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García-Pérez D, Panero I, Lagares A, Gómez PA, Alén JF, Paredes I. Atlanto-occipital dislocation with concomitant severe traumatic brain injury: A retrospective study at a level 1 trauma center. NEUROCIRUGIA (ENGLISH EDITION) 2023; 34:12-21. [PMID: 36623889 DOI: 10.1016/j.neucie.2022.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Accepted: 12/16/2021] [Indexed: 01/09/2023]
Abstract
BACKGROUND Traumatic atlanto-occipital dislocation (AOD) is a life-threatening injury. Although traumatic brain injury (TBI) is associated with increased mortality in AOD patients, a detailed individual analysis of these patients is lacking in the literature. METHODS Patients ≥16 years old who were diagnosed of AOD with concomitant severe TBI from 2010 to 2020 were included in this retrospective study. We examined the epidemiology, injury mechanisms, associated injuries, and outcomes of these patients. RESULTS Eight patients were included. Six patients died before any intervention could be performed, and two patients underwent an occipito-cervical fixation, showing a notorious neurologic improvement on follow-up. Cardiorespiratory arrest (CRA) was a strong predictor of subsequent death. CT signs of diffuse axonal injury (DAI) were present in most patients and were confirmed by magnetic resonance imaging (MRI) in survivors. Although TBI was not the main cause of death, it was responsible for the delayed neurological improvement and deferred stabilization. The average sensitivity of the different used methodologies for AOD diagnosis ranged from 0.50 to 1.00, being the Basion Dens Interval (BDI) and the Condyle-C1 interval (CCI) sum the most reliable criteria. Non-survivors tended to show greater distraction measurements. The high incidence of condylar avulsion fractures suggests that their visualization on the initial CT study should heighten the suspicion for AOD. CONCLUSIONS Our data suggest that patients with AOD and concomitant severe TBI might be salvageable patients. In those who survive beyond the first hospital days and show neurological improvement, surgical treatment should be performed as they can achieve an important neurologic recovery.
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Affiliation(s)
- Daniel García-Pérez
- Department of Neurosurgery, University Hospital 12 de Octubre, Madrid, Spain.
| | - Irene Panero
- Department of Neurosurgery, University Hospital 12 de Octubre, Madrid, Spain
| | - Alfonso Lagares
- Department of Neurosurgery, University Hospital 12 de Octubre, Madrid, Spain
| | - Pedro Antonio Gómez
- Department of Neurosurgery, University Hospital 12 de Octubre, Madrid, Spain
| | - José F Alén
- Department of Neurosurgery, University Hospital 12 de Octubre, Madrid, Spain
| | - Igor Paredes
- Department of Neurosurgery, University Hospital 12 de Octubre, Madrid, Spain
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Garvayo M, Belouaer A, Barges-Coll J. Atlanto-occipital dislocation in a child: a challenging diagnosis. Illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2022; 3:CASE21712. [PMID: 36209404 PMCID: PMC9379628 DOI: 10.3171/case21712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 01/27/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND
Atlanto-occipital dislocation (AOD) is a highly unstable injury of the osseoligamentous complex at the craniocervical junction that is more common in children. Its diagnosis remains a challenging process that must integrate clinical presentation and radiological criteria.
OBSERVATIONS
A 9-year-old child presented with severe craniocervical trauma (Glasgow Coma Scale score 6) and cardiorespiratory arrest on-site. Prompt resuscitation on-site and transfer to the university hospital were performed, and a computed tomography (CT) scan showed a subarachnoid hemorrhage around the brainstem and a retroclival hematoma. Most of the radiological criteria on CT scans for AOD were negative, except for the occipital condyle–C1 interval, and further imaging with magnetic resonance imaging permitted the diagnosis of AOD with rupture of both the tectorial membrane and the transverse ligament. Occipital-cervical Oc-C1–2 fixation was performed. The neurological outcome was excellent, with full recovery 6 months after the trauma.
LESSONS
AOD should be suspected in all high-intensity trauma in children, especially if the clinical presentation includes cardiorespiratory arrest and other brainstem and/or upper cervical cord symptoms along with premedullary subarachnoid hemorrhage. Understanding the ligamentous nature of the injury resulting in “normal” radiographs or CT scans is important to avoid underdiagnosing AOD, which can have detrimental consequences.
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Affiliation(s)
- Marta Garvayo
- Department of Neurosurgery and Spine Surgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Amani Belouaer
- Department of Neurosurgery and Spine Surgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Juan Barges-Coll
- Department of Neurosurgery and Spine Surgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
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García-Pérez D, Panero I, Lagares A, Gómez PA, Alén JF, Paredes I. Atlanto-occipital dislocation with concomitant severe traumatic brain injury: A retrospective study at a level 1 trauma center. Neurocirugia (Astur) 2022. [DOI: 10.1016/j.neucir.2021.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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4
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Jung MK, Hörnig L, Stübs MMA, Grützner PA, Kreinest M. Analysis of diagnostics, therapy and outcome of patients with traumatic atlanto-occipital dislocation. Spine J 2021; 21:1513-1519. [PMID: 33757869 DOI: 10.1016/j.spinee.2021.03.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 03/08/2021] [Accepted: 03/16/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Patients' outcome following traumatic atlanto-occipital dislocation (AOD) has been poor. In recent years, an increasing number of patients surviving the initial trauma are admitted to hospital. In order to further improve the management of these patients, the knowledge of diagnostics and therapy as well as possible complications should be increased. PURRPOSE The aim of this study was to evaluate diagnostic parameters, therapy, early complications and outcome of patients with traumatic AOD. STUDY DESIGN Monocentric retrospective cohort study. PATIENT SAMPLE A total of 12 patients were included in this study. OUTCOME MEASURES The main outcome measure was functional patient outcome. Furthermore, radiographic and treatment data were analyzed. METHODS All patients suffering from traumatic AOD within an 8-year time period were included. Demographic data, radiological diagnostic parameters (condylar sum, basion dens interval, basion axis interval, power´s ratio, x-line method), as well as treatment data and complications of every patient were analyzed. Radiological parameters were compared with each other. Outcome was analyzed by a follow up examination. RESULTS The accident mechanisms were motor vehicle accidents (MVA), fall from high and low height. Basion dens interval, basion axis interval, power's ratio and x-line method were not reliable in identifying traumatic AOD (only up to 33% of the patients were identified). Twelve patients could be reviewed. Three patients were treated with surgery, five patients were treated nonsurgically. Four patients died before surgical therapy. All seven surviving patients (survival rate: 58.3%) were re-examined (mean follow-up time: 6.7 months). All patients had a GCS of 15. Three surviving patients suffered from persisting neurological deficits. CONCLUSIONS The most reliable way to diagnose AOD in Computer Topography is using the condylar sum. Surgical and nonsurgical measures can be employed with reasonable outcomes. Patient specific injury burden and clinical presentation should be taken into account when making treatment decisions for AOD.
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Affiliation(s)
- Matthias K Jung
- BG Trauma Center Ludwigshafen, University of Heidelberg, Clinic for Trauma and Orthopaedic Surgery, Ludwig-Guttmann-Straße 13, 67071 Ludwigshafen on the Rhine, Germany
| | - Lukas Hörnig
- BG Trauma Center Ludwigshafen, University of Heidelberg, Clinic for Trauma and Orthopaedic Surgery, Ludwig-Guttmann-Straße 13, 67071 Ludwigshafen on the Rhine, Germany
| | - Michael M A Stübs
- Department of Anesthesiology, Stiftung Krankenhaus Bethanien, Bethanienstraße 21, 47441 Moers, Germany
| | - Paul A Grützner
- BG Trauma Center Ludwigshafen, University of Heidelberg, Clinic for Trauma and Orthopaedic Surgery, Ludwig-Guttmann-Straße 13, 67071 Ludwigshafen on the Rhine, Germany
| | - Michael Kreinest
- BG Trauma Center Ludwigshafen, University of Heidelberg, Clinic for Trauma and Orthopaedic Surgery, Ludwig-Guttmann-Straße 13, 67071 Ludwigshafen on the Rhine, Germany.
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5
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Joaquim AF, Schroeder GD, Vaccaro AR. Traumatic Atlanto-Occipital Dislocation-A Comprehensive Analysis of All Case Series Found in the Spinal Trauma Literature. Int J Spine Surg 2021; 15:724-739. [PMID: 34289992 DOI: 10.14444/8095] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Traumatic atlanto-occipital dislocation (TAOD) is one of the most devastating traumatic injuries, generally associated with immediate death after high-energy trauma. The aim of this study was to perform a systematic literature review of all cases series of TAOD and present the current state of this entity. METHODS A systematic literature review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Only case series with at least 5 cases were included in the analysis. We focused on survival rates, diagnostic methods, delays in diagnosis, outcomes, and cases successfully treated nonoperatively. RESULTS A total of 17 articles were included (16 retrospective and 1 prospective study) with 341 patients. Six studies included pediatric patients only. The mean Glasgow Coma Scale at admission was ≤8 in all studies. Many different diagnostic criteria were used, but none of them had high accuracy. The overall mortality rate was 34.8%, but the studies' designs were heterogeneous (some included only survivors). A high rate of concomitant traumatic brain injury was documented in some studies. We found it interesting that some patients were treated with cervical immobilization (37/341; 10.8%), which was generally used in less unstable injuries; however, the majority of patients were managed with an occipito-cervical fusion (193/341; 56.5%). CONCLUSIONS TAOD is a devastating traumatic injury, with a high mortality rate. An MRI may be recommended when there are subtle findings of TAOD and a normal computed tomography scan, such as subarachnoid hemorrhage in the posterior fossa, upper cervical injuries, or consistent neurological findings. Further studies are necessary to identify patients with mild MRI findings and TAOD that may be managed nonoperatively.
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Affiliation(s)
| | - Gregory D Schroeder
- Department of Orthopaedic Surgery and Neurosurgery at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Alexander R Vaccaro
- Department of Orthopaedic Surgery and Neurosurgery at Thomas Jefferson University, Philadelphia, Pennsylvania
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Sarmiento JM, Chang D, Nisson PL, Chan JL, Perry TG. Occipitocervical fusion of traumatic atlanto-occipital dissociation in a patient with autofused cervical facet joints: illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2021; 2:CASE21276. [PMID: 35854957 PMCID: PMC9272367 DOI: 10.3171/case21276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 05/24/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND Patients who survive traumatic atlanto-occipital dissociation (AOD) may
present with normal neurological examinations and near-normal-appearing
diagnostic images, such as cervical radiographs and computed tomography (CT)
scans. OBSERVATIONS The authors described a neurologically intact 64-year-old female patient with
a degenerative autofusion of her right C4–5 facet joints who
presented to their center after a motor vehicle collision. Prevertebral soft
tissue swelling and craniocervical subarachnoid hemorrhage prompted
awareness and consideration for traumatic AOD. An abnormal occipital
condyle–C1 interval (4.67 mm) on CT and craniocervical junction
ligamentous injury on magnetic resonance imaging (MRI) confirmed the
diagnosis of AOD. Her autofused right C4–5 facet joints were
incorporated into the occipitocervical fusion construct. LESSONS Traumatic AOD can be easily overlooked in patients with a normal neurological
examination and no associated upper cervical spine fractures. A high index
of suspicion is needed when evaluating CT scans because normal values for
craniocervical parameters are significantly different from the accepted
ranges of normal on radiographs in the adult population. MRI of the cervical
spine is helpful to evaluate for atlanto-occipital ligamentous injury and
confirm the diagnosis. Occipitocervical fusion construct may need to be
extended to incorporate spinal levels with degenerative autofusion to
prevent adjacent level degeneration.
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Affiliation(s)
- J. Manuel Sarmiento
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Daniel Chang
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Peyton L. Nisson
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Julie L. Chan
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Tiffany G. Perry
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California
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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: 0.3] [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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8
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Independent predictors of survival after traumatic atlanto-occipital dissociation. J Trauma Acute Care Surg 2019; 85:375-379. [PMID: 30080783 DOI: 10.1097/ta.0000000000001953] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Atlanto-occipital dissociation (AOD) occurs when the skull base is forcibly separated from the vertebral column. Existing literature on AOD is sparse and risk factors for mortality are unknown. This study determined independent predictors of survival after AOD. METHODS Patients who sustained AOD were identified from the National Trauma Data Bank (2007-2014). Those arriving without signs of life or with missing mortality data were excluded. Study groups were defined as patients who survived to hospital discharge versus patients who died in hospital. Demographics, injury data, interventions, and outcomes were compared between groups using univariate analysis. Multivariate logistic regression was used to determine independent predictors of survival. RESULTS After applying exclusion criteria, 1,489 patients (<1% of National Trauma Data Bank) were identified. Median age was 37 years (interquartile range [IQR), 20-59 years], and 59% of patients were male. Atlanto-occipital dissociation occurred almost exclusively after blunt mechanisms (97%), most commonly motor vehicle collisions (66%). Median injury severity score (ISS) was 25 (IQR, 10-36), with 22% mortality. Median time to death was 1,358 minutes (IQR, 281-4,451 minutes), approximately 23 hours. Independent predictors of survival were higher Glasgow Coma Scale score on admission (p < 0.001), lower ISS (p = 0.011), lower Abbreviated Injury Scale score for the head (p = 0.001), and the lack of need for exploratory laparotomy (p < 0.001). Time to neurosurgical intervention of the spine was not predictive of survival (p > 0.05). Patients who survived had a median hospital length of stay of 5 days (IQR, 1-14 days) and intensive care unit length of stay of 1 day (IQR, 0-7 days). The most common discharge destination was home (n = 393 [34%]). CONCLUSIONS Traumatic AOD is not uniformly fatal, with 78% of patients who arrive alive to hospital surviving to discharge. When death occurs, it is typically within the first 23 hours. Lower ISS and higher Glasgow Coma Scale score on admission independently predict survival, while time to neurosurgical intervention does not. Survivors have a short hospital stay and are commonly discharged home. This study suggests that AOD among patients who arrive alive to hospital may not be as devastating as previously considered. LEVEL OF EVIDENCE Progonostic/Epidemiological, level III; Therapeutic, level IV.
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Sinclair K, Emerson JA, Tanaka T. Atlantoaxial Instability Resulting in Intractable Nausea in a Person with C5 Complete Spinal Cord Injury: A Case Report. PM R 2019; 11:440-445. [PMID: 30779866 DOI: 10.1002/pmrj.12004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Accepted: 10/17/2018] [Indexed: 11/11/2022]
Abstract
Individuals with spinal cord injury (SCI) have altered neurophysiology and present with symptoms that must be interpreted in the context of their specific neurologic injury. This is a case of a 16-year-old female adolescent with C5 American Spinal Injury Association Impairment Scale A SCI who presented with intractable nausea. Multiple etiologies for her nausea, including medication effect, metabolic and gastrointestinal disorders, autonomic dysreflexia, and mood disorder, were systematically ruled out. Due to the persistence of the patient's symptoms and suboptimal progression in her rehabilitation, a central nervous system etiology was investigated. Ultimately, atlantoaxial instability with odontoid compression on the medulla was identified and her refractory nausea resolved following an occiput to C2 fusion. To our knowledge, this is the first reported case of atlantoaxial instability causing intractable nausea due to brain stem compression in a patient with SCI. Level of Evidence: V.
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Affiliation(s)
- Katie Sinclair
- Department of Physical Medicine and Rehabilitation, University of Missouri School of Medicine, Columbia, MO 65212
| | - Jane A Emerson
- Department of Physical Medicine and Rehabilitation, University of Missouri School of Medicine, Columbia, MO 65212
| | - Tomoko Tanaka
- Division of Neurosurgery, University of Missouri School Medicine, Columbia, MO 65212
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10
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Occipitocervical Dislocation in Low-Energy Trauma. Case Rep Orthop 2018; 2018:3931525. [PMID: 30631620 PMCID: PMC6304856 DOI: 10.1155/2018/3931525] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 11/19/2018] [Indexed: 11/18/2022] Open
Abstract
Traumatic occipitocervical dislocation (OCD) is described in the literature as a potentially fatal injury secondary to high-energy trauma. We describe a case of OCD occurring in a patient who sustained a ground-level fall whose only clinical symptom was posterior neck pain without neurologic compromise. Computed tomography (CT) and magnetic resonance imaging (MRI) were used to diagnose severe injury to the structurally important ligamentous complex that stabilizes the base of the skull to the spine, along with unstable fractures of the occipital condyle and C1. Emergent surgical instrumentation and fusion of occiput-C2 was performed. Postoperatively, neurologic integrity was maintained. This case illustrates that traumatic OCD is not exclusively secondary to high-energy mechanisms. It also demonstrates that severe neck pain as the only clinical manifestation in a patient with head or neck low-energy trauma is suggestive of a possible OCD. We highlight the importance of the use of head and neck CT as the first imaging-based diagnostic tool to aid in identifying this injury. Finally, surgical stabilization should be performed as soon as possible to minimize neurologic sequelae.
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11
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Abouelleil M, Siddique D, Dahdaleh NS. Failure of the Condyle-C1 Interval Method to Diagnose Atlanto-occipital Dislocation in the Presence of an Associated Atlanto-axial Dislocation: A Case Report. Cureus 2018; 10:e2486. [PMID: 29922527 PMCID: PMC6003796 DOI: 10.7759/cureus.2486] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Atlanto-occipital dislocation (AOD) is a craniocervical injury that has serious neurological consequences and is often fatal. High-speed blunt trauma, such as motor vehicle accidents, that extend and put traction on the head can cause this injury. The current recommendation for diagnosis is to measure the condyle-C1 interval (CCI) using a computed tomography (CT) scan in the coronal plane and more recently in the sagittal plane. We report the case of a patient who suffered a motor vehicle accident and had concomitant AOD and atlanto-axial dislocation. In this particular case, the CCI method failed to diagnose AOD and the diagnosis was made using the basion-dens interval (BDI) and other methodologies, as well as the presence of ligamentous disruption at the craniovertebral junction (CVJ) on magnetic resonance imaging (MRI). A 19-year-old female suffered a motor vehicle accident in which she was ejected from the car. Her neck was immobilized on the scene and she was brought to the emergency department complaining of neck pain. CT of the cervical spine showed concomitant atlanto-occipital and atlanto-axial dissociation. MRI of the cervical spine confirmed the diagnosis with total ligamentous disruption at the CVJ and distraction of the atlanto-axial joints bilaterally. While the CCI was normal, the BDI was diagnostic of AOD. The current recommendations for using the CCI interval method may not diagnose AOD in the presence of associated atlanto-axial dislocation. Other methodologies should be employed including BDI and basion-axial interval (BAI) as well as MR imaging showing ligamentous disruption.
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Affiliation(s)
| | | | - Nader S Dahdaleh
- Neurological Surgery, Northwestern University Feinberg School of Medicine
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12
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Anania P, Fiaschi P, Sbaffi PF, Zona G. A Case of Asymptomatic Occipital Condyle Fracture with Incomplete Occipitocervical Dislocation: How Did It Happen? World Neurosurg 2017; 109:403-408. [PMID: 29081394 DOI: 10.1016/j.wneu.2017.10.082] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 10/13/2017] [Accepted: 10/14/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND Atlanto-occipital dislocation (AOD) is a lesion rarely observed in a trauma center, because of high mortality in the preclinical phase. The number of AOD survivors is increasing thanks to the improvement in prehospital resuscitation. CASE DESCRIPTION Our goal is to describe a case of incomplete atlanto-occipital dislocation presented without any neurologic, cardiorespiratory, or metabolic problems, which remained constant even after surgical treatment. Our purpose is also to discuss treatment approaches to minimize subsequent neurologic deficits. CONCLUSIONS We recommend a rapid immobilization with spine table and cervical collar, the consensual stabilization of hemodynamic and respiratory parameters, and a successive prompt occipitocervical stabilization. C2 should be included in the stabilization because of the ligamentous conformation of craniocervical joint.
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Affiliation(s)
- Pasquale Anania
- Department of Neurosurgery, San Martino-IST University Hospital, University of Genoa, Genoa, Italy
| | - Pietro Fiaschi
- Department of Neurosurgery, San Martino-IST University Hospital, University of Genoa, Genoa, Italy.
| | - Pier Filippo Sbaffi
- Department of Neurosurgery, San Martino-IST University Hospital, University of Genoa, Genoa, Italy
| | - Gianluigi Zona
- Department of Neurosurgery, San Martino-IST University Hospital, University of Genoa, Genoa, Italy
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13
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Menon KV, Al Habsi I, Al Ghafri K. Traumatic occipito-cervical dissociation in adults: a Middle Eastern cohort study. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2017; 28:381-387. [PMID: 28986644 DOI: 10.1007/s00590-017-2053-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Accepted: 10/03/2017] [Indexed: 11/25/2022]
Abstract
The objective of this study is to describe a series of cranio-cervical dissociation victims and evaluate their outcomes as well as discuss the clinical dilemmas we faced in the context of current literature evidence. This is a retrospective cohort study of traumatic occipito-cervical dissociation in five patients (three males and two females) encountered between 2010 and 2016 at a tertiary care facility in the Middle East region. All patients underwent occipito-cervical fusion using screws and rods system with mean postoperative follow-up period of 2.5 years. All patients survived, and four were independently mobile and one wheel chair bound. Most had some degree of neurological sequelae, often due to associated injuries and all complained of limited neck range of motion. Contemporary literature review shows that CT scan with MRI is often the best diagnostic modality. Surgery is usually indicated though rare cases treated conservatively have been reported. The commonest predictor of mortality is missed injury, associated head injury and wide separation between the skull base and C1 on imaging studies.
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Affiliation(s)
| | - Ismail Al Habsi
- Oman Medical Specialty Board, Khoula Hospital, Mina al Fahal, Muscat, Sultanate of Oman
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14
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Scholz M, Kandziora F, Hildebrand F, Kobbe P. [Injuries of the upper cervical spine : Update on diagnostics and management]. Unfallchirurg 2017; 120:683-700. [PMID: 28776221 DOI: 10.1007/s00113-017-0380-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Injuries to the upper cervical spine represent a diagnostic and therapeutic challenge to the treating surgeon due to the complex anatomical relationships and biomechanical features. In this further education article the diagnostic principles, established classifications and therapeutic recommendations as well as injury-specific characteristics of bony and ligamentous injuries to the upper cervical spine (C0-C2) are presented.
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Affiliation(s)
- Matti Scholz
- BG Unfallklink Frankfurt am Main gGmbH, Zentrum für Wirbelsäulenchirurgie und Neurotraumatologie, Frankfurt, Deutschland
| | - Frank Kandziora
- BG Unfallklink Frankfurt am Main gGmbH, Zentrum für Wirbelsäulenchirurgie und Neurotraumatologie, Frankfurt, Deutschland
| | - Frank Hildebrand
- Klinik für Unfall- und Wiederherstellungschirurgie, Uniklinik RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland
| | - Philipp Kobbe
- Klinik für Unfall- und Wiederherstellungschirurgie, Uniklinik RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland.
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15
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The spectrum of traumatic injuries at the craniocervical junction: a review of imaging findings and management. Emerg Radiol 2017; 24:377-385. [DOI: 10.1007/s10140-017-1490-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Accepted: 02/14/2017] [Indexed: 12/15/2022]
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Riascos R, Bonfante E, Cotes C, Guirguis M, Hakimelahi R, West C. Imaging of Atlanto-Occipital and Atlantoaxial Traumatic Injuries: What the Radiologist Needs to Know. Radiographics 2016; 35:2121-34. [PMID: 26562241 DOI: 10.1148/rg.2015150035] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Approximately one-third of all cervical spine injuries involve the craniocervical junction (CCJ). Composed of the occiput and the first two cervical vertebrae, this important anatomic landmark, in conjunction with an intricate ligamentous complex, is essential to maintaining the stability of the cervical spine. The atlantoaxial joint is the most mobile portion of the spine, predominantly relying on the ligamentous framework for stability at that level. As acute onsite management of trauma patients continues to improve, CCJ injuries, which often lead to death onsite where the injury occurred, are increasingly being encountered in the emergency department. Understanding the anatomy of the CCJ is crucial in properly evaluating the cervical spine, allowing the radiologist to assess its stability in the trauma setting. The imaging findings of important CCJ injuries, such as atlanto-occipital dissociation, occipital condyle fractures, atlas fractures with transverse ligament rupture, atlantoaxial distraction, and traumatic rotatory subluxation, are important to recognize in the acute setting, often dictating patient management. Thin-section multidetector computed tomography with sagittal and coronal reformats is the study of choice in evaluating the extent of injury, allowing the radiologist to thoroughly evaluate the stability of the cervical spine. Furthermore, magnetic resonance (MR) imaging is increasingly being used to evaluate the spinal soft tissues and ligaments, and to identify associated spinal cord injury, if present. MR imaging is also indicated in patients whose neurologic status cannot be evaluated within 48 hours of injury. .
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Affiliation(s)
- Roy Riascos
- From the Department of Diagnostic and Interventional Imaging, University of Texas Health Science Center at Houston, 6431 Fannin St, MSB 2.130B, Houston, TX 77030 (R.R., E.B., M.G., C.W.); and Department of Radiology, University of Texas Medical Branch, Galveston, Tex (C.C., R.H.)
| | - Eliana Bonfante
- From the Department of Diagnostic and Interventional Imaging, University of Texas Health Science Center at Houston, 6431 Fannin St, MSB 2.130B, Houston, TX 77030 (R.R., E.B., M.G., C.W.); and Department of Radiology, University of Texas Medical Branch, Galveston, Tex (C.C., R.H.)
| | - Claudia Cotes
- From the Department of Diagnostic and Interventional Imaging, University of Texas Health Science Center at Houston, 6431 Fannin St, MSB 2.130B, Houston, TX 77030 (R.R., E.B., M.G., C.W.); and Department of Radiology, University of Texas Medical Branch, Galveston, Tex (C.C., R.H.)
| | - Mary Guirguis
- From the Department of Diagnostic and Interventional Imaging, University of Texas Health Science Center at Houston, 6431 Fannin St, MSB 2.130B, Houston, TX 77030 (R.R., E.B., M.G., C.W.); and Department of Radiology, University of Texas Medical Branch, Galveston, Tex (C.C., R.H.)
| | - Reza Hakimelahi
- From the Department of Diagnostic and Interventional Imaging, University of Texas Health Science Center at Houston, 6431 Fannin St, MSB 2.130B, Houston, TX 77030 (R.R., E.B., M.G., C.W.); and Department of Radiology, University of Texas Medical Branch, Galveston, Tex (C.C., R.H.)
| | - Clark West
- From the Department of Diagnostic and Interventional Imaging, University of Texas Health Science Center at Houston, 6431 Fannin St, MSB 2.130B, Houston, TX 77030 (R.R., E.B., M.G., C.W.); and Department of Radiology, University of Texas Medical Branch, Galveston, Tex (C.C., R.H.)
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Fard SA, Avila MJ, Johnstone CM, Patel AS, Walter CM, Skoch J, Sattarov KV, Baaj AA. Prognostic factors in traumatic atlanto-occipital dislocation. J Clin Neurosci 2016; 33:63-68. [PMID: 27554925 DOI: 10.1016/j.jocn.2016.05.021] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 05/05/2016] [Indexed: 12/19/2022]
Abstract
Traumatic atlanto-occipital dislocation (AOD) is an ominous injury with high mortality and morbidity in trauma patients. Improved survival has been observed with advancements in pre-hospital and hospital care. Furthermore, high quality imaging studies are accessible at most trauma centers; these are crucial for prompt diagnosis of AOD. The objective of this study is to perform a comprehensive literature review of traumatic AOD, with specific emphasis on identifying prognostic factors for survival. A review of the literature was performed using the Medline database for all traumatic atlanto-occipital articles published between March 1959 and June 2015; 141 patients from 60 total studies met eligibility criteria for study inclusion. A binary logistic regression model was utilized to identify prognostic factors. The analysis assessed age, sex, spinal cord injury (SCI), traumatic brain injury (TBI), polytrauma injury (PI), and Traynelis AOD Classification. Only TBI was statistically significantly associated with death (OR 8.05 p<0.05); SCI did not reach statistical significance for predicting mortality in AOD patients (OR 1.25 p>0.05). Age, sex, PI, and Traynelis AOD Classification did not meet significance to predict mortality in AOD patients. We found that patients with TBI are eight times more likely to die than patients without TBI. A high degree of suspicion for AOD during pre-hospital care, as well as, prompt diagnosis and management in the trauma center play a key role in the treatment of this devastating injury. The relationship between survival and factors such as TBI and SCI should be further explored.
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Affiliation(s)
- Salman Abbasi Fard
- Division of Neurosurgery, University of Arizona, 1501 N Campbell Ave, Tucson, AZ 85724, USA
| | - Mauricio J Avila
- Weill Cornell Brain and Spine Center, 525 East 68 Street, Box 99, New York, NY 10065, USA.
| | - Cameron M Johnstone
- Division of Neurosurgery, University of Arizona, 1501 N Campbell Ave, Tucson, AZ 85724, USA
| | - Apar S Patel
- Division of Neurosurgery, University of Arizona, 1501 N Campbell Ave, Tucson, AZ 85724, USA
| | - Christina M Walter
- Division of Neurosurgery, University of Arizona, 1501 N Campbell Ave, Tucson, AZ 85724, USA
| | - Jesse Skoch
- Division of Neurosurgery, University of Arizona, 1501 N Campbell Ave, Tucson, AZ 85724, USA
| | - Kamran V Sattarov
- Division of Neurosurgery, University of Arizona, 1501 N Campbell Ave, Tucson, AZ 85724, USA
| | - Ali A Baaj
- Weill Cornell Brain and Spine Center, 525 East 68 Street, Box 99, New York, NY 10065, USA
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Baumann F, Ernstberger T, Neumann C, Nerlich M, Schroeder GD, Vaccaro AR, Loibl M. Pediatric Cervical Spine Injuries: A Rare But Challenging Entity. ACTA ACUST UNITED AC 2016; 28:E377-84. [PMID: 26165728 DOI: 10.1097/bsd.0000000000000307] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Injuries to the cervical spine in pediatric patients are uncommon. A missed injury can have devastating consequences in this age group. Because of the lack of routine in diagnosis and management of pediatric cervical spine injuries (PCSI), each of these cases represents a logistic and personal challenge. METHODS By means of clinical cases, we demonstrate key points in diagnostics and treatment of pediatric spine injuries. We highlight typical pediatric injury patterns and more adult-like injuries. RESULTS The most common cause of injury is blunt trauma. There is an age-related pattern of injuries in pediatric patients. Children under the age of 8 frequently sustain ligamentous injuries in the upper cervical spine. After the age of 8, the biomechanics of the cervical spine are similar to adults, and therefore, bony injuries of the subaxial cervical spine are most likely to occur. Clinical presentation of PCSI is heterogeneous. Younger children can neither interpret nor communicate neurological abnormalities, which make timely and accurate diagnosis difficult. Plain radiographs are often misinterpreted. We find different types of injuries at different locations, because of different biomechanical properties of the immature spine. We outline that initial management is crucial for long-term outcome. CONCLUSIONS Knowledge of biomechanical properties and radiographic presentation of the immature spine can improve the awareness for PCSI. Diagnosis and management of pediatric patients after neck trauma can be demanding. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Florian Baumann
- *Department of Trauma Surgery, Regensburg University Medical Center, Regensburg, Germany †The Rothman Institute at Thomas Jefferson University, Philadelphia, PA
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Mendenhall SK, Sivaganesan A, Mistry A, Sivasubramaniam P, McGirt MJ, Devin CJ. Traumatic atlantooccipital dislocation: comprehensive assessment of mortality, neurologic improvement, and patient-reported outcomes at a Level 1 trauma center over 15 years. Spine J 2015; 15:2385-95. [PMID: 26165481 DOI: 10.1016/j.spinee.2015.07.003] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Revised: 05/28/2015] [Accepted: 07/01/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Only Level 3 evidence exists for the diagnosis and treatment of atlantooccipital dislocation (AOD) with few studies examining mortality, neurologic improvement, and patient-reported outcomes (PROs). PURPOSE First, the aim was to determine: the incidence of AOD, 90-day surgical morbidity and mortality after AOD, patient factors that may be associated with delayed or missed diagnosis, and factors that were associated with mortality and neurologic improvement after AOD. Secondly, the aim was to quantify the pain, disability, and quality of life experienced by patients surviving AOD. STUDY DESIGN/SETTING This was a retrospective cohort study. PATIENT SAMPLE A total of 5,337 consecutive spine computed tomography traumagrams from 1997 to 2012 were included. OUTCOME MEASURES Mortality, neurologic improvement, complications, EuroQol five dimensions (EQ-5D), Neck Disability Index (NDI), Numeric Rating Scale (NRS)-neck, NRS-arm, and return-to-work were the outcome measures. METHODS Patients were considered to have AOD if they met one of the following radiographic criteria: basion-dens interval greater than 10 mm; basion-axial interval: anterior displacement greater than 12 mm or posterior displacement greater than 4 mm between the basion and posterior C2 line; and condyle to C1 interval greater than 1.4 mm. Linear regression analysis was performed to identify factors associated with 90-day mortality, neurologic improvement, and missed diagnosis. Patient-reported outcomes were assessed via phone interview. RESULTS Thirty-one patients met radiographic criteria for AOD; an incidence of 0.6% over 15 years. Twenty-one (68%) patients were treated with occipital cervical fusion. At 90 days postoperatively, there were no new neurologic deficits or reoperations. Eight (26%) patients died within 90 days. All patients who died had no documented AOD diagnosis and were not treated surgically. Missed AOD diagnosis was the strongest predictor of mortality. Younger age, lower Glasgow Coma Score, lower Injury Severity Score (ISS) score, and worse initial American Spinal Injury Association (ASIA) score were significantly associated with greater neurologic improvement. Higher ISS score and better ASIA score were significantly associated with missed AOD diagnosis. The average PROs metrics at time of telephone follow-up were as follows: EQ-5D=0.73±0.19, NDI=30.89±18.57, NRS-neck=2.33±2.21, NRS-arm=2.00±2.54. Of the patients with follow-up data, four were employed full-time, and five were receiving disability. CONCLUSIONS Our work suggests that failure to diagnose AOD is a powerful predictor of mortality. Higher ISS scores and better neurologic presentation were significantly associated with missed diagnosis. Craniocervical arthrodesis preserved neurologic function with low complication rate and unexpectedly high PROs and return-to-work. These results must be carefully interpreted because it is unclear whether missed AOD diagnosis accompanies another death-causing injury (eg, traumatic brain injury) or if failure to treat AOD contributes to mortality in a multifactorial manner.
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Affiliation(s)
- Stephen K Mendenhall
- Department of Neurological Surgery, Vanderbilt University Medical Center, T-4224 Medical Center N., 1611 21st Ave. S., Nashville, TN 37232, USA
| | - Ahilan Sivaganesan
- Department of Neurological Surgery, Vanderbilt University Medical Center, T-4224 Medical Center N., 1611 21st Ave. S., Nashville, TN 37232, USA
| | - Akshitkumar Mistry
- Department of Neurological Surgery, Vanderbilt University Medical Center, T-4224 Medical Center N., 1611 21st Ave. S., Nashville, TN 37232, USA
| | - Priya Sivasubramaniam
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, 1215 21st Ave. S. #4200, Nashville, TN 37232, USA
| | - Matthew J McGirt
- Department of Neurological Surgery, Vanderbilt University Medical Center, T-4224 Medical Center N., 1611 21st Ave. S., Nashville, TN 37232, USA; Carolina Neurosurgery and Spine Associates, 225 Baldwin Ave., Charlotte, NC 28204, USA
| | - Clinton J Devin
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, 1215 21st Ave. S. #4200, Nashville, TN 37232, USA.
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Plackett TP, Wright F, Baldea AJ, Mosier MJ, Thomas C, Luchette FA, Ton-That HH, Esposito TJ. Cervical spine clearance when unable to be cleared clinically: a pooled analysis of combined computed tomography and magnetic resonance imaging. Am J Surg 2015; 211:115-21. [PMID: 25997715 DOI: 10.1016/j.amjsurg.2014.12.041] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Revised: 12/19/2014] [Accepted: 12/22/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND The role of cervical spine magnetic resonance imaging (MRI) in the evaluation of clinically unevaluable blunt trauma patients has been called into question by several recent studies. METHODS A PubMed search was performed for all studies comparing computed tomography and MRI in the assessment of the cervical spine in patients who cannot be evaluated clinically. The radiologic findings and clinical outcomes from each study were collated for analysis. RESULTS Data for 1,714 patients were available. All patients had a negative computed tomography scan and then underwent an MRI. There were 271 (15.8%) patients who had a previously undocumented finding on MRI with the majority (98.2%) being a ligamentous injury. Only 5 injuries (1.8%) resulted in surgical intervention. CONCLUSIONS MRI identifies additional injuries; however, the vast majority are of minor clinical significance. Routine MRI after a negative computed tomography of the cervical spine is not supported by the current literature.
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Affiliation(s)
- Timothy P Plackett
- Division of Trauma, Surgical Critical Care, & Burns, Department of Surgery, Loyola University Medical Center, 2160 S. First Avenue, Maywood, IL 60153, USA.
| | - Franklin Wright
- Division of Trauma, Surgical Critical Care, & Burns, Department of Surgery, Loyola University Medical Center, 2160 S. First Avenue, Maywood, IL 60153, USA
| | - Anthony J Baldea
- Division of Trauma, Surgical Critical Care, & Burns, Department of Surgery, Loyola University Medical Center, 2160 S. First Avenue, Maywood, IL 60153, USA
| | - Michael J Mosier
- Division of Trauma, Surgical Critical Care, & Burns, Department of Surgery, Loyola University Medical Center, 2160 S. First Avenue, Maywood, IL 60153, USA
| | - Casey Thomas
- Division of Trauma, Surgical Critical Care, & Burns, Department of Surgery, Loyola University Medical Center, 2160 S. First Avenue, Maywood, IL 60153, USA
| | - Fred A Luchette
- Division of Trauma, Surgical Critical Care, & Burns, Department of Surgery, Loyola University Medical Center, 2160 S. First Avenue, Maywood, IL 60153, USA
| | - Hieu H Ton-That
- Division of Trauma, Surgical Critical Care, & Burns, Department of Surgery, Loyola University Medical Center, 2160 S. First Avenue, Maywood, IL 60153, USA
| | - Thomas J Esposito
- Division of Trauma, Surgical Critical Care, & Burns, Department of Surgery, Loyola University Medical Center, 2160 S. First Avenue, Maywood, IL 60153, USA
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