Name:
FOCUS25824video5
Description:
FOCUS25824video5
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/70c1cb57-2ab0-497b-aa36-bf7904d5ac66/videoscrubberimages/Scrubber_1.jpg?sv=2019-02-02&sr=c&sig=vH82KcevrWMT4IQt0VPJHWROPKvjmZigLUTKVFXd%2Bro%3D&st=2026-05-13T19%3A53%3A14Z&se=2026-05-13T23%3A58%3A14Z&sp=r
Duration:
T00H05M47S
Embed URL:
https://stream.cadmore.media/player/70c1cb57-2ab0-497b-aa36-bf7904d5ac66
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/70c1cb57-2ab0-497b-aa36-bf7904d5ac66/5. 24-998.mp4?sv=2019-02-02&sr=c&sig=kOpob%2BdMBwqbE5kIL1fWSTaU2V38Fmjvr%2FLIZAaWsnQ%3D&st=2026-05-13T19%3A53%3A14Z&se=2026-05-13T21%3A58%3A14Z&sp=r
Upload Date:
2025-12-03T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
SPEAKER: This is the case of a 91-year-old female with multiple
SPEAKER: comorbidities who suffered a mechanical fall down the stairs. She did not have loss of consciousness and presented to an outside hospital neurologically intact. X-rays at that hospital demonstrated a type II odontoid fracture, with significant retropulsion of the tip of the odontoid behind the body of C2.
SPEAKER: In addition, AP x-rays demonstrated a slight "cock robin" appearance. CT scan redemonstrated the type II odontoid fracture and in addition showed a classic Jefferson's fracture of C1. MRI scan revealed significant spinal cord compression at the site of the odontoid fracture. The patient was neurologically intact. She was initially treated with bed rest and a cervical collar for 1 week.
SPEAKER: And then transferred to our facility at the request of the family. The patient was admitted to our intensive care unit and Gardner-Wells traction was applied. This resulted in moderate reduction of the odontoid fracture. The options of halo versus surgical stabilization were discussed with the patient and her family. Surgical stabilization was requested.
SPEAKER: The plan following this reduction was for a posterior C1–2 fusion using lateral mass and pedicle/pars screws placement. Excellent reduction of the odontoid fracture was demonstrated intraoperatively, after which C2 pedicle/pars and C1 lateral mass screws were placed using a cross- link for stabilization of the Jefferson fracture. Postoperative CT scan demonstrated excellent reduction of the odontoid fracture.
SPEAKER: The patient was extubated in the operating room. Postoperative examination demonstrated a patient that was awake and alert with 5/5 strength in all extremities and normal sensation. Approximately, 8 hours postsurgically, the patient's oxygen desaturated to the 60s, and she demonstrated no spontaneous movement or response to pain. Pupils at that time were minimally reactive.
SPEAKER: Stroke protocol MRI demonstrated infarction of the right parietal occipital region, entire cerebellum, and majority of the pons. Angiography demonstrated complete occlusion of all posterior circulation. Cervical CT scan demonstrated good position of the C2 pedicle screws, but partial obstruction of the left C1 foramen by the lateral mass screw.
SPEAKER: At the family's request, support was withdrawn, and the patient was pronounced dead shortly thereafter. In considering the etiology of this complication, one option is that the patient had a very dominant left vertebral artery, which was occluded by the screw, leading to the infarction. In that only lateral fluoroscopic imaging was used, the lateral relation of the screw to the vertebral artery is not visible and contributes to the risk of this procedure.
SPEAKER: However, the patient was normal immediately postoperatively, arguing against this option. A second option is that the left screw partially occluded the vertebral artery, and that it slowly clotted off over time. If there were a very dominant left vertebral artery, this is a possibility. However, if the right vertebral artery was patent, then this would also argue against that possibility.
SPEAKER: Alternative options are that the left vertebral artery was occluded by the screw, and a dissection of the right vertebral artery occurred, also leading to occlusion of that artery. It is also possible that blood clots had developed during her week-long confinement in bed, which then embolized, causing bilateral occlusion. Preoperative angiography could have altered the treatment plan for this patient if, for example, a dissection or a clot were detected.
SPEAKER: In any of the above scenarios, anticoagulant or endovascular intervention might have been utilized prior to fusion. In the context of a vertebral artery injury, if it is caused by either the drill or tap prior to placement of the screw, then following hemostasis an urgent angiography and possible stent placement could avoid disaster. If, however, as in this case, the screws were already placed, it is possible that the outcome is unalterable.
SPEAKER: It is also reasonable to consider the possibility of not operating on this patient and maintaining her in a soft collar. If this was a simple type II odontoid fracture, the literature does suggest this is a reasonable option in a very elderly patient. However, in the context of a classic Jefferson fracture, this would not provide sufficient support to the C1 fracture.
SPEAKER: Finally, one could consider the option of placing this patient in a halo. Given the high morbidity that has been demonstrated in placing elderly patients in halos, this also is not a reasonable option. Certainly, one lesson learned in this case is that shorter lateral mass screws could have avoided compromising the vertebral artery foramen.
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