High Cervical Dislocation in Pediatric Trauma

Introduction: Atlantooccipital dislocation (AOD) is a rare injury mostly seen in high velocity blunt pediatric trauma. As AOD carries high risk of mortality and severe neurologic sequelae, early recognition and management are essential. Given its rarity, however, there is no consensus on specific diagnostic or treatment algorithms. In this descriptive study, we seek to identify the incidence and outcome of AOD in a suburban setting to better understand risk and prognostic factors of AOD and guide its management.

Methods: Retrospective chart review was conducted on all patients ( < 18 years) who were identified in the trauma registry with a cervical spine injury at a Level I Pediatric Trauma Center from January 2010 - December 2022. Patients with AOD were identified and demographic data, clinical presentation, associated injuries, intervention, and outcome were obtained. Atlantodental interval and Power’s ratio were calculated to characterize the degree of AOD.

Results: Of 48 pediatric trauma patients with cervical spine injuries, 6 were found to have atlantooccipital dislocation. 83% (5/6) patients were male and mean age was 7.1±1.7 years. Mechanism of injury all involved motor vehicle accident. 4 patients had radiographical evidence of associated brain injury (2 with SAH; 1 with SAH and SDH, 1 with herniation) TBI and 1 had anoxic brain injury. 2 patients underwent EVD and 1 patient underwent operative stabilization. Only 1 of 6 patients survived with a neurologic deficit of quadriplegia.

Conclusion : In our limited sample, 12.5% of those with concern for cervical injury were found to have AOD. AOD carried a mortality rate of 83%. Only 1 patient, who did not have an associated TBI received operative stabilization and fixation and survived. This may suggest that the mortality rate, and the decision to intervene on AOD heavily depends on its associated injuries and the true outcome of isolated AOD is unknown.