Craniovertebral Junctional Injuries and Management

Abstract

Objective: Craniocervical junction injuries are less common. They are unique in their presentation and need specialized management. The objective was to determine diagnosis initial management and ultimate surgical procedures performed and efficacy of these procedures.
Materials and Methods: A five year study from April 2003 to Oct. 2008 was conducted at department of neurosurgery unit II Lahore general hospital Lahore. A total of fifteen patients were included. All patients with upper cervical trauma with all modes of injuries were included irrespective of their age and sex. All patients were evaluated with routine X-rays cervical spine, anterioposterior, lateral and open mouth views. While dynamic views were advised only in those having osodontoideum. C.T with saggital reconstruction and MRI were performed in all patients to further augment and detect bony and soft tissue details. In all modes of injuries we maintain their airway breathing and circulation.
Clinical Presentation: Out of total fifteen patients mostly were young in their twenties and thirtees, only two patients (13.33%) were below twenty and one patient (6.66%) was above fourty years. The main culprit was road traffic accident in most of patients (thirteen patients 80%) followed by fall in two patients (13.33%) and assault in one patient (6.66%). The odontoid fracture with reductable atlantoaxial instability was appeared to the most common problem in five patients (33.33%). In two patients (13.33%) transverse ligament found to be intact. In two other cases (13.33%) atlas fracture was simultaneously found. Osodontoideum detected in two patients (13.33%) while basilar invagination seen in one patient (6.66%). Irreducable atlantoaxial instability was seen in three patients (20%). Out of fifteen patients, three patients (20%) were neurologically intact, while one patient (6.66%) had complete injury. Eleven patients (73%) had partial injury.
Surgical Procedures: In order to achieve stability, we performed posterior instrumentation and bony fusion in all nine reducible injury patients (60%). Atlanto axial fusion performed in seven patients (46.66%), while in two patients (13.33%) having concomitant C1 injury occipitocervical fusion was done. Initial transoral decompres-sion, prior to posterior fusion was done in all four (26.66%) non reducible injury patients. Transodontoid screw fixation was done in two patients (13.33%) having intact transverse ligament.
Outcome: Overall 07 (46.66%) cases revealed excellent results all recovered without any complication. Four (26.66%) cases had some complication but recovered within 02 weeks and result was labeled as good. Two cases who had neurological deterioration, recovered slowly within 03 months. Recovery was labeled as fair. One patient who suffered neurological deterioration did not recovered and result was labeled as poor.
Complications: One patient (6.66%) died after severe chest infection, although severe chest infection observed in three patients (20%). Mild wound infection and wound dehiscence seen in one patient (6.66%) each. These patients managed conservatively successfully. Neurological deterioration observed in three patients (20%), out of them two patients (13.66%) improved with 3 months.