Tectorial Membrane Injury, Frequently Identified in Adult Trauma Patients Who Undergo Occipital-Cervical Fusion for Craniocervical Instability.

Peter Fiester,Dinesh Rao,Matthew Jenson,Jeet Patel,Erik Soule

doi:10.7759/cureus.14254

Abstract

BackgroundIn the absence of frank craniocervical dissociation, there is a lack of consensus regarding what patterns of craniocervical junction ligamentous injuries require occipital-cervical fusion. This study was undertaken to examine the integrity of the craniocervical junction ligaments and analyze clinical outcomes in patients who underwent occipital-cervical fusion for craniocervical junction injury.MethodsAdult patients requiring occipital-cervical fusion were identified retrospectively utilizing keyword searches in cervical computed tomography and magnetic resonance imaging reports between 2012 and 2020 using Nuance mPower software (Nuance, Burlington, MA). The cervical magnetic resonance imaging examinations for these patients were reviewed for craniocervical ligamentous injury by two neuroradiologists. Descriptions of craniocervical junction injuries, demographic information, clinical history, surgical management, and global outcomes were recorded.ResultsNine adult patients were identified with an acute, post-traumatic craniocervical junction injury requiring occipital-cervical fusion. All nine patients demonstrated a ligamentous tear in at least one of the four major craniocervical junction ligaments - the occipital condylar-C1 capsular ligaments, alar ligaments, tectorial membrane, and posterior atlantooccipital membrane. The tectorial membrane was the most commonly torn ligament followed by the alar ligament(s), posterior atlantooccipital membrane, and capsular ligament(s). There was wide variability in the number of major craniocervical junction ligaments torn, ranging from one ligament to all four ligaments. Four patients suffered persistent neurologic deficits following surgery.ConclusionCraniocervical injury is best evaluated by cervical magnetic resonance imaging. In the absence of overt craniocervical dissociation, we propose that an injury of the tectorial membrane in the adult population may indicate patients with significant craniocervical instability, possibly necessitating occipital-cervical fusion.

Highlights

The craniocervical junction (CCJ) is a unique osteoligamentous structure that comprises the occipital condyles, skull base, first and second cervical vertebrae
Nine adult patients were identified with an acute, post-traumatic craniocervical junction injury requiring occipital-cervical fusion
The tectorial membrane was the most commonly torn ligament followed by the alar ligament(s), posterior atlantooccipital membrane, and capsular ligament(s)

Summary

Introduction

The craniocervical junction (CCJ) is a unique osteoligamentous structure that comprises the occipital condyles, skull base, first and second cervical vertebrae. CT is the modality of choice to evaluate for CCJ trauma since it readily depicts bony fractures and condylar-C1 joint subluxation and dislocation [3]. In the absence of bony trauma or abnormal joint space widening at the CCJ, CT may underreport significant craniocervical trauma. This situation may have devastating clinical consequences since the early diagnosis of unstable craniocervical junction injury and treatment with spinal stabilization protect against worsening spinal cord. In the absence of frank craniocervical dissociation, there is a lack of consensus regarding what patterns of craniocervical junction ligamentous injuries require occipital-cervical fusion. This study was undertaken to examine the integrity of the craniocervical junction ligaments and analyze clinical outcomes in patients who underwent occipital-cervical fusion for craniocervical junction injury

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