However, the surgical option we chose resulted in more anterior displacement of the C1 posterior arch caused by an iliac bone block. If we had instrumented only C1 and C2, this might not have occurred because the cross link might have pulled each C1 lateral mass towards the center, resulting in a more posterior location of the C1 posterior arch. Another possible cause of root compression was the rotation of the C1 posterior arch caused by the surgical position. We attempted to compress the iliac bone block to the C1 posterior arch with a wire to achieve good fusion however, this maneuver resulted in compression of the dura by the C1 posterior arch. The canal diameter decreased from 20.20mm before surgery to 15.13mm after the surgery, despite an improvement in the atlanto-dens interval. Occipital neuralgia in our patient may have been caused by direct dural compression or bilateral C2 root compression by the C1 posterior arch. However, direct compression of the C2 nerve rootafter treatment of a Jefferson fracture has not previously been described. Occipital neuralgia has many causes including C1 lateral mass screw irritation and C2 nerveroot retraction during C1-C2 fusion 1, 2, 4, 5, 7). One month later, the patient reported improvement of the occipital and neck pain (intensity of 1-2 on a visual analog scale). After identifying bilateral C2 root redundancy by palpation, we completed the surgery ( Fig.
We therefore performed bilateral C2 nerve root decompression followed by central canal decompression. Removal of the latter showed that the C1 posterior arch had severely compressed the dural sac. During the operation, we found that the previous implantation of bone chips had resulted in firm bone stability and rigid bone fusion however, we also observed a bone block resorption from the occiput to the C2 as well as replacement by thick fibrous tissue. A diagnostic bilateral C2 root block resulted in mild pain improvement therefore, we decided to decompress the canal and bilateral C2 roots surgically. From the pain dermatome and C1 lamina-induced dural compression we suspected C2 compression. Although MRI revealed no evidence of cord compression, a C1 lamina compressed dural sac and C2 root compression could not be excluded ( Fig. The pain dermatome was located mainly in the great occipital nerve territory and posterior neck ( Fig. The patient had normal neurological status, but reported neck pain and occipital headache, which we initially believed was part of the normal postoperative course however, the patient reported sustained continuous pain for 1 year, despite strong analgesics. There were no complications during or after surgery. Postoperative lateral X-rays showed an atlanto-dens interval of 3.12mm and a C1 canal anterior-posterior diameter of 15.13mm( Fig. The C1 lamina was used as a fusion bed with an iliac bone block from the occiput and C2, and further bone fusion from the occiput to C5 was per formed using iliac bone chips. We decided to perform fusion surgery from the occiput to C5 without decompression of C1. Keywords: Spinal fracture, Cervical atlas, Nerve root compression This case indicates that occipital neuralgia, suggesting the need for diagnostic block, should be considered in the differential diagnosis of patients with sustained occipital headache after occipitocervical fusion surgery. After decompression surgery, pain was reduced. After decompression, bilateral C2 root redundancy was identified by palpation. We performed bilateral C2 root decompression via a C1 laminectomy. Magnetic resonance images revealed no evidence of cord compression, however a C1 lamina compressed dural sac and C2 root compression could not be excluded. The pain dermatome was located mainly in the great occipital nerve territory and posterior neck. The patient reported sustained continuous pain throughout the following year despite strong analgesics. We performed fusion surgery from the occiput to C5 without decompression of C1. Preoperative lateral X-ray revealed an atlanto-dens interval of 4.8mm and a C1 canal anterior-posterior diameter of 19.94mm. A 70-year-old male was admitted to our center with a Jefferson fracture induced by a car accident. In this report we describe a patient with an unstable Jefferson fracture who was treated by occipitocervical fusion and later reported sustained postoperative occipital neuralgia.
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