Occipital Condyle Fractures: Epidemiology, Classification, and Treatment

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Occipital Condyle Fractures Epidemiology,
Classification, and Treatment

• Sabih T Effendi, Kevin C Morrill, Howard Morgan,
  David P Chason, Richard A Suss, Christopher J
  Madden
• Department of Neurosurgery
• University of Texas Southwestern Medical Center
• Dallas, TX

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Disclosure Statement

• Nothing to disclose

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History

• Sir Charles Bell (1817)
• Rare entity
• Increasingly diagnosed
• Imaging enhancements
• Routine imaging

Middlesex Hospital Journal 4469-470, 1817
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REVIEW OF LITERATURE
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Classification Systems

• Anderson and Montesano (1988)
• Mechanism of injury ? fracture morphology
• Type I comminuted Type II basilar skull fx

• Type III avulsed

Spine 13 731-736, 1988
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Classification Systems

• Tuli et al (1997)
• Type 1 non-displaced
• Type 2 displaced (2A stable, 2B unstable)
• Instability
• CT/Xray subluxation OR MRI avulsed
  transverse ligament
• Newer systems
• A-M system
• Stability assessment
• Hanson et al (2001) bilateral O-C1-C2 joint
  complex injury
• Malham et al (2009) displaced fracture or
  malalignment of joint

Neurosurgery 41368-377, 1997
American Roent Ray Soc 178 1261-68,
2002 Emergency Radiology Online, 2009
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Treatment

• Experience or non-radiographic outcome
• wide range of treatments suggested
• Radiographic outcome data
• Capuano et al (2004)
• 10 pts, CT for fusion
• All isolated OCF healed well with cervical collar
• Malham et al (2009)
• 24 pts, CT for fusion and alignment pain and
  disability scales
• Isolated type I and II heal well with C collar
• Isolated type III may benefit from halo vs collar

Acta Neurochirurgica 146 779-784, 2004 Emergency
Radiology Online, 2009
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Design

• Retrospective Review
• Parkland Memorial Hospital (Dallas, TX)
• 4 year period
• Information obtained
• Clinical data from medical charts
• Initial C-spine CT
• f/u flexion extension films

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Methods - Classification

• Type I vs Type III
• Modified Anderson-Montesano system
• Type I, II, III
• Type I or III Type I and III
• (inability to differentiate) (evidence of both)

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Methods - Instability

• Radiographic Instability Risk Factors

Criteria
1. Fragments involve 25 of condylar articulating surface
2. Fragment displacement 4 mm
3. Atlanto-occipital dislocation
4. Subluxation of 0-C1 or C1-2
5. 0-C1 or C1-2 joint widening
6. Complete transverse fracture through congenitally fused O-C1
Methods - Outcome

• Neurological Exam
• Lateral Flexion-Extension radiographs

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EPIDEMIOLOGY

• 89 OCF in 79 patients
• 13 bilateral
• Gender 63 M, 37 F
• Age 14-64, mean 30, SD 11
• Mechanism of Injury
• High energy trauma
• Associated Fractures
• 47 with spinal fractures

Mechanism Number
MVC 49 (62)
MCC 19 (24)
Fall 5 (6)
MPC 3 (4)
Assault 1 (1)
ATV 1 (1)
Airplane 1 (1)
Fracture Number
At least 1 71 (90)
2 45 (57)
Other cranial 15 (19)
Cervical spine 25 (32)
Thoracic spine 9 (11)
Lumbar spine 6 (8)
Facial 26 (33)
Appencidular 41 (52)
Rib 10 (13)
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CLASSIFICATION
Type Number
I 11 (12)
II 15 (17)
III 40 (45)
I and III 4 (5)
I or III 19 (21)
INSTABILITY

• Type I and II
• All radiographically stable
• Type III, IandIII, IorIII
• 27 with instability risk
• 73 radiographically stable

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TREATMENT

• 7 patients died
• Remaining 72 patients
• Hard cervical collar, CTO, Halo-vest
• 4 to 12 weeks
• None required surgery

TREATMENT OUTCOME

• 50 (69) at initial follow-up
• No new neurological deficits
• 21 (29) with flexion-extension films

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TREATMENT OUTCOME

• Type I and II

Number Radiographic stability Treatment Number FollowUp Flex-Exten stable/obtained
24 (30) All Stable Cervical collar 20 3/3
24 (30) All Stable Halo-vest 1 -
24 (30) All Stable Death before tx 3 -
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TREATMENT OUTCOME

• Type III, IorIII, IandIII

Number Radiographic stability Number Treatment Number FollowUp Flex-Exten stable/obtained
55 (70) Stable 40 (73) Cervical collar 34 8/8
55 (70) Stable 40 (73) CTO 2 1/1
55 (70) Stable 40 (73) Halo-vest 1 0/0
55 (70) Stable 40 (73) Death before tx 3 -
55 (70) Unstable 15 (27) Cervical collar 1 0/1
55 (70) Unstable 15 (27) Halo-vest 13 8/8
55 (70) Unstable 15 (27) Death before tx 1 -
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CONCLUSIONS

• High energy trauma, associated fractures
• Modified A-M Classification System
• Majority are type III
• Stability
• Type I and II appear stable
• Type III concerning for instability
• Treatment
• None required surgery
• Type I and II
• Hard cervical collar
• Type III
• Stable hard cervical collar
• Unstable - halo

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LIMITATIONS

• Limited number with complete outcome data
• Others

FUTURE INVESTIGATION

• Assessing stability in type III fracture
• Do all type I and II need collar immobilization?
• Can some unstable type III be treated with
  collars?

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Thank You

• Dr. Christopher Madden
• Dept of Neurosurgery at UT Southwestern