Abstract
Primary Subject area
Emergency Medicine - Paediatric
Background
Atlanto-occipital dislocation (AOD) is a type of cervical spine injury (CSI) that is commonly fatal or associated with severe neurologic consequences. Although rare, AOD is now more commonly recognized in children as improved prehospital care allows for more patients to reach trauma centres and undergo definitive imaging. Patients with AOD often present with cardiorespiratory instability and prompt diagnosis is crucial. However, diagnosis may be delayed due to variation in imaging practices and lack of literature on this topic.
Objectives
Primary objective: Describe the demographic characteristics, clinical presentation, and long-term outcomes of children with AOD, compared to other upper CSI. Secondary objective: Describe the frequency of AOD and other upper CSI in pediatric traumatic cardiac arrest (PTCA) and the utility of a lateral c-spine radiograph in this setting.
Design/Methods
This was a retrospective, single-centre case series of all pediatric trauma patients age < 16 years diagnosed with upper CSI seen at a tertiary pediatric trauma centre from 2000-2020. Patients were included if they had evidence of bony or ligamentous injury from C0-2. The diagnosis of upper CSI was ascertained on autopsy, when available, then cross-sectional imaging, then plain radiographs, when the other modalities were unavailable. Data was obtained from manual chart review and analyzed using descriptive statistics.
Results
Thirty-six patients were excluded for not meeting upper CSI criteria. Of 93 patients with upper CSI, 24 had AOD: 14 (15%) complete and 10 (11%) incomplete (Table 1). The mechanism of injury was motor-vehicle-collision in 23 (96%) of these patients, and a fall in one (4%). All patients with complete AOD presented in PTCA and only one (7%) survived. Of seven patients with AOD who received a lateral c-spine x-ray during resuscitation, 5 (71%) had identifiable injuries. In contrast, of the 10 patients with incomplete AOD, only 1 (10%) presented in arrest and none died. Only one patient received an x-ray during resuscitation, which showed the injury but went undetected, and 100% of final diagnoses were made through CT. The majority of incomplete AOD patients were managed non-operatively and had minimal to mild disability.
Conclusion
In our study population, complete AOD was highly fatal with all patients presenting in PTCA. In contrast, incomplete AOD carried a more favorable prognosis with 100% survival and minimal-mild disability. If there is suspicion for AOD, a lateral c-spine XR in the trauma bay can aid in early diagnosis, guiding neurosurgical management and/or goals of care discussions.
When should screening of pediatric trauma patients for adult behaviors start?
