma on Cervical Spine CT: A Novel Imaging Sign of Posterior Atlanto-Occipital Membrane Stripping Injury. Cureus 2021; 13:e19543. [PMID: 34934561 PMCID: PMC8668148 DOI: 10.7759/cureus.19543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 11/12/2021] [Indexed: 11/28/2022] Open
Abstract
Background and Purpose: Identify patients with a dorsal epidural hematoma at C1-C2 and examine the major craniocervical junction ligaments for injury on follow-up magnetic resonance imaging. Materials and Methods: Adult and pediatric trauma patients who suffered a dorsal epidural hematoma at C1-C2 were identified using Nuance mPower software (Nuance Communications, United States). The cervical computed tomography and magnetic resonance imaging exams for these patients were reviewed for craniocervical junction osteoligamentous injuries. An age-matched control group was obtained. Results: Eight trauma patients were identified with a dorsal epidural fluid collection at C1-C2. All patients with a dorsal epidural hematoma, who underwent follow-up cervical magnetic resonance imaging demonstrated a stripping injury of the posterior atlanto-occipital membrane from the C1 posterior arch with increased short tau inversion recovery signal in the posterior atlanto-occipital membrane complex. Disruption of additional major craniocervcial ligaments on magnetic resonance imaging was relatively common with the most frequently associated ligamentous injuries involving the tectorial membrane (five patients) followed by the alar ligaments and anterior altanto-occiptial membrane (four patients each). Conclusions: A C1-C2 dorsal epidural hematoma is a rare injury that may be identified on cervical spine computed tomography but may be easily overlooked by the radiologist. We propose that a C1-C2 dorsal epidural hematoma is a direct result of a significant hyperflexion-hyperextension force with subsequent stripping of the posterior atlanto-occipital membrane from the posterior C1 arch. Trauma patients with a C1-C2 dorsal epidural hematoma on cervical spine computed tomography should undergo a cervical magnetic resonance imaging examination to evaluate the integrity of the posterior atlanto-occipital membrane complex and remaining craniocervical junction ligaments for injury.
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Affiliation(s)
- Peter Fiester
- Neuroradiology, University of Florida College of Medicine, Jacksonville, USA
| | - Erik Soule
- Interventional Radiology, University of Florida College of Medicine, Jacksonville, USA
| | - Gazanfar Rahmathulla
- Neurological Surgery, University of Florida College of Medicine, Jacksonville, USA
| | - Dinesh Rao
- Neuroradiology, University of Florida College of Medicine, Jacksonville, USA
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31
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Ikwuezunma IA, Sponseller PD. Surgical Evaluation and Management of Spinal Pathology in Patients with Connective Tissue Disorders. Neurosurg Clin N Am 2021; 33:49-59. [PMID: 34801141 DOI: 10.1016/j.nec.2021.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Connective tissue disorders represent a varied spectrum of syndromes that have important implications for the spine deformity surgeon. Spine surgeons must be aware of these diverse and global manifestations of disease because they have significant impact on perioperative and postoperative outcomes.
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Affiliation(s)
- Ijezie A Ikwuezunma
- Department of Orthopaedic Surgery, Johns Hopkins Medical Institutions, Baltimore, MD 21287, USA
| | - Paul D Sponseller
- Pediatric Orthopaedics, Johns Hopkins Medical Institutions, Baltimore, MD 21287, USA.
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32
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Koljonen PA, Cheung KM. Concomitant atlantoaxial and atlanto-occipital rotatory dislocation in children: Radiological features, diagnostic pitfalls, and long-term outcome. J Orthop Surg (Hong Kong) 2021; 29:23094990211015502. [PMID: 33998343 DOI: 10.1177/23094990211015502] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
While the pathological manifestation of atlantoaxial rotatory dislocation has been well described in the medical literature, the combined dislocation of the atlantoaxial and atlanto-occipital joints, or OAARD - short for occipital-atlantoaxial rotatory dislocation - is a condition which has been poorly elucidated and probably underdiagnosed. We believe that the pathogenesis of combined atlantoaxial and atlanto-occipital dislocation is most likely a result of untreated atlantoaxial rotatory dislocation leading to chronic secondary compensation measures occurring at the occiput-C1 joints. Unique clinical and radiological features lead to difficulty in diagnosis, and conventional treatment algorithms may not apply. This paper describes a combination of clinical and radiological features which can help clinicians correctly diagnose and treat OAARD.
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Affiliation(s)
- Paul A Koljonen
- Department of Orthopaedics and Traumatology, Li Ka Shing Faculty of Medicine, 25809The University of Hong Kong, Hong Kong
| | - Kenneth Mc Cheung
- Department of Orthopaedics and Traumatology, Li Ka Shing Faculty of Medicine, 25809The University of Hong Kong, Hong Kong
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33
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Occipital condylar avulsion fractures in the acute trauma setting: Stable or unstable injury? 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 2021; 30:3128-3134. [PMID: 34338873 DOI: 10.1007/s00586-021-06949-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 06/15/2021] [Accepted: 07/23/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND AND PURPOSE Occipital condylar avulsion fractures are considered potentially unstable, associated with craniocervical dissociation spectrum injuries, and thought to carry a relatively high mortality rate based on the current literature. The purpose of this study was to identify patient with acute, occipital condylar avulsion fractures and evaluate for the incidence of concomitant cervical osteoligamentous trauma and craniocervical dissociation spectrum injury on cervical spine CT and MRI. MATERIALS AND METHODS Patients who suffered an inferomedial occipital condylar avulsion fracture were identified retrospectively using Nuance mPower software. Cervical spine CT and MRI reports performed within 48 h for this patient cohort were then reviewed by two CAQ certified neuroradiologists. Confirmation of an occipital condylar avulsion fracture was recorded along with any concomitant craniocervical junction injury. Relevant clinical history, including management and outcomes, was recorded for each patient. RESULTS Thirty-four patients were identified with an inferomedial fracture of the occipital condyle. Of the 85% of patients who underwent cervical MRI, all but one patient demonstrated a 'negative' MRI without major craniocervical junction ligamentous injury. These patients were treated conservatively with external bracing without persistent neurologic deficits upon 4-month follow-up. CONCLUSIONS Inferomedial fractures of the occipital condyle are currently classified as potentially unstable fractures based on the Anderson classification system. Our data suggest that an isolated occipital condylar avulsion fracture without an additional C1-C2 fracture or widening of the atlanto-occipital joint space is likely a stable injury that can be treated conservatively with excellent clinical outcomes.
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Wu B, Yi X, Cui W, Rong T, Sang D, Xiao B, Zhao S, Wang D, Zhang J, Liu B. An Unrecognized Ligament and its Ossification in the Craniocervical Junction: Prevalence, Patient Characteristics, and Anatomic Evidence. Clin Orthop Relat Res 2021; 479:1816-1826. [PMID: 33739308 PMCID: PMC8277284 DOI: 10.1097/corr.0000000000001719] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 02/10/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND In the craniocervical junction, the ligaments between the anterior foramen magnum and the anterior arch of the atlas are not well defined, and ossification of the ligaments in this region has rarely been reported. Characterizing the anatomy and ossification of these ligaments may help in the diagnosis and treatment of disorders in this region. QUESTIONS/PURPOSES (1) What is the prevalence of an unrecognized ossification at the craniocervical junction in patients with cervical spine disorders, and what are the patient characteristics associated with this ossification? (2) Do patients with this ossification have a greater risk of ossification of other structures at the craniocervical junction or cervical spine? (3) Is there an unreported ligament at this ossified site? METHODS We conducted a retrospective study of 578 hospitalized patients who underwent CT for cervical spine disorders between January 2016 and July 2020. Based on the inclusion criteria, 11% (66 of 578) were excluded because of a cervical or craniocervical tumor, deformity, infection, fracture or dislocation, or prior surgery, leaving 89% (512 of 578) for analysis. These 512 patients had diagnoses of cervical radiculopathy, cervical myelopathy, cervical spondylotic amyotrophy, cervical spinal cord injury without a radiographic abnormality, or axial neck pain. Their mean age was 57 years (range 22-90 years), and 60% of the patients were men. Patient characteristics including age, gender, and diagnosis were retrieved from a longitudinally maintained institutional database. CT images were used to assess the presence of a previously unrecognized ossification and ossification of other structures in the craniocervical junction and cervical spine, including the posterior longitudinal ligament, anterior longitudinal ligament, nuchal ligament, ligamentum flavum, transverse ligament, and apical ligament, as well as diffuse idiopathic skeletal hyperostosis (DISH). The association between these structures was also assessed. This unreported ossification was called the capped dens sign. It was defined and graded from 1 to 3. Grade 3 was defined as the typical capped dens sign. Cervical spine MRI was used to assess whether there was an unreported structure in the same region as where the capped dens sign was detected on CT images. In the database of a recent study, there were 33 patients younger than 41 years. Nine percent (three of 33) were excluded because they did not have cervical spine MRI. MRIs of the remaining 30 patients were assessed. Their mean age was 35 years (range 22-40 years), and 58% were men. All cervical spine CT images and MRIs were reviewed by one senior spine surgeon and one junior spine surgeon twice with a 2-week interval. Blinding was accomplished by removing identifying information from the radiographs and randomly assigning them to each examiner. Any discrepancy with respect to the grade of the capped dens sign was adjudicated by a third blinded senior spine surgeon. Intrarater and interrater reliabilities were assessed by calculating weighted kappa statistics. No ligament or membrane was reported at this site. MRI is not sensitive to identify thin tissue in this region, especially when severe degeneration has occurred. A cadaveric study was conducted to discover a potential ligament between the inferior margin of the foramen magnum and the anterior arch of the atlas, as prompted by the newly discovered ossification in the clinical analysis of this study. Six embalmed human cadaveric craniocervical regions (three male and three female cadavers; median age 56 years, range 45-78 years) were dissected by a senior anatomist and a senior anatomy technician. A mid-sagittal section of the craniocervical junction was created, allowing us to explore the interval between the anterior foramen magnum and anterior arch of the atlas. A histologic analysis was conducted in two of the six cadavers (a male cadaver, 45 years; and a female cadaver, 51 years). Slides were made with 4-µm sections and stained with hematoxylin and eosin. RESULTS A novel capped dens sign was detected in 39% (198 of 512) of the patients and the most typical capped dens sign was detected in 19% (96 of 512) of patients. The prevalence of this sign was the highest in patients with cervical spondylotic amyotrophy (12 of 25 patients). The prevalence of ossification of the anterior longitudinal ligament, ligamentum nuchae, and apical ligament, as well as DISH, was higher in patients with a capped dens sign than in those without (p = 0.04, p < 0.001, p < 0.001, and p = 0.001, respectively). The capped dens sign was identified in 69% (18 of 26) of the patients with DISH. A thin and short band-like structure or osteophyte was detected on MRI in 87% (26 of 30), in the same region as the capped dens sign. In the cadaveric study, an unreported, distinct ligamentous structure was identified at this ossified site. It originated from the posterosuperior rim of the anterior arch of the atlas to the inferior margin of the foramen magnum, which we called the inter-atlanto-occipital ligament. It was found in all six dissected craniocervical junctions. The histologic analysis revealed dense connective tissue. CONCLUSION More than one-third of the patients in this series demonstrated CT evidence of a previously unrecognized ossification in the craniocervical junction, which we called the capped dens sign. Anatomic evidence of this sign, which was a previously unidentified ligament, was also newly discovered in this region. This study was conducted among Asian patients and specimens. Further studies among diverse ethnic groups may be needed to generalize the results. An additional well-designed prospective study will be needed to provide further evidence regarding the potential pathophysiology and clinical relevance of the capped dens sign. Furthermore, the cadaveric analysis in this study was only a preliminary report of the ligament; further biomechanical research is needed to investigate its function. CLINICAL RELEVANCE Knowledge of this novel ligament may improve the diagnosis and treatment of craniocervical stability and dislocation. Ossification of this ligament is correlated with age, cervical spondylotic amyotrophy, and DISH. We wonder whether patients with cervical degenerative disorders who also have a capped dens sign may be at risk for the formation of osteophytes of an uncovertebral joint, which may result in palsy of the upper limb muscles. The capped dens sign may be the craniocervical manifestation of DISH. This possible association between the capped dens sign and DISH should be considered when performing surgery on patients with the capped dens sign.
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Affiliation(s)
- Bingxuan Wu
- Department of Orthopaedic Surgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xin Yi
- Department of Human Anatomy, Medical School, Nantong University, Nantong, China
| | - Wei Cui
- Department of Orthopaedic Surgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Tianhua Rong
- Department of Orthopaedic Surgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Dacheng Sang
- Department of Orthopaedic Surgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Bowei Xiao
- Department of Orthopaedic Surgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shuqing Zhao
- Department of Human Anatomy, Medical School, Nantong University, Nantong, China
| | - Dian Wang
- Department of Orthopaedic Surgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jianhao Zhang
- Department of Orthopaedic Surgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Baoge Liu
- Department of Orthopaedic Surgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Zhou C, Guo R, Wang C, Tsai TY, Yu Y, Wang W, Li G, Cha T. Ligament deformation patterns of the craniocervical junction during head axial rotation tracked by biplane fluoroscopes. Clin Biomech (Bristol, Avon) 2021; 88:105442. [PMID: 34390949 PMCID: PMC8490296 DOI: 10.1016/j.clinbiomech.2021.105442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 07/13/2021] [Accepted: 07/25/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Frequently, treatment decisions for craniocervical injuries and instability are based on imaging findings, but in vivo ligament kinematics were poorly understood. This study was to determine in vivo deformation patterns of primary ligaments in the craniocervical junction (i.e., C0-2), including the cruciform ligament, alar ligaments, and accessory ligaments, during dynamic head axial rotation. METHODS The skulls and cervical spines of eight asymptomatic female subjects were dynamically imaged using a biplane fluoroscopic imaging system, when they performed left and right head axial rotations. Using a 3D-to-2D registration technique, the in vivo positions and orientations of cervical segments were determined. An optimization algorithm was implemented to determine ligament wrapping paths, and the resulting ligament deformations were represented by percent elongations. Using paired t-tests, ligament deformations in the end-range position were compared to those in the neutral position. FINDINGS No significant differences were observed in segmental motions during left and right head rotations (p > 0.05). In general, slight deformations occurred in each component of the cruciform ligament. For the alar ligaments, the ipsilateral ligament was lengthened from -0.7 ± 13.8% to 16.6 ± 15.7% (p < 0.001*). For the accessory ligaments, the contralateral ligament was lengthened from -2.9 ± 7.5% to 10.1 ± 6.2% (p < 0.001*). INTERPRETATION This study reveals that there are distinct deformation patterns in craniocervical junction ligaments during dynamic axial head rotation. These ligament deformation data can enhance our understanding of the synergic function of craniocervical junction ligaments, and guide the treatment of craniocervical instability.
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Affiliation(s)
- Chaochao Zhou
- Orthopaedic Bioengineering Research Center, Newton-Wellesley Hospital, Harvard Medical School, Newton, MA, USA,Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Runsheng Guo
- Orthopaedic Bioengineering Research Center, Newton-Wellesley Hospital, Harvard Medical School, Newton, MA, USA,Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA,Department of Orthopaedics, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Cong Wang
- School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Tsung-Yuan Tsai
- School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Yan Yu
- Department of Spine Surgery, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Wei Wang
- Orthopaedic Bioengineering Research Center, Newton-Wellesley Hospital, Harvard Medical School, Newton, MA, USA,Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA,School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Guoan Li
- Orthopaedic Bioengineering Research Center, Newton-Wellesley Hospital, Harvard Medical School, Newton, MA, USA,Corresponding author at: Orthopaedic Bioengineering Research Center Department of Orthopaedic Surgery Newton-Wellesley Hospital 159 Wells Avenue, Newton, MA, 02459, USA,
| | - Thomas Cha
- Orthopaedic Bioengineering Research Center, Newton-Wellesley Hospital, Harvard Medical School, Newton, MA, USA,Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Henderson FC, Rosenbaum R, Narayanan M, Koby M, Tuchman K, Rowe PC, Francomano C. Atlanto-axial rotary instability (Fielding type 1): characteristic clinical and radiological findings, and treatment outcomes following alignment, fusion, and stabilization. Neurosurg Rev 2021; 44:1553-1568. [PMID: 32623537 PMCID: PMC8121728 DOI: 10.1007/s10143-020-01345-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 06/22/2020] [Accepted: 06/26/2020] [Indexed: 02/05/2023]
Abstract
Atlanto-axial instability (AAI) is common in the connective tissue disorders, such as rheumatoid arthritis, and increasingly recognized in the heritable disorders of Stickler, Loeys-Dietz, Marfan, Morquio, and Ehlers-Danlos (EDS) syndromes, where it typically presents as a rotary subluxation due to incompetence of the alar ligament. This retrospective, IRB-approved study examines 20 subjects with Fielding type 1 rotary subluxation, characterized by anterior subluxation of the facet on one side, with a normal atlanto-dental interval. Subjects diagnosed with a heritable connective tissue disorder, and AAI had failed non-operative treatment and presented with severe headache, neck pain, and characteristic neurological findings. Subjects underwent a modified Goel-Harms posterior C1-C2 screw fixation and fusion without complication. At 15 months, two subjects underwent reoperation following a fall (one) and occipito-atlantal instability (one). Patients reported improvement in the frequency or severity of neck pain (P < 0.001), numbness in the hands and lower extremities (P = 0.001), headaches, pre-syncope, and lightheadedness (all P < 0.01), vertigo and arm weakness (both P = 0.01), and syncope, nausea, joint pain, and exercise tolerance (all P < 0.05). The diagnosis of Fielding type 1 AAI requires directed investigation with dynamic imaging. Alignment and stabilization is associated with improvement of pain, syncopal and near-syncopal episodes, sensorimotor function, and exercise tolerance.
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Affiliation(s)
- Fraser C Henderson
- Department of Neurosurgery, University of Maryland Capital Region Health Prince George's Hospital Center, Cheverly, MD, USA.
- Doctors Community Hospital, Lanham, MD, USA.
- Metropolitan Neurosurgery Group LLC, Silver Spring, MD, USA.
| | - Robert Rosenbaum
- Department of Neurosurgery, University of Maryland Capital Region Health Prince George's Hospital Center, Cheverly, MD, USA
- Doctors Community Hospital, Lanham, MD, USA
- Metropolitan Neurosurgery Group LLC, Silver Spring, MD, USA
- Department of Neurosurgery, Walter Reed-Bethesda National Military Medical Center, Bethesda, MD, USA
| | - Malini Narayanan
- Department of Neurosurgery, University of Maryland Capital Region Health Prince George's Hospital Center, Cheverly, MD, USA
- Doctors Community Hospital, Lanham, MD, USA
- Metropolitan Neurosurgery Group LLC, Silver Spring, MD, USA
| | - Myles Koby
- Doctors Community Hospital, Lanham, MD, USA
| | - Kelly Tuchman
- Metropolitan Neurosurgery Group LLC, Silver Spring, MD, USA
| | - Peter C Rowe
- Department of Pediatrics, Johns Hopkins University, Baltimore, MD, USA
| | - Clair Francomano
- Medical and Molecular Genetics, Indiana University Health Physicians, Indianapolis, IN, USA
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Winn A, Martin A, Castellon I, Sanchez A, Lavi ES, Munera F, Nunez D. Spine MRI: A Review of Commonly Encountered Emergent Conditions. Top Magn Reson Imaging 2021; 29:291-320. [PMID: 33264271 DOI: 10.1097/rmr.0000000000000261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Over the last 2 decades, the proliferation of magnetic resonance imaging (MRI) availability and continuous improvements in acquisition speeds have led to significantly increased MRI utilization across the health care system, and MRI studies are increasingly ordered in the emergent setting. Depending on the clinical presentation, MRI can yield vital diagnostic information not detectable with other imaging modalities. The aim of this text is to report on the up-to-date indications for MRI of the spine in the ED, and review the various MRI appearances of commonly encountered acute spine pathology, including traumatic injuries, acute non traumatic myelopathy, infection, neoplasia, degenerative disc disease, and postoperative complications. Imaging review will focus on the aspects of the disease process that are not readily resolved with other modalities.
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Affiliation(s)
- Aaron Winn
- University of Miami, Jackson Memorial Hospital, Miami, FL
| | - Adam Martin
- University of Miami, Jackson Memorial Hospital, Miami, FL
| | - Ivan Castellon
- University of Miami, Jackson Memorial Hospital, Miami, FL
| | - Allen Sanchez
- University of Miami, Jackson Memorial Hospital, Miami, FL
| | | | - Felipe Munera
- University of Miami, Jackson Memorial Hospital, Miami, FL
| | - Diego Nunez
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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Fiester P, Rahmathulla G, Haymes D, Soule E, Rao D. Proposed Grading System for Posterior Atlantooccipital Membrane Complex Injuries on Cervical Magnetic Resonance Imaging. World Neurosurg 2021; 151:e663-e671. [PMID: 33940267 DOI: 10.1016/j.wneu.2021.04.098] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 04/21/2021] [Accepted: 04/21/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND The posterior atlantooccipital membrane complex consists of the posterior atlantooccipital membrane and posterior atlantoaxial membrane. Posttraumatic, posterior atlantooccipital membrane complex injuries may have varied appearances on cervical magnetic resonance imaging. The purpose of this study was to identify the different types of posterior atlantooccipital membrane complex injuries that occur in trauma patients. METHODS Patients who suffered a posterior atlantooccipital membrane complex injury were identified retrospectively using key word searches of cervical magnetic resonance imaging reports between 2013 and 2020 using Nuance mPower software. All relevant imaging studies were reviewed by 2 neuroradiologists. A description of the location and type of posterior atlantooccipital membrane complex injury was recorded, along with additional osteoligamentous trauma of the craniocervical junction and relevant clinical history. RESULTS Forty-one patients were identified with acute posterior atlantooccipital membrane complex injury. Four distinct patterns of posterior atlantooccipital membrane complex injury were observed. CONCLUSIONS A grading system for posterior atlantooccipital membrane complex injuries is proposed on the basis of these data: grade 1-edema confined to the posterior atlantooccipital and atlantoaxial membrane; grade 2-edema confined to the posterior atlantooccipital and atlantoaxial membrane and ligamentum nuchae; grade 3-stripping injury of the posterior atlantooccipital membrane with C1-C2 dorsal epidural hematoma; and grade 4-frank disruption of the posterior atlantooccipital membrane at C1 with edema in the remaining posterior atlantooccipital membrane complex.
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Affiliation(s)
- Peter Fiester
- Department of Neuroradiology, University of Florida College of Medicine, Jacksonville, Florida, USA.
| | - Gazanfar Rahmathulla
- Department of Neuroradiology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Dalys Haymes
- Department of Neuroradiology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Erik Soule
- Department of Neuroradiology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Dinesh Rao
- Department of Neuroradiology, University of Florida College of Medicine, Jacksonville, Florida, USA
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A Rare Cause of Torticollis in Children: Atlantoaxial Rotatory Subluxation. JOURNAL OF CONTEMPORARY MEDICINE 2021. [DOI: 10.16899/jcm.872812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Fiester P, Rao D, Soule E, Jenson M, Patel J. Tectorial Membrane Injury, Frequently Identified in Adult Trauma Patients Who Undergo Occipital-Cervical Fusion for Craniocervical Instability. Cureus 2021; 13:e14254. [PMID: 33959441 PMCID: PMC8093123 DOI: 10.7759/cureus.14254] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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.
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Affiliation(s)
- Peter Fiester
- Neuroradiology, University of Florida College of Medicine, Jacksonville, USA
| | - Dinesh Rao
- Neuroradiology, University of Florida College of Medicine, Jacksonville, USA
| | - Erik Soule
- Interventional Radiology, University of Florida College of Medicine, Jacksonville, USA
| | - Matthew Jenson
- Neuroradiology, University of Florida College of Medicine, Jacksonville, USA
| | - Jeet Patel
- Neuroradiology, University of Florida College of Medicine, Jacksonville, USA
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Fiester P, Rao D, Soule E, Orallo P, Rahmathulla G. Anatomic, functional, and radiographic review of the ligaments of the craniocervical junction. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2021; 12:4-9. [PMID: 33850375 PMCID: PMC8035576 DOI: 10.4103/jcvjs.jcvjs_209_20] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 12/22/2020] [Indexed: 11/04/2022] Open
Abstract
The craniocervical junction (CCJ) is a complex and unique osteoligamentous structure that balances maximum stability and protection of vital neurovascular anatomy with ample mobility and range of motion. With the increasing utilization and improved resolution of cervical magnetic resonance imaging, craniocervical injury is being more accurately defined as a spectrum of injury that ranges in severity from overt craniocervical disassociation to isolated injuries of one more of the craniocervical ligaments, which may also lead to craniocervical instability. Thus, it is vital for the radiologist and neurosurgeon to have a thorough understanding of the imaging anatomy and function of the CCJ.
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Affiliation(s)
- Peter Fiester
- Department of Neuroradiology, University of Florida Health, Jacksonville, FL, USA
| | - Dinesh Rao
- Department of Neuroradiology, University of Florida Health, Jacksonville, FL, USA
| | - Erik Soule
- Department of Neuroradiology, University of Florida Health, Jacksonville, FL, USA
| | - Peaches Orallo
- Department of Anesthesia, University of Florida Health, Jacksonville, FL, USA
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Ishak B, Dupont G, Lachkar S, Yilmaz E, Glinski AV, Altafulla J, Kikuta S, Iwanaga J, Chapman JR, Oskouian R, Tubbs RS. Update on the Biomechanics of the Craniocervical Junction-Part I: Transverse Atlantal Ligament in the Elderly. Global Spine J 2021; 11:180-186. [PMID: 32875854 PMCID: PMC7882814 DOI: 10.1177/2192568219896544] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
STUDY DESIGN In vitro biomechanical study. OBJECTIVE The transverse ligament is the strongest ligament of the craniocervical junction and plays a critical role in atlanto-axial stability. The goal of this cadaveric study, and the subsequent study (part II), was to reevaluate the force required for the transverse ligament and alar ligament to fail in a more physiological biomechanical model in elderly specimens. METHODS Twelve C1-2 specimens were harvested from fresh-frozen Caucasian cadavers with a mean age at death of 81 years (range 68-89 years). Only the transverse ligament was preserved, and the bony C1-2 complex was left intact. The dens was pulled away from the anterior arch of C1 using a strength test machine that applies controlled increasing force. After testing, the axis was split in half to check for hidden pathologies and osteoporosis. The differences in the failure force between sex and age groups (group 1: <80 years, group 2: >80 years) were compared. RESULTS The mean force required for the transverse ligament to fail was 236.2 ± 66 N (range 132-326 N). All but 2 specimens had significant osteoporotic loss of trabecular bone. No significant differences between sex and age groups were found. CONCLUSIONS The transverse ligament's failure in elderly specimens occurred at an average force of 236 N, which was lower than that reported in the previous literature. The ligament's failure force in younger patients differs and may be similar to the findings published to date.
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Affiliation(s)
- Basem Ishak
- Seattle Science Foundation, Seattle, WA, USA,Swedish Neuroscience Institute, Seattle, WA, USA,Heidelberg University Hospital, Heidelberg, Germany,Basem Ishak, Swedish Neuroscience Institute, Seattle, WA 98122, USA.
| | | | | | - Emre Yilmaz
- Seattle Science Foundation, Seattle, WA, USA,Swedish Neuroscience Institute, Seattle, WA, USA
| | | | | | | | - Joe Iwanaga
- Seattle Science Foundation, Seattle, WA, USA
| | | | - Rod Oskouian
- Seattle Science Foundation, Seattle, WA, USA,Swedish Neuroscience Institute, Seattle, WA, USA
| | - R. Shane Tubbs
- Seattle Science Foundation, Seattle, WA, USA,St. George’s University, Grenada, West Indies
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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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Beyer B, Feipel V, Dugailly PM. Biomechanics of the upper cervical spine ligaments in axial rotation and flexion-extension: Considerations into the clinical framework. J Craniovertebr Junction Spine 2020; 11:217-225. [PMID: 33100772 PMCID: PMC7546058 DOI: 10.4103/jcvjs.jcvjs_78_20] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 06/26/2020] [Indexed: 12/13/2022] Open
Abstract
Context: The motion of the upper cervical spine (UCS) has a great interest for analyzing the biomechanical features of this joint complex, especially in case of instability. Although investigators have analyzed numerous kinematics and musculoskeletal characteristics, there are still little data available regarding several suboccipital ligaments such as occipito-atlantal, atlantoaxial, and cruciform ligaments. Objective: The aim of this study is to quantify the length and moment arm magnitudes of suboccipital ligaments and to integrate data into specific 3D-model, including musculoskeletal and motion representation. Materials and Methods: Based on a recent method, suboccipital ligaments were identified using UCS anatomical modeling. Biomechanical characteristics of these anatomical structures were assessed for sagittal and transversal displacements regarding length and moment arm alterations. Results: Outcomes data indicated length alterations >25% for occipito-atlantal, atlanto-axial and apical ligaments. The length alteration of unique ligaments was negligible. Length variation was dependent on the motion direction considered. Regarding moment arm, larger magnitudes were observed for posterior ligaments, and consistent alteration was depicted for these structures. Conclusion: These outcomes supply relevant biomechanical characteristics of the UCS ligaments in flexion-extension and axial rotation by quantifying length and moment arm magnitude. Moreover, 3D anatomical modeling and motion representation can help in the process of understanding of musculoskeletal behaviors of the craniovertebral junction.
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Affiliation(s)
- Benoît Beyer
- Department of Physiotherapy and Rehabilitation, Faculty of Motor Sciences, Laboratory of Functional Anatomy, Université Libre de Bruxelles, Brussels, Belgium.,Department of Anatomy, Faculty of Medicine, Laboratory of Anatomy, Biomechanics and Organogenesis, Université Libre de Bruxelles, Brussels, Belgium
| | - Véronique Feipel
- Department of Physiotherapy and Rehabilitation, Faculty of Motor Sciences, Laboratory of Functional Anatomy, Université Libre de Bruxelles, Brussels, Belgium.,Department of Anatomy, Faculty of Medicine, Laboratory of Anatomy, Biomechanics and Organogenesis, Université Libre de Bruxelles, Brussels, Belgium
| | - Pierre-Michel Dugailly
- Department of Physiotherapy and Rehabilitation, Faculty of Motor Sciences, Laboratory of Functional Anatomy, Université Libre de Bruxelles, Brussels, Belgium.,Department of Osteopathy, CESPU - Escola Superior de Saùde do Vale do Ave, Famalicão, Portugal
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Davis JR, Kluckman ML, Mallory GW, Ritter JL. Successful non-operative management for atlanto-occipital dislocation resulting in spinal cord contusion in a patient with atlanto-occipital assimilation and severe Chiari I malformation. Surg Neurol Int 2020; 11:338. [PMID: 33194272 PMCID: PMC7656000 DOI: 10.25259/sni_419_2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 09/17/2020] [Indexed: 11/04/2022] Open
Abstract
Background: Atlanto-occipital dislocation (AOD) is a rare, highly morbid, and highly lethal injury that results from high-energy trauma and almost universally requires operative management for satisfactory outcomes. It can be difficult to identify the severity of injury at the time of presentation, and when diagnosis is delayed outcomes worsen significantly. Anatomic anomalies of the craniovertebral junction may further complicate its detection. When such anomalies are present either singly or in combination, they are known to cause space constraints which may increase the likelihood of spinal cord injury. Given that such anomalies and AOD are rare, few examples of patients with both are reported in the literature. Furthermore, it is not clear in what way patient management may be impacted in this context. Case Description: We will present a unique case of an 18-year-old patient with traumatic AOD and an intact neurologic examination who was found to have atlanto-occipital assimilation (AOA), platybasia, basilar invagination, and severe Chiari I malformation, who was treated effectively with non-operative management. Conclusion: Our case demonstrates the successful application of a non-operative treatment strategy in a carefully selected patient with AOD in the context of AOA.
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Affiliation(s)
- Jordan R. Davis
- Departments of Radiology San Antonio Uniformed Services Health Education Consortium, JBSA Ft. Sam Houston, Texas, United States of America
| | - Matthew L. Kluckman
- Departments of Radiology San Antonio Uniformed Services Health Education Consortium, JBSA Ft. Sam Houston, Texas, United States of America
| | - Grant W. Mallory
- Departments of Neurosurgery, San Antonio Uniformed Services Health Education Consortium, JBSA Ft. Sam Houston, Texas, United States of America
| | - John L. Ritter
- Departments of Radiology San Antonio Uniformed Services Health Education Consortium, JBSA Ft. Sam Houston, Texas, United States of America
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Souslian FG, Patel PD, Elsherif MA. Atlanto-occipital Dissociation in the Setting of Relatively Normal Radiologic Findings. World Neurosurg 2020; 143:405-411. [PMID: 32763369 DOI: 10.1016/j.wneu.2020.07.214] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 07/26/2020] [Accepted: 07/28/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Craniocervical junction (CCJ) dislocations are often fatal. Atlanto-occipital dissociation can be challenging to diagnose, especially in patients who present with absent or subtle radiologic signs. CASE DESCRIPTION A neurologically intact 37-year-old patient presented to the hospital following a high-speed motor vehicle accident. Initial computed tomography scans showed normal CCJ anatomy, but magnetic resonance imaging (MRI) of the CCJ was performed to further evaluate perimesencephalic subarachnoid hemorrhage. MRI revealed partial disruption of the anterior atlantoaxial membrane and tectorial membrane as well as complete disruption of the posterior atlanto-occipital membrane, ligamentum flavum, and apical ligament, signifying atlanto-occipital dissociation. Halo spinal immobilization was performed in preparation for stabilization with posterior occipitocervical fusion; however, the CCJ distracted widely during surgery owing to the accident-related dislocation, signifying an unstable fracture. Posterolateral fusion was performed, and the distraction injury was corrected via posterior surgical instrumentation. CONCLUSIONS Normal occiput-C1 craniometric parameters in the setting of unexplained perimesencephalic subarachnoid hemorrhage does not eliminate the possibility of missed or delayed diagnosis of traumatic atlanto-occipital dissociation injuries. Cervical MRI without contrast should be considered in patients with vertebral artery dissection or perimesencephalic subarachnoid hemorrhage after a blunt injury with neck pain. When MRI shows evidence of disruption of ≥2 atlanto-occipital ligaments, surgical stabilization should be considered, as these are clinically very unstable injuries.
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Affiliation(s)
- Fotis G Souslian
- Department of Neurologic Surgery, Regions Hospital, Saint Paul, Minnesota, USA; Department of Neurological Surgery, Neurosurgery One, Saint Anthony Hospital, Denver, Colorado, USA.
| | - Puja D Patel
- Department of Neuroscience, University of Southern California, Los Angeles, California, USA
| | - Mohamed A Elsherif
- Department of Neurologic Surgery, Hamad Medical Corporation, Doha, Qatar; Department of Neurologic Surgery, Tanta University Hospitals, Tanta, Egypt
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Abstract
STUDY DESIGN Narrative literature review. OBJECTIVE To review and present details on the occipitocervical fixation (OCF) technique as well as considerations for planning the procedure. METHODS We present the surgical technique of OCF in a step-by-step didactic and practical manner with surgical tips and tricks, including C1 and C2 screw fixation techniques. Additionally, we discuss complications, the extension of fusion, types of OCF, and how to avoid common side effects associated with OCF. RESULTS The complex and mobile anatomy of the craniocervical junction, when requiring fixation and fusion, warrants rigid instrumentation that can be achieve using a modern screw-plate-rod construct. Indications for OCF are craniocervical instability, and atlantoaxial instability when selective atlantoaxial fusion is not feasible. OCF generally involves occiput-C2 fusion. C1 fixation is generally unnecessary, since it increases the surgical time and is associated with the risk of vascular complications. Selective occiput-C2 fusion is recommended when there is no need for including the cervical subaxial region (eg, when stenosis or fractures coexist in the subaxial spine), and good fixation is achieved at C2. Most instrumentation systems now have occipital plates that are not pre-integrated to rods, making fixation much simpler. Surgical steps, from position to wound closure, are presented in detail, with pearls for practice and discussion of cervical alignment. CONCLUSIONS OCF is a challenging procedure, with potential risk of severe adverse effects. Understanding the surgical indications, as well as the nuances of the surgical technique, is required to improve patient outcomes and avoid complications.
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48
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Wang MX, Beckmann NM. Imaging of pediatric cervical spine trauma. Emerg Radiol 2020; 28:127-141. [PMID: 32601894 DOI: 10.1007/s10140-020-01813-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 06/19/2020] [Indexed: 11/25/2022]
Abstract
While pediatric cervical spine injuries (CSI) are rare, they are associated with high morbidity and mortality and sometimes require expeditious surgical management. In this article, we aim to improve the diagnostic accuracy of pediatric CSI by reviewing normal pediatric cervical anatomy, typical pediatric CSI patterns, and common mimics of pediatric CSI. A literature review was conducted on pediatric CSI, its epidemiology, and the various imaging manifestations and mimics. The most common pediatric CSI occur in the upper cervical spine owing to the higher fulcrum and larger head at a young age, namely prior to age 9 years, while lower CSI occur more frequently in patients older than 9 years. While various craniocervical measurements may be utilized to identify craniocervical disruption, soft tissue injuries may be the only manifestation, thus making pediatric CSI difficult to diagnose on initial imaging. In the acute setting, CT cervical spine is an appropriate initial imaging modality for pediatric CSI evaluation. MRI serves as an additional tool to exclude or identify injuries when initial findings are equivocal. It is essential to recognize the unique anatomy and biomechanics of the pediatric spine and thus discern common pediatric CSI patterns and their mimics.
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Affiliation(s)
- Mindy X Wang
- Department of Diagnostic and Interventional Imaging, Memorial Hermann, Houston, TX, USA.
- Department of Diagnostic and Interventional Imaging, McGovern Medical School, The University of Texas Health Science Center at Houston, 6431 Fannin Street, 2.130B, Houston, TX, 77030, USA.
| | - Nicholas M Beckmann
- Department of Diagnostic and Interventional Imaging, Memorial Hermann, Houston, TX, USA
- Department of Diagnostic and Interventional Imaging, McGovern Medical School, The University of Texas Health Science Center at Houston, 6431 Fannin Street, 2.130B, Houston, TX, 77030, USA
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Kimchi G, Greenberg G, Traynelis VC, Witiw CD, Knoller N, Harel R. Integrity of the tectorial membrane is a favorable prognostic factor in atlanto-occipital dislocation. Br J Neurosurg 2020; 34:470-474. [PMID: 32368931 DOI: 10.1080/02688697.2020.1761292] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Objective: Atlanto-occipital dislocation is usually considered to be a fatal injury or one that leaves the victim with serious neurological deficits. The aim of this study is to illustrate a novel positive prognostic factor for atlanto-occipital dislocation, based on cervical MRI studies of patients who suffered this injury.Methods: Over the course of the past year, the authors have treated three consecutive patients with atlanto-occipital dislocation who attained an excellent clinical outcome. We retrospectively evaluated clinical, surgical and radiographic parameters in search of a common denominator to explain the excellent outcome of these patients.Results: All patients presented with severe polytrauma that required urgent surgical intervention including two laparotomies and a thoracotomy. The patients were subsequently treated with an occipitocervical fusion. No patient developed neurological deficits on long-term follow-up. The cervical MRI studies of all patients were notable for a having a preserved tectorial membrane, while other primary stabilizers of the craniocervical junction such as the apical, alar and cruciate ligaments were shown to be severely disrupted. We consider this anatomical distinction to account for their benign clinical course.Conclusion: A preserved tectorial membrane appears to be an important favorable prognostic factor in atlanto-occipital dislocation and may serve to mitigate neurological outcome in such injuries. To determine the integrity of the ligament and consequently affect clinical management, expeditious MRI of the cranio-cervical junction should be considered routinely in such injuries in addition to cervical CT scans.
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Affiliation(s)
- Gil Kimchi
- Department of Neurosurgery, Sheba Medical Center, Ramat-Gan, Israel (affiliated to Sackler School of Medicine, Tel Aviv University)
| | - Gahl Greenberg
- Department of Radiology, Neuroradiology Division, Sheba Medical Center, Ramat-Gan, Israel
| | - Vincent C Traynelis
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
| | | | - Nachshon Knoller
- Department of Neurosurgery, Sheba Medical Center, Ramat-Gan, Israel (affiliated to Sackler School of Medicine, Tel Aviv University)
| | - Ran Harel
- Department of Neurosurgery, Sheba Medical Center, Ramat-Gan, Israel (affiliated to Sackler School of Medicine, Tel Aviv University)
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Effect of alar ligament transection in side-bending stress test: A cadaveric study. Musculoskelet Sci Pract 2020; 46:102110. [PMID: 31989964 DOI: 10.1016/j.msksp.2020.102110] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Revised: 12/14/2019] [Accepted: 01/13/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND The side-bending stress test is a pre-manipulative screening test for assessing upper cervical instability. To our knowledge, there is no study that simulates the clinical application of side bending stress test before and after alar ligament transection with fixation of C2. OBJECTIVE To simulate the effect of alar ligament transection in the side bending stress test for an in vitro validation. DESIGN In vitro study. METHODS After the dissection of the superficial structures to the alar ligament and the fixation of C2, ten cryopreserved upper cervical spines were manually mobilized in right and left lateral flexion with and without right alar ligament transection. Upper cervical lateral flexion range of motion and mobilization force were measured with the Vicon motion capture system and a load cell respectively. RESULTS The right alar ligament transection increased the upper cervical spine (UCS) range of motion (ROM) in both side bendings (1.30°±1.54° and 1.88°±1.51° increase for right and left side bending respectively). As an average, with standardized forces of 2N, 4N and 6N, right alar ligament transection increased both right and left lateral flexion UCS ROM. CONCLUSION This in vitro study simulates the clinical application of the side bending stress test with intact and right transected alar ligament. Unilateral transection of the alar ligament revealed a predominantly bilateral increase in upper cervical side bending and variability in the mobilization force applied during the test.
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