Cranio-cervical stabilization of traumatic atlanto-occipital dislocation with minimal resultant neurological deficit

Abstract

Our purpose is to describe a case of atlanto-occipital dislocation and discuss treatment approaches to minimize subsequent neurological deficits. Traumatic atlanto-occipital dislocation, has traditionally been considered rare and lethal, due to resulting high levels of spinal cord injury. Outcomes are generally expected to be poor. However, recent case reports indicate that survival is increasing. Of patients who survive cranio-cervical dislocation, many endure resulting neurological deficits. We present a rare case of a 23-year-old male, who sustained an atlanto-occipital dislocation in a motor vehicle accident. The patient presented with a Glasgow Coma Scale (GCS) of 11T. Lateral C-spine x-ray and thin-section slices CT delineated a C1 ring fracture on the left side with approximately 1 cm anterior and superior subluxation of the occipital condyles of the cranium in reference to C1. The patient was completely awake, alert, and was following commands. The patient underwent a cranio-cervical stabilization from occiput to C3, using lateral mas screws (C1-C3) and transarticular screws (C2-C3). The Vertex (Medtronics) system used included longitudinal bars connected to the lateral mas plating system, which was subsequently used to place screws within the keel of the occipital bone. Motor strength and sensation remained intact following surgery. One-week post-operation, the patient was ambulating 140 feet, conversationally appropriate, and had a GCS of 15. This case illustrates the possibility for neurosurgical intervention of cranio-cervical dislocations to achieve optimal outcome and demonstrates that survival from this injury is not only conceivable, but recovery of function is also possible.

Atlantooccipital dislocation in motor vehicle side impact, derivation of the mechanism of injury, and implications for early diagnosis

“…[48] The present study adds to the body of literature and emphasizes the occurrence of AOD caused by vehicle-size mismatch. Investigation of the collision determined that the interior of the sedan door and parts of the truck grille struck the left side of the occupant during impact.…”

“…[79–11] Diagnosis is usually based on associated injuries and a high degree of clinical suspicion. [4710] A cervical spine distraction mechanism resulting in AOD is often associated with facial abrasions and lacerations, mandible fractures, arrhythmia, apnea, asymmetric cranial nerve palsies, loss of consciousness, subarachnoid hemorrhages, and thoracic or abdominal injuries. [14579–12] Our patient sustained a number of these associated injuries [Table 1].…”

“…[23] To the knowledge of the authors, only one trauma patient has been reported in the literature who survived AOD during a side impact collision. [4] Reported AODs in the literature suggest that the presence of associated injuries should lead to a high index of suspicion. [5] Cranial nerve deficits are common among such injuries.…”

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

“…Traction may be helpful for achieving an anatomic correct position, but it may also be harmful. 44,45 However, in the case of AOD with longitudinal distraction, further traction is not indicated.…”

Intraarticular Atlantooccipital Fusion for the Treatment of Traumatic Occipitocervical Dislocation in a Child

“…[2][3][4][5][6] Others advocate occipitocervical fusion including the atlantoaxial complex. 1,[7][8][9][10][11][12][13][14][15][16][17][18][19][20][21] However, this results in significant reduction of the mobility of the cervical spine, predominantly in relation to head rotation, which may in turn initiate accelerated degeneration of the subaxial cervical spine. 8 A logical way of surgical treatment would be to fuse the injured C0-C1 segment only.…”