Survival and neurological outcomes after traumatic atlanto-occipital dislocation: a combined multicenter clinical and forensic study

Traumatic atlanto-occipital dislocation (AOD) is a rare, severe high-energy injury historically associated with near-100% fatality. Improved prehospital care and diagnostics have enhanced survivability, underscoring the need for prompt stabilization without traction to avert secondary spinal cord injury (SCI). This combined clinical-forensic study evaluates modern management, survival, and neurological outcomes in AOD. Retrospective multicenter review (6 German level I trauma centers, 2007–2023) of 19 AOD cases, plus forensic analysis of 897 road traffic accident (RTA) autopsies (2003–2023) for AOD frequency and mechanisms. Outcomes included mortality, AIS grades (ISNCSCI 2019/2023), and clinical neurological status. Statistics: Welch t-test, chi-square; exploratory (n = 19/92 total, no power). Mean age 41 years (range 9–86). Traynelis types I:3, II:14, III:2. Mean GCS arrival: 6 (3–15). Two patients (10.5%) died preoperatively. Of 17 surgical patients, 5 (29.4%, 95% CI 13.0–52.6%) died postoperatively, yielding overall in-hospital mortality 7/19 (36.8%, 95% CI 19.1–59.0%). Of 12 survivors, 2/12 (16.7%, 95% CI 4.7–44.8%) improved ≥ 1 AIS grade; 10/12 (83.3%, 95% CI 55.2–95.3%) showed clinical neurological improvement per clinicians (e.g., motor gains/vent wean in stable AIS D; AIS insensitive for incompletes—Kirshblum, Spinal Cord 2022). Forensic: AOD in 8.1% RTA fatalities (73/897; 57 no SCI + 16 SCI), brainstem lacerations (65%), aortic injuries (48%) dominant; polytrauma (52%) leading death cause (chi-sq vs. non-AOD p = 0.012). Dens–McGregor distance higher in deaths (10.8 mm SD 5.7 vs. survival 5.8 mm SD 4.1; Welch p = 0.068, power = 0.12). AOD survivorship ~ 63%, with dual metrics revealing 83% clinical improvement post-stabilization (17% AIS shifts). Forensic data (chi-sq link) frame prehospital risks (e.g., traction aligning with brainstem patterns), suggesting time-critical occipitocervical fusion (C0–C2) without traction. Early high-resolution CT pivotal.