Fracture of the occipital condyle: case report and review of the literature

Fracture of the occipital condyle is a rare injury. We report a patient with an occipital condyle fracture who presented with negative plain films and a cranial nerve palsy. Diagnosis was established with high-resolution computed tomography. This fracture should be considered in a trauma patient with neck pain, negative plain cervical spine radiographs, and a cranial nerve palsy.     

Unusual case of depressed fracture of the posterior cranial fossa associated with the syndrome of acute central cervical spinal cord injury

Linear fractures through the occipital bone are common, whereas depressed fractures in the posterior cranial fossa are rare because the occipital bone is protected by the surrounding thick muscles. The authors describe an unusual case of depressed fracture localized in the posterior cranial fossa associated with the syndrome of acute central cervical spinal cord injury. A 50-year-old female struck her face against the table and fell backward, while drunk, resulting in the bruise over the occipital region. Three days after injury she was transferred to our hospital because of progressive disturbance of consciousness, brain stem dysfunction and tetraplegia. Neurological examination on admission showed that she was drowsy, had tetraplegia and could not speak. However, she could obey commands only by moving her eyes and the ocular movements were normal in all directions except for horizontal nystagmus. Plain skull x-ray revealed a conspicuously depressed fracture in the posterior cranial fossa, but cervical spine x-ray showed neither fracture nor dislocation. Immediately suboccipital craniectomy was done and there were a thin subdural hematoma on the cerebellar surface, cerebellar contusion, and subarachnoid hemorrhage around the cisterna magna. Soon after operation impaired consciousness and paraplegia were improved, but recovery of both arms was delayed. Five months after injury, she still had left IX, X and XI nerve paresis, bilateral arm weakness, dysarthria, swallowing disturbance and bilateral sensory disturbance below C4 level. These findings indicated that she had sustained brain stem and cerebellar compression by the depressed fracture and also had suffered an acute central cervical spinal cord injury.     

Traumatic occipital condyle fracture, multiple cranial nerve palsies, and torticollis: a case report and review of the literature.

A 32-year-old man sustained a unique combination of injuries: an occipital condyle fracture, left tenth to twelfth cranial nerve palsies, and chronic torticollis secondary to atlantoaxial rotatory fixation. Computed tomography (CT) demonstrated a triangular fragment of bone in the posterior fossa, and three-dimensional CT-reconstructed images confirmed the bone fragment to be from the occipital condyle. The patient made a good recovery with conservative management. Few occipital condyle fractures have been reported, and they should be suspected in patients who sustain painful neck and lower cranial nerve palsy following trauma. CT and plain films are complementary in confirming the diagnosis.     

Catastrophic football injuries: 1977-1998

The primary purpose of this study was to investigate the occurrence of catastrophic football head and spine injuries, in an attempt to reduce their frequency. We analyzed epidemiological and medical data from 1977 through 1998. Catastrophic football injuries are defined as football injuries that result in death, brain or spinal cord injury, or cranial or spinal fracture. All studied cord injuries involved the cervical region. During the period covered by this study, 118 athletes died as a direct result of participation in the skills of football, 200 football players received a permanent cervical cord injury, and 66 sustained a permanent cerebral injury. Most cervical injuries occurred to defensive players during the act of tackling. The axial loading mechanism of spinal cord injury was identified in 27% of tackling injuries. To further reduce catastrophic injuries, players must stop tackling with the head down and using the head as a battering ram; instead, players should use the shoulder for blocking and tackling. Other recommendations for reducing catastrophic injuries are presented.     

The Beirut terrorist bombing

The Beirut terrorist bombing on October 23, 1983, caused 234 immediate deaths and injured at least 112 survivors. Military medical records were available for each casualty; postmortem examination reports were available for each immediate fatality. This represented a unique opportunity to assess type, incidence, treatment, and outcome of neurological injuries suffered in a mass casualty terrorist bombing situation. Three categories of neurological injuries are described: head injuries, spine and spinal cord injuries, and peripheral nerve injuries. The following types and numbers of injuries occurred among the 112 immediate survivors of the explosion: 37 head injuries--28 concussions, 20 scalp lacerations, 13 skull fractures, 6 facial bone fractures, 4 cerebral contusions, 5 dural lacerations, 2 cerebrospinal fluid fistulas, and 2 intracerebral hematomas; 2 spine or spinal cord injuries--1 cervical and 1 thoracolumbar spine fracture associated with neurological deficit; and 9 peripheral nerve injuries--1 facial nerve palsy, 2 brachial plexus palsies, 1 median and 1 radial nerve palsy, and 4 peroneal nerve palsies. Among 234 immediate fatalities, the types and numbers of neurological injuries were: 167 head injuries--93 scalp lacerations, 85 skull fractures, and 24 facial bone fractures; and 22 spine and spinal cord injuries--15 cervical and 7 thoracolumbar fractures. Seven of the 112 immediate survivors died; 4 of these deaths were related to severe head injuries. The treatment and outcome of survivors with neurological injuries is briefly described. One-third of the immediate survivors who suffered either a scalp laceration or a concussion had a concomitant skull fracture.(ABSTRACT TRUNCATED AT 250 WORDS)     

Cranial and neck nerve injuries following carotid endarterectomy intervention. Review of the literature

The aim of the study was to establish the operative techniques and findings that can influence the reported incidence of cranial and cervical nerve injuries. Eight main studies comprising 1,616 carotid endarterectomies and published over the period from 1990 to October 2000 were reviewed. There were no statistically significant differences between neck incision (vertical or transverse) and number of injuries. In one study, multiple deficits were observed most frequently in patients treated by the eversion technique (P = 0.2). Additional prospective trials are needed in large numbers of patients to assess the incidence of cranial and cervical nerve injuries. Most injuries are transient and involve the vagus and hypoglossal nerves. A number of factors related to the operation, such as general anaesthesia, eversion technique and the surgeon's experience, may influence the incidence of such injuries. Repeat endarterectomy is associated with a high incidence of cranial and/or cervical nerve injuries. This is extremely important for establishing the real advantage of endovascular angioplasty or stenting of the carotid artery.     

Collet-Sicard syndrome resulting from closed head injury: case report

A 67-year-old man developed paralysis of the right ninth, tenth, eleventh, and twelfth cranial nerves (Collet-Sicard syndrome) after sustaining a closed head injury. Plain x-ray films of the skull revealed two linear fractures of the occipital bone (one of them probably traversing through the right occipital condyle) and a prominent soft-tissue shadow in the region of the nasopharynx, suggestive of a skull base fracture. The patient was managed conservatively. This is the only case of unilateral multiple caudal cranial nerve palsies (IX through XII), seen by us over a 20-year period, from among more than 5,000 moderate to significant head injuries.     

Cranial and cervical nerve injuries after repeat carotid endarterectomy

BACKGROUND AND PURPOSE: The incidence of cranial and/or cervical nerve injuries after primary carotid endarterectomy (CEA) ranges from 3% to 48%; however, the clinical outcome of these injuries after repeat CEA has not been thoroughly analyzed in the English-language medical literature. This prospective study analyzes the incidence and outcome of cranial nerve injuries after repeat CEA. PATIENTS AND METHODS: This study includes 89 consecutive patients who had repeat CEAs. Preoperative and postoperative cranial nerve evaluations were performed, including clinical examinations (neurologic) and direct laryngoscopy. Patients with vagal or glossopharyngeal nerve injuries also underwent comprehensive speech evaluations, video stroboscopy, fluoroscopy, and methylene blue testing for aspiration. Patients with postoperative cranial nerve injuries were followed up for a long time to assess their recovery. RESULTS: Twenty-five cranial and/or cervical nerve injuries were identified in 19 patients (21%). They included 8 hypoglossal nerves (9%), 11 vagal nerves or branches (12%) (6 recurrent laryngeal nerves [7%], 3 superior laryngeal nerves [3%], and 2 complex vagal nerves [2%]), 3 marginal mandibular nerves (3%), 2 greater auricular nerves (2%), and 1 glossopharyngeal nerve (1%). Twenty-two (88%) of these injuries were transient with a complete healing time ranging from 2 weeks to 28 months (18 of 22 injuries healed within 12 months). The remaining three injuries (12%) were permanent (1 recurrent laryngeal nerve, 1 glossopharyngeal nerve, and 1 complex vagal nerve injury). The recurrent laryngeal nerve injury had a longer healing time than the other cranial nerve injuries. CONCLUSIONS: Repeat CEA is associated with a high incidence of cranial and/or cervical nerve injuries, most of which are transient. However, some of these have a long healing time, and a few can be permanent with significant disability.     

无骨折、脱位的颈脊髓损伤

通过对176例外伤性颈脊髓损伤中24例无骨折、脱位病例的回顾分析,认为MRI对不伴骨折或脱位的颈髓损伤的诊断是目前较可靠手段。提出这些病例可分为脊髓压迫型和无脊髓压迫型。治疗上前者以前路减压为佳,而脊髓内外联合减压术对阻止后者神经损害的进展有帮助。早期诊断,尽早制动,牵引乃至手术十分必要。     

The infant whiplash-shake injury syndrome: a clinical and pathological study

The cases of 13 infants (median age, 3 months) who sustained nonaccidental trauma were reviewed. All presented with profound neurological impairment, seizures, retinal hemorrhages, and intracranial subarachnoid and/or subdural hemorrhages. Of 8 infants who died, autopsy was performed on 6. No patient had a skull fracture, and only one had an extracalvarial contusion. Five of the 6 patients on whom autopsy was performed had injuries at the cervicomedullary junction consisting of sub- or epidural hematomas of the cervical spinal cord with proximal spinal cord contusions. The authors conclude that direct cranial trauma is not an essential element of the injury mechanism in young patients who sustain severe whiplash-shake injuries. In addition to the classic injuries reported to occur with the shaken-baby syndrome, hemorrhages and contusions of the high cervical spinal cord may contribute to morbidity and mortality.     

Bilateral multiple cervical root avulsions without skeletal or ligamentous damage resulting from blast injury: case report

OBJECTIVE AND IMPORTANCE: We describe a unique case of multiple bilateral cervical root injuries without ligamentous or bony injury secondary to a sandblast accident. CLINICAL PRESENTATION: A 19-year-old man sustained a sandblast injury to his face, neck, chest, and upper extremities, with immediate loss of motor and sensory function occurring in both of his upper extremities. Cervical spine x-rays, computed tomography, and magnetic resonance imaging demonstrated no fracture, soft tissue abnormality, or malalignment. The restriction of deficits to the patient's upper extremities suggested a central cervical spinal cord injury, bilateral brachial injuries, or a conversion disorder. INTERVENTION: Cervical computed tomographic myelography revealed multiple bilateral nerve root injuries. CONCLUSION: This case report is unique in the literature in that it describes a patient with multiple cervical nerve root injuries secondary to sandblast injury without ligamentous or bony injury. Although magnetic resonance imaging remains the diagnostic modality of choice in patients with acute spinal cord injury, it is deficient in demonstrating cervical root injury in the acute setting. In this setting, computed tomographic myelography is superior.     

Three-dimensional computed tomography in evaluation of occipital condyle fracture

Fracture of the occipital condyle is a rare sequela of craniocervical trauma. The diagnosis can be suspected in an injured patient with disproportionate torticollis, uncertain evidence of subluxation, and lower cranial nerve symptoms. Standard radiographic diagnosis of this fracture is difficult owing to its superimposition on other bony structures. Film tomography or computed tomography (CT) is usually required to identify the fracture. We report a case of occipital condyle fracture initially masked by atlantoaxial subluxation, but then best demonstrated by three-dimensional CT.     

Jefferson fracture resulting in Collet-Sicard syndrome

STUDY DESIGN: A case report and review of the literature. OBJECTIVE: To increase awareness of and add to the spectrum of injury that can result from Jefferson fractures, to suggest a possible mechanism of injury, and to give a brief review of pertinent facts regarding C1 burst fractures and the Collet-Sicard Syndrome. SUMMARY OF BACKGROUND DATA: To the author's knowledge, this is the first reported case of a Jefferson fracture resulting in Collet-Sicard Syndrome. It represents only the second reported case of cranial nerve palsy caused by Jefferson fracture. METHODS: A 56-year-old man sustained a C1 burst fracture in a rollover motor vehicle accident. Repeated neurologic examinations over the ensuing days revealed lesions of cranial nerves IX, X, XI, and XII on the left side. RESULTS: Two weeks of traction, 10 weeks in a halo vest, and 2 weeks in a cervical collar resulted in adequate fracture healing and almost complete resolution of the patient's neurologic symptoms. CONCLUSION: Although this is the first reported case of Collet-Sicard Syndrome caused by Jefferson fracture, the authors' review of the literature suggests that cranial nerve injuries may go unrecognized in some patients with C1 burst fractures. The importance of a thorough neurologic examination, including examination of the cranial nerves, in all cases of cervical spine injury cannot be overemphasized.     

Abducens nerve palsy as a rare complication of spinal surgery: a case report

We describe a case of diplopia due to abducens nerve palsy after upper cervical spinal surgery. A 22-year-old woman presented with a chief complaint of numbness and weakness in her left hand. A spinal cord tumor was detected at the C1/2 level. These complaints disappeared after resection of the spinal cord tumor; however, she presented with diplopia due to abducens nerve palsy 3 days after surgery. Brain computed tomography and magnetic resonance imaging revealed no abnormalities. Within 1 month there was complete spontaneous resolution of the abducens nerve dysfunction. It is important for spinal surgeons to be aware of cranial nerve palsy as a potential complication of cervical spinal surgery.     

下颈椎损伤改良Moore分类的临床应用研究

目的：探讨改良Moore分类法在下颈椎损伤中的临床应用。方法：2006年8月至2010年3月收治下颈椎损伤患者200例,男165例,女35例;年龄19-88岁,平均52岁。应用下颈椎损伤改良Moore分类全面地描述下颈椎损伤的状态,颈椎损伤严重程度（稳定性）量化评分与有否神经症状表现相结合,根据骨折类型和稳定性、脊髓或神经根受压损伤情况、韧带损伤后的稳定程度及其他参考因素进行分类诊治,选择治疗方法。其中伴有脊髓神经损伤者130例（ASIA评分：A级6例,B级13例,C级43例,D级68例）,不伴有脊髓神经损伤者70例。对伴有脊髓神经损伤的下颈椎损伤患者,根据ASIA评分进行疗效评定;对不伴有脊髓神经损伤的患者,根据影像学检查对颈椎的序列和高度进行观察。结果：前、左、右侧和后柱均损伤35例;前柱损伤33例;前、后柱均损伤90例;前、左侧和后柱均损伤5例;前、右侧和后柱均损伤3例;前、左侧和右侧柱均损伤3例;前、右侧柱损伤2例;前、左侧柱损伤5例;后柱损伤12例;左侧柱损伤7例;右侧柱损伤5例。200例患者中手术治疗98例,非手术治疗102例（其中可以手术而患者家属要求非手术治疗39例）。完全性脊髓损伤患者中3例行手术后脊髓功能无恢复迹象,ASIA分级无变化,但其肢体麻木、疼痛等症状有不同程度的缓解,另3例未手术患者脊髓功能及肢体症状均无变化。不完全性脊髓损伤患者手术后脊髓功能均有一定程度恢复,ASIA评分平均提高1．2级。未手术的不完全性脊髓损伤患者非手术治疗后ASIA评分平均提高0.3级。不伴有脊髓神经损伤者手术后经影像学检查显示均恢复了颈椎的正常序列和高度。结论：根据改良Moore分类法,稳定性量化评分值大于等于4分有下颈椎不稳可能,需要手术治疗,分值越大,手术指征越明显,若伴有脊髓或神经根受压损伤表现者则有绝对手术指征。稳定性量化评分为3分且伴有脊髓或神经根受压损伤表现者一般也有手术指征。稳定性量化评分为3分不伴有脊髓或神经根受压损伤表现者或3分以下者均不需要手术治疗。应用改良Moore分类法有利于下颈椎损伤患者的临床规范化、标准化诊治,以获得较满意的疗效。     

Disc herniation in cervical fracture subluxation

Previous reports of computed tomographic scan with contrast myelography in cervical spinal cord injury have shown a rate of disc herniation of less than 5%. We hypothesized that injuries associated with forces adequate to cause bone or ligamentous injury in the region of the disc space could be associated with higher and more significant rates of disc herniation. Thirty-seven consecutive traumatic midcervical fracture subluxations were reviewed. Fracture subluxation was defined by fracture of the facet joints, pedicles, or vertebral bodies or more than 3.5 mm subluxation from C2-C3 to C7-T1. Reduction was achieved in 97% and was not associated with neurological deterioration. On the basis of plain films, tomograms, and plain computed tomographic scans, the injuries were classified as flexion dislocation, flexion compression, compression burst, or extension injuries. Twenty-five computed tomographic scans with contrast myelograms and one magnetic resonance imaging scan were obtained. All patients with partial neurological deficits were studied. A herniated disc was defined as that which deformed the thecal sac and/or nerve roots. Retrospectively, a neuroradiologist reviewed the studies for the presence of herniated disc. Disc herniation was seen at the level of injury in 9 (35%) patients and not seen in other patients. Forty-seven percent of the patients with partial deficits had herniated discs. Herniated disc was seen most frequently in flexion dislocation and flexion compression injuries. Three patients (20%) with partial deficits underwent discectomy. Patients with partial spinal cord injury and discectomy, on average, improved more than other patients with partial spinal cord injury.(ABSTRACT TRUNCATED AT 250 WORDS)     

Imaging diagnosis of cervical spine and spinal cord injuries in children

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Blunt craniocervical artery injury in cervical spine lesions: the value of CT angiography

Objective  

The awareness of traumatic craniocervical artery injuries has increased over the last years, and the detection rate varies in published trauma series. These injuries are often associated with cervical spinal and cranial trauma. The purpose of this prospective study was to determine the frequency and injury characteristics of blunt traumatic cervical artery injuries in patients suffering from cervical spine injuries by using a standardized CT angiography (CTA) protocol of the craniocervical vessels.     

Cranial nerve injuries following carotid endarterectomy: an analysis of 336 procedures

Cranial nerve injuries may result from carotid endarterectomy. From January 1984 to December 1987, a total of 336 carotid endarterectomies were performed at University Hospitals of Cleveland and Cleveland Veterans Administration Hospital. Forty-five cranial nerve injuries were documented (13.5%). Twenty patients (6%) had documented unilateral vocal cord paralysis, 16 (4.8%) had hypoglossal injuries, 8 (2.4%) had facial nerve paresis, and 1 (0.3%) had an injury to the spinal accessory nerve. Although most injuries were due to either retraction or edema of cranial nerves, long-term follow-up regarding recovery of function is very important. We feel that proper clinical evaluation of these patients should be routinely done preoperatively in order to document possible preexisting cranial nerve deficits. Postoperatively, if symptoms of possible cranial nerve abnormalities occur, these patients should have a thorough head and neck evaluation in order to identify possible lesions and institute further treatment to improve their quality of life.