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Bai J, Ismail R, Kessler A, Kawakyu-O'Connor D. Imaging of cerebrovascular complications from blunt skull base trauma. Emerg Radiol 2024; 31:529-542. [PMID: 38806851 PMCID: PMC11289000 DOI: 10.1007/s10140-024-02243-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Accepted: 05/13/2024] [Indexed: 05/30/2024]
Abstract
Cerebrovascular complications from blunt trauma to the skull base, though rare, can lead to potentially devastating outcomes, emphasizing the importance of timely diagnosis and management. Due to the insidious clinical presentation, subtle nature of imaging findings, and complex anatomy of the skull base, diagnosing cerebrovascular injuries and their complications poses considerable challenges. This article offers a comprehensive review of skull base anatomy and pathophysiology pertinent to recognizing cerebrovascular injuries and their complications, up-to-date screening criteria and imaging techniques for assessing these injuries, and a case-based review of the spectrum of cerebrovascular complications arising from skull base trauma. This review will enhance understanding of cerebrovascular injuries and their complications from blunt skull base trauma to facilitate diagnosis and timely treatment.
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Affiliation(s)
- James Bai
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY, USA.
- School of Medicine and Dentistry, University of Rochester Medical Center, 601 Elmwood Ave, Box 648, 14642, Rochester, NY, USA.
| | - Rahim Ismail
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY, USA
| | - Alex Kessler
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY, USA
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2
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Scheyerer MJ, Bigdon SF, Gaudin R, Gercek E, Müller CW, Osterhoff G, Pumberger M, Ryang YM, Scholz C, Schömig F, Spiegl UJA, Taheri N, Schnake KJ. [Cervical Spine Injuries]. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2024; 162:429-443. [PMID: 39116860 DOI: 10.1055/a-2190-3115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/10/2024]
Abstract
Around a third of all cervical spine injuries occur in the upper cervical spine in the area between the occiput and the second cervical vertebra. The latter being the most common location of the injury with around 70%. But also atlas fractures, occipital condyle fractures, traumatic spondylolisthesis of C2, atypical fractures in the corpus area as well as atlantooccipital and atlantoaxial ligamentous lesions should be mentioned in connection with injuries in this area. In many cases, conservative therapy regimen is possible. In unstable or displaced injuries, however, surgical intervention is required, with various surgical procedures being used. The frequency, diagnostics, classification, and standard therapy of the individual entities are presented in detail in this continuing medical education article.
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Morris L, Lawless A, McDonnell JM, Wilson KV, Marland H, Darwish S, Butler JS. Retrospective case series of vertebral artery injuries associated with cervical spine trauma. Surgeon 2024:S1479-666X(24)00079-9. [PMID: 39084923 DOI: 10.1016/j.surge.2024.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 07/20/2024] [Accepted: 07/22/2024] [Indexed: 08/02/2024]
Abstract
BACKGROUND Vertebral artery injuries (VAI) can occur due to cervical spine trauma. VAI can prove a serious complication and potentially compromise vascular supply to the posterior aspect of the brain. Currently, there is a paucity of evidence with regards to incidence, management, and outcomes for these patients. The purpose of this study is to investigate and elucidate the incidence of VAI associated with cervical trauma at a national tertiary referral centre for spinal pathology, their respective management, and associated outcomes. METHODS A retrospective review was conducted from 2012 to 2021 to identify patients with VAI secondary to cervical spine trauma. Demographic, clinical, and radiological data was collected to identify common traits in injury characteristics and management. RESULTS 1013 spine patients presented to our institution across the 10-year period. 739/1013 (72.9 %) were trauma patients. 42/739 (5.7 %) were imaged for suspected VAI secondary to trauma. There were 14/739 (1.9 %) confirmed VAI. All patients had CT-angiography for diagnosis. Four of the confirmed VAI patients (28.6 %) had additional MR-angiography imaging. Right-side was the most common side of VAI injury (7/14; 50 %), followed by left (5/14; 35.7 %) and bilateral (2/14; 14.3 %) injuries. 8/14 (57.1 %) patients were prescribed anti-thrombotic therapy. Acute mortality within 3-months was noted to be 2/14 (14.3 %) and occurred at 49 days and 57 days respectively. CONCLUSION VAI associated with cervical spine injury is rare in occurrence. However, it can be associated with high morbidity and mortality. As such, a multi-disciplinary approach to care is integral to ensuring good outcomes in these patients.
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Affiliation(s)
- Leah Morris
- National Spinal Injuries Unit, Mater Misericordiae University Hospital, Dublin, Ireland; School of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Anna Lawless
- National Spinal Injuries Unit, Mater Misericordiae University Hospital, Dublin, Ireland; School of Medicine, University College Dublin, Dublin, Ireland
| | - Jake M McDonnell
- National Spinal Injuries Unit, Mater Misericordiae University Hospital, Dublin, Ireland; Trinity Centre of Biomedical Engineering, Trinity College Dublin, Dublin, Ireland
| | - Kielan V Wilson
- National Spinal Injuries Unit, Mater Misericordiae University Hospital, Dublin, Ireland; School of Medicine, University College Dublin, Dublin, Ireland.
| | - Harry Marland
- National Spinal Injuries Unit, Mater Misericordiae University Hospital, Dublin, Ireland; School of Medicine, University of Galway, Galway, Ireland
| | - Stacey Darwish
- National Spinal Injuries Unit, Mater Misericordiae University Hospital, Dublin, Ireland; Department of Orthopaedics, St. Vincent's University Hospital, Dublin, Ireland
| | - Joseph S Butler
- National Spinal Injuries Unit, Mater Misericordiae University Hospital, Dublin, Ireland; School of Medicine, University College Dublin, Dublin, Ireland
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Choucha A, Barraque T, Meyer M, Dufour H, Farah K, Fuentes S. Fractured cervical spine, dissected vertebral artery, and life-threatening stroke: A challenging case report and literature review. Neurochirurgie 2024; 70:101561. [PMID: 38621474 DOI: 10.1016/j.neuchi.2024.101561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Revised: 04/02/2024] [Accepted: 04/09/2024] [Indexed: 04/17/2024]
Abstract
INTRODUCTION Vertebral artery injury (VAI) following blunt trauma can lead to acute or delayed life-threatening posterior fossa ischemic stroke. Its management raises controversial issues and is still open to debate. MATERIAL & METHOD We report the case of a 48-year-old male who presented a life-threatening posterior circulation ischemic stroke, secondary to a vertebral artery dissection caused by a cervical spine fracture. This case was successfully managed through intravenous thrombolysis and endovascular thrombectomy followed by antiplatelet therapy and an anterior cervical discectomy and fusion. At the one-year follow-up, the patient had no persisting deficit and was back working as a policeman. CONCLUSION Rapid management of patients with dramatic clinical presentation can lead to full recovery. Implications include a systematic screening of blunt trauma VAI through computed tomography angiography when dealing with high-risk cervical spine fractures; patients harboring both a cervical spine fracture and a VAI must be transferred to a tertiary referral hospital able to deal both with strokes and cervical spine surgery to ensure responsiveness in case of stroke.
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Affiliation(s)
- Anis Choucha
- Aix Marseille Univ, APM, UH Timone, Department of Neurosurgery, Marseille, France; Laboratory of Biomechanics and Application, UMRT24, Gustave Eiffel University, Aix Marseille University, Marseille, France.
| | - Thomas Barraque
- Aix Marseille Univ, APHM, UH Timone, Department of Emergency Medicine, Marseille, France
| | - Mikael Meyer
- Aix Marseille Univ, APM, UH Timone, Department of Neurosurgery, Marseille, France
| | - Henry Dufour
- Aix Marseille Univ, APM, UH Timone, Department of Neurosurgery, Marseille, France
| | - Kaissar Farah
- Aix Marseille Univ, APM, UH Timone, Department of Neurosurgery, Marseille, France
| | - Stephane Fuentes
- Aix Marseille Univ, APM, UH Timone, Department of Neurosurgery, Marseille, France
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Garg S, Maniakhina L, Muir SM, Gill AK, Gill SS. Preventing Iatrogenic Injury to the Vertebral Artery in Cervical Spine Surgery: A Case Report. Clin Spine Surg 2024:01933606-990000000-00309. [PMID: 38650070 DOI: 10.1097/bsd.0000000000001619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 02/28/2024] [Indexed: 04/25/2024]
Abstract
SUMMARY OF BACKGROUND DATA Iatrogenic injury of the vertebral artery (VA) in the context of surgical approaches to the cervical spine has been cited as a relatively rare complication with varying degrees of severity ranging from minimal injury to acute stroke and can result in death. It is estimated that ~50% of cases of iatrogenic VA injury are preventable after postoperatively examining a patient's preoperative imaging. Despite the low incidence (<2%) of this complication, the potential associated morbidity demonstrates the importance of meticulous preoperative vascular consideration. OBJECTIVE This study aims to emphasize the importance of preoperative vascular screening during anterior cervical access planning visualized through a rare case of a VA aberration in a 47-year-old patient. STUDY DESIGN This study is designed as a retrospective case report. METHODS A thorough chart review was performed for this subject including all prior medical records, imaging studies, imaging reports, operative notes, and communication records. RESULTS The subject was found to have a history of patent foramen ovale (PFO) repair with a rare vertebral artery malformation described as a medial transposition of the vertebral artery out of the vertebral artery foramen between C3 and C4. CONCLUSIONS Consideration of cervical anatomy, particularly the VA, is key to minimizing the risk of adverse surgical outcomes in both anterior and posterior approaches to the cervical spine. During the workup process, the patient's primary care providers, radiologists, and surgeons should be aware of the potential variations of the VA with particular attention given to the course of the VA on MR imaging. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Sahil Garg
- Steadman Philippon Research Institute, The Steadman Clinic, Vail, CO
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Irawany V, Nasution VAF, Amalia N. Bilateral vertebral artery injury leads to brain death following traumatic brain injury: a case report. J Med Case Rep 2024; 18:106. [PMID: 38491407 PMCID: PMC10943836 DOI: 10.1186/s13256-024-04432-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 02/02/2024] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND Vertebral artery injury is a rare condition in trauma settings. In the advanced stages, it causes death. CASE A 31-year-old Sundanese woman with cerebral edema, C2-C3 anterolisthesis, and Le Fort III fracture after a motorcycle accident was admitted to the emergency room. On the fifth day, she underwent arch bar maxillomandibular application and debridement in general anesthesia with a hyperextended neck position. Unfortunately, her rigid neck collar was removed in the high care unit before surgery. Her condition deteriorated 72 hours after surgery. Digital subtraction angiography revealed a grade 5 bilateral vertebral artery injury due to cervical spine displacement and a grade 4 left internal carotid artery injury with a carotid cavernous fistula (CCF). The patient was declared brain death as not improved cerebral perfusion after CCF coiling. CONCLUSIONS Brain death due to cerebral hypoperfusion following cerebrovascular injury in this patient could be prevented by early endovascular intervention and cervical immobilisation.
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Affiliation(s)
- Vera Irawany
- Fatmawati National General Hospital, Jakarta, Indonesia
- Anesthesiology and Intensive Care Department, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Vizzi A F Nasution
- Anesthesiology and Intensive Care Department, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia.
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Lee S, Hur JW, Oh Y, An S, Yun GY, Ahn JM. Current Concepts in the Treatment of Traumatic C2 Vertebral Fracture : A Literature Review. J Korean Neurosurg Soc 2024; 67:6-13. [PMID: 37461838 PMCID: PMC10788552 DOI: 10.3340/jkns.2023.0098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 07/12/2023] [Accepted: 07/14/2023] [Indexed: 01/17/2024] Open
Abstract
The integrity of the high cervical spine, the transition zone from the brainstem to the spinal cord, is crucial for survival and daily life. The region protects the enclosed neurovascular structure and allows a substantial portion of the head motion. Injuries of the high cervical spine are frequent, and the fractures of the C2 vertebra account for approximately 17-25% of acute cervical fractures. We review the two major types of C2 vertebral fractures, odontoid fracture and Hangman's fracture. For both types of fractures, favorable outcomes could be obtained if the delicately selected conservative treatment is performed. In odontoid fractures, as the most common fracture on the C2 vertebrae, anterior screw fixation is considered first for type II fractures, and C1-2 fusion is suggested when nonunion is a concern or occurs. Hangman's fractures are the second most common fracture. Many stable extension type I and II fractures can be treated with external immobilization, whereas the predominant flexion type IIA and III fractures require surgical stabilization. No result proves that either anterior or posterior surgery is superior, and the surgeon should decide on the surgical method after careful consideration according to each clinical situation. This review will briefly describe the basic principles and current treatment concepts of C2 fractures.
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Affiliation(s)
- Subum Lee
- Department of Neurosurgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Junseok W Hur
- Department of Neurosurgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Younggyu Oh
- Department of Neurosurgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Sungjae An
- Department of Neurosurgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Gi-Yong Yun
- Department of Neurosurgery, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Jae-Min Ahn
- Department of Neurosurgery, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea
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Essa A, Khatib S, Beit Ner E, Smorgick Y, Mirovsky Y, Anekstein Y, Rabau O. Traumatic Posterior Atlantoaxial Dislocation With an Associated Fracture: A Systematic Review. Clin Spine Surg 2023; 36:323-329. [PMID: 36750437 DOI: 10.1097/bsd.0000000000001431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 12/01/2022] [Indexed: 02/09/2023]
Abstract
STUDY DESIGN Systematic review. OBJECTIVE To investigate the clinical presentation, mechanism of injury, patients' characteristics, diagnosis, treatment, and prognosis of traumatic posterior atlantoaxial dislocation with fracture (TPAD). BACKGROUND TPAD is an extremely rare entity, with a limited number of cases reported in the literature. Although rare, a thorough understanding of the pathogenesis and management of such cases is required due to the high risk of spinal cord compression and the severity of neurological deficits. We conducted a systematic review of all cases of TPAD with fractures reported in the literature. METHODS This systematic review was conducted following the Preferred Reporting Items for Systematic reviews and Meta-analysis guidelines. Relevant literature was retrieved from the Pubmed database. All published English-written studies involving human subjects with relevant data regarding TPAD were included. RESULTS Two case series and 20 case reports published between 1924 and 2021 describing 28 patients with TPAD were included. The median age at presentation was 51.5 years, with male predominance (83%). The most common fracture pattern was Anderson and D'alonzo type II odontoid fracture (78%). Neurological exam at presentation was intact in 52% of patients. The primary diagnostic imaging was computed tomography employed in 96% of cases. The management consisted of 2 stages protocol, initially, a temporary axial traction was employed (54%), and later definitive surgical treatment was employed (93%). The posterior surgical approach was favored in 82% of cases. CONCLUSION TPAD with fracture occurred in the majority of cases with Anderson and D'alonzo type II odontoid fracture, predominantly in males. Diagnosis is usually established based on computed tomography imaging; further imaging may not be indicated as it does not seem to alternate the patient's management course. Surgical intervention was employed in almost all cases, with favored results through posterior C1-C2 fusion. LEVEL OF EVIDENCE Level-IV.
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Affiliation(s)
- Ahmad Essa
- Department of Orthopedics, Shamir (Assaf Harofeh) Medical Center
- Faculty of Medicine, Tel Aviv University, Tel Aviv
| | - Salah Khatib
- Department of Orthopedics, Shamir (Assaf Harofeh) Medical Center
- Faculty of Medicine, Tel Aviv University, Tel Aviv
| | - Eran Beit Ner
- Department of Orthopedics, Shamir (Assaf Harofeh) Medical Center
- Faculty of Medicine, Tel Aviv University, Tel Aviv
| | - Yossi Smorgick
- Department of Orthopedics, Shamir (Assaf Harofeh) Medical Center
- Faculty of Medicine, Tel Aviv University, Tel Aviv
- Department of Orthopedic Surgery, Spine Unit, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
| | - Yigal Mirovsky
- Department of Orthopedics, Shamir (Assaf Harofeh) Medical Center
- Faculty of Medicine, Tel Aviv University, Tel Aviv
- Department of Orthopedic Surgery, Spine Unit, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
| | - Yoram Anekstein
- Department of Orthopedics, Shamir (Assaf Harofeh) Medical Center
- Faculty of Medicine, Tel Aviv University, Tel Aviv
- Department of Orthopedic Surgery, Spine Unit, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
| | - Oded Rabau
- Department of Orthopedics, Shamir (Assaf Harofeh) Medical Center
- Faculty of Medicine, Tel Aviv University, Tel Aviv
- Department of Orthopedic Surgery, Spine Unit, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
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Maclean MA, Touchette CJ, Duda T, Almojuela A, Bergeron D, Kameda-Smith M, Persad ARL, Sader N, Alant J, Christie SD. Work-up and Management of Asymptomatic Extracranial Traumatic Vertebral Artery Injury. Can J Neurol Sci 2023; 50:662-672. [PMID: 36017734 DOI: 10.1017/cjn.2022.292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Non-penetrating head and neck trauma is associated with extracranial traumatic vertebral artery injury (eTVAI) in approximately 1-2% of cases. Most patients are initially asymptomatic but have an increased risk for delayed stroke and mortality. Limited evidence is available to guide the management of asymptomatic eTVAI. As such, we sought to investigate national practice patterns regarding screening, treatment, and follow-up domains. METHODS A cross-sectional, electronic survey was distributed to members of the Canadian Neurosurgical Society and Canadian Spine Society. We presented two cases of asymptomatic eTVAI, stratified by injury mechanism, fracture type, and angiographic findings. Screening questions were answered prior to presentation of angiographic findings. Survey responses were analyzed using descriptive statistics. RESULTS One hundred-eight of 232 (46%) participants, representing 20 academic institutions, completed the survey. Case 1: 78% of respondents would screen for eTVAI with computed topography angiography (CTA) (97%), immediately (88%). The majority of respondents (97%) would treat with aspirin (89%) for 3-6 months (46%). Respondents would follow up clinically (89%) or radiographically (75%), every 1-3 months. Case 2: 73% of respondents would screen with CTA (96%), immediately (88%). Most respondents (94%) would treat with aspirin (50%) for 3-6 months (35%). Thirty-six percent of respondents would utilize endovascular therapy. Respondents would follow up clinically (97%) or radiographically (89%), every 1-3 months. CONCLUSION This survey of Canadian practice patterns highlights consistency in the approach to screening, treatment, and follow-up of asymptomatic eTVAI. These findings are relevant to neurosurgeons, spinal surgeons, stroke neurologists, and neuro-interventionalists.
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Affiliation(s)
- Mark A Maclean
- Division of Neurosurgery, Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Charles J Touchette
- Division of Neurosurgery, Universite de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Taylor Duda
- Division of Neurosurgery, Department of Surgery, Hamilton General Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Alysa Almojuela
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - David Bergeron
- Division of Neurosurgery, Universite de Montreal, Montreal, Quebec, Canada
| | - Michelle Kameda-Smith
- Division of Neurosurgery, Department of Surgery, Hamilton General Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Amit R L Persad
- Division of Neurosurgery, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Nicholas Sader
- Division of Neurosurgery, University of Calgary, Calgary, Alberta, Canada
| | - Jacob Alant
- Division of Neurosurgery, Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Sean D Christie
- Division of Neurosurgery, Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
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Di Francesco ME, Magunia H, Örgel A, Tatagiba M, Radwan M, Adib SD. Case report: Interdisciplinary treatment of complex C1/C2 fractures in a patient with concomitant three-vessel coronary artery disease requiring bypass surgery. Front Surg 2023; 10:1123947. [PMID: 37260599 PMCID: PMC10228685 DOI: 10.3389/fsurg.2023.1123947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 04/25/2023] [Indexed: 06/02/2023] Open
Abstract
Background Acute myocardial infarction (MI) frequently leads to consciousness disturbance following hemodynamic collapse. Therefore, MI can occur together with upper cervical spine trauma. Herein, we report the successful treatment of complex C1/C2 fractures in a patient with concomitant three-vessel coronary artery disease (CAD). Case presentation A 70-year-old patient presented in our emergency outpatient clinic after a hemodynamic collapse without neurological deficits or heart-related complaints. Computed tomography (CT) scan of the cervical spine revealed a dislocated odontoid fracture Anderson and D'Alonzo type II and an unstable Gehweiler type III injury (Jefferson's fracture). An intradiploic arachnoid cyst in the posterior wall of the posterior fossa was a coincident radiological finding. Furthermore, coronary angiography confirmed three-vessel CAD with high-grade coronary artery stenosis. Indication for upper cervical spine surgery and bypass surgery was given. An interdisciplinary team of neurosurgeons, cardiothoracic surgeons and anesthesiologists evaluated the patient's case to develop the most suitable therapy concept and alternative strategies. Finally, in first step, C1-C2 fusion was performed by Harms technique under general anesthesia with x-ray guidance, spinal neuronavigation, Doppler ultrasound and cardiopulmonary monitoring. Cardiothoracic surgeons were on standby. One month later bypass surgery was performed uneventfully. Follow-up CT scan of cervical spine revealed intraosseous screw positioning and beginning fusion of the fractures. The patient did not develop neurological deficits and recovered completely from both surgeries. Conclusions Treating complex C1/C2 fractures with concomitant severe CAD requiring treatment is challenging and carries a high risk of complications. To our knowledge, the literature does not provide any guidelines regarding therapy of this constellation. To receive upper cervical spine stability and to prevent both, spinal cord injury and cardiovascular complications, an individual approach is required. Interdisciplinary cooperation to determine optimal therapeutic algorithms is needed.
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Affiliation(s)
| | - H. Magunia
- Department of Anesthesiology and Intensive Care Medicine, University of Tuebingen, Tuebingen, Germany
| | - A. Örgel
- Department of Diagnostic and Interventional Neuroradiology, University of Tuebingen, Tuebingen, Germany
| | - M. Tatagiba
- Department of Neurosurgery, University of Tuebingen, Tuebingen, Germany
| | - M. Radwan
- Department of Thoracic and Cardiovascular Surgery, University of Tuebingen, Tuebingen, Germany
| | - S. D. Adib
- Department of Neurosurgery, University of Tuebingen, Tuebingen, Germany
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11
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Alhelal F, AlAssiri S, Aleissa SI, Konbaz FM, Abaalkhail M, Altahan H. Delayed Sub-axial Fracture Dislocation Surgical Management: Technical Notes and Review of the Literature. Cureus 2023; 15:e39539. [PMID: 37366433 PMCID: PMC10290902 DOI: 10.7759/cureus.39539] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/24/2023] [Indexed: 06/28/2023] Open
Abstract
The surgical treatment of delayed, unstable sub-axial cervical spine injuries is challenging. Multiple treatment regimens have been described in the literature, although there is no consensus regarding the best treatment approach. This report presents a 35-year-old obese woman who experienced a delayed sub-axial fracture-dislocation following a motor vehicle accident (MVA) and was successfully managed after three weeks via pre-operative traction followed by a novel single-surgery, single-approach technique with pedicle screws and tension-band wiring as a reduction method. A 35-year-old obese woman with a body mass index (BMI) of 30.1 sustained a frontal impact MVA and suffered from complete quadriplegia below C5 (American Spinal Cord Association Injury A) three weeks prior to presentation. She was intubated and presented with a Glasgow Coma Scale score of 11/15. Trauma computed tomography (CT) showed an isolated spine injury. Moreover, whole-spine CT showed an isolated cervical spine injury involving a basin tip fracture, a comminuted C1 arch fracture, a C2 fracture, and a C6-C7 fracture-dislocation. In addition, magnetic resonance imaging revealed cord contusion at the same level, with C1-C2 left atlantoaxial joint instability. Neck magnetic resonance angiograms and carotid CT angiograms showed left vertebral artery attenuation. She was admitted to the intensive care unit and taken for C6-C7 reduction and instrumentation using only a posterior approach after medical optimization and the application of sufficient traction. Delayed cervical spine fracture-dislocation imposes a challenge for surgical reduction. However, a proper reduction can be achieved through a sufficient duration of pre-operative traction and an isolated anterior or posterior approach.
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Affiliation(s)
- Fahad Alhelal
- Orthopaedic Surgery, King Abdulaziz Medical City Riyadh, Riyadh, SAU
- Orthopaedic Surgery, King Abdullah International Medical Research Center, Riyadh, SAU
- Orthopaedic Surgery, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Suhail AlAssiri
- Orthopaedic Surgery, King Abdulaziz Medical City Riyadh, Riyadh, SAU
- Orthopaedic Surgery, King Abdullah International Medical Research Center, Riyadh, SAU
- Orthopaedic Surgery, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Sami I Aleissa
- Orthopaedic Surgery, King Abdulaziz Medical City Riyadh, Riyadh, SAU
- Orthopaedic Surgery, King Abdullah International Medical Research Center, Riyadh, SAU
- Orthopaedic Surgery, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Faisal M Konbaz
- Orthopaedic Surgery, King Faisal Specialist Hospital and Research Centre, Riyadh, SAU
| | - Majed Abaalkhail
- Orthopaedic Surgery, King Abdulaziz Medical City Riyadh, Riyadh, SAU
- Orthopaedic Surgery, King Abdullah International Medical Research Center, Riyadh, SAU
- Orthopaedic Surgery, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Husam Altahan
- Orthopaedic Surgery, King Abdulaziz Medical City Riyadh, Riyadh, SAU
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12
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Karim N, Johnson M. Fitness Training-Associated Vertebral Artery Dissection. Curr Sports Med Rep 2023; 22:158-160. [PMID: 37141608 DOI: 10.1249/jsr.0000000000001068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Affiliation(s)
- Nurose Karim
- Division of Cerebrovascular Disease, Department of Neurology, ECU Health Medical Center, Greenville, NC
| | - Mark Johnson
- Division of Cerebrovascular Disease, Department of Neurology, UT Southwestern Medical Center, Dallas, TX
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Almalki M, Alghamdi EA, Alasmari R, Aldossary N, Hussain T, Hamad A. A C1 Jefferson Fracture With Vertebral Artery Occlusion and Cerebellar Infarction: A Case Report. Cureus 2023; 15:e38789. [PMID: 37303435 PMCID: PMC10250134 DOI: 10.7759/cureus.38789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/09/2023] [Indexed: 06/13/2023] Open
Abstract
Jefferson fracture is a C1 fracture, which happens when an axial load is from the occiput downward to the C1 ring. Usually, it causes outward displacement of the C1 arch, which can injure the vertebral artery. We present a Jefferson fracture with vertebral artery injury, resulting in an asymptomatic ischemic stroke of the left cerebellum. Usually, vertebral artery injuries are asymptomatic since the contralateral vertebral artery and the collateral arteries will adequately supply the cerebellum. Vertebral artery injury (VAI) is typically treated with conservative management with anticoagulants and antiplatelet therapy.
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Affiliation(s)
| | | | - Reem Alasmari
- Medicine and Surgery, College of Medicine, Princess Nourah Bint Abdulrahman University, Riyadh, SAU
| | - Norah Aldossary
- Medicine, Princess Nourah Bint Abdul Rahman University, Riyadh, SAU
| | - Turki Hussain
- Orthopedic Surgery, King Saud Medical City, Riyadh, SAU
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Orhan G, Malikov A, Hajiyev O, Secen AE, Karaman A, Gurpinar I, Akmangit I, Sayin B, Arli B, Ozbakir MO, Altay O, Daglioglu E, Belen AD. Craniovertebral junction aneurysms. Clin Neurol Neurosurg 2023; 228:107704. [PMID: 37003100 DOI: 10.1016/j.clineuro.2023.107704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 03/11/2023] [Accepted: 03/26/2023] [Indexed: 03/30/2023]
Abstract
OBJECTIVE The course of the vertebral artery and its relationship to the C0-1-2 structures render it particularly vulnerable to mechanical trauma. In the present study, we investigated the course of vertebral arteries along the craniovertebral junction (CJ) to cast light on the biomechanical aspects of aneurysm formation, focusing mainly on the relation of the vertebral artery injuries to the CJ bony landmarks. Herein, we report our experience with fourteen cases of craniovertebral junction vertebral artery (CJVA) aneurysms and their presentations, management, and outcomes. MATERIALS AND METHODS We extracted from 83 vertebral artery aneurysms only those 14 cases whose aneurysms were located at the C0-1-2. We reviewed all medical records, including operative reports and radiologic images. We divided the CJVA into 5 segments and then carefully reviewed the cases, largely focusing on the CJVA segments involved in the aneurysm. Angiographic outcomes were determined by angiography, which was scheduled at 3-6 months, 1, 2.5, and 5 years postoperatively. RESULTS A total of 14 patients with CJVA aneurysms were included in the present study. 35.7 % had cerebrovascular risk factors, while 23.5 % had other predisposing factors such as an AVM, an AVF, or a foramen magnum tumor. Predisposing factors in the form of neck trauma, both direct and indirect, were identified in 50 % of cases. The segmental distribution of aneurysms was as follows: three (21.4 %) at CJV 1, one (7.1 %) at CJV 2, four (28.6 %) at CJV 3, two (14.3 %) at CJV 4, and four (28.6 %) isolated to the CJV 5 segment. Of the 6 indirect traumatic aneurysms, 1 (16.7 %) was located at CJV 1, 4 (66.7 %) were located at CJV 3 and 1 (16.7 %) was located at CJV 5. The 1/1 direct traumatic aneurysm (100 %) from the penetrating injury was located at CJV 1. 100 % of cases with cerebrovascular risk factors, the affected vessels were on the dominant side. 42.9 % of cases presented symptoms of a vertebrobasilar stroke. All 14 aneurysms were managed only endovascularly. 85.8 % of patients we implemented flow diverters only. 57.1 % of follow-up cases were completely occluded angiographically, and 42.9 % of cases were near-completely or incompletely occluded at 1, 2.5, and 5-year follow-ups. CONCLUSIONS The current article is the first report of a series of vertebral artery aneurysms located in CJ. Herein, the association of vertebral artery aneurysm, hemodynamics, and trauma is well established. We clarified all segments of the CJVA and showed that the segmental distribution of CJVA aneurysms significantly differs between traumatic and spontaneous cases. We showed that treatment with flow diverters should be the mainstay of CJVA aneurysm treatment.
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15
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Asukai M, Ushirozako H, Suda K, Matsumoto Harmon S, Komatsu M, Minami A, Takahata M, Iwasaki N, Matsuyama Y. Safety of early posterior fusion surgery without endovascular embolization for asymptomatic vertebral artery occlusion associated with cervical spine trauma. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2022; 31:3392-3401. [PMID: 35821446 DOI: 10.1007/s00586-022-07302-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 02/24/2022] [Accepted: 06/23/2022] [Indexed: 12/14/2022]
Abstract
PURPOSE Vertebral artery occlusion (VAO) is an increasingly recognized complication of cervical spine trauma. However, the management strategy of VAO remains heavily debated. Therefore, the aim of this retrospective study was to investigate the safety of early fusion surgery for traumatic VAO. METHODS This study included a total of 241 patients (average age 64.7 years; 201 men) who underwent early surgical treatment for acute cervical spine injury between 2012 and 2019. The incidence of VAO, cerebral infarction rates, the recanalization rates, and cerebral thromboembolism after recanalization were retrospectively analyzed. RESULTS VAO occurred in 22 patients (9.1%). Of the 22 patients with VAO, radiographic cerebral infarction was detected in 4 patients (21.1%) at initial evaluation, including 1 symptomatic medullar infarction (4.5%) and 3 asymptomatic cerebrum infarctions. A patient who experienced right medullar infarction showed no progression of the neurologic damage. Follow-up imaging revealed that the VAOs of 9 patients (40.9%) were recanalized, and the recanalization did not correlate with clinical adverse outcomes. The arteries of the remaining 13 (59.1%) patients remained occluded and clinically silent until the final follow-up (mean final follow-up 33.0 months). CONCLUSION Despite the lack of a concurrent control group with preoperative antiplatelet therapy or endovascular embolization for VAO, our results showed low symptomatic stroke rate (4.5%), high recanalization rate (40.9%), and low mortality rate (0%). Therefore, we believe that the indication for early stabilization surgery as management strategy of asymptomatic VAO might be one of the safe and effective treatment options for prevention of symptomatic cerebral infarction.
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Affiliation(s)
- Mitsuru Asukai
- Department of Orthopaedic Surgery, Hokkaido Spinal Cord Injury Center, 3-1 Higashi-4 Minami-1, Bibai, Hokkaido, 072-0015, Japan.
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan.
| | - Hiroki Ushirozako
- Department of Orthopaedic Surgery, Hokkaido Spinal Cord Injury Center, 3-1 Higashi-4 Minami-1, Bibai, Hokkaido, 072-0015, Japan
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | - Kota Suda
- Department of Orthopaedic Surgery, Hokkaido Spinal Cord Injury Center, 3-1 Higashi-4 Minami-1, Bibai, Hokkaido, 072-0015, Japan
| | - Satoko Matsumoto Harmon
- Department of Orthopaedic Surgery, Hokkaido Spinal Cord Injury Center, 3-1 Higashi-4 Minami-1, Bibai, Hokkaido, 072-0015, Japan
| | - Miki Komatsu
- Department of Orthopaedic Surgery, Hokkaido Spinal Cord Injury Center, 3-1 Higashi-4 Minami-1, Bibai, Hokkaido, 072-0015, Japan
| | - Akio Minami
- Department of Orthopaedic Surgery, Hokkaido Spinal Cord Injury Center, 3-1 Higashi-4 Minami-1, Bibai, Hokkaido, 072-0015, Japan
| | - Masahiko Takahata
- Department of Orthopaedic Surgery, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido, Japan
| | - Norimasa Iwasaki
- Department of Orthopaedic Surgery, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido, Japan
| | - Yukihiro Matsuyama
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
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16
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Son JI, An TY, Ko MJ, Park SW, Lee YS. Occlusion of Both Vertebral Arteries With Development of Collateral Circulation From the Deep Cervical Artery After Cervical Spine Trauma. Korean J Neurotrauma 2022; 18:374-379. [PMID: 36381429 PMCID: PMC9634321 DOI: 10.13004/kjnt.2022.18.e57] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 08/31/2022] [Accepted: 09/07/2022] [Indexed: 10/07/2023] Open
Abstract
Careful evaluation of vertebral artery injuries is important after cervical translation injuries or transverse foramen fractures. Treatment of trauma can be complicated in cases of concomitant vertebral artery injuries. A 76-year-old woman was admitted to our hospital with left hemiparesis (Motor grade 3) after a motorcycle accident. Cervical spine magnetic resonance imaging (MRI) and computed tomography (CT) revealed a C3 burst fracture and a left C3 lateral mass and lamina fracture. CT angiography revealed fracture fragments that predisposed the vertebral artery to injury throughout its course in the area. CT angiography confirmed that both vertebral arteries were occluded at the C3 fracture site. Subsequent brain MRI revealed acute infarction in the right occipital area. Although both vertebral arteries were occluded, the infarction site did not correspond to the territory supplied by these vessels; therefore, we performed transfemoral cerebral angiography, which revealed collateralization of the bilateral vertebral arteries by the deep cervical artery.. The deep cervical arteries are located between the posterior muscles; therefore, a fixation operation performed using the posterior approach may have affected the collateral circulation and led to exacerbation of the infarction site. Therefore, surgery was performed using an anterior approach and it was possible to minimize the risk of cerebral infarction through preservation of collateral circulation.
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Affiliation(s)
- Jun-Ik Son
- Department of Neurosurgery, College of Medicine, Chung-Ang University, Seoul, Korea
- Department of Neurosurgery, College of Medicine, Chung-Ang University Hospital, Seoul, Korea
| | - Tae Yong An
- Department of Neurosurgery, Gyeongsang National University School of Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - Myeong Jin Ko
- Department of Neurosurgery, College of Medicine, Chung-Ang University, Seoul, Korea
- Department of Neurosurgery, Gyeongsang National University School of Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - Seung Won Park
- Department of Neurosurgery, College of Medicine, Chung-Ang University, Seoul, Korea
- Department of Neurosurgery, College of Medicine, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong, Korea
| | - Young-Seok Lee
- Department of Neurosurgery, College of Medicine, Chung-Ang University, Seoul, Korea
- Department of Neurosurgery, College of Medicine, Chung-Ang University Hospital, Seoul, Korea
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17
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Vierunen RM, Haapamäki VV, Koivikko MP, Bensch FV. Ankylosis of the cervical spine increases the incidence of blunt cerebrovascular injury (BCVI) in CTA screening after blunt trauma. Emerg Radiol 2022; 29:507-517. [PMID: 35296926 PMCID: PMC9123032 DOI: 10.1007/s10140-022-02022-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 01/10/2022] [Indexed: 11/05/2022]
Abstract
PURPOSE To examine the incidence, location, and grade of blunt cerebrovascular injury (BCVI), as well as associated strokes in patients with ankylosis of the cervical spine, imaged with CT angiography (CTA) after blunt trauma. The related etiologies of ankylosis had an additional focus. MATERIALS AND METHODS Altogether of 5867 CTAs of the craniocervical arteries imaged after blunt trauma between October 2011 and March 2020 were manually reviewed for a threshold value of ankylosis of at least three consecutive cervical vertebrae. BCVI was the primary outcome and associated stroke as the secondary outcome. Variables were craniofacial and cervical spine fractures, etiology and levels of ankylosis, traumatic brain injury, spinal hematoma, spinal cord injury, and spinal cord impingement, for which correlations with BCVI were examined. RESULTS Of the 153 patients with ankylosis and blunt trauma of the cervical spine, 29 had a total of 36 BCVIs, of whom two had anterior and 4 posterior circulation strokes. Most of the BCVIs (n = 32) were in the vertebral arteries. Injuries were graded according to the Biffl scale: 17 grade II, 4 grade III, 14 grade IV, and 1 grade V. A ground-level fall was the most common trauma mechanism. Cervical spine fracture was the only statistically significant predictor for BCVI (OR 7.44). Degenerative spondylosis was the most prevalent etiology for ankylosis. CONCLUSION Ankylosis of the cervical spine increases the incidence of BCVI up to sevenfold compared to general blunt trauma populations, affecting especially the vertebral arteries.
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Affiliation(s)
- Riku M Vierunen
- Department of Radiology, Helsinki University and Helsinki University Hospital, Töölö Hospital, Topeliuksenkatu 5, FIN-00029, Helsinki, Finland.
| | - Ville V Haapamäki
- Department of Radiology, Helsinki University and Helsinki University Hospital, Töölö Hospital, Topeliuksenkatu 5, FIN-00029, Helsinki, Finland
| | - Mika P Koivikko
- Department of Radiology, Helsinki University and Helsinki University Hospital, Töölö Hospital, Topeliuksenkatu 5, FIN-00029, Helsinki, Finland
| | - Frank V Bensch
- Department of Radiology, Helsinki University and Helsinki University Hospital, Töölö Hospital, Topeliuksenkatu 5, FIN-00029, Helsinki, Finland
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18
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Christodoulides A, Mitchell S, Bohnstedt BN. Endovascular treatment of penetrating nail gun injury of the cervical spine and vertebral artery: a case report. JOURNAL OF TRAUMA AND INJURY 2022. [DOI: 10.20408/jti.2021.0082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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19
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Pinter ZW, Wagner S, Sebastian AS, Roach WB. Is Anticoagulation Necessary for Asymptomatic Unilateral Vertebral Artery Injury? Clin Spine Surg 2022; 35:E65-E67. [PMID: 33086254 DOI: 10.1097/bsd.0000000000001085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 06/02/2020] [Indexed: 11/26/2022]
Affiliation(s)
| | - Scott Wagner
- Walter Reed National Military Medical Center, Bethesda, MD
| | | | - William B Roach
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
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20
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Byard RW. Vertebral artery transection: an unusual lethal seat belt injury. Forensic Sci Med Pathol 2021; 18:103-105. [PMID: 34655043 DOI: 10.1007/s12024-021-00429-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/24/2021] [Indexed: 11/28/2022]
Abstract
An 89-year-old man involved in a vehicle crash was found at autopsy to have a linear seat belt mark on the right side of his neck associated with extensive injuries of the right paraspinal muscles with fracture-dislocation and separation of cervical vertebrae 5 and 6. There was also fracture of the right facet joint between cervical vertebrae 5 and 6 and laceration of the right vertebral artery. Death was due to a cervical seat belt injury with spinal fracture and laceration of the right vertebral artery. The presence of extensive injuries to the right paraspinal muscles and cervical vertebra 5-6 fact joint beneath the seat belt mark would be in keeping with trauma due to the belt webbing, rather than mere hyperextension/flexion of the cervical spine. This report demonstrates a rare form of seat belt injury, transection of the vertebral artery, and suggests that the finding of seat belt markings on the lateral aspect of the neck should prompt examination for this type of lethal vascular injury at autopsy.
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Affiliation(s)
- Roger W Byard
- Forensic Science SA, Adelaide, Australia. .,Adelaide Medical School, The University of Adelaide, Level 2, Room N237, Helen Mayo North, Frome Road, Adelaide, SA, 5005, Australia.
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21
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Nonaka S, Oishi H, Tsutsumi S, Ishii H. Traumatic cervical vertebral artery aneurysm associated with suicidal stabs. Surg Neurol Int 2021; 12:452. [PMID: 34621567 PMCID: PMC8492432 DOI: 10.25259/sni_662_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 08/17/2021] [Indexed: 11/04/2022] Open
Abstract
Background Cervical vertebral artery (VA) aneurysm occasionally develops in association with penetrating injury. However, its treatment strategy is not yet determined. Case Description A 50-year-old woman with bipolar disorder attempted suicide by stabbing herself in the lateral neck. At presentation, focal neurological deficits were not observed. Spinal computed tomography (CT) showed unclear delineation of the VA in the right C4/5 intervertebral foramen. CT performed 7 days later identified an aneurysm of the right VA at C4/5, with abnormal arteriovenous shunts between the aneurysm and paravertebral venous plexus. The patient underwent coil embolization of the VA segment involving the aneurysm on the same day that was complicated by cerebellar ataxia due to procedure-associated infarction. Conclusion Traumatic VA aneurysms associated with penetrating injuries should be carefully managed with a detailed presurgical evaluation of the relevant cranial and spinal structures.
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Affiliation(s)
- Senshu Nonaka
- Department of Neurosurgery, Juntendo University Urayasu Hospital, Chiba, Japan
| | - Hidenori Oishi
- Department of Neurological Surgery, Juntendo University and Graduate School of Medicine, Tokyo, Japan
| | - Satoshi Tsutsumi
- Department of Neurosurgery, Juntendo University Urayasu Hospital, Chiba, Japan
| | - Hisato Ishii
- Department of Neurosurgery, Juntendo University Urayasu Hospital, Chiba, Japan
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22
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Jung MK, Hörnig L, Stübs MMA, Grützner PA, Kreinest M. Development and first application testing of a new protocol for CT-based stability evaluation of the injured upper cervical spine. Eur J Trauma Emerg Surg 2021; 48:1389-1399. [PMID: 34032871 DOI: 10.1007/s00068-021-01702-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 05/13/2021] [Indexed: 01/01/2023]
Abstract
PURPOSE For trauma surgeons, the evaluation of the stability of the upper cervical spine may be demanding. The aim of this study was to develop a protocol for decision-making on upper cervical spine stability in trauma patients based on established parameters obtained by CT imaging as well as testing the protocol by having it applied by trauma surgeons. METHODS A structured literature search on upper cervical spine stability was performed. The best evaluated instability criteria in CT imaging were determined. Based on these parameters a protocol for stability evaluation of the injured upper cervical spine was developed. A first application testing was performed. In addition to the assessment of instability, the time required for the assessment was analyzed. RESULTS A protocol for CT-based stability evaluation of the injured upper cervical spine based on the current literature was developed and displayed in a flow chart. Testing of the protocol found the stability of the cervical spine was correctly assessed in 55 of 56 evaluations (98.2%). In one test run, a stable upper cervical spine was judged to be unstable. Further analysis showed that this case was based on a measurement error. The assessment time of CT-images decreased significantly during repeat application of the protocol (p < 0.0001), from 336 ± 108 s (first case) to 180 ± 30 s (fourth case). CONCLUSION The protocol can be applied quickly and safely by non-specialized trauma surgeons. Thus, the protocol can support the decision-making process in CT-based evaluation of the stability of the injured upper cervical spine.
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Affiliation(s)
- Matthias K Jung
- Klinik Für Unfallchirurgie Und Orthopädie, BG Klinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
| | - Lukas Hörnig
- Klinik Für Unfallchirurgie Und Orthopädie, BG Klinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
| | - Michael M A Stübs
- Klinik Für Anästhesiologie, Stiftung Krankenhaus Bethanien, Bethanienstraße 21, 47441, Moers, Germany
| | - Paul A Grützner
- Klinik Für Unfallchirurgie Und Orthopädie, BG Klinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
| | - Michael Kreinest
- Klinik Für Unfallchirurgie Und Orthopädie, BG Klinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany.
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23
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Ramamurti P, Weinreb J, Fassihi SC, Rao R, Patel S. Vertebral Artery Injury in the Cervical Spine: Anatomy, Diagnosis, and Management. JBJS Rev 2021; 9:e20.00118. [PMID: 33470592 DOI: 10.2106/jbjs.rvw.20.00118] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
» Although rare, injury to the vertebral artery (VA) can occur after blunt trauma or iatrogenically during surgery. Clinicians should be aware of the anatomic variants of the VA, the presence of which may increase the risk of iatrogenic VA injury (VAI). » If VAI is suspected following blunt trauma, rapid identification via advanced imaging modalities, such as computed tomography angiography, can help clarify the site of injury and guide management. » VAI can be classified according to the Denver grading scale for blunt cerebrovascular injury, ranging from grade I to grade V, which includes intimal narrowing, pseudoaneurysm formation, complete occlusion, and arterial transection. » Treatment modalities remain controversial and include anticoagulation, endovascular interventions, surgical tamponade, ligation, and microvascular repair. The choice of treatment is influenced by the setting of the injury (iatrogenic injury in the operating room versus blunt trauma in the field) and the laterality of the dominant VA with respect to brain perfusion.
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Affiliation(s)
- Pradip Ramamurti
- George Washington School of Medicine and Health Sciences, Washington, DC
| | - Jeffrey Weinreb
- Department of Orthopaedic Surgery, George Washington University, Washington, DC
| | - Safa C Fassihi
- Department of Orthopaedic Surgery, George Washington University, Washington, DC
| | - Raj Rao
- Department of Orthopaedic Surgery, George Washington University, Washington, DC
| | - Shalin Patel
- Department of Orthopaedic Surgery, George Washington University, Washington, DC
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24
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Kansagra AP, Balasetti V, Huang MC. Neurovascular trauma: Diagnosis and therapy. HANDBOOK OF CLINICAL NEUROLOGY 2021; 176:325-344. [PMID: 33272402 DOI: 10.1016/b978-0-444-64034-5.00012-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Traumatic cerebrovascular injuries are common in both military and civilian populations. Whether such injuries occur in the aftermath of blunt or penetrating trauma has major implications for characteristics, classification, diagnosis, and optimal management of these lesions. Advances in screening methods, including particularly the dramatic rise of high-quality CT angiography, have facilitated early detection of these lesions. Fortunately, these diagnostic advances have occurred alongside improvements in pharmacological treatment and endovascular intervention, which now play an important role alongside surgical intervention in reducing the likelihood of adverse clinical outcomes. While the management of victims of trauma remains challenging, improved understanding of and ability to appropriately manage traumatic cerebrovascular lesions promises to yield better clinical outcomes for these vulnerable patients.
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Affiliation(s)
- Akash P Kansagra
- Departments of Radiology, Neurological Surgery, and Neurology, Washington University School of Medicine, St. Louis, MO, United States.
| | - Vamshi Balasetti
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, United States
| | - Michael C Huang
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, United States
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25
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Sharif S, Ali MYJ, Sih IMY, Parthiban J, Alves ÓL. Subaxial Cervical Spine Injuries: WFNS Spine Committee Recommendations. Neurospine 2020; 17:737-758. [PMID: 33401854 PMCID: PMC7788423 DOI: 10.14245/ns.2040368.184] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 09/14/2020] [Accepted: 09/14/2020] [Indexed: 12/16/2022] Open
Abstract
To formulate specific guidelines for the recommendation of subaxial cervical spine injuries concerning classification, management, posttraumatic locked facets and vertebral artery injury. Computerized literature was searched on PubMed and google scholar database from 2009 to 2020. For classification, keywords "Sub Axial Cervical Spine Classification," resulting in 22 articles related to subaxial cervical spine injury classification system (SLICS) system and 11 articles related to AO (Arbeitsgemeinschaft für Osteosynthesefragen, German for "Association for the Study of Internal Fixation") Spine system. The literature search yielded 210 and 78 articles on "management of subaxial cervical spine injuries" and the role of "SLICS" and "AO Spine" respectively. Keywords "management of traumatic facet locks" were searched and closed reduction, traction, approaches and techniques were studied. "Vertebral artery injury and cervical fracture" exhibited 2,328 references from the last 15 years. The objective was to identify the appropriate diagnostic tests and optimal treatment. Up-to-date information was reviewed, and statements were produced to reach a consensus in 2 separate consensus meetings of World Federation of Neurosurgical Societies (WFNS) Spine Committee. The statements were voted and reached a positive or negative consensus using Delphi method. Based on the most relevant literature, panelists in Moscow consensus meeting conducted in May 2019 drafted the statements, and after a preliminary voting session, the consensus was identified on various statements. Another meeting was conducted at Peshawar in November 2019, where in addition to previous statements, few other statements were discussed and voted. Specific recommendations were then formulated guiding classification, management, locked facets and vertebral artery injuries. This review summarizes the WFNS Spine Committee recommendations on subaxial cervical spine injuries.
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Affiliation(s)
- Salman Sharif
- Department of Neurosurgery, Liaquat National Hospital & Medical College, Karachi, Pakistan
| | | | - Ibet Marie Y. Sih
- Institute for the Neurosciences, St. Luke’s Medical Center, University of the Philippines – Philippine General Hospital, Metro Manila, The Philippines
| | - Jutty Parthiban
- Department Neurosurgery and Spine Unit, Kovai Medical Center and Hospital, Coimbatore, India
| | - Óscar L. Alves
- Department of Neurosurgery, Hospital Lusíadas, Porto, Portugal
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26
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Dunn CJ, Changoor S, Issa K, Moore J, Moontasri NJ, Faloon MJ, Sinha K, Hwang KS, Ruoff M, Emami A. Cervical Computed Tomography Angiography Rarely Leads to Intervention in Patients With Cervical Spine Fractures. Global Spine J 2020; 10:992-997. [PMID: 32875840 PMCID: PMC7645098 DOI: 10.1177/2192568219885897] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVES To evaluate the impact of computed tomography angiography (CTA) in the management of trauma patients with cervical spine fractures by identifying high-risk patients for vertebral artery injury (VAI), and evaluating how frequently patients undergo subsequent surgical/procedural intervention as a result of these findings. METHODS All trauma patients with cervical spine fractures who underwent CTA of the head and neck at our institution between January 2013 and October 2017 were identified. Patients were indicated for CTA according to our institutional protocol based on the modified Denver criteria, and included patients with cervical fractures on scout CT. Those with positive VAI were noted, along with their fracture location, and presence or absence of neurological deficit on physical examination. Statistical analysis was performed and odds ratios were calculated comparing the relationship of cervical spine fracture with presence of VAI. RESULTS A total of 144 patients were included in our study. Of those, 25 patients (17.4%) were found to have VAI. Two patients (1.4%) with VAI underwent subsequent surgical/procedural intervention. Of the 25 cervical fractures with a VAI, 20 (80%), were found to involve the upper cervical region (4.2 OR, 95% CI 1.5-12.0; P = .007). Of the 25 who had a VAI, 9 were unable to undergo reliable neurologic examination. Of the remaining 16 patients, 5 (31.3%) had motor or sensory deficits localized to the side of the VAI, with no other attributable etiology. CONCLUSIONS Cervical spine fractures located in the region of the C1-C3 vertebrae were more likely to have an associated VAI on CTA. VAI should also be considered in cervical trauma patients who present with neurological deficits not clearly explained by other pathology. Despite a finding of VAI, patients rarely underwent subsequent surgical or procedural intervention.
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Affiliation(s)
- Conor John Dunn
- Department of Orthopaedic Surgery, St. Joseph’s University Medical Center, Paterson, NJ, USA
| | - Stuart Changoor
- Department of Orthopaedic Surgery, St. Joseph’s University Medical Center, Paterson, NJ, USA
| | - Kimona Issa
- Department of Orthopaedic Surgery, St. Joseph’s University Medical Center, Paterson, NJ, USA
| | - Jeffrey Moore
- Department of Orthopaedic Surgery, St. Joseph’s University Medical Center, Paterson, NJ, USA
| | - Nancy J. Moontasri
- Department of Orthopaedic Surgery, St. Joseph’s University Medical Center, Paterson, NJ, USA
| | - Michael Joseph Faloon
- Department of Orthopaedic Surgery, St. Joseph’s University Medical Center, Paterson, NJ, USA
- Department of Orthopaedic Surgery, Morristown Medical Center, Morristown, NJ, USA
| | - Kumar Sinha
- Department of Orthopaedic Surgery, St. Joseph’s University Medical Center, Paterson, NJ, USA
| | - Ki Soo Hwang
- Department of Orthopaedic Surgery, St. Joseph’s University Medical Center, Paterson, NJ, USA
| | - Mark Ruoff
- Department of Orthopaedic Surgery, St. Joseph’s University Medical Center, Paterson, NJ, USA
| | - Arash Emami
- Department of Orthopaedic Surgery, St. Joseph’s University Medical Center, Paterson, NJ, USA
- Arash Emami, University Spine Center, 504 Valley Road, Suite 203, Wayne, NJ 07470, USA.
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New ischemic lesions on brain magnetic resonance imaging in patients with blunt traumatic cerebrovascular injury. J Trauma Acute Care Surg 2020; 88:796-802. [PMID: 32176175 DOI: 10.1097/ta.0000000000002660] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patients with blunt cerebrovascular injuries are at risk of thromboembolic stroke. Although primary prevention with antithrombotic therapy is widely used in this setting, its effectiveness is not well defined and requires further investigation. The aim of this study was to evaluate the utility of magnetic resonance imaging (MRI)-detected ischemic brain lesions as a possible future outcome for randomized clinical trials in this patient population. METHODS This prospective observational study included 20 adult blunt trauma patients admitted to a level I trauma center with a screening neck CTA showing extracranial carotid or vertebral artery injury. All subjects lacked initial evidence of an ischemic stroke and were managed with antithrombotic therapy and observation and then underwent brain MRI within 30 days of the injury to assess for ischemic lesions. The MRI scans included diffusion, susceptibility, and Fluid-attenuated Inversion Recovery (FLAIR) sequences, and were reviewed by two neuroradiologists blinded to the computed tomography angiography (CTA) findings. RESULTS Eleven CTAs were done in the emergency department upon admission. There were 12 carotid artery dissections and 11 unilateral or bilateral vertebral artery injuries. Median interval between injury and MRI scan was 4 days (range, 0.1-14; interquartile range, 3-7 days). Diffusion-weighted imaging evidence of new ischemic lesions was present in 10 (43%) of 23 of the injured artery territories. In those injuries with ischemic lesions, the median number was 8 (range, 2-25; interquartile range, 5-8). None of the lesions were symptomatic. Blunt cerebrovascular injury was associated with a higher mean ischemic lesion count (mean count of 3.17 vs. 0.14, p < 0.0001), with the association remaining after adjusting for injury severity score (p < 0.0001). CONCLUSION In asymptomatic blunt trauma patients with CTA evidence of extracranial cerebrovascular injury and treated with antithrombotic therapy, nearly half of arterial injuries are associated with ischemic lesions on MRI. LEVEL OF EVIDENCE Therapeutic/care management, level IV.
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Posttraumatic Vertebral Arteriovenous Fistula: A Lifeline from Tetraplegia? World Neurosurg 2020; 142:413-419. [PMID: 32668335 DOI: 10.1016/j.wneu.2020.07.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 07/02/2020] [Accepted: 07/05/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND Vertebral artery (VA) rupture is a rare condition that occurs about in 0.5% of cervical trauma. The management of our case was complicated by a spinal epidural hematoma (SEH) leading to worsening neurologic deficits. Only 1 similar case has been reported before in the literature. CASE DESCRIPTION We report the case of a 37-year-old victim of a serious car accident. Shortly after admission to the emergency department, she developed weakness in all 4 limbs and sensory deficit below T6 level. Cervical spine computed tomography scan revealed an SEH from C1 to T3. Computed tomography angiography scan showed rupture of the left VA at C3 level, with a posttraumatic vertebral arteriovenous fistula at the same level, draining in the epidural venous plexus and to the right jugular internal vein. Immediately after embolization of the left VA, we performed a cervical decompression from C2 to C7. Three months after surgery the patient had a full recovery. CONCLUSIONS No guidelines exist to treat this situation. We propose consequential steps to treat a posttraumatic cervical SEH with evidence of VA rupture.
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Courson R, Ellis J, Herring SA, Boden BP, Henry G, Conway D, McNamara L, Neal TL, Putukian M, Sills AK, Walpert KP. Best Practices and Current Care Concepts in Prehospital Care of the Spine-Injured Athlete in American Tackle Football March 2-3, 2019; Atlanta, GA. J Athl Train 2020; 55:545-562. [PMID: 32579669 PMCID: PMC7319739 DOI: 10.4085/1062-6050-430-19] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Sport-related spine injury can be devastating and have long-lasting effects on athletes and their families. Providing evidence-based care for patients with spine injury is essential for optimizing postinjury outcomes. When caring for an injured athlete in American tackle football, clinicians must make decisions that involve unique challenges related to protective equipment (eg, helmet and shoulder pads). The Spine Injury in Sport Group (SISG) met in Atlanta, Georgia, March 2-3, 2019, and involved 25 health care professionals with expertise in emergency medicine, sports medicine, neurologic surgery, orthopaedic surgery, neurology, physiatry, athletic training, and research to review the current literature and discuss evidence-based medicine, best practices, and care options available for the prehospital treatment of athletes with suspected cervical spine injuries.1,2 That meeting and the subsequent Mills et al publication delineate the quality and quantity of published evidence regarding many aspects of prehospital care for the athlete with a suspected cervical spine injury. This paper offers a practical treatment guide based on the experience of those who attended the Atlanta meeting as well as the evidence presented in the Mills et al article. Ongoing research will help to further advance clinical treatment recommendations.
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Affiliation(s)
| | - James Ellis
- University of South Carolina School of Medicine, Greenville
| | - Stanley A Herring
- Department of Rehabilitation Medicine and The Sports Institute, University of Washington, Seattle
| | - Barry P Boden
- The Orthopaedic Center, A Division of CAO, Rockville, MD
| | | | | | - Lance McNamara
- Barrow County Schools, Winder-Barrow High School, Winder, GA
| | | | - Margot Putukian
- University Health Services, Rugers Robert Wood Johnson Medical School, Princeton, NJ
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Epidemiology and Imaging Classification of Pediatric Cervical Spine Injuries: 12-Year Experience at a Level 1 Trauma Center. AJR Am J Roentgenol 2020; 214:1359-1368. [DOI: 10.2214/ajr.19.22095] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Merrill S, Clifton W, Valero-Moreno F, Damon A, Rahmathulla G. Vertebral Artery Injury with Coinciding Unstable Cervical Spine Trauma: Mechanisms, Evidence-based Management, and Treatment Options. Cureus 2020; 12:e7225. [PMID: 32274283 PMCID: PMC7141798 DOI: 10.7759/cureus.7225] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Unstable traumatic cervical spine fracture is a commonly encountered neurosurgical issue. Concomitant vertebral artery injuries present a challenge in surgical decision-making regarding the timing and order of surgical intervention with respect to endovascular intervention and internal fixation of the unstable fracture. Currently, there are no studies that have specifically examined stroke rate or outcomes for patients who have vertebral artery injuries and unstable cervical spine fractures with respect to temporal treatment course. The purpose of this paper is to review the current evidence for the standards of diagnosis and management of vertebral artery injuries with coinciding unstable cervical spine injuries and propose an evidence-based algorithm for workup and treatment.
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Affiliation(s)
- Sarah Merrill
- Neurological Surgery, Mayo Clinic Alix School of Medicine, Scottsdale, USA
| | | | | | - Aaron Damon
- Neurological Surgery, Mayo Clinic, Jacksonville, USA
| | - Gazanfar Rahmathulla
- Neurological Surgery, University of Florida College of Medicine, Gainesville, USA
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Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE Compare a novel two-step algorithm for indicating a computed tomography angiography (CTA) in the setting of a cervical spine fracture with established gold standard criteria. SUMMARY OF BACKGROUND DATA As CTA permits the rapid detection of blunt cerebrovascular injuries (BCVI), screening criteria for its use have broadened. However, more recent work warns of the potential for the overdiagnosis of BCVI, which must be considered with the adoption of broad criteria. METHODS A novel two-step metric for indicating CTA screening was compared with the American College of Surgeons guidelines and the expanded Denver Criteria using patients who presented with cervical spine fractures to a tertiary-level 1 trauma center from January 1, 2012 to January 1, 2016. The ability for each metric to identify BCVI and posterior circulation strokes that occurred during this period was assessed. RESULTS A total of 721 patients with cervical fractures were included, of whom 417 underwent CTAs (57.8%). Sixty-eight BCVIs and seven strokes were diagnosed in this cohort. All algorithms detected an equivalent number of BCVIs (52 with the novel metric, 54 with the ACS and Denver Criteria, P = 0.84) and strokes (7/7, 100% with the novel metric, 6/7, 85.7% with the ACS and Denver Criteria, P = 1.0). However, 63% fewer scans would have been needed with the proposed screening algorithm compared with the ACS or Denver Criteria (261/721, 36.2% of all patients with our criteria vs. 413/721, 57.3% with the ACS standard and 417/721, 57.8%) with the Denver Criteria, P < 0.0002 for each). CONCLUSION A two-step criterion based on mechanism of injury and patient factors is a potentially useful guide for identifying patients at risk of BCVI and stroke after cervical spine fractures. Further prospective analyses are required prior to widespread clinical adoption. LEVEL OF EVIDENCE 4.
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Antiplatelet versus Anticoagulation for Asymptomatic Patients with Vertebral Artery Injury during Anterior Cervical Surgery-Two Case Reports and Review of Literature. Brain Sci 2019; 9:brainsci9120345. [PMID: 31795259 PMCID: PMC6955904 DOI: 10.3390/brainsci9120345] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 11/16/2019] [Accepted: 11/22/2019] [Indexed: 11/30/2022] Open
Abstract
Vertebral Artery Injury (VAI) while performing cervical spinal reconstruction surgery is rare, but it can lead to catastrophic events. Treatment for this injury with regard to antiplatelet versus anticoagulation therapy is controversial. The purpose of this report is to discuss two cases of VAI that occurred during the performance of cervical reconstruction surgery and provide a guideline based on a literature review about whether to use anticoagulant or antiplatelet therapy for treatment of asymptomatic VAI. In case 1, iatrogenic injury occurred to the left C5 vertebral artery (VA) during high speed burr removal of an osteophyte on the left C5/6 uncovertebral joint, resulting in VAI. This patient was treated with Heparin resulting in respiratory complication. Case 2 encountered VAI while using the kerrison rongeur to perform a right sided C5/6 foraminotomy. Antiplatelet therapy was administered. Fourteen publications relevant to Antiplatelet versus Anticoagulation treatment were reviewed. Anticoagulation has similar results to antiplatelet therapy. Studies are limited; there were no common guidelines or parameters concerning the utilization of Antiplatelets versus Anticoagulants. Anticoagulation achieved similar results as Antiplatelet therapy; based on the limited relevant data, the superiority of one treatment over the other cannot be concluded in VAI after cervical spinal reconstruction surgery.
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Kiessling JW, Whitney E, Fiani B, Khan YR, Mahato D. C2-3 Fracture Dislocation and Bilateral Vertebral Artery Occlusion Without Neurological Injury: A Case Report. Cureus 2019; 11:e5538. [PMID: 31687311 PMCID: PMC6819066 DOI: 10.7759/cureus.5538] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
A 27-year-old female involved a motor vehicle collision as the restrained driver presented to the ER with agonal breathing and a Glasgow Coma Scale (GCS) of 3. Radiographic imaging demonstrated C2-3 craniocaudal dislocation, bilateral C2 comminuted pedicle fractures extending through the transverse foramina, complete bilateral vertebral artery occlusion, and negative signs of stroke with MRI. After halo immobilization, surgical stabilization, and medical treatment the patient was discharged and at her six-month follow up she was without neurological deficit.
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Affiliation(s)
| | - Eric Whitney
- Neurosurgery, Desert Regional Medical Center, Palm Springs, USA
| | - Brian Fiani
- Neurosurgery, Desert Regional Medical Center, Palm Springs, USA
| | - Yasir R Khan
- Neurosurgery, Desert Regional Medical Center, Palm Springs, USA
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Sharma P, Hegde R, Kulkarni A, Sharma S, Soin P, Kochar PS, Kumar Y. Traumatic vertebral artery injury: a review of the screening criteria, imaging spectrum, mimics, and pitfalls. Pol J Radiol 2019; 84:e307-e318. [PMID: 31636765 PMCID: PMC6798777 DOI: 10.5114/pjr.2019.88023] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 05/01/2019] [Indexed: 11/17/2022] Open
Abstract
PURPOSE Traumatic vertebral artery injury (TVAI) can have a varied clinical presentation and appearance on imaging. In this review, we present the screening criteria, spectrum of imaging features, grading, and imaging pitfalls of TVAI. Our review focuses on the imaging of TVAI on computed tomography angiography (CTA), magnetic resonance angiography (MRA), and cases of TVAI mimics. IMAGING The imaging spectrum on CTA can range from either focal or long segment luminal stenosis (the most common findings), smooth or tapered narrowing of lumen, string of pearls appearance, concentric intramural haematoma, intimal flap (the most definite sign), and double lumen of the artery. On time-of-flight MRA, the most common findings include loss of flow void within the vessel due to slow flow, thrombosis or occlusion, and hyperintense signal within the vessel wall due to intramural haematoma on T1 fat-saturated images. CONCLUSION The reader should be aware of the screening criteria, common and uncommon findings, variant anatomy, artifacts, and mimics of TVAI when evaluating cases of craniocervical trauma, to be competent in calling in or ruling out injury.
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Affiliation(s)
- Pranav Sharma
- Yale New Haven Health Bridgeport Hospital, Connecticut, USA
| | - Rahul Hegde
- Yale New Haven Health Bridgeport Hospital, Connecticut, USA
| | | | | | - Priti Soin
- Weil Cornell College Of Medicine, New York, USA
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Indo M, Oya S, Shojima M, Inokuchi K, Yahata T, Sugiyama S, Matsui T. Prevention of Thromboembolic Infarction After Surgery for Traumatic Cervical Fracture with Vertebral Artery Occlusion by Preoperative Endovascular Coil Embolization. World Neurosurg 2019; 129:e838-e844. [PMID: 31207373 DOI: 10.1016/j.wneu.2019.06.046] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Revised: 06/03/2019] [Accepted: 06/03/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND Vertebral artery injuries (VAIs) caused by cervical trauma include irregularities with narrowing of the arterial wall, dissection, pseudoaneurysm formation, occlusion, and transection. Although recent guidelines have recommended anticoagulant or antiplatelet therapy to prevent subsequent stroke in patients with traumatic VAIs, regardless of the type of vascular injury, the clinical role of endovascular surgery in the treatment of traumatic VAIs remains to be elucidated. METHODS We retrospectively evaluated the treatment outcomes of 23 patients with cervical fracture and vertebral artery occlusion (VAO) who had required cervical surgery in the acute stage. RESULTS No patient received antiplatelet or anticoagulant therapy, because the VAs had already become occluded. After cervical surgery, 5 of the 23 patients developed radiologically confirmed thromboembolic stroke after cervical surgery. None of these 5 patients with postoperative infarction had undergone preoperative VA embolization. Univariate analysis revealed that only the implementation of preoperative VA embolization was associated with the prevention of postoperative infarction (P = 0.004). Factors such as age, reduction, level of VAO, and diabetes mellitus did not correlate with increased risk. CONCLUSIONS The clinical role of endovascular surgery for traumatic VAI has not been previously established; however, a more specific selection of patients according to the VAI type might be necessary. Our data have indicated that preoperative embolization of the occluded VA significantly reduces the risk of postoperative infarction in a specific cohort of patients with traumatic VAI (i.e., patients with post-traumatic VAO who require cervical surgery).
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Affiliation(s)
- Masahiro Indo
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Soichi Oya
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University, Saitama, Japan.
| | - Masaaki Shojima
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Koichi Inokuchi
- Department of Emergency and Critical Care Medicine, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Tadashi Yahata
- Department of Emergency and Critical Care Medicine, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Satoru Sugiyama
- Department of Emergency and Critical Care Medicine, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Toru Matsui
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University, Saitama, Japan
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Prost S, Barrey C, Blondel B, Fuentes S, Barresi L, Nicot B, Challier V, Lleu M, Godard J, Kouyoumdjian P, Lonjon N, Marinho P, Freitas E, Schuller S, Allia J, Berthiller J, Charles YP. Hangman's fracture: Management strategy and healing rate in a prospective multi-centre observational study of 34 patients. Orthop Traumatol Surg Res 2019; 105:703-707. [PMID: 31005699 DOI: 10.1016/j.otsr.2019.03.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 02/27/2019] [Accepted: 03/14/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Hangman's fractures account for 15% to 20% of all cervical spine fractures. The grading system developed by Effendi and modified by Levine and Edwards is generally used as the basis for management decisions. Nonetheless, the optimal management remains controversial. The objective of this study was to describe the treatments used in France in patients with hangman's fractures. The complications and healing rates were analysed according to the fracture type and treatment used. HYPOTHESIS Among patients with hangman's fracture, those with disc damage must be treated surgically. MATERIAL AND METHODS A prospective, multi-centre, observational study was conducted under the aegis of the French Society for Spine Surgery (SociétéFrançaisedeChirurgieRachidienne, SFCR). Patients were included if they had computed tomography (CT) evidence of hangman's fracture. Follow-up data were collected prospectively. Fracture healing was assessed on CT scans obtained 3 and 12 months after the injury. The type of treatment and complications were recorded routinely. RESULTS We included 34 patients. The fracture type according to Effendi modified by Levine and Edwards was I in 68% of patients, II in 29% of patients, and III in a single patient (3%). The treatment was non-operative in 21 (62%) patients and surgical in 11 (32%). All 28 patients re-evaluated after 1 year had evidence of fracture healing. The remaining 6 patients were lost to follow-up. CONCLUSION Hangman's fracture is associated with low rates of mortality and neurological complications. Non-operative treatment is appropriate in Type I hangman's fracture, with a 100% healing rate in our study. Types II and III are characterised by damage to the ligaments and discs requiring either anterior C2-C3 fusion or posterior C1-C3 screw fixation. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Solène Prost
- ISM, CNRS, unité de chirurgie rachidienne, Aix-Marseille université, CHU de Timone, AP-HM, 264, rue Saint-Pierre, 13005 Marseille, France
| | - Cédric Barrey
- Service de neurochirurgie C et chirurgie du rachis, université Claude-Bernard Lyon 1, hôpital P. Wertheimer, 59, boulevard Pinel, 69003 Lyon, France
| | - Benjamin Blondel
- ISM, CNRS, unité de chirurgie rachidienne, Aix-Marseille université, CHU de Timone, AP-HM, 264, rue Saint-Pierre, 13005 Marseille, France.
| | - Stéphane Fuentes
- ISM, CNRS, unité de chirurgie rachidienne, Aix-Marseille université, CHU de Timone, AP-HM, 264, rue Saint-Pierre, 13005 Marseille, France
| | - Laurent Barresi
- Unité de chirurgie rachidienne, CHU de Nice, Institut universitaire de l'appareil Locomoteur et du sport, hôpital Pasteur 2, 30, voie Romaine, 06001 Nice, France
| | - Benjamin Nicot
- Département de neurochirurgie, CHU de Grenoble, avenue Maquis-du-Grésivaudan, 38700 La Tronche, France
| | - Vincent Challier
- Unité d'orthopédie-traumatologie rachis I, CHU de Bordeaux, hôpital Tripode, place Amélie-Raba-Léon, 33076 Bordeaux cedex, France
| | - Maxime Lleu
- Service de neurochirurgie, CHU de Dijon, 14, rue Paul-Gaffarel, 21000 Dijon cedex, France
| | - Joël Godard
- Service de neurochirurgie, hôpital Jean-Minjoz, 3, boulevard A. Fleming, 25030 Besançon cedex, France
| | - Pascal Kouyoumdjian
- Service d'orthopédie-traumatologie, CHU de Nîmes, avenue du Pr. Debré, 30000 Nîmes, France
| | - Nicolas Lonjon
- Service de neurochirurgie, hôpital Gui de Chauliac, 80, avenue Augustin-Fliche, 34090 Montpellier, France
| | - Paulo Marinho
- Service de neurochirurgie, CHRU de Lille, hôpital Roger-Salengro, rue Emile-Laine, 59037 Lille, France
| | - Eurico Freitas
- Service de neurochirurgie C et chirurgie du rachis, université Claude-Bernard Lyon 1, hôpital P. Wertheimer, 59, boulevard Pinel, 69003 Lyon, France
| | - Sébastien Schuller
- Service de chirurgie du rachis, hôpitaux universitaires de Strasbourg, 1, place de l'Hôpital, BP 426, 67091 Strasbourg cedex, France
| | - Jérémy Allia
- Unité de chirurgie rachidienne, CHU de Nice, Institut universitaire de l'appareil Locomoteur et du sport, hôpital Pasteur 2, 30, voie Romaine, 06001 Nice, France
| | - Julien Berthiller
- Pôle IMER, hospices civils de Lyon, 162, avenue Lacassagne, 69424 Lyon cedex 03, France
| | - Yann Philippe Charles
- Service de chirurgie du rachis, hôpitaux universitaires de Strasbourg, 1, place de l'Hôpital, BP 426, 67091 Strasbourg cedex, France
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- Société Française de Chirurgie Rachidienne, 56, rue Boisonnade, 75014 Paris, France
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Çakır T, Kayacı S, Aydın MD, Özöner B, Çalık İ, Altınkaynak K. A New Neuropathologic Mechanism of Blood pH Irregularities After Neck Trauma: Importance of Carotid Body-Glossopharyngeal Nerve Network Degeneration. World Neurosurg 2019; 125:e972-e977. [PMID: 30763747 DOI: 10.1016/j.wneu.2019.01.218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 01/25/2019] [Accepted: 01/28/2019] [Indexed: 01/04/2023]
Abstract
OBJECTIVE We created a neck trauma model by injecting blood into the sheath of rabbits' carotid bodies (CBs). Then we determined the relationship between neuronal degeneration of the CB due to hemorrhage of this organ and its clinical effects such as blood pH and heart rhythm. METHODS The present study included 24 adult male New Zealand rabbits. The animals were divided into 3 groups: control (n = 5); sham (0.5 mL saline injected into CBs; n = 5); and study (CB trauma model; n = 14). pH values and heart rhythms were recorded before the experiment to determine the values under normal conditions, and measurements were repeated thrice in the days following the experiment. The number of normal and degenerated neuron density of CBs was counted. The relationship between the blood pH values, heart rhythms, and degenerated neuron densities was analyzed. RESULTS Heart rhythms were 218 ± 20 in the control group, 197 ± 16 in the sham group (P = 0.09), and 167 ± 13 in the study group (P < 0.0005). pH values were 7.40 ± 0.041 in the control group, 7.321 ± 0.062 in the sham group (P = 0.203), and 7.23 ± 0.02 in study group (P < 0.0005). Degenerated neuron densities were 12 ± 4/mm3 in the control group, 430 ± 74/mm3 in the sham group (P < 0.005), and 7434 ± 810/mm3 in the study group (P < 0.0001). CONCLUSIONS A high degenerate neuron density in the CB can decrease blood pH and hearth rhythm after neck trauma, and there might be a close relationship between the number of degenerated neurons and clinical findings (such as heart rhythm and blood pH). This relationship suggests that injury to the glossopharyngeal nerve-CB network can cause acidosis by disturbing the breathing-circulating reflex and results in respiratory acidosis.
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Affiliation(s)
- Tayfun Çakır
- Department of Neurosurgery, Medical Faculty of Erzincan Binali Yildirim University, Erzincan, Turkey
| | - Selim Kayacı
- Department of Neurosurgery, Medical Faculty of Erzincan Binali Yildirim University, Erzincan, Turkey
| | - Mehmet Dumlu Aydın
- Department of Neurosurgery, Medical Faculty of Ataturk University, Turkey.
| | - Barış Özöner
- Department of Neurosurgery, Medical Faculty of Erzincan Binali Yildirim University, Erzincan, Turkey
| | - İlknur Çalık
- Department of Pathology, Medical Faculty of Fırat University, Elazığ, Turkey
| | - Konca Altınkaynak
- Department of Biochemistry, Erzurum Research-Training Hospital, Erzurum, Turkey
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Abstract
BACKGROUND Radiological imaging is important in the preoperative diagnosis of many forms of spinal pathology and plays a fundamental role in the assessment of p.o. effects, which can be verified on the spinal column as well as on the surrounding soft tissues, depending on the imaging method used. AIM The article provides an overview of the current status and possibilities of radiological diagnostic methods for the verification of possibly recommended spine surgery in the context of degenerative, inflammatory-infectious, post-traumatic or p.o. pathologies and changes in the spine: X‑rays, computed tomography (CT), magnetic resonance imaging (MRI). The supplementary nuclear medicine procedures (scintigraphy, PET[-CT], SPECT, etc.) which may be required for special questions are not discussed. MATERIAL AND METHODS The merits and limitations of the techniques used in the investigation of advanced degenerative spinal pathologies and post-traumatic conditions are discussed, with multidetector CT being the focus of attention in spinal clearance for traumatic injuries. In most cases of spinal infection, MRI images, as a central diagnostic tool, show typical findings such as destruction of adjacent endplates, bone marrow and intervertebral disc abnormalities, and paravertebral or epidural abscesses. However, it is not always easy to diagnose a spinal infection, especially if atypical MR patterns of infectious spondylitis are present. Knowledge of them means misdiagnosis and improper treatment can be avoided. RESULTS It is shown that high-quality modern radiological examinations are essential for diagnosis and p.o. management, as these provide answers to the main questions in the treatment: Is the entity/injury stable or unstable, acute or old, benign or malign; is there a myelopathy or p.o. complication? DISCUSSION The main indications for p.o. diagnostic imaging, difficulties such as metal artefact formation, and potential pitfalls are analyzed. Entity-specific radiological image patterns, imaging algorithms and differential diagnostic peculiarities are presented and discussed based on current literature and selected case studies.
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Affiliation(s)
- Uwe H W Schütz
- Klinik für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Deutschland. .,Orthopädie und Schmerzmedizin am Grünen Turm, Grüner-Turm-Str. 4-10, 88212, Ravensburg, Deutschland.
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40
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Crilly SM, McElroy E, Ryan J, O'Donohue M, Lawler LP. "Mixed" trauma to the carotid artery in a mixed martial arts injury - A case report and review of the literature. J Radiol Case Rep 2019; 12:1-11. [PMID: 30651908 DOI: 10.3941/jrcr.v12i5.3234] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
We present the case of a mixed martial arts (MMA) cage fighter who presented to the emergency department with a right sided common carotid artery pseudoaneurysm as a result of a neck trauma at an MMA event. We discuss the management of blunt force neck trauma, differential diagnosis, imaging findings and review the literature on blunt cerebrovascular injury following blunt force injury to the neck.
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Affiliation(s)
- Shane M Crilly
- Department of Surgery, Royal Perth Hospital, Perth, WA, Australia
| | - Eileen McElroy
- Department of Medicine, Fiona Stanley Hospital, Murdoch, Perth, WA, Australia
| | - Jonathan Ryan
- Department of Diagnostic Radiology, Sligo University Hospital, Sligo, Republic of Ireland
| | - Martin O'Donohue
- Department of Vascular Surgery, Mater Misericordiae University Hospital, Dublin, Republic of Ireland
| | - Leo P Lawler
- Department of Diagnostic Radiology, Mater Misericordiae University Hospital, Dublin, Republic of Ireland
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41
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Burks JD, Conner AK, Briggs RG, Bonney PA, Smitherman AD, Baker CM, Glenn CA, Ghafil CA, Pryor DP, O'Connor KP, Bohnstedt BN. Blunt vertebral artery injury in occipital condyle fractures. J Neurosurg Spine 2018; 29:500-505. [PMID: 30074441 DOI: 10.3171/2018.3.spine161177] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 03/14/2018] [Indexed: 12/25/2022]
Abstract
OBJECTIVEA shifting emphasis on efficient utilization of hospital resources has been seen in recent years. However, reduced screening for blunt vertebral artery injury (BVAI) may result in missed diagnoses if risk factors are not fully understood. The authors examined the records of blunt trauma patients with fractures near the craniocervical junction who underwent CTA at a single institution to better understand the risk of BVAI imposed by occipital condyle fractures (OCFs).METHODSThe authors began with a query of their prospectively collected trauma registry to identify patients who had been screened for BVAI using ICD-9-CM diagnostic codes. Grade and segment were recorded in instances of BVAI. Locations of fractures were classified into 3 groups: 1) OCFs, 2) C1 (atlas) fractures, and 3) fractures of the C2-6 vertebrae. Univariate and multivariate analyses were performed to identify any fracture types associated with BVAI.RESULTSDuring a 6-year period, 719 patients underwent head and neck CTA following blunt trauma. Of these patients, 147 (20%) had OCF. BVAI occurred in 2 of 43 patients with type I OCF, 1 of 42 with type II OCF, and in 9 of 62 with type III OCF (p = 0.12). Type III OCF was an independent risk factor for BVAI in multivariate modeling (OR 2.29 [95% CI 1.04-5.04]), as were fractures of C1-6 (OR 5.51 [95% CI 2.57-11.83]). Injury to the V4 segment was associated with type III OCF (p < 0.01).CONCLUSIONSIn this study, the authors found an association between type III OCF and BVAI. While further study may be necessary to elucidate the mechanism of injury in these cases, this association suggests that thorough cerebrovascular evaluation is warranted in patients with type III OCF.
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Brommeland T, Helseth E, Aarhus M, Moen KG, Dyrskog S, Bergholt B, Olivecrona Z, Jeppesen E. Best practice guidelines for blunt cerebrovascular injury (BCVI). Scand J Trauma Resusc Emerg Med 2018; 26:90. [PMID: 30373641 PMCID: PMC6206718 DOI: 10.1186/s13049-018-0559-1] [Citation(s) in RCA: 85] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 10/10/2018] [Indexed: 01/12/2023] Open
Abstract
Blunt cerebrovascular injury (BCVI) is a non-penetrating injury to the carotid and/or vertebral artery that may cause stroke in trauma patients. Historically BCVI has been considered rare but more recent publications indicate an overall incidence of 1-2% in the in-hospital trauma population and as high as 9% in patients with severe head injury. The indications for screening, treatment and follow-up of these patients have been controversial for years with few clear recommendations. In an attempt to provide a clinically oriented guideline for the handling of BCVI patients a working committee was created. The current guideline is the end result of this committees work. It is based on a systematic literature search and critical review of all available publications in addition to a standardized consensus process. We recommend using the expanded Denver screening criteria and CT angiography (CTA) for the detection of BCVI. Early antithrombotic treatment should be commenced as soon as considered safe and continued for at least 3 months. A CTA at 7 days to confirm or discard the diagnosis as well as a final imaging control at 3 months should be performed.
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Affiliation(s)
- Tor Brommeland
- Department of Neurosurgery, Oslo University Hospital Ullevål, Kirkeveien 166, 0450 Oslo, Norway
| | - Eirik Helseth
- Department of Neurosurgery, Oslo University Hospital Ullevål, Kirkeveien 166, 0450 Oslo, Norway
- Faculty of Medicine, University of Oslo, Problemveien 7, 0315 Oslo, Norway
| | - Mads Aarhus
- Department of Neurosurgery, Oslo University Hospital Ullevål, Kirkeveien 166, 0450 Oslo, Norway
| | - Kent Gøran Moen
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Medical Imaging, Nord-Trondelag Health Trust, Levanger, Norway
| | - Stig Dyrskog
- Department of Neurointensive care, Aarhus University Hospital, Nørrebrogade 44, 8000 Aarhus, C, Denmark
| | - Bo Bergholt
- Department of Neurosurgery, Aarhus University Hospital, Nørrebrogade 44, 8000 Aarhus, C, Denmark
| | - Zandra Olivecrona
- Department of Anestesia and Intensive care, Section for Neurosurgery, Faculty of Health and Medicine, Department for Medical Sciences, Södre Grev Rosengatan, 70185 Örebro, Sweden
| | - Elisabeth Jeppesen
- National Trauma Registry, Department of Research and Development, Division of Orthopedics, Oslo University Hospital, NO-0424 Oslo, Norway
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43
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Scholz M, Kandziora F, Kobbe P, Matschke S, Schleicher P, Josten C. Treatment of Axis Ring Fractures: Recommendations of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU). Global Spine J 2018; 8:18S-24S. [PMID: 30210957 PMCID: PMC6130108 DOI: 10.1177/2192568217745061] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
STUDY DESIGN Narrative literature review and expert recommendation. OBJECTIVE To establish treatment recommendations for axis ring fractures based on the knowledge of the experts of the Spine Section of the German Society for Orthopaedics and Trauma. METHODS This recommendation summarizes the knowledge of the experts of the Spine Section of the German Society for Orthopaedics and Trauma with regard to the treatment of axis ring fractures based on a narrative literature review. RESULTS Typical "hangman's fractures" with bilateral separation of the neural arch from C2 and atypical "hangman's fractures" with irregular fracture morphology are described. Computed tomography is the "gold" standard used to detect and analyse these fractures adequately. Furthermore, the detection of vertebral artery integrity is necessary. To classify axis ring fractures, the Levine-Edwards or Josten classification is recommended. In particular, the integrity of the C2/3 disc and the integrity of the anterior longitudinal ligament are used to determine the treatment strategy. While Levine-Edwards type I and type IIA (Josten type 1 and 2) fractures should be treated conservatively, Levine type II and type III (Josten type 3 and 4) fractures should be treated operatively. Levine-Edwards type II fractures will be predominately treated by anterior C2/3 fusion. Levine-Edwards type III fractures have to be primary reduced, if an anterior fusion is planned (anterior cervical discectomy and fusion [ACDF] C2/3). If a closed reduction of a type III fracture is impossible, an open reduction and posterior fixation/fusion is the treatment of choice. CONCLUSION Conservative treatment is predominantly reserved for Levine-Edwards I and IIA fractures. Operative treatment should be performed in case of Levine-Edwards II and III fractures.
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Affiliation(s)
- Matti Scholz
- BG Unfallklinik Frankfurt am Main gGmbH, Frankfurt am Main, Germany,Matti Scholz, BG Unfallklinik Frankfurt am Main gGmbH, Friedberger Landstraße 430, 60389 Frankfurt am Main, Germany.
| | - Frank Kandziora
- BG Unfallklinik Frankfurt am Main gGmbH, Frankfurt am Main, Germany
| | | | - S. Matschke
- BG Klinik Ludwigshafen, Ludwigshafen, Germany
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Paramaswamy R. Airway management in a displaced comminuted fracture of the mandible and atlas with a vertebral artery injury: A case report. J Dent Anesth Pain Med 2018; 18:183-187. [PMID: 29984323 PMCID: PMC6031976 DOI: 10.17245/jdapm.2018.18.3.183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 05/25/2018] [Accepted: 06/04/2018] [Indexed: 11/15/2022] Open
Abstract
Complex cervical spine fractures are a serious complications of maxillofacial trauma and associated with high mortality and neurological morbidity. Strict vigilance in preventing further insult to the cervical spine is a crucial step in managing patients who are at risk for neurologic compromise. We report a rare case of a right transverse process of atlas fracture with right-sided vertebral artery injury that was associated with a comminuted fracture of the body and angle of the mandible, which restricted mouth opening. Airway management was performed by an awake fiber-optic nasotracheal intubation, where neck movement was avoided with a cervical collar. Vertebral artery injuries may have disastrous consequences, such as basilar territory infarction and death, and should be suspected in patients with head and neck trauma. After mandibular plating, the patient was on cervical collar immobilization for 12 weeks and anti-coagulant therapy.
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45
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Konomi T, Suda K, Matsumoto S, Komatsu M, Takahata M, Iwasaki N, Minami A. Awareness of traumatic occult lateral mass fracture of the cervical spine triggered by the presence of unilateral vertebral artery occlusion: a case report. Spinal Cord Ser Cases 2018; 4:20. [PMID: 29560277 DOI: 10.1038/s41394-018-0060-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 02/13/2018] [Accepted: 02/15/2018] [Indexed: 11/09/2022] Open
Abstract
Introduction We present an unusual case of traumatic occult lateral mass fracture of the cervical spine with unilateral occlusion of the vertebral artery (VA), that was missed by plain X-ray and magnetic resonance imaging (MRI), but identified by computed tomography (CT) after suspecting high-energy trauma as the underlying cause. Case presentation A 67-year-old male was injured in a car accident and came to our institute on foot 4 days after injury with complaints of neck pain and numbness in the right hand. Although, no specific bone injury was visible on plain X-ray, the absence of flow voids in the right VA was confirmed on axial T2-weighted MRI. We suspected high-energy trauma of the cervical spine at that point and performed CT for a more detailed assessment. Consequently, a fracture was detected in the right lateral mass of C6 and we speculated that spontaneous reduction of the fracture-dislocation had occurred. One-stage surgery with posterior fixation was subsequently performed for instability. The patient's preoperative symptoms were improved and neither recanalization of the occlusion nor another VA occlusion was observed after surgery. Discussion VA injury occurs frequently as a complication of blunt cervical spine trauma. In the present case, however, the lateral mass fracture was not seen on MRI and missed until the unilateral VA injury was detected. When high-energy trauma of the cervical spine is suspected, it is important to evaluate damage to the spinal cord, bone, soft-tissue, and VA by MRI and CT.
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Affiliation(s)
- Tsunehiko Konomi
- Department of Orthopedic Surgery, Hokkaido Spinal Cord Injury Center, 3-1 Higashi-4 Minami-1, Bibai, Hokkaido 072-0015 Japan.,2Department of Orthopedic Surgery, Murayama Medical Center, National Hospital Organization, 2-37-1 Gakuen, Musashimurayama, Tokyo 208-0011 Japan
| | - Kota Suda
- Department of Orthopedic Surgery, Hokkaido Spinal Cord Injury Center, 3-1 Higashi-4 Minami-1, Bibai, Hokkaido 072-0015 Japan
| | - Satoko Matsumoto
- Department of Orthopedic Surgery, Hokkaido Spinal Cord Injury Center, 3-1 Higashi-4 Minami-1, Bibai, Hokkaido 072-0015 Japan
| | - Miki Komatsu
- Department of Orthopedic Surgery, Hokkaido Spinal Cord Injury Center, 3-1 Higashi-4 Minami-1, Bibai, Hokkaido 072-0015 Japan
| | - Masahiko Takahata
- 3Department of Orthopedic Surgery, Graduate School of Medicine, Hokkaido University, Kita 8, Nishi 5, Kita-ku, Sapporo, Hokkaido 060-0808 Japan
| | - Norimasa Iwasaki
- 3Department of Orthopedic Surgery, Graduate School of Medicine, Hokkaido University, Kita 8, Nishi 5, Kita-ku, Sapporo, Hokkaido 060-0808 Japan
| | - Akio Minami
- Department of Orthopedic Surgery, Hokkaido Spinal Cord Injury Center, 3-1 Higashi-4 Minami-1, Bibai, Hokkaido 072-0015 Japan
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Two-stage corrective surgery for severe rigid cervical kyphotic deformity with unilateral vertebral artery occlusion after old blunt trauma: a case report. Spinal Cord Ser Cases 2018. [PMID: 29531796 DOI: 10.1038/s41394-018-0051-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Introduction There are considerable risks for vertebral artery (VA) injury in case of corrective surgery for a severe and rigid cervical kyphotic deformity. This case report describes a rare case of surgical management for pre-existing traumatic rigid cervical kyphosis associated with unilateral VA occlusion. Case presentation A 73-year-old male fell down and injured his neck. He was referred to our hospital 10 months after injury because his degree of head drop progressed gradually to a chin-on-chest position such that he could not look straight forward. On plain X-ray, the C2-7 angles in the neutral, flexion, and extension positions were 61°, 71°, and 50°, respectively. CT revealed a collapse of the C5 vertebral body and bone fusion between C4 and C5 in the anterior vertebrae, and unilateral VA occlusion was confirmed by angiography. Two-stage surgery was planned to correct the kyphosis. In the first stage, anterior release of the C4/5 bone-spur fusion and dissection of the intervertebral disk were performed. After release, angiography confirmed neither occlusion nor rupture of the VA. In the second stage, anterior and posterior fixation was performed at correcting position while maintaining slight kyphosis in order to avoid excessive distortion of the VA. The postoperative C2-7 kyphosis angle improved to 16° without any VA injury, and the patient could look forward easily. Discussion The degree of correction as well as risk management of VAs should be considered carefully during corrective surgery for severe and rigid cervical kyphosis, especially with unilateral VA occlusion.
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Mehdi E, Aralasmak A, Toprak H, Yıldız S, Kurtcan S, Kolukisa M, Asıl T, Alkan A. Craniocervical Dissections: Radiologic Findings, Pitfalls, Mimicking Diseases: A Pictorial Review. Curr Med Imaging 2018; 14:207-222. [PMID: 29853818 PMCID: PMC5902863 DOI: 10.2174/1573405613666170403102235] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background: Craniocervical Dissections (CCD) are a crucial emergency state causing 20% of strokes in patients under the age of 45. Although DSA (digital substraction angiography) is regarded as the gold standard, noninvasive methods of CT, CTA and MRI, MRA are widely used for diagnosis. Aim: Our aim is to illustrate noninvasive imaging findings in CCD. Conclusion: Emphasizing on diagnostic pitfalls, limitations and mimicking diseases.
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Affiliation(s)
- Elnur Mehdi
- Bezmialem Vakif University, Department of Radiology, Istanbul, Turkey
| | - Ayse Aralasmak
- Bezmialem Vakif University, Department of Radiology, Istanbul, Turkey
| | - Huseyin Toprak
- Bezmialem Vakif University, Department of Radiology, Istanbul, Turkey
| | - Seyma Yıldız
- Bezmialem Vakif University, Department of Radiology, Istanbul, Turkey
| | - Serpil Kurtcan
- Bezmialem Vakif University, Department of Radiology, Istanbul, Turkey
| | - Mehmet Kolukisa
- Bezmialem Vakif University, Department of Neurology, Istanbul, Turkey
| | - Talip Asıl
- Bezmialem Vakif University, Department of Neurology, Istanbul, Turkey
| | - Alpay Alkan
- Bezmialem Vakif University, Department of Radiology, Istanbul, Turkey
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Traumatic vertebral artery rupture causing intraspinal hematoma and progressive neurological symptoms. Acta Neurochir (Wien) 2018; 160:249-251. [PMID: 29188367 DOI: 10.1007/s00701-017-3407-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 11/14/2017] [Indexed: 10/18/2022]
Abstract
Traumatic vertebral artery rupture is extremely rare. Herein, we report a case of traumatic vertebral artery rupture causing extensive intraspinal hematoma and progressive neurological symptoms.
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49
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Endovascular Treatment of Penetrating Injury to the Vertebral Artery by a Stab Wound: Case Report and Literature Review. Ann Vasc Surg 2017; 45:267.e1-267.e5. [DOI: 10.1016/j.avsg.2017.06.145] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 06/13/2017] [Accepted: 06/20/2017] [Indexed: 11/24/2022]
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50
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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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