Injuries to the cervical spine occur in 2%–4% of all patients on admission to the emergency room, but may be life-threatening if associated with spinal cord injury (SCI) (1). Between 19%–51% of spinal trauma cases involve injuries to the cervical spine (2), and approximately 30% affecting the atlantoaxial region, with the odontoid being the most common site of injury to the C2 vertebra (3–6). Typical causes of accidents are high-velocity impact in polytraumatized patients and increasingly low-energy trauma e.g., domestic collapses in the elderly due to hyperextension on head impact (7, 8). Identification of craniovertebral junction (CVJ) injury is difficult as patients often present with reduced level of consciousness. Related lesions are traumatic brain injury, additional fractures of the spine, the midface, the extremities (2, 9) and vertebral artery injury (10–12). Hence, immediate neuroradiological diagnostic is crucial, dictating patient management.

One of the most common reasons for emergency department admission remains chest pain caused by acute coronary syndrome. Myocardial infarction (MI) often manifests itself atypically e.g., dyspnea, cardiac arrhythmias, abdominal pain and autonomic dysregulation. The last is observed especially in women, the elderly and patients with diabetes mellitus or chronic renal insufficiency (13, 14). In addition, acute MI can lead to syncope, consciousness disturbance and cerebral dysfunction following hemodynamic collapse (15). Therefore, upper cervical spine trauma can occur together with MI (16). Treating complex CVJ-fractures with coronary artery disease (CAD) requiring treatment is challenging and carries a high risk of complications. To our knowledge, the literature does not provide any guidelines regarding the therapy of this constellation. Herein, we report the successful management of complex C1/C2 fractures in a patient with concomitant three-vessel CAD.

A 70-year-old male patient presented in our emergency outpatient clinic after a syncope, causing a bicycle accident. On admission, the patient had no neurological deficits or heart-related complaints. Identified cardiovascular risk factors were hypertension, obesity, smoking and diabetes mellitus. A computed tomography (CT) scan of the cervical spine revealed a displaced odontoid type II-C fracture (17, 18) and an unstable Gehweiler (19) type III injury (Jefferson's fracture) with a fracture of the anterior arch on the right, dual fractures of the posterior arch, and a fracture of the left lateral mass of C1 (Figure 1). A coincident finding was an intradiploic arachnoid cyst in the posterior wall of the posterior fossa (Figure 1). Other lesions included minor head trauma, a fracture of the T2 vertebral body, and rib fractures. CT angiography of cervical spine revealed no vascular injury and regular V3 segment of vertebral arteries (Figure 2). Furthermore, cardiac diagnostics revealed atrial fibrillation and non-ST-segment elevation MI. Coronary angiography confirmed a three-vessel CAD with high-grade stenosis not suitable for coronary stent insertion of left anterior descending artery, ramus circumflex, ramus diagonalis proximalis (RD1) and right coronary artery. Indication for upper cervical spine surgery and bypass surgery was given. The patient's case was evaluated by an interdisciplinary team of neurosurgeons, cardiothoracic surgeons and anesthesiologists to develop the most suitable therapeutic concept.

The following three different strategies were discussed: 1.

Conservative therapy of the upper cervical spine fractures and secondary bypass surgery after bone fusion.

The second option also has the advantage that no fusion surgery is required. During the intervention, bypass surgery could be performed using a Mayfield Headrest System to prevent SCI. Immobilization of the upper cervical spine in a neck brace or halo-fixation would not have been possible during surgery because of the necessary sternotomy. A neck brace or halo-fixation must be worn immediately after surgery. These orthoses might exert pressure on the sternotomy wound leading to delayed wound healing. The physical rehabilitation after coronary artery bypass surgery is also limited while wearing an orthosis. Furthermore, there is a residual risk of neurological impairment during surgery requiring intraoperative neuromonitoring (IOM).

The third option has the advantage that bypass surgery can be performed without any risk of SCI because of the dislocation of the fractures. However, there is a higher intraoperative risk of cardiac events during fusion surgery of the upper cervical spine and a myocardial infarction risk in the time between surgeries. Decision making depends mostly on the severity of MI and how near-term bypass surgery must be performed. Advanced anaesthesiological management is also required. In the present case, considering the patient's age and comorbidities, and due to the fact, that bypass surgery was not emergently indicated, a conservative therapy based on immobilization of the cervical spine in a neck brace was tried. In absence of fracture healing after 4 weeks, surgical approaches were again discussed. Aware of the risk of further dislocation and life-threatening SCI, neurosurgical intervention was performed first in interdisciplinary consent. The setup included general anesthesia, single-shot antibiotics and cardiopulmonary monitoring with resuscitation equipment. Cardiothoracic surgeons were on standby. Occipitocervical fusion was discussed, but not possible, due to the suboccipital intradiploic arachnoid cyst causing a cerebrospinal fluid (CSF) leak after exposure to the skull during surgery (Figure 1). This CSF-leak was closed by bone wax. Finally, the C1-C2 fusion was performed by Harms technique (20) with x-ray guidance, spinal neuronavigation (BrainLab AG, Feldkirchen, Germany) and Doppler ultrasound. Bilateral pedicle screws (Symphony, DePuy Synthes, Raynham, MA, USA) fixed the C2 vertebra, while bilateral mass screws (Symphony, DePuy Synthes, Raynham, MA, USA) were positioned in C1. The posterior atlas fragments were removed by laminectomy, and bone granulate was deposited.

The patient was monitored postoperatively in the intensive care unit (ICU) and later transferred to the neurosurgical ward in stable condition. Postoperative CT scan confirmed correct intraosseous screw positioning. Thromboprophylaxis (enoxaparin) was administered, while aspirin was paused pre- and postoperatively to prevent hemorrhage. Intravenous antibiotics (vancomycin, meropenem, clindamycin) were administered and a lumbar drain was placed. In the course, infection parameters decreased and wound healing was regular. The patient was discharged on day 12. Soft cervical collar was recommended for additional 4 weeks. One month later coronary artery bypass surgery (anastomosis of the left mammary artery to RD1 and the left radial artery to posterior interventricular ramus) was performed. Life-long medication with aspirin was resumed. Rivaroxaban was started due to intermittent atrial fibrillation. The patient was discharged to rehabilitation on day 7.

Treating complex C1/C2 fractures with concomitant CAD requiring cardiac surgery is challenging. In addition to surgical indications, the patient's individual risk factors must be considered when determining the definitive therapy (1, 2, 6, 9, 21). Bypass surgery is the standard of care in three-vessel or left main CAD, resulting in lower rates of cardiac or cerebrovascular events compared with percutaneous coronary intervention (22). Preferably, surgery is performed after a stable interval of 2–3 days (14). Myocardial infarction is also a severe complication of noncardiothoracic surgery. For lumbar spine surgery, Harwin et al. (23) reported a significantly higher risk of postoperative MI in men, which increases with age. Furthermore, the incidence was higher in fusion surgeries than in nonfusion surgeries (23). Although systematic evidence is lacking, to best of our knowledge cases of postoperative MI have been described following upper cervical spine fusion (9, 24, 25). In high-risk constellations, it is advisable to provide cardiac and hemodynamic monitoring in the ICU. Decompression of cervical spine trauma at risk for secondary SCI is recommended at least within the first 24 h (21). Cardiovascular complications are a leading cause of death in cervical or high-thoracic (above T6) SCIs because of damage of supraspinal sympathetic nervous system control (26). Consecutive shift towards parasympathetic-dominated heart control leads to bradycardia, orthostatic hypotension, autonomic dysreflexia, and cardiac arrest (26). Hence, early management of cardiac arrhythmias and neurogenic shock is crucial to improve patient outcome.

Complex C1/C2 fractures with concomitant severe CAD remain challenging and require an individual approach to receive upper cervical spine stability and to prevent both, SCI and cardiovascular complications. If the injuries are unstable and bypass surgery is not immediately necessary, surgical intervention is indicated. Therefore, interdisciplinary cooperation is essential to determine optimal therapeutic algorithms.