Traumatic Atlanto-Occipital Dislocation in Children

Background: Traumatic atlanto-occipital dislocation (AOD) is a rare and often fatal injury. Although historically most cases are reported as fatal, the advent of modern pre-hospital care and rapid transportation to medical facilities has led to an increase in survival following this injury. A subset of these patients may achieve or maintain satisfactory neurologic function following early intervention, stabilization and definitive management. A case series of traumatic AOD with their outcome in a tertiary level pediatric trauma center is presented.

Methods: Using the trauma registry at the Children’s Hospital of Philadelphia, we identified all cases of traumatic AOD between 1986 and 2003. Sixteen cases were identified. The hospital charts, clinic notes and radiographs were reviewed. In addition, a clinical and functional assessment of the survivors was performed.

Results: Average patient age was seven years (range: 2 - 16 years). Mechanisms of injury were diverse. The average GCS score was 7.4 (range of 3 - 15). Eleven patients (11/16: 69%) underwent field intubations. Eight patients survived (8/16: 50%) the initial episode of injury after being transferred to the medical facility. Immediate diagnosis in the emergency room was made in all cases. Patients were initially immobilized in a Halo vest and all received intravenous steroids. Four patients with OC disruption underwent occiput-C2 fusion and one was managed with Minerva cast. Three of the initial survivors expired intraoperatively while undergoing neurosurgical procedures for extensive head injuries. Five patients eventually survived; one was neurologically normal, three had mild hemiparesis but were essentially functional, and one remained a ventilator dependent quadriplegic. Our follow-up averaged 50 months with a range of 28 months to 99 months.

Conclusions: Prompt recognition and treatment of AOD can result in survival in the pediatric population. Early diagnosis, prompt intubation, early and adequate immobilization of the head and spine, and use of IV steroids facilitates survival. We recommend surgical stabilization of the craniovertebral junction in all unstable cases, with incomplete cord injury.