Atlanto-occipital Dislocation after a Crane Accident
A 54-year-old Hispanic male sustained a crush injury on a construction site after sticking his head out of the crane window and subsequently being struck by the crane boom. His head was briefly pinned between the body of the crane and the boom.
Upon arrival to the Emergency Department, a rapid neurological assessment was performed prior to the administration of the rapid sequence intubation medications. Initial assessment findings in the emergency department included Glasgow Coma Score (GCS) of 4, pupils equal and reactive to light at 2mm, tetraplegia, and an American Spinal Injury Association (ASIA) score of A (complete motor and sensory deficit with no sacral sparing).
The patient was noted to be hypertensive and tachycardic. He sustained mid-face and mandible trauma as well. All other body systems were found to be without injury on initial assessment.
He was given an Injury Severity Score (ISS) of 75 based on the severity of his cervical spine injury and resultant neurologic destruction. The patient was given a predicted death rate of 93.4% using the Trauma Injury Severity Scoring System (TRISS).(1-4)
The opening axial CT scan of the brain revealed evidence of a subarachnoid hemorrhage surrounding portions of the brainstem and proximal cervical cord (Fig. 1), with an associated subdural hemorrhage along the left side of the tentorium and lateral aspect of the left cerebellar hemisphere.
Figure 1. Brainstem and proximal cervical cord subarachnoid hemorrhage
Cervical spine studies revealed the patient had sustained an atlanto-occipital dislocation (AOD) (Fig. 2 & 3) and had developed prominent prevertebral soft tissue swelling extending from the skull base to the level of C5.
Figure 2. AOD per BDI (Wholey) method-normal measurement < 8.5mm; (9, 10) case study patient's 23.84mm
Figure 3. AOD per Powers method-normal ratio <1; (9, 10)] case study patient's 1.57
The facial scan confirmed displaced fractures to bilateral mandible and medial left pterygoid. The chest CT scan revealed infiltrates in bilateral lung apices. MRI of the brain and cervical spine confirmed the findings listed prior. Additional findings included bulging disks at the C2-C3 and C3-C4 interspace.
Atlanto-occipital dislocation, subarachnoid and subdural hemorrhages, and "locked-in" syndrome
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The plan for stabilization of the occiput-cervical junction was made for a later time pending the patient's survival of the initial neurologic insult. While awaiting operative intervention, the patient remained in a rigid cervical collar and was placed on a ROTO bed in the intensive care unit.
Once control of the patient's medical status was established, he underwent an occipital-cervical fusion. After induction of anesthesia, Mayfield head pins were placed, and with the patient in prone position, his head was stabilized with the Mayfield head holder. The occipital to C4 fusion was executed using lateral mass screws, rods, occipital plate (Fig. 4) and BMP onlay graft.
Figure 4. Lateral postoperative radiograph demonstrating fixation with occipital plating and lateral mass screws.
The patient presented with a static neurologic exam for the first week after surgery; alert, able to blink his eyes, and protrude his tongue. On postop day 8, he demonstrated gross motor movement and the ability to sensate in all of his extremities. He remained hospitalized for an additional month during which time he underwent 2 additional surgeries to repair his mandible fractures and a procedure for inferior vena cava filter placement. During this time the patient also required frequent electrolyte replacement therapy to control his waning muscular strength. He was weaned from the ventilator and demonstrated the ability to support his own respiratory efforts prior to discharge.
Routine follow-ups reveal arthrodesis without instrumentation problems. Eight months after the injury, the patient remains in a rigid cervical collar secondary to severe ligamentous damage suffered during the traumatic event. He demonstrated a motor strength of 2/5 to his upper extremities, spastic movement to the lower extremities, and a very limited ability to verbally communicate with his wife at the time of his last follow up visit.
Goldberg et al (2001) indicates that less than 2.5% of blunt trauma victims sustain cervical spine injuries. (5) In adults, the majority of these injuries are located in the subaxial cervical spine at the C-6 and C-7 levels. (5) Atlanto-occipital dislocation has been reported to account for approximately 3.1% of all cervical injuries. (6) Our case study demonstrates how aggressive initial treatment, team work and patience can increase the survivability of an extraordinary injury that carries a very high mortality rate.
Our institution's practice is to have the initial stabilization and trauma workup completed within 20 minutes of arrival to the emergency department. Early detection and definitive diagnosis of an anterior atlanto-occipital dislocation alerted the trauma team to the importance of maintaining meticulous control of the patient's cervical spine to prevent further injury from rotational, flexion, extension, or traction forces being applied to the neck. The trauma team remained aggressive in their treatment of the patient's medical condition throughout his stay.
In contrast, the neurosurgical approach to this patient was more cautious secondary to his massive neurologic damage and associated high mortality rate. Because the potential repercussions of not treating an unstable injury can result in significant morbidity and mortality, this approach seems to be contrary to the "early" stabilization advocated in the literature. (7, 6, 1, 4)
The only cervical spine stabilization this patient received while awaiting operative intervention was from wearing a rigid cervical collar continuously. A halo was not placed, since it was felt that our patient's physiologic state could not take another insult upon his admission to the Intensive Care Unit. The original projected surgical date had to be postponed as previously described. This delay did not seem to have any untoward effects on the patient's neurologic status. The patient was taken to the operating room approximately one-month after hospital arrival; tolerating stabilization procedure without incident.
Our case demonstrates why the question of "early" versus "late" surgical stabilization remains controversial. (8) Even though the optimal timing for occipito-cervical stabilization had to be delayed, our experience was that waiting a longer time for surgical repair did not compromise our patient and possibly even allowed him to survive by giving his own immune system the chance to fight one offense at a time. This case also demonstrates how multi-trauma patients with high ISS on arrival can experience positive outcomes. The combination of good communication between collaborating disciplines, meticulous nursing care, appropriate medical treatment, and patience proved a successful combination for our patient; allowing this gentleman, who was originally given a less than 7% chance of survival, to be discharged from the hospital.
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5. Goldberg W, Mueller C, Panacek E. (2001). Distribution and patterns of blunt traumatic cervical spine injury. Ann Emerg Med, 38, 17-21.
6. Saeheng S, Phuenpathom N. (2001). Traumatic occipito-atlantal dislocation. Surgical Neurology, 55, 35-40.
7. Bellabarba C, Mirza S, West A. (2006). Diagnosis and treatment of craniocervical dislocation in a series of 17 consecutive survivors during an 8-year period. J Neurosurg: Spine, 4, 429-40.
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10. Rojas C, Bertozzi J, Martinez C. (2007). Reassessment of the craniocervical junction: Normal Values on CT. American Journal of Neuroradiology, 28, 1819-1823.
This report illustrates a rare patient with occipito-cervical dislocation who survived and had undergone appropriate treatment. It is important to make the correct diagnosis initially by paying special attention to clinical and neurological features associated with occipito-cervical dislocation. Secondly, traction is contraindicated, as further neurological injury or death may result by stretching the spinal cord and brainstem at the occipito-cervical junction. The use of a rigid collar in a ROTO-bed and attentive medical supports in the initial phase are important for patient survival, as done for this patient.
Surgical treatment is posterior stabilization at the occipito-cervical junction. The authors have appropriately discussed the timing of surgery. As soon as the patient is medically stabilized, surgery is recommended to avoid further trauma to the occipito-cervical junction and to mobilize the patient as soon as possible. As done for this patient, the current technique of rigid fixation using the plate or rod / screws instrumentation has been developed to avoid the use of bulky external bracing or halo-vest postoperatively. The authors should be congratulated for reporting this rare case, managing the patient appropriately from beginning, and discussing the salient features of occipito-cervical dislocation.
The authors would like to thank Dr. An for his comments and insight. This case highlights the complexity of atlanto-occipital spinal injury management and its unique requirements for diligent care in all phases of the trauma care continuum to ensure the best opportunity for an optimal outcome.