Incidence and outcome of atlanto-occipital dissociation at a level 1 trauma centre: a prospective study of five cases within 5 years

Abstract

Background Prospective evaluation of atlanto-occipital dissociations (AODs) at a level 1 trauma centre within 5 years. Methods Over a period of 5 years (2005)(2006)(2007)(2008)(2009), all CT scans of the skull base and the upper cervical spine due to traumatic injuries were prospectively entered into a database. Furthermore, in cases of confirmed AOD all empirical data were prospectively collected. A more detailed data analysis of all AOD patients was conducted 2 years post-trauma. If required, another prospective follow-up was performed. Results 2,616 CT scans were performed in total. Out of these, there were five male patients with confirmed AOD. Thus, the total incidence was 0.2 %. AOD was associated with occipital condyle fractures in three out of the five cases. Three out of five patients (60 %) died due to the severity of the injury. It was possible to stabilise two patients surgically with a clinical/radiological follow-up 2 years post-surgery. At that time, one patient had an incomplete tetraplegia and was wheelchair ridden without needing ventilation, while the other patient suffered from post-traumatic stress disorder, but was able to walk and live alone. Conclusions AOD is a rarely seen injury, even in a level 1 trauma centre, and is associated with high morbidity and mortality. However, it is possible for adults to survive this severe occipito-cervical injury after surgical repair while maintaining the ability to walk. All the results and recommendations are still based on a low level of evidence, due to the low incidence of this injury.

Atlantoaxial Instability Resulting in Intractable Nausea in a Person with C5 Complete Spinal Cord Injury: A Case Report

“…Upon reimaging of this patient, migration of the dens onto the lower brain stem was noted; this compression was focused on the medulla, which comprises the emetogenic center of the brain, ultimately causing this patient's intractable nausea . Due to the small number of cases reported with atlantoaxial instability, there is no consensus regarding treatment, which can range from conservative simple distraction therapy to craniocervical fusions and decompressions . Once the patient underwent occiput to C2 fusion, her symptoms resolved, demonstrating that direct compression of the medulla was the etiology of her intractable symptoms.…”

“…3 Due to the small number of cases reported with atlantoaxial instability, there is no consensus regarding treatment, which can range from conservative simple distraction therapy to craniocervical fusions and decompressions. 17 Once the patient underwent occiput to C2 fusion, her symptoms resolved, demonstrating that direct compression of the medulla was the etiology of her intractable symptoms. To our knowledge, this is the first reported case of atlantoaxial instability causing intractable nausea due to brain stem compression in a patient with SCI.…”

“…Due to the exhaustive treatment of peripheral, psychological, and environmental causes of nausea, a centralized etiology was further investigated. Traumatic atlanto‐occipital dissociation is a rare injury, occurring in 1%‐8% of all cervical spine injuries . Furthermore, atlanto‐occipital dislocation is often missed on presentation due to its rarity, with almost 20% of patients with subluxation injury presenting with initial normal neurologic examine .…”

“…Traumatic atlantooccipital dissociation is a rare injury, occurring in 1%-8% of all cervical spine injuries. 16,17 Furthermore, atlantooccipital dislocation is often missed on presentation due to its rarity, with almost 20% of patients with subluxation injury presenting with initial normal neurologic examine. [18][19][20] Upon reimaging of this patient, migration of the dens onto the lower brain stem was noted; this compression was focused on the medulla, which comprises the emetogenic center of the brain, ultimately causing this patient's intractable nausea.…”

Pediatric Cervical Spine Injuries

“…Pediatric patients, especially children under the age of 8 have a higher risk of sustaining an AOD due to ligamentous laxity and lower facet joint angulation. 27,32,[42][43][44][45][46] Clinical presentation in AOD is heterogenous, ranging from catastrophic neurological impairment to axial neck pain, and it has even been diagnosed in asymptomatic children. Although it is rarely diagnosed, autopsy studies have identified AOD as the most common cause of death after high-impact road traffic accident.…”