Non-operative management of traumatic occipitocervical distraction injuries in children: a systematic review

Clinical Snapshot

Key Findings

• P Value: Not reported; no statistical testing performed

• Effect Size: 82.5% (33 of 40 patients) successfully managed with non-operative treatment alone

• Primary Outcome: Successful non-operative management of paediatric traumatic occipitocervical distraction injuries without neurological deterioration

• Nnt Or Sensitivity: Not calculable — no comparator arm; 17.5% (7/40 patients) crossed over to surgical management; no neurological decline reported in any patient during orthotic treatment or in relation to crossover

• Confidence Interval: Not reported; estimated 95% CI approximately 67–93% based on sample size (not provided by authors)

Clinical Application

Non-operative management with external orthotic devices (cervical collar, halo vest) is technically feasible in paediatric patients but requires experienced multidisciplinary teams, close neurological monitoring, serial imaging, and clear escalation protocols. Halo vest application in young children carries specific technical challenges. Implementation outside major paediatric neurosurgical centres would require significant protocol development and training. In Australia, management of paediatric traumatic OCDI occurs at major paediatric trauma centres (e.g., The Royal Children's Hospital Melbourne, Sydney Children's Hospital, Queensland Children's Hospital). Current RACGP and neurosurgical society guidance aligns with international recommendations favouring OCF for confirmed AOD. This systematic review does not provide sufficient evidence to alter TGA-regulated device use or PBS-listed treatment pathways. The findings support the establishment of an Australian paediatric spinal trauma registry to prospectively capture OCDI cases and contribute to the international evidence base. Any deviation from current OCF guidelines should occur only within a formal research protocol at accredited paediatric neurosurgical centres, with ethics approval and informed consent. Paediatric patients presenting to tertiary trauma centres with traumatic occipitocervical distraction injuries, including the spectrum from partial ligamentous injury to atlanto-occipital dislocation, who are neurologically intact or have stable neurological deficits and are deemed suitable for external orthotic immobilisation by experienced paediatric neurosurgeons

Abstract

PURPOSE: Existing guidelines for the management of atlanto-occipital dislocation (AOD) recommend occipitocervical fusion (OCF) for these low frequency, high-consequence injuries. Recent literature has questioned this guidance and provided case examples of successful non-operative management of a more inclusive and broadly defined spectrum of injuries to the occipitocervical junction (OCJ) termed occipitocervical distraction injuries (OCDI). A systematic review of existing literature on this topic would inform efforts to investigate the safety and efficacy of non-operative management of these injuries. METHODS: We performed a systematic review based on preferred reporting items for systematic reviews (PRISMA) guidelines of English language publications to define and map literature related to non-operative management of pediatric traumatic OCDI. RESULTS: We identified 40 patients in 21 manuscripts meeting defined inclusion and exclusion criteria. 82.5% of patients were successfully managed with non-operative management alone. No patient declined neurologically during orthotic treatment or in relation to crossover to surgical management through a minimum of 3-month follow-up. CONCLUSIONS: This review supports the contention that non-operative management is both safe and effective in the management of OCDI. Further research to develop standardized diagnostic and treatment protocols for non-operative management of OCDI through registries and multi-center research efforts is needed.

References

1. 1.da Silva, L. C. A., Rankin, B., Bookland, M. J., Hersh, D. S., Anderson, R. C. E., & Martin, J. E. (2026). Non-operative management of traumatic occipitocervical distraction injuries in children: a systematic review. Child's Nervous System. Advance online publication. https://doi.org/10.1007/s00381-025-06842-y