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Vertical atlantoaxial distraction injuries: radiological criteria and clinical implications

L. Fernando Gonzalez, David Fiorella, Neil R. Crawford, Robert C. Wallace, Iman Feiz-Erfan, Denise Drumm, Stephen M. Papadopoulos, and Volker K.H. Sonntag

Object. The authors sought to establish radiological criteria for the diagnosis of C1–2 vertical distraction injuries.

Methods. Conventional radiography, computerized tomography (CT), and magnetic resonance (MR) imaging findings in five patients with a C1–2 vertical distraction injury were correlated with their clinical history, operative findings, and autopsy findings. The basion—dens interval (BDI) and the C-1 and C-2 lateral mass interval (LMI) were measured in 93 control patients who underwent CT angiography; these measurements were used to define the normal BDI and LMI. The MR imaging results obtained in 30 healthy individuals were used to characterize the normal signal intensity of the C1–2 joint. The MR imaging results were compared with MR images obtained in five patients with distraction injuries.

In the 93 patients, the BDI averaged 4.7 mm (standard deviation [SD] 1.7 mm, range 0.6–9 mm) and the LMI averaged 1.7 mm (SD 0.48 mm, range 0.7–3.3 mm). Based on CT scanning in the five patients with distraction injuries, the BDIs (mean 11.9 mm, SD 3.2 mm; p < 0.001) and LMIs (mean 5.5 mm, SD 2 mm; p < 0.0001) were significantly greater than in the control group. Fast—spin echo inversion-recovery MR images obtained in these five patients revealed markedly increased signal distributed throughout the C1–2 lateral mass articulations bilaterally.

Conclusions. In 95% of healthy individuals, the LMI ranged between 0.7 and 2.6 mm. An LMI greater than 2.6 mm indicates the possibility of a distraction injury, which can be confirmed using MR imaging. Patients with a suspected C1–2 distraction injury may be candidates for surgical fusion of C1–2.