Do Concomitant Cranium and Axis Injuries Predict Worse Outcome? A Trauma Database Quantitative Analysis

ABSTRACT

We performed a trauma database analysis to identify the effect of concomitant cranial injuries on outcome in patients with fractures of the axis. We identified patients with axis fractures over a 14-year period. A binary outcome measure was used. Univariate and multiple logistic regression analysis were performed. There were 259 cases with axis fractures. Closed head injury was noted in 57% and skull base trauma in 14%. Death occurred in 17 cases (6%). Seventy-two percent had good outcome. Presence of abnormal computed tomography head findings, skull base fractures, and visceral injury was significantly associated with poor outcome. Skull base injury in association with fractures of the axis is a significant independent predictor of worse outcomes, irrespective of the severity of the head injury. We propose that presence of concomitant cranial and upper vertebral injuries require careful evaluation in view of the associated poor prognosis.

KEYWORDS

Cervical spine - axis fractures - craniovertebral junction - skull base - trauma database

REFERENCES

• 1 Greene K A, Dickman C A, Marciano F F, Drabier J B, Hadley M N, Sonntag V K. Acute axis fractures. Analysis of management and outcome in 340 consecutive cases.  Spine (Phila Pa 1976). 1997;  22 (16) 1843-1852
• 2 Isolated fractures of the axis in adults.  Neurosurgery. 2002;  50(3, Suppl) S125-S139
• 3 Dashti R, Ulu M O, Albayram S, Aydin S, Ulusoy L, Hanci M. Concomitant fracture of bilateral occipital condyle and inferior clivus: what is the mechanism of injury?.  Eur Spine J. 2007;  16(Suppl 3) 261-264
• 4 Harris Jr J. The cervicocranium: its radiographic assessment.  Radiology. 2001;  218 (2) 337-351
• 5 Daffner R H. CT of the craniovertebral junction.  AJR Am J Roentgenol. 1996;  167 (2) 365-366
• 6 Kirshenbaum K J, Nadimpalli S R, Fantus R, Cavallino R P. Unsuspected upper cervical spine fractures associated with significant head trauma: role of CT.  J Emerg Med. 1990;  8 (2) 183-198
• 7 Link T M, Schuierer G, Hufendiek A, Horch C, Peters P E. Substantial head trauma: value of routine CT examination of the cervicocranium.  Radiology. 1995;  196 (3) 741-745
• 8 Sun P P, Poffenbarger G J, Durham S, Zimmerman R A. Spectrum of occipitoatlantoaxial injury in young children.  J Neurosurg. 2000;  93(1, Suppl) 28-39
• 9 Cunningham J, Brison R J, Pickett W. Concussive symptoms in emergency department patients diagnosed with minor head injury.  J Emerg Med. 2011;  40 (3) 262-266
• 10 Krakenes J, Kaale B R, Rorvik J, Gilhus N E. MRI assessment of normal ligamentous structures in the craniovertebral junction.  Neuroradiology. 2001;  43 (12) 1089-1097
• 11 Bloom A I, Neeman Z, Slasky B S et al.. Fracture of the occipital condyles and associated craniocervical ligament injury: incidence, CT imaging and implications.  Clin Radiol. 1997;  52 (3) 198-202
• 12 Hunink M GM. Decision making in the face of uncertainty and resource constraints: examples from trauma imaging.  Radiology. 2005;  235 (2) 375-383
• 13 Johnson F, Semaan M T, Megerian C A. Temporal bone fracture: evaluation and management in the modern era.  Otolaryngol Clin North Am. 2008;  41 (3) 597-618, x
• 14 Saboori M, Ahmadi J, Farajzadegan Z. Indications for brain CT scan in patients with minor head injury.  Clin Neurol Neurosurg. 2007;  109 (5) 399-405
• 15 Maas A IR, Steyerberg E W, Butcher I et al.. Prognostic value of computerized tomography scan characteristics in traumatic brain injury: results from the IMPACT study.  J Neurotrauma. 2007;  24 (2) 303-314
• 16 Feiz-Erfan I, Horn E M, Theodore N et al.. Incidence and pattern of direct blunt neurovascular injury associated with trauma to the skull base.  J Neurosurg. 2007;  107 (2) 364-369
• 17 Frye G, Wolfe T, Knopp R, Lesperance R, Williams J. Intracranial hemorrhage as a predictor of occult cervical-spine fracture.  Ann Emerg Med. 1994;  23 (4) 797-801
• 18 Koonsman M, Dunn E, Hughes K, Kendrick B, Moody J. How much monitoring is needed for basilar skull fractures?.  Am J Surg. 1992;  164 (5) 487-490
• 19 Society of Critical Care Medicine Ethics Committee . Consensus statement on the triage of critically ill patients.  JAMA. 1994;  271 (15) 1200-1203
• 20 Rodriguez R M, Wang N E, Pearl R G. Prediction of poor outcome of intensive care unit patients admitted from the emergency department.  Crit Care Med. 1997;  25 (11) 1801-1806
• 21 Hargrove J, Nguyen H B. Bench-to-bedside review: outcome predictions for critically ill patients in the emergency department.  Crit Care. 2005;  9 (4) 376-383
• 22 Murray G D, Butcher I, McHugh G S et al.. Multivariable prognostic analysis in traumatic brain injury: results from the IMPACT study.  J Neurotrauma. 2007;  24 (2) 329-337
• 23 Sharma B R. The injury scale—a valuable tool for forensic documentation of trauma.  J Clin Forensic Med. 2005;  12 (1) 21-28