PMC4811303_01
Conventional radiography shows the bullet in projection close proximity to the C1/C2 facet joint (A). Coronal (B), axial (C) and sagittal (D) CT reformations of the cervical spine show the trajectory of the bullet and the resulting complex fracture of the basis of the C2 vertebra (Benzel fracture Type 2) leaving the cervical spinal cord and left vertebral artery intact. The dotted lines indicate the bullet path (C, D), the asterisks indicate sensible vessel structures like the vertebral artery (C, D).
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Trauma Life Support (ATLS ) guidelines was performed. The conventional radiographs revealed a C2 fracture and a small-caliber bullet lodged laterally to the left C1/C2 facet joint and a fracture of the right mandibula (Figure 1A). Multiplanar computed tomography (CT) - reformations of the cervical spine showed a complex fracture of the body and the dens of the C2 vertebra, which had been penetrated by the bullet (Figures 1, 2).
Intact left carotid artery (A, arrow) and intact left vertebral artery (B, arrow) on rotated 3D CT reformations to analyze the bullet path and the vessel anatomy.
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Multiplanar computed tomography (CT) - reformations of the cervical spine showed a complex fracture of the body and the dens of the C2 vertebra, which had been penetrated by the bullet (Figures 1, 2). Most astonishingly, no vascular or neurological damage, which often concurs with such a trauma, was evident on CT images and in CT angiography (CTA, Figure 2).
Postoperative radiograph with complete fixation construct C1-C3 interoperatively (A), and in a radiographically lateral (B) and anterior-posterior (C) view.
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Following posterior approach to the craniovertebral junction, surgical removal of the bullet and closed reduction with fixation of the cervical vertebrae by posterior Harms-Goel fusion of C1-C3 (Figure 3) was performed.
Sagittal (A), coronal (B) and axial (C) CT-images 18 months after bullet removal and dorsal stabilization of the cervical spine with spondylodesis. The bone structure of the C2 vertebral body healed completely.
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Eighteen months after treatment follow-up CT imaging showed an almost complete consolidation of the fractured C2 vertebra (Figure 4).