Nonoperative Management of Craniocervical Ligamentous Distraction Injury: Literature Review

Pediatric Cervical Spine Trauma: Injury Patterns, Diagnosis, and Treatment

BACKGROUND

Traumatic injuries to the cervical spine or spinal cord are uncommon pathologies in the pediatric population. As injury severity is disproportionately higher among children due to significant risk for debilitating long-term disability, traumatic spinal fractures in children raise greater clinical concern than comparable injuries in adults.

SUMMARY

Unlike adults, children possess unique features such as incomplete ossification of vertebrae, synchondroses, pseudo-subluxation, horizontal alignment of ligaments, and absence of lordosis, which results in greater mobility and flexibility in the pediatric spine. These features are prominent in the cervical spine, which accounts for the most common area of traumatic spinal injuries in children.

KEY MESSAGES

In this review, we summarize injury patterns, diagnosis, and treatment of traumatic cervical spine injuries in the pediatric population.

Mechanisms of vascular injury in neurotrauma: A critical review of the literature

One in every two individuals will experience a traumatic brain injury in their lifetime with significant impacts on the global economy and healthcare system each year. Neurovascular injury is a key aspect of neurotrauma to both the brain and the spinal cord and an important avenue of current and future research seeking innovative therapies. In this paper, we discuss primary and secondary neurotrauma, mechanisms of injury, the glymphatic system, repair and recovery. Each of these topics are directly connected to the vasculature of the central nervous system, affecting severity of injury and recovery. Consequently, neurovascular injury in trauma represents a promising target for future therapeutics and innovation.

Successful non-operative treatment of traumatic atlanto-occipital dislocation: a case report

Background

Traumatic atlanto-occipital dislocation (AOD) is most commonly treated with cranio-cervical fusion. We present a unique case in which a partial neurological recovery was made after non-operative treatment was done for AOD. Reports of non-operative treatment of this condition are rare in the literature.

Case Description

An 18-year-old male sustained a traumatic AOD and atlanto-axial dislocation. His injury was characterized by bony avulsion fractures of the occipital condyles bilaterally as well as atlanto-axial dissociation. Non-operative treatment was done because of his comorbidities, primarily his morbid obesity. He was treated in a hard cervical collar for 6 months. He showed radiographic evidence of healing after being treated non-operatively in a rigid cervical collar for 6 months. Follow up at 17 months showed a partial neurological recovery with ability to ambulate assisted with a walker.

Conclusions

Successful outcomes are possible with non-operative treatment of AOD. A predominant factor contributing to this patient's successful outcome with non-operative management was likely related to the bony avulsion fractures he had which allowed bone to bone healing and settling of the fracture with gravity assisted reduction in a collar. Non-operative treatment may be considered in patients who are too unhealthy or unstable to undergo surgical intervention, although the standard of care remains surgical cranio-cervical fusion.

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

BACKGROUND AND PURPOSE

The purpose of this study was to identify and classify the different types of anterior atlanto-occipital membrane complex injuries on MRI and evaluate for the presence, size, and location of a prevertebral effusion on the preceding CT exams.

MATERIALS AND METHODS

Patients who suffered an anterior atlanto-occipital membrane complex injury were identified retrospectively utilizing Nuance mPower software. An anatomic-based description of the location of the anterior atlanto-occipital membrane complex injury was recorded along with any additional osteoligamentous trauma of the craniocervical junction. The preceding cervical CT exams for these patients were reviewed for the presence and location of a prevertebral effusion.

RESULTS

Fifty patients were identified with an acute, post-traumatic anterior atlanto-occipital membrane complex injury. Three distinct patterns of anterior atlanto-occipital membrane complex injury were observed. Nineteen patients demonstrated increased STIR signal with disruption of the anterior atlanto-occipital membrane, ten patients demonstrated increased STIR signal with disruption of the anterior atlanto-axial membrane, and twenty-one patients demonstrated increased STIR signal with disruption of both the anterior atlanto-occipital membrane and anterior atlanto-axial membrane. An effusion at the C1-C2 level was present in greater than 90% of patients with anterior atlanto-occipital membrane complex injury.

CONCLUSIONS

The presence of a craniocervical prevertebral effusion on CT in trauma patients may raise suspicion for an injury to the anterior atlanto-occipital membrane complex and potentially trigger additional investigation with cervical MRI.

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

The radiological image of an intact tectorial membrane (TM) became an important favorable prognostic factor for craniovertebral instability. This study visualized the fascial layers of the TM and adjacent connective tissues with clinical significance by micro-CT and histological analysis. The TM firmly attached to the bony surface of the clivus, traversed the atlantoaxial joint posteriorly, and was inserted to the body of the axis showing wide distribution on the craniovertebral junction. The supradental space between the clivus, dens of the axis, anterior atlantooccipital membrane, and the TM contained profound venous networks within the adipose tissues. At the body of the axis, the compact TM layer is gradually divided into multiple layers and the deeper TM layers reached the axis while the superficial layer continued to the posterior longitudinal ligament of the lower vertebrae. The consistent presence of the fat pad and venous plexus in the supradental space and firm stabilization of the TM on the craniovertebral junction was demonstrated by high-resolution radiologic images and histological analysis. The evaluation of the TM integrity is a promising diagnostic factor for traumatic craniovertebral dislocation.

Analysis of diagnostics, therapy and outcome of patients with traumatic atlanto-occipital dislocation

BACKGROUND CONTEXT

Patients' outcome following traumatic atlanto-occipital dislocation (AOD) has been poor. In recent years, an increasing number of patients surviving the initial trauma are admitted to hospital. In order to further improve the management of these patients, the knowledge of diagnostics and therapy as well as possible complications should be increased.

PURRPOSE

The aim of this study was to evaluate diagnostic parameters, therapy, early complications and outcome of patients with traumatic AOD.

STUDY DESIGN

Monocentric retrospective cohort study.

PATIENT SAMPLE

A total of 12 patients were included in this study.

OUTCOME MEASURES

The main outcome measure was functional patient outcome. Furthermore, radiographic and treatment data were analyzed.

METHODS

All patients suffering from traumatic AOD within an 8-year time period were included. Demographic data, radiological diagnostic parameters (condylar sum, basion dens interval, basion axis interval, power´s ratio, x-line method), as well as treatment data and complications of every patient were analyzed. Radiological parameters were compared with each other. Outcome was analyzed by a follow up examination.

RESULTS

The accident mechanisms were motor vehicle accidents (MVA), fall from high and low height. Basion dens interval, basion axis interval, power's ratio and x-line method were not reliable in identifying traumatic AOD (only up to 33% of the patients were identified). Twelve patients could be reviewed. Three patients were treated with surgery, five patients were treated nonsurgically. Four patients died before surgical therapy. All seven surviving patients (survival rate: 58.3%) were re-examined (mean follow-up time: 6.7 months). All patients had a GCS of 15. Three surviving patients suffered from persisting neurological deficits.

CONCLUSIONS

The most reliable way to diagnose AOD in Computer Topography is using the condylar sum. Surgical and nonsurgical measures can be employed with reasonable outcomes. Patient specific injury burden and clinical presentation should be taken into account when making treatment decisions for AOD.

Traumatic Atlanto-Occipital Dislocation-A Comprehensive Analysis of All Case Series Found in the Spinal Trauma Literature

BACKGROUND

Traumatic atlanto-occipital dislocation (TAOD) is one of the most devastating traumatic injuries, generally associated with immediate death after high-energy trauma. The aim of this study was to perform a systematic literature review of all cases series of TAOD and present the current state of this entity.

METHODS

A systematic literature review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Only case series with at least 5 cases were included in the analysis. We focused on survival rates, diagnostic methods, delays in diagnosis, outcomes, and cases successfully treated nonoperatively.

RESULTS

A total of 17 articles were included (16 retrospective and 1 prospective study) with 341 patients. Six studies included pediatric patients only. The mean Glasgow Coma Scale at admission was ≤8 in all studies. Many different diagnostic criteria were used, but none of them had high accuracy. The overall mortality rate was 34.8%, but the studies' designs were heterogeneous (some included only survivors). A high rate of concomitant traumatic brain injury was documented in some studies. We found it interesting that some patients were treated with cervical immobilization (37/341; 10.8%), which was generally used in less unstable injuries; however, the majority of patients were managed with an occipito-cervical fusion (193/341; 56.5%).

CONCLUSIONS

TAOD is a devastating traumatic injury, with a high mortality rate. An MRI may be recommended when there are subtle findings of TAOD and a normal computed tomography scan, such as subarachnoid hemorrhage in the posterior fossa, upper cervical injuries, or consistent neurological findings. Further studies are necessary to identify patients with mild MRI findings and TAOD that may be managed nonoperatively.

Identification of clinical and radiographic predictors of central nervous system injury in genetic skeletal disorders

Some studies report neurological lesions in patients with genetic skeletal disorders (GSDs). However, none of them describe the frequency of neurological lesions in a large sample of patients or investigate the associations between clinical and/or radiological central nervous system (CNS) injury and clinical, anthropometric and imaging parameters. The project was approved by the institution’s ethics committee (CAAE 49433215.5.0000.0022). In this cross-sectional observational analysis study, 272 patients aged four or more years with clinically and radiologically confirmed GSDs were prospectively included. Genetic testing confirmed the diagnosis in the FGFR3 chondrodysplasias group. All patients underwent blinded and independent clinical, anthropometric and neuroaxis imaging evaluations. Information on the presence of headache, neuropsychomotor development (NPMD), low back pain, joint deformity, ligament laxity and lower limb discrepancy was collected. Imaging abnormalities of the axial skeleton and CNS were investigated by whole spine digital radiography, craniocervical junction CT and brain and spine MRI. The diagnostic criteria for CNS injury were abnormal clinical and/or radiographic examination of the CNS. Brain injury included malacia, encephalopathies and malformation. Spinal cord injury included malacia, hydrosyringomyelia and spinal cord injury without radiographic abnormalities. CNS injury was diagnosed in more than 25% of GSD patients. Spinal cord injury was found in 21.7% of patients, and brain injury was found in 5.9%. The presence of low back pain, os odontoideum and abnormal NPMD remained independently associated with CNS injury in the multivariable analysis. Early identification of these abnormalities may have some role in preventing compressive CNS injury, which is a priority in GSD patients.

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

BACKGROUND AND PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Nonsurgical Management of Combined Occipitocervical and Atlantoaxial Distraction Injuries: A Case Report

CASE

A 41-year-old man sustained occipitocervical dislocation (OCD) and atlantoaxial dislocation (AAD) injuries in a motor vehicle collision. These injuries were treated nonoperatively with a hard cervical collar and activity restrictions with an excellent result at 4-year follow-up.

CONCLUSION

OCD and AAD injuries require prompt diagnosis and immobilization. Standard of care for coexisting injuries is occipitocervical fusion; however, some patients have coexisting injuries which may prevent operative treatment. These polytrauma patients require a creative nonoperative approach with close follow-up to avoid neurologic decline.

Spontaneous morphological remodelling of the O-C1 joint after posterior fusion for occipitocervical dislocation

BACKGROUND

Traumatic occipitocervical dislocation (OCD) occurs due to fatal high-energy injury. Modern screw-based constructs enable successful reduction and stabilisation. In view of this, there are no previous reports on the spontaneous remodelling of the O-C1 joint after posterior fusion. We report the first case of postoperative spontaneous remodelling and stabilisation of the O-C1 joint after traumatic OCD.Case description: A 9-year-old girl suffered from traumatic OCD, accompanied by complete rupture of the O-C1-C2 ligamentous complex. Halo-vest fixation, and subsequently posterior fusion surgery from the occipital bone to C2, with autologous iliac crest bone graft and an allograft were performed. However, we could not achieve complete reduction of the O-C1 joint during surgery owing to extremely severe instability.Postoperative X-ray and computed tomography scan showed incomplete reduction of the O-C1 joint. Insufficient congruity of the O-C1 joint persisted. Afterwards, gradual spontaneous remodelling of the O-C1 joint occurred, both anteriorly and posteriorly 3 months postoperatively. Solid union was achieved 6 months postoperatively. Two years later, bilateral O-C1 joints in the patient were completely reformed and restabilised by incredible vigorous remodelling. Insufficient reduction and persisting poor joint congruence after surgery for OCD was probably restabilised by further spontaneous remodelling of articular morphology in such a young patient.

CONCLUSIONS

Postoperative spontaneous remodelling of the O-C1 joint after posterior reconstruction for OCD may occur in young patients. Incomplete reduction of the O-C1 joint during surgery may be acceptable due to the possibility of postoperative bone remodelling and restabilisation.

Tectorial membrane injury in adult and pediatric trauma patients: a retrospective review and proposed classification scheme

BACKGROUND AND PURPOSE

Traumatic tectorial membrane injuries have different radiologic presentations in adult versus pediatric patients. The purpose of this study was to identify and classify the different types of tectorial membrane injuries that occur in the adult and pediatric populations.

MATERIALS AND METHODS

Patients who suffered tectorial membrane injury were identified retrospectively using the keywords 'tectorial membrane," "craniocervical ligament tear/injury," and "atlanto-occipital dissociation" included in radiology reports between 2012 and 2018 using Nuance mPower software. All relevant imaging studies were reviewed by two certificates of additional qualification-certified neuroradiologists. Detailed descriptions of injuries were recorded along with any relevant additional findings, including clinical history.

RESULTS

Ten adults and six pediatric patients were identified with acute traumatic injuries of the tectorial membrane. Ninety percent of the adult patients sustained complete disruptions inferior to the clivus, or subclival, with 22% of tears at the level of the basion and 78% at the level of the odontoid tip. In contrast, 83% of pediatric patients suffered a stripping injury of the tectorial membrane located posterior to the clivus, or retroclival. Stretch injuries of the tectorial membrane were identified in 10% of adults and 17% of pediatric patients. The juvenile-type injury, which causes retroclival epidural hematoma, was determined to preferentially occur in patients less than or equal to 14 years of age with a high level of statistical significance (p value = 0.0014).

CONCLUSIONS

A classification system for tectorial membrane injuries is proposed based on this data: type 1-retroclival stripping injury (more common in pediatric patients); type 2a-subclival disruption at the basion and type 2b-subclival disruption at the odontoid (both more common in adult patients); and type 3-thinning of the tectorial membrane.

Traumatic Occipitocervical Distraction Injuries in Children: A Systematic Review

BACKGROUND

Occipitocervical distraction injuries (OCDI) in children occur on a wide spectrum of severity, and decisions about treatment suffer from a lack of rigorous guidelines and significant inter-institutional variability. While clear cases of frank atlanto-occipital dislocation (AOD) are treated with surgical stabilization, the approach for less severe cases of OCDI is not standardized. These patients require a careful assessment of both radiographic and clinical criteria, as part of a complex risk-benefit analysis, to establish whether occipitocervical fusion (OCF) is indicated. Here, we performed a systematic review of the literature that describes traumatic OCDI in children < 18 years of age.

SUMMARY

We performed a systematic review, according to PRISMA guidelines, of children < 18 years of age presenting with traumatic etiologies of OCDI. We searched PubMed to identify papers congruent with these criteria. Exclusion criteria included (1) reports on atraumatic causes of OCDI and (2) studies with insufficient clinical and radiographic details on individual patients. We identified 16 reports describing a total of 144 patients treated for pediatric traumatic OCDI. Based on the synthesis of these findings and the collective experience of the authors, we present the demographic, clinical, and radiographic factors that underlie OC instability, which we hope will serve as components of a grading system in the future. We considered various clinical and radiographic findings including: (1) the mechanism of injury, (2) the patient's age, (3) CT/CT angiography of head and neck findings and parameters, (4) MRI findings, and (5) neurological exam, for the purpose of determining the severity of the OCDI and offering treatment guidelines based on the summative risk of underlying OC instability. Key Messages: OCDI is a potentially devastating injury, especially in children. Although missing the diagnosis can have potentially catastrophic consequences, reverting to surgical fixation in less severe cases can subject children to unnecessary operative risk and permanently reduce their range of motion. After reviewing all the available reports of pediatric traumatic OCDI in the neurosurgical literature, we propose an outline of clinical and radiographic factors influencing underlying OC instability that could be incorporated into a grading scale to guide treatment. We hope this study stimulates discussion on the standardization of treatment for pediatric OCDI.

Occipitocervical Dissociation in Three Siblings: A Pediatric Case Report and Review of the Literature

This report includes three cases of occipitocervical (OC) dissociation in three siblings involved in a single, head-on, motor vehicle accident. The oldest sibling, a 9-year-old girl, required surgical fixation. The second sibling, a 6-year-old boy, was treated nonsurgically with a neck brace. The youngest sibling, a 5-year-old boy, sustained a fatal OC dissociation. CT and MRI findings are used to assess the reliability of the currently recommended diagnostic modalities for OC dissociation. The literature review focuses on the diagnosis of OC dissociation via CT measurements and proposed treatment recommendations using CT and MRI classification systems. In the 9-year-old girl, the mean atlanto-occipital joint width, the interspinous ratio, and space available for cord measurements indicated OC dissociation. However, on MRI evaluation, OC dissociation was observed in both living siblings and severe ligamentous injury was noted in the girl. The proposed CT measuring techniques for the diagnosis of OC dissociation were inconsistent in our cases. In the setting of clinically suspected OC dissociation with normal CT measurements, we recommend obtaining a cervical spine MRI to properly assess the extent of ligamentous injury.

Traumatic occipito-cervical dissociation in adults: a Middle Eastern cohort study

The objective of this study is to describe a series of cranio-cervical dissociation victims and evaluate their outcomes as well as discuss the clinical dilemmas we faced in the context of current literature evidence. This is a retrospective cohort study of traumatic occipito-cervical dissociation in five patients (three males and two females) encountered between 2010 and 2016 at a tertiary care facility in the Middle East region. All patients underwent occipito-cervical fusion using screws and rods system with mean postoperative follow-up period of 2.5 years. All patients survived, and four were independently mobile and one wheel chair bound. Most had some degree of neurological sequelae, often due to associated injuries and all complained of limited neck range of motion. Contemporary literature review shows that CT scan with MRI is often the best diagnostic modality. Surgery is usually indicated though rare cases treated conservatively have been reported. The commonest predictor of mortality is missed injury, associated head injury and wide separation between the skull base and C1 on imaging studies.

Posterior occipito cervical decompression with fixation and fusion in Cranio vertebral junction compression

OBJECTIVE

To find out the clinical outcome of posterior decompression with occipitocervical fixation and fusion in patients with Craniovertebral junction instability.

METHODS

Eighty consecutive patients of cranio vertebral junction (CVJ) compression were treated in the department of neurosurgery, Jinnah Postgraduate Medical Centre (JPMC), Karachi over a period of 05 years from 1st January 2012 till 31st August 2016. All patients underwent posterior decompression with occipitocervical fusion (OCF) and fixation. The clinical outcome was assessed by Japanese Orthopedic Association (JOA) score and grading.

RESULTS

Out of 80 patients with CVJ instability, 64 (80%) were due to non traumatic causes, while 16 (20%) were secondary to trauma. All 80 patients(100%) showed post operative relief in pain. Sixty four (80%) patients showed improvement in power post operatively while six (7.5%) had no change, four (5%) showed deterioration and six (7.5%) patients expired. Sixty four (80%) patients had improvement of the JOA scores at last follow-up. According to etiology, the JOA score for patients with trauma improved in 12(75%) patients and 52(81.25%) for non traumatic causes while six patients (7.5%) expired. Fusion was achieved in 64 (80%) patients at last follow-up.

CONCLUSION

Posterior decompression with occipitocervical fusion and fixation is safe and can be recommended in cases of CVJ compression.