Abstract Trauma to the brain or calvaria may causesome cranial nerve damage. This may be transitory orpermanent. Occipital condyle fracture (OCF) is a rarelyencountered pathology not easily diagnosed by routineclinical and radiological evaluation and one of the causesof lower cranial nerve disability. Frequently, the hypo-glossal nerve is involved. Here we present two cases ofOCF caused by motor vehicle accidents. Both of the pa-tients complained of dysphagia and voice disturbance.After detailed neurologic and radiologic evaluation, theywere diagnosed with OCF. They were both treated con-servatively. OCF as a cause of lower cranial nerve dam-age is rarely reported. Since it is hard to diagnose OCFby routine cranial and cervical evaluation, detailed radio-logical study in suspected cases is a must. Since one ofour patients was admitted 6 years after the trauma, thisarticle is also noteworthy as a report on radiologicalchanges of the OCF.

Key words Lower cranial nerve paralysis · Occipitalcondyle fracture

Introduction

Cranial nerve signs and symptoms are frequently en-countered in many pathologic conditions related to thebrain and/or skull, some of which are demyelinating dis-eases, tumorous conditions of the brain, infectious condi-tions of the central nervous system, vascular lesions of

the brain, and trauma to the head and neck [16, 24, 33,41]. Occipital condyles are located on the anterolateralpart of the foramen magnum in close relation to the hy-poglossal canal and jugular foramen [26, 32]. Craniocer-vical trauma rarely causes OCF. OCF is a rarely reportedpathology in the literature and most of the studies appearas case reports (Table 1) [8, 15, 42]. Here we describetwo patients with diagnoses of traumatic OCF. Theirclinical and radiological characteristics are discussedwith a review of the literature.

Case report

Case 1

A 36-year-old female complaining of neck pain, hoarseness, anddysphagia after a traffic accident was admitted to our neurosurgeryclinic. On clinical examination, she was alert and well-oriented,ovula deviated to the right, and strength of the sternocleidomas-toid and deltoid was depressed. Plain X-ray films of the cervicalvertebrae and cranium were normal. A thin-slice computed tomog-raphy (CT) scan of the craniocervical region revealed a fracture ofthe left occipital condyle (Fig. 1). Further workup included elec-

B. Cirak (✉ )Yuzuncu Yil Universitesi, Tip Fakultesi Arastirma Hastanesi,Beyin Cerrahisi, 65300, Van, TurkeyTel.: +90-432-2150479, Fax: +90-432-2167519

G. AkpinarDepartment of Neurosurgery, Bayindir Medical Center,Ankara, Turkey

S. PalaogluDepartment of Neurosurgery,Hacettepe University Medical School, Ankara, Turkey

Neurosurg Rev (2000) 23:161–164 © Springer-Verlag 2000

C A S E R E P O RT

Bayram Cirak · Gokhan Akpinar · Selcuk Palaoglu

Traumatic occipital condyle fractures

Received: 12 January 1999 / Accepted: 15 April 1999

Fig. 1 Axial CT through the fracture line on the left occipital con-dyle (arrow)

troneuromyography (ENMG), which showed partial denervationof the left cranial nerves XI and XII. She was diagnosed as a type2 stable OCF according to Anderson and Montesano [3]. A semi-rigid cervical collar was recommended. After 3 months of follow-up, the dysphagia and hoarseness had disappeared. ENMG per-formed in the fourth post-traumatic month showed signs of rein-nervation of both cranial nerves XI and XII.

Case 2

A 52-year-old male complaining of dysphagia and blurred speechwas admitted to our neurosurgery clinic. A detailed history of thepatient revealed he had had a traffic accident 6 years earlier andcomplained of these symptoms since then. Neurologic examina-tion revealed paralysis of the right cranial nerves IX and XII. PlainX-ray films were normal. A craniocervical CT showed callus for-mation on the right occipital region revealing an old OCF (Fig. 2).

It was a stable type-2 fracture. Since it was an old fracture, notherapeutic recommendation was given to the patient.

Discussion

Lower cranial nerves are frequently damaged in process-es involving the brain stem, foramen magnum, and cere-bellopontine angle [16, 26, 33]. OCF is a very rare trau-matic lesion of the skull base, causing lower cranialnerve damage [3, 7]. To date, including our cases, therehave been 75 cases of OCF in survivors reported in38 articles, and 38 postmortem cases reported in eightarticles [14, 42]. Table 1 lists the reported cases of OCFsurvivors. Occipital condyles are in close relationship tothe hypoglossal canal (less than 0.5 cm) and the jugularforamen (less than 1 cm), which includes cranial nervesIX, X, and XI. Occipital condyles also have a vital ana-tomical relationship to the brain stem and vascular struc-tures [26, 32]. Traumatic lesions of the occipital con-

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Table 1 Review of the litera-ture for occipital condyle frac-ture. Cranial nerve (CN); fe-male (F); male (M); sterno-occipitomandibular immobili-zation (SOMI)

Reference Year Age (sex) Involved CN Treatment

Ahlgren et al. [2] 1962 25 (M) X CollarAhlgren [1] 1964 51 (F) None CollarAhlgren [2] 1964 82 (F) None NoneSchliak [37] 1965 29 (M) VI, XI, XII CollarWackenheim [44] 1974 Six cases ConservativeBolender [7] 1978 23 (M) IX, XII None

22 (M) VI, VII, IX, X NoneHandel [20] 1981 18 (M) None CollarGoldstein [18] 1982 24 (F) None CollarPeeters [35] 1983 17 (M) None CollarCamassa [10] 1983 42 (M) XI CollarSpencer [38] 1984 19 (M) X Halo westSpirig [39] 1985 30 (M) None Traction-SOMIHollerhage [25] 1986 18 (M) XII CollarClavier [11] 1986 25 (F) VI, XII CollarHashimoto [22] 1988 71 (M) IX, XII CollarCurri [13] 1988 16 (F) None CollarAnderson-Montesano [3] 1988 Six cases 5 Collar,1 HaloSavoleine [36] 1989 71 (F) VI Halo westOrbay [34] 1989 37 (M) XII NoneValaskatzis [43] 1990 19 (M) None CollarDesai [14] 1990 33 (M) VI CollarJones [28] 1990 43 (M) Quadriplegic CollarMariani [30] 1990 30 (M) None CollarWessels [45] 1990 26 (M) VII, X, XII Collar

7/12 (M) V, VII, IX, X, XII Collar27 (M) VII, X, XII Collar

Bridgman [9] 1992 32 (M) X, XII CollarBozboga [8] 1992 34 (F) X, XII Collar

37 (M) XII SurgeryMody [31] 1992 21 (M) None TractionLeventhal [29] 1992 Six cases Traction (1), Collar (5)Bettini [5] 1993 Four cases CollarYoung [46] 1994 26 (F) IX, XII Halo west

20 (M) None Collar22 (M) None Collar

Stroobants [40] 1994 27 (M) None CollarBloom [6] 1996 Nine cases ConservativeCottalorda [12] 1996 Adolescent None CollarHeinz [24] 1997 Three cases None ConservativeTuli [42] 1997 27 (M) None None

64 (F) None Collar69 (F) VII None

Ide [27] 1998 Adult None CollarGasser [17] 1998 Adolescent None CollarOur cases 1998 36 (F) XI, XII Collar

52 (M) IX, XII None

dyles can cause lower cranial nerve lesions or even brainstem damage. In clinical practice, most patients sufferlower cranial nerve dysfunction [7, 8, 15, 22]. Becauselesions in the brain stem and vessels are often fatal, someauthors attribute their rarity to this fact [14, 26]. OCFwas first reported by Bell in 1817 [4]. Anderson andMontesano [3] classified OCF into three types: (1) burstfractures caused by axial loading, (2) extension from abasilar skull fracture, and (3) avulsion fractures at the in-sertion site of the alar ligaments. Tuli et al. [42] latermodified this classification. Considering the relationshipof the occipital condyle to the jugular foramen with cra-nial nerves IX, X, and XI and to the hypoglossal canalwith nerve XII, it is not difficult to imagine how an OCFcan produce lower cranial nerve damage. Cranial nervepalsies may result from nerve compression, nervestretching, or nerve rootlet avulsion [23, 24]. There havebeen reports of cases with symptoms ranging from iso-lated paralysis of the hypoglossal nerve to full lower cra-nial nerve palsy (Collet Sicard syndrome) [22]. Grundyet al. [19] have suggested that cranial nerve palsies maybe secondary to vertebral artery insufficiency. There mayalso be torticollis due to OCF. In severe torticollis, posi-tioning the patient for plain film can be difficult and X-ray films may not show anatomic relationships wellenough for an accurate diagnosis. CT scanning andthree-dimensional CT (3D CT) provide a clear view ofthe lesion [6, 36]. Since bony structures are not very welldelineated, MR is rarely used in diagnostic evaluationof OCF, but it is helpful in demonstrating the brainstem, vascular structures, and cranial nerve involvement[8, 17].

In the management of OCF, surgery might be indicat-ed for two reasons: decompression and stabilization[8, 46]. Compression of the cranial nerves or the brainstem structures are the indications for surgical decom-pression. But because of the difficulties in operating in

such a small and critical space, most authors preferred tohandle OCF conservatively. Because of this, most au-thors agree that treatment should be conservative, evenwhen surgical neural decompression is suggested, be-cause if the nerve does not recover, it is likely to havebeen injured by a combination of traction or crushing,which will not be helped by decompression. Patients alsomake a good functional recovery with conservative ther-apy in the case of unilateral lesions, as described in ourfirst case. Surgical intervention for an isolated OCF hasbeen described in only one case to date, by Bozboga etal. [8]. Lower cranial nerve paralysis caused by callusformation secondary to an old OCF as a delayed neurop-athy has never been reported before. We treated our firstcase conservatively. Her signs and symptoms improved,but in the second case we did not use any therapeutic ap-proach, since it was an old fracture.

With respect to the literature and our experience inthese two cases, we can conclude: OCF is indeed not asrare as reported and, in some cases with interference tovascular structures and the brain stem, mortality is highand thus prevents diagnosis. The most frequent signs andsymptoms of OCF are related to the involvement of low-er cranial nerves. Cranial nerve involvement may be de-layed and the hypoglossal nerve is the most frequentlydamaged nerve in OCF. The mainstone in the diagnosisof OCF is to be suspicious in cases with complaints oflower cranial nerve damage. CT and, in selected cases,3D CT and MRI, are the main diagnostic tools. In stablecases, a cervical collar is recommended, while in unsta-ble cases, rigid fixation with a halo west is mandatory.

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