PMC10364009_01
Injury cervical spine CT scan showing (A) subtle subluxation of the left occipitocervical junction with impaction of the O-C1 facet joint and distraction of the atlantoaxial interval, (B) normal appearing right occipitocervical junction, and (C) distraction of the atlantoaxial interval. CT, computed tomography; O-C1, atlanto-occipital.
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CT of the head revealed bilateral mandibular fractures, and a right lateral pterygoid fracture, without evidence of intracranial hemorrhage or embolus. CT of the full spine revealed distraction of the C1-C2 articulation without associated fracture, and without clear disruption or distraction of the O-C1 joint (Figure 1A-1C).
Postoperative lateral (A) and open mouth (B) C1-C2 fixation showing reduced C1-C2 interval and without evidence of transverse ligament disruption. L, left.
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He first underwent external fixation of his right pilon fracture, followed by C1-C2 posterior instrumentation and fusion (Figure 2).
Post-operative CT C-spine revealing (A) coronal view showing distraction of bilateral O-C1 joints, (B) sagittal view showing increased BDI, (C) sagittal view showing right O-C1 joint distraction, (D) sagittal view showing left O-C1 joint distraction. CT, computed tomography; O-C1, atlanto-occipital; BDI, basion-dens interval.
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Per our institution protocol, post-operative cervical spine CT was obtained which revealed further distraction and subluxation of the occipitocervical junction bilaterally, with a CCI of 4 mm bilaterally, a basion-dens interval (BDI) of 10 mm, and a Power's Ratio of 1.1 (Figure 3).
Intraoperative fluoroscopic images showing traction testing, (A) before manual traction and (B) after manual traction, showing no significant distraction at the O-C1 joint. O-C1, atlanto-occipital.
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Manual traction was applied, without evidence of widening of the O-C1 joint (Figure 4), and therefore the traction test was confirmed to be negative.
Lateral cervical XR at 12 weeks post-operatively showing maintained alignment without hardware complication of both the C1-C2 joint, and the O-C1 joint. XR, X-ray; O-C1, atlanto-occipital.
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At 12 weeks post-operatively from C1-C2 posterior instrumentation and fusion, he was evaluated in clinic and found to have no motor or sensory deficits, no neck pain and maintained C1-C2 and O-C1 articulations, without subluxation on flexion and extension views (Figure 5).