Cranio-Cervical Junction Acute Injury

Julia Crim, MD

DIFFERENTIAL DIAGNOSIS

Common

Trauma
- Odontoid C2 Fracture
- Burst Fracture, C2
- Hangman’s C2 Fracture
- Jefferson C1 Fracture
- Occipital Condyle Fracture
- Dissection, Vertebral Artery
- Traumatic Disc Herniation
- Os Odontoideum
- Spinal Cord Injury Without Radiographic Abnormality (SCIWORA)
Nontraumatic Mimics
- Pathologic Vertebral Fracture
- Craniovertebral Junction Variants
- Incomplete Fusion, Posterior Element
- Pseudosubluxation C2-3
- Torticollis

Less Common

Atlanto-Occipital Dislocation
Atlanto-Axial Rotary Subluxation

ESSENTIAL INFORMATION

Key Differential Diagnosis Issues

MR very useful to evaluate for ligament injuries
- Coronal STIR rarely performed but useful in this region
Coronal, sagittal reformations essential on CT for full evaluation of injury
CT arteriogram equally accurate and faster than MR arthrogram for vertebral dissection
- Time is often of the essence in these patients, who tend to have multiple injuries

Helpful Clues for Common Diagnoses

Odontoid C2 Fracture
- Usually low-velocity injury in elderly
Jefferson C1 Fracture
- If combined displacement of lateral masses > 6.9 mm, unstable
- High likelihood of other fractures: Spine, skull, pelvis, lower extremity
Os Odontoideum
- Chronic, nonunited odontoid fracture
Spinal Cord Injury Without Radiographic Abnormality (SCIWORA)
- Occurs primarily in children
- MR: Injuries to cord, ligaments, intervertebral discs, cartilaginous endplates
- 2/3 severe cervical injuries in children < 8 years are SCIWORA
Pseudosubluxation C2-3
- Children < 10 years old, anterolisthesis may measure up to 4 mm

Helpful Clues for Less Common Diagnoses

Atlanto-Occipital Dislocation
- High incidence cord injury
- Formerly usually fatal; now often survive to hospital

Image Gallery

Sagittal NECT shows type 2 dens fracture

in an osteoporotic patient. Soft tissue swelling is mild. These fractures are commonly subtle on radiographs and best seen on lateral (not odontoid) view.

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