A major pitfall to avoid: Retroclival hematoma due to odontoid fracture

Background: Retroclival hematoma (RCH) is a rare occurrence. The hemorrhage is usually small and hidden and can be easily missed on CT scan. Here, we report the association of a RCH with an odontoid fracture. Methods: Case report and review of the literature. Results: We describe a case of a 75-year-old man with a history of squamous cell carcinoma of the tongue base, treated with chemo-radiation. He was on warfarin for atrial fibrillation. He presented to the hospital 6 weeks after falling from standing height, with headache, neck pain, and stiffness. Clinical examination did not show any focal neurologic deficits. INR measured 4 days before admission was 6.0, but therapeutic at 2.4 on the day of admission. CT scan of the head showed a RCH. CT angiogram of the neck unexpectedly showed a type II odontoid fracture with instability of the upper cervical spine and extension of the hematoma to the upper cervical spine. Anticoagulation was reversed with factor IX complex (Bebulin). He underwent C1-C2 fusion without any complications. The immediate post-operative period was unremarkable. Unfortunately, he succumbed to airway obstruction due to mucus plugging 14 days into hospitalization. Conclusions: In the appropriate clinical setting, when a RCH is found, further imaging should be considered to rule out fracture of the cervical spine. Odontoid fractures can lead to compression of the spinal cord or lower medulla. To prevent neurologic injury and subsequent complications, prompt recognition of type II odontoid fracture should lead to immediate spine stabilization.