Traumatic C1 Fracture
A 30-year-old male was involved in a motor vehicle accident, where he sustained a C1 fracture. The patient was neurologically intact but complaining of neck pain.
The CT scan at the time of presentation showed that the fracture involved the anterior and posterior arch. There was no overhang of C1 on C2 lateral masses. The atlanto-dental interval showed a 2mm displacement, as shown in Figure 1 below.
At the time of presentation, the patient was treated conservatively with a rigid cervical collar.
Three weeks after discharge from the hospital, the patient returned to the clinic with increased and constant severe neck and suboccipital pain (VAS 9).
Images (x-ray and CT) revealed occipito-cervical instability (C1-C2) with increased atlanto-dental interval, significant overhang of C1 lateral mass over C2 and cranial settling, as shown in Figure 2 below.
Figure 1: CT scan images showing craniocervical junction and C1 fracture
Presentation after Treatment with Rigid Cervical Collar
Figure 2: CT scan images showing cranial settling, and C1 displacement
The patient was diagnosed with occipito-cervical instability.
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The patient was placed under GETA, and SSEP/MEP monitoring was established, including hypoglossal EMG nerve monitoring. Proper alignment was confirmed with fluoroscopy and intraoperative CT navigation.
The patient underwent posterior occipito-C2 fusion instrumentation utilizing the occipital condyle screws as cranial fixation points (polyaxial screw rod construct). This technique was described by Uribe et al.1 You can see this in Figure 3, which is immediate post-op.
Figure 3: Immediate post-operative x-ray and CT scan images showing occipital condyle screws and C2 pedicle screws and rod construct.
Figure 4: Cervical lateral, flexion, and extension x-rays demonstrating adequate fusion at 1-year follow-up.
At 1-year follow-up, the patient had clinical improvement (VAS 1), a stable occipital cervical junction, and evidence of solid fusion, as shown in Figure 4 above.
- Uribe JS, Ramos E, Baaj A. Occipital Cervical Stabilization Using Occipital Condyles For Cranial Fixation: Technical Case Report. Neurosurgery 65:E1216-E1217, 2009.
The authors present a case of a patient with significant post-traumatic occipitocervical instability requiring stabilization. There are several options for adequate internal fixation when managing such patients. The use of the occipital condyles for this purpose, as described by Uribe et al, is certainly a reasonable consideration. One must keep in mind the course of the hypoglossal nerves when carrying out occipital condyle screw fixation.