Complications in Surgical Management of Craniovertebral Junction Trauma

The craniovertebral junction (CVJ) area is a very special, intricate, and complex region of the spine and about half of all cervical fractures occur in this area. Many of these patients need surgery for an unstable cervical spine, which may be associated with variety of complications.

Materials and Methods: In this retrospective study (January 2008 to December 2016), we enrolled all surgically treated odontoid fractures, hangman’s fracture, and traumatic atlantoaxial dislocations (AAD) and analyzed them for surgery related complications.

Results: We have identified a total of 313 surgically treated patients of CVJ trauma (odontoid no. 197; hangman’s no. 56; AAD-60). In odontoid, a total of 111 patients underwent anterior odontoid screw (OS) fixation which had 10% overall morbidity and 0.9% mortality (due to cranial migration of K wire causing subarachnoid hemorrhage) related to procedure. Failure of fixation due to screw cut through and nonunion occurred in 3.6% patients each. One patient developed K-wire breakage during surgery and two patients had postoperative dysphagia. Overall, 6.3% patients underwent second surgery.

Posterior fixation was performed in 202 patients (odontoid no. 86, hangman’s no. 56, and 60 AAD patients). Posterior fixation includes variety of procedures like traditional occipito-cervical fixation and C1-C2 wiring to more challenging C1-C2 transarterial screw (Magerl technique) and Goel-Harms technique. Overall there was vertebral artery injury in 1%, CSF leak in 3%, wound infection in 3.5%, meningitis in 0.5% and procedure related death in 0.5% patient. 8 patients (4%) required revision surgery for either fixation failure or nonunion. In surgery for hangman’s fracture, 2 patients also had distal junctional kyphosis requiring revision surgery.

Conclusion: So in conclusion, treatment of CV junction fracture is challenging and one should have knowledge of all the nuances of anterior and posterior CVJ fixation to avoid complications as well as provide optimal treatment to the patients.