Redislocation in a Halo Vest of an Atlanto-Occipital Dislocation in a Child: Recommendations for Treatment

Abstract

A case of a child with a traumatic atlanto-occipital dislocation (AOD), with unexpected secondary redislocation in a halo vest is presented. An extensive literature review was performed. To show the difficulties in diagnosing AOD, to emphasize its intrinsic instability, and to make recommendations for treatment of this condition. AOD is a rare condition that is difficult to diagnose. Because of the high neurologic morbidity, this injury often results in death. Different diagnostic approaches have been evaluated throughout the literature. Also, there are different opinions on how to treat AOD. There is no large trial that compares conservative treatment with surgery. A 4-year-old child with a longitudinal distraction of the head is described. Because of his tenuous medical condition, initial treatment was in a halo vest. However, redislocation occurred inside the vest, so surgical stabilization was performed as soon as the patient's condition allowed. To diagnose AOD, different measuring techniques can be applied on a lateral cervical spine radiograph. Using a combination of these tools, the sensitivity of the examination can be increased. There are 3 types of dislocation. Type II, which is a longitudinal distraction, is most unstable. Once confirmed, AOD should be immobilized. This can temporarily be performed with a halo-frame, but our case shows that this does not necessarily provide a stable situation, and early surgical reconstruction should be considered. AOD can be an extremely unstable lesion and is difficult to diagnose. Although initial treatment in a halo vest is recommended, redislocation can occur even in the vest. We recommend urgent surgical stabilization.