Trauma of the upper cervical spine: focus on vertical atlantoaxial dislocation

Traumatic ligament injuries of the craniovertebral junction, either isolated or associated with bone avulsion or fracture, often lead to death. These injuries are rare and underrated but are increasingly seen in emergency departments due to the improvement in initial on-scene management of accidents. Vertical atlantoaxial dislocation (AAD) is a specific lesion that was barely reported. Based on our experience, our goal was to systematically investigate the prevalence and prognosis of traumatic vertical AAD and discuss its management.

All cervical CT scans performed at our institution between 2006 and 2010 for cervical trauma in adults were retrospectively reviewed. Based on the measurement of lateral mass index (LMI), defined as the gap between C1 and C2 articular facets, we identified three cases of traumatic vertical AAD in 300 CT scans. Their medical records were investigated.

The incidence of vertical AAD was 1% in the exposed population. One case was an isolated vertical AAD and two were associated with a type II odontoid fracture. We report the first case in the literature of unilateral vertical AAD. Two patients died rapidly; the survivor was treated with occipitocervical fixation. Specific maneuvers were used for immobilization and reduction.

This study found a not insignificant incidence of vertical AAD and a high lethality rate. LMI appears to be a relevant radiological criterion for this diagnosis, for which traction is contraindicated. Associated neurological or vascular damage should be suspected and investigated. In our experience, spinal surgical fixation is required because of major instability.