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Traumatic atlanto-occipital dislocation in children: evaluation, treatment, and outcomes
Nelson Astur1, Paul Klimo2, Jeffrey R Sawyer1
1University of Tennessee-Campbell Clinic Dept. of Orthopaedic Surgery, 1211 Union Avenue, Suite 510, Memphis, TN 38104. E-mail address for J.R. Sawyer: jsawyer@campbellclinic.com.
Insights
Pediatric atlanto-occipital dislocation survival is increasing, but many children face associated injuries and neurological deficits. Early occipitocervical fusion is recommended for stabilization and improved outcomes.
Area of Science:
- Pediatric Neurosurgery
- Spinal Trauma
- Orthopedic Surgery
Background:
- Improved emergency care and diagnostics enhance survival rates for pediatric atlanto-occipital dislocation.
- This study presents one of the largest pediatric atlanto-occipital dislocation case series.
Purpose of the Study:
- To analyze the clinical characteristics, treatment, and outcomes of pediatric patients with atlanto-occipital dislocation.
- To evaluate the efficacy of early occipitocervical fusion in managing pediatric atlanto-occipital dislocation.
Main Methods:
- Retrospective review of pediatric patients (newborn to 16 years) diagnosed with atlanto-occipital dislocation (1991-2011).
- Inclusion criteria: complete records, minimum six-month follow-up.
- Data collected: demographics, injury mechanism, associated injuries, neurological status, surgical intervention, complications, and outcomes.
Main Results:
- Fourteen patients (mean age 5.2 years) were included; automobile accidents were the most common injury mechanism.
- Twelve patients had associated injuries, including brain injury (11) and spinal cord injury (nearly half).
- All patients underwent posterior occipitocervical fusion; 50% had neurological impairment at follow-up (mean 75.4 months), with hydrocephalus being the most common complication (4 patients).
Conclusions:
- Increased survival for pediatric atlanto-occipital dislocation, often with significant associated injuries and neurological impairment.
- Early occipitocervical fusion and stabilization are the preferred management strategies.
- Suspect obstructive hydrocephalus in cases of neurological decline post-spinal fixation.
Background:
Advancements in emergency care and diagnostic methods have increased the number of children who survive atlanto-occipital dislocation. We report our experience with one of the largest series of pediatric patients with atlanto-occipital dislocation.
Methods:
Patients ranging in age from newborn to sixteen years old who had a diagnosis of atlanto-occipital dislocation from 1991 through 2011 were identified. Inclusion criteria were complete radiographic and clinical records and duration of follow-up of at least six months. Basic patient characteristics, mechanism of injury, associated injuries, neurological impairment, surgical treatment and type of implant used for fixation, complications, and clinical and radiographic outcomes were recorded.
Results:
The fourteen patients who were included (seven male and seven female) had a mean age of 5.2 years at the time of injury. An automobile accident in which the victim was a passenger was the most common mechanism of injury. Twelve patients had associated injuries, with a brain injury in eleven of them, and nearly half sustained a spinal cord injury. According to the Traynelis classification system, eight patients had a type-II (longitudinal) atlanto-occipital dislocation, five had a type-I (anterior) dislocation, and one had a type-III (posterior) dislocation. All patients had posterior occipitocervical fusion with internal fixation. The mean duration of follow-up was 75.4 months. The most common postoperative complication was hydrocephalus, which occurred in four patients. Spinal fusion occurred in all patients by four to six months postoperatively. At the time of the most recent follow-up evaluation, half of the patients had neurological impairment.
Conclusions:
More patients with atlanto-occipital dislocation now survive the initial trauma, although most have associated injuries and many have neurological impairment. Our preferred management is early occipitocervical fusion and stabilization. If there is neurological decline after spinal fixation, obstructive hydrocephalus should be suspected.
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