185 lines
16 KiB
Markdown
185 lines
16 KiB
Markdown
---
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title: "Craniocervical Junction Acute Injury"
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docid: "89ec23bf-2ed4-4694-98a7-7064d22cbf16"
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authors:
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- key: "bee1f359-33fb-4cba-9e6b-ed1ca1842439"
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value: "Jeffrey S. Ross, MD"
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- key: "86b8c311-8667-4afd-9b2b-0c2036a02b8a"
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value: "Julia R. Crim, MD"
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breadcrumbs:
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-
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name: "Spine"
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slug: "spine"
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treeNodeId: "b337a156-914a-4696-a77c-af206720fab5"
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-
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name: "Differential Diagnosis"
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slug: "differential-diagnosis"
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treeNodeId: "ef5fd925-2033-4f3b-aa7c-640fef9aa956"
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-
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name: "Craniovertebral Junction"
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slug: "craniovertebral-junction"
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treeNodeId: "1b500928-e185-4268-95e4-d472fc416f2c"
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-
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name: "Anatomically Based Differentials"
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slug: "anatomically-based-differentials"
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treeNodeId: "13201c88-825d-423b-a917-f0e7cce4a599"
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-
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name: "Craniocervical Junction Acute Injury"
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slug: "craniocervical-junction-acute-inju-"
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treeNodeId: null
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category: "Spine"
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documentVersionId: "a58ff524-e50c-41ce-8979-65b534939534"
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imageCount: 21
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lastUpdated: "02/02/23"
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pageDescription: "Craniocervical Junction Acute Injury"
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pageKeywords: "Spine, Differential Diagnosis, Craniovertebral Junction, Anatomically Based Differentials, Craniocervical Junction Acute Injury"
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pageTitle: "Craniocervical Junction Acute Injury | STATdx"
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enhancedTitle: "Craniocervical Junction Acute Injury"
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type: "DDX"
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breadcrumbs:
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- "Spine"
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- "Differential Diagnosis"
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- "Craniovertebral Junction"
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- "Anatomically Based Differentials"
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- "Craniocervical Junction Acute Injury"
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---
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# ESSENTIAL INFORMATION
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- ## Key Differential Diagnosis Issues
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- Coronal, sagittal CT reformations essential for full evaluation of injury
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- MR very useful to evaluate for ligament injuries, cord injury, disc herniations
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- CT angiogram equally accurate (and faster) than MR angiogram for vertebral dissection
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- Time is often of essence in these patients, who tend to have multiple injuries
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- ## Helpful Clues for Common Diagnoses
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- **Occipital Condyle Fracture**
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- CT best method of diagnosis
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- Symptoms and outcome determined by associated head injury
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- Cranial nerve deficits in 30%
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- **Jefferson C1 Fracture**
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- If combined displacement of lateral masses > 6.9 mm, unstable
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- High likelihood of other fractures: Spine, skull, pelvis, lower extremity
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- **Odontoid C2 Fracture**
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- Usually low-velocity injury in older adult
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- Type II most frequent
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- **Chronic Injury Mimics**
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- **Os odontoideum**
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- Chronic, nonunited odontoid fracture
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- Smooth corticated margins
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- **Nontraumatic Mimics**
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- **Pseudosubluxation C2-C3**
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- Children < 10 years old; anterolisthesis may measure up to 4 mm
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- ## Helpful Clues for Less Common Diagnoses
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- **Atlantoccipital Dislocation**
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- High incidence of cord injury
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- Formerly usually fatal; now patients often survive to hospital
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- **Atlantoaxial Dislocation**
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- Normal atlantoaxial joint space < 3.4 mm in adults on CT
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- **Spinal Cord Injury Without Radiographic Abnormality (SCIWORA)**
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- Occurs primarily in children
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- MR: Injuries to cord, ligaments, intervertebral discs, cartilaginous endplates
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- 2/3 of severe cervical injuries in children < 8 years are SCIWORA
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## Images
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### Selected Images
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**Occipital Condyle Fracture**
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*Coronal NECT shows a nondisplaced occipital condyle fracture <img src='img/arrows/WS.png'/> as well as a C4 articular pillar fracture <img src='img/arrows/WO.png'/>, reflecting lateral flexion injury.*
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**Occipital Condyle Fracture**
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*Coronal NECT shows a nondisplaced occipital condyle fracture <img src='img/arrows/WS.png'/> as well as a C4 articular pillar fracture <img src='img/arrows/WO.png'/>, reflecting lateral flexion injury.*
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**Occipital Condyle Fracture**
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*Axial CT shows a type 3 condyle fracture <img src='img/arrows/WS.png'/> rotated into the foramen magnum. Note the normal position of the right condyle <img src='img/arrows/WO.png'/>.*
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**Jefferson C1 Fracture**
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*Axial bone CT shows multiple fractures of the C1 ring <img src='img/arrows/WS.png'/>. Lateral displacement in this patient indicates rupture of the transverse ligament of dens and resultant instability.*
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**Occipital Condyle Fracture**
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*Parasagittal CT shows a condyle fracture <img src='img/arrows/WS.png'/> that has maintained its relationship with the lateral mass of C1 <img src='img/arrows/WO.png'/> despite the posterior displacement.*
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**Odontoid C2 Fracture**
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*Sagittal NECT shows a type 2 dens fracture <img src='img/arrows/WS.png'/> in an osteoporotic patient. Soft tissue swelling is mild. These fractures are commonly subtle on radiographs and best seen on lateral (not odontoid) view. If there is any question, perform CT.*
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**Odontoid C2 Fracture**
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*Plain radiograph shows a fracture through the base of the odontoid <img src='img/arrows/WS.png'/>, which is displaced posteriorly with slight extension.*
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**Burst Fracture, C2**
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*Sagittal bone CT shows a comminuted C2 body fracture with characteristic retropulsion of the posterior cortex <img src='img/arrows/WS.png'/>. Additional burst fractures are commonly present elsewhere in the spine.*
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**Odontoid C2 Fracture**
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*Sagittal T1WI MR shows a well-defined fracture line <img src='img/arrows/WO.png'/>. MR is useful for defining soft tissue abnormalities but should not be relied upon for pure bony fracture identification.*
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**Hangman's C2 Fracture**
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*Sagittal oblique 3D CT shows bilateral C2 pedicle fractures <img src='img/arrows/WS.png'/> without fracture of the vertebral body. Effendi classification uses the presence of disruption of the C2-C3 disc and facet joints as a measure of the severity of injury.*
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**Atlantoaxial Rotary Subluxation/Fixation**
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*3D CT reconstruction visualizes the markedly left rotated C1 <img src='img/arrows/WS.png'/> with respect to the mildly rotated C2 <img src='img/arrows/WO.png'/>. Findings are typical of a Fielding-Hawkins type I atlantoaxial rotatory fixation.*
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**Os Odontoideum**
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*Sagittal bone CT shows a chronic, nonunited dens fracture <img src='img/arrows/WS.png'/>, so-called os odontoideum. This may be unstable, and flexion-extension views should be performed.*
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**Craniovertebral Junction Variants**
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*Axial bone CT shows anterior and posterior clefts <img src='img/arrows/WO.png'/> of C1. Smooth, corticated margins are signs distinguishing this from trauma.*
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**Craniovertebral Junction Variants**
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*Sagittal bone CT shows the anterior arch of C1 fused to the clivus <img src='img/arrows/WS.png'/> and posterior arch fused to C2 <img src='img/arrows/WO.png'/>.*
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**Atlantooccipital Dislocation**
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*Parasagittal CT shows posterior displacement of the lateral mass of C1 with respect to the occipital condyle <img src='img/arrows/WO.png'/>. The normal condyle would be closely applied to the lateral mass of C1.*
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**Atlantooccipital Dislocation**
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*Sagittal CT shows widening of the basion-dental interval <img src='img/arrows/WS.png'/> and slight posterior displacement of the odontoid with respect to the foramen magnum <img src='img/arrows/WC.png'/> (i.e., abnormal Wackenheim clival line).*
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**Atlantooccipital Dislocation**
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*Parasagittal CT shows slight widening of both C0-C1 <img src='img/arrows/WS.png'/> and C1-C2 <img src='img/arrows/WO.png'/> articulations in this patient with both atlantooccipital and atlantoaxial subluxations.*
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**Atlantooccipital Dislocation**
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*Sagittal STIR MR shows diffuse prevertebral high signal from edema <img src='img/arrows/WS.png'/> and a widened basion-dental interval <img src='img/arrows/WO.png'/>. Note the disruption of the tectorial membrane <img src='img/arrows/WC.png'/>.*
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**Atlantoaxial Dislocation**
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*Sagittal STIR MR shows abnormal hyperintensity within the C0-C1 and C1-C2 articulations <img src='img/arrows/WC.png'/> due to simultaneous atlantooccipital and atlantoaxial subluxations. The 2-level abnormality is important to identify since the posterior fusion will be extended more inferiorly.*
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**Atlantoaxial Dislocation**
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*Coronal CT shows the disrupted spinal articulations at C1-C2 (atlantoaxial dissociation). There is widening of the atlantoodontoid articulation <img src='img/arrows/WS.png'/> and widening/dislocation of the lateral masses of C1 and C2 <img src='img/arrows/WC.png'/>.*
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**Atlantoaxial Dislocation**
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*Sagittal CT shows gross widening of the atlantoodontoid articulation <img src='img/arrows/WS.png'/>. The ring of C1 has maintained position with respect to the foramen magnum <img src='img/arrows/WO.png'/>, but C2 is displaced posteriorly <img src='img/arrows/WC.png'/>.*
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### Additional Images
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**Atlantooccipital Dislocation**
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*Sagittal bone CT shows occipital condyle <img src='img/arrows/BC.png'/> widely separated from lateral mass of C1 <img src='img/arrows/WC.png'/>, indicating longitudinal atlantooccipital dislocation. Dislocation may also be anterior or posterior in direction.*
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