Traumatic Atlanto-occipital Dislocation in Children Followed by Hydrocephalus ­ A Case Report and Literature Review / Deslocamento atlanto-occipital em crianças seguido por hidrocefalia ­ Relato de caso e revisão da literatura

Traumatic atlanto-occipital dislocation (TAOD) are uncommon injuries associated with high immediate mortality rate and occurs more than twice in children than adults, due to biomechanical properties and immaturity of children's cervical spine. We report a pediatric patient with TAOD, who underwent occipitocervical stabilization and also developed a late hydrocephalus requiring a shunt procedure. A six-year-old boy was admitted to the emergency department after a car accident with refractory cervical pain. A cervical computed tomography (CT) scan showed an anterior C1­C2 level hematoma, and a dynamic CT scan demonstrated an increasing basion-dens interval on extension. Cervical magnetic resonance imaging (MRI) showed discontinuity of the tectorial membrane and diffused hyperintense signal on the left alar ligament. These findings were attributed to TAOD, and an occipitocervical fusion was performed. The pain and neurological status improved after surgery, but after 3 months he returned with persistent vomiting, headache, and a CT scan showing hydrocephalus. Then, a ventriculoperitoneal shunt was performed, improving the symptoms. One year after the injury, the patient remained asymptomatic, and a later radiography demonstrated satisfactory bone fusion. In conclusion, the decision-making process regarding treatment should consider several clinical and radiographic findings. Occipitocervical fusion is the treatment of choice, while hydroceph alus is not an unusual complication in children.

O deslocamento atlanto-occipital (DAO) é uma lesão incomum associada a uma alta taxa de mortalidade imediata que ocorre duas vezes mais em crianças do que em adultos, fato relacionado às propriedades biomecânicas e à imaturidade da coluna cervical pediátrica. Relatamos o caso de um paciente pediátrico com DAO traumático submetido à fixação occipitocervical, evoluindo com hidrocefalia e necessidade de um procedimento de derivação liquórica. Paciente do sexo masculino de 6 anos de idade admitido no pronto-socorro após um acidente automobilístico, apresentando dor cervical refratária. A tomografia computadorizada (TC) de coluna cervical demostrou um hematoma epidural ao nível de C1­C2, e a TC dinâmica evidenciou um intervalo basion-odontoide aumentado em extensão. A ressonância magnética (RM) da coluna cervical demonstrou descontinuidade da membrana tectorial e hiperintensidade difusa no ligamento alar esquerdo. Esses achados permitiram o diagnóstico de um DAO, sendo realizada uma fusão occipitocervical. A dor e o status neurológico melhoraram após a cirurgia, mas 3 meses após, o paciente evoluiu com vômitos persistentes, cefaleia e TC de crânio evidenciando hidrocefalia. Em seguida, foi realizada uma derivação ventriculoperitoneal, com melhora dos sintomas. Um ano após, o paciente permaneceu assintomático, e a radiografia demonstrou fusão óssea satisfatória. Em conclusão, o processo de tomada de decisão quanto ao tratamento deve levar em consideração diversos achados clínicos e radiográficos. A fixação occipitocervical é o tratamento de escolha, enquanto a hidrocefalia não é uma complicação incomum em crianças.

Traumatic Atlanto-Occipital Dislocation-A Comprehensive Analysis of All Case Series Found in the Spinal Trauma Literature.

BACKGROUND: Traumatic atlanto-occipital dislocation (TAOD) is one of the most devastating traumatic injuries, generally associated with immediate death after high-energy trauma. The aim of this study was to perform a systematic literature review of all cases series of TAOD and present the current state of this entity. METHODS: A systematic literature review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Only case series with at least 5 cases were included in the analysis. We focused on survival rates, diagnostic methods, delays in diagnosis, outcomes, and cases successfully treated nonoperatively. RESULTS: A total of 17 articles were included (16 retrospective and 1 prospective study) with 341 patients. Six studies included pediatric patients only. The mean Glasgow Coma Scale at admission was ≤8 in all studies. Many different diagnostic criteria were used, but none of them had high accuracy. The overall mortality rate was 34.8%, but the studies' designs were heterogeneous (some included only survivors). A high rate of concomitant traumatic brain injury was documented in some studies. We found it interesting that some patients were treated with cervical immobilization (37/341; 10.8%), which was generally used in less unstable injuries; however, the majority of patients were managed with an occipito-cervical fusion (193/341; 56.5%). CONCLUSIONS: TAOD is a devastating traumatic injury, with a high mortality rate. An MRI may be recommended when there are subtle findings of TAOD and a normal computed tomography scan, such as subarachnoid hemorrhage in the posterior fossa, upper cervical injuries, or consistent neurological findings. Further studies are necessary to identify patients with mild MRI findings and TAOD that may be managed nonoperatively.