Traumatic atlanto-occipital dislocation with survival: a case report and review of the literature

Traumatic atlanto-occipital dislocation with successfully bystander resuscitation after cardiopulmonary arrest: A case report

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.

Atlanto-occipital dislocation in a patient presenting with out-of-hospital cardiac arrest: a case report and literature review

Background

Atlanto-occipital dislocation is a rare and severe injury of the upper spine associated with a very poor prognosis.

Case presentation

We report the case of a 59-year-old European man who suffered from out-of-hospital cardiac arrest following a motor vehicle accident. Cardiopulmonary resuscitation was initiated immediately by bystanders and continued by emergency medical services. After 30 minutes of cardiopulmonary resuscitation with a total of five shocks following initial ventricular fibrillation, return of spontaneous circulation was achieved. An electrocardiogram recorded after return of spontaneous circulation at the scene showed signs of myocardial ischemia as a possible cause for the cardiac arrest. No visible signs of injury were found. He was transferred to the regional academic trauma center.

Following an extended diagnostic and therapeutic workup in the emergency room, including extended focused assessment with sonography for trauma ultrasound, whole-body computed tomography, and magnetic resonance imaging (of his head and neck), a diagnosis of major trauma (atlanto-occipital dislocation, bilateral serial rip fractures and pneumothoraces, several severe intracranial bleedings, and other injuries) was made. An unfavorable outcome was initially expected due to suspected tetraplegia and his inability to breathe following atlanto-occipital dislocation.

Contrary to initial prognostication, after 22 days of intensive care treatment and four surgical interventions (halo fixation, tracheostomy, intracranial pressure probe, chest drains) he was awake and oriented, spontaneously breathing, and moving his arms and legs. Six weeks after the event he was able to walk without aid. After 2 months of clinical treatment he was able to manage all the activities of daily life on his own.

It remains unclear, whether cardiac arrest due to a cardiac cause resulted in complete atony of the paravertebral muscles and caused this extremely severe lesion (atlanto-occipital dislocation) or whether cardiac arrest was caused by apnea due the paraplegia following the spinal injury of the trauma.

Conclusions

A plausible cause for the trauma was myocardial infarction which led to the car accident and the major trauma in relation to the obviously minor trauma mechanism. With this case report we aim to familiarize clinicians with the mechanism of injury that will assist in the diagnosis of atlanto-occipital dislocation. Furthermore, we seek to emphasize that patients presenting with electrocardiographic signs of myocardial ischemia after high-energy trauma should primarily be transported to a trauma facility in a percutaneous coronary intervention-capable center rather than the catheterization laboratory directly.

Management of cervical spine trauma in children

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.

Paradoxical Distraction with Upright Position After Halo Fixation in 2 Patients with Atlanto-Occipital Dislocation

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.

A Case of Asymptomatic Occipital Condyle Fracture with Incomplete Occipitocervical Dislocation: How Did It Happen?

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.

Prognostic factors in traumatic atlanto-occipital dislocation

Traumatic atlanto-occipital dislocation (AOD) is an ominous injury with high mortality and morbidity in trauma patients. Improved survival has been observed with advancements in pre-hospital and hospital care. Furthermore, high quality imaging studies are accessible at most trauma centers; these are crucial for prompt diagnosis of AOD. The objective of this study is to perform a comprehensive literature review of traumatic AOD, with specific emphasis on identifying prognostic factors for survival. A review of the literature was performed using the Medline database for all traumatic atlanto-occipital articles published between March 1959 and June 2015; 141 patients from 60 total studies met eligibility criteria for study inclusion. A binary logistic regression model was utilized to identify prognostic factors. The analysis assessed age, sex, spinal cord injury (SCI), traumatic brain injury (TBI), polytrauma injury (PI), and Traynelis AOD Classification. Only TBI was statistically significantly associated with death (OR 8.05 p<0.05); SCI did not reach statistical significance for predicting mortality in AOD patients (OR 1.25 p>0.05). Age, sex, PI, and Traynelis AOD Classification did not meet significance to predict mortality in AOD patients. We found that patients with TBI are eight times more likely to die than patients without TBI. A high degree of suspicion for AOD during pre-hospital care, as well as, prompt diagnosis and management in the trauma center play a key role in the treatment of this devastating injury. The relationship between survival and factors such as TBI and SCI should be further explored.

Complete medulla/cervical spinal cord transection after atlanto-occipital dislocation: An extraordinary case

STUDY DESIGN

Case report.

SUMMARY OF BACKGROUND DATA

Traumatic atlanto-occipital dislocation (AOD) with a complete medulla/spinal cord transection is rare and believed to be fatal owing to the high level of the spinal cord injury. Clinical outcome is poor. Consequently, relatively few case reports of adult patients surviving this injury appear in the literature. OBJECTIVES AND RESULT: We present the case of a 20-year-old male, who sustained an AOD with a complete medulla/spinal cord transection in a motorcycle accident to discuss the possibility of long-term survival with this condition. The patient underwent occipito-cervical stabilization. With an Injury Severity Score of 75, by definition unsurvivable, the patient is 16 months after the injury, ventilated and fully dependent for all care.

CONCLUSION

Long-term survival following AOD with a complete medulla/spinal cord transection is possible if immediate resuscitation at the scene is available. Nevertheless, it remains questionable whether or not a patient with such a devastating injury and without any prospect of functional recovery should be kept alive under all circumstances.

Verletzungen des kraniozervikalen Übergangs

Injuries to the upper cervical spine (C0-C2) play a major role in surgical treatment of traumatic sequelae in the entire cervical spine. Even though the number of such operations has increased in recent years, there are no clear treatment recommendations for most types of cervical spine injuries. In view of the wide range of injury types and the correspondingly large number of treatment options, this review focuses mainly on the following types of injuries: C0 fractures, occipital condyle fractures (OCF), atlanto-occipital dislocation (AOD), atlas fractures, atlantoaxial dislocation (AAD), and axis fractures. Important aspects of the mechanisms of injury, clinical signs and symptoms, diagnostic procedures, and treatment options are discussed. Special emphasis is placed on comparatively reviewing the different treatment options discussed in the literature. A summary in table form is presented at the end of each chapter for quick reference.

Tectorial Membrane Injuries in Children

We report three cases of tectorial membrane injury in children. An increased interspinous ratio was identified on cervical spine radiographs. The tectorial membrane injuries were diagnosed by magnetic resonance imaging. The three children were restrained passengers in high-speed motor vehicle accidents, and all sustained polytrauma. Two children with partial tears of the tectorial membrane were immobilized in a halo, and one with a longitudinal tear of the tectorial membrane had an occiput-to-C2 fusion.

Atlanto-occipital dislocation: four case reports of survival in adults and review of the literature

Traumatic atlanto-occipital dislocation (AOD) is a rare cervical spine injury and in most cases fatal. Consequently, relatively few case reports of adult patients surviving this injury appeared in the literature. We retrospectively report four patients who survived AOD injury and were treated at our institution. A young man fell from height and a woman was injured in a traffic accident. Both patients survived the injury but died later in the hospital. The third patient had a motorcycle accident and survived with incomplete paraplegia. The last patient, a man involved in a working accident, survived without neurological deficit of the upper extremities. Rigid posterior fixation and complete reduction of the dislocation were applied in last two cases using Cervifix together with a cancellous bone grafting. Previously reported cases of patients surviving AOD are reviewed, and clinical features and operative stabilisation procedures are discussed.

Circumferential fracture of the skull base causing craniocervical dislocation. Case report

Fractures of the craniocervical junction are common in victims of high-speed motor vehicle accidents; indeed, injury to this area is often fatal. The authors present the unusual case of a young woman who sustained a circumferential fracture of the craniocervical junction. Despite significant trauma to this area, she suffered remarkably minor neurological impairment and made an excellent recovery. Her injuries, treatment, and outcome, as well as a review of the literature with regard to injuries at the craniocervical junction, are discussed.

Diagnosis and management of traumatic atlanto-occipital dislocation injuries

DIAGNOSTIC

STANDARDS

There is insufficient evidence to support diagnostic standards.

GUIDELINES

There is insufficient evidence to support diagnostic guidelines.

OPTIONS

A lateral cervical x-ray is recommended for the diagnosis of atlanto-occipital dislocation. If a radiological method for measurement is used, the basion-axial interval-basion-dental interval method is recommended. The presence of upper cervical prevertebral soft tissue swelling on an otherwise nondiagnostic plain x-ray should prompt additional imaging. If there is clinical suspicion of atlanto-occipital dislocation, and plain x-rays are nondiagnostic, computed tomography or magnetic resonance imaging is recommended, particularly for the diagnosis of non-Type II dislocations.

TREATMENT

STANDARDS

There is insufficient evidence to support treatment standards.

GUIDELINES

There is insufficient evidence to support treatment guidelines.

OPTIONS

Treatment with internal fixation and arthrodesis using one of a variety of methods is recommended. Traction may be used in the management of patients with atlanto-occipital dislocation, but it is associated with a 10% risk of neurological deterioration.

Transarticular screw fixation for atlanto-occipital dislocation

STUDY DESIGN

A case report of traumatic atlanto-occipital dislocation managed by transarticular screw fixation.

OBJECTIVES

To present a case with initial failed wire fixation but successful reduction and fixation with transarticular screw fixation and occipitocervical plate stabilization.

SUMMARY OF BACKGROUND DATA

Atlanto-occipital dislocation is generally a fatal injury, except when it occurs in children. Management of this injury is difficult because of multidirectional instability and the problems associated with technical stabilization.

METHODS

Intraoperative atlanto-occipital reduction was achieved and maintained by direct C0-C1 transarticular screw fixation. To protect this fixation, a posterior occipitocervical fusion at C0-C2 using a Y-plate was performed.

RESULTS

The internal fixation and reduction were maintained, indicating a good surgical outcome, at examination 2 years after surgery. The initially severe neurologic deficit was reduced to some motor weakness of the right hand and weakness of oculomotor function.

CONCLUSIONS

Anatomic reduction and reliable fixation with transarticular screws may provide satisfactory clinical results with important neurologic recovery in cases of atlanto-occipital dislocation.

Traumatic occipitoatlantal dislocation

BACKGROUND

Traumatic occipitoatlantal dislocation (OAD) is a severe ligamentous injury resulting in instantaneous death or severe neurological deficit. However, survivors of OAD, both short and long term, have been increasingly reported; this may be because of improved prehospital care, more rapid transportation, a high index of suspicion, and new radiological techniques.

METHODS

The medical records and film of three patients who had traumatic OAD were retrospectively reviewed. Diagnosis was made by lateral cervical spine radiography, computed tomography (CT), or magnetic resonance imaging (MRI). Treatment consisted of early respiratory support and subsequent posterior surgical fusion.

RESULTS

The three survivors of traumatic OAD represent 3.1% of all cervical spine injuries in our service. Two were children and the other was a 64-year-old man, all of whom suffered from severe neurological deficits. Lateral cervical spine radiographs led to the diagnosis of OAD. Two were longitudinal, and one was anterior. Two patients died within 2 weeks after injury. The remaining patient, who had anterior OAD, survived longer, which allowed posterior fusion with a U-shape Steinman pin and wiring to be performed. However, she died 5 months after injury because of septicemia.

CONCLUSION

Early recognition and treatment may improve the outcome of this injury. Treatment consists of early respiratory support and subsequent surgical fusion.

Unrecognized traumatic atlanto-occipital dislocation

This report describes the case of a 67-year-old male victim of an auto-pedestrian accident who was alert and neurologically intact on initial presentation. The patient denied head or neck pain and was without evidence of craniocervical injury. A lateral c-spine radiograph did not show any abnormal findings. The patient deteriorated during his trauma evaluation and was refractory to resuscitation. At autopsy, he was found to have an atlanto-occipital dislocation (AOD). The case is discussed and the anatomic, clinical, and radiographic features of atlanto-occipital dislocation are reviewed.

Craniocervical junction subarachnoid hemorrhage associated with atlanto-occipital dislocation

STUDY DESIGN

The sensitivity of plain radiographs for diagnosing traumatic atlanto-occipital dislocation and its association with craniocervical junction subarachnoid hemorrhage was examined in a retrospective review of seven patients.

OBJECTIVE

The purpose of this study was to demonstrate the frequency of nondiagnostic plain radiographs and the common association of craniocervical junction subarachnoid hemorrhage in the context of reported cases of atlanto-occipital dislocation to facilitate better recognition of this injury. The use of sagittal reconstructions of computed tomography or sagittal magnetic resonance imaging for diagnosis was evaluated.

SUMMARY OF BACKGROUND DATA

Although traumatic atlanto-occipital dislocation is a common cause of motor vehicle fatalities, survival has been more common in the last 16 years. However, the diagnosis was missed on lateral cervical radiographs in 38% of children and 59% of adults; fewer than half were diagnosed subsequently with plain radiography. Moreover, the diagnosis of traumatic atlanto-occipital dislocation often was not considered, because more than half of the survivors had no neurologic abnormality or unilateral deficit. Consequently, more than one third of initially undiagnosed patients experienced neurologic deterioration due to inadequate cervical immobilization. Additional radiographic studies allowing diagnosis were prompted by the neurologic worsening.

METHODS

The authors reviewed seven patients treated with traumatic atlanto-occipital dislocation during a 14-year period. Emergency department records were compared with reexamination of initial cervical radiographs to determine the success in diagnosis by means of published methods. The frequency of cranio-cervical junction subarachnoid hemorrhage on computed tomography was determined, and the use of sagittal imaging for subsequent diagnosis was evaluated.

RESULTS

In the emergency department, only one patient's condition was diagnosed as atlanto-occipital dislocation. Review of the initial radiographs identified an additional four patients for whom atlanto-occipital dislocation could be diagnosed. Sagittal computed tomography reconstruction or sagittal magnetic resonance imaging identified the remaining two. All but one patient had craniocervical junction subarachnoid hemorrhage. A review of reported cases revealed a common association of craniocervical junction subarachnoid hemorrhage with traumatic atlanto-occipital dislocation but not with traumatic head injury.

CONCLUSIONS

The diagnosis of traumatic atlanto-occipital dislocation is often missed in the emergency department, and current methods for evaluating the integrity of the atlanto-occipital joint on cervical radiographs fail to identify all patients with this injury. Although infratentorial subarachnoid hemorrhage is uncommon in traumatic head injury, craniocervical junction subarachnoid hemorrhage is often associated with atlanto-occipital dislocation and should raise the suspicion of severe craniocervical ligamentous injury. Sagittal computed tomography reconstructions or sagittal magnetic resonance imaging can allow for the diagnosis when plain radiography is inconclusive.

Traumatic atlanto-occipital dislocation: a potentially survivable injury

Although survival with traumatic atlanto-occipital dislocation (AOD) is rare, there have been reports of victims who have sustained this injury with good neurological outcome. Plain lateral cervical spine radiography is the initial diagnostic procedure but may miss subtle dislocations. Several methods for the interpretation of the normal atlanto-occipital alignment have been devised and are discussed. Computed tomography (CT) and magnetic resonance imaging (MRI) are valuable studies in the diagnosis and management of AOD. Halo immobilization and posterior spinal fusion are the preferred modes of treatment. Vascular injury may contribute to the neurological deficits seen with AOD and is potentially reversible. Three cases are reported, two with survival of 1 day, and one long-term survivor with poor neurological outcome because of associated cerebral trauma.

Traumatic atlantooccipital dislocation injury in children

The tragedy of trauma turns into triumph when the surgery team members' efforts result in victory for the patient. Nowhere is this more true than in successful pediatric trauma care. Giving a child a second chance at life and the family an opportunity for a new beginning is the highest reward for the trauma team's years of professional training and practice. Traumatic atlantoocipital dislocation injury usually results in death, but recent neurosurgery trauma advances are increasing pediatric survival rates.