Craniovertebral junction injuries in children: a single center retrospective review

The craniovertebral junction is a unique structure consisting of the occipito-atlantal and atlanto-axial joints and their associated ligaments. The aim of the present study was to characterize the presentation, underlying mechanism of trauma, clinical and radiological findings, management, and outcome of children with craniovertebral junction injury treated in our institution.

We undertook a retrospective review of all patients with craniovertebral junction injuries treated at our institution between January 2016 and June 2024. Craniovertebral junction injury was defined as presence of one or more of (i) bony fracture or dislocation of the occipital condyles and/or any part of the atlas or axis, (ii) atlanto-axial dislocation/subluxation identified as per standard radiological criteria as described in literature, (iii) ligamentous injury identified on MRI or instability identified on dynamic imaging, and (iv) spinal extra-axial and spinal parenchymal hemorrhage at the level of craniovertebral junction. Patients who had non-traumatic anomalies of the craniovertebral junction and who had incomplete records were excluded from the study.

From 732 patients who underwent imaging evaluation at the emergency department for traumatic cervical spine injury, we identified 33 patients who met our inclusion criteria for craniovertebral junction injury. Motor vehicle accidents were the most common cause of injury, with the majority of patients suffering from ligamentous injury. Fractures of the occipital condyle were the most common bony injury of the craniovertebral junction. Most of the patients had good neurological outcomes, with mortality reported in 2/33. Multiple correspondence analysis identified a high-severity phenotype characterized by CVJ injury together with neurological and systemic compromise. An exploratory eight-item CVJ Injury Score was derived to characterize this phenotype.

Craniovertebral junction injury in children is relatively rare, occurring in 4.5% of patients undergoing imaging evaluation for cervical spine injury in our series. It encompasses a broad clinical spectrum, ranging from injuries successfully managed non-operatively to severe injuries associated with neurological, vascular, and systemic physiological compromise. The proposed CVJ Injury Score represents an exploratory framework for characterizing this high-severity phenotype and requires external multicenter validation.