The risk for patients with a clivus fracture of sustaining concomitant neurovascular deficiencies is high because of the anatomic proximity to cranial nerves, the brainstem and the vertebrobasilar artery. With longitudinal clivus fractures especially, an entrapment of the basilar artery can occur and lead to ischemia of the brainstem, which may result in death of the patient. There are also reports in the literature, however, of possible preventions of this fatal course. Sato et al.[6] treated patients with a concomitant vascular lesion with aspirin 100 mg per day. Another treatment option, found in the literature, was anticoagulation with argatroban [7]. Further patients could successfully be treated with anticoagulation through heparin and later warfarin [5].
There are also descriptions in the literature of lethal courses of concomitant vascular injuries such as a report of death of a patient with recurrent vasospasms of the carotid artery [3]. Further, clivus fractures with traumatic brain injuries are associated with very high risk of life-threatening complications [3, 6]. But in many cases, neurologic deficits secondary to lesions of the cranial nerves can be found. Commonly the 6th and 7th cranial nerves are affected. Whereas a 6th nerve palsy is often linked to transverse clivus fractures, a 7th is usually affected only in longitudinal fracture types [3, 6, 8, 9]. Further symptoms that may also occur are rhinorrhea, otorrhea [3, 9], fistulas between the carotid artery and the sinus cavernosus, or an ophthalmoplegia [10].
With extension into the petrous bone, a deterioration of hearing may occur [5, 8]. In the case of a lesion of the sella turcica, diabetes insipidus may result, which in most cases is transient and can be treated by a temporary hormone substitution [3].
The list of possible symptom complexes is long and well described in the literature. But options for a feasible therapy for this fracture entity are scarce. Dashti et al.[4] report a successful course of a patient with a clivus fracture, treated with a halo.
A more unstable injury of the craniocervical conjunction like reported by Maughan et al.[11] with an avulsion fracture of the foramen magnum with bilateral fractures of the occipital condyles, and extension into the inferior clivus attained good results with an occipito-cervical fusion.
This fracture in our patient was a combination-fracture of the craniocervical junction. Due to the extension of the clivus fracture into the left occipital condyle, exact classification of this fracture type was difficult. The anterior arch fracture of the atlas itself was stable and did not need as rigid a stabilization as the halo device.
The extension of the fracture line into the occipital condyle alone was comparable to a type II fracture according to Anderson and Montesano [12]. This fracture entity was regarded as stable or unstable, depending on radiologic signs for instability and or ligamentous disruption and should be treated with or a hard collar or a halo device or a surgical stabilization [13].
As this was a complex craniocervical lesion, with an extended fracture of the clivus together with its complete avulsion and associated disruption of the alar ligaments, the decision to apply a halo device was made.
In this case, the primary closed reduction of the clivus fracture and the immobilization with a halo device was the therapy of choice and led to consolidation of the fracture. A final dynamic examination of the cervical spine after removal of the halo was conducted to exclude persistent ligamentous instability. Persistent ligamentous instability would indicate an occipito-cervical fusion.
