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  • By Author: Dickman, Curtis A. x
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  • By Author: Horn, Eric M. x
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Eric M. Horn, Iman Feiz-Erfan, Gregory P. Lekovic, Curtis A. Dickman, Volker K. H. Sonntag and Nicholas Theodore

Object

Although rare, traumatic occipitoatlantal dislocation (OAD) injuries are associated with a high mortality rate. The authors evaluated the imaging and clinical factors that determined treatment and were predictive of outcomes, respectively, in survivors of this injury.

Methods

The medical records and imaging studies obtained in 33 patients with OAD were reviewed retrospectively. Clinical factors that predicted outcomes, especially neurological injury at presentation and imaging findings, were evaluated.

The most sensitive method for the diagnosis of OAD was the measurement of basion axial–basion dens interval on computed tomography (CT) scanning. Five patients with severe traumatic brain injuries (TBIs) were not treated and subsequently died. Of the 28 patients in whom treatment was performed, 23 underwent fusion and five were fitted with an external orthosis. Abnormal findings of the occipitoatlantal ligaments on magnetic resonance (MR) imaging, associated with no or questionable abnormalities on CT scanning, provided the rationale for nonoperative treatment. Of the 28 patients treated for their injuries, perioperative death occurred in five, three of whom had presented with severe neurological injuries. The mortality rate was highest in patients with a TBI at presentation. The mortality rate was lower in patients presenting with a spinal cord injury, but in this group there was a higher rate of persistent neurological deficits.

Conclusions

The spines in patients with CT-documented OAD are most likely unstable and need surgical fixation. In patients for whom CT findings are normal and MR imaging findings suggest marginal abnormalities, nonoperative treatment should be considered. The best predictors of outcome were severe brain or upper cervical injuries at initial presentation.

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Eric M. Horn, Nicholas Theodore, Iman Feiz-Erfan, Gregory P. Lekovic, Curtis A. Dickman and Volker K. H. Sonntag

Object

The risk factors of halo fixation in elderly patients have never been analyzed. The authors therefore retrospectively reviewed data obtained in the treatment of such cases.

Methods

A discharge database was searched for patients 70 years of age or older who had undergone placement of a halo device. In a search of cases managed between April 1999 and February 2005, data pertaining to 53 patients (mean age 79.9 years [range 70–97 years]) met these criteria. Forty-one patients were treated for traumatic injuries. Ten patients had deficits ranging from radiculopathy to quadriparesis, and 43 had no neurological deficit. Adequate follow-up material was available in 42 patients (mean treatment duration 91 days). Halo immobilization was the only treatment in 21 patients, and adjunctive surgical fixation was undertaken in the other 21 patients. There were 31 complications in 22 patients: respiratory distress in four patients, dysphagia in six, and pin-related complications in 10. Eight patients died; in two of these cases, the cause of death was clearly unrelated to the halo brace. The other six patients died of respiratory failure and cardiovascular collapse (perioperative mortality rate 14%). Three patients who died had sustained acute trauma and three had undergone surgical stabilization.

Conclusions

External halo fixation can be used safely to treat cervical instability in elderly patients. The high complication rate in this population may reflect the significant incidence of underlying disease processes.