The craniocervical junction: embryology, anatomy, biomechanics and imaging in blunt trauma

Anatomical variability, morphofunctional characteristics, and clinical relevance of accessory ossicles of the back: implications for spinal pathophysiology and differential diagnosis

PURPOSE

This study explored the anatomical variations and clinical implications of accessory ossicles in the spine, which are often identified incidentally but can significantly impact the differential diagnosis of spinal disorders.

METHODS

A comprehensive review of the literature from MEDLINE, the Cochrane Library, ScienceDirect, and Google Scholar up to April 2024 was conducted. Statistical analyses emphasized distinct patterns in prevalence, location, and correlation with symptoms, reinforcing the importance of accurate identification and appropriate patient management.

RESULTS

Limbus Vertebra (LV) was observed in 2.5% of the cases, predominantly in the lumbar spine (70%). Ossicles of the nuchal ligament were identified in approximately 5.6% of cases, with a higher prevalence in males than in females.Correlation analysis indicated a weak positive correlation between LV and symptom severity (r = 0.25, p = 0.05) and a strong positive correlation between the ossicles of the nuchal ligament and male predominance (r = 0.75, p < 0.01). Additional accessory ossicles, including Oppenheimer's ossicles, accessory ossicles of the atlas, persistent ossiculum terminale, and os odontoideum, exhibited lower prevalence rates (< 2%), emphasizing their infrequency.

CONCLUSIONS

Accessory ossicles of the spine exhibit varied prevalence and clinical significance, with some presenting minor associations with symptoms and others linked to specific syndromes or spinal disorders. The prevalence of different ossicles shows notable heterogeneity, highlighting the need for careful differential diagnosis to prevent the misinterpretation of fractures or other spinal pathologies.

Odontoid Fractures: A Review of the Current State of the Art

Odontoid fractures (OFs) represent up to 15% of all cervical fractures encountered and present most commonly amongst elderly patients, typically in the setting of low energy trauma such as falls. The Anderson and D'Alonzo classification and Roy-Camille subtype description are the most clinically noteworthy descriptions of OFs used. Even though most patients will not present with neurological injury, mechanical instability can occur with type II and type III (Anderson and D'Alonzo) fractures, particularly if the transverse ligament of the atlas is ruptured; however, this is very rare. Conservative treatment is usually employed for type I and type III injuries, and to a varying degree for non-displaced type II injuries. Surgical treatment is typically reserved for type II fractures, patients with neurological injury, and in the setting of other associated fractures or ligamentous injury. Anterior screw fixation is a viable option in the setting of a favorable fracture line orientation in type II fractures, whereas posterior C1-C2 screw fixation is an option for any type II or type III fracture presentation. There is evidence that surgery for type II fractures has higher rates of union and lower mortality than nonoperative treatments. While surgical options have increased over the decades and the management of OF has been optimized by considering fracture subtypes and patient factors, there remains a significant morbidity and mortality associated with OFs. The aging population and changing demographics suggest that there will be an ongoing rise in the incidence of OFs. Therefore, the appropriate management of these cases will be essential for ensuring optimization of health care resources and the quality of life of affected patients.

Differentiating the Structural and Functional Instability of the Craniocervical Junction

This paper presents the anatomical and biomechanical aspects of chronic instability of the craniocervical junction (CCJ) with a discussion on clinical diagnostics based on mobility tests and provocative tests related to ligamentous system injuries, as well as radiological criteria for CCJ instability. In addition to the structural instability of the CCJ, the hypothesis of its functional form resulting from cervical proprioceptive system (CPS) damage is discussed. Clinical and neurophysiological studies have shown that functional disorders or organic changes in the CPS cause symptoms similar to those of vestibular system diseases: dizziness, nystagmus, and balance disorders. The underlying cause of the functional form of CCJ instability may be the increased activity of mechanoreceptors, leading to "informational noise" which causes vestibular system disorientation. Due to the disharmony of mutual stimulation and the inhibition of impulses between the centers controlling eye movements, the cerebellum, spinal motoneurons, and the vestibular system, inadequate vestibulospinal and vestibulo-ocular reactions occur, manifesting as postural instability, dizziness, and nystagmus. The hyperactivity of craniocervical mechanoreceptors also leads to disturbances in the reflex regulation of postural muscle tone, manifesting as "general instability". Understanding this form of CCJ instability as a distinct clinical entity is important both diagnostically and therapeutically as it requires different management strategies compared to true instability. Chronic CCJ instability significantly impacts the quality of life (QOL) of affected patients, contributing to chronic pain, psychological distress, and functional impairments. Addressing both structural and functional instability is essential for improving patient outcomes and enhancing their overall QOL.

Challenges in Contemporary Spine Surgery: A Comprehensive Review of Surgical, Technological, and Patient-Specific Issues

Spine surgery has significantly progressed due to innovations in surgical techniques, technology, and a deeper understanding of spinal pathology. However, numerous challenges persist, complicating successful outcomes. Anatomical intricacies at transitional junctions demand precise surgical expertise to avoid complications. Technical challenges, such as underestimation of the density of fixed vertebrae, individual vertebral characteristics, and the angle of pedicle inclination, pose additional risks during surgery. Patient anatomical variability and prior surgeries add layers of difficulty, often necessitating thorough pre- and intraoperative planning. Technological challenges involve the integration of artificial intelligence (AI) and advanced visualization systems. AI offers predictive capabilities but is limited by the need for large, high-quality datasets and the "black box" nature of machine learning models, which complicates clinical decision making. Visualization technologies like augmented reality and robotic surgery enhance precision but come with operational and cost-related hurdles. Patient-specific challenges include managing postoperative complications such as adjacent segment disease, hardware failure, and neurological deficits. Effective patient outcome measurement is critical, yet existing metrics often fail to capture the full scope of patient experiences. Proper patient selection for procedures is essential to minimize risks and improve outcomes, but criteria can be inconsistent and complex. There is the need for continued technological innovation, improved patient-specific outcome measures, and enhanced surgical education through simulation-based training. Integrating AI in preoperative planning and developing comprehensive databases for spinal pathologies can aid in creating more accurate, generalizable models. A holistic approach that combines technological advancements with personalized patient care and ongoing education is essential for addressing these challenges and improving spine surgery outcomes.

Knockdown of best1 Gene in Zebrafish Caused Abnormal Neuronal and Skeletal Development - A Subtype of Craniovertebral Junction Malformation?

OBJECTIVE

To investigate the developmental defects caused by knockdown of best1 gene in zebrafish as a model for a subtype of craniovertebral junction (CVJ) malformation.

METHODS

Two antisense morpholinos (MOs) were designed targeting zebrafish best1 to block translation (ATG-MO) or to disrupt splicing (I3E4-MO). MOs were microinjected into fertilized one-cell embryos. Efficacy of splicing MO was confirmed by reverse transcription-polymerase chain reaction. Phenotypes were analyzed and quantified by microscopy at multiple developmental stages. Neuronal outgrowth was assessed in transgenic zebrafish expressing green fluorescent protein in neurons. Skeletal ossification was visualized by Calcein staining.

RESULTS

Knockdown of best1 resulted in zebrafish embryos with shorter body length, curved axis, low survival rate, microcephaly, reduced eye size, smaller head and brain, impaired neuronal outgrowth, and reduced ossification of craniofacial and vertebral bone.

CONCLUSION

Best1 gene plays critical roles in ophthalmologic, neurological and skeletal development in zebrafish. A patient with a premature stop codon in BEST1 gene exhibited similar phenotypes, implying a subtype of CVJ malformation.

Anatomy of the craniocervical junction - A review

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.

Imaging Assessment of Nontraumatic Pathologic Conditions at the Craniovertebral Junction: A Comprehensive Review

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.

Revealing an Uncommon Presentation of Chiari I Malformation With Diverse Craniovertebral Anomalies in the Absence of Syringomyelia and Atlanto-Occipital Subluxation: A Case Report

A Chiari I malformation is a frequently encountered anomaly of the posterior fossa, occurring in a notable percentage of the population. It often coexists with various other craniovertebral junction abnormalities, albeit less frequently with Klippel-Feil syndrome. Interestingly, the majority of individuals with Chiari I malformation do not exhibit any symptoms. We present a rare case of a 25-year-old male with chronic neck and occipital pain, along with progressive weakness and sensory disturbances in all four limbs, urinary urgency, and elevated left shoulder. Examination unveiled spasticity, weakness, and brisk reflexes. On extensive radiological evaluation (X-ray, CT, and MRI), findings revealed various anomalies in the craniovertebral junction, including complete atlanto-occipital assimilation, basilar invagination, and platybasia. Furthermore, cervical segmentation abnormalities indicative of Klippel-Feil syndrome were observed, along with Sprengel's deformity. MRI confirmed Chiari I malformation with tonsillar herniation and myelomalacia, as well as compression at the cervico-medullary junction. This patient underwent a surgical procedure that included transoral odontoidectomy combined with occipito-cervical fixation, after which a good clinical response was observed. It emphasizes the necessity of radiological imaging for the diagnosis of Chiari and other associated abnormalities in the craniovertebral junction.

Anatomical variations of the atlas arches: prevalence assessment, systematic review and proposition for an updated classification system

Objective and background

This study focuses on the atlas, a pivotal component of the craniovertebral junction, bridging the cranium and spinal column. Notably, variations in its arches are documented globally, necessitating a thorough assessment and categorization due to their significant implications in clinical, diagnostic, functional, and therapeutic contexts. The primary objective is to ascertain the frequency of these anatomical deviations in the atlas arches among a Colombian cohort using cone-beam computed tomography (CBCT).

Methodology

Employing a descriptive, cross-sectional approach, this research scrutinizes the structural intricacies of the atlas arches in CBCT scans. Analytical parameters included sex distribution and the nature of anatomical deviations as per Currarino's classification. Statistical analyses were conducted to identify significant differences, including descriptive statistics and Chi-square tests. A systematic review of the literature was conducted in order to enhance the current Currarino's classification.

Results

The study examined 839 CBCT images, with a nearly equal sex distribution (49.7% female, 50.3% male). Anatomical variations were identified in 26 instances (3%), displaying a higher incidence in females (X2 [(1, N = 839) = 4.0933, p = 0.0430]). The most prevalent variation was Type A (2.5%), followed by Type B (0.4%), and Type G (0.2%) without documenting any other variation. The systematic review yielded 7 studies. A novel classification system for these variations is proposed, considering global prevalence data in the cervical region.

Conclusion

The study highlights a statistically significant predominance of Type A variations in the female subset. Given the critical nature of the craniovertebral junction and supporting evidence, it recommends an amendment to Currarino's classification to better reflect these clinical observations. A thorough study of anatomical variations of the upper cervical spine is relevant as they can impact important functional aspects such as mobility as well as stability. Considering the intricate anatomy of this area and the pivotal function of the atlas, accurately categorizing the variations of its arches is crucial for clinical practice. This classification aids in diagnosis, surgical planning, preventing iatrogenic incidents, and designing rehabilitation strategies.

Real-time ultrasound guidance in the endoscopic endonasal resection of a retro-odontoid pannus: Technical note and case illustration

Background and Objectives

Odontoidectomy is a surgical procedure indicated in the setting of various pathologies, with the main goal of decompressing the ventral brain stem and spinal cord as a result of irreducible compression at the craniovertebral junction. The endoscopic endonasal approach has been increasingly used as an alternative to the transoral approach as it provides a straightforward, panoramic, and direct approach to the odontoid process. In addition, intraoperative ultrasound (US) guidance is a technique that can optimize safety and surgical outcomes in this context. It is used as an adjunct to neuronavigation and provides intraoperative confirmation of decompression of craniovertebral junction structures in real time. The authors aim to present the use and safe application of real-time intraoperative US guidance during endonasal endoscopic resection of a retro-odontoid pannus.

Methods

A retrospective chart review of a single case was performed and presented herein as a case report and narrated operative video.

Results

A minimally invasive US transducer was used intraoperatively to guide the resection of a retro-odontoid pannus and confirm spinal cord decompression in real time. Postoperative examination of the patient revealed immediate neurological improvement.

Conclusions

Intraoperative ultrasonography is a well described and useful modality in neurosurgery. However, the use of intraoperative US guidance during endonasal endoscopic approaches to the craniovertebral junction has not been previously described. As demonstrated in this technical note, the authors show that this imaging modality can be added to the ever-evolving armamentarium of neurosurgeons to safely guide the decompression of neural structures within the craniocervical junction with good surgical outcomes.

Utility of Anterior Atlantodens Interval Widening on Cervical Spine CT for Assessing Transverse Atlantal Ligament Injury

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.

C2 Synchondrosal Injuries: A Case Report and Anatomic Review

Developmental succession in the pediatric patient requires special consideration in post-traumatic assessment. An understanding of the sequential development of this region and common patterns of injury can provide an accurate initial assessment before proceeding to further management and prognostic evaluation. Primarily, this article focuses on the synchondrosal development of C2 and its role in the craniocervical junction, as well as its common patterns of injury. This article presents two sample cases and offers a review of treatment options with added prognostic factors.

Imaging of the Craniocervical Junction: A Pictorial Review

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.

Advances, Challenges, and Future Directions in the Management of Craniovertebral Junction Pathologies

In this third article in a 3-article series on the craniocervical junction, we define the terms "basilar impression," "cranial settling," "basilar invagination," and "platybasia," noting that these terms are often used interchangeably but represent distinct entities. We then provide examples that represent these pathologies and treatment paradigms. Finally, we discuss the challenges and future direction in the craniovertebral junction surgery space.

Treatment of high cervical arteriovenous fistulas in the craniocervical junction region

The craniocervical junction (CCJ) is a complex region. Rarely, arteriovenous fistulas (AVFs) can occur in the CCJ region. Currently, it is accepted that CCJ AVFs should only refer to AVFs at the C1-C2 levels. It is reasonable to assume that high cervical CCJ AVFs are being referred to when discussing CCJ AVFs. High cervical CCJ AVFs can be divided into the following four types: dural AVF, radicular AVF, epidural AVF and perimedullary AVF. Until now, it was difficult to understand high cervical CCJ AVFs and provide a proper treatment for them. Therefore, an updated review of high cervical CCJ AVFs is necessary. In this review, the following issues are discussed: the definition of high cervical CCJ AVFs, vessel anatomy of the CCJ region, angioarchitecture of high cervical CCJ AVFs, treatment options, prognoses and complications. Based on the review and our experience, we found that the four types of high cervical CCJ AVFs share similar clinical and imaging characteristics. Patients may present with intracranial hemorrhage or congestive myelopathy. Treatment, including open surgery and endovascular treatment (EVT), can be used for symptomatic AVFs. Most high cervical CCJ AVFs can be effectively treated with open surgery. EVT remains challenging due to a high rate of incomplete obliteration and complications, and it can only be performed in superselective AVFs with simple angioarchitecture. Appropriate treatment can lead to a good prognosis.

A pictorial review of imaging findings associated with upper cervical trauma

The diagnosis of cervical spine injury in the emergency department remains a critical skill of emergency room physicians as well as radiologists. Such diagnoses are often associated with high morbidity and mortality unless readily identified and treated appropriately. Both computed tomography (CT) and magnetic resonance imaging (MRI) often are crucial in the workup of spinal injury and play a key role in arriving at a diagnosis. Unfortunately, missed cervical spine injuries are not necessarily uncommon and often precede detrimental neurologic sequalae. With the increase in whole-body imaging ordered from the emergency department, it is critical for radiologists to be acutely aware of key imaging features associated with upper cervical trauma, possible mimics, and radiographic clues suggesting potential high-risk patient populations. This pictorial review will cover key imaging features from several different imaging modalities associated with upper cervical spine trauma, explore patient epidemiology, mechanism, and presentation, as well as identify confounding radiographic signs to aid in confident and accurate diagnoses.

Cervical MRI assessment of traumatic anterior atlanto-occipital membrane complex injuries with evaluation of ancillary findings

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.

Can you see with CT? Is cervical spine computed tomographic imaging sufficient in pediatric trauma?

BACKGROUND

Traumatic cervical spine injury (CSI) is fundamentally different in children, and imaging recommendations vary; however, prompt diagnosis is necessary.

METHODS

We conducted a retrospective cohort study, evaluating children who presented after traumatic injury from 7/1/2012 to 12/31/2019 receiving a cervical spine CT. Evaluation of the incidence and clinical significance of CSI undetected on CT subsequently diagnosed on MRI was conducted. Additionally, all with CSI underwent image review to evaluate for potential overlooked, but visible pathology.

RESULTS

1487 children underwent a cervical spine CT, revealing 52 with CSI. 237 underwent MRI due to an abnormal CT or continued clinical concern. Ultimately, three were discovered to have clinically significant CSI missed on CT. In all cases, retrospective review demonstrated a retroclival hematoma when soft tissue windows were formatted in sagittal and coronal views.

CONCLUSIONS

A normal CT may be sufficient to rule-out clinically significant CSI. However, the presence of a retroclival hematoma must be evaluated.

An anatomical and radiological study of the tectorial membrane and its clinical implications

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.

Craniocervical instability in patients with Ehlers-Danlos syndrome: controversies in diagnosis and management

Ehlers-Danlos syndrome (EDS) is a rare hereditary condition that can result in ligamentous laxity and hypermobility of the cervical spine. A subset of patients can develop clinical instability of the craniocervical junction associated with pain and neurological dysfunction, potentially warranting treatment with occipitocervical fixation (OCF). Surgical decision-making in patients with EDS can be complicated by difficulty distinguishing from hypermobility inherent in the disease and true pathological instability necessitating intervention. Here we comprehensively review the available medical literature to critically appraise the evidence behind various proposed definitions of instability in the EDS population, and summarize the available outcomes data after OCF. Several radiographic parameters have been used, including the clivo-axial angle, basion-axial interval, and pB-C2 measurement. Despite increasing recognition of EDS by spine surgeons, there remains a paucity of data supporting proposed radiographic parameters for spinal instability among EDS patients. Furthermore, there is a lack of high-quality evidence concerning the efficacy of surgical treatments for chronic debilitating pain prevalent in this population. More standardized clinical measures and rigorous study methodologies are needed to elucidate the role of surgical intervention in this complex patient population.

The cervical spine in paediatric radiology

Accurate radiological assessment of the cervical spine is vital in the management of the child presenting with trauma. Compared to an adult's spine, the significant differences in the developmental anatomy (variants or synchondrosis), biomechanics and fracture patterns in the paediatric cervical spine makes assessment difficult, even for experienced radiologists. This review discusses the unique biomechanical factors, developmental anatomy, patterns of injury and imaging strategy in the paediatric population.

Interrelationship Between Craniocervical Dissociation Spectrum Injuries and Atlantoaxial Instability on Trauma Cervical MRI Examinations

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.

Appropriateness of Cervical Magnetic Resonance Imaging in the Evaluation and Management of C1 Jefferson Fractures

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.

Radiologic utility of the Gehweiler and AO spine classification systems for C1 Trauma: A retrospective review from a Level I trauma center

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.

Pediatric craniocervical fusion: predictors of surgical outcomes, risk of recurrence, and re-operation

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.

Asymmetry of the C2 pars interarticularis: a clinical anatomical study with relevance to screw placement

PURPOSE

Potential asymmetries of the C2 posterior elements pose a problem for the spine surgeon seeking to make the best choice for spinal stabilization while reducing morbidity.

METHODS

A digital caliper was used to measure the pars interarticularis height and length on left and right sides of 25 adult C2 vertebrae. The pars interarticularis was defined as the bone between the posterior most aspect of the superior articular process and the anterior most aspect of the inferior articular process of C2. Also, the C2 vertebrae from 49 patients were scanned by CT. Parasagittal images were reviewed and using the same definitions as were used for the skeletal specimens, the length and the height of the C2 pars interarticularis from both the left and right sides were measured using CT. The image slices were acquired at 3 mm intervals. The pars interarticularis height was determined on sagittal CT reconstruction, while the pars interarticularis length was calculated on the basis of the axial images.

RESULTS

The lengths and the heights of the left and right pars interarticularis were compared using CTs of patients and skeletal specimens. No significant differences were found in the length and height measurements of the CT images on both sides. However, in the skeletal specimens, the left and right pars interarticularis did not differ significantly in length but differed significantly in height (p = 0.003). The mean height of the left pars interarticularis was approximately two times larger than the right in the skeletal specimens. Absolute differences were calculated between the side with the greater length and height and the side with the lesser length and height irrespective of their left-right orientations. For CT measurements, most differences in length and height between the greater pars interarticularis and lesser pars interarticularis occurred between 0 and 1 mm with each successive disparity interval yielding lower numbers. Skeletal measurements revealed a similar length disparity distribution to the CT measurements. However, height measurements in the skeletal specimens varied widely. Eight pars interarticularis specimens demonstrated a height difference between 0 and 1 mm. No dry bone pars interarticularis specimens demonstrated a height difference between 1 and 2 mm. The pars interarticularis of nine specimens demonstrated a height difference between 2 and 3 mm. Two demonstrated a height difference between 3 and 4 mm. Four demonstrated a height difference between 4 and 5 mm and two demonstrated a height difference greater than 5 mm. The greater pars interarticularis lengths and heights were combined and compared to their lesser counterparts on CT and skeletal measurements. In all measurements of this type, significant differences were found in the pars interarticularis length and height, whether measured through CT or via digital calipers.

CONCLUSION

Asymmetry between the left and right C2 pars interarticularis as shown in the present study can alter surgical planning. Therefore, knowledge of this anatomical finding might be useful to spine surgeons.

Occult craniocervical dissociation on cervical CT: an under-appreciated presentation of craniocervical trauma requiring occipital cervical fusion

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.

PECULIARITIES OF THE HUMAN MAXILLA MORPHOGENESIS

OBJECTIVE

The aim: To find out the sources of formation and the chronological sequence of the morphogenesis of the maxilla at the early stages of human ontogenesis.

PATIENTS AND METHODS

Materials and methods: 14 series of consecutive histological specimens of human embryos and prefetuses (4,0-66,0 mm of parietal-coccygeal length) aged from 4 to 11 weeks of intrauterine development with the use of a complex of modern morphological methods of investigation (anthropometry, morphometry, microscopy, and 3D computer reconstruction) were studied.

RESULTS

Results: On the basis of a complex of morphological research methods, data were obtained that made it possible to establish the general patterns of development of the human maxilla: separation of the pharyngeal apparatus (4th week), convergence and fusion of the jaw processes (5-8th weeks), formation of tooth buds (7-8th weeks), which allows considering the specified periods as critical in the formation of possible anomalies in the facial part of the skull. At the same time, a tendency of heterochrony of morphological transformations in the maxilla and maxilla was revealed.

CONCLUSION

Conclusions: 1. At the beginning of the 4th week of intrauterine development, 3 pairs of pharyngeal arches are formed. Detachment of the mandibular and maxillary processes of the mandibular pharyngeal arch is planned. 2. During the 7th week of intrauterine development, the maximum convergence of the maxillary processes with the lateral and medial nasals occurs, and in embryos of 20.0 mm PCL grow with the frontal process, forming the maxilla and upper lip. During the 8th week of intrauterine development, the bone base of the jaws is modeled as a result of the increase in the size of osteogenic islands and their fusion, alveolar processes are formed. 3. During the 9-10th weeks of intrauterine development, the primary palate is formed as a result of the fusion of the palatine processes. 4. At the 11th week of intrauterine development, the bone base models both jaws. Due to the processes of histogenesis of the soft tissues of the maxillofacial apparatus, the face acquires anthropomorphic definitive human features.

C1-C2 Dorsal Epidural Hematoma on Cervical Spine CT: A Novel Imaging Sign of Posterior Atlanto-Occipital Membrane Stripping Injury

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.

Occipital condylar avulsion fractures in the acute trauma setting: Stable or unstable injury?

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.

Ligament deformation patterns of the craniocervical junction during head axial rotation tracked by biplane fluoroscopes

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.

Comparison of Upper Neck Loading in Young Adult and Elderly Volunteers During Low Speed Frontal Impacts

Cervical pain and injuries are a major health problem globally. Existing neck injury criteria are based on experimental studies that included sled tests performed with volunteers, post-mortem human surrogates and animals. However, none of these studies have addressed the differences between young adults and elderly volunteers to date. Thus, this work analyzed the estimated axial and shear forces, and the bending moment at the craniocervical junction of nine young volunteers (18–30 years old) and four elderly volunteers (>65 years old) in a low-speed frontal deceleration. Since the calculation of these loads required the use of the mass and moment of inertia of the volunteers' heads, this study proposed new methods to estimate the inertial properties of the head of the volunteers based on external measurements that reduced the error of previously published methods. The estimated mean peak axial force (Fz) was −164.38 ± 35.04 N in the young group and −170.62 ± 49.82 N in the elderly group. The average maximum shear force (Fx) was −224.42 ± 54.39 N and −232.41 ± 19.23 N in the young and elderly group, respectively. Last, the estimated peak bending moment (My) was 13.63 ± 1.09 Nm in the young group and 14.81 ± 1.36 Nm in the elderly group. The neck loads experienced by the elderly group were within the highest values in the present study. Nevertheless, for the group of volunteers included in this study, no substantial differences with age were observed.

Treatment of Unstable Occipital Condylar Fractures in Children-A STROBE-Compliant Investigation

Background and objectives: Occipital condyle fractures (OCF) occur rarely in children. The choice of treatment is based on the Anderson-Montesano and Tuli classification systems. We evaluated the outcome of unstable OCF in children and adolescents after halo-vest therapy. Materials and Methods: We treated 6 pediatric patients for OCF, including 3 patients (2 girls, 1 boy) with unstable OCF. Among the 3 patients with unstable OCF, 2 patients presented with an Anderson-Montesano type III and Tuli type IIB injury, while 1 patient had an Anderson-Montesano type I fracture (Tuli type IIB) accompanied by a C1 fracture. On admission, the children underwent computed tomography (CT) of the head and cervical spine as well as magnetic resonance imaging (MRI) of the cervical spine. We treated the children diagnosed with unstable OCF with halo-vest immobilization. Before removing the halo vest at the end of therapy, we applied the CT and MRI to confirm OCF consolidation. At follow-up, we rated functionality of the craniocervical junction (CCJ) based on the Neck Disability Index (NDI) and Questionnaire Short Form 36 Health Survey (SF-36). Results: All children achieved OCF consolidation after halo-vest therapy for a median of 13.0 weeks (range: 12.5-14.0 weeks). CT and MRI at the end of halo-vest therapy showed no signs of C0/C1 subluxation and confirmed the correct consolidation of OCF. The only complication associated with halo-vest therapy was a superficial infection caused by a halo-vest pin. At follow-up, all children exhibited favorable functionality of the CCJ as documented by the NDI score (median: 3 points; range: 3-11 points) and SF-36 score (median: 91 points; range: 64-96 points). Conclusions: In our small case series, halo-vest therapy resulted in good mid-term outcome in terms of OCF consolidation and CCJ functionality. In pediatric patients with suspected cervical spine injuries, we recommend CT and MRI of the CCJ to establish the diagnosis of OCF and confirm stable fracture consolidation before removing the halo vest.

"Supradental space sign" on cervical spine CT-a sign of tectorial membrane injury in adults trauma patients

BACKGROUND AND PURPOSE

The supradental space is a small, predominantly fat-filled recess superior to the atlanto-axial joint and inferior to the basion of the clivus that contains a small venous plexus. The posterior boundary of the supradental space is formed by the tectorial membrane, a stabilizing ligament of the craniocervical junction. The purpose of our study was to examine the imaging appearance of the supradental space in patients with tectorial membrane injury.

MATERIALS AND METHODS

Adult patients with tectorial membrane injury were identified utilizing keyword searches of radiology reports using Nuance mPower software. Age-matched positive and negative control groups were obtained. Two CAQ-certified neuroradiologists evaluated the cervical CT exams of these patients for supradental fat pad effacement from hematoma formation. The integrity of the osteoligamentous structures of the craniocervical junction was recorded on CT and MRI exams along with demographic information, clinical history, surgical management, and global outcome. Statistical analysis was performed.

RESULTS

Sixteen adults were diagnosed with tectorial membrane injury on cervical MRI. All patients with a visible supradental space demonstrated fat pad effacement and Hounsfield units consistent with hematoma formation. The positive and negative control groups demonstrated supradental fat pad effacement in 2/16 and 1/16 patients, respectively. A p-value of < 0.001 was obtained.

CONCLUSION

The "supradental space sign," defined as hematoma formation in the supradental space with effacement of the supradental fat pad is associated with tectorial membrane injury in adult trauma patients with sensitivity of 93.75% (95% confidence interval 69.77 to 99.84%) and specificity of 90.62% (95% confidence interval 74.98 to 98.02%).

Spine MRI: A Review of Commonly Encountered Emergent Conditions

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.

Proposed Grading System for Posterior Atlantooccipital Membrane Complex Injuries on Cervical Magnetic Resonance Imaging

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.

Anatomic, functional, and radiographic review of the ligaments of the craniocervical junction

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.

Resolution of retro-odontoid cyst in a patient with atlanto-occipital assimilation after occipitocervical fixation

Background:

Fusion of the atlas with the lower part of the occiput is clinically known as atlanto-occipital assimilation (AOA) or atlas occipitalization. This can be either partial or complete depending on the extent of fusion. AOA is one of the most common congenital anomalies of the craniovertebral junction and is usually asymptomatic.

Case Description:

An 80-year-old female presented with a retro-odontoid cyst in conjunction with AOA. Following posterior occipitocervical fixation without resection of the cyst, the patient improved, and the postoperative MR documented cyst resolution.

Conclusion:

Patients with AOA and a retro-odontoid cyst may be successfully managed with occipitocervical fixation without resection of the cyst. However, we would recommend preoperative computed tomography angiography to document whether the vertebral artery follows an anomalous course to avoid an intraoperative neurovascular injury.

Intraoperative image guidance for cervical spine surgery

Intraoperative image-guidance in spinal surgery has been influenced by various technological developments in imaging science since the early 1990s. The technology has evolved from simple fluoroscopic-based guidance to state-of-art intraoperative computed tomography (iCT)-based navigation systems. Although the intraoperative navigation is more commonly used in thoracolumbar spine surgery, this newer imaging platform has rapidly gained popularity in cervical approaches. The purpose of this manuscript is to address the applications of advanced image-guidance in cervical spine surgery and to describe the use of intraoperative neuro-navigation in surgical planning and execution. In this review, we aim to cover the following surgical techniques: anterior cervical approaches, atlanto-axial fixation, subaxial instrumentation, percutaneous interfacet cage implantation as well as minimally invasive posterior cervical foraminotomy (PCF) and unilateral laminotomy for bilateral decompression. The currently available data suggested that the use of 3D navigation significantly reduces the screw malposition, operative time, mean blood loss, radiation exposure, and complication rates in comparison to the conventional fluoroscopic-guidance. With the advancements in technology and surgical techniques, 3D navigation has potential to replace conventional fluoroscopy completely.

Duplication of the odontoid process with other congenital defects of the craniocervical Junction: case report and review of the literature

Duplication of the odontoid process remains a rare developmental pathology that is underrepresented in the current literature. As the pivot point for the craniovertebral junction, the odontoid process is vital for the integrity of the atlanto-axial joint and the ability of the head and cervical spine to rotate correctly. The pathogenesis being incompletely understood, it has been proposed that odontoid process duplication involves faulty sclerotome migration and disruption of the axis ossification center. Patients presenting with this pathology usually have associated structural abnormalities. A detailed anatomical and embryological understanding of the odontoid process is necessary for successful management and treatment of patients presenting with odontoid process duplication. We present a rare case of a patient with a duplicated odontoid process in association with C2–C3 fusion, incomplete anterior arch of C1, variant inferior bony process of the transverse process of C1, and enlarged right jugular foramen.

Fractures of C2 (Axis) Vertebra: Clinical Presentation and Management

BACKGROUND

Injuries of the upper cervical spine are a major cause of morbidity and mortality due to associated spinal cord and head injuries. The injury patterns of the upper cervical spine are numerous, and the neurologic sequelae are diverse. The axis (C2) is the most commonly fractured vertebra in the upper cervical spine; its unique anatomy and architecture pose difficulties in the diagnosis and the management of its fractures.

METHODS

All cases of acute spinal injuries at Prince Mohammed Bin Abdulaziz Hospital in Riyadh, Saudi Arabia, were screened for fractures of C2 vertebrae. These patients underwent computerized tomography (CT) imaging of the cervical spine with special attention paid to the cranio-cervical junction. Magnetic resonance imaging (MRI) and angiography of the neck were performed to exclude ligamentous tears and vascular injuries. Unstable fractures were fixed surgically. In the remaining cases, a conservative trial was given. All patients were followed up once every 3 months for a period of 1 year. During follow-up, some patients underwent additional CT imaging of the cervical spine to monitor the healing of fractures.

RESULTS

Out of 230 spinal trauma patients, 43.5% suffered from cervical spine injury. C2 fractures were recorded in 26% cases, and fractures of the C2 vertebral body, including pedicles, laminae, lateral masses, and articular processes, were found in many cases, followed by odontoid fractures (50%). No case of atlanto-axial or atlanto-occipital dislocation was recorded. Road traffic accidents were found to be responsible for 92% of cases. The majority of patients were young males, and 96% of patients had no neurological deficit. Only 15% of the patients required surgery for their unstable fractures. Half of the patients attended outpatient follow -up appointments, all of whom underwent CT scanning of the cervical spine 9 months after the accident or operation.

CONCLUSIONS

The axis (C2) is the most commonly affected vertebra in cervical spine trauma, and odontoid fractures make up 50% of all C2 fractures. C2 fractures rarely cause any neurological deficit or vascular injury, and the majority of affected patients can be managed conservatively; only a small proportion requires surgical intervention. Surgical intervention leads to early and complete healing.

Two-Stage Approach for Unstable Pediatric Craniocervical Junction Anomalies with a Halo Vest and Delayed Occipitocervical Fusion: Technical Note, Case Series, and Literature Review

OBJECTIVE

Malformations in the craniocervical junction (CCJ) are rare in the pediatric population but often need surgical treatment. We present a pediatric case series of patients treated with a 2-stage surgical approach with a halo vest and occipitocervical fusion and review complications and outcomes.

METHODS

A retrospective analysis of a single-center case series was performed. Pediatric patients affected by congenital craniocervical junction anomalies and treated with a 2-stage approach were included. A halo vest was implanted in the first surgery, and ambulatory progressive reduction was performed. When a favorable anatomic situation was observed, arthrodesis was performed. Safety analysis was undertaken by analyzing the incidence of complications in both procedures. Effectivity analysis was carried out analyzing radiologic and clinical outcome (Goel grade and modified Japanese Orthopaedic Association score). Student t test was used for statistical analysis.

RESULTS

Sixteen cases were included. Mean age of patients was 9.38 years. Safety analysis showed 2 halo loosenings, 1 pin infection, 2 wound infections, 1 cerebrospinal fluid leak, and 2 delayed broken rods. No major complications were observed. Radiologic analysis showed an improvement in the tip of the odontoid process to the McRae line distance (from -3.26 mm to -6.16 mm), atlantodental interval (from 3.05 mm to 1.88 mm), clival-canal angle (from 134.61° to 144.38°), and cervical kyphosis (from 6.39° to 1.54°). Clinical analysis also showed improvement in mean Goel grade (from 1.75 to 1.44) and modified Japanese Orthopaedic Association score (from 15.12 to 16.41).

CONCLUSIONS

The 2-stage approach was a suitable and effective treatment for craniocervical junction anomalies in pediatric patients.

Embryological considerations and evaluation of congenital anomalies of craniovertebral junction: A single-center experience

Objectives

Craniovertebral junction (CVJ) abnormalities constitute a group of treatable neurological disorders, especially in the Indian subcontinent. Thus, it is essential that clinicians should be able to make a precise diagnosis of abnormalities and rule out important mimickers on multidetector computed tomography (MDCT) as this information ultimately helps determine the management, prognosis, and quality of life of patients. CVJ is the most complex part of the cervical region. Congenital malformations of this region can cause serious neurological deficit and require a surgical intervention. The present study was undertaken to know the embryological basis of the CVJ and to identify commonly observed congenital CVJ abnormalities, their frequency, and mode of presentation.

Materials and Methods

Diagnosed cases of CVJ anomalies on dynamic MDCT head were reviewed at a tertiary care center between January 2014 to December 2019. Type of anomaly, clinical presentation, and associated malformations were recorded. Different types of variations were expressed in terms of percentage.

Results

Congenital anomalies were seen in 42 cases. Fifteen types of anomalies were detected. Anomalies were either singly or in combination. The CVJ anomalies were more common in young adults (28%), almost equal in both sexes. The most common anomaly was basilar invagination (52.3%), followed by atlanto-occipital assimilation (33.3%), and Arnold-Chiari malformation is the most common soft tissue anomaly. In fourteen cases, additional anomalies of other vertebrae were present. The most common symptoms were weakness of extremities, neck pain, paresthesia, torticollis, and gait disturbances. About 28 patients got improved, 8 patients had residual deficit as that of preoperative status, and 4 patients got deteriorated after surgery, at 1-month follow-up. About 34 patients had improved, 5 remained static, and 3 patients got worsened at the end of 3-month follow-up. About 37 patients had improved, 4 patients remained static, and 2 patients got deteriorated at 6 months of follow-up. The patients with increased atlantodens interval 3-5 mm showed 77% improvement after surgery.

Conclusion

Congenital CVJ anomalies, though rare, are fatal. CVJ abnormalities constitute an important group of treatable neurological disorders with diagnostic dilemma. The atlantodental interval is the most important preoperative prognostic marker. Dynamic CT imaging can provide additional useful information to the diagnosis of CVJ instability. To prevent long-term neurological problems, early diagnosis and treatment of congenital bony CVJ anomalies is important.

Occipital Condyle Screw Placement in Patients with Chiari Malformation: A Radiographic Feasibility Analysis and Cadaveric Demonstration

OBJECTIVE

Patients who undergo decompression surgery for Chiari malformation frequently require occipitocervical fixation. This is typically performed with occipital plates, which may cause intracranial injuries due to multiple fixation points. We undertook this study to assess the feasibility of occipital condyle (OC) screw placement as an alternative method of occipitocervical fixation in this patient population.

METHODS

Using a cadaveric model with navigational assistance, we performed the complete surgical procedure for occipitocervical fixation with OC screws. We then performed a morphometric analysis using measurements from computed tomography scans of 49 patients (32 adult, 17 pediatric) who had undergone occipitocervical fusion with instrumentation following decompression surgery for Chiari malformation. Bilateral morphometric data were analyzed for the adult and pediatric subgroups separately, as well as for the overall group.

RESULTS

The surgical procedure was successfully performed in the cadaveric model, demonstrating the feasibility of the proposed method. Ninety-eight OCs were studied in the morphometric analysis, and 80 (81.6%) met our eligibility criteria for OC screw placement. However, in 14.1% of adult OCs and 26.5% of pediatric OCs studied, placement of condylar screws would have been challenging or unsafe, according to our criteria.

CONCLUSIONS

Our findings suggest that OC screws provide a useful option for occipitocervical fixation in a substantial proportion of patients with Chiari malformation. However, rigorous preoperative analysis would be essential to identify appropriate candidates for this technique and exclude those in whom it should not be attempted. Additional study is warranted.

Traumatic Craniocervical Dissociation in Patients with Congenital Assimilation of the Atlas to the Occiput

Traumatic atlantooccipital dissociation (AOD) is a severe and usually fatal injury. Patients with assimilation of the atlas to the skull are exposed to a higher risk of injury and delay diagnosis due to the abnormal anatomy. We report two cases of acute traumatic craniocervical dislocation in patients with baseline congenital assimilation of the atlas to the skull. Computer tomography (CT) was used to identify the injury. Computer tomography angiography (CTA) showed variations of the vertebral arteries' location on both patients. Assimilation of the atlas was complete in patient one and partial in patient two. Emergent surgical instrumentation and fusion were performed with a very careful and meticulous posterior dissection. As general rule, most of the patients with CCD will undergo occiput to C2 posterior segmental instrumentation and fusion. In the presented cases, a more extensive fusion was necessary based on the type and severity of the CCJ injury and the anatomical anomalies associated. Postoperatively, patient one remained neurologically intact and patient two died. Alternative fixation techniques should be used to minimize risk of VA injury during the surgical procedures.