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Traumatic Atlantooccipital Dislocation (AOD)
P. Suchomel and V. Beneš
8
Atlanto-occipital dislocation (AOD) is a rare, highly
unstable injury of the craniovertebral junction (CVJ)
and, as such, is associated with high mortality and neurological morbidity. Its first description dates back to
1908, when Blackwood described a patient surviving his
injury for nearly 35 h [3]. AOD may be defined as acute
traumatic osteoligamentous instability between the
occiput and the atlas [2]. According to the relationship
of atlas and occiput, Traynelis, in 1986, classified AOD
into three types [28]. Type I involves anterior displacement of the occiput with respect to the atlas. Type II is a
longitudinal distraction, whereas Type III results when
the occiput is displaced posteriorly relative to the atlas.
8.1 Etiology
Although AOD is relatively rare, it was found in up to
90% of fatal cervical spine injuries [1, 4] and represented 1% of all (dead or surviving) cervical spine
injuries [23]. High energy trauma, such as motor vehicle accident (MVA), is the usual cause, with an incidence of 8–31% among traffic victims [4, 29]. AOD is
more common among children and young adults due to
increased laxity of ligaments and the disparity between
occipital condyles and articular surfaces of the atlas [5,
19, 26]. The disproportionate size of the head in rela-
tion to spine can also play a significant role [14].
8.2 Clinical Symptoms
AOD victims can have surprisingly few or no neurological symptoms [2, 14]. In one series, 27% of patients
did not present with neurological deficits [14]. More
commonly, patients present with spinal cord injury of
a varying degree, lower cranial nerve deficits, or bulbar-cervical dissociation [2, 10, 14, 24, 25, 28]. AOD
frequently results into sudden death and is diagnosed
at postmortem examination [1, 20]. Other associated
injuries are common and include, traumatic brain
injury, skull fractures, concomitant traumatic instability of lower cervical spine, and other injuries to multiple organ systems in context of a polytrauma victim [1,
2, 9, 14, 17, 18, 24].
Due to improved rescue services and emergency
protocols, more AOD victims nowadays reach hospital
alive. High index of suspicion for AOD must be maintained, since delay in diagnosis can have devastating
consequences [2, 14]. Impaired consciousness and
other associated injuries in a polytraumatized victim
can lead to an under-appreciation of the situation and
delay in diagnosis. In Bellabarba’s series, a delay in
diagnosis occurred in 75% of patients and 38% of those
were diagnosed with AOD only after a neurological
deterioration [2]. Therefore, a careful and thorough
radiological evaluation is of utmost importance and
AOD must be ruled out in every polytrauma patient,
especially with impaired level of consciousness.
8.3 Radiology
P. Suchomel and V. Beneš
Department of Neurosurgery, Neurocenter,
Regional Hospital Liberec, Husova St. 10, 46063 Liberec,
Czech Republic
P. Suchomel and O. Choutka, Reconstruction of Upper Cervical Spine and Craniovertebral Junction,
DOI: 10.1007/978-3-642-13158-5_8, © Springer-Verlag Berlin Heidelberg 2011
CT especially in 3D or midsagittal reconstruction
(Fig. 8.1) and lateral cervical spine radiography
(Fig. 8.2) can show increased both basion – dens
139
140
Fig. 8.1 Atlantooccipital
dislocation (AOD) with
distraction type II according to
Traynelis. (a) Lateral view of
3D reconstruction, note
increased BDI. (b)
Reconstruction in coronal
plane
8 Traumatic Atlantooccipital Dislocation (AOD)
Fig. 8.2 Plain X-rays of
AOD with anterior dislocation, type I according to
Traynelis in two different
patients. (a) Note contrast
media in vessels. Picture
obtained after angiography
confirming the brain death
because of legal reasons
interval (BDI) as well as basion – axial interval (BAI);
the cut-off value is considered 12 mm for both parameters [2, 12, 13]. The Powers ratio is greater than 1.0
[23]. Associated injuries to the C0-C2 complex can
also be appreciated this way and are rather common in
AOD patients [2, 14]. Cranial CT may reveal evidence
of intracranial traumatic injuries.
If a CT scan is without abnormalities and a high
suspicion for upper cervical spine injury still exists, an
MRI can confirm AOD diagnosis. The findings then
include abnormal signal in the C0-C1 joint capsule or
ligamentous structures, such as the posterior atlantooccipital membrane, alar, apical, and cruciate ligaments [6,
14, 16]. Based on ligamentous injury, Bellabarba et al.
classified AOD into three stages. Stage 1 was defined
as stable minimally or non-displaced injury with sufficiently preserved ligamentous integrity. Such injury
included unilateral alar ligament avulsion or partial ligamentous injury or sprain. Stage 2 injury was partially
or completely spontaneously reduced bilateral AOD
with minimal displacement, where traction test confirms loss of ligamentous integrity. Both BDI and BAI
are no more than 2 mm beyond normal values. Stage 3
injury denotes a gross craniocervical displacement with
BDI and BAI more than 2 mm beyond upper limit [2].
Horn [14] pointed out a drawback of this classification
8.5 Our Preference
141
system: its reliance on plain and dynamic radiography
to determine instability, and proposed his own classification. It relies on described CT and MRI features. Grade I
injury denotes normal findings on CT (Powers ratio, BDI,
BAI) with moderately abnormal findings on MRI (high
signal in posterior ligaments or occipitoatlantal joints).
Grade II injury shows more than one abnormal finding on
CT or grossly abnormal MRI findings in occipitoatlantal
joints, tectorial membrane, or alar or cruciate ligaments
[14]. Previously mentioned two classification scales [2,
14] have therapeutic implications.
8.4 Treatment Strategy
It is important to emphasize again that AOD represents a
highly unstable pure ligamentous injury, which can be
seen in up to 31% of traffic accident victims. Therefore,
it is extremely important to consider this entity during
first aid and transportation of a trauma victims. Any
undesirable head movement can cause fatal upper spinal
cord injury. This is of particular importance during extrication of MVA victims trapped in their vehicles. AOD is
the most dangerous spine injury in terms of inappropriate
handling of patients and its potential occurrence was one
of the main reasons for changing rescue guidelines in the
past. It is now a standard that emergency service personnel always immobilize the victim’s cervical spine with a
hard collar at the scene prior to any manipulation.
AOD treatment is either conservative and relies on
external immobilization, or surgical, in which case the
mainstay is posterior occipitocervical fusion. External
orthosis, such as halo vest or Philadelphia collar are possible therapeutical solutions in selected cases (Bellabarba
Stage 1 and Horn Grade I injuries). However, this therapy can also be associated with neurological deterioration [7, 8, 15] or late segmental instability [8, 15, 22,
27]. These therapeutical measures can be recommended
as a provisional fixation until a definite treatment is
undertaken or in relatively stable injuries in children,
where potential of ligamentous healing is expected.
Since AOD is primarily a ligamentous injury, posterior occipitocervical fixation and fusion with a bone
graft offer a definitive treatment. As emphasized earlier,
AOD is associated with high rates of morbidity and mortality. The high fatality rate suggests that a chance of
surviving this injury is remote [1]. However, upon reaching a hospital, the best predictor of outcome is the
severity of neurological injuries at presentation. In a
series of 17 treated survivors, functional status improved
after surgery in 85% of those presenting with spinal cord
injury and no change was noted in two patients initially
neurologically intact [2]. Another institutional series of
33 patients reported 28 survivors; remarkably, 14 of
these were neurologically intact [14]. Surgical complications with neurological consequences from these two
only series reported to date were seen in one [2] and two
[14] patients, respectively.
When appropriate, high dose steroid regimen is
implemented upon presentation and any surgical intervention is undertaken under electrophysiological monitoring. The patient is usually intubated fiberoptically and
maintained under total intravenous anesthesia (TIVA) to
allow for motor-evoked potential monitoring. Halo ring
or halo vest are applied without traction to stabilize the
CVJ, baseline electrophysiological data are obtained,
and then the patient is carefully positioned prone and
secured to the operating table. The occiput and at least
the first two cervical vertebrae are exposed using a standard posterior midline approach. The occipitocervical
fixation is then carried out with the C0-C1 joints anatomically aligned. The exact type of fixation and fusion
is dependent on the severity of injury. In mild forms,
especially in children and young adults, only a short
construct can be used. Grob et al. published a technique
of direct atlanto-occipital screw fixation in such cases
[11]. Similarly, Maughan et al. used a short occipitoatlantal fixation using an occipital plate connected with
rods to polyaxial C1 lateral mass screws for the treatment of circular occipital bone fracture [21]. However,
in more severe grades of AOD, a strong construct
between occiput and at least two cervical vertebrae is
preferred. External immobilization (e.g., halo, SOMI, or
hard collar) is commonly continued for 3 months postoperatively even following a solid fixation and fusion.
8.5 Our Preference
Unfortunately, large series of AOD survivors are
mostly published in the United States. This is probably
due to a superior organization and standard protocols
adopted by the emergency medical services when it
comes to extrication and transport of polytrauma victims. In Europe, survivors are discussed in case reports
and the majority of our patients with AOD are
142
8 Traumatic Atlantooccipital Dislocation (AOD)
admitted to the hospital in pentaplegic status. Thus, a
proper education of public and emergency services is
essential to avoid a secondary injury associated with
improper manipulation of the head of an injured victim. This includes traction. A prompt placement of
rigid external orthosis and full spinal precautions at the
scene of an accident are a standard ATLS protocol.
In our opinion, the morphological classification is
slightly misleading. If the head is structurally disconnected from the spine, it can freely move in any direction. Therefore, its position at the time of CT image
acquisition may be quite different from that at the time
of impact. In terms of surgical indication, the abovementioned Horn grading system is more practical.
Upon arrival to the hospital, most trauma patients are
stabilized in the trauma bay and then transported from
the emergency department to a CT scanner. A spiral
CT scanner may reveal a possible AOD and thus dictate further manipulation precautions (Fig. 8.3). In
such cases of suspected AOD, it is time-consuming
and inefficient to be obtaining plain radiographs. If
the patient is hemodynamically stable, we prefer a
direct MRI evaluation of the CVJ (Fig. 8.4). In indicated cases, the patient should undergo surgical fixation as soon as possible, provided no other emergent
surgical treatments are necessary. Immediate surgical
fixation rids the patient of any subsequent manipulation hazard.
Intubation (preferably fiberoptic) and prone positioning on the surgical table need to be carried out with
extreme caution. Electrophysiological monitoring
should be instituted prior to those maneuvers.
Depending on the severity of the injury, the occiput
and UCS and/or more caudal cervical vertebrae are
exposed via a standard posterior midline approach in
all cases of AOD. Being careful around the vertebral
artery behind the C1 lateral mass, the degree of dislocation of the atlanto-occipital joint should be visualized directly. Reduction, if necessary, is achieved
directly by manipulation of the head relative to C1
under direct vision and fluoroscopic guidance. Our
preferred construct involves an occipital plate firmly
anchored in the midline and directly connected to C1
lateral mass screws and C2 pedicle screws by two
appropriately shaped rods (Fig. 8.5). In situations
where such construct is not possible due to the morphology of the injury, we extend the fixation to lower
levels. Iliac crest bone graft is always added to allow
for fusion between the occiput and UCS (both laminae
and spinous process). A short monosegmental construct in mild forms of AOD may be sufficient as
described by some authors but we do not share such
experience. We obtain a postoperative CT to check
adequacy of the construct and upright films in external
orthosis as soon as possible to assess the construct
under appropriate loading. The length of period of
external immobilization is judged on an individual
basis depending on the injury, construct used, compliance of the patient, and follow-up imaging.
In conclusion, AOD is a highly unstable injury and
must be ruled out in any major trauma victim, because
delayed diagnosis frequently results in neurological
deterioration. Computer tomography is the study of
choice as a fast, first-line evaluation of trauma severity
to the CVJ. However, time and situation permitting, an
MRI evaluation allows for a better assessment of the
Fig. 8.3 AOD type I according
to Traynelis. (a) Whole spine
spiral CT. (b) Detail of 3D
reconstruction in sagittal plane
References
Fig. 8.4 MRI in a patient surviving the AOD type I. Edema of
upper spinal cord and lower brain stem
Fig. 8.5 Occipitocervical fusion in patient with AOD
ligaments of the CVJ. Despite the high mortality rate,
survival is well documented. External orthosis can be
used in carefully selected cases or as a temporary measure prior to a definitive treatment. Occipitocervical
fusion is the treatment of choice that offers an immediate, solid stabilization of the CVJ.
143
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13. Harris Jr., J.H., Carson, G.C., Wagner, L.K., et al.: Radiologic
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14. Horn, E.M., Feiz-Erfan, I., Lekovic, G.P., et al.: Survivors of
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Occipital Condyle Fractures
P. Suchomel and L. Jurák
9
Occipital condyle fracture (OCF) was first described
by Charles Bell after an autopsy [4]. OCF was considered to be a very rare injury accompanying head trauma
with a high rate of mortality in the past [5, 6, 14].
Nowadays, it is encountered more frequently due to
developed rescue services allowing higher survival
rate, especially for traffic accident victims. The polytrauma patients are usually transported directly to
emergency department where the first radiological
investigation is a “whole body” spiral CT scan. This
means a much earlier diagnosis of UCS injury including OCF [3, 11, 15]. Nevertheless, it is still quite a rare
injury, which can easily be overlooked [3, 11, 15].
Despite a lack of uniformly accepted clinical evaluation of the patient’s status, there are two widely
accepted classifications of OCFs.
The first descriptive classification was suggested by
Anderson and Montesano (1988) derived from an
analysis of their six patients [1] dividing OCFs into
three types.
Type I: occipital condyle comminution with no or
minimal displacement
Type II: dislocated occipital condyle fractures
Type III: those with stable C0-1-2 complex
The authors proposed that condyle comminution is a
result of extreme axial load; the avulsion occurs if the
axial force is combined with bending and/or rotation
with concomitant participation of alar ligament traction and that the type II is a part of skull base injury
usually caused by high energy blunt trauma.
P. Suchomel and L. Jurák
Department of Neurosurgery,
Neurocenter, Regional Hospital Liberec,
Husova St. 10, 46063 Liberec, Czech Republic
Tuli et al. opposed that the above classification does
not provide any risk stratification or treatment guidance and instead suggested dividing OCFs into two
basic types and two other subtypes [22]. Their classification was based on a review of literature and analysis
of only three of their own cases.
Type 1: fractures of condyle without dislocation
Type 2: dislocated occipital condyle fractures
Type 2a: those with stable C0-1-2 complex
Type 2b:
In this schema, only the very rare type 2b fractures are
considered for surgery. Although this classification seems
to be more logical than the first one, it is not easy to determine stability based on the authors’ required parameters
that can only be measured on thin sliced CT images with
some of them obtained in dynamic positions.
OCF displacement is usually defined as greater than
2 mm of fragment separation [3, 11].
Currently, two basic questions have to be answered
when deciding whether to operate or not [15]: Firstly, is
there any reason to decompress neural structures possibly compressed by the condyle fragments? Secondly, is
the OCF unstable enough to require surgical fixation?
fractures with evidence of occipitoatlanto-axial instability (OAA)
9.1 Etiology and Epidemiology
OCFs are present in 0.1–0.4% of patients admitted to
hospitals with traumatic injuries. Often, OCF is caused
by high impact blunt trauma [3, 11]. Patients are most
frequently involved in MVA (55%) but also falls from
height (34%) and assaults (9%) can result in condylar
P. Suchomel and O. Choutka, Reconstruction of Upper Cervical Spine and Craniovertebral Junction,
DOI: 10.1007/978-3-642-13158-5_9, © Springer-Verlag Berlin Heidelberg 2011
145
146
9 Occipital Condyle Fractures
injury [15]. TBI is concomitantly present in up to 56%
patients and associated injuries of the rest of the cervical spine are found in 20–31% patients [3, 11, 15].
There is a significant male predominance (70%) and the
types II and III, according to Anderson and Montesano,
are the most frequent types. The vast majority of diagnosed cases are unilateral and do not have any condyle
fragment displacement (Tuli Type I) [3, 11, 15].
9.2 Clinical Symptoms
Neurologic deficit is rarely seen in isolated, unilateral
OCFs [15]. The patient usually suffers from a nonspecific pain exacerbated by head movement; however,
unilateral hypoglossal paralysis due to OCF has been
described [10, 12, 21, 23].
Clinical symptoms related to OCFs are masked by
the overwhelming effects of TBI or other traumatic injuries in more than a half of the patients [15]. The most
Fig. 9.1 CT of broad condyle
avulsion. (a) Axial image.
(b) Reconstruction in frontal
plane
complex clinical findings are seen in those with
impaired consciousness and neurologic deficit caused
by TBI [1–3, 7, 8, 13, 20, 22].
Sometimes, clinical symptoms of cranial nerve
involvement do not appear initially but present in a
delayed fashion. It may be due to osseous and fibrous
tissue proliferation as a reparative process or due to inadequate stabilization of bony fragments [7, 9, 16, 19, 22].
9.3 Radiology
The diagnosis of OCF is rarely made on plain films.
Computerized tomography is the modality of choice.
Fracture lines visible on standard axial CT are usually
inadequate in defining the exact morphology and extent
of the fracture (Fig. 9.1). 3D CT reconstructions are usu-
ally necessary to delineate the true fracture pattern and
the degree of displacement (Fig. 9.2). Fracture morphology is not the only parameter determining the
Fig. 9.2 3D CT of broad
condyle avulsion, the same
patient from Fig. 9.1.
(a) Lateral view. (b) Internal
view
9.5 Our Preference
Fig. 9.3 Normal CCI distance (less than 2 mm) depicted on
parasagittal CT reconstruction in a case of condyle avulsion
management of the injury. Stability of the AO joint must
also be established. Apart from different techniques used
in the evaluation of AOD, the occipital condyle – C1
interval (CCI) is considered to be the most relevant index.
Pang et al. [17, 18] described it to be symmetrical and not
exceed 2 mm (Fig. 9.3). MRI is indicated to evaluate the
ligamental integrity and possible neural compression in
patients with suspicion for instability or those with neurological deficit [2, 3, 11, 15, 22]. Certainly, more exten-
sive workup is needed in OCFs combined with other
upper cervical spine (UCS) injuries.
9.4 Treatment Strategy
Treatment of OCFs is conservative in the vast majority
of cases. Surgical decompression is rarely indicated
only if neural structures are directly compressed by
147
displaced fracture fragments. Stabilization procedures
are seldom necessary and required only in situations
with AO instability, malalignment or complex instabilities of UCS in the combined injuries.
Depending on fracture type, conservative management varies from activity restriction only without
immobilization to a rigid cervical collar for 6 weeks
followed by dynamic plain films or CT. Halo-vest or
SOMI brace are rarely used except for combined UCS
injuries [15]. Patients with bilateral OCFs or occipitoatlantal or atlantoaxial instability may require halo
traction followed by hard external bracing or surgical
occipitocervical fusion [11].
In the largest published retrospective analysis of
100 patients with 106 OCFs reported by Masserati
et al. [15], only two patients with AO malalignment
required surgical stabilization (one primarily and one
delayed) and in the other four halo-vests were used (in
three because of combined UCS injury). Conversely,
19.3% of their patients were discharged without any
external cervical support.
9.5 Our Preference
Single, isolated nondislocated fractures of all Anderson
and Montesano types can be treated conservatively, in our
opinion. Those patients with type I fractures where the
condyle bearing capacity looks damaged by less than 50%
can be treated by simple activity restriction without external support (Fig. 9.4). Similarly, external immobilization
seems to be unnecessary when it comes to wedge locked,
broad based, type III fractures, and single line fractures of
skull base extending into occipital condyle (Fig. 9.5).
However, type III fractures where the alar ligament insertion tubercle is detached, hard collar should
Fig. 9.4 Nondisplaced
comminuted fracture of
occipital condyle (Type I
Anderson and Montesano)
successfully treated without
bracing. (a) Axial CT scan.
(b) Coronal reconstruction