Survivors of occipitoatlantal dislocation injuries: imaging and clinical correlates

Restricted access

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.

Abbreviations used in this paper:BAI = basion–axial interval; BDI = basion–dens interval; CT = computed tomography; MR = magnetic resonance; OAD = occipitoatlantal dislocation; SCI = spinal cord injury; TBI = traumatic brain injury.

Article Information

Address reprint requests to: Nicholas Theodore, M.D., Neuroscience Publications, Barrow Neurological Institute, 350 West Thomas Road, Phoenix, Arizona 85013. email: neuropub@chw.edu.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    A–C: Reconstructed sagittal CT scans obtained in a 17-year-old patient, showing OAD as measured using the Power method (A), the BDI method (B), and the BAI–BDI method (C). D: Sagittal T2-weighted MR image revealing high signal intensity (arrow) in the occipitoatlantal joint.

  • View in gallery

    Lateral postoperative radiograph of the same case represented in Fig. 1, demonstrating the fixation construct.

  • View in gallery

    Sagittal T2-weighted MR images acquired in a 10-year-old patient, demonstrating abnormal high signal intensity (arrows) in the occipitoatlantal joints on both the right (A) and left (B) sides.

  • View in gallery

    Sagittal T2-weighted MR image obtained in a 9-year-old patient, revealing abnormal high signal intensity (arrow) in the posterior occipitoatlantal soft tissue and ligaments.

References

1

Alker GJ JrOh YSLeslie EV: High cervical spine and craniocervical junction injuries in fatal traffic accidents: a radiological study. Orthop Clin North Am 9:100310101978

2

Apostolides PJDickman CAGolfinos JGPapadopoulos SMSonntag VK: Threaded Steinmann pin fusion of the craniovertebral junction. Spine 21:163016371996

3

Bani AGilsbach JM: Atlantooccipital distraction: a diagnostic and therapeutic dilemma: report of two cases. Spine 28:E95E972003

4

Bellabarba CMirza SKWest GAMann FADailey ATNewell DW: Diagnosis and treatment of craniocervical dislocation in a series of 17 consecutive survivors during an 8-year period. J Neurosurg Spine 4:4294402006

5

Blackwood NJ: Atlanto-occipital dislocation. A case of fracture of the atlas and axis, and forward dislocation of the occiput on the spinal column, life being maintained for thirty-four hours and forty minutes by artificial respiration, during which a laminectomy was performed upon the third cervical vertebra. Ann Surg 47:6546581908

6

Bohlman HH: Acute fractures and dislocations of the cervical spine. An analysis of three hundred hospitalized patients and review of the literature. J Bone Joint Surg Am 61:111911421979

7

Bools JCRose BS: Traumatic atlantooccipital dislocation: two cases with survival. AJNR Am J Neuroradiol 7:9019041986

8

Bulas DIFitz CRJohnson DL: Traumatic atlanto-occipital dislocation in children. Radiology 188:1551581993

9

Bundschuh CVAlley JBRoss MPorter ISGudeman SK: Magnetic resonance imaging of suspected atlanto-occipital dislocation. Two case reports. Spine 17:2452481992

10

Chaljub GSingh HGunito FC JrCrow WN: Traumatic atlanto-occipital dislocation: MRI and CT. Neuroradiology 43:41442001

11

de Oliveira ERhoton AL JrPeace D: Microsurgical anatomy of the region of the foramen magnum. Surg Neurol 24:2933521985

12

Deliganis AVBaxter ABHanson JAFisher DJCohen WAWilson AJ: Radiologic spectrum of craniocervical distraction injuries. Radiographics 20:Spec No:S237S2502000

13

Dickman CAHadley MNPappas CTSonntag VKGeisler FH: Cruciate paralysis: a clinical and radiographic analysis of injuries to the cervicomedullary junction. J Neurosurg 73:8508581990

14

Dickman CAPapadopoulos SMSonntag VKSpetzler RFRekate HLDrabier J: Traumatic occipitoatlantal dislocations. J Spinal Disord 6:3003131993

15

Donahue DJMuhlbauer MSKaufman RAWarner WCSanford RA: Childhood survival of atlantooccipital dislocation: underdiagnosis, recognition, treatment, and review of the literature. Pediatr Neurosurg 21:1051111994

16

Dziurzynski KAnderson PABean DBChoi JLeverson GEMarin RL: A blinded assessment of radiographic criteria for atlanto-occipital dislocation. Spine 30:142714322005

17

Farthing JW: Atlantocranial dislocation with survival: A case report. NC Med J 9:34361948

18

Feiz-Erfan IGonzalez LFDickman CA: Atlantooccipital transarticular screw fixation for the treatment of traumatic occipitoatlantal dislocation. Technical note. J Neurosurg Spine 2:3813852005

19

Fruin AHPirotte TP: Traumatic atlantooccipital dislocation. Case report. J Neurosurg 46:6636661977

20

Fujimura YNishi YChiba KKobayashi K: Prognosis of neurological deficits associated with upper cervical spine injuries. Paraplegia 33:1952021995

21

Gonzalez LFFiorella DCrawford NRWallace RCFeiz-Erfan IDrumm D: Vertical atlantoaxial distraction injuries: radiological criteria and clinical implications. J Neurosurg Spine 1:2732802004

22

Gonzalez LFKlopfenstein JDCrawford NRDickman CASonntag VK: Use of dual transarticular screws to fixate simultaneous occipitoatlantal and atlantoaxial dislocations. J Neurosurg Spine 3:3183232005

23

Govender SVlok GJFisher-Jeffes NDu Preez CP: Traumatic dislocation of the atlanto-occipital joint. J Bone Joint Surg Br 85:8758782003

24

Grabb BCFrye TAHedlund GLVaid YNGrabb PARoyal SA: MRI diagnosis of suspected atlanto-occipital dissociation in childhood. Pediatr Radiol 29:2752811999

25

Guigui PMilaire MMorvan GLassale BDeburge A: Traumatic atlantooccipital dislocation with survival: case report and review of the literature. Eur Spine J 4:2422471995

26

Hadley MNWalters BCGrabb PAOyesiku NMPrzybylski GJResnick DK: Diagnosis and management of traumatic atlanto-occipital dislocation injuries. Neurosurgery 50:S105S1132002

27

Harris JH JrCarson GCWagner LKKerr N: Radiologic diagnosis of traumatic occipitovertebral dissociation: 2. Comparison of three methods of detecting occipitovertebral relationships on lateral radiographs of supine subjects. AJR Am J Roentgenol 162:8878921994

28

Horn EMLekovic GPFeiz-Erfan ISonntag VKTheodore N: Cervical magnetic resonance imaging abnormalities not predictive of cervical spine instability in traumatically injured patients. Invited submission from the Joint Section Meeting on Disorders of the Spine and Peripheral Nerves, March 2004. J Neurosurg Spine 1:39422004

29

Hosalkar HSCain ELHorn DChin KRDormans JPDrummond DS: Traumatic atlanto-occipital dislocation in children. J Bone Joint Surg Am 87:248024882005

30

Houle PMcDonnell DEVender J: Traumatic atlanto-occipital dislocation in children. Pediatr Neurosurg 34:1931972001

31

Kenter KWorley GGriffin TFitch RD: Pediatric traumatic atlanto-occipital dislocation: five cases and a review. J Pediatr Orthop 21:5855892001

32

Labbe JLLeclair ODuparc B: Traumatic atlanto-occipital dislocation with survival in children. J Pediatr Orthop B 10:3193272001

33

Labler LEid KPlatz ATrentz OKossmann T: Atlanto-occipital dislocation: four case reports of survival in adults and review of the literature. Eur Spine J 13:1721802004

34

Ladouceur DVeilleux MLevesque RY: Cruciate paralysis secondary to C1 on C2 fracture-dislocation. Spine 16:138313851991

35

Naso WBCure JCuddy BG: Retropharyngeal pseudomenin-gocele after atlanto-occipital dislocation: report of two cases. Neurosurgery 40:128812911997

36

Page CPStory JLWissinger JPBranch CL: Traumatic atlantooccipital dislocation. Case report. J Neurosurg 39:3943971973

37

Papadopoulos SMDickman CASonntag VKRekate HLSpetzler RF: Traumatic atlantooccipital dislocation with survival. Neurosurgery 28:5745791991

38

Pappas CTGibson ARSonntag VK: Decussation of hind-limb and fore-limb fibers in the monkey corticospinal tract: relevance to cruciate paralysis. J Neurosurg 75:9359401991

39

Park JBHa KYChang H: Traumatic posterior atlantooccipital dislocation with Jefferson fracture and fracture-dislocation of C6-C7: a case report with survival. Eur Spine J 10:5245282001

40

Przybylski GJClyde BLFitz CR: Craniocervical junction sub-arachnoid hemorrhage associated with atlanto-occipital dislocation. Spine 21:176117681996

41

Rahimi SYStevens EAYeh DJFlannery AMChoudhri HFLee MR: Treatment of atlantoaxial instability in pediatric patients. Neurosurg Focus 15:6ECP12003

42

Reed CMCampbell SEBeall DPBui JSStefko RM: Atlanto-occipital dislocation with traumatic pseudomeningocele formation and post-traumatic syringomyelia. Spine 30:E128E1332005

43

Rhoton AL Jrde Olivera EAnatomic basis of surgical approaches to the region of the foramen magnum. Dickman CASpetzler RFSonntag VKH: Surgery of the Craniovertebral Junction New YorkThieme1998. 1355

44

Saeheng SPhuenpathom N: Traumatic occipitoatlantal dislocation. Surg Neurol 55:35402001

45

Seibert PSStridh-Igo PWhitmore TADufty BMZimmerman CG: Cranio-cervical stabilization of traumatic atlanto-occipital dislocation with minimal resultant neurological deficit. Acta Neurochir (Wien) 147:4354422005

46

Steinmetz MPLechner RMAnderson JS: Atlantooccipital dislocation in children: presentation, diagnosis, and management. Neurosurg Focus 14:2ecp12003

47

Sun PPPoffenbarger GJDurham SZimmerman RA: Spectrum of occipitoatlantoaxial injury in young children. J Neurosurg 93:1 Suppl28392000

48

Traynelis VCMarano GDDunker ROKaufman HH: Traumatic atlanto-occipital dislocation. Case report. J Neurosurg 65:8638701986

49

van de Pol GJHanlo PWOner FCCastelein RM: Redislocation in a halo vest of an atlanto-occipital dislocation in a child: recommendations for treatment. Spine 30:E424E4282005

50

Werne S: Studies in spontaneous atlas dislocation. Acta Orthop Scand Suppl 23:11501957

51

Williams MJElliott JLNichols J: Atlantooccipital dislocation: a case report. J Clin Anesth 7:1561591995

52

Woodring JHSelke AC JrDuff DE: Traumatic atlantooccipital dislocation with survival. AJR Am J Roentgenol 137:21241981

TrendMD

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 88 88 25
Full Text Views 66 66 14
PDF Downloads 113 113 11
EPUB Downloads 0 0 0

PubMed

Google Scholar