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Tue May 12 13:20:13 BST 2009

Numbers please, Dr. Mattox?

A quick Google and Medscape search  shows that the most recent article had 
a series of six cases, over the  space of 12 months prior to submission for 
publication, admittedly covering only  survivors: 

Internal Decapitation: Survival After Head to  Neck Dissociation Injuries
Ben-Galim, Peleg J. MD; Sibai, Tarek A. MD; Hipp,  John A. PhD; Heggeness, 
Michael H. MD, PhD; Reitman, Charles A. MDSpine: 

Spine 15 July  2008 - Volume 33 - Issue 16 - pp 1744-1749
doi:  10.1097/BRS.0b013e31817bb0e0

salient points from this article:

<block quote>
The injury patterns in 5 cases were the result  of high energy motor 
vehicle accidents. One case resulted from low energy trauma  with underlying joint 
instability. The final event leading to medical evaluation  included a 
distraction-type mechanism of injury in all cases.
</block quote>

<block quote>
Clinical findings included limited painful  guarding of neck motion in all 
cases and visible external soft tissue swelling  about the upper neck that 
was apparent in two cases
</block quote> 

and

<block quote>
However, prevertebral soft tissue shadows  [on plain film lateral c spine] 
were greater than normal. Computed  tomography (CT) scan was more revealing, 
and with critical review, some  abnormality was seen in all cases, 
although, most often the osseous  abnormalities were subtle and underestimated the 
true extent of injury. The  hallmark of these injuries was extensive soft 
tissue disruption of the upper  cervical motion segments
</block quote>

which means that a physician with a high index  of suspicion from mechanism 
of injury (high speed unrestrained MVC, history of  joint instability), AND 
the patient failing protocols such as the Nexus critera,  AND evidence of 
prevertebral soft tissue swelling, wouldn't have missed any of  the patients 
listed.

An experienced EP should be able to recognize  all of those factors and 
make the appropriate referral.

This article goes on to point out:

<block quote>
It is estimated that 10,000 new cases of spinal  cord injury occur each 
year in the United States, of which 35.9% are caused by  vehicle crashes with 
annual aggregate direct costs of $3.48 billion._[4]_ 
(javascript:newshowcontent('active','references');)   Approximately 5% to 10% of unconscious 
patients, who present to the ED as a  result of a motor vehicle accident or a fall, 
may have a major injury to the  cervical spine
</block quote>

<block quote>
Less than 100 severe occipitocervical injury  survivors have been 
reported._[1]_ (javascript:newshowcontent('active','references');)  The true  
incidence is uncertain and 2 series of postmortem evaluation of victims of motor  
vehicle collisions attributed death to occipitocervical injury in 
approximately  39% of the cervical injury cases studied
</block quote>

They further go on to say:

<block quote>
It was evident in retrospect that for these  injuries, the amount of 
protection afforded by active muscle control was  remarkably substantial, and this 
stability was completely abolished once the  patient was placed under 
anesthesia.
</block quote>

Which argues against heavy sedation in patients  with the potential for 
this kind of injury AND for a higher index of suspicion  in patients with a 
compromised level of consciousness.

The take home lesson from this article is that  proper in line 
stabilization DOES include prevention of rotation and flexion and  DOES NOT include 
traction (including the use of oversized cervical collars),  especially in 
patients who are mentally compromised AND that emergent  neurosurgical and MRI 
evaluation should be considered in patients where there is  a suspicion of 
high cervical injury (gee, that sounds like something that ATLS  has been 
teaching for 20 years or more...).

In the next listed article, 16 more cases were  reported during the period 
1986-2003 in: 
Traumatic Atlanto-Occipital  Dislocation  in Children 
<NOBR>Harish S. Hosalkar1, , <NOBR>Eric L. 1, , <NOBR>David  1, , 
<NOBR>Kingsley R. 2,  ,  <NOBR>John P. D1 and  and <NOBR>Denis S. Dru1 

The Journal of Bone and Joint Surgery  (American). 2005;87:2480-2488.
doi:10.2106/JBJS.D.01897

the results of this retrospective  study?
<block quote>
Results: The  mean age of  the  sixteen patients at the  time of the  
injury was 7.6  years.  The  mechanisms of  injury were diverse. The  mean 
Glasgow Coma Scale score was 7.4  points.  Eleven of the  sixteen patients 
underwent intubation in the  field, two were intubated in the  emergency 
department, and  three were not intubated.  Eight of  the  sixteen patients were 
declared dead on arrival in the  emergency department.  The  eight surviving 
patients initially were immobilized with either  a halo vest or another  
orthosis.  All patients except one received intravenous steroids in the  emergency 
department.  Three of  the  patients who survived the  initial injury 
subsequently died while undergoing neurosurgical  procedures for the  treatment of 
 extensive intracranial injuries.  Four of  the  remaining five survivors 
underwent occiput-C2 fusion, and  one was managed with a Minerva cast.  At 
the  time of  the  final follow-up, at a mean of  4.2  years after the  
injury, one patient was neurologically normal, three had mild  spastic hemiparesis 
and  were very functional, and  one had spastic quadriplegia and  was 
ventilator-dependent.

</block quote>

so in two articles we have a total of 22 cases  (or about 1/5th of all 
reported cases) covering at least a 10 year period.  Of those 22 cases, 8 were 
DOA, three had hemiparesis but were functional, two  had significant 
quadriplegia, and the remaining six were neurologically intact.  While not 
vanishingly rare in the overall scheme of things, in all but the  largest trauma 
centers, most EPs and trauma surgeons will see at worst a handful  of these 
cases in a long career.

Given appropriate in line immobilization by  the first responders and 
paramedics, adequate suspicion on the part of the EP, a  decent history from and 
physical exam of the patient, and proper evaluation of  imaging studies, 
prevention of catastrophic results in patients who arrive to  the ED 
neurologically intact is possible. That being said, AO injuries (internal  
decapitation) are by nature critically unstable, and even a sneeze by the  patient can 
cause irreparable damage or even death. 

ck
Charles S. Krin, DO

In a message dated 5/12/2009 05:18:32 Central  Standard Time, 
KMATTOX at aol.com writes:

Yes,  

Yes

Unfortunately

Many

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