IntroductionThe frequency of vertebrobasilar ischemia in patients with cervical spine trauma had been regarded as low in many published papers. However, some case reports have described cervical spine injury associated with blunt vertebral artery injury. Many aspects of the management of vertebral artery injuries still remain controversial, including the screening criteria, the diagnostic modality, and the optimal treatment for various lesions. The case of a patient who had a brain infarction due to recanalization of his occluded vertebral artery following open reduction of cervical spinal dislocation is presented here.Case presentationA 41-year-old Asian man presented with C4 to C5 distractive flexion injury manifesting with quadriplegia and anesthesia below his C3 cord level (including phrenic nerve paralysis), and bowel and bladder dysfunction. Magnetic resonance angiography and computed tomography angiography showed left extracranial vertebral artery occlusion and patent contralateral vertebral artery. He was observed without antiplatelet and/or anticoagulation therapy, and underwent surgery (open reduction and internal fusion of C4 to C5, and tracheostomy) 8 hours after the injury. After surgery, supraspinal symptoms such as left horizontal nystagmus and left homonymous hemianopsia led to cranial computed tomography and magnetic resonance imaging, which showed left-side cerebellar infarction in his posterior inferior cerebellar artery territory and right-side posterior cerebral artery infarction. Magnetic resonance angiography and computed tomography angiography demonstrated patent bilateral vertebral artery (but hypoplastic right vertebral artery) and occluded right posterior cerebral artery. His injured vertebral artery was treated conservatively, which did not cause any other ischemic complications.ConclusionsThe management of asymptomatic vertebral artery injury is controversial with several treatment options available, including observation alone, antiplatelet therapy, anticoagulation therapy, or invasive intervention. Although there are some reports in which management with observation alone is described as safe, we should pay serious attention to the vertebral artery injury caused by cervical spine trauma.

Objective: Polyaxial screw-rod fixation of C1-C2 is a relatively new technique to treat atlantoaxial instability, and there have been few reports in the literature outlining all possible complications. The purpose of this case report is to present the occurrence and management of occipital bone erosion induced by the protruded rostral part of a posterior atlantoaxial screwrod construct causing headache. Clinical Features: A 70-year-old Asian man with rheumatoid arthritis initially presented to our institution with atlantoaxial instability causing progressive quadraparesis and neck pain. Intervention and Outcome: Posterior atlantoaxial instrumented fixation using C1 lateral mass screws in conjunction with C2 pedicle screws was performed to stabilize these segments. Postoperatively, the patient regained the ability to independently walk and had no radiographic evidence of instrumentation hardware failure and excellent sagittal alignment. However, despite a well-stabilized fusion, the patient began to complain of headache during neck extension. Follow-up imaging studies revealed left occipital bone erosion induced by a protruded titanium rod fixed with setscrews. During revision surgery, the rod protrusion was modified and the headaches diminished. Conclusion: This case demonstrates that occipital bone erosion after posterior atlantoaxial fixation causing headache may occur. The principal cause of bone erosion in this case was rod protrusion. Although posterior atlantoaxial fixation using the screw-rod system was selected Journal of Chiropractic Medicine (2014) 13, 278-281 to manage atlantoaxial instability because it has less complications than other procedures, surgeons should pay attention that the length of the rod protrusion should not exceed 2 mm.

Objective: The purpose of this case report is to describe a patient with brain infarction due to recanalization of an occluded vertebral artery (VA) following closed reduction and open fixation of cervical spinal dislocation and to discuss the management of asymptomatic VA injuries associated with spine trauma. Clinical Features: A 41-year-old Asian man experienced a C4-5 distractive-flexion injury manifesting with quadriplegia and anesthesia below the C3 cord level (including phrenic nerve paralysis), and bowel and bladder dysfunction. Magnetic resonance angiography and computed tomography angiography showed left extracranial VA (V2) occlusion and a patent contralateral VA. Intervention and Outcome: The patient was observed without antiplatelet and/or anticoagulation therapy and underwent open reduction and internal fusion of C4/5 and tracheostomy 8 hours after the injury. After surgery, supraspinal symptoms such as left horizontal nystagmus and left homonymous hemianopsia led to cranial computed tomography and magnetic resonance imaging, which showed left-side cerebellar infarction in the posterior inferior cerebellar artery territory and right-side posterior cerebral artery infarction. Magnetic resonance angiography and computed tomography angiography demonstrated patent bilateral VA (but hypoplastic right VA) and occluded right posterior cerebral artery. The injured VA was treated conservatively, and there were no other ischemic complications. Conclusion: The management of asymptomatic VA injury is controversial, with several treatment options available, including observation alone, antiplatelet therapy, anticoagulation therapy, or invasive intervention. Although there are some reports described where management with observation alone seems safe, serious attention should be given to the VA injury caused by cervical spine trauma.

Objective: Lumbar fracture-dislocations are rare and invariably due to high-energy trauma. The purpose of this study is to report the surgical management of a man with lateral lumbar dislocations in 2 noncontiguous lesions. Clinical features: A 49-year-old Asian man was crushed by a bulldozer. The patient was transported to a major medical center where he was found to be conscious, and the primary spinal injuries were fracture-dislocation of L1-L2 and L4-L5. His preoperative neurologic status showed a partial paraparesis to all motor groups of the lower extremities bilaterally. His radiological and operative findings showed a rupture of the thoracolumbar fascia and latissimus dorsi muscle, left L1-L2 dislocated facet, right L4-5 facet fracture, and dural tear. Intervention and outcome: The patient underwent a posterior reduction, decompression, instrumentation, and fusion surgery from T12 to S1 with autologous bone graft and pedicle screw instrumentation. Postoperatively, his neurologic status improved, allowing him to be ambulatory using a Lofstrand crutch with improved lumbosacral alignment being well maintained. Two weeks postoperatively, the patient regained voluntary bowel and bladder function. At the 1-year follow-up evaluation, his motor power was full in the left leg; however, sensation to pin prick remained lost on the right L5 and S1 distributions. He continued to ambulate using a Lofstrand crutch. Conclusion: Lateral lumbar fracture-dislocation at 2 noncontiguous levels is an unusual injury that results from high-energy trauma. Prompt recognition of the injuries, reduction of the fracture-dislocations, and posterior stabilization are recommended for neural decompression, spinal alignment, and long-term stabilization.

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