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Conservative Management of a Clivus Fracture

William Coggins

University of Texas Medical Branch School of Medicine

Introduction: Clival fractures are rare injuries that occur during traumatic events such as motor vehicle crashes. These fractures can be divided into three categories: longitudinal, transverse, and oblique. Fractures of the clivus remain a rare sequela of traumatic head injuries with an estimated 1% incidence in cases of head trauma. Clival fractures are associated with high mortality, reported to be between 24 to 44% in the literature. This is thought to be due to the anatomic proximity of the clivus to vital neurovascular structures such as the brainstem itself and vessels supplying the posterior circulation of brain. Any displacement of fragments could compromise integrity of these structures. Methods: A 23-year-old female was transported to our emergency room following a motor vehicle rollover. Upon arrival, the patient underwent our trauma protocol, involving a pan-CT scan, which notably revealed bilateral temporal bone fractures, clival fracture, and pneumocephalus. Importantly, head and neck CT angiography were unremarkable for any vascular injury. Results: Treatment varies per case. Decompressive craniectomies are commonly performed due to comorbid injuries from the causal traumatic event. However, given that our patient was relatively stable and alert, we elected to pursue conservative management. The patient was placed in a Miami J cervical collar, started on seizure prophylaxis, and monitored for potential cerebrospinal fluid (CSF) leaks. Her hospital course was complicated by cranial nerve V, VI, and VII palsies, but the patient progressed well, was switched to an Aspen collar, and ultimately, discharged. At her three-month follow-up, there was improvement but not resolution of her cranial nerve palsies, and a CT scan revealed healing fractures. Thus, the cervical collar was removed, and range-of-motion was assessed with expected stiffness but without major limitations. Physical therapy participation was encouraged. Conclusion: We present the case of a patient with a transverse clival and bilateral temporal fractures with multiple cranial nerve palsies who recovered with conservative management. Although she still has some residual cranial nerve palsies, this case is noteworthy as the patient successfully recovered despite the extent of the injuries sustained. Fractures of the clivus, although rare, are important clinical entities to recognize in order to prevent devastating neurological outcomes.

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