title: Intracranial hemorrhage and spinal cord injury from a fractured C1-C2 sublaminar cable: case report.
abstract: OBJECTIVE
  This is a unique case report of a fractured atlantoaxial interspinous multistranded cable leading to intracranial hemorrhage and spinal cord injury.
  
  
  METHODS
  A 61-year-old woman, with a history of rheumatoid arthritis and C1-C2 interspinous wiring with allograft for atlantoaxial instability, presented with neck pain and progressive decline in mental status. Prior to transfer to our institution from a referral hospital, imaging studies revealed progressive hydrocephalus with interval development of subarachnoid and fourth ventricular hemorrhage. Initial and repeat angiographic work-up was negative for vascular lesions. Magnetic resonance imaging revealed a subdural hematoma and signal changes at the cervicomedullary junction. Computed tomography of the cervical spine revealed a fractured interspinous cable, intradural penetration, and atlantoaxial instability.
  
  
  METHODS
  After ventriculostomy, both the patient's mental status and quadriparesis improved to a C on the American Spinal Injury Association (ASIA) scale. During surgery, the fractured cable and subdural hematoma were removed revealing an area of spinal cord impalement. She underwent C1-C3 lateral mass fixation with iliac crest autograft for fusion and was discharged to rehabilitation after a ventriculoperitoneal shunt was placed. At her 6-month follow-up, she was independent and had improved to ASIA E. Computed tomography confirmed fusion.
  
  
  CONCLUSIONS
  Spinal instrumentation eventually fails from pseudarthrosis and can cause neurological injury. In patients with atlantoaxial instability, direct C1-C2 screw fixation with posterior interspinous wiring using autograft offers the best chance for fusion. Cervical spine pathology can cause intracranial hemorrhage, and unconventional causes of injury must be considered when routine workup is negative.
authors.affiliation: Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
authors.forename: Udaya K
authors.initials: UK
authors.lastname: Kakarla
authors.forename: Juan Valdivia
authors.initials: JV
authors.lastname: Valdivia
authors.forename: Volker K H
authors.initials: VK
authors.lastname: Sonntag
authors.forename: Nicholas C
authors.initials: NC
authors.lastname: Bambakidis
mesh_terms: D001172:Arthritis, Rheumatoid / Q000150:complications / Q000601:surgery; D001268:Atlanto-Axial Joint / Q000601:surgery*; D001864:Bone Wires / Q000009:adverse effects*; D001270:Cervical Atlas / Q000601:surgery; D005260:Female; D006801:Humans; D020300:Intracranial Hemorrhages / Q000209:etiology* / Q000601:surgery; D007593:Joint Instability / Q000209:etiology / Q000601:surgery; D008875:Middle Aged; D011475:Prosthesis Failure; D013119:Spinal Cord Injuries / Q000209:etiology* / Q000601:surgery