Traumatic Atlanto-Occipital Dislocation in Children
Evaluation, Treatment, and Outcomes
Nelson Astur, MD; Paul Klimo Jr., MD, MPH; Jeffrey R. Sawyer, MD; Derek M. Kelly, MD; Michael S. Muhlbauer, MD; William C. Warner Jr., MD


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.

Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.


  • Investigation performed at Le Bonheur Children’s Hospital, Memphis, Tennessee

  • Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

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