title: Traumatic atlanto-occipital dislocation in children: evaluation, treatment, and outcomes.
abstract: BACKGROUND
  Advancements in emergency care and diagnostic methods have increased the number of children who survive atlanto-occipital dislocation. We report our experience with one of the largest series of pediatric patients with atlanto-occipital dislocation.
  
  
  METHODS
  Patients ranging in age from newborn to sixteen years old who had a diagnosis of atlanto-occipital dislocation from 1991 through 2011 were identified. Inclusion criteria were complete radiographic and clinical records and duration of follow-up of at least six months. Basic patient characteristics, mechanism of injury, associated injuries, neurological impairment, surgical treatment and type of implant used for fixation, complications, and clinical and radiographic outcomes were recorded.
  
  
  RESULTS
  The fourteen patients who were included (seven male and seven female) had a mean age of 5.2 years at the time of injury. An automobile accident in which the victim was a passenger was the most common mechanism of injury. Twelve patients had associated injuries, with a brain injury in eleven of them, and nearly half sustained a spinal cord injury. According to the Traynelis classification system, eight patients had a type-II (longitudinal) atlanto-occipital dislocation, five had a type-I (anterior) dislocation, and one had a type-III (posterior) dislocation. All patients had posterior occipitocervical fusion with internal fixation. The mean duration of follow-up was 75.4 months. The most common postoperative complication was hydrocephalus, which occurred in four patients. Spinal fusion occurred in all patients by four to six months postoperatively. At the time of the most recent follow-up evaluation, half of the patients had neurological impairment.
  
  
  CONCLUSIONS
  More patients with atlanto-occipital dislocation now survive the initial trauma, although most have associated injuries and many have neurological impairment. Our preferred management is early occipitocervical fusion and stabilization. If there is neurological decline after spinal fixation, obstructive hydrocephalus should be suspected.
authors.affiliation: University of Tennessee-Campbell Clinic Dept. of Orthopaedic Surgery, 1211 Union Avenue, Suite 510, Memphis, TN 38104. E-mail address for J.R. Sawyer: jsawyer@campbellclinic.com.
authors.forename: Nelson
authors.initials: N
authors.lastname: Astur
authors.affiliation: Semmes-Murphey Neurologic & Spine Institute, 6325 Humphreys Boulevard, Memphis, TN 38120.
authors.forename: Paul
authors.initials: P
authors.lastname: Klimo
authors.affiliation: University of Tennessee-Campbell Clinic Dept. of Orthopaedic Surgery, 1211 Union Avenue, Suite 510, Memphis, TN 38104. E-mail address for J.R. Sawyer: jsawyer@campbellclinic.com.
authors.forename: Jeffrey R
authors.initials: JR
authors.lastname: Sawyer
authors.affiliation: University of Tennessee-Campbell Clinic Dept. of Orthopaedic Surgery, 1211 Union Avenue, Suite 510, Memphis, TN 38104. E-mail address for J.R. Sawyer: jsawyer@campbellclinic.com.
authors.forename: Derek M
authors.initials: DM
authors.lastname: Kelly
authors.affiliation: Semmes-Murphey Neurologic & Spine Institute, 6325 Humphreys Boulevard, Memphis, TN 38120.
authors.forename: Michael S
authors.initials: MS
authors.lastname: Muhlbauer
authors.affiliation: University of Tennessee-Campbell Clinic Dept. of Orthopaedic Surgery, 1211 Union Avenue, Suite 510, Memphis, TN 38104. E-mail address for J.R. Sawyer: jsawyer@campbellclinic.com.
authors.forename: William C
authors.initials: WC
authors.lastname: Warner
mesh_terms: D000063:Accidents, Traffic; D000293:Adolescent; D001269:Atlanto-Occipital Joint / Q000293:injuries*; D001930:Brain Injuries / Q000150:complications / Q000175:diagnosis / Q000601:surgery; D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D004204:Joint Dislocations / Q000150:complications / Q000000981:diagnostic imaging* / Q000601:surgery*; D008297:Male; D011859:Radiography; D013119:Spinal Cord Injuries / Q000150:complications / Q000175:diagnosis / Q000601:surgery; D013123:Spinal Fusion; D016896:Treatment Outcome