The majority of atlanto-occipital (AO) dislocations result in death at the scene of injury. Survivors, as noted above, may have severe brainstem, upper cervical-spinal cord and lower cranial-nerve injuries, as well as head injury. This diagnosis is often missed in the resuscitation phase of care. Suspicion should arise for any child with severe mechanism of injury (e.g., pedestrian vs. car), intermittent respiratory or blood pressure instability, and lower cranial-nerve abnormalities. Great care should be taken in the management of these patients to avoid any distracting force (sometimes even placement in too large of a cervical collar can result in deterioration).
Lateral X-ray films may demonstrate anterior or posterior translation of skull-base landmarks relative to the ring of C1 (Power's ratio) or longitudinal distraction of the skull from the cervical spine (base of clivus to dens interval of >14 mm). A CT scan extending to C3 is critical in making the diagnosis in less severely injured patients who are still at serious risk of secondary injury from craniocervical junction instability. Soft-tissue swelling and/or subarachnoid or subdural hemorrhage at the craniocervical junction are generally present. Immediate halo-ring and vest placement with relative craniocervical compression is indicated. Severe craniocervical ligamentous injury is the rule, mandating operative fusion of the occipital bone to C3 in most cases.
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