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Combined fractures of the atlas and axis are rare, with only four cases reported in the English literature. Combined fractures occur most frequently in the elderly. Computerized axial tomography and other special techniques are required for adequate visualization of these complex fractures.
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Primary radiological diagnostics of cervical spine injuries is difficult. It can be improved by making observations on the signs which indicate a fracture, such as alterations in prevertebral soft tissue structures. Several authors have given different suggestions for normal values of prevertebral soft tissue width. It is influenced by the level of the measurement, the posture of the spine, and the patient's age. The soft tissue changes have been stated to often occur with injuries of the anterior parts of the cervical spine, but also with severe injuries in the upper and posterior parts. However, different authors have reported considerably varying figures of incidence of prevertebral soft tissue widening. The article will deal with these matters; it will be based on a material of 165 patients with cervical spine injury, a series of 70 noninjury patients, and the flexion-extension radiograms of the latter group.
The authors describe a systematic approach to the radiographic evaluation of spinal trauma, discussing cervical spine anatomy, the mechanism of injury, and classification of injuries, and then discuss several specific injuries of the cervical and thoracolumbar spine and their radiographic evaluation.
Craniocervical junctions in 35 abnormal and 10 normal subjects were studied with a 0.5 T superconducting magnetic resonance imaging system. Sagittal spin echo with 30 msec echo times and 500 msec repetition times constituted the most informative imaging plane and sequence. The anterior aspect of the foramen magnum was well delineated; the posterior margin was less constant in appearance. Compression and distortion of the medulla and upper cervical cord by bony and extramedullary lesions were seen easily. Intramedullary cysts were differentiated from solid tumors, but ventricular communication was evaluated less successfully because of partial-volume effect of the sections. Cerebellar ectopias were detected in some asymptomatic patients.
One hundred and twenty-one patients with juvenile rheumatoid arthritis were studied clinically and roentgenographically for evidence of disease of the cervical spine. None of the fifty-seven patients with pauciarticular-onset juvenile rheumatoid arthritis had cervical symptoms or signs, and only one had minor roentgenographic changes of disease in the cervical spine. In contrast, clinical stiffness and roentgenographic changes in the cervical spine occurred commonly in the fifty-one patients with polyarticular-onset disease and in the thirteen patients with systemic-onset disease. Despite extensive roentgenographic involvement of the cervical spine, however, pain in the neck was not a common complaint. Neither severe pain in the neck nor torticollis, occurring either separately or concomitantly, is frequently found in patients with juvenile rheumatoid arthritis, and its presence may suggest an intercurrent problem such as a fracture or infection. As patients with juvenile rheumatoid arthritis rarely have disease in the cervical spine alone, the patient should be carefully examined for involvement of multiple joints.
Trauma to the upper cervical spine results in injuries to the C1-C2 complex that may differ significantly from those in the lower cervical spine. Five major types of injuries occur, and their treatment is based on an understanding of the mechanisms of injury.
In a prospective randomized study, we compared the results of surgical treatment of 25 patients with infantile esotropia, using bilateral medial rectus muscle recession of a graded amount without severing the check ligaments, to results obtained with a similar group of 23 patients in whom check ligaments were severed at the time of bimedial surgery. No significant difference could be found in the immediate postoperative and 6-month postoperative ocular alignment of the two groups.
32 patients with traumatic injuries of the cervical spine were investigated by CT. All patients were initially examined by plain films. CT was definitely superior to conventional radiology in compressive fractures of vertebral bodies. In flexion-extension injuries CT was useful showing fractures of the posterior elements in great detail. Conventional tomography was superior to CT in patients with complex dislocations of vertebral bodies. In the absence of fracture CT failed to detect disruptions of ligaments, which were readily shown by functional examination.
A retrospective review of 262 consecutive cervical spine fractures revealed that 41 (16%) were odontoid fractures. Twenty patients were younger than 40 years of age (19 fractures were the result of a motor vehicle accident), whereas 19 fractures occurred in subjects older than 60 (13 were the result of a fall). Fractures were of the Anderson-D'Alonzo Types I (one patient), II (19 patients), and III (21 patients). Significant displacement was present in 31 patients. Anterior and posterior displacement occurred equally, but most of the anterior fractures were seen in patients younger than 40, and the majority of the posterior fractures occurred in those older than 60. Primary fusion was performed in 12 cases. Conservative management was used in 26. Three patients died (one from a spinal cord transection and two from other injuries). In the conservatively treated group, the average time to healing was 12 weeks, but the overall nonunion rate was nine out of 26 (7/13 Type II, 2/13 Type III fractures). The halothoracic jacket was poorly tolerated in patients older than 75 years of age. If daily supervision is not possible, early C1-2 fusion or treatment in an appropriate brace seems superior in the elderly patient.
The authors report the intermaxillo-hyoido-retropharyngeal approach for cranio-cervical junction's pathology. They underline its advantages. It's indications are discussed by six personal cases.
We report on the case of a 33 year old woman with acute tetraparesis and radiological evidence of atlantoaxial dislocation who had to undergo several attempts at osteosynthetic stabilisation of the cervical spine. She was afflicted with a spastic walk since the early years of childhood which had been explained by encephalitis after umbilical sepsis. The etiology of this severe and grave cervical instability however was found in a very rare congenital developmental disturbance of the occipitocervical passage with dystope os odontoid, extreme hypoplasia of the dens axis and additionally an osseous link between left processus transversus atlantis and occiput. Diagnostic problems arose from a simultaneous psoriasis, because a psoriatic cervical spondylitis seemed possible.
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