title: Severe spinal cord injury in craniocervical dislocation. Case-based update.
abstract: BACKGROUND
  Craniocervical distraction injuries, including atlanto-axial dislocation (AAD) and atlanto-ocipital dislocation (AOD), are often associated with severe spinal cord involvement with high morbidity and mortality rates. Many patients with these injuries die at the accident scene, but advances in emergency resuscitation and transport permit that many patients arrive alive to hospitals.
  
  
  CONCLUSIONS
  Children with craniocervical distraction injuries usually present with a severe cranioencephalic traumatism that is the most relevant lesion at admission. After resuscitation and hemodynamic stabilization, the spinal cord damage appears as the main lesion. Apnea and quadriparesis, or quadriplegia, are usually present at the onset. Early diagnosis and management perhaps decrease life-threatening manifestations of the spinal lesion. But even so, the primary spinal cord insult is often irreversible and precludes obtaining a satisfactory functional outcome.
  
  
  METHODS
  We report the findings of four children with craniocervical distraction injuries (AOD and AAD) who presented with severe spinal cord damage. All patients were admitted with respiratory distress or apnea together with significant brain injuries. The medical records pertaining to these patients are summarized in regard to clinical features, management, and outcome.
  
  
  CONCLUSIONS
  In spite of timely and aggressive management, craniocervical injuries with spinal cord involvement continue to have a dismal prognosis. Outcome is closely related to the severity of the initial brain and spinal cord damage and is nearly always fatal in cases of complete spinal cord transection. Priority should be given to life-threatening complications. Ethic issues on indications for surgery deserve a detailed discussion with the children's parents.
authors.affiliation: Unit of Pediatric Neurosurgery, Regional Service of Neurosurgery, Virgen de la Arrixaca University Children's Hospital, 30120 El Palmar, Murcia, Spain. juanf.martinezlage@cablemurcia.com
authors.forename: Juan F
authors.initials: JF
authors.lastname: Martínez-Lage
authors.forename: Fernando
authors.initials: F
authors.lastname: Alarcón
authors.forename: Raul
authors.initials: R
authors.lastname: Alfaro
authors.forename: Amparo
authors.initials: A
authors.lastname: Gilabert
authors.forename: Susana B
authors.initials: SB
authors.lastname: Reyes
authors.forename: María-José
authors.initials: MJ
authors.lastname: Almagro
authors.forename: Antonio
authors.initials: A
authors.lastname: López López-Guerrero
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D007223:Infant; D004204:Joint Dislocations / Q000150:complications / Q000175:diagnosis*; D008297:Male; D012720:Severity of Illness Index; D013119:Spinal Cord Injuries / Q000150:complications / Q000175:diagnosis*; D020196:Trauma, Nervous System / Q000150:complications / Q000175:diagnosis*