Elsevier

World Neurosurgery

Volume 83, Issue 6, June 2015, Pages 1180.e1-1180.e6
World Neurosurgery

Case Report
Acute Traumatic Cervical Cord Injury in Pediatric Patients with os Odontoideum: A Series of 6 Patients

https://doi.org/10.1016/j.wneu.2014.12.036Get rights and content

Objective

Os odontoideum can lead to instability of the atlantoaxial joint and places the spinal cord at significant risk for acute traumatic catastrophic events or chronic neurologic change. The purpose of this study was to retrospectively review acute cervical cord injury after minor trauma in 6 pediatric patients with os odontoideum.

Methods

Between 2012 and 2013, 6 pediatric patients with os odontoideum who suffered acute traumatic cervical cord injury were reviewed retrospectively. Their clinical history, neurologic symptoms, radiological investigations, follow-up period, American Spinal Injury Association (ASIA) impairment classification, and motor score were reviewed.

Results

There were 2 male and 4 female subjects ranging in age from 4 to 18 years (mean 11.8 years). Before the traumatic injury, 2 cases were asymptomatic and 4 complained of myelopathic feature with unsteadiness on feet. Falls were the most common injury (n = 5), followed by a minor motor vehicle accident (n = 1). Atlantoaxial instability and cord compression were presented in all cases with dynamic cervical lateral radiographs and magnetic resonance imaging. Most patients presented with spinal cord thinning and hyperintensity on T2-weighted sequences in magnetic resonance imaging. Spinal cord compression was anterior in 2 cases and both anterior and posterior in 4. Two patients was classified as ASIA B, 1 as ASIA C, and 3 as ASIA D category on admission. Two patients presented with respiratory failure with mechanical ventilation for over 2 weeks in perioperative period. Postoperatively, all patients improved neurologically and clinically after underwent posterior atlantoaxial fixation and fusion.

Conclusions

Pediatric patients with asymptomatic or myelopathic atlantoaxial instability secondary to os odontoideum are at risk for acute spinal cord injury even after minor traumatic injury. Sufficient fixation and fusion should be undertaken as prophylactic treatment of developing myelopathy and to improve neurologic symptoms with acute traumatic cervical cord injury in pediatric patients with os odontoideum.

Introduction

Os odontoideum is an abnormality of the upper cervical spine in which the odontoid process is a separate ossicle from the body of the axis. This abnormality occurs as a result of a congenital defect or trauma and also may result from fracture of the odontoid synchondrosis before closure at 5–6 years of age. Os odontoideum can lead to instability of the atlantoaxial joint, placing the spinal cord at significant risk for acute catastrophic events. Several authors have reported detailed series of patients with os odontoideum who do not have a history of trauma 11, 13, 30, 31. Trauma has been clearly noted to be a contributing factor in both adult and pediatric patients 6, 8, 9, 10, 15, 23. However, acute traumatic severe cervical cord injury has not been reported in pediatric patients with os odontoideum. We present 6 pediatric cases with os odontoideum who experienced acute cervical cord injury as a result of minor trauma. The purpose of this study was to review retrospectively our experience of acute cervical cord injury and to evaluate surgical management in pediatric patients.

Section snippets

Materials and Methods

Between 2012 and 2013, 17 patients with os odontoideum were admitted to the investigator's group (Z.Z.). We retrospectively reviewed 6 pediatric patients with trauma who had been managed initially by the emergency department and were transferred for surgery because of os odontoideum and acute spinal cord injury. Eleven adult patients were excluded from the study because they presented with progressive neurologic injury without cervical trauma. There were 2 male and 4 female patients ranging in

Results

Clinical data are summarized in Table 1 and Figure 1. All patients had no history of cervical trauma. Before the traumatic injury, 2 patients were asymptomatic and 4 patients had experienced neurologic symptoms with unsteadiness on feet. Falls accounted for the trauma in 5 patients and motor vehicle accident in 1. Falling down at a sports class was the most common in patients with unsteadiness on feet (4 cases). For the patient (case 3) who involved in motor vehicle accident, injury was

Illustrative Patient (Case 4)

An 11-year-old girl was admitted with quadriparesis after a minor cervical injury that occurred after a fall to the ground at a sports class. Neurologic examination revealed bilateral upper limb and lower limbs weakness (ASIA B). Findings of the CT scan revealed os odontoideum, atlantoaxial instability, and spinal cord compression from posterior and anterior. This abnormality was not reported initially in her previous hospital records; however, she complained unsteadiness on her feet

Discussion

Atlantoaxial instability secondary to os odontoideum leads to a high risk of potential acute spinal cord injury after minor trauma. Previously, os odontoideum was not able to be well illustrated on cervical spine radiographs, and it was reported to cause fatal high cervical spinal cord injury and death after a low-speed collision in several previously healthy patients without apparent injury 19, 20. A delay in diagnosis is not uncommon because patients often are asymptomatic or present with

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    Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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