ASSOCIATION FOR ACADEMIC SURGERY Identifying Survivors With Traumatic Craniocervical Dissociation: A Retrospective Study Zara Cooper, M.D., M.Sc.,* ,1 Joel A. Gross, M.D.,† J. Matthew Lacey, M.D.,‡ Neal Traven, Ph.D.,§ Sohail K. Mirza, M.D.,k and Saman Arbabi, M.D., M.P.H.{ *Department of Surgery, Brigham and Women’s Medical Center, Harvard University, Boston, Massachusetts; †Department of Radiology, Harborview Medical Center, University of Washington, Seattle, Washington; ‡Department of Medicine, University of Washington Medical Center (Formerly of the King County Medical Examiner’s Office), Seattle, Washington; §Harborview Injury and Prevention and Research Center, Seattle, Washington; k Department of Orthopedic Surgery, Harborview Medical Center, University of Washington, Seattle, Washington; and { Department of Surgery and the Harborview Injury Prevention and Research Center, Harborview Medical Center, University of Washington, Seattle, Washington Submitted for publication January 9, 2009 Background. Traumatic craniocervical dissocia- tion (CCD), which includes atlanto-occipital dissocia- tion and vertical distraction between C1-C2, is often an immediately fatal injury that has increasingly been associated with survival to the hospital. Our aim was to identify survivors of CCD based on clinical presentation. Methods. We retrospectively reviewed the Harbor- view Medical Center Trauma Registry and the King County Medical Examiners database from 2001 to 2006. Patients ‡ 12 y old were identified by ICD-9 code, radiographic diagnosis on lateral cervical spine films, and CT. We examined age, gender, mechanism of injury, presentation and prehospital and hospital interventions, and radiographic findings to distin- guish survivors and non-survivors. Results. Of 69 patients with CCD, 47 were diagnosed post mortem, 22 were diagnosed in hospital, and seven survived to discharge. When comparing survivors and non-survivors, age, gender, and injury severity score were not significant. Survivors had significantly higher GCS, and were more likely to be normotensive; none had cervical cord injury; 80% of non-survivors had a basion-dental interval (BDI) of ‡16 mm. Conclusions. Trauma patients diagnosed with CCD in the ED, with cervical cord injury, requiring CPR, and with GCS of 3 will not survive their injury. Wider BDI is associated with mortality. Ó 2010 Elsevier Inc. All rights reserved. Key Words: craniocervical dissociation; atlanto occipital dissociation; autopsy study; basion-dental interval; AOD; CCD. INTRODUCTION Traumatic craniocervical dissociation (CCD) is a rare and usually fatal injury involving disruption of the sin- gle functional joint between the skull base and C2 [1]. The most important of these injuries are atlanto-occip- ital dissociation (AOD), which is disruption of the joint between the occipital condyle and the lateral mass of C1 (the atlas), and C1-C2 vertical distraction injuries. CCD is associated with brainstem injury, neurogenic shock, and respiratory failure with instantaneous death [2, 3]. Despite high mortality rates at the time of injury [4], improvements in prehospital resuscitation and im- mobilization have increased the number of patients with CCD who survive to reach the hospital [5–7]. Patients with CCD often present in extremis [8], and once CCD is diagnosed, resuscitation stops. However, for those who will survive, early identification and treatment prevents progressive neurological injury and worse outcome [9–11]. CCD should be suspected in patients with severe head injury and a hemodynamic profile consistent with brainstem injury. The diagnosis can often be made on the lateral cervical spine radio- graph obtained during the initial trauma series [3, 12, 13], although it is frequently missed because of low clin- ical suspicion, and landmarks that are obscure and dif- ficult to measure due to joint instability [14, 15–18]. 1 To whom correspondence and reprint requests should be ad- dressed at Department of Surgery, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115. E-mail: zcooper@partners.org. 0022-4804/09 $36.00 Ó 2010 Elsevier Inc. All rights reserved. 3 Journal of Surgical Research 160, 3–8 (2010) doi:10.1016/j.jss.2009.04.004