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𝐒𝐩𝐢𝐧𝐞 𝐂𝐨𝐧𝐬𝐮𝐥𝐭- 🔩🩸High Riding Vertebral Artery 🩸🔩 𝐇𝐢𝐬𝐭𝐨𝐫𝐲: 82 year old walker dependent female fell at her home several weeks ago. She was treated with a C-collar per her family at another hospital. She has had continued neck pain, and recently when bending over had a syncopal episode and fell. She is now diagnosed with a left distal radius fracture and as well as cervical spine fracture after being admitted to a level 1 trauma center. 🆔️ - 🔎 Exam: 👀 Clinically stable 👀 4s in b/l upper extremities and 5s in lower extremity 👀 No Hoffman b/l, No clonus b/l 👀 Left wrist fracture in a splint - 🏥 𝐃𝐢𝐚𝐠𝐧𝐨𝐬𝐢𝐬: 1- Unstable Odontoid C2 fracture, possibly acute on chronic 2- Spinal cord compression due to C2 instability - ⚠️🅲🆃/🅼🆁🅸: 1- Non-union type 2 odontoid fracture with displacement and canal stenosis at C2. 2- C2 pedicle width 8.5mm left and 4.0mm right 3- C2 isthmus height 4.3mm left 4- C2 superior pars internal height 5.2mm left and 5.7mm right - ✅ 𝐏𝐫𝐨𝐜𝐞𝐝𝐮𝐫𝐞: 1- Posterior cervical C1-C2 instrumented fusion with C2 laminar screw fixation 2- Closed reduction C2 fracture 3- Posterior iliac crest bone graft harvest right side - 🤠 𝐌𝐘 𝐓𝐀𝐊𝐄: The patient has a displaced C2 fracture, possibly acute but likely sustained weeks ago from the first fall. She has pain, instability and is a polytrauma with her radius fracture. This odontoid fracture should be stabilized. - The classic Dan Riew article defines high riding vertebral arteries HRVA as internal height less than 2mm, isthmus height less than 5mm, and pedicle width less than 4mm,TSJ 2013; PMID: 23684237. - This is seen on the right C2 pedicle width and left C2 isthmus height. Per Riew 2013 those with narrow pedicles and HRVA had 76% violation rate in his study! A strategy to avoid vertebral artery complications is the use of laminar screws at C2. Doing so obviously precludes a C2 decompression due to the need for posterior structures, so this must be weighed. Another approach is to posteriorly decompress the C-spine but would now need occipital fusion! - We were able to complete the closed reduction C2 fracture via extending head posterior, relative to C1, and then locked this reduction in with our Mayfield. The patient regained all strength several days post operative. This was a central cord syndrome picture, normally I would argue for decompression but in this situation stabilization and time was sufficient!