Traumatic atlanto-occipital dislocation in children-a case-based update on clinical characteristics, management and outcome

Atlanto-occipital dislocation (AOD) is a rare but severe sequela of high energy trauma. Children are at increased risk, due to their immature spine and biomechanical characteristics. The prevailing mechanism of injury is motor vehicle collision as passenger. AOD commonly presents with cardiorespiratory arrest, spinal cord injury or cranial nerve deficits. Concomitant injuries, such as traumatic brain injury, are frequently encountered. Diagnosis is made on CT and MRI imaging. Posterior internal fixation is the recommended treatment. Thirty-four percent of patients die, 41 % survive with deficits and 25 % have a complete neurological recovery. Initial symptoms, GCS score and degree of spinal cord injury appear to be predictors of outcome. We report the case of a 9-year-old boy, who presented in extremis with cardiac arrest after a motor vehicle collision. Upon successful resuscitation, diagnostic imaging showed AOD and a Chiari I malformation. An occiput-C2 posterior instrumented fusion was performed. The patient subsequently received intensive rehabilitation and recovered to independent ambulation, with a persistent, asymptomatic Chiari I malformation. This case highlights the potential for positive outcome in paediatric AOD, despite the presence of strong predictors of poor or fatal outcome at presentation.