Treatment of Unstable Occipital Condylar Fractures in Children—A STROBE-Compliant Investigation

Abstract

Background and objectives: Occipital condyle fractures (OCF) occur rarely in children. The choice of treatment is based on the Anderson–Montesano and Tuli classification systems. We evaluated the outcome of unstable OCF in children and adolescents after halo-vest therapy. Materials and Methods: We treated 6 pediatric patients for OCF, including 3 patients (2 girls, 1 boy) with unstable OCF. Among the 3 patients with unstable OCF, 2 patients presented with an Anderson–Montesano type III and Tuli type IIB injury, while 1 patient had an Anderson–Montesano type I fracture (Tuli type IIB) accompanied by a C1 fracture. On admission, the children underwent computed tomography (CT) of the head and cervical spine as well as magnetic resonance imaging (MRI) of the cervical spine. We treated the children diagnosed with unstable OCF with halo-vest immobilization. Before removing the halo vest at the end of therapy, we applied the CT and MRI to confirm OCF consolidation. At follow-up, we rated functionality of the craniocervical junction (CCJ) based on the Neck Disability Index (NDI) and Questionnaire Short Form 36 Health Survey (SF-36). Results: All children achieved OCF consolidation after halo-vest therapy for a median of 13.0 weeks (range: 12.5–14.0 weeks). CT and MRI at the end of halo-vest therapy showed no signs of C0/C1 subluxation and confirmed the correct consolidation of OCF. The only complication associated with halo-vest therapy was a superficial infection caused by a halo-vest pin. At follow-up, all children exhibited favorable functionality of the CCJ as documented by the NDI score (median: 3 points; range: 3–11 points) and SF-36 score (median: 91 points; range: 64–96 points). Conclusions: In our small case series, halo-vest therapy resulted in good mid-term outcome in terms of OCF consolidation and CCJ functionality. In pediatric patients with suspected cervical spine injuries, we recommend CT and MRI of the CCJ to establish the diagnosis of OCF and confirm stable fracture consolidation before removing the halo vest.

Occipital condyle fracture in the pediatric population: A management algorithm and systematic review

“…For unstable fractures, CT and MRI revealed a translation ranging between 3 and 4 mm between C0 and C1 and a rotational displacement of C0/C1 by 10 and 12 degrees. 4,9,20 This range of findings is similar to the Tuli criteria definitions, 9 which describe instability as >1 mm C0 and C1 translation or >8 degrees of C0/C1 axial rotation, among other criteria such as >7 mm C1 overhang onto C2, >45 degrees of C1-C2 to one side, >4 mm C1-C2 translation, and ligament injury. Notably, while these findings were described in a majority adult population, these established measurements can largely be applied to the population included in this review as the majority sustained their injury during or after puberty.…”

“…8 For patients who received halo vests, all underwent MRI within 9 days (median = 5.6 days, range = 3-9 days) of halo removal. 4,8 Operative Two patients required operative intervention in the form of ventriculoperitoneal shunt 4 and craniotomy. 15 These patients presented with Type III and Type II OCFs, respectively.…”

“…Serial imaging is also supported by the literature, with Ucler and Yucetas 19 and other works highlighting that CT scanning at set time intervals is essential for thorough neurological examination. 4,15 Operative intervention was not utilized within our patient population, apart from two operations for associated injuries. In addition, one patient received fixation-fusion due to C1-C2 instability after initial ventriculoperitoneal shunt placement and halo vest treatment.…”

“…Surgery should be used only in special and comparatively extreme circumstances in the skeletally mature patient. 2,4,5,9,19 Outcomes and follow-up Key outcomes assessed included post-treatment CCJ functionality, neck ROM restoration, pain resolution, and alleviation of CN deficits. All but one patient reported complete painless return of neck ROM.…”

“… 1 OCFs in the pediatric population are not extensively described in the literature; despite often being considered rare, 1 – 3 they manifest in 1%–16% of cervical spine injuries. 1 , 2 – 5 OCFs are most associated with high-energy traumas, such as motor vehicle accidents (MVA) or falls from heights. 1 , 2 , 4 , 6 OCFs in the pediatric population can occur even without indicative symptoms associated with other cervical spine injuries.…”