Traumatic Atlanto-Occipital Dislocation in Children

Astur, Nelson; Klimo, Paul; Sawyer, Jeffrey R.; Kelly, Derek M.; Muhlbauer, Michael S.; Warner, William C.

doi:10.2106/jbjs.l.01295

Cited by 42 publications

(30 citation statements)

References 33 publications

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“…Thirty-seven (43%) had a combined OC screw-rod and sublaminar wiring construct. Twenty-eight patients (33%) from 2 studies underwent exclusive rod-based constructs, utilizing a uniquely fashioned U-shaped or Luque rod, and 17 of these patients also had supplemental sublaminar wiring [10, 11]. Eighteen patients (21%) from 1 study underwent a combined OC wiring and screw-rod construct [12].…”

Section: Resultsmentioning

confidence: 99%

Traumatic Occipitocervical Distraction Injuries in Children: A Systematic Review

et al. 2019

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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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Section: Resultsmentioning

confidence: 99%

Traumatic Occipitocervical Distraction Injuries in Children: A Systematic Review

et al. 2019

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“…In adults, the National Emergency X-Radiography Utilization Study (NEXUS) criteria are well established. 3,[9][10][11]26,27 Garton and Hammer 28 found a remarkably lower sensitivity for the NEXUS criteria of 85% among children under the age of 9 years, and because of this, the Congress of Neurological Surgeons guidelines recommend application of the NEXUS decision instrument only in children over the age of 9 years. At least 1 positive item of the NEXUS criteria could be found in the 30 pediatric patients with a confirmed cervical spine injury in this study.…”

Section: Diagnosis and Initial Therapeutic Managementmentioning

confidence: 99%

“…27,32,[42][43][44] The proportionally larger head of small children also leads to a higher impact on the upper cervical spine. 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.…”

Section: Atlanto-occipital Dissociation (Aod)mentioning

confidence: 99%

“…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.…”

Section: Atlanto-occipital Dissociation (Aod)mentioning

confidence: 99%

“…Therefore, identification of AOD can be difficult. 3,27,32,[42][43][44][45]49,50 In addition to the bone graft, older children require dorsal instrumentation to achieve dorsal fusion of the atlanto-occipital junction. In case of clinical suspicion but unclear radiographs, a functional fluoroscopic examination can be helpful; however, a CT scan is commonly used in the diagnosis, as it is the most sensitive for an AOD in children.…”

Section: Atlanto-occipital Dissociation (Aod)mentioning

confidence: 99%

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