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Final operative view of the C1-C2 posterior fusion. Bilateral C1 lateral mass screws and C2 crossing laminar screws are connected to rods with lateral offset. Beta-tricalcium phosphate granules (arrowheads) combined with local bone chips are placed between the lateral masses of C1 and C2
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Figure 3: Final operative view of the C1-C2 posterior fusion. Bilateral C1 lateral mass screws and C2 crossing laminar screws are connected to rods with lateral offset. Beta-tricalcium phosphate granules (arrowheads) combined with local bone chips are placed between the lateral masses of C1 and C2

Mentions: A 63-year-old man had suffered from dysesthetic pain in his right upper extremity and cough-induced headache for 30 years. He was followed up under a diagnosis of syringomyelia at his local practitioner until he noticed mild motor weakness of his right hand in 2006. He was referred to Iwate Medical University in 2009. A diagnosis of Chiari malformation type 1 with syringomyelia was established. A standard foramen magnum decompression (suboccipital craniectomy and C1 laminectomy) was carried out on 4 June 2009. His postoperative course was uneventful until the patient noticed progressive posterior cervical pain 5 months after the operation. Computed tomography (CT) of the upper cervical spine revealed left C1 anterior arch fracture [Figure 1]. Since preoperative CT showed intact C1, it is evident that the C1 anterior arch fracture has spontaneously developed following foramen magnum decompression with C1 laminectomy. The patient was referred to our hospital at the end of January 2010. Cervical radiography showed slight instability at the C1–C2 level [Figure 2]. C1-C2 posterior fusion was carried out in March 2010. Bilateral C2 crossing laminar screws were first inserted with the assistance of a navigation system (Stealth Station; Medtronic Sofamor Danek, Memphis, Tennessee, USA). We considered crossing laminar screws for C2 to be safer for this patient because of the narrow passage of bilateral C2 pedicles. C1 lateral mass screws were then inserted under fluoroscopic guidance. The screws at C1 and C2 were connected with rods combined with lateral offset at the left and right sides, respectively (VERTEX-MAX system; Medtronic Sofamor Danek). Beta-tricalcium phosphate granules[28] mixed with local bone chips were placed between the lateral masses of C1 and C2 for better bony fusion [Figure 3]. Postoperative studies showed adequate placement of the implants with good cervical alignment and stability Figure 4. Complete pain relief was achieved immediately after the second operation, and the patient resumed his daily activities as a tobacco farmer.

Spontaneous C1 anterior arch fracture as a postoperative complication of foramen magnum decompression for Chiari malformation type 1

Hirano Y, Sugawara A, Mizuno J, Takeda M, Watanabe K, Ogasawara K - Surg Neurol Int (2011)

Bottom Line: Complete pain relief was achieved immediately after the second operation, and the patient resumed his daily activities.Anterior atlas fracture following foramen magnum decompression for Chiari malformation type 1 is very rare, but C1 laminectomy carries the risk of anterior arch fracture.Neurosurgeons should recognize that fracture of the atlas, which commonly results from an axial loading force, can occur in the postoperative period in patients with Chiari malformation.

Affiliation: Center for Spine and Spinal Cord Disorders, Southern Tohoku General Hospital, 1-2-5, Satonomori, Iwanuma, Miyagi 989-2483, Japan.

ABSTRACT

Background: C1 fracture accounts for 2% of all spinal column injuries and 10% of cervical spine fractures, and is most frequently caused by motor vehicle accidents and falls. We present a rare case of C1 anterior arch fracture following standard foramen magnum decompression for Chiari malformation type 1.

Case description: A 63-year-old man underwent standard foramen magnum decompression (suboccipital craniectomy and C1 laminectomy) under a diagnosis of Chiari malformation type 1 with syringomyelia in June 2009. The postoperative course was uneventful until the patient noticed progressive posterior cervical pain 5 months after the operation. Computed tomography of the upper cervical spine obtained 7 months after the operation revealed left C1 anterior arch fracture. The patient was referred to our hospital at the end of January 2010 and C1-C2 posterior fusion with C1 lateral mass screws and C2 laminar screws was carried out in March 2010. Complete pain relief was achieved immediately after the second operation, and the patient resumed his daily activities.

Conclusion: Anterior atlas fracture following foramen magnum decompression for Chiari malformation type 1 is very rare, but C1 laminectomy carries the risk of anterior arch fracture. Neurosurgeons should recognize that fracture of the atlas, which commonly results from an axial loading force, can occur in the postoperative period in patients with Chiari malformation.

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