Atlanto-occipital Dislocation Research Articles

LUXAÇÃO TRAUMÁTICA ATLANTO-OCCIPITAL COM MELHORA DO DÉFICIT NEUROLÓGICO: RELATO DE CASO

ABSTRACT Traumatic atlanto-occipital dislocation is a rare, severe, and usually fatal injury. In this paper, we report the case of a 28-year-old patient with multiple trauma, who suffered an atlanto-occipital dislocation (AOD) associated with rotatory dislocation at C1-C2, condyle fracture and traumatic brain injury resulting from a car accident, with a cardiopulmonary arrest at the accident site. The patient had motor and sensory deficits, suffering other complications of clinical severity during hospitalization. After two years of surgical treatment follow-up, the patient had a complete recovery of neuromotor and sensory functions. This case demonstrates that neurological recovery with minimal sequelae is possible, even after an unfavorable prognosis resulting from a severe injury with a high risk of death as this kind of trauma. It is essential for health professionals to have the ability to identify and treat AOD, ensuring improved clinical outcomes, reducing mortality and morbidity, and providing a better life to affected patients. Level of Evidence IV; Cases Series.

Atlanto-occipital dislocation-A challenge with respect to making the diagnosis and treatment

The correct diagnosis and treatment of the atlanto-occipital dislocation (AOD) remains amajor challenge. To evaluate the different radiological diagnostic criteria for AOD and discuss potential treatment strategies based on acase with AOD and additional fracture of the atlas. A29-year-old male patient is presented who suffered from AOD with concomitant fracture of the anterior and posterior arches of the atlas with rotational atlantoaxial dislocation following an accident in forestry. The following parameters were evaluated for the diagnosis and assessment of postoperative reduction: Powers ratio, the X‑lines-method, Wackenheim line, basion-dens interval (BDI), basion-axial interval (BAI) and occipital condyle-C1 interval (CCI). Stabilization was performed by occipitocervical spondylodesis from C0 to C2/3. For final reduction it was necessary to reduce the malrotation of the atlas. In the presented case, the revised CCI proved to be asensitive and valid yet practical parameter. Powers' ratio and the BDI were less suited for assessing the diagnosis. The X‑lines-method, Wackenheim line and the BAI did not adequately detect the pathological situation. The AOD is asevere injury requiring immediate correct diagnosis for later adequate treatment results. Among the published parameters, the revised CCI proved to be apractical and valid parameter to detect AOD. For definitive treatment, the operative occipitocervical stabilization is regarded as the method of choice.

Reduction of Atlanto-Occipital Dislocation After Cervical Collar Removal

A 39-year-old male pedestrian-hit-by-car was transferred to our institution with atlantooccipital dislocation (AOD) on outside computed tomography (CT) imaging. On arrival he had a rigid cervical collar in place. Given the reported AOD, we placed the patient flat, removed the cervical collar, and supported the head in neutral alignment with sandbags. Due to a technical issue uploading his prior imaging to our system, the patient underwent repeat CTs at our center. Subsequently, after the outside images were uploaded, we were able to compare his cervical spine CT images before and after removing his cervical collar. On comparison, we noted a substantial reduction in AOD after collar removal. We hope this serves as a reminder of this key step in managing a rare but deadly clinical entity and a small demonstration of the efficacy of this intervention.

Congenital atlanto-occipital dislocation in a patient with Down syndrome: a case report

Down syndrome, also known as trisomy 21, is associated with congenital cervical spine abnormalities, including atlantoaxial instability with or without os odontoideum, atlanto-occipital instability, and hypoplasia of the atlas. Herein, we report a case of Down syndrome complicated by congenital atlanto-occipital dislocation. The patient presented with severe cervical myelopathy at 13 years of age after a 10-year follow-up. Radiography and computed tomography revealed os odontoideum protruding into the foramen magnum and congenital anterior atlanto-occipital dislocation. Additionally, a bifurcated internal occipital crest with a thinned central portion of the occipital bone was noted. Magnetic resonance imaging revealed kyphotic alignment of the spinal cord with severe compression at the foramen magnum level. As the neurological impairment was partially improved by halo vest immobilization, we performed in situ O-C2 fusion with an iliac autograft and decompression of the foramen magnum and posterior arch of C1. An improvement was observed immediately after surgery. Two years after surgery, radiography and computed tomography showed solid O-C2 segment fusion. The accumulation of similar cases is essential for determining the prognosis or optimal treatment for this rare congenital condition.

Atlanto-occipital dislocation with concomitant severe traumatic brain injury: A retrospective study at a level 1 trauma center

BackgroundTraumatic atlanto-occipital dislocation (AOD) is a life-threatening injury. Although traumatic brain injury (TBI) is associated with increased mortality in AOD patients, a detailed individual analysis of these patients is lacking in the literature. MethodsPatients ≥16 years old who were diagnosed of AOD with concomitant severe TBI from 2010 to 2020 were included in this retrospective study. We examined the epidemiology, injury mechanisms, associated injuries, and outcomes of these patients. ResultsEight patients were included. Six patients died before any intervention could be performed, and two patients underwent an occipito-cervical fixation, showing a notorious neurologic improvement on follow-up. Cardiorespiratory arrest (CRA) was a strong predictor of subsequent death. CT signs of diffuse axonal injury (DAI) were present in most patients and were confirmed by magnetic resonance imaging (MRI) in survivors. Although TBI was not the main cause of death, it was responsible for the delayed neurological improvement and deferred stabilization. The average sensitivity of the different used methodologies for AOD diagnosis ranged from 0.50 to 1.00, being the Basion Dens Interval (BDI) and the Condyle-C1 interval (CCI) sum the most reliable criteria. Non-survivors tended to show greater distraction measurements. The high incidence of condylar avulsion fractures suggests that their visualization on the initial CT study should heighten the suspicion for AOD. ConclusionsOur data suggest that patients with AOD and concomitant severe TBI might be salvageable patients. In those who survive beyond the first hospital days and show neurological improvement, surgical treatment should be performed as they can achieve an important neurologic recovery.

A Clue Supporting a Diagnosis of Atlanto-Occipital Dislocation Based on a Traumatic Vacuum Phenomenon.

Sir, The high spatial and densitometric resolution of computed tomography (CT) means that it frequently shows gas (vacuum phenomenon [VP]) in tissues. VP is observed at locations that experience traumatic impact; thus, an analysis of VP may be useful for elucidating the mechanism of injury.[1] The mechanism responsible for the formation of VP is as follows: if an enclosed tissue space is allowed to expand as a rebound phenomenon after an external impact, the volume within the enclosed space will increase. In the setting of expanding volume, the pressure within the space will decrease. The solubility of the gas in the enclosed space will decrease as the pressure of the space decreases. Decreased solubility allows a gas to leave a solution. We herein report a patient in whom VP was detected near the foramen magnum after blunt trauma that resulted in a successful diagnosis of atlanto-occipital dislocation. The patient was a 53-year-old man who suddenly crashed while motorcycling on a passing lane of a national route. He was thrown from the vehicle and hit a guardrail on the median. At 16 min from the first call, emergency medical technicians reached him. He was in cardiac arrest at the time, and the initial rhythm was asystole. Bystander basic life support was absent. He was bleeding from the nose and mouth. He was transported to the grounds of a nearby elementary school and evacuated by a physician-staffed helicopter. On arrival, he remained in cardiac arrest. He underwent resuscitative thoracotomy, but it failed to obtain the return of spontaneous circulation. Autopsy CT showed subarachnoid hemorrhaging at the basal cistern and posterior fossa. A sagittal view of the skull and cervical bone on CT did not show any fracture or dislocation. However, he had several small gas densities at the deep neck area near the posterior foramen magnum [Figure 1], so the complication of atlanto-occipital dislocation was suspected. Autopsy imaging of magnetic resonance imaging showed atlanto-occipital dislocation compressing the junction between the medulla and spinal cord [Figure 1].Figure 1: Sagittal view of computed tomography (CT, left and middle) with bony field and magnetic resonance imaging (MRI, short-tau inversion recovery image) on arrival. The CT showed several small gas densities (white triangle) at the deep neck area near the posterior foramen magnum without fracture or dislocation. MRI showed atlanto-occipital dislocation (black triangle) compressing the junction between the medulla and spinal cord. The airway was shifted frontally by a hematoma (star). CT: Computed tomography, MRI: Magnetic resonance imagingThis is the first case report, wherein VP near the foramen magnum was a clue supporting a diagnosis of atlanto-occipital dislocation. The diagnosis of atlanto-occipital dislocation by imaging is not easy, and indeed, one report showed no correct diagnoses of atlanto-occipital dislocation when patients were in cardiac arrest.[2,3] Overlooking atlanto-occipital dislocation can result in a fatal outcome.[4] Accordingly, physician should strongly suspect the complication of atlanto-occipital dislocation when patients have traumatic VP near the foramen magnum on CT. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent form. In the form, the patient’s family has given his consent for his image and other clinical information to be reported in the journal. The patient’s family understands that his name and initial will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed. Research quality and ethics statement The authors followed applicable EQUATOR Network (https:// www.equator-network.org/) guidelines, notably the CARE guideline, during the conduct of this report. Financial support and sponsorship This work was supported in part by a Grant-in-Aid for Special Research in Subsidies for ordinary expenses of private schools from The Promotion and Mutual Aid Corporation for Private Schools of Japan. Conflicts of interest There are no conflicts of interest.

Case report: 3D-printed model for surface mould preparation on a patient with Down’s syndrome

Abstract Introduction: A patient with Down’s syndrome, with dermatofibrosarcoma protuberans, was intended for adjuvant radiotherapy. The lesion was on the parietal region of the head of the patient. Given the proximity of the lesion to the brain, the curvature of the lesion, and potential complications of anaesthesia for a Down’s syndrome patient, brachytherapy was the appropriate treatment. Anaesthesia complications for patients with Down’s syndrome are airway infections, atlanto-occipital dislocation and bradycardia. Method: Instead of sedating the patient in order to prepare a mould applicator, a 3D-printed model of the patient’s head was used. This allowed us greater time to prepare the applicator in a more relaxed environment. Result: The fit of the mould applicator on the patient was satisfactory. Minimum air gaps were observed. The treatment could be completed with sedation only. Conclusion: We were able to achieve an equivalent dose of 44·69 Gy in 5 sessions of brachytherapy, significantly reducing the anaesthesia sessions and the associated risks. A drawback of 3D printing is that it takes several hours to print the model.

Atlanto-occipital dislocation with concomitant severe traumatic brain injury: A retrospective study at a level 1 trauma center

Traumatic atlanto-occipital dislocation (AOD) is a life-threatening injury. Although traumatic brain injury (TBI) is associated with increased mortality in AOD patients, a detailed individual analysis of these patients is lacking in the literature. Patients ≥16 years old who were diagnosed of AOD with concomitant severe TBI from 2010 to 2020 were included in this retrospective study. We examined the epidemiology, injury mechanisms, associated injuries, and outcomes of these patients. Eight patients were included. Six patients died before any intervention could be performed, and two patients underwent an occipito-cervical fixation, showing a notorious neurologic improvement on follow-up. Cardiorespiratory arrest (CRA) was a strong predictor of subsequent death. CT signs of diffuse axonal injury (DAI) were present in most patients and were confirmed by magnetic resonance imaging (MRI) in survivors. Although TBI was not the main cause of death, it was responsible for the delayed neurological improvement and deferred stabilization. The average sensitivity of the different used methodologies for AOD diagnosis ranged from 0.50 to 1.00, being the Basion Dens Interval (BDI) and the Condyle-C1 interval (CCI) sum the most reliable criteria. Non-survivors tended to show greater distraction measurements. The high incidence of condylar avulsion fractures suggests that their visualization on the initial CT study should heighten the suspicion for AOD. Our data suggest that patients with AOD and concomitant severe TBI might be salvageable patients. In those who survive beyond the first hospital days and show neurological improvement, surgical treatment should be performed as they can achieve an important neurologic recovery. La luxación atlantooccipital (AOD) traumática es una lesión potencialmente mortal. Aunque el traumatismo craneoencefálico (TCE) se asocia con un aumento de la mortalidad en los pacientes con AOD, no existe en la literatura un análisis individual detallado de estos pacientes. En este estudio retrospectivo se incluyeron pacientes mayores de 16 años que fueron diagnosticados de AOD con TCE grave concomitante durante el periodo 2010-2020. Estudiamos la epidemiología, los mecanismos lesionales, así como las lesiones asociadas y los resultados de estos pacientes. Se incluyeron ocho pacientes. Seis pacientes fallecieron antes de que se pudiera realizar cualquier intervención y dos pacientes fueron sometidos a una fijación occipitocervical, mostrando una notoria mejoría neurológica durante el seguimiento. La parada cardiorrespiratoria fue un predictor de muerte. En la TC inicial, signos de lesión axonal difusa estaban presentes en la mayoría de los pacientes y se confirmaron mediante imágenes de resonancia magnética en los supervivientes. Aunque el TCE no fue la principal causa de muerte, fue responsable de una mejoría neurológica tardía y por ello una estabilización diferida. La sensibilidad de las diferentes metodologías utilizadas para el diagnóstico de AOD osciló entre 0,50 y 1,00, siendo el intervalo Basion Dens y la suma del intervalo Condylo-C1 los criterios más fiables. Además, los no supervivientes presentaban mayores medidas de distracción. La alta incidencia de fracturas de cóndilo por avulsión sugiere que su visualización en el estudio de TC inicial debería aumentar la sospecha de AOD. Nuestros datos sugieren que los pacientes con AOD y TCE grave concomitante podrían ser pacientes salvables. En aquellos que sobreviven más allá de los primeros días de hospitalización y presentan mejoría neurológica, se debe considerar realizar un tratamiento quirúrgico ya que pueden lograr una importante recuperación neurológica.

Fatal blast injuries in tyre blowouts: two autopsy case reports

BackgroundFatal blast injuries are generally reported as a consequence of explosions, mainly in terrorist events, work-related detonations, or domestic settings. Although quite rare, blast injuries of high kinetic energy can be seen in tyre blowouts and are very dangerous and potentially lethal because of their unpredictability. This phenomenon is rarely reported in the existing forensic literature.The aim of this study was to report two cases of fatal truck tyre bursts and to discuss the mechanisms leading to the burst and the pattern of injuries.Case presentationsCase 1 was of a 58-year-old truck driver man who was standing nearby a detached tyre that was being inflated in a repair shop when the burst occurred. The tyre struck him in the face and threw him. The medicolegal autopsy showed a right periorbital haematoma, a large wound of the left parietal scalp, a diffuse subarachnoid haemorrhage, an atlanto-occipital dislocation, a fracture of the hyoid bone, multiple rib fractures, and lacerations of the ascending aorta and the pulmonary arteries. Case 2 involved a young man of 24-year-old, a worker in a tyre repair shop, who was inflating a truck’s tyre when it burst violently. The injuries sustained included bleeding from the right ear, fractures of the facial bones, a left hemispheric subdural haematoma associated with the fracture of the skull base, a rib fracture, and diffuse areas of contusions to the lungs. Toxicological analyses were negative in both cases.ConclusionFatalities related to tyre blowout accidents are uncommon. The mechanisms leading to a blowout can be mechanical or chemical in origin, and the main danger of a burst often occurs when air enters the tyre during inflation. Internal damage caused by the pressure waves of the blast often exceeds what would be expected based on external signs alone.

Evaluation of U-Net models in automated cervical spine and cranial bone segmentation using X-ray images for traumatic atlanto-occipital dislocation diagnosis

Segmentation of the cervical spine in tandem with three cranial bones, hard palate, basion, and opisthion using X-ray images is crucial for measuring metrics used to diagnose traumatic atlanto-occipital dislocation (TAOD). Previous studies utilizing automated segmentation methods have been limited to segmenting parts of the cervical spine (C3 ~ C7), due to difficulties in defining the boundaries of C1 and C2 bones. Additionally, there has yet to be a study that includes cranial bone segmentations necessary for determining TAOD diagnosing metrics, which are usually defined by measuring the distance between certain cervical (C1 ~ C7) and cranial (hard palate, basion, opisthion) bones. For this study, we trained a U-Net model on 513 sagittal X-ray images with segmentations of both cervical and cranial bones for an automated solution to segmenting important features for diagnosing TAOD. Additionally, we tested U-Net derivatives, recurrent residual U-Net, attention U-Net, and attention recurrent residual U-Net to observe any notable differences in segmentation behavior. The accuracy of U-Net models ranged from 99.07 to 99.12%, and dice coefficient values ranged from 88.55 to 89.41%. Results showed that all 4 tested U-Net models were capable of segmenting bones used in measuring TAOD metrics with high accuracy.

Management of Traumatic Atlantooccipital Dissociation at a Level 1 Trauma Center: A Retrospective Case Series

Atlantooccipital dislocation (AOD) is a highly unstable and often neurologically devastating injury to the craniocervical junction that typically results from high-energy trauma. Management of these devastating injuries is complex, with prognostication difficult due to high rates of concomitant intracranial and systemic injuries. This report highlights advances in management of AOD andappropriate implementation of operative adjuncts including neuronavigation and the use of intraoperative neuromonitoring. All patients with AOD presenting to a high-volume, level 1 trauma center between January 2015 and August 2021 were retrospectively identified through a prospectively maintained database of patients presenting with traumatic spine injuries. Medical records, including imaging reports, clinical documentation, and intraoperative neurophysiological reports were reviewed. A total of 11 patients were identified with patterns of injury consistent with AOD. Fifty-five percent of patients survived until discharge. 73% of patients underwent surgery for stabilization. All 4 patients with preoperative neurologic deficits who underwent surgery had monitorable transcranial motor evoked potentials and somatosensory evoked potentials. Two experienced significant motor recovery postoperatively, and 2 did not survive to discharge. Blunt cerebrovascular injuries were identified in 73% of patients. AOD is encountered with increasing frequency. The identification and management of this specific injury is complicated by the volume and severity of associated injuries, especially concomitant traumatic brain injury. Timely recognition is critical and the use of surgical adjuncts including intraoperative neurophysiologic monitoring and surgical navigation can increase the safety and success of these procedures while also providing prognostic information on potential for motor recovery.

Traumatic Atlanto-occipital Dislocation in Children Followed by Hydrocephalus – A Case Report and Literature Review

AbstractTraumatic 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 C1–C2 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 hydrocephalus is not an unusual complication in children.

Injury patterns in motor vehicle collision-pediatric pedestrian deaths

Objective To describe fatal pediatric pedestrian injury patterns and correlate them with motor vehicle collision (MVC) characteristics and pedestrian kinematics using data from medicolegal death investigations of MVCs occurring in the current Canadian MV fleet and determine the applicability of the classical “Waddell’s triad” comprising knee, hip (femur) or pelvis and craniocerebral injuries to present data injury patterns. Methods An Injury Data Collection Form was used to extract MV, MVC, pedestrian demographic and injury information from the Office of the Chief Coroner for Ontario database using autopsy data from 2013 to 2018. Injuries were coded using the Abbreviated Injury Scale (AIS) 2015 revision. The study focused on AIS ≥3 injuries utilizing the Maximum Abbreviated Injury Scale (MAIS), MAIS by Body Region (MAISBR) and Injury Severity Score (ISS). Results Between 2013 and 2018, there were 25 pediatric deaths. The pedestrians were either struck and run over (n = 17, 68%; 56% low speed) or struck and projected (n = 8, 32%). Twenty-two deaths were from frontal impacts; three were from reversing vehicles. Fourteen of the 17 (82.4%) run over cases occurred at low speed (<30 km/h). In 9 (36%) cases, the vehicle was turning at impact (right n = 3, left n = 6). A majority of the vehicles had a high hood edge. The head was the most severely injured (median MAISBR = 5 overall and ≤10 years; median MAISBR = 6 for 11–14 years old) followed by the neck (MAISBR = 3 overall; 6–14 years old), and the thorax (median MAISBR = 3 overall; all age groups). For the early adolescents (11-14 years old), the serious injury pattern included the abdomen (median MAISBR = 3.5). Nearly half (n = 11, 44%) sustained brainstem injuries. Over fifty percent of the 16 cases with neck injuries (n = 9, 56.3%) had atlanto-occipital or axial dislocation. Conclusion More than half of the deaths occurred during low speed run overs. MAIS ≥3 injuries trended to a dyad of head and thorax in ≤5 years old, a triad of head, neck, and thorax injuries in children 6–10 years old and a tetrad with the addition of abdominal injuries in pedestrians ≥11 years old. Waddell’s triad was not applicable to the fatal cases in the present study.

189. Radiographic predictors of mortality following atlanto-occipital dissociation

189. Radiographic predictors of mortality following atlanto-occipital dissociation

Upper cervical spine instability systematic review: a bibliometric analysis of the 100 most influential publications.

Instability in the upper cervical spine, although rare, can be devastating. This spectrum of conditions includes occipitocervical instability, atlantoaxial instability and atlantoaxial rotatory displacement. Knowledge of the literature can provide better understanding of disease processes and management, and aid in clinical decision making. The objective of this study was to perform a bibliometric analysis to formulate a comprehensive review of the most cited publications. A systematic search of the literature was conducted using the Clarivate Web of Science database. The search query was '"Atlanto-occipital dislocation" OR "atlanto-occipital dissociation" OR "atlantoaxial rotatory displacement" OR "atlantoaxial instability"'. The top 100 articles based on frequency of citation were included in our study. Data extracted from articles included frequency of citation, year of publication, country of origin, journal of publication, level of evidence and article type. Our initial search yielded 257 results that met the criteria. Articles not pertaining to atlanto-occipital instability were removed. Citation frequency ranged from 15 to 195. The most cited article was "Traumatic Anterior Atlanto-Occipital Dislocation" published by Powers et al. in 1979. The most productive decade was 2000-2009 with 45 publications. All decades showed a progressive increase in the number of papers published except for 2010-2019. Overall, 19 countries contributed and the most productive was the United States (n=61). The articles found in our search were cited a total of 4,095 times (3,463 without self-citations) averaging 40.95 citations per publication. The goal of a bibliometric study is to assess trends in a specific field of study, provide evidence for the impact of an individual or field of study's research, and highlight potential areas for future research. While the number of citations does not necessarily reflect publication quality, it reflects overall influence based on recognition by peers in the field. Publications from the last 20 years have emphasized the use of newer technologies such as computed tomography (CT) and magnetic resonance imaging (MRI) to aid in diagnosis. Our study highlights the lack of high-level evidence articles and underscores that our understanding of these conditions in both pediatric and adult patients is maturing.

Factors Affecting the Outcomes of Traumatic Atlanto-Occipital Dislocations in Adults: A Systematic Review

The objectives of this study were to conduct a systematic review of the literature to determine the optimal treatment method for patients with atlanto-occipital dislocation (AOD) and to identify possible factors influencing their outcomes. We conducted a systematic review of the PubMed database between January 1966 and December 2020. The main inclusion criterion was articles that discussed AOD treatment methods, and outcome descriptions were selected for analysis. Intergroup differences were assessed using nonparametric statistical methods. Of the 657 articles identified initially, only 54 met the inclusion criteria, resulting in data from 139 patients. Type I or II AODs were more frequent in patients injured in road traffic accidents, whereas type III AODs were more frequent in patients with catatrauma (P=0.027). Spinal cord injury was more frequently observed in patients with types I and II AODs than in those with type III AOD (P=0.026). Improved outcomes were more common in the surgical treatment group (P<0.001). Significant differences in treatment outcomes between the halo device and orthosis groups were not observed (P=0.32). Prognosis of AOD is unfavorable in adults with dislocations resulting from road traffic accidents, those with types I and II AOD, and patients younger than 22years and older than 47years. Surgical treatment was optimal for adult patients with an AOD, and treatment outcomes did not depend on the number of occipitocervical fusion levels. Immobilization with the halo device showed no advantages over use of an external orthosis.

A Case of Traumatic Vertical Atlanto-occipital Dislocation

Advances in both critical care medicine and diagnostic imaging have allowed increased recognition of traumatic atlanto-occipital dislocation (AOD). AOD is often overlooked due to severe coexistent complications, and even in cases with mild concomitant complications, AOD may be overlooked because of its anatomical specificity. Here we report a case of traumatic AOD in a 38-year-old woman. She had fallen from the 4th floor of a building and was unconscious on arrival at the hospital, with a Glasgow Coma Scale score of E1V1M1. In the emergency ward, a chest drain was inserted for left traumatic hemopneumothorax. After her vital signs had stabilized, clinical and radiological workups revealed traumatic AOD with subarachnoid hemorrhage at the craniocervical junction. Furthermore, multiple rib fractures, traumatic aortic dissection, T10 burst fracture, and dislocation of the temporomandibular joint were diagnosed. After intensive care treatment, the patient regained consciousness and could move her limbs fully except for the left deltoid muscle (manual muscle test, 4/5). Fixation was performed for the ribs and thoracic burst fracture before occipital-C2 fusion. She was able to walk and manage all activities of daily living after 2 months of clinical treatment and rehabilitation. As emergency medicine and care continue to develop, survival after AOD will increase, meaning that immediate and appropriate diagnosis and treatment will be increasingly important. Traumatic subarachnoid hemorrhage at the craniocervical junction is often complicated by AOD. This is important to keep in mind for doctors who do not specialize in pathologies of the spinal cord.

Actual concepts of classification, diagnosis and treatment of atlanto-occipital dislocations in adults: non-systematic literature review

Objective. To review the literature on atlanto-occipital dislocation (AOD) in adults to determine the optimal classification, diagnostic method and treatment.Material and Methods. A search was conducted in the PubMed database for the period from 1966 to 2020. The initial search revealed 564 abstracts of articles. A total of 95 studies were selected for a detailed study of the full text, of which 47 studies describing data from 130 patients were included in this review.Results. The paper describes all the available AOD classifications, and discusses their advantages and disadvantages. The clinical picture, features of the diagnosis in published observations of AOD in adults, as well as the applied treatment methods and their results are presented.Conclusion. Atlanto-occipital dislocation is one of the most severe types of injuries of the cervical spine in adults, which is accompanied by damage to the medulla oblongata and gross neurological deficit in 70 % of cases. The sensitivity of radiography for the diagnosis of AOD was 56.3 %. In 18.5 % of patients, its use led to untimely diagnosis and could cause subsequent deterioration. The CT sensitivity was 96.8 %. The most accurate method of AOD verification was to determine the atlanto-occipital interval (100 % sensitivity and specificity). The optimal method of treating victims with AOD is surgical one.

Analysis of features of frontal collision of class D cars

Currently, there is a significant increase in road accidents, which can be associated with an increase in the number of cars, the condition of roads in the country and compliance with road discipline by road users. Modern automotive industry pays great attention to road safety. This is ensured by changes in the design of car interiors, which significantly affects the nature of injuries to victims of road accidents. That is why the solution of this issue has become extremely relevant for forensic expert practice.&#x0D; Aim of the work. To establish the characteristic injuries of the driver and passenger in the cabin of class D cars in a frontal collision.&#x0D; Material and methods. The analysis of road accidents from 2008 to 2021 in Zhytomyr, Rivne, Volyn regions of Ukraine is carried out. Cases of a fatal head-on collision with a driver and passenger in the front seat of a car with an engine capacity of 2-2.5 liters up to 4.7 meters long and 1.81 meters wide were considered. General and special methods used: system-structural analysis, observation, comparison, description. In addition, a forensic examination of the damage was conducted. Statistical analysis included primary data processing by descriptive statistics methods and null hypothesis testing by multifactor analysis.&#x0D; Results. A number of new features have been identified, which are inherent in the damage received in the cabin of a class D car, which can help to identify during the forensic examination. In particular, you should pay attention to the presence of neck injuries. According to the literature, injuries of the cervical spine are among the key and include: rupture of the atlanto-occipital ligament, dislocation and subluxation of the atlanto-axial joint, damage to the spinal cord and its membranes.&#x0D; Conclusions: The location and morphological features of spinal injuries can be used as diagnostic criteria in determining the location of the victim in the cabin of a mobile car class D in a frontal collision. The most informative is the analysis of injuries of the cervical spine of the driver and front passenger.

Cervical Myelopathy Caused by Posttraumatic Osteophytes Resulting From Long-Standing Neglected Posterior Atlanto-Occipital Dislocation More Than 30 years: A Case Report

Introduction:Traumatic atlanto-occipital dislocation (AOD) is a rare but usually fatal injury. To our knowledge, no study has reported long-standing neglected posterior AOD more than 30 years in a patient who survived and later experienced cervical myelopathy.Methods:A 75-year-old man presented with symptoms of cervical myelopathy. On history, the patient was diagnosed with posterior AOD that occurred after a fall 31 years ago, but he did not undergo surgery. Radiologic evaluation of cervical spine revealed severe spinal cord compression caused by posttraumatic osteophytes of the C0-C1-C2 joints resulting from long-standing neglected posterior AOD. However, no instability of the C0-C1-C2 joints was found.Results:Laminectomy of the C1 posterior arch was performed without occipitocervical fusion considering the long-standing severe osteoarthritic changes and no instability of the C0-C1-C2 joints. Cervical myelopathy significantly improved, and the patient was doing well without recurrence at the 7-year follow-up.Discussion:To our knowledge, this is the first report of a patient with cervical myelopathy caused by neglected posterior AOD with posttraumatic osteophytes of the C0-C1-C2 joints. Laminectomy of the C1 posterior arch without occipitocervical fusion achieved satisfactory outcomes for cervical myelopathy caused by posttraumatic osteophytes resulting from long-standing neglected posterior AOD more than 30 years.