Occipitocervical fusion complicated with cerebellar abscess:
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For C1-C2 instability, C1-C2 fixation is a common and well-developed technique. However, this procedure is more challenging and has higher incidence of the risk of damaging vertebral artery (VA) due to the complexity of C1-C2. Instead, some surgeons will choose occipito-cervical (OC) fixation and skip C1-C2 instead of C1-C2 instrumentation to avoid the high risk of injury to the VA. There are some postoperative disadvantages of OC fixation, such as reduced cervical mobility, difficulty in swallowing, postoperative neck stiffness, etc. Possible complications of OC fixation includes VA injury, screw loosening, neurological deterioration, bone fusion failure, cerebellar infarction, nerve or cord injury, and wound infection.

A 63-year-old male patient had been suffering from long-term neck pain and limb numbness and weakness. Cervical spine examination revealed tight stenosis at C1 level and instability in the C1-C2 joints. A C1 laminectomy with OC fusion was performed, and the patient was discharged. Unfortunately, a few days later, he went to the emergency department and complained of persistent dizziness, vomiting, and unsteady gait. Computed tomography (CT) and magnetic resonance imaging (MRI) images revealed a suspicious cerebellar abscess formation and hydrocephalus. Furthermore, CT images indicated that the left screw was loose, and the diameter of the right screw hole was much larger than the size of the screw. Besides, inappropriate length of the screw penetrated the occipital bone and may cause the disruption of dura mater. The patient underwent external ventricular drainage first, followed by abscess drainage and C1-C2 fixation a few days later. He was discharged without any further neurological deficits or infectious problems. The patient recovered with intact consciousness, full muscle strength, and improved numbness throughout the extremities, with a Nurick grade of 1. A follow-up magnetic resonance imaging at 3 months after surgery revealed near total resolution of the abscess.

In conclusion, OC fusion complicated with cerebellar abscess and resultant obstructive hydrocephalus has never been reported. Choosing the most tailored approach and being familiar with each surgical step are essential to avoid major complications.

Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7049210/