Management of traumatic atlanto-occipital dislocation in a 10-year-old with noninvasive halo immobilization: A case report

Abstract

Background: Traumatic atlanto-occipital dislocation is an unstable injury of the craniocervical junction. For pediatric patients, surgical arthrodesis of the occipitocervical junction is the recommended management. While having a high success rate for stabilization, the fusion comes with obvious morbidity of limitation in cervical spine flexion, extension, and rotation. An alternative is external immobilization with a conventional halo.

Case description: We describe the case of a 10-year-old boy who was treated successfully for traumatic AOD with a noninvasive pinless halo. Following initial brain trauma management, we immobilized the craniocervical junction with a pinless halo after reducing the atlanto-occipital dislocation. The pinless halo was kept on at all times for the next 3 months. The craniocervical junction alignment was monitored with weekly cervical spine X-rays and CT craniocervical junction on day 15^th, day 30^th, and day 70^th. A follow-up MRI C-spine 3 months from presentation confirmed resolution of the soft-tissue injury and the pinless halo was removed. Dynamic cervical spine X-rays revealed satisfactory alignment in both flexion and extension views. The patient has been followed up for 2 years postinjury and no issues were identified.

Conclusion: Noninvasive pinless halo is a potential treatment option for traumatic pediatric atlanto-occipital dislocation. This should be considered bearing in mind multiple factors including age and weight of the patient, severity of the atlanto-occipital dislocation (Grade I vs. Grade II and incomplete vs. complete), concomitant skull and scalp injury, and patient's ability to tolerate the halo. It is vital to emphasize that this necessitates close clinicoradiological monitoring.

Keywords: Atlanto-occipital dislocation; Children; Halo; Trauma.

Figure 1:

(a) CT brain shows intraventricular hemorrhage and hydrocephalus, (b) sagittal MPR shows the intraventricular hemorrhage and extensive extra-axial hematoma anterior to the brainstem and extending to cervical spine, and (c) CT brain (bone window) shows fracture of the right occipital condyle with medial displacement of fractured fragment.

Figure 2:

CT MPR showing increase in the basion-dens interval from 6 mm to 11 mm between the index CT and the D7 CTA, (b) CT MPR showing increase in the right C0C1 interval from 2 mm to 5 mm between the index CT and the D7 CTA, (c) CT MPR showing increase in the left C0C1 interval from 2 mm to 5 mm between the index CT and the D7 CTA, (d) MR cervical spine (midsagittal T2) shows apical ligament injury and intact tectorial membrane elevated by retroclival hematoma, and (e) MR cervical spine (parasagittal T2) shows C0C1 joint injury with hemorrhage.

Figure 3:

Intraoperative cervical spine lateral X-rays showing reduction in the basion-dens interval from 13 mm to 6 mm following reduction of the atlanto-occipital dislocation.

Figure 4:

Parasagittal MPR views of follow-up CT scans showing well-apposed right C0C1 joint.

Figure 5:

CT brain shows worsening in hydrocephalus post-CSF drainage withdrawal.

Figure 6:

Three-month MR showing healing of craniocervical junction injury and 3-month X-ray showing normal craniocervical junction alignment.