Skip to main content
SpringerLink
Log in

Traumatic Atlanto-Occipital Dislocation in Children

  • Living reference work entry
  • First Online:
Textbook of Pediatric Neurosurgery

  • 267 Accesses

Abstract

Traumatic atlanto-occipital dislocation (AOD) refers to severe instability at the atlanto-occipital (AO) joints due to traumatic disruption of the osseo-ligamentous structures, in which neurological damage is present or imminent if left untreated. AOD represents the most severe form of cervical injuries, but the bony displacements at the AO joints may be inconspicuous on routine radiology, somewhat incongruous with what the term dislocation implies. Other terms such as atlanto-occipital dissociation (Cooper et al. 2010), atlanto-occipital distraction (Bani and Gilsbach 2003), atlanto-cranial dislocation, and craniocervical dislocation (Bellabarba et al. 2006) have been used. Sometimes, qualifiers such as complete or partial AOD are added (Grabb et al. 1999; Shamoun et al. 1999; Horn et al. 2007). Our preference is with the most widely adopted – atlanto-occipital dislocation, and without any qualifiers because partial AOD is a dubious entity and if it exists at all must be exceedingly rare. Moreover, the lack of a universally acknowledged diagnostic imaging criterion for AOD perpetuates its myth and compounds the difficulties in making a prompt diagnosis, which is essential for good outcome. Fortunately, the treatment of AOD is a more straightforward issue with occipito-cervical fusion.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution

Institutional subscriptions

References

  • Adams VI (1992) Neck injuries: I. Occipitoatlantal dislocation – a pathologic study of twelve traffic fatalities. J Forensic Sci 37:556–564

    CAS  PubMed  Google Scholar 

  • Astur N, Klimo P Jr, Sawyer JR et al (2013) Traumatic atlanto-occipital dislocation in children: evaluation, treatment, and outcomes. J Bone Joint Surg Am 95:e194(1-8)

    Article  Google Scholar 

  • Bani A, Gilsbach JM (2003) Atlantooccipital distraction: a diagnostic and therapeutic dilemma: report of 2 cases. Spine 28:E95–E97

    PubMed  Google Scholar 

  • Baumert B, Wörtler K, Steffinger D et al (2009) Assessment of the internal craniocervical ligaments with a new magnetic resonance imaging sequence: three-dimensional turbo spin echo with variable flip-angle dis- tribution (SPACE). Magn Reson Imaging 27:954–960

    Article  PubMed  Google Scholar 

  • Bellabarba C, Mirza SK, West GA, Mann FA, Dailey AT, Newell DW, Chapman JR (2006) Diagnosis and treatment of craniocervical dislocation in a series of 17 consecutive survivors during and 8-year period. J Neurosurg Spine 4:429–440

    Article  PubMed  Google Scholar 

  • Bertozzi JC, Rojas CA, Martinez CR (2009) Evaluation of the pediatric craniocervical junction on MDCT. AJR 192:26–31

    Article  PubMed  Google Scholar 

  • Bucholz RW, Burkhead WZ (1979) The pathological anatomy of fatal atlanto-occipital dislocations. J Bone Joint Surg Am 61:248–250

    Article  CAS  PubMed  Google Scholar 

  • Chaput CD, Torres E, Davis M et al (2011) Survival of atlanto-occipital dissociation correlates with atlanto-occipital distraction, injury severity score, and neurologic status. J Trauma 71:393–395

    Article  PubMed  Google Scholar 

  • Cooper Z, Gross JA, Lacey JM, Traven N, Mirza SK, Arbabi S (2010) Identifying survivors with traumatic craniocervical dissociation: a retrospective study. J Surg Res 160:3–8

    Article  PubMed  Google Scholar 

  • Corcoran B, Linscott LL, Leach JL et al (2016) Application of normative occipital condyle-C1 interval measurements to detect atlanto-occipital injury in children. AJNR Am J Neuroradiol 37:958–962

    Article  CAS  PubMed  Google Scholar 

  • Crisco JJ 3rd, Oda T, Panjabi MM et al (1991a) Transections of the C1-C2 joint capsular ligaments in the cadaveric spine. Spine (Phila Pa 1976) 16(10 Suppl):S474–S479

    Article  Google Scholar 

  • Crisco JJ III, Panjabi MM, Dvorak J (1991b) A model of the alar liga- ments of the upper cervical spine in axial rotation. J Biomech 24:607–614

    Article  PubMed  Google Scholar 

  • Donahue DJ, Muhlbauer MS, Kaufman RA, Warner WC, Sanford RW (1994) Childhood survival of atlantooccipital dislocation: underdiagnosis, recognition, treatment, and review of the literature. Pediatr Neurosurg 21:105–111

    Article  CAS  PubMed  Google Scholar 

  • Dvorak J, Panjabi MM (1987) Functional anatomy of the alar ligaments. Spine (Phila Pa 1976) 12:183–189

    Article  CAS  Google Scholar 

  • du Plessis JP, Dix-Peek S, Hoffman EB et al (2012) Pediatric atlanto-occipital dissociation: radiographic findings and clinical outcome. Evid Based Spine Care J 3:19–26

    PubMed  PubMed Central  Google Scholar 

  • Ehlinger M, Charles YP, Adam P, Bierry G, Dosch JC, Steib JP, Bonnomet F (2011) Survivor of a traumatic atlanto-occipital dislocation. Orthop Traumatol Surg Res 97:335–340

    Article  CAS  PubMed  Google Scholar 

  • Evarts CM (1970) Traumatic occipito-atlantal dislocation. J Bone Joint Surg Am 52:1653–1660

    Article  CAS  PubMed  Google Scholar 

  • Farley FA, Gebarśki SS, Garton HL (2005) Tectorial membrane injuries in children. J Spinal Disord Tech 18:136–138

    Article  PubMed  Google Scholar 

  • Feiz-Erfan I, Gonzalez LF, Dickman CA (2005) Atlantooccipital transarticular screw fixation for the treatment of traumatic occipitoatlantal dislocation. Technical note. J Neurosurg Spine 2:381–385

    Article  PubMed  Google Scholar 

  • Garrett M, Consiglieri G, Kakarla UK, Chang SW, Dickman CA (2010) Occipitoatlantal dislocation. Neurosurgery 66(3 Suppl):48–55

    Article  PubMed  Google Scholar 

  • Georgopoulos G, Pizzutillo PD, Lee MS (1987) Occipito-atlantal instability in children. A report of five cases and review of the literature. J Bone Joint Surg Am 69:429–436

    Article  CAS  PubMed  Google Scholar 

  • 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  PubMed  Google Scholar 

  • Gonzalez LF, Sonntag VK, Dickman CA, Crawford NR (2002) Technique for fixating the atlantooccipital complex with a transarticular screw. Spine (Phila Pa 1976) 27:219–220

    Article  Google Scholar 

  • Grabb BC, Frye TA, Hedlund GL, Vaid YN, Grabb PA, Royal SA (1999) MRI diagnosis of suspected atlanto-occipital dissociation in childhood. Pediatr Radiol 29:275–281

    Article  CAS  PubMed  Google Scholar 

  • Grob D (2001) Transarticular screw fixation for atlanto-occipital dislocation. Spine (Phila Pa 1976) 26:703–707

    Article  CAS  Google Scholar 

  • Gutiérrez-González R, Boto GR, Pérez-Zamarrón A et al (2008) Retropharyngeal Pseudomeningocele formation as a traumatic atlanto-occipital dislocation complication: case report and review. Eur Spine J 17(Suppl 2):S253–S256

    Article  PubMed  Google Scholar 

  • Hamilton MG, Myles ST (1992) Pediatric spinal injury: review of 61 deaths. J Neurosurg 77:705–708

    Article  CAS  PubMed  Google Scholar 

  • Harris MB, Duval M, Davis JA, Bernini PM (1993) Anatomical and roentgenographic features of atlantooccipital instability. J Spinal Disord 6:5-10

    Article  PubMed  Google Scholar 

  • Harris J Jr, Carson GC, Wagner LK (1994) Radiologic diagnosis of traumatic occipitovertebral dislocation. 1. Normal occipitovertebral relationships on the lateral radiographs of supine subjects. AJNR 162:881–886

    Google Scholar 

  • Horn EM, Feiz-Erfan I, Lekovic GP, Dickman CA et al (2007) Survivors of occipitoatlantal dislocation injuries: imaging and clinical correlates. J Neurosurg Spine 6:113–120

    Article  PubMed  Google Scholar 

  • Hosalkar HS, Cain EL, Horn D, Chin KR, Dormans JP, Drummond DS (2005) Traumatic atlanto-occipital dislocation in children. J Bone Joint Surg Am 87:2480–2488

    PubMed  Google Scholar 

  • Iai H, Moriya H, Goto S, Takahashi K, Yamagata M, Tamaki T (1993) Three-dimensional motion analysis of the upper cervical spine during axial rotation. Spine 18:2388–2392

    Article  CAS  PubMed  Google Scholar 

  • Ide C, Niscolle JF, Mission N, Trigaux JP et al (1998) Unusual occipitoatlantal fracture dissociation with no neurological impairment. A case report. J Neurosurg 88:773–776

    Article  CAS  PubMed  Google Scholar 

  • Imaizumi T, Sohma T, Hotta H, Teto I et al (1995) Associated injuries and mechanism of atlanto-occipital dislocation caused by trauma. Neurol Med Chir (Tokyo) 35:385–391

    Article  CAS  Google Scholar 

  • Jeszenszky D, Fekete TF, Lattig F, Bognár L (2010) Intraarticular atlantooccipital fusion for the treatment of traumatic occipitocervical dislocation in a child: a new technique for selective stabilization with nine years follow-up. Spine (Phila Pa 1976) 35:E421–E426

    Article  Google Scholar 

  • Junewick JJ, Meesa IR, Luttenton CR, Hinman JM (2009) Occult injury of the pediatric craniocervical junction. Emerg Radiol 16:483–488

    Article  PubMed  Google Scholar 

  • Kaufman RA (1994) Abnormal atlantooccipital measurements. AJNR 15:990

    CAS  PubMed  Google Scholar 

  • Kaufman RA, Carroll CD, Buncher CR (1987) Atlantooccipital junction: standards for measurement in normal children. AJNR 8:995–999

    CAS  PubMed  Google Scholar 

  • Kenter K, Worley G, Griffin T, Fitch RD (2001) Pediatric traumatic atlanto-occipital dislocation: five cases and a review. J Pediatr Orthop 21:585–589

    CAS  PubMed  Google Scholar 

  • Klimo P Jr, Ware ML, Gupta N, Brockmeyer D (2007) Cervical spine trauma in the pediatric patient. Neurosurg Clin N Am 18:599–620

    Article  PubMed  Google Scholar 

  • Krakenes J, Kaale BR, Moen G et al (2003) MRI of the tectorial and posterior atlanto-occipital membranes in the late stage of whiplash injury. Neuroradiology 45:585–591

    Article  CAS  PubMed  Google Scholar 

  • Lang J (1993) Clinical anatomy of the cervical spine. Thieme, Stuttgart, p 57

    Google Scholar 

  • Lee C, Woodring JH, Walsh JW (1991) Carotid and vertebral artery injury in survivors of atlanto-occipital dislocation: case reports and literature review. J Trauma 31:401–407

    Article  CAS  PubMed  Google Scholar 

  • Levine AM, Edwards CC (1989) Traumatic lesions of the occipitoatlantoaxial complex. Clin Orthop Relat Res 239:53-68

    Google Scholar 

  • Lowry DW, Pollack IF, Clyde B, Albright AL, Adelson PD (1997) Upper cervical spine fusion in the pediatric population. J Neurosurg 87:671–676

    Article  CAS  PubMed  Google Scholar 

  • Luck JF, Nightingale RW, Song Y, Kait JR et al (2013) Tensile failure properties of the perinatal, neonatal, and pediatric cadaveric cervical spine. Spine (Phila Pa 1976) 38:E1–12

    Article  Google Scholar 

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

    Article  PubMed  Google Scholar 

  • Meoded A, Singhi S, Poretti A, Eran A, Tekes A, Huisman TA (2011) Tectorial membrane injury: frequently overlooked in pediatric traumatic head injury. AJNR 32:1806–1811

    Article  CAS  PubMed  Google Scholar 

  • Montane I, Eismont FJ, Green BA (1973) Traumatic occipitoatlantal dislocation. Case report. J Neurosurg 39:394–397

    Article  Google Scholar 

  • Montesano PX, Juach EC, Anderson PA, Benson DR, Hanson PB (1994) Biomechanics of cervical spine internal fixation. Spine 16:10–16

    Article  Google Scholar 

  • Oda T, Panjabi MM, Crisco JJ III, Bueff HU, Grob D, Dvotak J (1992) Role of the tectorial membrane in the stability of the upper cervical spine. Clin Biomech 7:201–207

    Article  CAS  Google Scholar 

  • Osmotherly PG, Rivett DA, Rowe LJ (2012) Construct validity of clinical tests for alar ligament integrity: an evaluation using magnetic resonance imaging. Phys Ther 92:718–725

    Article  PubMed  Google Scholar 

  • Osmotherly PG, Rivett DA, Mercer SR (2013) Revisiting the clinical anatomy of the alar ligaments. Eur Spine J 22:60–64

    Article  PubMed  Google Scholar 

  • Pait TG, Al-Mefty O, Boop FA, Arnautovic KI, Rahman S, Ceola W (1999) Inside-outside technique for posterior occipitocervical spine instrumentation and stabilization: preliminary results. J Neurosurg 90(1 Suppl):1–7

    CAS  PubMed  Google Scholar 

  • Pang D (1995) Principles and pitfalls of spinal stabilization in children. In: Pang D (ed) Disorders of the pediatric spine. Raven Press, New York, pp 575–604

    Google Scholar 

  • Pang D (2012) Treating atlantooccipital dislocation in very young children and infants: solving the Archimedean spiral. World Neurosurg 78:614–616

    Article  PubMed  Google Scholar 

  • Pang D, Li V (2004) Atlantoaxial rotatory fixation: part 1 – biomechanics of the normal rotation at the atlantoaxial joint in children. Neurosurgery 55:614–626

    Article  PubMed  Google Scholar 

  • Pang D, Wilberger JE Jr (1980) Traumatic atlanto-occipital dislocation with survival: case report and review. Neurosurgery 7:503–508

    Article  CAS  PubMed  Google Scholar 

  • Pang D, Wilberger JE Jr (1982) Spinal cord injury without radiographic abnormalities in children. J Neurosurg 57:114–129

    Article  CAS  PubMed  Google Scholar 

  • Pang D, Wong ST (2016) Chapter 50: pediatric vertebral column and spinal cord injuries. In: Cohen A (ed) Pedistric neurosurgery: tricks of the trade. Thieme, New York

    Google Scholar 

  • Pang D, Nemzek WR, Zovickian J (2007a) Atlanto-occipital dislocation: part 1—normal occipital condyle-C1 interval in 89 children. Neurosurgery 61:514–521

    Article  PubMed  Google Scholar 

  • Pang D, Nemzek WR, Zovickian J (2007b) Atlanto-occipital dislocation – part 2: the clinical use of (occipital) condyle-C1 interval, comparison with other diagnostic methods, and the manifestation, management, and outcome of atlanto-occipital dislocation in children. Neurosurgery 61:995–1015

    Article  PubMed  Google Scholar 

  • Panjabi M, Dvorak J, Crisco J 3rd, Oda T, Hilibrand A, Grob D (1991) Flexion, extension, and lateral bending of the upper cervical spine in response to alar ligament transections. J Spinal Disord 4:157–167

    Article  CAS  PubMed  Google Scholar 

  • Patel JC, Tepas JJ 3rd, Mollitt DL, Pieper P (2001) Pediatric cervical spine injuries: defining the disease. J Pediatr Surg 36:373–376

    Article  CAS  PubMed  Google Scholar 

  • Penning L (1978) Normal movements of the cervical spine. Am J Roentgenol 130:317–326

    Article  CAS  Google Scholar 

  • Piatt JH Jr, Grissom LE (2011) Developmental anatomy of the atlas and axis in childhood by computed tomography. J Neurosurg Pediatr 8:235–243

    Article  PubMed  Google Scholar 

  • Powers B, Miller MD, Kramer RS, Martinez S, Gehweiler JA Jr (1979) Traumatic anterior atlanto-occipital dislocation. Neurosurgery 4:12–17

    Article  CAS  PubMed  Google Scholar 

  • Rockswold GL, Seljeskog EL (1979) Traumatic atlantocranial dislocation with survival. Minn Med 62:151–152

    CAS  PubMed  Google Scholar 

  • Rojas CA, Bertozzi JC, Martinez CR, Whitlow J (2007) Reassessment of the craniocervical junction: normal values on CT. AJNR 28:1819–1823

    Article  CAS  PubMed  Google Scholar 

  • Sasso RC, Jeanneret B, Fischer K, Magerl F (1994) Occipitocervical fusion with posterior plate and screw instrumentation: a long-term follow-up study. Spine 19:2364–2368

    Article  CAS  PubMed  Google Scholar 

  • Scheuer L, Black S (2000a) Developmetal juvenile osteology. Elsevier, Amsterdam, p 60

    Google Scholar 

  • Scheuer L, Black S (2000b) Developmetal juvenile osteology. Elsevier, Amsterdam, p 198

    Google Scholar 

  • Shamoun JM, Riddick L, Powell RW (1999) Atlanto-occipital subluxation/dislocation: a “survivable” injury in children. Am Surg 65:317–320

    CAS  PubMed  Google Scholar 

  • Shin JI, Lee NJ, Cho SK (2016) Pediatric cervical spine and spinal cord injury: a national database study. Spine 41:283–292

    Article  PubMed  Google Scholar 

  • Smith MD, Anderson P, Grady MS (1993) Occipitocervical arthrodesis using contoured plate fixation: an early report on a versatile fixation technique. Spine 18:1984–1990

    Article  CAS  PubMed  Google Scholar 

  • Smith P, Linscott LL, Vadivelu S et al (2016) Normal development and measurements of the occipital condyle-C1 interval in children and young adults. AJNR 37:952–957

    Article  CAS  PubMed  Google Scholar 

  • Sponseller PD, Cass JR (1997) Atlanto-occipital fusion for dislocation in children with neurologic preservation. A case report. Spine (Phila Pa 1976) 22:344–347

    Article  CAS  Google Scholar 

  • Steinmetz MP, Lechner RM, Anderson JS (2003) Atlantooccipital dislocation in children: presentation, diagnosis, and management. Neurosurg Focus 14(2):ecp1

    Article  PubMed  Google Scholar 

  • Sun PP, Poffenbarger GJ, Durham S, Zimmerman RA (2000) Spectrum of occipitoatlantoaxial injury in young children. J Neurosurg 93(1 Suppl):28–39

    CAS  PubMed  Google Scholar 

  • Takayasu M, Hara M, Suzuki Y, Yoshida J (1999) Treatment of traumatic atlanto-occipital dislocation in chronic phase. Neurosurg Rev 22:135–137

    Article  CAS  PubMed  Google Scholar 

  • Tillmann B, Lorenz R (1978) The stress at the human atlanto-occipital joint. I. The development of the occipital condyle. Anat Embryol (Berl) 153:269–277

    Article  Google Scholar 

  • van de Pol GJ, Hanlo PW, Oner FC, Castelein RM (2005) Redislocation in a halo vest of an atlanto-occipital dislocation in a child: recommendations for treatment. Spine (Phila Pa 1976) 30:E424–E428

    Article  Google Scholar 

  • Vachhrajani S, Sen AN, Satyan K et al (2014) Estimation of normal computed tomography measurements for the upper cervical spine in the pediatric age group. J Neurosurg Pediatr 14:425–433

    Article  PubMed  Google Scholar 

  • Werne S (1957) Studies in spontaneous atlas dislocation. Acta Orthop Scand Suppl 23:1–150

    CAS  PubMed  Google Scholar 

  • Wholey MH, Bruwer AJ, Baker HL Jr (1993) The lateral roentgenogram of the neck; with comments on the atlanto-odontoid relationship. Radiology 71:350–356

    Article  Google Scholar 

  • Wong ST, Ernest K, Fan G, Zovickian J, Pang D (2014) Isolated unilateral rupture of the alar ligament. J Neurosurg Pediatr 13:541–547

    Article  PubMed  Google Scholar 

  • Yüksel KZ, Yüksel M, Gonzalez LF, Baek S, Heiserman JE, Sonntag VK et al (2008) Occipitocervical vertical distraction injuries: anatomical biomechanical, and 3-tesla magnetic resonance imaging investigation. Spine (Phila Pa 1976) 33:2066–2073

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Neurosurgery, Tuen Mun Hospital, Hong Kong, China

    Sui-To Wong

  2. Department of Paediatric Neurosurgery, Kaiser Permanente Medical Centre, 3600 Broadway Street, 3rd Floor, Suite 39, Oakland, CA, 94611, USA

    Dachling Pang

  3. University of California, Davis, CA, USA

    Dachling Pang

  4. Regional Centre for Paediatric Neurosurgery, Kaiser Permanente Hospitals, Oakland, CA, USA

    Dachling Pang

  5. Great Ormond Street Hospital For Children, NHS Trust, London, UK

    Dachling Pang

Authors
  1. Sui-To Wong
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Dachling Pang
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Dachling Pang .

Editor information

Editors and Affiliations

  1. International Neuroscience Institute, Hannover, Germany

    Concezio Di Rocco

  2. Oakland Medical Center, Oakland, California, USA

    Dachling Pang

  3. University of Toronto Hospital for Sick Children, Toronto, Ontario, Canada

    James T. Rutka

Section Editor information

  1. Davis; and Kaiser Permanente Hospitals of Northern California, University of California, Oakland, United States of America

    Dachling Pang

Rights and permissions

Reprints and permissions

Copyright information

© 2017 Springer International Publishing AG

About this entry

Cite this entry

Wong, ST., Pang, D. (2017). Traumatic Atlanto-Occipital Dislocation in Children. In: Di Rocco, C., Pang, D., Rutka, J. (eds) Textbook of Pediatric Neurosurgery. Springer, Cham. https://doi.org/10.1007/978-3-319-31512-6_135-1

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-31512-6_135-1

  • Received:

  • Accepted:

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-31512-6

  • Online ISBN: 978-3-319-31512-6

  • eBook Packages: Springer Reference Biomedicine and Life SciencesReference Module Biomedical and Life Sciences

Publish with us

Policies and ethics

Search

Navigation