FATAL TRANSDENTAL POSTERIOR ROTARY SUBLUXATION OF THE CERVICAL-SPINE - A CASE-REPORT

Study Design. The cervical spine of an 85-year-old man known to have a fracture of the odontoid process was removed at autopsy and dissected . Objectives. To establish the cause of death, which was not apparent. Summary of Background Data. Ruptures of the vertebral arteries in pat ients with fractures of the odontoid process are rare. Only a few repo rts are published in the literature. Those that address postmortem fin dings in patients with fractures of the odontoid process do not make a ny reference to associated capsular and ligamentous injuries and the r esultant instabilities. Methods. Because of legal constraints, the cer vical spine was removed en bloc 1 week after the patient's death and c arefully dissected. Results. In addition to the known bony injury, rup ture of the left vertebral artery, epidural hematoma, disruption of th e posterior atlantoaxial ligaments, hemorrhage into the anterior ligam entous structures, rupture of the capsule of the right atlantoaxial jo int, and stretching of the capsule of the left joint were found to be present. Displacement of the spinal cord by an epidural hematoma secon dary to rupture of the left vertebral artery was recorded as the appar ent cause of death. The rupture had obviously been caused by the abnor mal rotation of the atlas on the axis in a clockwise direction. Conclu sions. Both the fatal outcome and the pathologic examination showed th at established management concepts, particularly screw fixation of a f ractured odontoid process, should be reconsidered in light of the pote ntial occurrence of transdental posterior rotary subluxation. Because the incidence of capsular, ligamentous, and vascular injuries associat ed with fractures of the odontoid process is still poorly understood, more autopsies would be needed. The case also raises the question of w hether, in an elderly patient like ours, a fracture of the odontoid pr ocess should prompt immediate surgical stabilization.