Can Anterior Osteophyte Fractures Be Distinguished From Fracture Mimics in the Subaxial Cervical Spine? A Retrospective Analysis Evaluating Reported Fractures With Clinical Management Correlation.

OBJECTIVE: This study aimed to retrospectively distinguish true- from false-positive fractures of anterior subaxial cervical osteophytes, which were reported on noncontrast computed tomography reports, and to correlate the imaging findings with patient symptoms and analyze the downstream impact on management of both true and false positive fractures. METHODS: A total of 127 patients had computed tomography reports of anterior osteophyte fractures. Radiology reports and imaging studies were evaluated to distinguish true fractures from fracture mimics. We analyzed imaging features including rigid spine (RS), prevertebral soft tissue swelling (PVSTS), and instability. We categorized symptoms and examination findings into 3 groups (0, asymptomatic; 1, neck pain; 2, neurological symptoms). Management was categorized into 3 groups (0, no treatment; 1, external bracing; 2, surgery). Associations between imaging features, fracture classification, clinical symptoms, magnetic resonance imaging utilization, and management were calculated using χ2 with Cramer V test to determine effect size. RESULTS: Eighty patients had false-positive fractures, and 47 were true positive. There were significant associations between magnetic resonance imaging utilization and fracture classification (P ≤ 0.001), PVSTS (P ≤ 0.005), patient symptoms (P ≤ 0.001), and patient management (P ≤ 0.001). There were significant associations between patient management and fracture classification (P ≤ 0.001), patient symptoms (P ≤ 0.001), PVSTS (P ≤ 0.001), imaging findings of instability (P ≤ 0.001), and RS (P ≤ 0.021). There were significant associations between fracture classification and patient symptoms (P ≤ 0.045), and RS (P ≤ 0.006). CONCLUSIONS: Subaxial isolated anterior osteophyte fractures fell into 3 major categories. By our methodology, if a suspected fracture was determined to be a fracture mimic in an asymptomatic patient, it was unlikely to be clinically significant. Isolated anterior osteophyte fractures without neurological symptoms or more concerning imaging findings can be treated conservatively. Finally, fractures that demonstrate indirect signs of instability or are associated with RS are more associated with surgical management.

The 5-Factor Modified Frailty Index Score Predicts Return to the Operating Room for Patients Undergoing Posterior Spinal Fusion for Traumatic Spine Injury.

OBJECTIVE: Within the trauma spine surgery literature, the effect of patient frailty on postoperative outcomes for posterior spinal fusion (PSF) remains clear. In this study, the authors quantified the influence of the 5-factor modified frailty index (mFI-5) score on hospital length of stay, diagnosis of a postoperative infection, 30-day readmission, and 90-day return to operating room (OR). METHODS: The authors retrospectively reviewed the records of all patients with traumatic spine injury undergoing PSF by a single surgeon at our institution from 2016 to 2021. Data were extracted using manual chart review and the mFI-5 score was calculated using data on comorbidities. Bivariate (Mann-Whitney U test and Fisher exact test) and multivariate regressions (linear and logistic) revealed whether there was an independent relationship between patient frailty and postoperative outcomes. RESULTS: The patient cohort included 263 patients (52.00 ± 19.04), 67 (25.5) were classified as frail, defined as having an mFI-5 score ≥2. Patients who were classified as frail were significantly more likely to have diabetes (odds ratio = 21.53; P < 0.001) and active cancer (odds ratio = 10.03; P = 0.004). Patients with mFI-5 scores ≥2 were also significantly older (P < 0.001) and had higher body mass index (BMI) (P = 0.007). Patients with mFI-5 scores >2 were more likely to return to the OR (odds ratio = 2.43; P = 0.037) on bivariate analysis. When controlling for demographics and clinical characteristics, mFI-5 score independently predicted return to OR (odds ratio = 1.294; P = 0.041). CONCLUSIONS: Patient frailty independently predicted a return to OR in patients undergoing PSF for traumatic spine injury. Future studies can investigate methods for patient risk optimization to reduce morbidity and mortality.

Incisional Wound Vacuum-Evaluation of Wound Outcomes in Comparison With Standard Dressings for Posterior Spinal Fusions in Traumatic Patients.

BACKGROUND: Postoperative incisional negative pressure wound vacuum-assisted closure (VAC) dressings are being used as a primary dressing to optimize wound healing and help avoid complications of infection and dehiscence. Few studies have investigated whether application of VAC dressings on postoperative posterior spinal wounds can reduce the incidence of surgical site infections. OBJECTIVE: To describe our single-surgeon experience of using primary VAC after posterior spinal fusion (PSF) in a large sample of trauma patients. METHODS: This was an Institutional Review Board-approved retrospective comparative study and included all trauma patients presenting to our level 1 safety-net trauma center who required PSF and were operated on by the senior surgeon between 2016 and 2021. Primary outcomes were complications (surgical site infection, readmission for infection, and wound-related return to operating room [OR]) within 90 days after surgery. χ2 testing and Student t testing were used to assess differences between treatment groups while bivariate and multivariate regression was performed for outcome assessment. RESULTS: Two hundred sixty-four patients met criteria and were included. One hundred fifty-seven (59%) were treated with standard dressing and 107 (41%) with VAC. Patients treated with VAC were more likely to be older (P = .015), have diabetes (P = .041), have an elevated body mass index (P = .020), and had more levels of fusion (P = .002). Despite this, presence of VAC was independently associated with decreased 90-day infection (hazard ratio = 0.397, P = .023) and decreased 90-day return to OR for wound-related reasons (hazard ratio = 0.099, P = .031). CONCLUSION: Compared with the use of standard dressing, VAC was found to decrease surgical site infection and return to OR risk in trauma patients undergoing PSF.

Cost Savings Associated with Vacuum-Assisted Closure in Trauma Patients Undergoing Posterior Spinal Fusion.

OBJECTIVE: To investigate the implications of vacuum-assisted closure (VAC) versus standard wound dressings on postoperative posterior spinal fusion (PSF) wounds with respect to potential cost savings associated with reduced incidence of surgical site infections. METHODS: This was a retrospective review of trauma patients who underwent open PSF under the care of a single surgeon at a Level I trauma center. Patients were postoperatively monitored for 90 days. Statistical analysis was performed with χ2 testing with the calculation of number needed to treat values. RESULTS: Inclusion criteria were met by 208 patients who underwent open PSF. The χ2 test revealed a significant increase in incidence of surgical site infections (20% vs. 8%; P = 0.021) in the non-VAC group (n = 112) compared with the VAC group (n = 96). Cost-benefit analysis revealed that use of VAC in patients undergoing open PSF could enable a mean cost savings of $163,492 per 100 patients. CONCLUSIONS: Use of VAC in patients undergoing open PSF was associated with a 2-fold decrease in incidence of surgical site infections and an infection-related cost savings of $163,492 per 100 patients. Further investigation is needed to ascertain additional benefits of VAC usage in patients undergoing open PSF.

Post-Transplant Lymphoproliferative Disorder: A Rare Case of CNS Involvement following Renal Transplant.

BACKGROUND: Post-transplant lymphoproliferative disorders (PTLD) are rare immunosuppression complications affecting 5% of transplant patients. Isolated central nervous system (CNS)-PTLD without nodal or extra-nodal organ involvement is rarely reported and is difficult to diagnose due to the non-specific clinical manifestations and imaging features overlapping with other common CNS lesions. CASE PRESENTATION: We present a case of a 72-year-old female subjected to a renal transplant 11 years ago with progressively worsening headaches and confusion. Imaging revealed vasogenic edema in the left frontal and bilateral temporal lobes. She was subjected to a craniotomy and excisional biopsy to obtain tissue for diagnostic and therapeutic interventions. Pathology examination showed atypical EBV-positive lymphoplasmacytic infiltrate, consistent with Polymorphic type PTLD. CONCLUSIONS: Patients diagnosed with PTLD need to have close monitoring of immunosuppressive medications while in the hospital. Early diagnosis is essential for patient survival with PTLD, as their health can deteriorate fast.

Outcomes After Minimally Invasive Sacroiliac Joint Fusion: A Scoping Review.

BACKGROUND: Sacroiliac joint (SIJ) dysfunction is a significant contributor to lower back pain. Although open surgical treatment for persistent pain has long been the standard, it is associated with significant surgical morbidity, high complication rates, and variable patient satisfaction. Minimally invasive SIJ fusion (MISJF) is a promising and effective approach. This scoping review was carried out to map the available evidence on outcomes after MISJF. METHODS: This review was conducted in accordance with the PRISMA guidelines. Inclusion criteria were all full-text articles reporting on functional, clinical, and quality-of-life outcomes after MISJF. Exclusion criteria consisted of studies including patients with traumatic sacroiliac injuries or congenital spinal abnormalities, and procedures involving multiple spinal fusions or an open approach to SIJ fusion. RESULTS: A total of 1305 studies were identified across 6 databases. After duplicate removal and further screening, 33 independent studies were included in our review. Regarding pain management, 21 studies reported visual analog scale scores, and all showed significant (>50%) reductions in pain at multiple time points postoperatively. Six studies reported on quality-of-life outcomes and showed significant increases, especially compared with nonsurgical treatment. CONCLUSIONS: This study highlights the existing literature regarding outcomes after MISJF. MISJF provides favorable responses in quality-of-life metrics, pain scores, and overall postoperative outcomes in select patients. Although outcomes have been widely studied, more studies, especially prospectively designed and those without industry influence, should be performed to elucidate the optimal management of patients with intractable SIJ pain.

Upper Extremity Monoplegia following Prone Surrender Position for Spinal Surgery.

Background Secondary peripheral nerve injuries remain a significant perioperative problem due to patient positioning and contribute to reduced patient quality of life and exacerbated professional liability. Comorbidities and concomitant lesions can further elicit these injuries in patients undergoing spinal surgeries. Case Presentation We report a case of a 70-year-old male polytrauma patient presenting with a left first-rib fracture and an adjacent hematoma around the brachial plexus without preoperative deficits. Subsequent to a lumbar spinal fusion in the prone position, he developed a postoperative left upper extremity monoplegia. The postoperative magnetic resonance imaging revealed an enhanced asymmetric signal in the trunks and cords of the left brachial plexus. He progressively improved with rehabilitation, a year after the initial presentation, with a residual wrist drop. Conclusions Pan brachial plexus monoplegia, following spine surgery, is rare and under-reported pathology. To minimize the occurrence of this rare morbidity, appropriate considerations in preoperative evaluation and counseling, patient positioning, intraoperative anesthetic, and electrophysiological monitoring should be performed. We emphasize an unreported risk factor in polytrauma patients, predisposing this rare injury that is associated with prone spinal surgery positioning, SEPs being an extremely sensitive test intraoperatively and highlight the importance of counseling patients and families to the possibility of this rare occurrence.

Appropriateness of Cervical Magnetic Resonance Imaging in the Evaluation and Management of C1 Jefferson Fractures.

BACKGROUND: Traditionally, C1 fractures have been designated as stable or unstable based on the inherent integrity of the transverse altantal ligament. The purpose of our study was to identify adult trauma patients with C1 fractures on cervical computed tomography and evaluate whether C1-C2 alignment differed in patients with and without an associated transverse atlantal ligament injury on follow-up cervical magnetic resonance imaging. METHODS: Adult trauma patients who suffered a C1 fracture were identified retrospectively. The cervical computed tomography examinations for these patients were reviewed for the following: C1 fracture classification, anterior atlantodens interval (ADI) widening, asymmetry in the lateral atlantodens interval, C1 lateral mass offset, and atlantoaxial rotation. RESULTS: Acute C1 fractures were grouped into those with an unequivocal transverse atlantal ligament injury (n = 12), and patients with an unequivocally intact transverse atlantal ligament (n = 20). Three patients were classified as indeterminate for transverse atlantal ligament injury. Statistically significant increases in lateral ADI asymmetry and combined C1 lateral mass offset were identified in patients with transverse atlantal ligament tears. CONCLUSIONS: Lateral ADI asymmetry (using a cutoff of >3 mm), combined C1 lateral mass offset, and anterior ADI demonstrate robust specificity to "rule in" transverse atlantal ligament injury. Atlantoaxial alignment was overall relatively insensitive as a screening test although sensitivity can be improved using a cutoff of >2 mm for lateral ADI asymmetry. Our findings reinforce the role of cervical magnetic resonance imaging in the diagnostic workup and clinical management of trauma patients with an acute burst fracture of the C1 vertebra.

Current Advances in the Management of Adult Craniopharyngiomas.

Craniopharyngiomas (CPs) are slow growing, histologically benign intracranial tumors located in the sellar-suprasellar region. Although known to have low mortality, their location and relationship to the adjacent neural structures results in patients having significant neurologic, endocrine, and visual comorbidities. The invasive nature of this tumor makes complete resection a challenge and contributes to its recurrence. Additionally, these tumors are bimodally distributed, being treated with surgery, and are followed by other adjuncts, such as focused radiation therapy, e.g., Gamma knife. Advances in surgical techniques, imaging tools, and instrumentations have resulted in the evolution of surgery using endoscopic techniques, with residual components being treated by radiotherapy to target the residual tumor. Advances in molecular biology have elucidated the main pathways involved in tumor development and recurrence, but presently, no other treatments are offered to patients, besides surgery, radiation, and endocrine management, as the disease and tumor evolve. We review the contemporary management of these tumors, from the evolution of surgical treatments, utilizing standard open microscopic approaches to the more recent endoscopic surgery, and discuss the current recommendations for care of these patients. We discuss the developments in radiation therapy, such as radiosurgery, being used as treatment strategies for craniopharyngioma, highlighting their beneficial effects on tumor resections while decreasing the rates of adverse outcomes. We also outline the recent chemotherapy modalities, which help control tumor growth, and the immune landscape on craniopharyngiomas that allow the development of novel immunotherapies.

Occult craniocervical dissociation on cervical CT: an under-appreciated presentation of craniocervical trauma requiring occipital cervical fusion.

BACKGROUND AND PURPOSE: Craniocervical dissociation is a rare and life-threatening injury that results from a significant hyperflexion-hyperextension force. Occult craniocervical dissociation is defined as an unstable craniocervical injury in the absence of atlanto-occipital joint space widening or other skull base line abnormality. The early and accurate diagnosis of craniocervical dissociation is crucial since the early diagnosis and subsequent stabilization with occipital-cervical fusion has been shown to reduce neurologic morbidity and mortality. Several normative skull base lines have been developed to predict craniocervical dissociation. The purpose of our study was to measure the atlanto-occipital joint space and four other common skull base lines in patients who underwent occipital-cervical fusion for post-traumatic craniocervical instability. MATERIALS AND METHODS: Patients who underwent occipital-cervical fusion for craniocervical injury were identified retrospectively using a keyword search of radiology reports using Nuance mPower software. The cervical CT and MRI exams for these patients were reviewed and the atlanto-occipital joint space, Powers ratio, Wackenheim line, posterior axial line, and basion dens interval were measured. Detailed descriptions of craniocervical ligament injuries on MRI were recorded along with patient demographic information, clinical history, management, and outcome. RESULTS: Nine adult patients who underwent occipital-cervical fusion for an acute craniocervical injury were identified. Six patients demonstrated an atlanto-occipital joint space measuring 2 mm or less on cervical spine CT with no additional abnormality in the Powers ratio, Wackenheim line, posterior axial line, or basion-dens interval. Three patients demonstrated widening of the atlanto-occipital joint space with two patients demonstrating an abnormality in at least two additional skull base lines. Clinical outcomes were variable with nearly half of the patients demonstrating persistent neurologic deficits, including one quadriplegic patient. CONCLUSIONS: A normal atlanto-occipital joint space and skull base line measurements on cervical CT demonstrated a low predictive value for detecting unstable craniocervical injuries. Occult craniocervical dissociation was present in two-thirds of patients who underwent occipital cervical fusion for acute, craniocervical trauma. A high clinical and radiologic index of suspicion for craniocervical trauma with subsequent follow-up cervical MRI to directly evaluate ligamentous integrity is necessary to accurately diagnose and triage patients with high velocity trauma.

Radiologic utility of the Gehweiler and AO spine classification systems for C1 Trauma: A retrospective review from a Level I trauma center.

Objective: The purpose of our study was to identify adult trauma patients with an acute C1 burst fracture, evaluate for concomitant transverse atlantal ligament (TAL) injury, and apply the modified Gehweiler and AO spine classification systems to determine the utility of these classification systems in accurately defining C1 trauma. Materials and Methods: Adult trauma patients with an acute C1 fracture were identified retrospectively using Nuance mPower software. The C1 fracture was described based on whether the fracture involved the anterior arch, posterior arch, lateral mass, medial tubercle, and/or transverse process. If follow-up cervical magnetic resonance imaging (MRI) was performed, the presence and location of an associated TAL injury was recorded. The anatomic location of the C1 burst fracture and TAL injury, if present, were compared with the descriptive classification systems outlined by Gehweiler/Dickman (modified) and the AO Spine society. Any additional osseous trauma of the skull base and C1-C2 was also recorded along with relevant clinical history and management. Results: Thirty-nine patients were identified with an acute C1 burst fracture on cervical computed tomography (CT) with seventy-seven percent of patients undergoing follow-up cervical MRI. Observed fracture patterns were divided into five distinct types based on CT findings and further subdivided based on the integrity of the transverse altantal ligament on MRI. TAL tears were observed exclusively in type 3 fractures (anterior and posterior arch fractures) and type 4 fractures (anterior arch, posterior arch, and lateral mass fractures). The modified Gehweiler classification system failed to accurately describe the anatomic location of the C1 fracture in forty-four percent of patients, whereas the AO spine was too broad and failed to accurately describe fracture location in our cohort. Conclusions: The Gehweiler and AO spine classifications demonstrated significant shortcomings in the accurate description of patients with C1 trauma. Whereas the Gehweiler system did not accurately describe the anatomic location of the various C1 fractures, the AO spine system was too broad and failed to radiologically classify fracture location. Moreover, there was a high number of patients with AO spine type B injuries without atlantoaxial translation that nevertheless required C1-C2 fusion for atlantoaxial instability. We suggest the need for an updated classification system that takes into account both the CT (fracture location) and MRI (TAL integrity) appearance of C1 trauma. An updated classification strategy will offer a radiologic standardization of C1 trauma that will aid in future research studies and help optimize patient management.

C1-C2 Dorsal Epidural Hematoma on Cervical Spine CT: A Novel Imaging Sign of Posterior Atlanto-Occipital Membrane Stripping Injury.

BACKGROUND AND PURPOSE:  Identify patients with a dorsal epidural hematoma at C1-C2 and examine the major craniocervical junction ligaments for injury on follow-up magnetic resonance imaging. MATERIALS AND METHODS:  Adult and pediatric trauma patients who suffered a dorsal epidural hematoma at C1-C2 were identified using Nuance mPower software (Nuance Communications, United States). The cervical computed tomography and magnetic resonance imaging exams for these patients were reviewed for craniocervical junction osteoligamentous injuries. An age-matched control group was obtained. RESULTS:  Eight trauma patients were identified with a dorsal epidural fluid collection at C1-C2. All patients with a dorsal epidural hematoma, who underwent follow-up cervical magnetic resonance imaging demonstrated a stripping injury of the posterior atlanto-occipital membrane from the C1 posterior arch with increased short tau inversion recovery signal in the posterior atlanto-occipital membrane complex. Disruption of additional major craniocervcial ligaments on magnetic resonance imaging was relatively common with the most frequently associated ligamentous injuries involving the tectorial membrane (five patients) followed by the alar ligaments and anterior altanto-occiptial membrane (four patients each).  Conclusions: A C1-C2 dorsal epidural hematoma is a rare injury that may be identified on cervical spine computed tomography but may be easily overlooked by the radiologist. We propose that a C1-C2 dorsal epidural hematoma is a direct result of a significant hyperflexion-hyperextension force with subsequent stripping of the posterior atlanto-occipital membrane from the posterior C1 arch. Trauma patients with a C1-C2 dorsal epidural hematoma on cervical spine computed tomography should undergo a cervical magnetic resonance imaging examination to evaluate the integrity of the posterior atlanto-occipital membrane complex and remaining craniocervical junction ligaments for injury.

Falx Cerebelli Meningioma: Case Report of a Rarely Occurring Tumor, Management Nuances, and Literature Review.

The falx cerebelli is a small crescent fold of dura mater that is attached to the internal occipital crest and projects forward into the posterior cerebellar notch between the cerebellar hemispheres. We report a rare case of a 61-year-old female who presented with a 1-month history of headache and gait instability. Imaging findings were suggestive of a meningioma arising from the falx cerebelli. Complete surgical resection was achieved with a standard posterior fossa midline approach. Duraplasty was performed using animal allograft dura (Duraguard) and additional layers of oxidized cellulose preparation (Surgicel), fibrin sealant, and nonsuturable collagen matrix (Duragen) were utilized to reduce the risk of a cerebrospinal fluid leak. Pathology confirmed a World Health Organization (WHO) grade-I meningioma. Postoperatively, patient with asymptomatic thrombosis of the left transverse/sigmoid sinuses and later with a pseudomeningocele managed with a lumbar drain. To our knowledge, this is the second documented case in the literature. We discuss intraoperative nuances and unique aspects in the postoperative care and management of these patients.

Spinal Tuberculosis Secondary to Intravesical Bacille Calmette-Guerin Treatment for Bladder Cancer.

Intravesical administration of bacille Calmette-Guérin (BCG) is an important component of the gold standard in treating non-muscle invasive bladder cancer (NMIBC). However, complications of this treatment include infections caused by the dissemination of Mycobacterium bovis. We present a case of a 62-year-old man who had been treated with intravesical BCG for bladder cancer and developed an M. bovis infection of his vertebral column. About four months after completing the BCG treatment, he developed an acute onset of severe upper thoracic radicular back pain, with radiation anteriorly to his sternum. Examination revealed the presence of early myelopathy. After other causes were ruled out, he was diagnosed with the infection four months later. He was investigated for the pain, with resulting imaging identifying an erosive ventral epidural mass at the T4-T5 levels causing cord compression. The patient underwent a transthoracic procedure to evacuate the paraspinal mass lesion and obtain a diagnostic biopsy, followed by a posterolateral decompression of the lesion and posterior instrumented stabilization. Pathology resulted in the identification of a granuloma with a single acid-fast bacillus (AFB) from the paraspinal abscess, thus being diagnostic of a mycobacterial granuloma with paraspinal involvement. We subsequently performed an extensive review of current literature, looking at articles on spinal osteomyelitis following intravesical BCG treatment of bladder cancer. We identified 26 documented cases in English literature. We present our case report with a good outcome at 24 months, resolving with appropriate chemotherapy. Additionally, we completed a systematic review of the literature and discuss this infrequent iatrogenic pathology. Our report reveals the good response to targeted therapy in the case of osteomyelitis at other skeletal sites and that practitioners caring for these patients maintain a high degree of suspicion in the workup of these patients. Early identification and treatment can appropriately treat osteomyelitis with good long-term outcomes.

Occipital condylar avulsion fractures in the acute trauma setting: Stable or unstable injury?

BACKGROUND AND PURPOSE: Occipital condylar avulsion fractures are considered potentially unstable, associated with craniocervical dissociation spectrum injuries, and thought to carry a relatively high mortality rate based on the current literature. The purpose of this study was to identify patient with acute, occipital condylar avulsion fractures and evaluate for the incidence of concomitant cervical osteoligamentous trauma and craniocervical dissociation spectrum injury on cervical spine CT and MRI. MATERIALS AND METHODS: Patients who suffered an inferomedial occipital condylar avulsion fracture were identified retrospectively using Nuance mPower software. Cervical spine CT and MRI reports performed within 48 h for this patient cohort were then reviewed by two CAQ certified neuroradiologists. Confirmation of an occipital condylar avulsion fracture was recorded along with any concomitant craniocervical junction injury. Relevant clinical history, including management and outcomes, was recorded for each patient. RESULTS: Thirty-four patients were identified with an inferomedial fracture of the occipital condyle. Of the 85% of patients who underwent cervical MRI, all but one patient demonstrated a 'negative' MRI without major craniocervical junction ligamentous injury. These patients were treated conservatively with external bracing without persistent neurologic deficits upon 4-month follow-up. CONCLUSIONS: Inferomedial fractures of the occipital condyle are currently classified as potentially unstable fractures based on the Anderson classification system. Our data suggest that an isolated occipital condylar avulsion fracture without an additional C1-C2 fracture or widening of the atlanto-occipital joint space is likely a stable injury that can be treated conservatively with excellent clinical outcomes.

Halo vest immobilization - an institutional review of safety in acute cervical spine injury from 2013 to 2017.

Objective: Halo vest immobilization (HVI) remains an important treatment option for occipital-cervical injuries. It provides the surgeon with a safe and effective medical treatment options for challenging patients. The aim of this study was to evaluate the safety of HVI in these patients.Methods: This retrospective study identified adult patients treated with Halo vests immobilization (HVI) for acute cervical spine injury at our metropolitan level 1 trauma center from 2013 to 2017. This heterogenous cohort included 67 consecutive patients with acute cervical spine injury secondary to trauma or iatrogenic injury following surgical intervention with a mean age of 52 and a mean injury severity score (ISS) of 18. Forty-six percent of patients were treated with HVI as an adjunct therapy to surgical fixation (both short- and long-term immobilization), 45% of patients were treated with HVI as a primary medical treatment, and 9% of patients were treated with HVI instead of failed conservative medical treatment, such as cervical braces. Results: Pneumonia during the initial hospital stay was the most common complication (25%), followed by the correction of loose pins (22%) and pin site infections (18%). Overall, 51% of patients experienced at least one of these complications. There were significant associations between low initial GCS scores and the development of pneumonia (p < 0.001), high ISS scores and the development of pneumonia (p < 0.01), and duration of HVI and the occurrence of loose pins (p < 0.05). Four patients initially treated with HVI as primary medical treatment was converted to surgical treatment due to an intolerance of HVI or non-healing injuries.Conclusions:The HVI is a safe and effective treatment modality in a subset of patients with complex cervical junction and subaxial cervical spine pathology.

Proposed Grading System for Posterior Atlantooccipital Membrane Complex Injuries on Cervical Magnetic Resonance Imaging.

BACKGROUND: The posterior atlantooccipital membrane complex consists of the posterior atlantooccipital membrane and posterior atlantoaxial membrane. Posttraumatic, posterior atlantooccipital membrane complex injuries may have varied appearances on cervical magnetic resonance imaging. The purpose of this study was to identify the different types of posterior atlantooccipital membrane complex injuries that occur in trauma patients. METHODS: Patients who suffered a posterior atlantooccipital membrane complex injury were identified retrospectively using key word searches of cervical magnetic resonance imaging reports between 2013 and 2020 using Nuance mPower software. All relevant imaging studies were reviewed by 2 neuroradiologists. A description of the location and type of posterior atlantooccipital membrane complex injury was recorded, along with additional osteoligamentous trauma of the craniocervical junction and relevant clinical history. RESULTS: Forty-one patients were identified with acute posterior atlantooccipital membrane complex injury. Four distinct patterns of posterior atlantooccipital membrane complex injury were observed. CONCLUSIONS: A grading system for posterior atlantooccipital membrane complex injuries is proposed on the basis of these data: grade 1-edema confined to the posterior atlantooccipital and atlantoaxial membrane; grade 2-edema confined to the posterior atlantooccipital and atlantoaxial membrane and ligamentum nuchae; grade 3-stripping injury of the posterior atlantooccipital membrane with C1-C2 dorsal epidural hematoma; and grade 4-frank disruption of the posterior atlantooccipital membrane at C1 with edema in the remaining posterior atlantooccipital membrane complex.

Anatomic, functional, and radiographic review of the ligaments of the craniocervical junction.

The craniocervical junction (CCJ) is a complex and unique osteoligamentous structure that balances maximum stability and protection of vital neurovascular anatomy with ample mobility and range of motion. With the increasing utilization and improved resolution of cervical magnetic resonance imaging, craniocervical injury is being more accurately defined as a spectrum of injury that ranges in severity from overt craniocervical disassociation to isolated injuries of one more of the craniocervical ligaments, which may also lead to craniocervical instability. Thus, it is vital for the radiologist and neurosurgeon to have a thorough understanding of the imaging anatomy and function of the CCJ.