D. M. Filiberto1, J. P. Sharpe1, M. A. Croce1, T. C. Fabian1, L. J. Magnotti1 1University Of Tennessee Health Science Center,Surgery,Memphis, TN, USA
Introduction: Although rare, traumatic atlanto-occipital dissociation (AOD) injuries are considered highly unstable and are associated with a high mortality rate. In fact, these injuries were once believed to be uniformly fatal in adults. However, with recent advances in pre-hospital care coupled with early diagnosis and stabilization, these injuries are now potentially survivable. The purpose of this study was to evaluate the effect of rapid diagnosis and treatment (stabilization) of traumatic AOD following blunt injury in one of the largest single institutional series reported in the literature.
Methods: Patients with traumatic AOD following blunt injury treated over a 17-year period were identified from the trauma registry of a level I trauma center and stratified by age, gender, injury severity (as measured by Injury Severity Score [ISS] and admission Glasgow Coma Scale [GCS] score) and severity of shock (as measured by admission base excess [BE] and 24-hour transfusions). Time to diagnosis, time to and method of stabilization, and mortality were recorded and compared. Multivariable logistic regression (MLR) was performed to determine which risk factors were independent predictors of death following AOD.
Results: 52 patients were identified: 35 men (67%) and 17 women (33%) with a mean age, admission GCS and ISS of 44, 8 and 34, respectively. Mean admission BE was -7.7 with patients requiring on average 3.7 units of packed red blood cells over the first 24 hours. 30 patients (58%) underwent stabilization: 16/30 underwent fusion, 5/30 were fitted with an external orthosis and 9/30 had a combination of both. Overall mortality was 32.7%. 16 of the deaths (94%) were secondary to severe traumatic brain injury. 3 of the deaths (17.6%) were among those patients who had undergone stabilization. Of the survivors, 34 patients (97%) were discharged neurologically intact: 15 patients went home, 15 to a rehabilitation center and 4 to a skilled nursing facility. Only one patient was discharged with neurological deficits to a rehabilitation center. There were no missed or delayed diagnosis related to AOD over the study. MLR identified admission GCS (OR 0.7; 95%CI 0.552-0.877) as the only independent predictor of death in patients with AOD after adjusting for severity of shock, injury severity, and time to stabilization.
Conclusion: Traumatic AOD remains a relatively rare injury following blunt trauma. Prompt diagnosis is crucial in promoting rapid stabilization and contributing to increasing survivability. Traumatic AOD should no longer be considered a uniformly fatal injury in adults.