Posttraumatic Anatomical Injuries of the Craniovertebral Junction and Treatment Implications: Part I

Clinical Diagnosis and Treatment of 43 Cases of Occipital Condylar Fractures: A Single-Center Retrospective Study

OBJECTIVE

This study aimed to examine the mechanism of occipital condyle fractures (OCFs), their clinical symptoms, computer tomography (CT) scan findings, treatment options, and classification.

METHODS

A retrospective analysis was conducted on 43 patients with OCFs who were admitted to our neurosurgery center between 2017 and 2023.

RESULTS

The investigation covered their clinical symptoms, CT scan results, and treatment outcomes. It was found that 25.6% of the patients suffered from severe craniocerebral injuries with Glasgow Coma Scale (GCS) scores of 3-8 points, 9.3% had moderate injuries with GCS scores of 9-12 points, and 65.1% exhibited mild injuries with GCS scores of 13-15 points. Of these patients, 90.7% showed improvement upon discharge, 4.7% succumbed to their injuries, and another 4.7% developed paraplegia. Symptoms indicative of OCF in individuals with CCJ injuries included neck pain, swelling, cranial nerve palsy, and posterior pharyngeal wall swelling. Frequently observed complications in OCF patients included cerebral contusion, occipital bone fractures, and skull base fractures. Employing thin-layer CT scans of the CCJ area, along with sagittal and coronal CT reconstructions, is essential for identifying OCFs. The fractures were classified into 3 types based on the Anderson-Montesano classification, which, when modified, provides enhanced treatment guidance.

CONCLUSIONS

OCFs are predominantly present in cases of high-energy trauma, with high-resolution thin-layer CT scans serving as the preferred diagnostic method. The application of the modified Anderson-Montesano classification, distinguishing between stable and unstable fractures, facilitates the determination of suitable treatment strategies. Stable OCFs can be managed using a rigid neck brace, while unstable OCFs may require Halo-vest frame fixation or surgical intervention.

Direct Transpedicular C2 Fixation for the Surgical Management of Hangman's Fractures: A "Second Youth" for the Judet Approach

PURPOSE

The optimal management of hangman's fractures is controversial and the standard of care has been neither established nor supported by strong evidence. The Judet approach has been introduced in 1970 as surgical option to treat selected cases of hangman's fractures, harboring the advantage to preserve motion of the craniovertebral junction and to restore the C2 vertebra anatomy by insertion of transpedicular screws through the fracture line. This paper reviews the literature on hangman's fractures surgically managed by Judet approach, and reports two new illustrative cases.

METHODS

The PubMed database was searched for the review process. After initial screening of abstracts and papers, 13 manuscripts were included in the present review.Two cases of hangman's fractures, a Levine-Edwards type I and a type IIA, respectively, treated with direct transpedicular C2 screw fixation are reported. Surgical steps of the Judet approach are also described.

RESULTS

Our literature review revealed that the technique described by Judet is gaining appeal only in recent years and there is no consensus on surgical indications.No surgery-related complications were observed in the two reported cases. Patients experienced a significant reduction of neck pain postoperatively. Motion of craniovertebral junction was preserved in both patients at 3-, 6-, and 12-month follow-ups.

CONCLUSIONS

Direct transpedicular osteosynthesis of C2-pars interarticularis fracture has been already demonstrated as effective in type II and IIA hangman's fractures. The application of such technique in selected patients with atypical type I fractures should also be considered in order to achieve early mobilization and avoid external fixation.

Atlantoaxial posterior screw fixation using intra-operative spinal navigation with three-dimensional isocentric C-arm fluoroscopy

PURPOSE

Intra-operative image acquisition coupled with navigation aims to increase screw placement accuracy, and it is particularly helpful in complex spinal procedures. The aim of this study is to analyze the accuracy and reliability of posterior atlanto-axial fixation using spinal navigation combined with intra-operative 3D isocentric C-arm.

METHODS

We retrospectively reviewed all patients presenting with C1-C2 instability and treated by posterior atlanto-axial fixation in our center between December 2016 and September 2018. Screw positioning was guided by intra-operative navigation, registered with surface matching procedure on a previously obtained CT scan and controlled by intra-operative 3D isocentric C-arm. Age, sex, pre- and post-operative neurological status, duration of surgery, presence/absence of vertebral artery injury, and screw placement were retrospectively collected from patients' records. All patients underwent clinical and radiological follow-up at three months after surgery. Radiological assessment of screw positioning was performed by an independent radiologist using the Gertzbein and Robbins grading.

RESULTS

N = 11 (7F, 4 M) consecutive patients were included, with a mean age of 72 years (range from 51 to 85). N = 44 navigated screws were inserted and controlled with intra-operative 3D fluoroscopy at the end of the procedure. An acceptable screw positioning (Gertzbein-Robbins grade A and B) was obtained in all cases (100%). No vertebral artery injury was observed. Mean operating time was 123 minutes. At three months, no screw loosening or displacement was observed.

CONCLUSION

In our experience, spinal navigation coupled with intra-operative 3D fluoroscopy proved to be reliable and safe for C1-C2 screw placement.