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CASE REPORT
Bilateral occipital condyle fractures leading toretropharyngeal haematoma and acuterespiratory distress
Brian J.C. Freeman*, Hannes Behensky
The Centre for Spinal Studies and Surgery, University Hospital, Queens Medical Centre,Nottingham NG7 2UH, UK
Accepted 27 May 2004
Introduction
Injuries to the occipito-cervical articulation arerare and not easily identified on conventional radio-graphs. We report a case where diagnosis wasdelayed; the patient developed acute respiratorydistress due to a rapidly developing retropharyngealhaematoma and required emergency endotrachealintubation. The patient subsequently developed apermanent palsy of the left hypoglossal nerve.
Case report
A 31-year-old motorcyclist crashed into a tyre wallat approximately 100 miles per hour during a motor-
cycle race. He lost consciousness for 15 min, butquickly improved to a Glasgow Coma Score of 15points. He complained of neck pain. The cervicalspine was immobilised with a hard collar and sand-bags. He was transferred to the local hospital.Examination revealed tenderness in the upper cer-vical spine posteriorly without major neurologicaldeficit.
Lateral, anterior—posterior, and open mouthradiographs of the cervical showed no obvious bonyinjury. The lateral radiograph did however revealretropharyngeal swelling (15 mm opposite C2 seeFig. 1) not appreciated at the time. A repeat lateralradiograph was obtained 4 h later showing massiveretropharyngeal haematoma (30 mm opposite C2see Fig. 2). A computed tomography (CT) scan ofthe head and cervical spine were obtained 2.5 hlater. The CT scan of the head was normal. The CTscan from C0—C2 revealed minimally displaced type
Injury, Int. J. Care Injured (2005) 36, 207—212
KEYWORDS
Occipital condyle
fracture;
Delayed diagnosis;
Respiratory compromise
Summary Injuries to the occipito-cervical junction are rare and not easily diagnosedon conventional radiographs. The authors report such a case where the diagnosis wasdelayed. The patient developed a significant retrophyarngeal haematoma resulting inacute respiratory distress and required emergency endotracheal intubation. Thepatient remained intubated for five days and received a tapered dose of intravenousdexamethazone to reduce swelling in the proximity of the airway. At six weeks thepatient had developed a left hypoglossal nerve palsy that persisted at 12 months.
Occipital condyle fractures and the difficulties of diagnosis are discussed. Theimportance of measuring pre-vertebral soft tissue swelling on lateral radiographs isemphasized. Computed tomography of the C0—C2 region should be performed toidentify base of skull and upper cervical fractures.� 2004 Elsevier Ltd. All rights reserved.
*Corresponding author. Tel.: þ44 115 970 9273;fax: þ44 115 970 9991.
E-mail address: [email protected](B.J.C. Freeman).
0020–1383/$ — see front matter � 2004 Elsevier Ltd. All rights reserved.doi:10.1016/j.injury.2004.05.026
I bilateral occipital condylar fractures (see Fig. 3). Atype I occipital condyle fracture typically occurs asa result of axial loading of the skull onto the atlas,similar to the mechanism described for a Jeffersonfracture.1 The classification of occipital condylefractures is shown in Fig. 4.1,2
The patient was immobilised in a hard cervicalcollar and maintained on 28% oxygen overnight. Hewas transferred to our institution the next morning.On arrival the patient was in acute respiratory dis-tress with marked stridor, hypoxia, dyspnoea, andhoarseness. He underwent immediate fibreopticintubation via the left nostril with application oflocal anaesthesia gel and cricoid pressure whilstmaintaining manual inline immobilisation. A size7.5 French nasal cuffed endotracheal tube waspassed and position found to be satisfactory on sub-sequent chest X-ray. Further examination revealednormal carotid pulsation bilaterally and normal
motor and sensory function in the trunk and extre-mities.
The patient remained intubated for 5 days andreceived a tapered dose of intravenous dexametha-sone for 4 days (commencing 4 mg four times perday) to reduce swelling in the proximity of theairway. A magnetic resonance scan performed at3 days confirmed minimally displaced occipital con-dyle fractures. The tectorial membrane, apical,alar and transverse ligaments were thought to beintact, as there was a normal atlanto-axialrelationship. Normal occipito-atlantal alignmentwas noted. Moderate prevertebral/retrovertebralsoft tissue swelling was still present from theskull base down to C5. Flow voids present in thevertebral arteries made occlusion of these vesselsunlikely.
Following extubation, the patient was fitted withan occipto-cervical-thoracic orthosis. Cranial and
Figure 1 Lateral radiograph cervical spine. Retropharyngeal heamatoma measures 15 mm opposite the secondcervical vertebrae marked with the symbol (*).
208 B.J.C. Freeman, H. Behensky
peripheral nerve examination was normal. Thepatient was discharged 9 days following admission.
The patient was reviewed at 6 weeks when neu-rological examination revealed a palsy of the lefthypoglossal nerve (see Fig. 5); all remaining cranialnerves were intact. Motor and sensory functions inthe trunk and extremities were normal. The patientremained in his brace and was reviewed 6 weekslater. Flexion/extension radiographs were per-formed at this stage demonstrating normal align-ment at the occipito-cervical junction. The bracewas removed and physiotherapy arranged.
Clinical review at 12 months confirmed the per-sistence of the left hypoglossal palsy. The patientreported difficulty in pronunciation and musclewasting was evident on the left side of the tongue.A full and painfree range of motion in the cervicalspine was noted.
Discussion
Occipital condylar fractures are rare and easilymissed. Patients often have concomitant headtrauma with impaired levels of consciousness mak-ing the assessment of such injuries difficult. Thestandard three radiographs (lateral, anterior—pos-terior and open mouth) taken to ‘clear the cervicalspine’ may not show such a fracture. The atlanto-occipital joints lie oblique to the plane of the X-raybeam and are therefore not normally visualised onthe lateral radiograph.
Mariani reported a patient presenting with a pre-vertebral haematoma caused by a unilateral occi-pital condylar fracture.8 He described pre-vertebralsoft tissue swelling on plain cervical spine radio-graphs. We report this case to emphasize the impor-tance of retro-pharyngeal soft tissue swelling. This
Figure 2 Lateral radiograph cervical spine 4 h later. Retropharyngeal heamatoma now measures 30 mm opposite thesecond cervical vertebrae marked with the symbol (*).
Bilateral occipital condyle fractures 209
was missed initially but picked up on subsequentradiographs. The patient was transferred in progres-sive respiratory distress, necessitating emergencyendotracheal intubation on arrival at our institu-
tion. The airway should always receive the highestpriority in the management of any patient.
A variety of neurologic injuries ranging from fatalbrain stem injury, to respiratory dependent tetra-
Figure 3 Axial computed tomography scan through occipito-cervical junction. Note minimally displaced bilateraloccipital condyle fractures.
Figure 4 Classification of occipital condyle fractures adapted from Anderson and Montesano 1988.1,2 Type I is animpaction fracture. Type II is an occipital condyle fracture associated with a basilar skull fracture. Type III is anavulsion fracture of the attachment of the alar ligaments.
210 B.J.C. Freeman, H. Behensky
plegia, spinal cord injury and injury to the lowercranial nerves (VI, VII, IX, X, XI and XII) have all beenreported following injuries to the occipito-cervicaljunction.3—7 The lower cranial nerves (IX—XII), inparticular the spinal part of the accessory and thehypoglossal nerve seem to be at greatest risk due totheir proximity to the occipital condyle. Differentialrotation between the head and the upper cervicalspine in high velocity injuries may also contribute.This case report is not the first to document adelayed hypoglossal nerve palsy following such afracture; the mechanism of which remainsobscure.6 Delayed hypoglossal nerve palsy mayresult from osseous or fibrous tissue proliferationas a result of the reparative process, alternativelyinadequate stabilisation of bony fragments mayberesponsible.9 With all cervical injuries it is manda-tory to formally test the cranial nerves and themotor and sensory function in both the trunk andall four extremities.
When reviewing lateral radiographs of the cervi-cal spine, measurement of the pre-vertebral softtissues is an important part of the examination.There are however many variables that may affectthis finding including: radiographic technique, thesite of injury and the time lapse between injury andradiographic examination. It has been shown thatfor pre-vertebral soft tissue measurements above10 mm there is a statistically significant probabilityof significant injury.10 If concern exists, computedtomography should be performed from C0 to C2 ifthese fractures at the base of the skull are not to bemissed, indeed it is the investigation of choiceaccording to many.1,2,7,8
References
1. Anderson PA, Montesano PX. Morphology and treatment ofoccipital condyle fractures. Spine 1988;13:731—6.
Figure 5 Clinical photograph. Note deviation of the tongue to the left indicative of a left hypoglossal nerve palsy.
Bilateral occipital condyle fractures 211
2. Anderson PA. Injuries to the occipital cervical arti-culation. In: Charles R Clark, editor. The cervical spine.3rd ed. Philadelphia: Lippincott-Raven; 1998. p. 387—99.
3. Castling B, Hicks K. Traumatic isolated unilateral hypoglos-sal nerve palsy. Case report and review of the literature. BrJ Oral Maxillofac Surg 1995;33:171—3.
4. Clavier E, Thiebot J, Hannequin D, Thomine JM, Benozio M.Cervico-occipital injury and bilateral paralysis of cranialnerve XII. Apropos of a case. J Radiol 1986;67(4):323—5[article in French].
5. Delamont RS, Boyle RS. Traumatic hypoglossal nerve palsy.Clin Exp Neurol 1989;26:239—41.
6. Demisch S, Lindner A, Beck R, Zierz S. The forgottencondyle. Delayed hypoglossal nerve palsy caused by fracture
of the occipital condyle. Clin Neurol Neurosurg 1998;100(1):44—5.
7. Legros B, Fournier P, Chiaroni P, Ritz O, Fusciardi J. Basalfracture of the skull and lower (IX, X, XI, XII) cranial nervespalsy. Four case reports including two fractures of theoccipital condyle: a literature review. J Trauma 2000;48(2):342—8.
8. Mariani PJ. Occipital condyle fracture presenting as retro-pharyngeal haematoma. Ann Emerg Med 1990;19:147—9.
9. Muthukumar N. Delayed hypoglossal palsy following occipi-tal condyle fracture–—case report. J Clin Neurosci 2002;9(5):580—2.
10. Templeton PA, Young JWR, Mirvis SE, et al. The value ofretropharyngeal soft tissue measurement in trauma of theadult cervical spine. Skeletal Radiol 1987;16:98—104.
212 B.J.C. Freeman, H. Behensky