title: Fatal transdental posterior rotary subluxation of the cervical spine. A case report.
abstract: METHODS
  The cervical spine of an 86-year-old man known to have a fracture of the odontoid process was removed at autopsy and dissected.
  
  
  OBJECTIVE
  To establish the cause of death, which was not apparent.
  
  
  BACKGROUND
  Ruptures of the vertebral arteries in patients with fractures of the odontoid process are rare. Only a few reports are published in the literature. Those that address postmortem findings in patients with fractures of the odontoid process do not make any reference to associated capsular and ligamentous injuries and the resultant instabilities.
  
  
  METHODS
  Because of legal constraints, the cervical spine was removed en bloc 1 week after the patient's death and carefully dissected.
  
  
  RESULTS
  In addition to the known bony injury, rupture of the left vertebral artery, epidural hematoma, disruption of the posterior atlantoaxial ligaments, hemorrhage into the anterior ligamentous structures, rupture of the capsule of the right atlantoaxial joint, and stretching of the capsule of the left joint were found to be present. Displacement of the spinal cord by an epidural hematoma secondary to rupture of the left vertebral artery was recorded as the apparent cause of death. The rupture had obviously been caused by the abnormal rotation of the atlas on the axis in a clockwise direction.
  
  
  CONCLUSIONS
  Both the fatal outcome and the pathologic examination showed that established management concepts, particularly screw fixation of a fractured odontoid process, should be reconsidered in light of the potential occurrence of transdental posterior rotary subluxation. Because the incidence of capsular, ligamentous, and vascular injuries associated with fractures of the odontoid process is still poorly understood, more autopsies would be needed. The case also raises the question of whether, in an elderly patient like ours, a fracture of the odontoid process should prompt immediate surgical stabilization.
authors.affiliation: Meidling, Traumatology Center, University of Vienna, Austria.
authors.forename: E
authors.initials: E
authors.lastname: Sim
authors.forename: A
authors.initials: A
authors.lastname: Berzlanovich
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001863:Bone Screws; D002574:Cervical Vertebrae / Q000098:blood supply / Q000293:injuries* / Q000601:surgery*; D017809:Fatal Outcome; D006470:Hemorrhage / Q000175:diagnosis / Q000209:etiology; D006801:Humans; D007593:Joint Instability / Q000150:complications / Q000000981:diagnostic imaging; D008297:Male; D009809:Odontoid Process / Q000293:injuries / Q000601:surgery; D012421:Rupture; D016103:Spinal Fractures / Q000150:complications / Q000000981:diagnostic imaging*; D014057:Tomography, X-Ray Computed; D014711:Vertebral Artery / Q000293:injuries