Atlantooccipital distraction: a diagnostic and therapeutic dilemma: report of two cases.
METHODS
Two cases of severe atlantooccipital distraction, one with a fatal outcome and one with survival and 2 years of follow-up evaluation, are reported.


OBJECTIVE
To show the problems in diagnosing and the dilemma in treating patients with severe atlantooccipital distraction in two cases with different outcomes.


BACKGROUND
Isolated severe traumatic atlantooccipital distraction without bony injuries is rarely seen in clinical practice. Because of high neurologic morbidity, most patients with the disorder are dead after the accident and before medical attention has arrived. However, because of improved immediate medical care for victims of motor vehicle accidents, an increased number of survivors are reported in the last years.


METHODS
Two cases of isolated atlantooccipital distraction are described. The first case involved a 13-year-old cyclist hit by a car. In the second case, a 40-year-old woman sustained a severe accident as a motorcycle driver. Both patients were found to have severe atlantooccipital distraction on the lateral topogram of the computed tomography. In both cases, the initial MRI of the craniocervical junction failed to show medullary contusion. The diagnosis of severe medullary contusion was made by follow-up MRI performed 48 hours later.


RESULTS
Both patients were treated initially with halo vest. Patient 1 survived the injury with tetraplegia and was referred to a spinal center for rehabilitation. At this writing, he is improving neurologically. Patient 2 did not recover and died 4 days after delivery to the neurosurgical intensive care unit because of circulatory failure.


CONCLUSIONS
Because of high neurologic morbidity and mortality, atlantooccipital distraction represents a diagnostic and therapeutic problem. The therapy should be symptomatic, with life supporting measures, allowing the recovery of consciousness and then further neurologic evaluation.
Bani
Alan
A
Department of Neurosurgery, Klinikum Duisburg-Wedau, Duisburg, Germany. a.bani@doctor.com
Gilsbach
Joachim M
JM
D000293:Adolescent; D000328:Adult; D001269:Atlanto-Occipital Joint / Q000293:injuries* / Q000503:physiopathology; D005073:Evoked Potentials, Somatosensory / Q000502:physiology; D017809:Fatal Outcome; D005260:Female; D006801:Humans; D004204:Joint Dislocations / Q000175:diagnosis* / Q000534:rehabilitation; D008297:Male; D013119:Spinal Cord Injuries / Q000175:diagnosis / Q000503:physiopathology / Q000534:rehabilitation