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How Surgeons Reattached a Toddler’s Head

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Doctors saved a child who had been “internally decapitated” in a car accident.

“When Rylea Taylor pulled her son Jaxon from the wreckage of their family car on September 15, she knew instantly that his neck was broken—an injury that usually leaves victims paralyzed or dead. The force of the 70-mile-per-hour head-on collision had fractured Jaxon’s top two vertebrae and torn apart the ligaments that stabilize them. His top vertebra and skull were completely detached from the rest of his spinal column. The spinal cord itself was bent at a 45-degree angle and dangerously vulnerable to further movements that could sever critical nerves.

Yet just three weeks later, the 16-month-old was stepping along with the wobbly gait common to toddlers, relying on nothing more for support than a chubby hand grasping his mother’s finger.

How did Jaxon make such a dramatic recovery? He was fortunate to survive and to come under the care of Geoffrey Askin, senior spinal surgeon at the Lady Cilento Children’s Hospital in Brisbane and the man known as Australia’s godfather of spinal surgery. The soft-spoken surgeon and a team of more than 20 doctors, nurses and support specialists planned a six-hour operation to put Jaxon’s skull back onto his spine.” said scientificamerican.com

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“Gruesomely nicknamed internal decapitation, this kind of injury often kills by severing the spine, impeding signals sent by the brain that tell the lungs to breathe from reaching their destination.

The prognosis for what is medically termed a C1–C2 dislocation is dire: A 2010 study of upper-neck dislocations found that 68 percent of victims die before the dislocation could even be diagnosed, often at the scene of the accident; another 22 percent die at the hospital. Even if patients are resuscitated and brought to the hospital in time, they may remain so severely paralyzed that they are permanently unable to breathe on their own. C1–C2 and other upper-neck dislocations most commonly occur in very young children, whose relatively heavy heads are not strongly stabilized by their extra-flexible ligaments. High-speed motor vehicle accidents cause 80 percent of these injuries, Askin says, often when the child’s body is securely strapped into their car seat and their head is flung forward.

The physician’s job is further complicated because even making a full assessment of the damage can be problematic. Regular x-rays have difficulty revealing the full extent of the injury, because the scanner stays still and the patient must be moved around to examine various angles—not ideal for a patient with a spinal injury who needs to be kept as still as possible.

To overcome the limitations of traditional x-rays, physicians turn to computed tomography (CT). At Moree District Hospital, near the crash site, Jaxon was placed on a platform inside a CT scanner where an x-ray beam rotated around him. The resulting 3-D images revealed the appalling extent of his injury. “They were pretty alarming,” says Askin, who received the images while Jaxon was being airlifted to Lady Cilento. “I thought, he can’t possibly be moving or breathing, he must have been resuscitated.” He was surprised to learn that Jaxon was still breathing by himself—which meant astonishingly that the nerves in the spinal cord had remained intact.

Once at Lady Cilento, doctors also used a magnetic resonance imaging (MRI) machine to further investigate the injury. In MRI radio waves and powerful magnets detailed a picture of swelling and ligament damage to confirm that Jaxon’s spinal cord was still intact. While Jaxon spent the night in intensive care, staff rallied for the next-day surgery. They even constructed necessary contraptions on the spot including a custom-fabricated halo brace that would hold Jaxon’s head and neck in the correct position for both the surgery and a time afterward.

Askin who routinely performs operations lasting more than six hours, likens the preparations to a military operation. “You’ve got to have a plan B in your preoperative plan—you’ve got to have every scenario nutted out,” he says. Because, despite the ever-more detailed images provided by modern CT and MRI scans, there’s no telling the true extent of the damage until a patient’s body is opened up in the theater.” said scientificamerican.com

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Bolts, wires and bone grafts
“Jaxon’s surgery began with bolting the custom-made halo brace into the bone of his skull with eight screws. Although it is the most rigid splint available, a halo is light enough even for a fussy toddler to tolerate. Named for the aluminum hoop that encircles the patient’s head, a halo is anchored to a vest worn on the patient’s body so that the neck cannot turn or bend in any direction. First, though, the broken neck must be properly aligned.

Guided by live x-ray images, Askin maneuvered Jaxon’s head until the cracked vertebrae and the spinal cord within were in the correct position. It’s a treatment fraught with risk: the area is grossly unstable and often contains sharp fragments of shattered bone. With one wrong move, critical nerves can be irreparably damaged, leaving the patient with partial or total paralysis. “It’s a pretty adrenaline-producing sort of operation,” Askin says. “You don’t know if the spinal cord is still working till the patient wakes up the next day.”

Only the most senior surgeons, who have honed their craft for years on less precarious injuries, perform these operations. Askin’s registrars, young doctors training to specialize as spinal surgeons, come to the operating theater to observe the 25-year veteran in this most delicate of operations. Askin operates on just one or two C1–C2 dislocations each year.

That’s not because the injury is so rare, but because it is so deadly that victims are more likely to die on the roadside than make it to the ER, let alone the operating room. Still, in the last decade advances in every step of medical care—from the time emergency responders arrive up to the moment the patient is wheeled into recovery—have increased survival chances so much that Askin is now contributing to a manual on standard-care practices for similar injuries in children. “Anesthetics are much safer, instruments for exposing the spine or passing wires are more sophisticated [and] preoperative imaging with CT scans provide much more information before we even make an incision,” Askin says. The CT scans can even be used to make a silicon 3-D model of the injury site to aid planning the operation.

Still, the improvements in tools were not quite enough in Jaxon’s case. Once the spine was properly aligned and Askin had made the 10-centimeter-long incision to expose the fractures, the team found that even the smallest surgical screws were too large to use on Jaxon’s tiny vertebrae. Using a microscope, Askin resorted to a long-superseded method: using wire to join the fractured bones together, a technique he describes as “primitive.”

Under the weight of Jaxon’s head, wires were not enough to keep the top C1 vertebra stacked correctly on top of the rest of the vertebrae. In a healthy spine a network of ligaments keeps the vertebrae properly stacked, but once torn or overstretched they never recover their former strength. Instead, Askin finished the surgery by grafting a 7.6-centimeter fragment of one of Jaxon’s ribs onto the joint.

The rib bone, laid against the back of the vertebrae with one end over each to form a bridge over the in-between joint, will continue to grow into the two vertebrae and eventually fuse them together. They will no longer be able to move independently of one another but children’s necks are so flexible that Jaxon’s other vertebral joints will compensate, and with continuous use will keep the ligaments flexible. His rib will grow back, too.” said scientificamerican.com

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From hospital to home
“Just three weeks after the devastating accident, Jaxon was able to not only leave the hospital, but even leave Brisbane for his home in the small town of Moranbah. His hometown’s tiny 12-bed hospital will regularly send x-rays to Askin to verify that Jaxon’s spine is staying in the correct position while he wears the halo brace for three months. After that, Jaxon should need no physiotherapy or extra treatment. Aside from not being able to play rugby or engage in other activities that could cause whiplash-style injuries, he should be able to live a normal life

No one knows why Jaxon’s spinal cord bent instead of tearing. Askin says it was the worst case of C1–C2 dislocation he has seen, and he has trouble imagining the separation between the vertebrae at the crash scene, which was undoubtedly worse than the extent of injury he encountered when Jaxon arrived at the hospital before emergency responders immobilized the child’s neck. ‘How the spinal cord managed to go around that corner and survive is a miracle really,’ he says. ‘He’s just really, really lucky.'” said scientificamerican.com

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“How Surgeons Reattached a Toddler’s Head”