Complex developmental abnormality of the atlas mimicking a Jefferson fracture: Diagnostic tips and tricks
The case of a 74 year-old man, who suffered a severe direct head and cervical spine traumatic injury is presented. On admission the patient was fully awake, he complained of mild neck pain, and upon clinical examination, presented stiffness of the posterior cervical musculature. The remainder of neurological examination was negative. He suffered from hypertension and benign prostatic hypertrophy and disclosed a β-thalassemic trait. The patient firmly denied any history of previous traumas in the cervical spine region nor any surgical operations.\nA head scan showed evidence of post-traumatic subarachnoid hemorrhage, along with a small right frontal cerebral contusion (volume < 0.7 cm3), without mass effect. The plain cervical X-rays, despite their technical limits, aroused the suspicion of a C1 fracture; therefore, the patient was immobilized in a Philadelphia collar and transferred to our neurosurgical ward. A cervical computed tomography (CT) scan, not only demonstrated an anterior small defect of the arch on its left side, with tiny bony fragments in the middle of the defect, but also a posterior rim defect at the level of the C1 tuberculum []. There was no major swelling of the paravertebral soft tissue. The absence of irregular, coarse, bony fragments (which were common in a traumatic case), and the presence of minimum sclerosis around the edge of the bony defect made us wonder about the real pathogenesis of the bony defect. A non-traumatic origin was sustained by cervical magnetic resonance imaging (MRI), which excluded the presence of blood and edema near the bony defect on T2 Weighted imaging []. Furthermore, a flexion-extension cervical X-ray [] definitely excluded the presence of abnormal movements. The Philadelphia collar was therefore removed, the patient reassured, and discharged 24 hours later, as no radiological evolution was detected on the control CT scan. After 12 months the patient was fine with no complaints.