1345. Traumatic Occipitocervical Distraction Injuries in Children: A Review of the Literature and the Identification of Factors that Determine Injury Severity

Authors: Irene Say, MD; Andrew Hale, MS; Smit Shah, BA; Michael Dewan, MD; Luke Tomycz, MD; Richard Anderson (Newark, NJ)

Introduction: Occipitocervical distraction injuries (OCDI) in children occur on a wide spectrum of severity, and decisions about treatment suffer from a lack of rigorous guidelines and significant inter-institutional variability. While frank atlanto-occipital dislocation (AOD) is treated with surgical stabilization, the approach to less severe cases of OCDI is not standardized. These patients require a careful assessment of radiographic and clinical criteria, with a complex risk-benefit analysis, to determine whether occipitocervical fusion is indicated. Methods: We performed a systematic literature review of all available reports of pediatric traumatic OCDI in the neurosurgical literature, according to PRISMA guidelines, of children <18 years of age. We queried PubMed to identify manuscripts congruent with these criteria. Exclusion criteria included 1) atraumatic OCDI and 2) insufficient clinical and radiographic patient details. Results: We identified sixteen reports describing 144 patients with pediatric traumatic occipitocervical distraction injury (OCDI) treated with occipitocervical fusion. Based on these findings and the authors' collective experience, we propose demographic, clinical, and radiographic factors underlying OC instability, to serve as components for a grading system. We considered clinical and radiographic findings including 1) mechanism of injury, 2) patient age, 3) CT/CTA findings and parameters, 4) MRI findings, and 5) neurologic exam to determine the severity of the OCDI and offer treatment guidelines based on the summative risk of underlying OC instability. Conclusion: OCDI is a potentially devastating injury, especially in children. Although missing the diagnosis can be catastrophic, reverting to surgical fixation in less severe cases subjects children to unnecessary operative risk and permanently reduces their range of motion. After reviewing all available reports of pediatric traumatic OCDI in the neurosurgical literature, we propose an outline of clinical and radiographic factors influencing underlying OC instability that can be incorporated into a treatment scoring system.