Occipitocervical Vertical Distraction Injuries

Yüksel, Kasım Zafer; Yüksel, Mürvet; Gonzalez, L. Fernando; Baek, Seungwon; Heiserman, Joseph E.; Sonntag, Volker K. H.; Crawford, Neil R.

doi:10.1097/brs.0b013e31817e2cfc

Cited by 33 publications

(3 citation statements)

References 27 publications

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“…Three different mechanisms can lead to AOD: hyperextension, hyperflexion, and lateral flexion of the upper cervical spine. A combination of these mechanisms is a predictor of AOD [10–12]. Predisposing conditions like rheumatoid arthritis, inflammation, and osteoporosis may increase the risk of AOD even in cases of relatively minor trauma [13].…”

Section: Introductionmentioning

confidence: 99%

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

Rief¹,

Zoidl²,

Zajic³

et al. 2019

J Med Case Reports

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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.

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Section: Introductionmentioning

confidence: 99%

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

Rief¹,

Zoidl²,

Zajic³

et al. 2019

J Med Case Reports

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“…Anatomically, the ligamentous complex of the craniovertebral junction has been studied meticulously in cadavers. [20] As the occipitocervical junction has horizontally oriented facets and lacks intervertebral discs, the stability of the craniovertebral junction is primarily dependent on the integrity of the ligaments and soft tissues. [2122] The alar ligaments are a paired structure that extends from the medial surface of the occipital condyles inferiorly to the tip of the dens.…”

Section: Discussionmentioning

confidence: 99%

“…[25] While debate exists in regards to each craniovertebral ligaments specific role in stability,[22] clinically significant instability of the occipitocervical region has been hypothesized to demonstrate disruption of the alar ligaments. [520]…”

Section: Discussionmentioning

confidence: 99%

Ability of magnetic resonance imaging to accurately determine alar ligament integrity in patients with atlanto-occipital injuries

Dyas

Niemeier

McGwin

et al. 2018

J Craniovert Jun Spine

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Objective:The objective of this study is to evaluate the the reliability of magnetic resonance imaging (MRI) in diagnosing alar ligament disruption in patients with potential atlanto-occipital dissociation (AOD).Materials and Methods:Three-blinded readers performed retrospective review on 6 patients with intra-operative confirmed atlanto-occipital dissocation in addition to a comparison cohort of patients with other cervical injuries that did not involve the atlanto-occipital articulation. Ligament integrity was graded from 1 to 3 as described by Krakenes et al. The right and left ligaments were assessed separately. Inter-observer agreement by patient, by group (AOD vs. non-AOD), and intra-observer agreement was calculated using weighted Cohen's kappa.Results:Interobserver agreement of alar ligament grade for individual patients ranged from slight to fair (κ = 0.05–0.30). Interobserver agreement of alar ligament grade for each group (AOD vs. non-AOD) ranged from fair to substantial (κ = 0.37–0.66). No statistically significant difference in categorical analysis of groups (AOD vs. non-AOD) and grade (0–1 vs. 2–3) was observed. Intraobserver agreement of individual patient's alar ligament grade ranged from moderate to substantial (κ = 0.50–0.62).Conclusion:The use of MRI to detect upper cervical ligament injuries in AOD is imperfect. Our results show inconsistent and unsatisfactory interobserver and intraobserver reliability in evaluation of alar ligament injuries. While MRI has immense potential for detection of ligamentous injury at the craniovertebral junction, standardized algorithms for its use and interpretation need to be developed.

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