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

Disclosure Statement

• Nothing to disclose

History

• Sir Charles Bell (1817)• Rare entity• Increasingly diagnosed

– Imaging enhancements– Routine imaging

Middlesex Hospital Journal 4:469-470, 1817

REVIEW OF LITERATURE

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

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 41:368-377, 1997

American Roent Ray Soc 178: 1261-68, 2002Emergency Radiology Online, 2009

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, 2004Emergency Radiology Online, 2009

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

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)

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

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%)

CLASSIFICATIONType 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

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

TREATMENT & OUTCOME

• Type I and II

NumberRadiographic

stabilityTreatment Number

FollowUp Flex-Exten stable/obtained

24 (30%) All Stable

Cervical collar 20 3/3

Halo-vest 1+ -

Death before tx 3 -

TREATMENT & OUTCOME

• Type III, IorIII, IandIII

NumberRadiographic

stabilityNumber Treatment Number

FollowUp Flex-Exten stable/obtained

55 (70%)

Stable 40 (73%)

Cervical collar 34 8/8

CTO 2 1/1

Halo-vest 1+ 0/0

Death before tx 3 -

Unstable 15 (27%)

Cervical collar 1 0/1

Halo-vest 13 8/8

Death before tx 1 -

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

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?

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