Tiirkish Neurosurgery 9: 73 - 75, 1999 Görgiilii: üeeipilal Condyle Fractiire

Occipital Condyle Fracture: Cas e Report:

Oksipital Kondil Kirigi: Olgu Sunumu

ASKIN GÖRGÜLÜ, SEBAHA ITIN ÇOBANOGLD, CANDAN HUNDEMIR

Trakya University, School of Medicine, Department of Neurosurgery, Edirne, Turkey

Abstract: Fracture of the ocdpital candyle is a very rareinjury. Complaints in these cases vary from upper cervical

• pain to the multiple cranial nerve palsies. We report thecase of a traffic acddent victim who had ocdpital candylefracture with no clinical symptoms about these fracture.A fracture of the ocdpital candyle was diagnosed duringinvestigations for middle cranial fossa fracture. High­resolution CT scan revealed a Type 2 ocdpital candylefracture. MRI showed no damage to the spinal cord, narto vaseular and ligamentous structures. The patient worea Philadelphia collar for 3 months, and then high­resolutian CT scan showed that the fracture of the occipitalcandyle had healed. Investigation of the craniovertebraljunction should be included in the cranial CT scan forpatients with clinical signs of basis cranii fracture.

Key Words: Cervical pain, head injury, occipital candylefracture

INTRODUCTION

Fracture of the occipital condyle was firstdescribed by Beii in 1817 (3). These fractures usuaiiyoccur secondary to serious trauma. Patients may dieduring the early stages postinjury or may suffer fromproblem s such as upper cervical pain and lowercranial nerve palsies (2,4,10,14,17,19,20). it is usuaiiydifficult to diagnose this fracture on plain x-ray filmsof the skuii and craniovertebral junction. The mostsensitiye radiological examination is a high-resolutioncomputed tomography (CT) sean of theatlantooccipital joint (18). We report a patient withfradure of the occipital condyle who was treated

Özet: Oksipital kandil kiriklari nadir olgulardir.Yakinmalar sadece üst servikal bölge agrisindan multiplkranyal sinir felçlerine bagli daha agir fonksiyonbozukluklarina kadar degisebilir. Trafik kazasi sonucuoksipital kandil kirigi saptanan ve kiriga bagli herhangibir yakinma ve bulgunun olmadigi bir olgusunulmaktadir. Oksipital kandil kirigi orta fossa kirigiiçin yapilan tetkikler sirasinda saptandi. Yüksekrezolusyonlu bilgisayarli tomografi Tip 2 oksipital kandilkiriginin mevcudiyetini gösterdi. Manyetik resonansgörüntülerne te tki ki spinal kordda, vasküler veligamentöz yapilarda hasar olmadigini ortaya koydu. Üçaylik Philadelphia tipi kolar kullanimindan sonra çekilenyüksek rezolusyolu bilgisayarli tomagrafide kandilkiriginin iyilestigi görüldü. Kafa tabani kiriginin klinikbulgulari olan olgularda kranyovertebral bileskebölgesinin te tki ki kranyal bilgisayarli tomografininparçasi olmalidir.Anahtar Kelimeler: Boyun agrisi, kafa travmasi, oksipitalkandil kirigi

conservatively. The patient presented with none ofthe complaints that typicaiiy accompany this typeof injury, and was diagnosed during work-up for amiddle cranial fossa fracture.

CASE REPORT

A 26-year-old man was admitted to our clinicwith a history of being thrown forward over thehandlebars and hitting headfirst on impact in amotorcycle accidenL The patient never lostconsciousness, but complained of pain in his rightear and left arm. Physical examination revealed aright temporal subgaleal hematoma, right otorrhea,

73

Turkish Neurosurgery 9: 73 - 75, 1999

and right peripheral facial palsy. Cervical palpationwas not painful, and plain x-rays of the cervical spineand skull showed no obvious fracture. Fractures ofthe left radius and ulna were diagnosed on plainfilms. A CT sean of the cranium and craniovertebral

junction revealed a fracture of the right mastoid boneand a small right temporal epidural hematoma(EDH). The image also raised suspicion of a fractureof the left occipital condyle. Further neurodiagnosticinformation was obtained using high-resolution CTsean (Figure I), 3D-CT sean (Figure 2), and magneticresonance imaging (MRI) of the craniovertebraljunction. High-resolution CT revealed a Type 2occipital condyle fracture (OCF). MRI showed nodamage to the spinal cord, or to vascular andligamentous structures. Transcranial Dopplerexamination of the vertebral arteries confirmed

normal blood flow. Repeat cranial CT seans done ontenth day of trauma showed that the EDH on the rightside was resolving. The follow-up period wasuneventful. The patient wore a Philadelphia collarfor 3 months, and then after which high-resolutionCT showed healing of the fracture.

DISCUSSION

A review of the literature on OCF yielded only61 reported cases of survivors and 38 postmortemcases (l,2,4,5,6,7,13,16,17,20,22,24). Bushels andBurkhead' s (6) postmortem examination of 112 fatalvehicle accidents included only two cases of OCF.Alker and colleagues (l) also found 2 cases in the irseries of 312 cases with fatal craniovertebral trauma.it should be kept in mind that these fractures are rare,and usually occur secondary to both serious andminor head trauma (lO,17). In some cases, uppercervical pa in may be the only complaint (8,17,18).Tuli et aL.(20) reported one patient with OCF who

Figure 1: Axial CT sean showing fracture of the Jeftoccipital condyle.

74

Görgüiii: Geeipilal Condyle Fraelure

had no suspicious symptoms of neck pain, cranialnerve or other types of associated neurologicaldeficits. They found the case during a retrospectivestudy. Mariani and colleagues (l2) reported anasymptomatic motorcycle accident victim in whoreithe only findings were prevertebral soft tissuebulging at Cl-2 on a lateral plain cervical x-ray. Inour case, although there was no complaint of paineve n on palpation, the diagnosis was made by­chance in an effort to work up a middle cranial fossafracture on CT sean. Upon noting a suspected fractureof the left occipital condyle, we opted for furtherneurodiagnostic investigation using high-resolutionCT, 3D-CT sean, and MRI of the craniovertebraljunction. High-resolution CT allowed positiveconfirmation of a fracture of the left occipital condyle,and MRI showed no ligamentous or neurovasculardamage. it is clear that this type of fracture may notalways be detected on plain cervical x-rays.Considering the literature on OCF, it should be keptin mind that further neurodiagnostic tests aresometimes necessary, including sagittal and coronal •reconstructed high-resolution CT sean and MRI ofthe craniovertebral region(l6). The 3D-CT seanshows the exact anatomica! relationship between theoccipital condyle, jugu1ar foramen, and craniovertebraljunction (15,23). The tectorial membran e preventshyperextension and hyperflexion of the atlantooccipitalarticulation, and excessive lateral flexion and rotationthe alar ligaments (23). The integrity of both the alarligaments and tectorial membrane is very importantfor stabilization in craniovertebral junction(2,9,11,20,21). Neurodiagnostic examination of thecraniovertebral junction by MRI shows not onlyneurovascular structure, but also the integrity ofligamentous elements. Thus, this technique is avaluable tool for evaluating craniovertebral junctionstability.

Figure 2: 3D-CT sean showing fracture of the left ocdpitalcondyle.

Turkish Neurosurgery 9: 73 - 75, 1999

Anderson and Montesano (2) divided occipitalcondyle fractures into three types, all thought to becaused by different mechanisms. Type 1 is anilI\'pacted comminuted fracture that represents abursting response to axial loading. Type 2 is afractured condyle as part of a basilar skull fracturethat extends to the foramen magnum. These twotypes are stable, while Type 3 is an avulsion fractureof the oceipital condyle, and is potentially unstable.In general, the treatment for OCF is conservative. Dueto their stability, fracture Types 1 and 2 can be treatedwith a Philadelphia collar. Type 3 fraetures shouldbe treated with a more rigid external orthosis.Bozboga et aL. (5) stated that surgical treatment isindicated when there is neurologic dysfunctionresulting from neurovascular compression. Our caseinvolved Type 2 OCF without neurovascularcompression, and the Philadelphia coHar wasadequate for treatment.

In the literature, OCF is considered a possibilityin cases that involve unconsciousness, lower cranial

nerve deficits, upper cervical pain, or Cl-4prevertebral soft tissue edema that is visible on plaincervical x-rays. it is important that the possibility ofthis type of fraeture should not be overlooked. Inour case, OCF was diagnosed during the work-upfor a suspeeted basis cranII fracture. Investigation ofthe craniovertebral junetion should be included inthe cranial CT sean when ev er the re is aciinical signsof basis cranII fraeture.

Correspondence: Askin GörgülüTrakya Üniversitesi Tip FakültesiNörosirürji Anabilim Dali22030 Edirne, TurkeyTel/Fax: (284) 2351651

REFERENCES

1. Alker Gl, Oh YS, Leslie EV: High cervical spine andcraniocervical junction injuries in fatal trafficacddents. a radiological study. Orth Clin North Am9: 1003-1010, 1978

2. Anderson PA, Montesano PX: Morphology andtreatment of ocdpital condyle fractures. Spine 13:731­736, 1988

3. BellC:Surgical observations. Middlesex Hosp J 4: 469­470, 1817

4. Bolender N, Cromwell LO, Wendling L: Fracture ofthe ocdpital condyle. AJR 131: 729- 731, 1978

5. Bozboga M, Ünal F, Hepgül K, Izgi N, Turantan MI,Türker K: Fracture of the ocdpital condyle; Casereport. Spine 17: 1119- 1121, 1992

Görgiilii: Occipila/ Coiidy/e Fraclure

6. Bucholz RW, Burkhead WZ: The pathologicalanatomy of fatal atlanto-ocdpital dislocations. J BoneJoint Surg (Am) 61: 248- 250, 1979

7. Clayman DA, Sykes CH, Wines FS: Ocdpital condylefractures. Clinical pres en ta tion and radiologicdetection. AJNR 15: 1309- 1315, 1994

8. Deeb ZL, Rothfus WE, Goldberg AL, Daffner RH:Occult ocdpital condyle fractures presenting astumorso J Comput Tomogr 12: 261- 263, 1988

9. Desai SS, Coumas JM, Danylevich A, Hayes E, DunnEJ: Fracture of the ocdpital condyle; Case report andreview of the literature. J Trauma 30: 240- 242, 1990

10. Hashimoto T, Watanabe O, Takase M, Koniyama J,Kobota M: Collet-Sickard syndrome after minor headtrauma. Neurosurgery 23: 367- 370, 1988

11. Mann FA, Cohen W: Ocdpital condyle fracture.Significance in the assessment of ocdpitoatlantalstability. AJR 163: 193-194, 1994

12. Mariani PJ: Occipital condyle fracture presenting asretropharyngeal hematoma. Ann Emerg Med 19:1447­1449,1990

13. Orbay T, Aykol S, Seçkin Z, Ergün R:Late hypoglossalnerve palsy following fracture of the ocdpital cond yle.Surg Neurol31: 402- 404,1989

14. Raila FA, Aitken AT, Vickers GN: Computedtomography and three-dimensional reconstruction inthe evaIuation of occipital condyle fracture. SkeletalRadioI22:269-271,1993

15. Savolaine ER, Ebraheim NA, Jackson WT, Rusin JJ:Three-dimensional computed tomography inevaIuation of occipital condyle fracture. J OrthopTrauma 3: 71, 1989

16. Spencer JA, Yeakley JW, Kaufman HH: Fractures ofthe ocdpital condyle. Neurosurgery 15: 101-103, 1984

17. Spirig P: A case of fracture of the ocdpital condyle. ZUnfallchir Versicherungsmed Berufskr 78: 119- 122,1985

18. Stroobants J, Fidlers L, Storms JL, Klaes R, Dua G,Hove MV: High cervical pain and impairment of skullmobility as the only symptoms of an ocdpital condylefracture; Case report. J Neurosurg 81: 137- 138, 1994

19. Stroobants J, Seynaeve P, Fidlers L, Klaes R, BrabantsK, Hove MV: Ocdpital condyle fracture must beconsidered in the paediatric population; Case report.J Trauma 36: 440- 441,1994

20. Tuli S, Tator CH, Feelings MG, Mackay M: Occipitalcondyle fractures. Neurosurgery 41: 368- 377,1997

21. Ünal F, Turantan MI, Hepgül K, Dösoglu M: Pediatricatlanto-occipital articulation trauma. Neuro­Orthopedics 19: 39- 44, 1995

22. Urculo E, Arrazola M, Riu I, Moyua A: Delayedglossopharyngeal and vagus paralysis followingocdpital condyle fracture. J Neurosurg 84: 522- 525,1996

23. Werne S: The possibilities of movements in thecraniovertebral joints. Acta Orthop Scand 28: 165, 1957

24. Young WF, Rosenwasser RH, Getch C, Jallo J:Diagnosis and management of ocdpital condylefractures. Neurosurgery 34: 257- 261,1994

75