Occipital Condyle Fractures: Epidemiology, Classification, and Treatment

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, 2002 Emergency 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, 2004 Emergency 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 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

CLASSIFICATION 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

TREATMENT & OUTCOME • Type III, IorIII, IandIII

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

Occipital Condyle Fractures: Epidemiology, Classification, and Treatment