Bilateral occipital condyle fractures leading to retropharyngeal haematoma and acute respiratory distress

CT diagnosis of occipital condyle fracture in a dog presented for severe cervical hyperesthesia

A 9-month-old male entire Doberman Pinscher presented with acute onset of severe cervical hyperesthesia after a fall. Neurological examination revealed a normal gait with low head carriage and severe cervical hyperesthesia. A CT scan of the cervical vertebral column revealed the presence of a comminuted fracture at the dorsomedial aspect of the right occipital condyle and sclerosis of the underlying bone. Medical management was initiated consisting of an external bandage, strict rest, and pain medication. Due to the lack of clinical improvement, the dog was euthanized 2 months after diagnosis. Histopathology of the lesion was compatible with a healing fracture.

Outcome of conservatively treated occipital condylar fractures - A retrospective study

Introduction:

Occipital condyle fracture (OCF) is rare. It may, however, pose a serious threat to the patient due to destabilization of the craniocervical junction. Correct diagnosis and effective treatment are essential to prevent long-term complications. The aim of this study was to retrospectively investigate our current treatment program with focus on the functional outcome. Diagnosis and classification systems were evaluated for their usefulness in the clinical practice.

Materials and Methods:

We retrospectively reviewed all patients treated conservatively for an occipital condylar fracture from 2010 to 2015 at our department. Fracture classifications were performed according to three established systems. The patients were followed up with clinical examination and plain radiographs at weeks 2, 6, and 12 with the addition of a dynamic flexion-extension X-ray at week 14.

Results:

Totally 24 patients met the inclusion criteria. One was lost to follow-up and two ended treatment before completing the full treatment program due to a clinical decision. Fracture displacement was neither detected nor was any neurological deficits observed. Most patients were pain free after 6 weeks. After 14 weeks’ treatment, two patients still had neck pain; the rest were pain free.

Conclusions:

Our data suggest that twelve weeks’ conservative treatment is not necessary for unilateral OCFs without atlanto-occipital dissociation (AOD). We recommend 6 weeks of conservative treatment, with clinical control and flexion-extension radiographs before ending treatment. Plain radiography is of limited value in the clinical control of this fracture type. Anderson and Montesano and Tuli et al. classification systems fulfill an academic role. We found the classification system by Mueller et al. to be more helpful in everyday clinical practice.

Traumatic injuries to the craniovertebral junction: a review of rare events

The craniovertebral junction is a specific region of the spine with unique anatomical and biomechanical properties that yields a wide variety of injury patterns. Junctional traumatic fractures and/or dislocations are widely reported in clinical practice, but we could identify only a subgroup of upper cervical spine traumatic injuries with very few cases reported in the literature, and for this reason may be considered rare. In some of these cases, the absence of spinal biomechanical instability, in association with moderate clinical symptoms (neck stiffness and pain) and the difficulty in fracture identification through standard cervical radiographs, leads to a high percentage of missed injuries. In other cases, traumatic events have been commonly described only in autopsy series due to the high degree of spinal biomechanical instability. Herein, we have summarized all the relevant literature concerning this issue and also included our cases, with the aim of emphasizing prompt diagnosis and correct management. We provide a guide for correctly identifying "rare" craniovertebral junction traumatic injuries.

Pathologic cervical burst fracture presenting with airway compromise

Mechanical airway compromise following cervical spine injury or fracture is a rare but known entity. It most commonly is the result of the development of a retropharyngeal hematoma or prevertebral soft tissue edema that obstructs the airway, leading to respiratory distress and emergent need for airway management and possible surgical intervention. We present a novel case of airway compromise following a C3 burst fracture without associated retropharyngeal hematoma or prevertebral soft tissue edema. Surgical management is discussed, and a review of relevant literature is provided. Pathological cervical spine fracture must be included in the differential diagnosis of a patient presenting with acute airway obstruction of unknown etiology.

Occipital condyle fractures

OBJECTIVE

The anatomy, clinical presentation, radiologic evaluation, treatment, and outcome of occipital condyle fractures are reviewed.

METHODS

We review and discuss the literature on occipital condyle fractures.

RESULTS

Occipital condyle fractures are best diagnosed with computed tomography. The neurologic presentation is variable. The majority of these injuries may be treated nonoperatively, but an occipitocervical fusion is necessary to restore stability across the craniovertebral junction.

CONCLUSION

Occipital condyle fractures are a rare but serious injury that requires prompt diagnosis and treatment.

Occipital condyle fractures: clinical decision rule and surgical management

OBJECT

Occipital condyle fractures (OCFs) are rare injuries and their treatment remains controversial. Several classification systems have been proposed, first by Anderson and Montesano and more recently by Tuli and colleagues and Hanson and associates, who sought to stratify these fractures in a manner that would guide treatment that has typically ranged from semirigid collar immobilization to halo fixation or occipitocervical fusion. It has been the authors' impression, based on experience with OCFs at their institution, that classification is cumbersome and contributes little to the clinical decision-making process, while the identification of craniocervical misalignment and neural element compromise is paramount, and sufficient, for the planning of treatment.

METHODS

The authors performed a retrospective review of 24,745 consecutive trauma presentations to a single Level I trauma center (UPMC Presbyterian Hospital) over a 6-year period, identifying 100 patients with 106 OCFs. All patients were evaluated by the spine trauma service and underwent imaging of the craniocervical junction using reconstructed CT scans. Patient characteristics, fracture characteristics (including fracture classification according to the 2 major classification systems), initial management, and status at follow-up were recorded.

RESULTS

The incidence of OCF in this trauma population was 0.4%. Two patients had evidence of craniocervical misalignment on reconstructed CT imaging at the time of admission; both patients underwent occipitocervical fusion. One patient underwent occipitocervical fusion for unrelated C1-2 fractures. The remainder of those surviving to discharge, whose fractures represented all fracture subtypes, received treatment with a rigid cervical collar or counseling alone. No patients, including 4 patients with bilateral OCFs, were found to have developed delayed craniocervical instability or misalignment on follow-up, or to require further neurosurgical intervention for an OCF. Neural element compression was not identified in any of the patients, and there were no cases of delayed cranial neuropathy.

CONCLUSIONS

Beyond the identification of craniocervical misalignment on reconstructed CT scans at admission, further classification of OCFs is unnecessary. Management should consist of up-front occipitocervical fusion or halo fixation in cases demonstrating occipitocervical misalignment, or of immobilization in a rigid cervical collar followed by delayed clinical and radiographic evaluation in a spine trauma clinic if misalignment is not present.

Occipital condyle fractures: incidence and clinical follow-up at a level 1 trauma centre

The purpose of the study was to investigate the incidence, management, and outcomes of occipital condyle fractures at a level 1 trauma center. Blunt trauma patients with occipital condyle fracture admitted to a level 1 trauma center over a 3-year period were identified. Prospective clinical and functional follow-up was undertaken, including further radiographic imaging. The incidence of occipital condyle fracture in patients presenting to our level 1 trauma center was 1.7/1,000 per year. Twenty-four patients were followed up at a mean of 27 months post-injury. There was one case of isolated occipital condyle fracture; all other patients had sustained additional orthopedic, cervical spine, and/or head injury. Seven (29%) patients sustained unilateral Type III avulsion fractures, none of which were isolated injuries. Traumatic brain injury was detected in 46% of study patients, and 42% had cervical spine injury. External halothoracic immobilization was used in 33% of cases. Fracture union with anatomical alignment occurred in 21 patients (88%). No patient had cranial nerve deficit at admission or follow-up. Three patients (12.5%) had moderate to severe neck pain/disability at follow-up, all of whom had sustained multiple injuries. Occipital condyle fractures most frequently occur in conjunction with additional injuries, particularly head and cervical spine injuries. Most cases can be managed successfully nonoperatively. Functional outcome is generally determined by pain and disability related to other injuries, rather than occipital fracture configuration.

Unilateral occipital condylar fracture presenting as neck pain and restriction of neck movements- Report of a case and review of literature

Occipital condylar fractures (OCFs) once rare injuries are not so at present. A young male, victim of motor vehicle accident, presented with severe high cervical pain and restriction of neck movements without any focal neurological deficit, with normal cervical spine x-rays and computerized tomography (CT) scans brain. CT scan and magnetic resonance (MR) imaging of the craniovertebral junction (CVJ) area revealed a retro-pulsed segment in the cervical spinal canal with no cord compression or ligament injury. Patient improved with immobilization of neck. Patients with severe high cervical pain and restricted head movements OCF should be suspected and patient should be evaluated further. Majority of stable OCF improve with immobilization only.

Bilateral occipital condylar fracture with associated haematomas

Occipital condylar fractures (OCFs) seem to be rare. The exact incidence is unknown, but a few studies reported a 3-4% incidence of OCFs in patients with severe head injury and altered Glasgow Coma Scale score. The low incidence of OCFs and missed diagnoses in these patients may result in late neurological deficits. We report the history of a patient with bilateral OCFs, a combined fracture of the anterior arcus of the atlas and associated retropharyngeal and epidural cervical haematomas, who presented without life-threatening symptoms or neurological deficits.

Occipital condylar fractures. Review of the literature and case report

Fractures of the occipital condyle are rare. Their prompt diagnosis is crucial since there may be associated cranial nerve palsies and cervical spinal instability. The fracture is often not visible on a plain radiograph. We report the case of a 21-year-old man who sustained an occipital condylar fracture without any associated cranial nerve palsy or further injuries. We have also reviewed the literature on this type of injury, in order to assess the incidence, the mechanism and the association with head and cervical spinal injuries as well as classification systems, options for treatment and outcome.