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Radiological and clinical features of traumatic atlanto-occipital dislocation

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Abstract

Purpose

We aimed to describe the findings of traumatic atlanto-occipital dislocation (AOD) on cervical spine CTs and differences leading to varying treatment of these patients.

Methods

We retrospectively identified 20 adult patients with AOD from cervical spine CTs demonstrating fracture or fracture dislocations over 19 years at 2 major trauma centers. Medical records were reviewed and craniovertebral junction (CVJ) metrics measured on CT. Intubation, Glasgow Coma Scale (GCS), additional injuries, occiput/atlas/axis fracture, concurrent atlantoaxial subluxation, vascular injury on CT angiography, and ligamentous injury on MRI were noted.

Results

Using the Traynelis Classification, eight patients had type 2 and eight patients type 3 AOD. Four of 5 patients who died within 14 days of CT had type 2 AOD. Three patients had medial/lateral AOD. Of the patients who survived initial injuries, a greater percentage who underwent surgical or halo fixation versus non-operatively treated patients had abnormal CVJ measurements including BDI (62.5% vs 0%), atlantoaxial subluxation (75% vs 14.3%), ligamentous injury (80% vs 66.7%), intubation (62.5% vs 28.6%), GCS<8 (62.5% vs 14.3%), and additional injuries (75% vs 71.4%) on presentation. MRI helped identify 2 cases of type 2 AOD and surgical decision making in 8 cases.

Conclusions

Types 2 and 3 were the most common, and type 2 is the deadliest type of AOD. A greater proportion of patients who undergo surgical or halo fixation have abnormal CT/MR findings with neurologic impairment at presentation. MRI aided detection of potentially missed type 2 AOD and was critical for surgical decision making.

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Notes

  1. Type 1 AOD: anterior displacement of the occiput relative to the atlas. Type 2 AOD: vertical distraction of the occiput from the atlas. Type 3 AOD: posterior displacement of the occiput relative to the atlas [4].

  2. The distance between the anterior cortex of the dens and the posterior cortex of the C1 anterior arch [12].

  3. The distance between the basion and posterior arch of the atlas divided by the distance between the opisthion and the anterior arch of the atlas [10]

  4. An abnormal X-line is defined as lack of intersection both between the posterosuperior surface of the dens with a line drawn from the basion to the C2 spinolaminar junction, and between C1 and a line drawn between the opisthion and the inferoposterior aspect of the C2 vertebra [10]

References

  1. Hall GC, Kinsman MJ, Nazar RG, Hruska RT, Mansfield KJ, Boakye M, Rahme R (2015) Atlanto-occipital dislocation. World J Orthop 6:236–243

    Article  Google Scholar 

  2. Radcliff K, Kepler C, Reitman C, Harrop J, Vaccaro A (2012) CT and MRI-based diagnosis of craniocervical dislocations: the role of the occipitoatlantal ligament. Clin Orthop Relat Res 470:1602–1613

    Article  Google Scholar 

  3. Payer M, Sottas CC (2005) Traumatic atlanto-occipital dislocation: presentation of a new posterior occipitoatlantoaxial fixation technique in an adult survivor: technical case report. Neurosurgery 56:E203 discussion E203

    PubMed  Google Scholar 

  4. Traynelis VC, Marano GD, Dunker RO, Kaufman HH (1986) Traumatic atlanto-occipital dislocation. Case report. J Neurosurg 65:863–870

    Article  CAS  Google Scholar 

  5. Khanpara SD, McCarty JL, Schmitt KM, Stark JR, West OC, Zhang X et al (2020) Atlanto-occipital distraction injuries in survivors: craniometrics and associated ligamentous, spinal cord, and blunt cerebrovascular injury. Emerg Radiol 28:83–92. https://doi.org/10.1007/s10140-020-01827-9

    Article  PubMed  Google Scholar 

  6. Menon KV, Al Habsi I, Al GK (2018) Traumatic occipito-cervical dissociation in adults: a Middle Eastern cohort study. Eur J Orthop Surg Traumatol 28:381–387

    Article  Google Scholar 

  7. Horn EM, Feiz-Erfan I, Lekovic GP, Dickman CA, Sonntag VKH, Theodore N (2007) Survivors of occipitoatlantal dislocation injuries: imaging and clinical correlates. J Neurosurg: Spine. pp. 113–120. https://doi.org/10.3171/spi.2007.6.2.113

  8. Rojas CA, Bertozzi JC, Martinez CR, Whitlow J (2007) Reassessment of the craniocervical junction: Normal Values on CT. Am J Neuroradiol. pp. 1819–1823. https://doi.org/10.3174/ajnr.a0660

  9. Griffen MM, Frykberg ER, Kerwin AJ, Schinco MA, Tepas JJ, Rowe K, Abboud J (2003) Radiographic clearance of blunt cervical spine injury: plain radiograph or computed tomography scan? J Trauma 55:222–226 discussion 226–7

    Article  Google Scholar 

  10. Gire JD, Roberto RF, Bobinski M, Klineberg EO, Durbin-Johnson B (2013) The utility and accuracy of computed tomography in the diagnosis of occipitocervical dissociation. Spine J 13:510–519

    Article  Google Scholar 

  11. Chang W, Alexander MT, Mirvis SE (2009) Diagnostic determinants of craniocervical distraction injury in adults. AJR Am J Roentgenol 192:52–58

    Article  Google Scholar 

  12. Anderson PA, Montesano PX. Morphology and treatment of occipital condyle fractures. Spine . 1988;13: 731–736.

  13. Biffl WL, Moore EE, Offner PJ, Brega KE, Franciose RJ, Burch JM (1999) Therapeutic implications of a new grading scale in 100 blunt carotid arterial injuries. J Trauma: Inj Infect Crit Care. p. 201. 10.1097/00005373-199901000-00044

  14. Riascos R, Bonfante E, Cotes C, Guirguis M, Hakimelahi R, West C (2015) Imaging of atlanto-occipital and atlantoaxial traumatic injuries: what the radiologist needs to know. Radiographics. 35:2121–2134

    Article  Google Scholar 

  15. Turns JE, Shaffer MA, Doris PE (1984) The modified odontoid view: an alternative visualization of the atlantoaxial joint. J Emerg Med 1:321–325

    Article  CAS  Google Scholar 

  16. Website. [cited 25 Nov 2020]. Available: https://aospine.aofoundation.org/Structure/education/online-education/classifications/Pages/classifications.aspx

  17. Harris JH Jr, Carson GC, Wagner LK, Kerr N (1994) 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 162:887–892

    Article  Google Scholar 

  18. Martinez-Del-Campo E, Kalb S, Soriano-Baron H, Turner JD, Neal MT, Uschold T et al (2016) Computed tomography parameters for atlantooccipital dislocation in adult patients: the occipital condyle-C1 interval. J Neurosurg Spine 24:535–545

    Article  Google Scholar 

  19. Kasliwal MK, Fontes RB, Traynelis VC (2016) Occipitocervical dissociation-incidence, evaluation, and treatment. Curr Rev Musculoskelet Med 9:247–254

    Article  Google Scholar 

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Availability of data and material

Our database is accessible to all employees of the two tertiary centers from which electronic medical records were obtained.

Code availability

N/A

Funding

The dislocation database for this study was funded by GE Healthcare LLC.

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Authors and Affiliations

  1. Department of Radiology, Brigham and Women’s Hospital and Harvard Medical School, 75 Francis St., Boston, MA, 02115, USA

    Anji Tang & Bharti Khurana

  2. Department of Orthopedic Surgery, Massachusetts General Hospital and Harvard Medical School, 55 Fruit St., Boston, MA, 02114, USA

    Daniel Tobert & Mitchel Harris

  3. Center for Clinical Data Science, Mass General Brigham, 100 Cambridge St., Boston, MA, 02115, USA

    Sujay Kakarmath

  4. Trauma Imaging Research and Innovation Center, Brigham and Women’s Hospital, 75 Francis St., Boston, MA, 02115, USA

    Bharti Khurana

Authors
  1. Anji Tang
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  2. Daniel Tobert
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  4. Mitchel Harris
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Correspondence to Bharti Khurana.

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The authors declare that they have no conflict of interest. Bharti Khurana- GE Healthcare Research Support; Book Royalties, Cambridge University Press; Section Editor Royalities, UptoDate, Wolter Kluwer.

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Tang, A., Tobert, D., Kakarmath, S. et al. Radiological and clinical features of traumatic atlanto-occipital dislocation. Emerg Radiol 28, 713–722 (2021). https://doi.org/10.1007/s10140-021-01912-7

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  • DOI: https://doi.org/10.1007/s10140-021-01912-7

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