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Inoue T, Morimoto T, Yoshihara T, Tsukamoto M, Hirata H, Mawatari M. Traumatic atlanto-occipital dislocation with successfully bystander resuscitation after cardiopulmonary arrest: A case report. Clin Case Rep 2024; 12:e8865. [PMID: 38855085 PMCID: PMC11157413 DOI: 10.1002/ccr3.8865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 03/20/2024] [Accepted: 04/15/2024] [Indexed: 06/11/2024] Open
Abstract
This case report describes successful bystander cardiopulmonary resuscitation after a cardiopulmonary arrest due to a traffic accident, followed by early diagnosis and treatment of a traumatic atlanto-occipital dislocation, resulting in successful community reintegration.
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Affiliation(s)
- Takayuki Inoue
- Department of Orthopedic Surgery, Faculty of MedicineSaga UniversitySagaJapan
| | - Tadatsugu Morimoto
- Department of Orthopedic Surgery, Faculty of MedicineSaga UniversitySagaJapan
| | - Tomohito Yoshihara
- Department of Orthopedic Surgery, Faculty of MedicineSaga UniversitySagaJapan
| | - Masatsugu Tsukamoto
- Department of Orthopedic Surgery, Faculty of MedicineSaga UniversitySagaJapan
| | - Hirohito Hirata
- Department of Orthopedic Surgery, Faculty of MedicineSaga UniversitySagaJapan
| | - Masaaki Mawatari
- Department of Orthopedic Surgery, Faculty of MedicineSaga UniversitySagaJapan
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Gelse K, Guggenberger M. [Atlanto-occipital dislocation-A challenge with respect to making the diagnosis and treatment]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2024; 127:322-329. [PMID: 38156996 DOI: 10.1007/s00113-023-01401-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/22/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND The correct diagnosis and treatment of the atlanto-occipital dislocation (AOD) remains a major challenge. OBJECTIVE To evaluate the different radiological diagnostic criteria for AOD and discuss potential treatment strategies based on a case with AOD and additional fracture of the atlas. MATERIAL AND METHODS A 29-year-old male patient is presented who suffered from AOD with concomitant fracture of the anterior and posterior arches of the atlas with rotational atlantoaxial dislocation following an accident in forestry. The following parameters were evaluated for the diagnosis and assessment of postoperative reduction: Powers ratio, the X‑lines-method, Wackenheim line, basion-dens interval (BDI), basion-axial interval (BAI) and occipital condyle-C1 interval (CCI). RESULTS Stabilization was performed by occipitocervical spondylodesis from C0 to C2/3. For final reduction it was necessary to reduce the malrotation of the atlas. In the presented case, the revised CCI proved to be a sensitive and valid yet practical parameter. Powers' ratio and the BDI were less suited for assessing the diagnosis. The X‑lines-method, Wackenheim line and the BAI did not adequately detect the pathological situation. DISCUSSION The AOD is a severe injury requiring immediate correct diagnosis for later adequate treatment results. Among the published parameters, the revised CCI proved to be a practical and valid parameter to detect AOD. For definitive treatment, the operative occipitocervical stabilization is regarded as the method of choice.
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Affiliation(s)
- Kolja Gelse
- Klinikum Traunstein, Abteilung für Unfallchirurgie und Orthopädische Chirurgie, Klinikumsverbund Südostbayern, Cuno-Niggl-Str. 3, 83278, Traunstein, Deutschland.
| | - Matthias Guggenberger
- Klinikum Traunstein, Abteilung für Unfallchirurgie und Orthopädische Chirurgie, Klinikumsverbund Südostbayern, Cuno-Niggl-Str. 3, 83278, Traunstein, Deutschland
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Holy M, Szigethy L, Joelson A, Olerud C. A Novel Treatment of Pediatric Atlanto-Occipital Dislocation with Nonfusion Using Muscle-Preserving Temporary Internal Fixation of C0-C2: Case Series and Technical Note. J Neurol Surg Rep 2023; 84:e11-e16. [PMID: 36703921 PMCID: PMC9873479 DOI: 10.1055/s-0043-1760830] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 10/20/2022] [Indexed: 01/26/2023] Open
Abstract
Study Design Case series with surgical technical note. Objectives This article reports experiences and results of muscle-preserving temporary C0-C2 fixation for the treatment of atlanto-occipital dislocation (AOD). Methods AOD is a rare injury caused by high-energy trauma, occurring in less than 1% of pediatric trauma patients. Recommended treatment is C0-C2 fusion which, however, will result in significant loss of mobility in the craniocervical junction (CCJ), especially C1-C2 rotation. An alternative approach, with the ability of preserving mobility in the C1-C2 segment, is a temporary fixation that allows the ligaments to heal, after which the implants can be removed to regain function in the CCJ joints. By using a muscle-preserving approach and navigation for the C2 screws, a relatively atraumatic fixation of the CCJ can be achieved with motion recovery after implant removal. Results We present two cases of AOD treated with temporary fixation. A 12-year-old boy involved in a frontal car collision, as a strapped back seat passenger, was treated with temporary C0-C2 fixation for 10 months. Follow-up at 11 months after implant removal included clinical evaluation, computed tomography, magnetic resonance imaging (MRI), and flexion-extension X-rays. He was free of symptoms at follow-up. The CCJ was radiographically stable and he had 45 degrees of C1-C2 rotation. A 7-year-old girl was hit by a car as she got off a bus. She was treated with temporary fixation for 4 months after which the implant was removed. Follow-up at 8 years included clinical evaluation and MRI in rotation. She was free of symptoms. The ligaments of the CCJ appeared normal and her C1-C2 rotation was 30 degrees. Conclusion C0-C2 fixation without fusion allows the CCJ ligaments to heal in pediatric AOD. By removing the implants after ligament healing, rotation in the C1-C2 segment can be regained without subsequent instability. Both our patients tolerated the treatment well and were free of symptoms at follow-up. By using minimally invasive muscle-preserving technique and navigation, temporary fixation of the CCJ can be achieved with minimal damage to the soft tissues allowing recovery of almost normal function after implant removal.
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Affiliation(s)
- Marek Holy
- Department of Orthopedics, Örebro University Hospital, Örebro University, Örebro, Sweden,Address for correspondence Marek Holy, MD Department of OrthopedicsÖrebro University Hospital, Örebro University, Örebro 70182Sweden
| | - Lilla Szigethy
- Department of Orthopedics, Örebro University Hospital, Örebro, Sweden
| | - Anders Joelson
- Department of Orthopedics, Örebro University Hospital, Örebro University, Örebro, Sweden
| | - Claes Olerud
- Department of Surgical Sciences, Uppsala University Hospital, Uppsala University, Uppsala, Sweden
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Michel C, Dijanic C, Abdelmalek G, Sudah S, Kerrigan D, Yalamanchili P. Upper cervical spine instability systematic review: a bibliometric analysis of the 100 most influential publications. JOURNAL OF SPINE SURGERY (HONG KONG) 2022; 8:266-275. [PMID: 35875624 PMCID: PMC9263731 DOI: 10.21037/jss-21-132] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Accepted: 04/02/2022] [Indexed: 06/15/2023]
Abstract
Background Instability in the upper cervical spine, although rare, can be devastating. This spectrum of conditions includes occipitocervical instability, atlantoaxial instability and atlantoaxial rotatory displacement. Knowledge of the literature can provide better understanding of disease processes and management, and aid in clinical decision making. The objective of this study was to perform a bibliometric analysis to formulate a comprehensive review of the most cited publications. Methods A systematic search of the literature was conducted using the Clarivate Web of Science database. The search query was '"Atlanto-occipital dislocation" OR "atlanto-occipital dissociation" OR "atlantoaxial rotatory displacement" OR "atlantoaxial instability"'. The top 100 articles based on frequency of citation were included in our study. Data extracted from articles included frequency of citation, year of publication, country of origin, journal of publication, level of evidence and article type. Results Our initial search yielded 257 results that met the criteria. Articles not pertaining to atlanto-occipital instability were removed. Citation frequency ranged from 15 to 195. The most cited article was "Traumatic Anterior Atlanto-Occipital Dislocation" published by Powers et al. in 1979. The most productive decade was 2000-2009 with 45 publications. All decades showed a progressive increase in the number of papers published except for 2010-2019. Overall, 19 countries contributed and the most productive was the United States (n=61). The articles found in our search were cited a total of 4,095 times (3,463 without self-citations) averaging 40.95 citations per publication. Discussion The goal of a bibliometric study is to assess trends in a specific field of study, provide evidence for the impact of an individual or field of study's research, and highlight potential areas for future research. While the number of citations does not necessarily reflect publication quality, it reflects overall influence based on recognition by peers in the field. Publications from the last 20 years have emphasized the use of newer technologies such as computed tomography (CT) and magnetic resonance imaging (MRI) to aid in diagnosis. Our study highlights the lack of high-level evidence articles and underscores that our understanding of these conditions in both pediatric and adult patients is maturing.
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Affiliation(s)
- Christopher Michel
- Department of Orthopedic Surgery, Monmouth Medical Center-RWJBarnabas Health, Long Branch, NJ, USA
| | - Christopher Dijanic
- Department of Orthopedic Surgery, Monmouth Medical Center-RWJBarnabas Health, Long Branch, NJ, USA
| | | | - Suleiman Sudah
- Department of Orthopedic Surgery, Monmouth Medical Center-RWJBarnabas Health, Long Branch, NJ, USA
| | - Daniel Kerrigan
- Department of Orthopedic Surgery, Monmouth Medical Center-RWJBarnabas Health, Long Branch, NJ, USA
| | - Praveen Yalamanchili
- Department of Orthopedic Surgery, Monmouth Medical Center-RWJBarnabas Health, Long Branch, NJ, USA
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An S, Hyun SJ. Pediatric Spine Trauma. J Korean Neurosurg Soc 2022; 65:361-369. [PMID: 35462522 PMCID: PMC9082124 DOI: 10.3340/jkns.2021.0282] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 01/25/2022] [Indexed: 11/27/2022] Open
Abstract
Pediatric spine has growth potential with incomplete ossification, and also unique biomechanics which have important implications for trauma patients. This article intends to review various aspects of pediatric spine trauma including epidemiology, anatomy and biomechanics, and clinically relevant details of each type of injury based on the location and mechanism of injury. With the appropriate but not superfluous treatment, pediatric spine trauma patients can have better chance of recovery. Therefore, as a spine surgeon, understanding the general concept for each injury subtype together with the debate and progress in the field is inevitable.
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Garvayo M, Belouaer A, Barges-Coll J. Atlanto-occipital dislocation in a child: a challenging diagnosis. Illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2022; 3:CASE21712. [PMID: 36209404 PMCID: PMC9379628 DOI: 10.3171/case21712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 01/27/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND
Atlanto-occipital dislocation (AOD) is a highly unstable injury of the osseoligamentous complex at the craniocervical junction that is more common in children. Its diagnosis remains a challenging process that must integrate clinical presentation and radiological criteria.
OBSERVATIONS
A 9-year-old child presented with severe craniocervical trauma (Glasgow Coma Scale score 6) and cardiorespiratory arrest on-site. Prompt resuscitation on-site and transfer to the university hospital were performed, and a computed tomography (CT) scan showed a subarachnoid hemorrhage around the brainstem and a retroclival hematoma. Most of the radiological criteria on CT scans for AOD were negative, except for the occipital condyle–C1 interval, and further imaging with magnetic resonance imaging permitted the diagnosis of AOD with rupture of both the tectorial membrane and the transverse ligament. Occipital-cervical Oc-C1–2 fixation was performed. The neurological outcome was excellent, with full recovery 6 months after the trauma.
LESSONS
AOD should be suspected in all high-intensity trauma in children, especially if the clinical presentation includes cardiorespiratory arrest and other brainstem and/or upper cervical cord symptoms along with premedullary subarachnoid hemorrhage. Understanding the ligamentous nature of the injury resulting in “normal” radiographs or CT scans is important to avoid underdiagnosing AOD, which can have detrimental consequences.
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Affiliation(s)
- Marta Garvayo
- Department of Neurosurgery and Spine Surgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Amani Belouaer
- Department of Neurosurgery and Spine Surgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Juan Barges-Coll
- Department of Neurosurgery and Spine Surgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
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Grin A, Lvov I, Talypov A, Kordonskiy A, Godkov I, Khushnazarov U, Krylov V. Factors affecting the outcomes of traumatic atlanto-occipital dislocations in adults: a systematic review. World Neurosurg 2022; 162:e568-e579. [DOI: 10.1016/j.wneu.2022.03.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 03/11/2022] [Accepted: 03/14/2022] [Indexed: 10/18/2022]
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Shiraishi D, Nishimura Y, Aguirre-Carreno I, Hara M, Yoshikawa S, Eguchi K, Nagashima Y, Ito H, Haimoto S, Yamamoto Y, Ginsberg HJ, Takayasu M, Saito R. Clinical and Radiological Clues of Traumatic Craniocervical Junction Injuries Requiring Occipitocervical Fusion to Early Diagnosis. Neurospine 2022; 18:741-748. [PMID: 35000327 PMCID: PMC8752707 DOI: 10.14245/ns.2142860.430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 10/16/2021] [Indexed: 11/19/2022] Open
Abstract
Objective The purpose of this study is to find the clinical and radiographic characteristics of traumatic craniocervical junction (CCJ) injuries requiring occipitocervical fusion (OC fusion) for early diagnosis and surgical intervention.
Methods We retrospectively reviewed 12 patients with CCJ injuries presenting to St. Michaels Hospital in Toronto who underwent OC fusion and looked into the following variables; (1) initial trauma data on emergency room arrival, (2) associated injuries, (3) imaging characteristics of computed tomography (CT) scan and magnetic resonance imaging (MRI), (4) surgical procedures, surgical complications, and neurological outcome.
Results All patients were treated as acute spinal injuries and underwent OC fusion on an emergency basis. Patients consisted of 10 males and 2 females with an average age of 47 years (range, 18–82 years). All patients sustained high-energy injuries. Three patients out of 6 patients with normal BAI (basion-axial interval) and BDI (basion-dens interval) values showed visible CCJ injuries on CT scans. However, the remaining 3 patients had no clear evidence of occipitoatlantal instability on CT scans. MRI clearly described several findings indicating occipitoatlantal instability. The 8 patients with normal values of ADI (atlantodens interval interval) demonstrated atlantoaxial instability on CT scan, however, all MRI more clearly and reliably demonstrated C1/2 facet injury and/or cruciate ligament injury.
Conclusion We advocate measures to help recognize CCJ injury at an early stage in the present study. Occipitoatlantal instability needs to be carefully investigated on MRI in addition to CT scan with special attention to facet joint and ligament integrity.
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Affiliation(s)
- Daimon Shiraishi
- Department of Neurosurgery, Nagoya University Hospital, Nagoya, Japan.,Department of Neurosurgery, Inazawa Manucipal Hospital, Aichi, Japan
| | - Yusuke Nishimura
- Department of Neurosurgery, Nagoya University Hospital, Nagoya, Japan
| | - Isaac Aguirre-Carreno
- Division of Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Masahito Hara
- Department of Neurosurgery, Aichi Medical University Hospital, Aichi, Japan
| | - Satoshi Yoshikawa
- Department of Neurosurgery, Nagoya University Hospital, Nagoya, Japan
| | - Kaoru Eguchi
- Department of Neurosurgery, Nagoya University Hospital, Nagoya, Japan
| | | | - Hiroshi Ito
- Department of Neurosurgery, Nagoya University Hospital, Nagoya, Japan
| | - Shoichi Haimoto
- Department of Neurosurgery, Nagoya University Hospital, Nagoya, Japan
| | - Yu Yamamoto
- Department of Neurosurgery, Inazawa Manucipal Hospital, Aichi, Japan
| | - Howard J Ginsberg
- Department of Neurosurgery, Inazawa Manucipal Hospital, Aichi, Japan
| | - Masakazu Takayasu
- Department of Neurosurgery, Aichi Medical University Hospital, Aichi, Japan
| | - Ryuta Saito
- Department of Neurosurgery, Nagoya University Hospital, Nagoya, Japan
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Use of halo fixation therapy for traumatic cranio-cervical instability in children: a systematic review. Eur J Trauma Emerg Surg 2021; 48:3505-3511. [PMID: 34881392 PMCID: PMC9532283 DOI: 10.1007/s00068-021-01849-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 11/23/2021] [Indexed: 11/02/2022]
Abstract
PURPOSE Traumatic cranio-cervical instability in childhood is rare and constitutes a challenge for the treating surgeon. The aim of therapy is to restore cervical stability without limiting the range of motion. The goal of this systematic review was to find out whether, over the last 10 years, halo fixation (HF) could still be considered a successful treatment option without major risks or complications. METHODS We analyzed studies describing the use of HF in traumatic injuries of the cranio-cervical junction in children under the age of 17. Searches were performed in PubMed, MEDLINE and Embase databases for the years from 2010 to 2020. The general success rate, the success rate related to underlying pathologies, and complication rates were evaluated. RESULTS The main indications for HF range from pre-surgical correction to postoperative fusion support. C2 is the most frequently injured vertebra in children. The overall success rate of HF was very high. Evaluation according to the underlying pathology showed that, except for atlanto-occipital dislocation, HF generates high fusion rates among different patient cohorts, mainly in C2 vertebra injuries and atlantoaxial rotatory subluxation. Only minor complications were reported, such as pin infections. CONCLUSION The current data show that, when used according to the appropriate indication, HF is an effective conservative treatment option for cranio-cervical instability, associated with only minor complications.
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Joaquim AF, Schroeder GD, Vaccaro AR. Traumatic Atlanto-Occipital Dislocation-A Comprehensive Analysis of All Case Series Found in the Spinal Trauma Literature. Int J Spine Surg 2021; 15:724-739. [PMID: 34289992 PMCID: PMC8375687 DOI: 10.14444/8095] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Traumatic atlanto-occipital dislocation (TAOD) is one of the most devastating traumatic injuries, generally associated with immediate death after high-energy trauma. The aim of this study was to perform a systematic literature review of all cases series of TAOD and present the current state of this entity. METHODS A systematic literature review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Only case series with at least 5 cases were included in the analysis. We focused on survival rates, diagnostic methods, delays in diagnosis, outcomes, and cases successfully treated nonoperatively. RESULTS A total of 17 articles were included (16 retrospective and 1 prospective study) with 341 patients. Six studies included pediatric patients only. The mean Glasgow Coma Scale at admission was ≤8 in all studies. Many different diagnostic criteria were used, but none of them had high accuracy. The overall mortality rate was 34.8%, but the studies' designs were heterogeneous (some included only survivors). A high rate of concomitant traumatic brain injury was documented in some studies. We found it interesting that some patients were treated with cervical immobilization (37/341; 10.8%), which was generally used in less unstable injuries; however, the majority of patients were managed with an occipito-cervical fusion (193/341; 56.5%). CONCLUSIONS TAOD is a devastating traumatic injury, with a high mortality rate. An MRI may be recommended when there are subtle findings of TAOD and a normal computed tomography scan, such as subarachnoid hemorrhage in the posterior fossa, upper cervical injuries, or consistent neurological findings. Further studies are necessary to identify patients with mild MRI findings and TAOD that may be managed nonoperatively.
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Affiliation(s)
| | - Gregory D. Schroeder
- Department of Orthopaedic Surgery and Neurosurgery at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Alexander R. Vaccaro
- Department of Orthopaedic Surgery and Neurosurgery at Thomas Jefferson University, Philadelphia, Pennsylvania
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Sarmiento JM, Chang D, Nisson PL, Chan JL, Perry TG. Occipitocervical fusion of traumatic atlanto-occipital dissociation in a patient with autofused cervical facet joints: illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2021; 2:CASE21276. [PMID: 35854957 PMCID: PMC9272367 DOI: 10.3171/case21276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 05/24/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND Patients who survive traumatic atlanto-occipital dissociation (AOD) may
present with normal neurological examinations and near-normal-appearing
diagnostic images, such as cervical radiographs and computed tomography (CT)
scans. OBSERVATIONS The authors described a neurologically intact 64-year-old female patient with
a degenerative autofusion of her right C4–5 facet joints who
presented to their center after a motor vehicle collision. Prevertebral soft
tissue swelling and craniocervical subarachnoid hemorrhage prompted
awareness and consideration for traumatic AOD. An abnormal occipital
condyle–C1 interval (4.67 mm) on CT and craniocervical junction
ligamentous injury on magnetic resonance imaging (MRI) confirmed the
diagnosis of AOD. Her autofused right C4–5 facet joints were
incorporated into the occipitocervical fusion construct. LESSONS Traumatic AOD can be easily overlooked in patients with a normal neurological
examination and no associated upper cervical spine fractures. A high index
of suspicion is needed when evaluating CT scans because normal values for
craniocervical parameters are significantly different from the accepted
ranges of normal on radiographs in the adult population. MRI of the cervical
spine is helpful to evaluate for atlanto-occipital ligamentous injury and
confirm the diagnosis. Occipitocervical fusion construct may need to be
extended to incorporate spinal levels with degenerative autofusion to
prevent adjacent level degeneration.
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Affiliation(s)
- J. Manuel Sarmiento
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Daniel Chang
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Peyton L. Nisson
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Julie L. Chan
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Tiffany G. Perry
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California
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12
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[The position of the head during treatment in the emergency room-an explorative analysis of immobilization of the cervical spine]. Anaesthesist 2021; 70:922-927. [PMID: 33909105 DOI: 10.1007/s00101-021-00965-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 01/23/2021] [Accepted: 03/07/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Immobilization of the cervical spine is a standard procedure in emergency medicine mostly achieved via a cervical collar. In the emergency room other forms of immobilization are utilized as cervical collars have certain drawbacks. The present study aimed to provide preliminary data on the efficiency of immobilization in the emergency room by analyzing the residual spinal motion of the patient's head on different kinds of head rests. METHODS In the present study biomechanical motion data of the cervical spine of a test subject were analyzed. The test subject was placed in a supine position on a mobile stretcher (Stryker M1 Roll-In System, Kalamazoo, MI, USA) wearing a cervical collar (Perfit ACE, Ballerup, Denmark). Three different head rests were tested: standard pillow, concave pillow and cavity pillow. The test subject carried out a predetermined motion protocol: right side inclination, left side inclination, flexion and extension. The residual spinal motion was recorded with wireless motion trackers (inertial measurement unit, Xsens Technologies, Enschede, The Netherlands). The first measurement was performed without a cervical collar or positioning on the pillows to measure the physiological baseline motion. Subsequently, three measurements were taken with the cervical collar applied and the pillows in place. From these measurements, a motion score was calculated that can represent the motion of the cervical spine. RESULTS When the test subject's head was positioned on a standard pillow the physiological motion score was reduced from 69 to 40. When the test subject's head was placed on concave pillow the motion score was further reduced from 69 to 35. When the test subject's head was placed on cavity pillow the motion score was reduced from 69 to 59. The observed differences in the overall motion score of the cervical spine are mainly due to reduced flexion and extension rather than rotation or lateral inclination. CONCLUSION The motion score of the cervical spine using motion sensors can provide important information for future analyses. The results of the present study suggest that trauma patients can be immobilized in the early trauma phase with a cervical collar and a head rest. The application of a cervical collar and the positioning on the concave pillow may achieve a good immobilization of the cervical spine in trauma patients in the early trauma phase.
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Kolz JM, Christensen TC, Diehn FE, Sebastian AS, Currier BL, Nassr AN. Nonsurgical Management of Combined Occipitocervical and Atlantoaxial Distraction Injuries: A Case Report. JBJS Case Connect 2021; 11:e20.00228. [PMID: 33502138 DOI: 10.2106/jbjs.cc.20.00228] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE A 41-year-old man sustained occipitocervical dislocation (OCD) and atlantoaxial dislocation (AAD) injuries in a motor vehicle collision. These injuries were treated nonoperatively with a hard cervical collar and activity restrictions with an excellent result at 4-year follow-up. CONCLUSION OCD and AAD injuries require prompt diagnosis and immobilization. Standard of care for coexisting injuries is occipitocervical fusion; however, some patients have coexisting injuries which may prevent operative treatment. These polytrauma patients require a creative nonoperative approach with close follow-up to avoid neurologic decline.
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Affiliation(s)
- Joshua M Kolz
- Department of Orthopaedic Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Felix E Diehn
- Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | - Arjun S Sebastian
- Department of Orthopaedic Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Ahmad N Nassr
- Department of Orthopaedic Surgery, Mayo Clinic, Rochester, Minnesota
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14
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Alves OL, Pereira L, Kim SH, Grin A, Shimokawa N, Konovalov N, Zileli M. Upper Cervical Spine Trauma: WFNS Spine Committee Recommendations. Neurospine 2020; 17:723-736. [PMID: 33401853 PMCID: PMC7788417 DOI: 10.14245/ns.2040226.113] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 10/10/2020] [Indexed: 01/12/2023] Open
Abstract
Craniovertebral junction (CVJ) trauma is a challenging clinical condition. Being a highly mobile functional unit at the junction of the skull and the vertebral column, traumatic events in this area may produce devastating neurological complications and death. Additionally, many of the CVJ traumatic injuries can be left undiagnosed or even raise difficult treatment dilemmas. We present a literature review in the format of recommendations on the diagnosis and management of different scenarios for upper cervical trauma and produce recommendations, which can be applicable to various areas of the globe.
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Affiliation(s)
- Oscar L Alves
- Department of Neurosurgery, Centro Hospitalar de Gaia/Espinho, Vila Nova de Gaia, Portugal.,Department of Neurosurgery, Hospital Lusiadas Porto, Porto, Portugal
| | - Leopoldina Pereira
- Department of Neurosurgery, Centro Hospitalar de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - Se-Hoon Kim
- Department of Neurosurgery, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
| | - Andrey Grin
- Sklifosovsky Research Institute for Emergency Medicine, Moscow, Russian Federation.,A.I. Evdokimov Moscow Medical University, Moscow, Russian Federation
| | | | - Nikolay Konovalov
- N. N. Burdenko National Medical Research Center of Neurosurgery, Moscow, Russian Federation
| | - Mehmet Zileli
- Department of Neurosurgery, Ege University, Izmir, Turkey
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15
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Motion preserving management of unstable traumatic clivus fracture extending through bilateral occipital condyles. J Clin Neurosci 2020; 80:257-260. [PMID: 33099356 DOI: 10.1016/j.jocn.2020.08.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 08/09/2020] [Indexed: 11/20/2022]
Abstract
We describe non-operative management a rare traumatic clival fracture extending through the bilateral occipital condyles. Clinical History: A 26-year-old female who was involved in a high-speed motor vehicle crash presented to an outside facility with difficulty speaking. Subsequent CT of the cervical spine demonstrated a fracture of the clivus with extension through the bilateral occipital condyles. She was then transferred to our hospital for further management where complete trauma survey noted multiple other injuries including traumatic subarachnoid hemorrhage, spinal epidural hematoma, bilateral pneumothoraces, liver laceration, bilateral upper extremity injuries, and lumbosacral fractures. Additional spinal imaging was negative for any associated vascular or spinal cord injury. Given her young age, there was a strong interest to preserve craniocervical motion and the decision was made to treat her with non-operatively with halo placement. After 18 weeks of rigid fixation, follow up imaging demonstrated completely healed fractures and at twenty-one weeks post fixation she demonstrated preserved motion of the craniocervical junction. This is a review of the literature and case report regarding this rare entity and its management.
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16
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Kimchi G, Greenberg G, Traynelis VC, Witiw CD, Knoller N, Harel R. Integrity of the tectorial membrane is a favorable prognostic factor in atlanto-occipital dislocation. Br J Neurosurg 2020; 34:470-474. [PMID: 32368931 DOI: 10.1080/02688697.2020.1761292] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Objective: Atlanto-occipital dislocation is usually considered to be a fatal injury or one that leaves the victim with serious neurological deficits. The aim of this study is to illustrate a novel positive prognostic factor for atlanto-occipital dislocation, based on cervical MRI studies of patients who suffered this injury.Methods: Over the course of the past year, the authors have treated three consecutive patients with atlanto-occipital dislocation who attained an excellent clinical outcome. We retrospectively evaluated clinical, surgical and radiographic parameters in search of a common denominator to explain the excellent outcome of these patients.Results: All patients presented with severe polytrauma that required urgent surgical intervention including two laparotomies and a thoracotomy. The patients were subsequently treated with an occipitocervical fusion. No patient developed neurological deficits on long-term follow-up. The cervical MRI studies of all patients were notable for a having a preserved tectorial membrane, while other primary stabilizers of the craniocervical junction such as the apical, alar and cruciate ligaments were shown to be severely disrupted. We consider this anatomical distinction to account for their benign clinical course.Conclusion: A preserved tectorial membrane appears to be an important favorable prognostic factor in atlanto-occipital dislocation and may serve to mitigate neurological outcome in such injuries. To determine the integrity of the ligament and consequently affect clinical management, expeditious MRI of the cranio-cervical junction should be considered routinely in such injuries in addition to cervical CT scans.
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Affiliation(s)
- Gil Kimchi
- Department of Neurosurgery, Sheba Medical Center, Ramat-Gan, Israel (affiliated to Sackler School of Medicine, Tel Aviv University)
| | - Gahl Greenberg
- Department of Radiology, Neuroradiology Division, Sheba Medical Center, Ramat-Gan, Israel
| | - Vincent C Traynelis
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
| | | | - Nachshon Knoller
- Department of Neurosurgery, Sheba Medical Center, Ramat-Gan, Israel (affiliated to Sackler School of Medicine, Tel Aviv University)
| | - Ran Harel
- Department of Neurosurgery, Sheba Medical Center, Ramat-Gan, Israel (affiliated to Sackler School of Medicine, Tel Aviv University)
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17
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Hadley MN, Walters BC. The case for the future role of evidence-based medicine in the management of cervical spine injuries, with or without fractures. J Neurosurg Spine 2019; 31:457-463. [PMID: 31574462 DOI: 10.3171/2019.6.spine19652] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Accepted: 06/19/2019] [Indexed: 11/06/2022]
Abstract
The authors believe that the standardized and systematic study of immobilization techniques, diagnostic modalities, medical and surgical treatment strategies, and ultimately outcomes and outcome measurement after cervical spinal trauma and cervical spinal fracture injuries, if performed using well-designed medical evidence-based comparative investigations with meaningful follow-up, has both merit and the remarkable potential to identify optimal strategies for assessment, characterization, and clinical management. However, they recognize that there is inherent difficulty in attempting to apply evidence-based medicine (EBM) to identify ideal treatment strategies for individual cervical fracture injuries. First, there is almost no medical evidence reported in the literature for the management of specific isolated cervical fracture subtypes; specific treatment strategies for specific fracture injuries have not been routinely studied in a rigorous, comparative way. One of the vulnerabilities of an evidenced-based scientific review in spinal cord injury (SCI) is the lack of studies in comparative populations and scientific evidence on a given topic or fracture pattern providing level II evidence or higher. Second, many modest fracture injuries are not associated with vascular or neural injury or spinal instability. The application of the science of EBM to the care of patients with traumatic cervical spine injuries and SCIs is invaluable and necessary. The dedicated multispecialty author groups involved in the production and publication of the two iterations of evidence-based guidelines on the management of acute cervical spine and spinal cord injuries have provided strategic guidance in the care of patients with SCIs. This dedicated service to the specialty has been carried out to provide neurosurgical colleagues with a qualitative review of the evidence supporting various aspects of care of these patients. It is important to state and essential to understand that the science of EBM and its rigorous application is important to medicine and to the specialty of neurosurgery. It should be embraced and used to drive and shape investigations of the management and treatment strategies offered patients. It should not be abandoned because it is not convenient or it does not support popular practice bias or patterns. It is the authors' view that the science of EBM is essential and necessary and, furthermore, that it has great potential as clinician scientists treat and study the many variations and complexities of patients who sustain acute cervical spine fracture injuries.
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Affiliation(s)
- Mark N Hadley
- 1Department of Neurosurgery, University of Alabama at Birmingham, Alabama; and
| | - Beverly C Walters
- 1Department of Neurosurgery, University of Alabama at Birmingham, Alabama; and
- 2Department of Neurosurgery, Henry Ford Health System, Detroit, Michigan
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18
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Copley PC, Tilliridou V, Kirby A, Jones J, Kandasamy J. Management of cervical spine trauma in children. Eur J Trauma Emerg Surg 2019; 45:777-789. [PMID: 30167742 PMCID: PMC6791958 DOI: 10.1007/s00068-018-0992-x] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Accepted: 08/16/2018] [Indexed: 12/11/2022]
Abstract
PURPOSE Paediatric cervical spine injuries are fortunately a rare entity. However, they do have the potential for devastating neurological sequelae with lifelong impact on the patient and their family. Thus, management ought to be exceptional from the initial evaluation at the scene of the injury, through to definitive management and rehabilitation. METHODS We set out to review cervical spine injuries in children and advise on current best practice with regards to management. RESULTS Epidemiology, initial management at the scene of injury, radiological findings and pitfalls of cervical spine trauma are outlined. Strategies for conservative and surgical management are detailed depending on the pattern of injury. The management of spinal cord injuries without radiological abnormality (SCIWORA) and cranio-cervical arterial injuries is also reviewed. CONCLUSIONS Due to a paucity of evidence in these rare conditions, expert opinion is necessary to guide best practice management and to ensure the best chance of a good outcome for the injured child.
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Affiliation(s)
- Phillip Correia Copley
- Department of Neurosurgery, Western General Hospital, University of Edinburgh, Crewe Road South, Edinburgh, EH4 2XU UK
| | - Vicky Tilliridou
- Department of Radiology, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Andrew Kirby
- Department of Radiology, The Royal Hospital for Sick Children, Edinburgh, UK
| | - Jeremy Jones
- Department of Radiology, The Royal Hospital for Sick Children, Edinburgh, UK
| | - Jothy Kandasamy
- Department of Neurosurgery, Western General Hospital, University of Edinburgh, Crewe Road South, Edinburgh, EH4 2XU UK
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19
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Dean LA, Aaronson EL, Wittels K, Wilcox SR. Fall From Height. J Emerg Med 2019; 57:241-244. [PMID: 31164234 DOI: 10.1016/j.jemermed.2019.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Accepted: 04/01/2019] [Indexed: 11/26/2022]
Affiliation(s)
- Laura A Dean
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Emily L Aaronson
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Kathleen Wittels
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Susan R Wilcox
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
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20
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Posttraumatic Anatomical Injuries of the Craniovertebral Junction and Treatment Implications: Part II. ACTA NEUROCHIRURGICA. SUPPLEMENT 2019. [PMID: 30610337 DOI: 10.1007/978-3-319-62515-7_43] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
This paper is Part II of a two-part report. In Part I of the report, injuries of the occipital bone, atlanto-occipital dissociation and the atlanto-occipital joint space were discussed. This part of the report discusses atlantoaxial dislocation and fractures of the atlas and axis.
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21
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Posttraumatic Anatomical Injuries of the Craniovertebral Junction and Treatment Implications: Part I. ACTA NEUROCHIRURGICA. SUPPLEMENT 2019. [PMID: 30610336 DOI: 10.1007/978-3-319-62515-7_42] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
Please check the hierarchy of the section headings and correct if necessary.
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22
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Kim JW. Atlanto-Occipital Dislocation: A Case Report. Korean J Neurotrauma 2019; 15:55-60. [PMID: 31098351 PMCID: PMC6495583 DOI: 10.13004/kjnt.2019.15.e3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 07/06/2018] [Accepted: 07/06/2018] [Indexed: 11/21/2022] Open
Abstract
Patients with atlanto-occipital dislocation (AOD) are increasingly being transported to emergency rooms, alive, by the improved pre-hospital emergency rescue system. The author reports a fatal case of AOD with severe neurovascular injuries following a high-speed pedestrian collision. Therefore, nowadays, neurosurgeons can expect an increase in the occurrence of such cases; an early diagnosis and prompt occipitocervical fusion can save lives. This report reviews the current concepts of AOD in mild to fatal conditions.
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Affiliation(s)
- Jin Wook Kim
- Department of Neurosurgery, Dongguk University Gyeongju Hospital, Dongguk University College of Medicine, Gyeongju, Korea
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23
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Hale AT, Say I, Shah S, Dewan MC, Anderson RCE, Tomycz LD. Traumatic Occipitocervical Distraction Injuries in Children: A Systematic Review. Pediatr Neurosurg 2019; 54:75-84. [PMID: 30844793 DOI: 10.1159/000496832] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 01/04/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Occipitocervical distraction injuries (OCDI) in children occur on a wide spectrum of severity, and decisions about treatment suffer from a lack of rigorous guidelines and significant inter-institutional variability. While clear cases of frank atlanto-occipital dislocation (AOD) are treated with surgical stabilization, the approach for less severe cases of OCDI is not standardized. These patients require a careful assessment of both radiographic and clinical criteria, as part of a complex risk-benefit analysis, to establish whether occipitocervical fusion (OCF) is indicated. Here, we performed a systematic review of the literature that describes traumatic OCDI in children < 18 years of age. SUMMARY We performed a systematic review, according to PRISMA guidelines, of children < 18 years of age presenting with traumatic etiologies of OCDI. We searched PubMed to identify papers congruent with these criteria. Exclusion criteria included (1) reports on atraumatic causes of OCDI and (2) studies with insufficient clinical and radiographic details on individual patients. We identified 16 reports describing a total of 144 patients treated for pediatric traumatic OCDI. Based on the synthesis of these findings and the collective experience of the authors, we present the demographic, clinical, and radiographic factors that underlie OC instability, which we hope will serve as components of a grading system in the future. We considered various clinical and radiographic findings including: (1) the mechanism of injury, (2) the patient's age, (3) CT/CT angiography of head and neck findings and parameters, (4) MRI findings, and (5) neurological exam, for the purpose of determining the severity of the OCDI and offering treatment guidelines based on the summative risk of underlying OC instability. Key Messages: OCDI is a potentially devastating injury, especially in children. Although missing the diagnosis can have potentially catastrophic consequences, reverting to surgical fixation in less severe cases can subject children to unnecessary operative risk and permanently reduce their range of motion. After reviewing all the available reports of pediatric traumatic OCDI in the neurosurgical literature, we propose an outline of clinical and radiographic factors influencing underlying OC instability that could be incorporated into a grading scale to guide treatment. We hope this study stimulates discussion on the standardization of treatment for pediatric OCDI.
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Affiliation(s)
- Andrew T Hale
- Medical Scientist Training Program, Vanderbilt University School of Medicine, Nashville, Tennessee, USA,
| | - Irene Say
- Department of Neurosurgery, New Jersey Medical School and Robert Wood Johnson Medical School, Rutgers University, Nashville, Tennessee, USA
| | - Smit Shah
- Department of Neurosurgery, New Jersey Medical School and Robert Wood Johnson Medical School, Rutgers University, Nashville, Tennessee, USA
| | - Michael C Dewan
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Richard C E Anderson
- Division of Pediatric Neurosurgery, The Spine Hospital, Columbia University Medical Center, The Neurological Institute of New York, New York City, New York, USA
| | - Luke D Tomycz
- Department of Neurosurgery, New Jersey Medical School and Robert Wood Johnson Medical School, Rutgers University, Nashville, Tennessee, USA
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24
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Occipitocervical Dislocation in Low-Energy Trauma. Case Rep Orthop 2018; 2018:3931525. [PMID: 30631620 PMCID: PMC6304856 DOI: 10.1155/2018/3931525] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 11/19/2018] [Indexed: 11/18/2022] Open
Abstract
Traumatic occipitocervical dislocation (OCD) is described in the literature as a potentially fatal injury secondary to high-energy trauma. We describe a case of OCD occurring in a patient who sustained a ground-level fall whose only clinical symptom was posterior neck pain without neurologic compromise. Computed tomography (CT) and magnetic resonance imaging (MRI) were used to diagnose severe injury to the structurally important ligamentous complex that stabilizes the base of the skull to the spine, along with unstable fractures of the occipital condyle and C1. Emergent surgical instrumentation and fusion of occiput-C2 was performed. Postoperatively, neurologic integrity was maintained. This case illustrates that traumatic OCD is not exclusively secondary to high-energy mechanisms. It also demonstrates that severe neck pain as the only clinical manifestation in a patient with head or neck low-energy trauma is suggestive of a possible OCD. We highlight the importance of the use of head and neck CT as the first imaging-based diagnostic tool to aid in identifying this injury. Finally, surgical stabilization should be performed as soon as possible to minimize neurologic sequelae.
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25
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Traumatic atlanto-occipital dissociation: No longer a death sentence. Surgery 2018; 164:500-503. [PMID: 30029987 DOI: 10.1016/j.surg.2018.05.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 03/16/2018] [Accepted: 05/01/2018] [Indexed: 11/20/2022]
Abstract
BACKGROUND Traumatic atlanto-occipital dissociation is considered highly unstable and was once believed to be uniformly fatal. With recent advances in prehospital care, coupled with early diagnosis and stabilization, these injuries are potentially survivable. The aim of this study was to identify potentially modifiable risk factors associated with improved outcomes after a traumatic atlanto-occipital dissociation. METHODS Patients with traumatic atlanto-occipital dissociation over a 17-year period were identified and stratified by age, sex, injury severity, and severity of shock. Time to diagnosis, time to and method of stabilization, and mortality were compared. Multivariable logistic regression was performed to determine which factors were independent predictors of mortality. RESULTS Fifty-two patients were identified with a mean age of 44, an admission Glasgow Coma Score of 8, and an Injury Severity Score of 34; of these 52 patients, 38 (73%) underwent stabilization. Overall mortality was 33%. Of the survivors, 34 patients (97%) were discharged neurologically intact. One patient was discharged with neurologic deficits. Multivariable logistic regression identified admission Glasgow Coma Score (odds ratio 0.7; 95% confidence interval 0.552-0.877) as the only independent predictor of death after traumatic atlanto-occipital dissociation. CONCLUSION Traumatic atlanto-occipital dissociation remains a rare injury following blunt trauma. Clinical presentation is a predictor of mortality. Prompt diagnosis is crucial in promoting rapid stabilization and improving survivability. Survival to hospital discharge portends improved functional outcome.
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Trends in Patient Care for Traumatic Spinal Injuries in the United States: A National Inpatient Sample Study of the Correlations With Patient Outcomes From 2001 to 2012. Spine (Phila Pa 1976) 2017; 42:1923-1929. [PMID: 28538594 DOI: 10.1097/brs.0000000000002246] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective database review. OBJECTIVE The aim of this study was to examine whether patient characteristics, distribution of care, and patient outcomes for spinal cord injury (SCI) in the United States have changed between 2001 and 2012. SUMMARY OF BACKGROUND DATA Although patient outcomes after cranial injury are better at high-volume centers with specialized, multidisciplinary teams, similar assessments have not been done for spinal injuries. METHODS We retrospectively reviewed the National and Nationwide Inpatient Samples for the years 2001, 2002, 2011, and 2012 to identify patients with spinal fracture with or without SCI. The demographic characteristics of the patient cohort, clinical course, hospital characteristics, interhospital transfer, and disposition were statistically analyzed relative to patient mortality, total hospital costs, and length of stay. How these data changed over this 11-year period was also evaluated. RESULTS A total of 159,875 cases were identified, with 141,737 fractures without SCI and 18,138 SCIs with or without fracture. There was a statistically significant decrease in the percentage of patients transferred with spine injury from 4.2% to 3.4% (P < 0.001) from the early years to the later years and in patient transfers for SCIs (8.1% vs. 6.5%, P < 0.001). Interestingly, the overall mortality rate (3.5% vs. 3.6%) remained unchanged (P = 0.679), but mortality from SCI increased (6.6-7.4%, P = 0.021). CONCLUSION From 2002 to 2012, the rate of interhospital transfer of spinal injury patients declined, while the mortality rate for patients with SCI increased. Interestingly, there was an increase in transfers after spinal surgery at the index hospital. The decentralization of spine care may be responsible for the increase in mortality. LEVEL OF EVIDENCE 4.
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Clifton W, Feindt A, Skarupa D, McLauchlin L, Tavanaiepour D, Rahmathulla G. Paradoxical Distraction with Upright Position After Halo Fixation in 2 Patients with Atlanto-Occipital Dislocation. World Neurosurg 2017; 110:303-308. [PMID: 29174236 DOI: 10.1016/j.wneu.2017.11.080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Revised: 11/13/2017] [Accepted: 11/15/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Atlanto-occipital dislocation (AOD) is the most uncommon form of traumatic cervical spine injury. The majority of patients die before reaching higher-level care, and only a small percentage of patients with AOD survive the initial injury after receiving tertiary care. As such, there is a paucity of evidence-based management guidelines for treating this condition. Halo vest fixation has been a proposed method for interim stability while these patients undergo medical optimization for surgical intervention. There have been several reports of worsening AOD after halo placement. Reverse Trendelenburg position after halo fixation has been previously described to aid in the reduction of AOD, as well as concomitant atlantoaxial dislocation by gravitational downward force. CASE DESCRIPTION In this series we present 2 cases of obese patients (body mass index >30) with AOD treated by halo fixation that had increased distraction after head of bed elevation. CONCLUSION Our theorized mechanism for this phenomenon is due to the downward pull of subaxial forces secondary to a large body habitus.
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Affiliation(s)
- William Clifton
- Department of Neurological Surgery, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Austin Feindt
- Department of Neurological Surgery, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - David Skarupa
- Department of Neurological Surgery, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Laura McLauchlin
- Department of Neurological Surgery, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Daryoush Tavanaiepour
- Department of Neurological Surgery, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Gazanfar Rahmathulla
- Department of Neurological Surgery, University of Florida College of Medicine, Jacksonville, Florida, USA.
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Anania P, Fiaschi P, Sbaffi PF, Zona G. A Case of Asymptomatic Occipital Condyle Fracture with Incomplete Occipitocervical Dislocation: How Did It Happen? World Neurosurg 2017; 109:403-408. [PMID: 29081394 DOI: 10.1016/j.wneu.2017.10.082] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 10/13/2017] [Accepted: 10/14/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND Atlanto-occipital dislocation (AOD) is a lesion rarely observed in a trauma center, because of high mortality in the preclinical phase. The number of AOD survivors is increasing thanks to the improvement in prehospital resuscitation. CASE DESCRIPTION Our goal is to describe a case of incomplete atlanto-occipital dislocation presented without any neurologic, cardiorespiratory, or metabolic problems, which remained constant even after surgical treatment. Our purpose is also to discuss treatment approaches to minimize subsequent neurologic deficits. CONCLUSIONS We recommend a rapid immobilization with spine table and cervical collar, the consensual stabilization of hemodynamic and respiratory parameters, and a successive prompt occipitocervical stabilization. C2 should be included in the stabilization because of the ligamentous conformation of craniocervical joint.
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Affiliation(s)
- Pasquale Anania
- Department of Neurosurgery, San Martino-IST University Hospital, University of Genoa, Genoa, Italy
| | - Pietro Fiaschi
- Department of Neurosurgery, San Martino-IST University Hospital, University of Genoa, Genoa, Italy.
| | - Pier Filippo Sbaffi
- Department of Neurosurgery, San Martino-IST University Hospital, University of Genoa, Genoa, Italy
| | - Gianluigi Zona
- Department of Neurosurgery, San Martino-IST University Hospital, University of Genoa, Genoa, Italy
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Robles LA, Mundis GM, Cuevas-Solórzano A. Atlanto-Occipital Rotatory Dislocation: A Case Report and Systematic Review. World Neurosurg 2017; 110:106-114. [PMID: 29133003 DOI: 10.1016/j.wneu.2017.11.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 10/31/2017] [Accepted: 11/02/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Atlanto-occipital rotatory dislocation (AORD) has rarely been reported in the literature; for this reason, the clinicoradiologic characteristics of this injury are not well described. METHODS We describe the case of a 67-year-old man who sustained a cervical spine trauma. He reported only neck pain and was neurologically intact. A computed tomography scan showed a rotatory displacement of the atlanto-occipital joints associated with a widened condylar-C1 interval; in addition, magnetic resonance imaging showed injuries to the stabilizing ligaments of this area. A systematic literature review was also performed to identify previous cases of patients with AORD. RESULTS The patient was treated with craniocervical fixation from occipital to C1, achieving a good outcome. The literature review yielded 9 cases of patients with AORD. Compared with patients with atlanto-occipital dislocation, patients with rotatory dislocations have a less severe degree of displacement of the atlanto-occipital joints and better clinical outcome. CONCLUSIONS Compared with previously classified atlanto-occipital dislocations, AORD is an independent and unique variation. AORD presents with different biomechanical, clinicoradiologic, and prognostic characteristics and represents an important addition to the spectrum of atlanto-occipital dislocation injuries.
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Affiliation(s)
- Luis A Robles
- Section of Neurosurgery, Hospiten, Puerto Vallarta, Jalisco, Mexico.
| | - Greg M Mundis
- San Diego Center for Spinal Disorders, La Jolla, California, USA
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30
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Chowdhury FH, Haque MR, Alam SM, Khaled Chowdhury SMN, Khan SI, Goel A. Condylar Joint Fusion and Stabilization (by Screws and Plates) in Nontraumatic Atlanto-Occipital Dislocation: Technical Report of 2 Cases. World Neurosurg 2017; 107:54-62. [PMID: 28765028 DOI: 10.1016/j.wneu.2017.07.127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 07/19/2017] [Accepted: 07/20/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Nontraumatic spontaneous atlanto-occipital dislocation (AOD) is rare. In this report, we discuss the technical steps of condylar joint fusion and stabilization (by screws and plates) in nontraumatic AOD. To the best of our knowledge, it is the first report of such techniques. MATERIAL AND METHODS A young girl and a young man with progressive quadriparesis due to nontraumatic spontaneous atlanto-occipital dislocation were managed by microsurgical reduction, fusion, and stabilization of the joint by occipital condylar and C1 lateral mass screw and plate fixation after mobilization of vertebral artery. RESULT In both cases, condylar joints fixation and fusion were done successfully. CONCLUSION Condylar joint stabilization and fusion may be a good or alternative option for AOD.
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Affiliation(s)
- Forhad H Chowdhury
- Department of Neurosurgery, National Institute of Neurosciences and Hospital, Shere-e-bangla nagar, Dhaka, Bangladesh.
| | | | - Sarwar Murshed Alam
- Department of Neurosurgery, National Institute of Neurosciences and Hospital, Shere-e-bangla nagar, Dhaka, Bangladesh
| | - S M Noman Khaled Chowdhury
- Department of Neurosurgery, National Institute of Neurosciences and Hospital, Shere-e-bangla nagar, Dhaka, Bangladesh
| | - Shamsul Islam Khan
- Department of Neurosurgery, National Institute of Neurosciences and Hospital, Shere-e-bangla nagar, Dhaka, Bangladesh
| | - Atul Goel
- Seth GS Medical College and KEM Hospital, Mumbai, India
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Kaneko S, Ishii K, Watanabe K, Tsuji T, Nakamura M, Matsumoto M, Yato Y, Asazuma T. Exploration for reliable radiographic assessment method for hinge-like hypermobility at atlanto-occipital joint. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2017; 27:1303-1308. [PMID: 29052813 DOI: 10.1007/s00586-017-5349-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2016] [Revised: 05/13/2017] [Accepted: 10/13/2017] [Indexed: 11/26/2022]
Abstract
PURPOSE Hinge-like hyper-mobility is occasionally observed at the atlanto-occipital (O-C1) joint. However, it has not been clear if this kind of hinge-like hyper-mobility at the O-C1 joint should be regarded as "pathologic", or referred to as "instability". To solve this issue, we aimed to establish a reliable radiographic assessment method for this specific type of O-C1 instability and figure out the "standard value" for the range of motion (ROM) of the O-C1 joint. METHODS To figure out the standard range of the O-C1 angle, we acquired magnetic resonance imaging (MRI) sagittal views of the cervical spine for 157 healthy volunteers [average: 37.4 year-old (yo)] without spine diseases, at neutral, maximum flexion and maximum extension positions. RESULTS The average value (AVE) for ROM of O-C1 angle was 9.91°. The standard value for ROM of O-C1 angle was calculated as 0°-21°. There was no statistically significant gender difference. We also found that the older population (≧ 40 yo) significantly had a larger ROM of O-C1 angle (AVE: 11.72°) compared to the younger population (< 40 yo) (AVE: 8.99°). CONCLUSIONS We consider that hinge-like instability at O-C1 joint, which cannot be assessed by measuring Powers ratio, can be assessed by measuring the range of O-C1 angles using dynamic-MRI. Evaluation of O-C1 instability is important especially when we perform surgical treatment for diseases with upper cervical instability (such as retro-odontoid pseudotumor). We consider that the current study provides important information in such a case.
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Affiliation(s)
- Shinjiro Kaneko
- Department of Orthopaedic Surgery, National Hospital Organization Murayama Medical Center, Tokyo, Japan.
- Keio Spine Research Group (KSRG), Tokyo, Japan.
| | - Ken Ishii
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan
- Keio Spine Research Group (KSRG), Tokyo, Japan
| | - Kota Watanabe
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan
- Keio Spine Research Group (KSRG), Tokyo, Japan
| | - Takashi Tsuji
- Department of Orthopaedic Surgery, Fujita Health University Hospital, Toyoake, Japan
- Keio Spine Research Group (KSRG), Tokyo, Japan
| | - Masaya Nakamura
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan
- Keio Spine Research Group (KSRG), Tokyo, Japan
| | - Morio Matsumoto
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan
- Keio Spine Research Group (KSRG), Tokyo, Japan
| | - Yoshiyuki Yato
- Department of Orthopaedic Surgery, National Hospital Organization Murayama Medical Center, Tokyo, Japan
- Keio Spine Research Group (KSRG), Tokyo, Japan
| | - Takashi Asazuma
- Department of Orthopaedic Surgery, National Hospital Organization Murayama Medical Center, Tokyo, Japan
- Keio Spine Research Group (KSRG), Tokyo, Japan
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Lee IL, Vasquez LF, Tyroch AH, Trier TT. Association of Atlanto-Occipital Dislocation, Retroclival Hematoma, and Hydrocephalus: Management and Survival in a Pediatric Patient. J Neurol Surg Rep 2017; 78:e53-e58. [PMID: 28321388 PMCID: PMC5357215 DOI: 10.1055/s-0037-1600914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Atlanto-occipital dislocation (AOD) is an injury with high morbidity and mortality. We present a case of survival of a pediatric patient with the diagnoses of AOD, retroclival hematoma, and resulting hydrocephalus. The patient's cervical spine was stabilized until occipital-cervical fusion provided definitive treatment, and the hydrocephalus was treated with a ventriculostomy. The patient survived with no neurological deficits. A better understanding and awareness of the radiologic criteria of AOD will lead to earlier recognition of AOD and improved outcomes, even in the presence of complications from AOD. Surgical fixation should be used for definitive treatment of injuries with AOD.
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Affiliation(s)
- Isaac L Lee
- Department of Surgery, Texas Tech University Health Sciences Center El Paso, El Paso, Texas, United States
| | - Luis F Vasquez
- Department of Neurosurgery, University Medical Center El Paso, El Paso, Texas, United States
| | - Alan H Tyroch
- Department of Surgery, Texas Tech University Health Sciences Center El Paso, El Paso, Texas, United States
| | - Todd T Trier
- Department of Neurosurgery, University Medical Center El Paso, El Paso, Texas, United States
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Beez T, Brown J. Traumatic atlanto-occipital dislocation in children-a case-based update on clinical characteristics, management and outcome. Childs Nerv Syst 2017; 33:27-33. [PMID: 27757567 DOI: 10.1007/s00381-016-3265-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Accepted: 10/04/2016] [Indexed: 01/18/2023]
Abstract
BACKGROUND Atlanto-occipital dislocation (AOD) is a rare but severe sequela of high energy trauma. Children are at increased risk, due to their immature spine and biomechanical characteristics. LITERATURE REVIEW The prevailing mechanism of injury is motor vehicle collision as passenger. AOD commonly presents with cardiorespiratory arrest, spinal cord injury or cranial nerve deficits. Concomitant injuries, such as traumatic brain injury, are frequently encountered. Diagnosis is made on CT and MRI imaging. Posterior internal fixation is the recommended treatment. Thirty-four percent of patients die, 41 % survive with deficits and 25 % have a complete neurological recovery. Initial symptoms, GCS score and degree of spinal cord injury appear to be predictors of outcome. ILLUSTRATIVE CASE We report the case of a 9-year-old boy, who presented in extremis with cardiac arrest after a motor vehicle collision. Upon successful resuscitation, diagnostic imaging showed AOD and a Chiari I malformation. An occiput-C2 posterior instrumented fusion was performed. The patient subsequently received intensive rehabilitation and recovered to independent ambulation, with a persistent, asymptomatic Chiari I malformation. CONCLUSION This case highlights the potential for positive outcome in paediatric AOD, despite the presence of strong predictors of poor or fatal outcome at presentation.
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Affiliation(s)
- Thomas Beez
- Paediatric Neurosurgery, Royal Hospital for Children, Glasgow, UK. .,Department of Neurosurgery, Medical Faculty, Heinrich Heine University, Moorenstrasse 5, 40225, Düsseldorf, Germany.
| | - Jennifer Brown
- Paediatric Neurosurgery, Royal Hospital for Children, Glasgow, UK
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Martinez-del-Campo E, Turner JD, Kalb S, Rangel-Castilla L, Perez-Orribo L, Soriano-Baron H, Theodore N. Occipitocervical Fixation. Neurosurgery 2016; 79:549-60. [DOI: 10.1227/neu.0000000000001340] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND
Occipitocervical junction instability can lead to serious neurological injury or death. Open surgical fixation is often necessary to provide definitive stabilization. However, long-term results are limited to small case series.
OBJECTIVE
To review the causes of occipitocervical instability, discuss the indications for surgical intervention, and evaluate long-term surgical outcomes after occipitocervical fixation.
METHODS
The charts of all patients undergoing posterior surgical fixation of the occipitocervical junction by the senior author were retrospectively reviewed. A total of 120 consecutive patients were identified for analysis. Patient demographic characteristics, occipitocervical junction pathology, surgical indications, and clinical and radiographic outcomes are reported.
RESULTS
The study population consisted of 64 male and 56 female patients with a mean age of 39.9 years (range, 7 months to 88 years). Trauma was the most common cause of instability, occurring in 56 patients (47%). Ninety patients (75%) were treated with screw/rod constructs; wiring was used in 30 patients (25%). The median number of fixated segments was 5 (O-C4). Structural bone grafts were implanted in all patients (100%). Preoperative neurological deficits were present in 83 patients (69%); 91% of those patients improved with surgery. Mean follow-up was 35.1 ± 27.4 months (range, 0-123 months). Two patients died, and 10 were lost to follow-up before the end of the 6-month follow-up period. Fusion was confirmed in 107 patients (89.1%). The overall complication rate was 10%, including 3 patients with vertebral artery injuries and 2 patients who required revision surgery.
CONCLUSION
Occipitocervical fixation is a durable treatment option with acceptable morbidity for patients with occipitocervical instability.
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Affiliation(s)
- Eduardo Martinez-del-Campo
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Jay D. Turner
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Samuel Kalb
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Leonardo Rangel-Castilla
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Luis Perez-Orribo
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Hector Soriano-Baron
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Nicholas Theodore
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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Martinez-Del-Campo E, Turner JD, Rangel-Castilla L, Soriano-Baron H, Kalb S, Theodore N. Pediatric occipitocervical fixation: radiographic criteria, surgical technique, and clinical outcomes based on experience of a single surgeon. J Neurosurg Pediatr 2016; 18:452-462. [PMID: 27286444 DOI: 10.3171/2016.2.peds15544] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE If left untreated, occipitocervical (OC) instability may lead to serious neurological injury or death. Open internal fixation is often necessary to protect the neurovascular elements. This study reviews the etiologies for pediatric OC instability, analyzes the radiographic criteria for surgical intervention, discusses surgical fixation techniques, and evaluates long-term postoperative outcomes based on a single surgeon's experience. METHODS The charts of all patients < 18 years old who underwent internal OC fixation conducted by the senior author were retrospectively reviewed. Forty consecutive patients were identified for analysis. Patient demographic data, OC junction pathology, radiological diagnostic tools, surgical indications, and outcomes are reported. RESULTS The study population consisted of 20 boys and 20 girls, with a mean age of 7.3 years. Trauma (45% [n = 18]) was the most common cause of instability, followed by congenital etiologies (37.5% [n = 15]). The condyle-C1 interval had a diagnostic sensitivity of 100% for atlantooccipital dislocation. The median number of fixated segments was 5 (occiput-C4). Structural bone grafts were used in all patients. Postsurgical neurological improvement was seen in 88.2% (15/17) of patients with chronic myelopathy and in 25% (1/4) of patients with acute myelopathy. Preoperatively, 42.5% (17/40) of patients were neurologically intact and remained unchanged at last follow-up, 42.5% (17/40) had neurological improvement, 12.5% (5/40) remained unchanged, and 2.5% (1/40) deteriorated. All patients had successful fusion at 1-year follow-up. The complication rate was 7.5% (3/40), including 1 case of vertebral artery injury. CONCLUSIONS Occipitocervical fixation is safe in children and provides immediate immobilization, with excellent survival and arthrodesis rates. Of the radiographic tools evaluated, the condyle-C1 interval was the most predictive of atlantooccipital dislocation.
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Affiliation(s)
- Eduardo Martinez-Del-Campo
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Jay D Turner
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Leonardo Rangel-Castilla
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Hector Soriano-Baron
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Samuel Kalb
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Nicholas Theodore
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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Kasliwal MK, Fontes RB, Traynelis VC. Occipitocervical dissociation-incidence, evaluation, and treatment. Curr Rev Musculoskelet Med 2016; 9:247-54. [PMID: 27255101 PMCID: PMC4958379 DOI: 10.1007/s12178-016-9347-6] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Traumatic occipitocervical dissociation (OCD) results from ligamentous injury to the craniocervical junction and is associated with a high rate of mortality and significant neurologic morbidity. The diagnosis is frequently missed on initial lateral cervical spinal radiographs mainly due to inadequate visualization of radiological landmarks and low degree of suspicion. Widespread availability of multidetector computed tomography (MDCT) of the spine and development of better diagnostic radiological criteria has allowed timely diagnosis and good clinical outcome following posterior occipitocervical fusion and instrumentation for a pathology that was once considered uniformly fatal. The present paper reviews the clinical features, diagnosis, and management of OCD in light of most recent literature.
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Affiliation(s)
- Manish K Kasliwal
- Department of Neurosurgery, Rush University Medical Center, 1725 W. Harrison St., Chicago, IL, 60612, USA
| | - Ricardo B Fontes
- Department of Neurosurgery, Rush University Medical Center, 1725 W. Harrison St., Chicago, IL, 60612, USA
| | - Vincent C Traynelis
- Department of Neurosurgery, Rush University Medical Center, 1725 W. Harrison St., Chicago, IL, 60612, USA.
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Dahdaleh NS, Khanna R, Menezes AH, Smith ZA, Viljoen SV, Koski TR, Hitchon PW, Dlouhy BJ. The Application of the Revised Condyle-C1 Interval Method to Diagnose Traumatic Atlanto-occipital Dissociation in Adults. Global Spine J 2016; 6:529-34. [PMID: 27555993 PMCID: PMC4993610 DOI: 10.1055/s-0035-1569058] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 09/22/2015] [Indexed: 12/04/2022] Open
Abstract
STUDY DESIGN Retrospective study. OBJECTIVE Traumatic atlanto-occipital dissociation (AOD) remains a diagnostic challenge, and delay in diagnosis is associated with catastrophic outcomes. Recently, a revised version of the condyl-C1 interval (CCI) utilizing parasagittal computed tomography (CT) reconstruction was used successfully with unilateral dislocation of 2.5 mm at the level of that joint diagnostic of AOD. We report the utility of this simple technique in the diagnosis of six patients with AOD. METHODS Two blinded neurosurgeons assessed CTs of six patients with AOD and 30 patients without AOD. The following methodologies were applied: basion-dens interval (BDI), basion-axial interval (BAI), Lee X-lines, Powers ratio, CCI, and revised CCI. The average sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) as well as the kappa statistic indicating interrater reliability of each method were investigated. RESULTS The average sensitivity for BDI, BAI, Lee X-lines, Power ratio, CCI, and revised CCI was 0.75, 0.33, 0.67, 0.50, 1.00, and 1.00, respectively. The average specificity was 1.00, 1.00, 0.50, 1.00, 0.94, and 1.00, respectively. The average PPV was 1.00, 1.00, 0.25, 1.00, 0.80, and 1.00, respectively. The average NPV was 0.96, 0.88, 0.89, 0.91, 1.00, and 1.00, respectively, and the kappa statistic was 0.57, 0.25, 0.25, 0.20, 1.00, and 1.00, respectively. CONCLUSION Based on this study, the revised CCI method is simple yet the most sensitive and reliable technique for the diagnosis of AOD.
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Affiliation(s)
- Nader S. Dahdaleh
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States,Address for correspondence Nader S. Dahdaleh, MD Department of Neurological Surgery, Northwestern University676 N. St. Clair, Suite 2210, Chicago, IL 60611United States
| | - Ryan Khanna
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
| | - Arnold H. Menezes
- Department of Neurological Surgery, University of Iowa, Carver School of Medicine, Iowa City, Iowa, United States
| | - Zachary A. Smith
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
| | - Stephanus V. Viljoen
- Department of Neurological Surgery, University of Iowa, Carver School of Medicine, Iowa City, Iowa, United States
| | - Tyler R. Koski
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
| | - Patrick W. Hitchon
- Department of Neurological Surgery, University of Iowa, Carver School of Medicine, Iowa City, Iowa, United States
| | - Brian J. Dlouhy
- Department of Neurological Surgery, University of Iowa, Carver School of Medicine, Iowa City, Iowa, United States
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Ducis K, Florman JE, Rughani AI. Appraisal of the Quality of Neurosurgery Clinical Practice Guidelines. World Neurosurg 2016; 90:322-339. [PMID: 26947727 DOI: 10.1016/j.wneu.2016.02.044] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Revised: 02/09/2016] [Accepted: 02/11/2016] [Indexed: 01/13/2023]
Abstract
OBJECTIVE The rate of neurosurgery guidelines publications was compared over time with all other specialties. Neurosurgical guidelines and quality of supporting evidence were then analyzed and compared by subspecialty. METHODS The authors first performed a PubMed search for "Neurosurgery" and "Guidelines." This was then compared against searches performed for each specialty of the American Board of Medical Specialties. The second analysis was an inventory of all neurosurgery guidelines published by the Agency for Healthcare Research and Quality Guidelines clearinghouse. All Class I evidence and Level 1 recommendations were compared for different subspecialty topics. RESULTS When examined from 1970-2010, the rate of increase in publication of neurosurgery guidelines was about one third of all specialties combined (P < 0.0001). However, when only looking at the past 5 years the publication rate of neurosurgery guidelines has converged upon that for all specialties. The second analysis identified 49 published guidelines for assessment. There were 2733 studies cited as supporting evidence, with only 243 of these papers considered the highest class of evidence (8.9%). These papers were used to generate 697 recommendations, of which 170 (24.4%) were considered "Level 1" recommendations. CONCLUSION Although initially lagging, the publication of neurosurgical guidelines has recently increased at a rate comparable with that of other specialties. However, the quality of the evidence cited consists of a relatively low number of high-quality studies from which guidelines are created. Wider implications of this must be considered when defining and measuring quality of clinical performance in neurosurgery.
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Affiliation(s)
- Katrina Ducis
- Division of Neurosurgery, Department of Surgery, University of Vermont, Burlington, Vermont, USA.
| | - Jeffrey E Florman
- Neuroscience Institute, Maine Medical Center, Portland, Maine, USA; Department of Neurosurgery, Tufts University Medical Center, Boston, Massachusetts, USA
| | - Anand I Rughani
- Neuroscience Institute, Maine Medical Center, Portland, Maine, USA; Department of Neurosurgery, Tufts University Medical Center, Boston, Massachusetts, USA; Center for Excellence in Neuroscience, University of New England, Biddeford, Maine, USA
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Martinez-Del-Campo E, Kalb S, Soriano-Baron H, Turner JD, Neal MT, Uschold T, Theodore N. Computed tomography parameters for atlantooccipital dislocation in adult patients: the occipital condyle-C1 interval. J Neurosurg Spine 2015; 24:535-45. [PMID: 26682597 DOI: 10.3171/2015.6.spine15226] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Atlantooccipital dislocation (AOD) in adults cannot be diagnosed with adequate specificity and sensitivity using only CT or plain radiography, and the spine literature offers no guidelines. In children, the most sensitive and specific radiographic measurement for the diagnosis of AOD is the CT-based occipital condyle-C1 interval (CCI). The goal of the current study was to identify the normal CCI in healthy adults and compare it with the CCI in adults with AOD to establish a highly sensitive and specific cutoff value for the neuroimaging diagnosis of AOD. METHODS A total of 81 patients, 59 without AOD and 22 with AOD, were included in this study. Measurements obtained from thin-slice CT scans of the craniovertebral joint to assess atlantooccipital dislocation included the CCI, condylar sum, the Wholey and Harris intervals, Powers and Sun ratios, Wackenheim line, and Lee X-lines. RESULTS The group of patients without AOD included 30 men (50.8%) and 29 women (49.2%) with a mean age of 42.4 ± 16 years (range 19-87 years). The group of patients with AOD included 10 men (45.5%) and 12 women (54.5%) with a mean age of 38.2 ± 9.7 years (range 20-56 years). Interrater reliabilities within a 95% CI were all greater than 0.98 for CCI measurements. A total of 1296 measurements of the CCI were made in 81 patients. The mean CCI for non-AOD patients was 0.89 ± 0.12 mm, the single largest CCI measurement was 1.4 mm, and the largest mean for either right or left CCI was 1.2 mm. The mean condylar sum was 1.8 ± 0.2 mm, and the largest condylar sum value was 2.2 mm. Linear regression with age predicted an increase in CCI of 0.001 mm/year (p < 0.05). The mean CCI in AOD patients was 3.35 ± 0.18 mm (range 1.5 mm-6.4 mm). The shortest single CCI measurements in the AOD patients were 1.1 mm and 1.2 mm. The mean condylar sum for all 22 AOD patients was 6.7 ± 2.7 mm and the shortest condylar sums were 3.0 mm. Cutoff values for AOD were set at 1.5 mm for the CCI and 3.0 mm for the condylar sum, both with a sensitivity of 1 and false-negative rate of 0. Sensitivity for the Powers, Wholey, Harris, Sun, Wackenheim, and Lee criteria were determined to be 0.55, 0.46, 0.27, 0.23, 0.41, and 0.41, respectively. CONCLUSIONS The CCI is shorter in adult patients as opposed to the pediatric population. The revised CCI (1.5 mm) and condylar sum (3.0 mm) cutoff values have the highest sensitivity and specificity for the diagnosis of AOD in the adult population.
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Affiliation(s)
- Eduardo Martinez-Del-Campo
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Samuel Kalb
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Hector Soriano-Baron
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Jay D Turner
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Matthew T Neal
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Timothy Uschold
- Southern Oregon Neurosurgical and Spine Associates, Medford, Oregon
| | - Nicholas Theodore
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
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Traumatic atlanto-occipital dissociation presenting as locked-in syndrome. J Clin Neurosci 2015; 22:1985-7. [DOI: 10.1016/j.jocn.2015.06.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 06/20/2015] [Indexed: 11/20/2022]
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Kaplan NB, Molinari C, Molinari RW. Nonoperative Management of Craniocervical Ligamentous Distraction Injury: Literature Review. Global Spine J 2015; 5:505-12. [PMID: 26682101 PMCID: PMC4671892 DOI: 10.1055/s-0035-1566290] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Study Design Literature review and case report. Objective Review the existing literature and report the successful nonoperative management of a two-level craniocervical ligamentous distraction injury. Methods A PubMed and Medline review revealed only three limited reports involving the nonoperative management of patients with craniocervical distraction injury. This article reviews the existing literature and reports the case of a 27-year-old man who was involved in a motorcycle accident and sustained multiple systemic injuries and ligamentous distraction injuries to both occipitocervical joints and both C1-C2 joints. The patient's traumatic brain injury and bilateral pulmonary contusions precluded safe operative management of the two-level craniocervical distraction injury. Therefore, the patient was placed in a halo immobilization device. Results The literature remains unclear as to the specific indications for nonoperative management of ligamentous craniocervical injuries. Nonoperative management was associated with poor outcomes in the majority of reported patients. We report a patient who was managed for 6 months in a halo device. Posttreatment computed tomography and flexion-extension radiographs demonstrated stable occipitocervical and C1-C2 joints bilaterally. The patient reported minimal neck pain and had excellent functional outcome with a Neck Disability Index score of 2 points at 41 months postoperatively. He returned to preinjury level of employment without restriction. Conclusions Further study is needed to determine which craniocervical injuries may be managed successfully with nonoperative measures.
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Affiliation(s)
- Nathan B. Kaplan
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, New York, United States
| | | | - Robert W. Molinari
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, New York, United States,Address for correspondence Robert W. Molinari, MD Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center601 Elmwood Avenue, Box 665, Rochester, NY 14642United States
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Mendenhall SK, Sivaganesan A, Mistry A, Sivasubramaniam P, McGirt MJ, Devin CJ. Traumatic atlantooccipital dislocation: comprehensive assessment of mortality, neurologic improvement, and patient-reported outcomes at a Level 1 trauma center over 15 years. Spine J 2015; 15:2385-95. [PMID: 26165481 DOI: 10.1016/j.spinee.2015.07.003] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Revised: 05/28/2015] [Accepted: 07/01/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Only Level 3 evidence exists for the diagnosis and treatment of atlantooccipital dislocation (AOD) with few studies examining mortality, neurologic improvement, and patient-reported outcomes (PROs). PURPOSE First, the aim was to determine: the incidence of AOD, 90-day surgical morbidity and mortality after AOD, patient factors that may be associated with delayed or missed diagnosis, and factors that were associated with mortality and neurologic improvement after AOD. Secondly, the aim was to quantify the pain, disability, and quality of life experienced by patients surviving AOD. STUDY DESIGN/SETTING This was a retrospective cohort study. PATIENT SAMPLE A total of 5,337 consecutive spine computed tomography traumagrams from 1997 to 2012 were included. OUTCOME MEASURES Mortality, neurologic improvement, complications, EuroQol five dimensions (EQ-5D), Neck Disability Index (NDI), Numeric Rating Scale (NRS)-neck, NRS-arm, and return-to-work were the outcome measures. METHODS Patients were considered to have AOD if they met one of the following radiographic criteria: basion-dens interval greater than 10 mm; basion-axial interval: anterior displacement greater than 12 mm or posterior displacement greater than 4 mm between the basion and posterior C2 line; and condyle to C1 interval greater than 1.4 mm. Linear regression analysis was performed to identify factors associated with 90-day mortality, neurologic improvement, and missed diagnosis. Patient-reported outcomes were assessed via phone interview. RESULTS Thirty-one patients met radiographic criteria for AOD; an incidence of 0.6% over 15 years. Twenty-one (68%) patients were treated with occipital cervical fusion. At 90 days postoperatively, there were no new neurologic deficits or reoperations. Eight (26%) patients died within 90 days. All patients who died had no documented AOD diagnosis and were not treated surgically. Missed AOD diagnosis was the strongest predictor of mortality. Younger age, lower Glasgow Coma Score, lower Injury Severity Score (ISS) score, and worse initial American Spinal Injury Association (ASIA) score were significantly associated with greater neurologic improvement. Higher ISS score and better ASIA score were significantly associated with missed AOD diagnosis. The average PROs metrics at time of telephone follow-up were as follows: EQ-5D=0.73±0.19, NDI=30.89±18.57, NRS-neck=2.33±2.21, NRS-arm=2.00±2.54. Of the patients with follow-up data, four were employed full-time, and five were receiving disability. CONCLUSIONS Our work suggests that failure to diagnose AOD is a powerful predictor of mortality. Higher ISS scores and better neurologic presentation were significantly associated with missed diagnosis. Craniocervical arthrodesis preserved neurologic function with low complication rate and unexpectedly high PROs and return-to-work. These results must be carefully interpreted because it is unclear whether missed AOD diagnosis accompanies another death-causing injury (eg, traumatic brain injury) or if failure to treat AOD contributes to mortality in a multifactorial manner.
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Affiliation(s)
- Stephen K Mendenhall
- Department of Neurological Surgery, Vanderbilt University Medical Center, T-4224 Medical Center N., 1611 21st Ave. S., Nashville, TN 37232, USA
| | - Ahilan Sivaganesan
- Department of Neurological Surgery, Vanderbilt University Medical Center, T-4224 Medical Center N., 1611 21st Ave. S., Nashville, TN 37232, USA
| | - Akshitkumar Mistry
- Department of Neurological Surgery, Vanderbilt University Medical Center, T-4224 Medical Center N., 1611 21st Ave. S., Nashville, TN 37232, USA
| | - Priya Sivasubramaniam
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, 1215 21st Ave. S. #4200, Nashville, TN 37232, USA
| | - Matthew J McGirt
- Department of Neurological Surgery, Vanderbilt University Medical Center, T-4224 Medical Center N., 1611 21st Ave. S., Nashville, TN 37232, USA; Carolina Neurosurgery and Spine Associates, 225 Baldwin Ave., Charlotte, NC 28204, USA
| | - Clinton J Devin
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, 1215 21st Ave. S. #4200, Nashville, TN 37232, USA.
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Baumann F, Ernstberger T, Neumann C, Nerlich M, Schroeder GD, Vaccaro AR, Loibl M. Pediatric Cervical Spine Injuries: A Rare But Challenging Entity. JOURNAL OF SPINAL DISORDERS & TECHNIQUES 2015; 28:E377-E384. [PMID: 26165728 DOI: 10.1097/bsd.0000000000000307] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Injuries to the cervical spine in pediatric patients are uncommon. A missed injury can have devastating consequences in this age group. Because of the lack of routine in diagnosis and management of pediatric cervical spine injuries (PCSI), each of these cases represents a logistic and personal challenge. METHODS By means of clinical cases, we demonstrate key points in diagnostics and treatment of pediatric spine injuries. We highlight typical pediatric injury patterns and more adult-like injuries. RESULTS The most common cause of injury is blunt trauma. There is an age-related pattern of injuries in pediatric patients. Children under the age of 8 frequently sustain ligamentous injuries in the upper cervical spine. After the age of 8, the biomechanics of the cervical spine are similar to adults, and therefore, bony injuries of the subaxial cervical spine are most likely to occur. Clinical presentation of PCSI is heterogeneous. Younger children can neither interpret nor communicate neurological abnormalities, which make timely and accurate diagnosis difficult. Plain radiographs are often misinterpreted. We find different types of injuries at different locations, because of different biomechanical properties of the immature spine. We outline that initial management is crucial for long-term outcome. CONCLUSIONS Knowledge of biomechanical properties and radiographic presentation of the immature spine can improve the awareness for PCSI. Diagnosis and management of pediatric patients after neck trauma can be demanding. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Florian Baumann
- *Department of Trauma Surgery, Regensburg University Medical Center, Regensburg, Germany †The Rothman Institute at Thomas Jefferson University, Philadelphia, PA
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Brotis AG, Paraskevi TM, Tsitsopoulos P, Tasiou A, Fotakopoulos G, Fountas KN. An evidence-based approach towards the cranio-cervical junction injury classifications. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2015; 24:931-9. [DOI: 10.1007/s00586-015-3877-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Revised: 02/07/2015] [Accepted: 03/11/2015] [Indexed: 12/12/2022]
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Hall GC, Kinsman MJ, Nazar RG, Hruska RT, Mansfield KJ, Boakye M, Rahme R. Atlanto-occipital dislocation. World J Orthop 2015; 6:236-243. [PMID: 25793163 PMCID: PMC4363805 DOI: 10.5312/wjo.v6.i2.236] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Revised: 05/02/2014] [Accepted: 10/27/2014] [Indexed: 02/06/2023] Open
Abstract
Atlanto-occipital dislocation (AOD) is being increasingly recognized as a potentially survivable injury as a result of improved prehospital management of polytrauma patients and increased awareness of this entity, leading to earlier diagnosis and more aggressive treatment. However, despite overall improved outcomes, AOD is still associated with significant morbidity and mortality. The purpose of this paper is to review the biomechanical aspects, clinical features, radiologic criteria, and treatment strategies of AOD. Given that the diagnosis of AOD can be very challenging, a high degree of clinical suspicion is essential to ensure timely recognition and treatment, thus preventing neurological decline or death.
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Abstract
Although once considered an invariably fatal injury, improvements in diagnosis and management have made atlanto-occipital dislocation (AOD) a survivable injury. MRI is the preferred imaging modality; occasionally, flexion/extension/distraction fluoroscopy may be required to determine craniovertebral stability. Early surgical stabilization is recommended for all children with AOD. Early occipitocervical fusion using screws in combination with a rod or plate, or sublaminar wires with a contoured rod, coupled with autograft bone, provide immediate stabilization and a high fusion rate. Halo immobilization and traction are contraindicated in the management of AOD in children because of the risk of displacement of the injured occipitocervical joint. Postoperative hydrocephalus is frequent and should be suspected when neurologic decline occurs after fixation. Nearly half of children who survive AOD will have residual neurologic deficits.
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