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Volpe A, Erra M, Risi C, Casella V, Cioffi A, Fenza G. "Split atlas" in a trauma and nontrauma patient: two different case reports for a rare congenital malformation. Radiol Case Rep 2021; 16:585-588. [PMID: 33391581 PMCID: PMC7773561 DOI: 10.1016/j.radcr.2020.12.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 12/17/2020] [Accepted: 12/18/2020] [Indexed: 11/16/2022] Open
Abstract
Congenital atlas abnormalities are rare and often asymptomatic findings, accidentally detected in trauma and, more rarely, in nontrauma patients. Rachischisis in both anterior and posterior atlas arches, condition defined as ‘‘split atlas,” is extremely uncommon and it may well be confused with fracture. Being able to discriminate between these 2 conditions is an essential step in patient care management. In this article, we report 2 cases of split atlas ascertained in both trauma and nontrauma patients. The first concerning a 54-year-old man fell from a 2 m scaffold, and the second related to a 25-year-old woman suffering from treatment-resistant headaches. Subsequently we proceed to analyse the embryology of these abnormalities, and later to discuss pitfalls, tips and tricks useful to a correct diagnosis, in order to achieve an accurate management of split atlas. Specifically, we outline the crucial radiological features to identify, that are beneficial to an efficient differential diagnosis between congenital atlas abnormalities and fracture. These include smooth corticated margins of the cleft, and <3 mm lateral displacement of C1 lateral masses.
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Affiliation(s)
- Alessio Volpe
- Department of Radiology, L. Curto Hospital, Via Luigi Curto, Polla, 84035, Salerno, Italy
| | - Maurizio Erra
- Department of Radiology, L. Curto Hospital, Via Luigi Curto, Polla, 84035, Salerno, Italy
| | - Chiara Risi
- Department of Radiology, L. Curto Hospital, Via Luigi Curto, Polla, 84035, Salerno, Italy
| | - Vincenzo Casella
- Department of Radiology, L. Curto Hospital, Via Luigi Curto, Polla, 84035, Salerno, Italy
| | - Annamaria Cioffi
- Department of Radiology, L. Curto Hospital, Via Luigi Curto, Polla, 84035, Salerno, Italy
| | - Giacomo Fenza
- Department of Radiology, L. Curto Hospital, Via Luigi Curto, Polla, 84035, Salerno, Italy
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The prevalence of congenital C1 arch anomalies. 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 2017; 27:1266-1271. [DOI: 10.1007/s00586-017-5283-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Revised: 07/30/2017] [Accepted: 08/19/2017] [Indexed: 10/19/2022]
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Mead LB, Millhouse PW, Krystal J, Vaccaro AR. C1 fractures: a review of diagnoses, management options, and outcomes. Curr Rev Musculoskelet Med 2016; 9:255-62. [PMID: 27357228 DOI: 10.1007/s12178-016-9356-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The atlas is subject to fracture under axial load, often due to traumatic injuries such as shallow dives and automobile accidents. These fractures account for 2-13 % of injuries to the cervical spine [Marcon RM et al. Clinics (Sao Paulo) 68(11):1455-61, 2013]. Fractures of the C1 vertebra are often difficult to diagnose, as there is often no neurological deficit or easily identifiable findings on radiographs. However, injuries to the atlas can be associated with vertebral artery injury and atlantoaxial or atlanto-occipital instability, making prompt and accurate diagnosis imperative. A detailed understanding of the anatomy, inherent stability, and common injury patterns is essential for any surgeon treating spinal trauma. This chapter explores the diagnosis and management of C1 fractures, as well as outcomes after treatment.
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Affiliation(s)
- Loren B Mead
- Rothman Institute, 925 Chestnut Street, 5th Floor, Philadelphia, PA, 19107, USA.
| | - Paul W Millhouse
- Thomas Jefferson University, 1015 Walnut St. Curtis 501, Philadelphia, PA, 19107, USA
| | - Jonathan Krystal
- Rothman Institute, 925 Chestnut Street, 5th Floor, Philadelphia, PA, 19107, USA
| | - Alexander R Vaccaro
- Rothman Institute, 925 Chestnut Street, 5th Floor, Philadelphia, PA, 19107, USA
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Difficulties in distinguishing between an atlas fracture and a congenital posterior atlas arch defect in postmortem analysis. Forensic Sci Int 2014; 242:e1-e5. [DOI: 10.1016/j.forsciint.2014.06.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2013] [Revised: 03/23/2014] [Accepted: 06/17/2014] [Indexed: 11/17/2022]
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Ganau M, Spinelli R, Tacconi L. Complex developmental abnormality of the atlas mimicking a Jefferson fracture: Diagnostic tips and tricks. J Emerg Trauma Shock 2013; 6:47-9. [PMID: 23493176 PMCID: PMC3589859 DOI: 10.4103/0974-2700.106325] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2012] [Accepted: 07/20/2012] [Indexed: 11/04/2022] Open
Abstract
Congenital atlas abnormalities are rare - often asymptomatic - findings, not requiring any specific treatment. They are frequently discovered, by chance, in trauma patients, in the course of the radiological work flow at the Emergency Department. In these cases they may represent a diagnostic challenge, since physicians are expected to differentiate them from complex C1 fractures (isolated Jefferson's fractures or associated with Anderson and d'Alonzo's fractures) requiring surgical treatment. Although difficult to identify, a correct diagnosis is mandatory in order to optimize the patient's treatment. In this article we report a case of congenital atlas abnormality, and discuss the tips and tricks to make a correct differential diagnosis through the most appropriate clinical and radiological work flow.
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Affiliation(s)
- Mario Ganau
- Department of Neurosurgery, University Hospital Cattinara, Trieste, Italy
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Smit RAJ, Coebergh JAF, Treurniet FEE, Kuiters RRF, Koppen H. A missing arch of the atlas vertebra in a patient struck by a tram. Neurol Sci 2013; 34:1855-6. [PMID: 23440493 DOI: 10.1007/s10072-013-1334-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2013] [Accepted: 02/12/2013] [Indexed: 11/28/2022]
Affiliation(s)
- R A J Smit
- Leiden University Medical Center, Albinusdreef 2, 2333, ZA, Leiden, The Netherlands,
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Petre BM, Karp JE, Riley LH. Athletic cervical spine injury in the setting of fusion failure of the anterior and posterior atlas. Orthopedics 2012; 35:e1449-52. [PMID: 22955419 DOI: 10.3928/01477447-20120822-39] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
This article describes a rare congenital abnormality of anterior and posterior C1 fusion failure presenting after an acute athletic injury to the fibrous nonunion. C1 congenital malformations are rare, occurring in approximately 2% of patients; even rarer are combined anterior and posterior arch malformations in the same patient. Posterior ring abnormalities are more common than anterior ring injuries (4.5:1, respectively). To the authors' knowledge, combined anterior and posterior ring congenital malformations with subsequent injury have not been previously described. In the current patient, a congenital failure of fusion of the anterior and posterior arches of C1 was identified. The anterior fibrous nonunion was injured while the patient played football, leading to transient neurologic injury and dysphagia from soft tissue swelling. The patient was initially diagnosed with an acute fracture at another facility; however, given advanced imaging, flexion and extension views, and a normal neurologic examination, the authors diagnosed a traumatized congenital defect. The injury healed with a short period of cervical collar immobilization and supportive measures. Such malformations are usually found incidentally, but they can be symptomatic after trauma. Images to distinguish these deficits can be difficult because the differences between chronic nonunions and congenital malformations are subtle. Surgery is rarely indicated for congenital malformations because they are often stable even after injury; however, they may predispose patients to neurologic injury in the future with high-risk activities. Because the current patient had an increased chance of future injury secondary to the lack of bone formation in the C1 vertebrae, he was restricted from participating in contact sports.
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Affiliation(s)
- Benjamin M Petre
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland, USA
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Martirosyan NL, Cavalcanti DD, Kalani MYS, Maughan PH, Theodore N. Aplasia of the anterior arch of atlas associated with multiple congenital disorders: case report. Neurosurgery 2012; 69:E1317-20. [PMID: 21712741 DOI: 10.1227/neu.0b013e31822a9ab1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND IMPORTANCE Congenital clefts and aplasias of the atlas vertebra are rare. A nonfused posterior arch occurs in 4% of the population; in contrast, a nonfused anterior arch occurs in only 0.1%. To the best of our knowledge, this is the first description of the combination of anterior arch aplasia and a cleft of the posterior arch of the atlas associated with Klippel-Feil and Treacher-Collins syndromes and Sprengel deformity. CLINICAL PRESENTATION An 11-year-old girl presented with neck pain and symptoms of myelopathy, including upper- and lower-extremity paresthesia. Computed tomography revealed significant congenital bony anomalies of the cervical spine, with congenital fusion of C2 through C5. There was aplasia of the anterior ring of C1 (A 2.3-cm gap was present within the anterior aspect of the lateral masses). The posterior elements of C3 and C4 were fused, and signs of Sprengel deformity were present. Magnetic resonance imaging revealed effacement of the ventral cerebrospinal fluid space at the craniocervical junction and mild mass effect at the cervicomedullary junction. Flexion and extension views showed abnormal motion at the craniocervical junction. There was no evidence of atlantoaxial instability, basilar invagination, or Chiari malformation. Occipito-C4-scapular fusion was performed to prevent spinal cord injury and further neurological symptoms. Postoperatively, the patient did extremely well, and her preoperative symptoms resolved. CONCLUSION We describe a rare case of aplasia of the anterior arch of the atlas and posterior arch midline cleft in association with Treacher-Collins syndrome, Klippel-Feil syndrome, and Sprengel deformity. The patient's atlantoaxial instability was managed surgically with a unique construct that provided occipito-C4-scapular fusion.
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Affiliation(s)
- Nikolay L Martirosyan
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona 85013, USA
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Doukas A, Petridis AK. A case of aplasia of the posterior arch of the atlas mimicking fracture: Review of the literature. Clin Anat 2011; 23:881-2. [PMID: 19941352 DOI: 10.1002/ca.20901] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Alexandros Doukas
- Department of Neurosurgery, University Hospital Schleswig-Holstein, Campus Kiel, Germany
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Guggenberger R, Andreisek G, Scheffel H, Wildermuth S, Leschka S, Stolzmann P. Absent cervical spine pedicle and associated congenital spinal abnormalities - a diagnostic trap in a setting of acute trauma: case report. BMC Med Imaging 2010; 10:25. [PMID: 21062465 PMCID: PMC2988693 DOI: 10.1186/1471-2342-10-25] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2010] [Accepted: 11/09/2010] [Indexed: 11/10/2022] Open
Abstract
Background Congenital spinal abnormalities can easily be misdiagnosed on plain radiographs. Additional imaging is warranted in doubtful cases, especially in a setting of acute trauma. Case Presentation This patient presented at the emergency unit of our university hospital after a motor vehicle accident and was sent to our radiology department for imaging of the cervical spine. Initial clinical examination and plain radiographs of the cervical spine were performed but not conclusive. Additional CT of the neck helped establish the right diagnosis. Conclusion CT as a three-dimensional imaging modality with the possibility of multiplanar reconstructions allows for the exact diagnosis and exclusion of acute traumatic lesions of the cervical spine, especially in cases of doubtful plain radiographs and when congenital spinal abnormalities like absent cervical spine pedicle with associated spina bifida may insinuate severe trauma.
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Burkhardt M, Garcia P, Fries P, Heinzmann J, Pohlemann T, Pizanis A. Posttraumatischer Tortikollis beim Schulkind. Unfallchirurg 2010; 113:230-4. [DOI: 10.1007/s00113-009-1696-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Kwon JK, Kim MS, Lee GJ. The incidence and clinical implications of congenital defects of atlantal arch. J Korean Neurosurg Soc 2009; 46:522-7. [PMID: 20062566 DOI: 10.3340/jkns.2009.46.6.522] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2009] [Revised: 09/04/2009] [Accepted: 11/09/2009] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE Atlantal arch defects are rare. Few cadaveric and imaging studies have been reported on the variations of such anomalies. Our goal in this study was to examine the incidence and review the clinical implications of this anomaly. METHODS A retrospective review of 1,153 neck or cervical spine computed tomography (CT) scans was performed to identify patients with atlantal arch defects. Neck CT scans were performed in 650 patients and cervical spine CT scans were performed in 503 patients. Posterior arch defects of the atlas were grouped in accordance with the classification of Currarino et al. In patients exhibiting this anomaly, special attention was given to defining associated anomalies and neurological findings. RESULTS Atlantal arch defects were found in 11 (11/1153, 0.95%) of the 1,153 patients. The type A posterior arch defect was found in nine patients and the type B posterior arch defect was found in two patients. No type C, D, or E defects were observed. One patient with a type A posterior arch defect had an anterior atlantal-arch midline cleft (1/1153, 0.087%). Associated cervical spine anomalies observed included one C(6-7) fusion and two atlantal assimilations. None of the reviewed patients had neurological deficits because of atlantal arch anomalies. CONCLUSION Most congenital anomalies of the atlantal arch are found incidentally during investigation of neck mass, neck pain, radiculopathy, and after trauma.
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Affiliation(s)
- Jong Kyu Kwon
- Department of Neurosurgery, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
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Beaumont Caminos C, Zazpe Cenoz I, Hernández Galán A, Jean Louis C, Fenández Esain B, Gimena Ramos I. Partial agenesis of the posterior arch of the atlas. Am J Emerg Med 2007; 26:118.e3-5. [PMID: 18082815 DOI: 10.1016/j.ajem.2007.07.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2007] [Accepted: 07/21/2007] [Indexed: 10/22/2022] Open
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