Occipital condyle syndrome

OBJECTIVE: Review the clinical features of occipital condyle syndrome. BACKGROUND: Occipital condyle syndrome consists of unilateral occipital region pain associated with ipsilateral 12th cranial nerve paresis. It is typically due to metastasis to the skull base and is underdiagnosed. DESIGN: We report a retrospective case series of 11 patients (8 men, 3 women), aged 32 to 72 years. RESULTS: Eleven cases of occipital condyle syndrome were identified. All patients complained of severe occipital region pain. In addition, 2 patients complained of ipsilateral ear or mastoid pain, 2 noted associated vertex pain, and 2 had frontal region pain. Six of the 11 cases involved the right side. In all patients, the occipital pain was ipsilateral to the 12th nerve paresis. All patients were mildly dysarthric, and 3 had dysphagia. In 7 of the 11 patients, occipital region pain preceded the hypoglossal paresis by several days to 10 weeks. On examination, tenderness to palpation of the occipital region was noted in all patients. All 11 patients had unilateral hypoglossal paresis. Skull films were abnormal in 2 of 5 patients for whom they were obtained, and tomograms were abnormal in 1 of 2 patients. High-quality computed tomography, bone scanning, and magnetic resonance imaging were abnormal in all cases in which they were performed. Nine patients had a known primary malignancy. The most common malignancies were breast cancer in women (2 of 3) and prostate cancer in men (4 of 8). In 2 patients, occipital condyle syndrome was the initial manifestation of a metastatic lesion. Radiation therapy was the treatment of choice for the occipital region pain. CONCLUSION: Occipital condyle syndrome is a rare, but stereotypic syndrome. Early detection has important therapeutic implications. Evaluation of the craniovertebral junction with special attention to the occipital condyles should be a routine part of all brain and cervical spine radiologic examinations, and the possibility of occipital condyle syndrome, particularly when patients have persistent occipital pain and a history of cancer, should be considered.     

Evaluation and management of acute cervical spine trauma

The evaluation and management of cervical spine injuries is a core component of the practice of emergency medicine. This article focuses on evaluation and management of blunt cervical spine trauma by the emergency physician. Pertinent anatomy of the cervical spine and specific cervical spine fractures are discussed, with an emphasis on unstable injuries and associated spinal cord pathology. The association of vertebral artery injury with cervical spine fracture is addressed, followed by a review of the most recent literature on prehospital care. Initial considerations in the emergency department, including cervical spine stabilization and airway management, are reviewed. The most current recommendations for cervical spine imaging with regard to indications and modalities are covered. Finally, emergency department management and disposition of patients with spinal cord injuries are reviewed.     

The unstable occult cervical spine fracture: a review.

The initial evaluation and management of cervical spine injuries is of critical importance because of the impact of early treatment and management on the patient's eventual outcome. The devastation and cost of missing even one unstable cervical spine fracture is tremendous. The existence of patients with an unsuspected cervical spine fracture who have few, if any, symptoms and/or signs of an injury to the cervical spine is a valid concern and a dilemma for the practicing physician. Thus the principle of the occult unstable cervical spine fracture, which has been established as the standard of care, has major significance and implications. Recently, however, the concept of the occult cervical spine fracture has been challenged. Does the entity of an occult cervical spine fracture exist? If so, how should this affect our indications for obtaining cervical spine radiographs? The author presents the case of an unstable occult cervical spine fracture and a review of the literature.     

Spinal fractures complicating ankylosing spondylitis

Individuals with ankylosing spondylitis (AS) are at increased risk for developing fractures of the spine, especially in the cervical region. This tendency is related to the ossification of spinal ligaments and osteopenic changes in the spinal vertebrae. We reviewed our clinical experience of SCI occurring due to AS, and the literature regarding the natural history of these fractures. A significant number of individuals are not aware of their increased risk for spinal fracture and sustain spinal fractures without realizing it. Difficulties in diagnosis and inappropriate management of spinal fractures in these individuals have often resulted in severe neurologic sequelae and a mortality rate approximately twice that observed with similar fractures in a normal spine. The need for better patient education emphasizing the significance of even minor trauma, and a thorough evaluation of AS patients with a history of trauma is stressed.     

Spine fractures in ankylosing spondylitis

Patients with ankylosing spondylitis are susceptible to spine fracture, usually in the cervical spine. Less frequently, the thoracic and lumbar spine is affected. The fracture line may involve anterior and posterior elements. Frequently, it extends through the entire width of the spine. As a result the fracture tends to be unstable and may cause neurologic damage. Prompt immobilization and reduction of the dislocated spine followed by stabilization may prevent neurologic damage. We report a 45-year-old man who fell and sustained a fracture dislocation of L2 vertebra. The patient was operated and stabilized with Harrington rods. A deep wound infection developed, which did not respond to antibiotic therapy and led to removal of the rods. In spite of bed immobilization with a body jacket the fracture remained unstable and dislocated. As a result the patient sustained severe neurologic damage. Many fractures in patients with ankylosing spondylitis occur following minor trauma. We feel that a very important aspect of ankylosing spondylitis management is prevention of these fractures. Alerting patients of their spine fragility and teaching then how to evade situations leading to spinal trauma may help in avoiding this situation.     

A pitfall in neck pain: occult odontoid fracture

Type III odontoid fractures of the axis are the second most common injuries of the cervical spine. Most of these result from motor vehicle accidents and falls. Occult odontoid fractures without preceding trauma are rarely reported in the literature and may be difficult to diagnose. We report the case of a healthy patient who had no history of trauma, but sustained sudden pain in the neck and guarding during head movement after sleep. Initial radiographs of the cervical spine including open-mouth, anterior-posterior, and lateral views did not reveal any obvious fractures. Type III odontoid fracture was uneventfully diagnosed via high-quality three-dimensional reconstruction of computed tomography. The possible mechanism was hyperextension of the neck during the change from the supine to the sitting position. Type III odontoid fractures can occur in the absence of major trauma. The usefulness of computed tomography is emphasized and the literature is also reviewed.     

Undetected hangman's fracture in a patient referred for physical therapy for the treatment of neck pain following trauma

BACKGROUND AND PURPOSE: This case report describes a patient referred for physical therapy treatment of neck pain who had an underlying hangman's fracture that precluded physical therapy intervention. CASE DESCRIPTION: This case involved a 61-year-old man who had a sudden onset of neck pain after a motor vehicle accident 8 weeks before his initial physical therapy visit. Conventional radiographs of his cervical spine taken on the day of the accident did not reveal any abnormalities. Based on the findings at his initial physical therapy visit, the physical therapist ordered conventional radiographs of the cervical spine to rule out the possibility of an undetected fracture. OUTCOMES: The radiographs revealed bilateral C2 pars interarticularis defects consistent with a hangman's fracture. The patient was referred to a neurosurgeon for immediate review. Based on a normal neurological examination, a relatively low level of pain, and the results of radiographic flexion and extension views of the cervical spine (which revealed no evidence of instability), the neurosurgeon recommended that the patient continue with nonsurgical management. DISCUSSION: In patients with neck pain caused by trauma, physical therapists should be alert for the presence of cervical spine fractures. Even if the initial radiographs are negative for a fracture, additional diagnostic imaging may be necessary for a small number of patients, because they may have undetected injuries that would necessitate medical referral and preclude physical therapy intervention.     

Spinal Cord Injury With a Narrow Spinal Canal: Utilizing Torg’s Ratio Method of Analyzing Cervical Spine Radiographs

A 65-year-old inebriated mancrashed his car and presented with spinal shock and neurogenic shock from a cervical spinal cord injury without cervical spine fracture or dislocation. The lateral cervical spine radiography was initially read as normal, except for degenerative disk disease; however, Torg’s ratio method of analyzing cervical spinal canal sagittal width indicated the spinal canal was congenitally narrow. Magnetic resonance imaging confirmed this and showed bulging and herniation of multiple invertebral disks between C2 and C7. This case illustrates the value of using Torg’s ratio method of analyzing lateral cervical spine radiographs. Although Torg’s method has not been prospectively validated, it may be useful to identify patients at risk for cervical spinal cord injuries without fractures or dislocations. An abnormal Torg’s ratio may be the only clue to the fact that the patient is at higher risk of spinal cord injury when the patient’s history or examination is questionable because of head injury, drug intoxication, or therapeutic sedation and paralysis.     

Fractures of the axis: a review of pediatric,adult, and geriatric injuries

Fractures of the second cervical vertebra (C2, axis) are common in adult spine surgery. Those fractures occurring in younger adult patients are often associated with high-energy mechanism trauma, resulting in a “Hangman’s Fracture.” Management of these fractures is often successful with nonoperative means, though surgery may be needed in those fractures with greater displacement and injury to the C2-C3 disc. Older patients are more likely to sustain fractures of the odontoid process. The evidence supporting surgical management of these fractures is evolving, as there may be a mortality benefit to surgery. Regardless of treatment, longer-term mortality rates are high in this patient population, which should be discussed with the patient and family at the time of injury. Pediatric patients may suffer fractures of the axis, though differentiation of normal and pathologic findings is necessary and more difficult with the skeletally immature spine.     

Spondylolisthesis on bilateral pedicle stress fracture in the lumbar spine: a case study

We report the clinical case of a 54-year-old woman presenting radicular low back pain on the right side of L4 associated to spondylolisthesis on L4-L5, without any notion of trauma or spine surgery. Furthermore this patient is regularly seen for benign rheumatoid polyarthritis complicated by steroid-induced osteoporosis. A preventive treatment was implanted with good results on pain improvement and functional capacities. For pedicle fractures the literature review reports several different etiologies: spontaneous fractures, hereditary fractures or stress-related fractures. There was a discussion on the various treatments available and in this case of spondylolisthesis on pedicle fracture a conservative treatment was implemented similar to the one for isthmic spondylolisthesis. It yielded satisfying results.     

Occipital neuralgia as an isolated symptom of C2 myelitis

Occipital neuralgia has been attributed to lesions at a peripheral nerve or radicular level. On rare occasions, it has been associated with cervical cord lesions. We report a 55-year-old woman who presented with an isolated occipital neuralgia and was found on further investigation to have a restricted, isolated myelitis at C2 level. This represents the second reported case of occipital neuralgia due to C2 myelitis and should alert clinicians to considering cervical MRI in patients with occipital neuralgia.     

Brown–sequard syndrome due to isolated blunt trauma

Blunt trauma without associated fracture or ligamentous injury is a rare cause of Brown–Sequard syndrome. We report a case of Brown–Sequard syndrome after a direct blow to the cervical spine that did not cause injury to adjacent bone or ligaments. Characteristic neurologic findings, including a unilateral hemiparesis with associated contralateral sensory findings, were noted at the time of presentation. High-dose steroids were instituted after recognition of the patient’s injury, and magnetic resonance imaging of the cervical spine revealed a unilateral cord contusion with no associated fractures. After 1 month, the patient had recovered much of his function and was able to ambulate unassisted.     

Presentation and management of traumatic occipital spur fracture

Occipital spur is an abnormal bony outgrowth of the external occipital protuberance (EOP). We describe an interesting and previously unreported case of fracture of an occipital spur following trauma. Our 20-year-old male patient was treated in the emergency department (ED) and discharged home without complication. Neurosurgical consultation was obtained but is not requisite for these injuries. Greater awareness of this unique presentation may help to expedite future emergency department treatment.     

Fracture of the occipital condyle: the forgotten part of the neck

A case of occipital condylar fracture in a multiply injured and unconscious motorcyclist is reported. This injury was clinically unsuspected but found on the lowest cuts of head computed tomography. It is shown that this site is often inadequately imaged when scanning the head and neck in victims of trauma. The Anderson and Montesano classification of occipital condylar fracture is described. It is noted that types 1 and 2 are stable injuries but type 3 is potentially unstable. A retrospective analysis of 30 head computed tomography scans in trauma cases revealed that in only 16 were the occipital condyles adequately imaged. It is emphasised that vigilance is required to detect fractures of the occipital condyle and that it should be standard practice to include this area when performing computed tomography of the head in trauma victims.     

Clinical-radiologic heterogeneity of occipital neuralgiform pain as multiple sclerosis relapse

Occipital neuralgia may be related to traumatic, compressive, or inflammatory injury to the occipital nerve or C2 radicular level and cervical spinal cord lesions. We report a series of 3 patients with definite relapsing-remitting multiple sclerosis (MS) who experienced sudden occipital neuralgiform pain with or without diminished sensation in the cervical region and associated with magnetic resonance imaging (MRI) evidence of a new active or new T2-weighted demyelinating C2 cervical lesion. We suggest that sudden paroxysmal occipital pain may signal relapse of MS and cervical MRI with gadolinium should be considered; these patients show good clinical response to high-dose intravenous corticosteroids.     

Cervical spine injuries in blunt trauma patients requiring emergent endotracheal intubation.

Airway management in the blunt trauma patient is complicated by the potential for causing or exacerbating an injury to the cervical cord if an unstable cervical fracture is present. The records of 987 blunt trauma patients who required emergent endotracheal intubation over a 5-year period were retrospectively reviewed to determine the incidence and type of cervical spine injury and the incidence of injury based on airway management. Sixty of the patients (6.1%) had a cervical fracture; 53 were potentially unstable injuries by radiographic criteria. Twenty patients had neurologic deficits prior to intubation. Twenty-six patients with unstable injuries were intubated orally, 25 nasally, and two by cricothyrotomy. One patient developed a neurologic deficit after nasotracheal intubation. Because of a possible selection bias in which severely injured patients were preferentially referred to this trauma center, the true incidence of cervical spine injuries may be lower than the 6.1% we found. The authors conclude that the incidence of serious cervical spine injury in a very severely injured population of blunt trauma patients is relatively low, and that commonly used methods of precautionary airway management rarely lead to neurologic deterioration.     

Occipital neuralgia evoked by facial herpes zoster infection

Occipital neuralgia is a pain syndrome which may usually be induced by spasms of the cervical muscles or trauma to the greater or lesser occipital nerves. We report a patient with occipital neuralgia followed by facial herpes lesion. A 74-year-old male experienced sudden-onset severe headache in the occipital area. The pain was localized to the distribution of the right side of the greater occipital nerve, and palpation of the right greater occipital nerve reproduces the pain. He was diagnosed with occipital neuralgia according to ICHD-II criteria. A few days later, the occipital pain was followed by reddening of the skin and the appearance, of varying size, of vesicles on the right side of his face (the maxillary nerve and the mandibular nerve region). This was diagnosed as herpes zoster. This case represents a combination of facial herpes lesions and pain in the C2 and C3 regions. The pain syndromes can be confusing, and the classic herpes zoster infection should be considered even when no skin lesions are established.     

Subaxial cervical spine trauma

Subaxial cervical spine trauma is common and an often missed diagnosis. Accurate and efficient diagnosis and management is necessary to avoid devastating complications such as spinal cord injury. Several classification schemes have been devised to help categorize fractures of the subaxial spine and define treatment algorithms. The Subaxial Cervical Spine Injury Classification System (SLIC) is widely used and evaluates not only fracture morphology but also considers ligamentous injury and neurological status in surgical decision making. However, interobserver reliability is poor, which proves to be the defining pitfall of this tool. More modern classification systems have been developed, which aim to improve the interobserver reliability; however, further large-scale studies are needed for more definitive evaluation. Overall, treatment of subaxial cervical spine injuries should include a protocol with initial trauma evaluation, leading to expedient operative intervention if indicated. Surgical techniques include both anterior and posterior approaches to the cervical spine depending on fracture classification.     

Injuries significantly associated with thoracic spine fractures: A case–control study

Objective: To determine injuries significantly associated with traumatic thoracic spine (T‐spine) fractures Methods: This was a case–control study undertaken in an adult trauma centre. Cases were patients admitted with a traumatic T‐spine fracture between January 1999 and August 2007. Each case had two controls matched for sex, age (±5 years) and injury severity classification (major/minor). Data were collected from patient medical records and the trauma service database. Multivariate logistic regression was used to determine injuries significantly associated with T‐spine fracture. Results: Two hundred and sixty‐one cases and 512 controls were enrolled. In both groups, mean age was 41 years and 70% of patients were male. Univariate analysis revealed a range of injuries that were significantly more common among the cases, especially cervical and lumbar spine injuries, sternal/scapular/clavicular/rib fractures, pneumo/haemothorax and pulmonary contusions (P < 0.01). Skull fractures and lower limb injuries were significantly more common among the controls (P < 0.01). Logistic regression analysis revealed that only cervical and lumbar spine injuries and rib fractures were positively associated with T‐spine fracture (P < 0.001). Skull fractures and lower limb injuries were negatively associated with T‐spine injury (P < 0.001). Conclusion: Cervical and lumbar spine injuries and rib fractures are significantly associated with T‐spine fracture. The presence of these injuries should raise suspicion of concomitant T‐spine injury.     

Management of Osteoporosis and Spinal Fractures: Contemporary Guidelines and Evolving Paradigms

Physicians involved in treating spine fractures secondary to osteopenia and osteoporosis should know the pathogenesis and current guidelines on managing the underlying diminished bone mineral density, as worldwide fracture prevention campaigns are trailing behind in meeting their goals. This is a narrative review exploring the various imaging and laboratory tests used to diagnose osteoporotic fractures and a comprehensive compilation of contemporary medical and surgical management. We have incorporated salient recommendations from the Endocrine Society, the American Association of Clinical Endocrinology (AACE), and the American Society for Bone and Mineral Research (ASBMR). The use of modern scoring systems such as Fracture Risk Assessment Tool (FRAX®) for evaluating fracture risk in osteoporosis with a 10-year probability of hip fracture and major fractures in the spine, forearm, hip, or shoulder is highlighted. This osteoporosis risk assessment tool can be easily incorporated into the preoperative bone health optimization strategies, especially before elective spine surgery in osteoporotic patients. The role of primary surgical intervention for vertebral compression fracture and secondary fracture prevention with pharmacological therapy is described, with randomized clinical trial-based wisdom on its timing and dosage, drug holiday, adverse effects, and relevant evidence-based literature. We also aim to present an evidence-based clinical management algorithm for treating osteoporotic vertebral body compression fractures, tumor-induced osteoporosis, or hardware stabilization in elderly trauma patients in the setting of their impaired bone health. The recent guidelines and recommendations on surgical intervention by various medical societies are covered, along with outcome studies that reveal the efficacy of cement augmentation of vertebral compression fractures via vertebroplasty and balloon kyphoplasty versus conservative medical management in the elderly population.