Continuous skull traction followed by closed reduction in chronic pediatric atlantoaxial rotatory fixation

Treating Pediatric Irreducible Atlantoaxial Rotatory Fixation (IAARF) by Unlocking Facet Joint Through Transoral Approach and Fixing With Slim-TARP Plate (15 Cases Series)

BACKGROUND

Irreducible atlantoaxial rotatory fixation (IAARF) often requires surgical treatment. Transoral unlocking the facet joints is a key measure for the treatment of IAARF. We investigate a novel method for treating pediatric IAARF by unlocking facet joint through transoral appraoch and fixed with slim-tarp plate in same stage with same approach.

OBJECTIVE

The objective of this study is to investigate the method and efficacy of a unique transoral approach to unlock facet joints and fixation with slim-shaped transoral anterior reduction plate (slim-TARP) plate in the treatment of IAARF.

METHODS

Fifteen patients diagnosed with AARF were transferred to our hospital. After 1 week of bidirectional cervical cranial traction, they were diagnosed with irreducible AARF that, and then underwent transoral release and fixation with slim-TARP plate procedures. Postoperative computed tomography and magnetic resonance were used to evaluate the reduction effect, bone fusion, and fusion time. Japanese orthopaedic association scores were used to compare the recovery of spinal cord function in patients before and after surgery. Complications such as wound infection, neurovascular injury, and loosening of internal fixation were evaluated too.

RESULTS

All 15 patients underwent transoral unlocking facet joint and fixation with slim-TARP procedures smoothly. The operation time were 129.2±11.9 minutes, blood loose were 83±23 mL. There were no neurological injury, wound infections, verified or suspected vertebral artery injury, etc. All patients were followed up for a mean of 17.8±6.6 months (range: 12 to 36 mo). Bony fusion was achieved in all patients. Mean fusion time was 3.6±1.2 months (range: 3 to 6 mo). Complete correction of torticollis was achieved in all 15 cases. Preoperative symptoms of neck pain and limitation of neck movement were effectively alleviated at 3 months after surgery. The 3 patients with preoperative neurological deficits had significant relief after surgery, and their latest follow-up results showed that their Japanese orthopaedic association scores increased from 13.0±1.0 to 16.3±0.6.

CONCLUSIONS

Transoral release and fixation with slim-TARP plate by transoral approach is a feasible and safe method for treating pediatric irreducible atlantoaxial rotatory fixation.

Primary treatment of atlantoaxial rotatory fixation in children: a multicenter, retrospective series of 125 cases

OBJECTIVE

The primary treatment for atlantoaxial rotatory fixation (AARF) remains controversial. The aim of this study was to investigate the primary treatment for AARF and create an algorithm for primary treatment.

METHODS

The authors analyzed the data of 125 pediatric patients at four medical institutions from April 1989 to December 2018. The patients were reported to have neck pain, torticollis, and restricted neck range of motion and were diagnosed according to the Fielding classification as type I or II. As a primary treatment, 88 patients received neck collar fixation, and 28 of these patients did not show symptom relief and required Glisson traction. Thirty-seven patients were primarily treated with Glisson traction. In total, 65 patients, including neck collar treatment failure patients, underwent Glisson traction in hospitals.

RESULTS

The success rate of treatment was significantly higher in the Glisson traction group (97.3%) than in the neck collar fixation group (68.2%) (p = 0.0001, Wilcoxon test). In the neck collar effective group, Fielding type I was more predominant (p = 0.0002, Wilcoxon test) and the duration from onset to the first visit was shorter (p = 0.02, Wilcoxon test) than that in the neck collar ineffective group. Using multivariate logistic regression analysis with the above items, the authors generalized from the estimated formula: logit [p(success group by neck collar fixation group)|duration from onset to the first visit (x1), Fielding type (x2)] = 0.4(intercept) - 0.15x1 + 1.06x2, where x1 is the number of days and x2 = 1 (for Fielding type I) or -1 (for Fielding type II). In cases for which the score is a positive value, the neck collar should be chosen. Conversely, in cases for which the score is a negative value, Glisson traction should be the first choice.

CONCLUSIONS

According to this formula, in patients with Fielding type I AARF, neck collar fixation should be allowed only if the duration from onset is ≤ 10 days. In patients with Fielding type II, because the score would be a negative value, Glisson traction should be performed as the primary treatment.

Atlantoaxial rotatory fixation in childhood: a staged management strategy incorporating manipulation under anaesthesia

AIMS

The aims were to evaluate the safety of manipulation under anaesthesia (MUA) for atlantoaxial rotatory fixation (AARF) and the relative efficacy of rigid collar vs halo-body orthosis (HBO) in avoiding relapse and the need for open surgery.

METHODS

Cases of CT-verified AARF treated by MUA were identified from a neurosurgical operative database. Demographic details, time to presentation and aetiology of AARF were ascertained through case note review. Cases were divided according to method of immobilisation after successful reduction, either rigid collar (group 1) or HBO (group 2). The primary outcome measure was relapse requiring open surgical arthrodesis.

RESULTS

Thirty-three patients (2.2-12.7 years) satisfied inclusion criteria. Time to presentation varied from 1 day to 18 months. There were 19 patients in group 1 and 14 in group 2. There were no adverse events associated with MUA. 9/19 (47%) patients in group 1 resolved without need for further treatment compared with 10/14 (71%) in group 2 (p = 0.15). Of the 10 patients who failed group 1 treatment, four resolved after HBO. A total of ten patients (30%) failed treatment and required open surgery.

CONCLUSIONS

MUA is a safe procedure for AARF where initial conservative measures have failed. MUA followed by immobilisation avoids the need for open surgery in over two thirds of cases. Immobilisation by cervical collar appears equally effective to HBO as an initial management, and so a step-wise approach may be reasonable. Delayed presentation may be a risk factor for relapse and need for open surgery.

Atlantoaxial Rotatory Fixed Dislocation: Report on a Series of 32 Pediatric Cases

STUDY DESIGN

Retrospective case series of atlantoaxial rotatory fixed dislocation (AARFD).

OBJECTIVE

To describe clinical features and the surgical treatment of AARFD.

SUMMARY OF BACKGROUND DATA

The classification and treatment strategy for atlantoaxial rotatory fixation (AARF) were previously described and remained controversial. AARF concomitant with atlantoaxial dislocation has different clinical features and treatment strategy with the most AARF. Due to deficiency of the transverse ligament or odontoid, the atlantoaxial remains unstable even after the torticollis relieved or cured. Because of the rarity, treatment strategy for this special condition has not been specialized and fully explored in the literatures.

METHODS

Thirty-two children with AARFD (sustained torticollis more than 6 weeks and atlanto-dental internal more than 5 mm) were retrospectively reviewed. Treatment methodology, pearls, and pitfalls of the treatment were discussed.

RESULTS

Thirty-two cases had sustained torticollis for an average of 5.7 months. ADI of them ranged from 8 to 22 mm, with a mean of 11.3 mm. Eight cases presented with signs and symptoms of spinal cord dysfunction. All 32 cases underwent surgery and had no spinal cord or vertebral artery injury. The surgery included posterior reduction and fusion (reducible dislocation and torticollis, 16 cases), and transoral release followed by posterior reduction and fusion (irreducible dislocation and torticollis, 16 cases). The average follow-up time was 42 months. Solid fusion and torticollis healing were achieved in 31 patients (96.9%) as detected radiologically. Two cases (6.3%, 2/32) suffered complications (cerebrospinal fluid leakage and recurred torticollis followed by revision).

CONCLUSION

AARFD had distinct clinical features relative to common presentations of AARF. Because of deficiency of the transverse ligament or odontoid and subsequent atlantoaxial dislocation, surgical treatments are applied for this condition, including transoral release and posterior C1-2 reduction and fusion. AARFD cases were successfully managed surgically without preoperative traction, with few complications seen.

LEVEL OF EVIDENCE

4.

Spontaneous Ankylosis of Occiput to C2 following Closed Traction and Halo Treatment of Atlantoaxial Rotary Fixation

Study Design Case report. Objective We report a case of spontaneous atlantoaxial rotatory fixation (AARF) presenting 9 months after onset in an 11-year-old boy. Methods This is a retrospective case report of spontaneous ankylosis of occiput to C2 following traction, manipulative reduction, and halo immobilization for refractory atlantoaxial rotatory fixation. Results The patient underwent traction followed by close manual reduction and placement of halo immobilization after 6 months of severe spontaneous-onset AARF that had been refractory to chiropractic manipulation and physical therapy. Imaging demonstrated dislocation of the left C1-C2 facet joint and remodeling changes of the C2 superior facet prior to reduction, followed by near complete reduction of the dislocation after manipulation and halo placement. Symptoms and clinical appearance were satisfactorily improved and the halo vest was removed after 3 months. At late follow-up, computed tomography demonstrated complete bony ankylosis of the occiput to C2. The patient was found to be HLA B27-positive, but he had no family history of ankylosing spondyloarthropathy or other joint symptoms. The underlying reasons for spontaneous fusion of the occiput to C2 could include the traction, HLA-B27-related spondyloarthropathy, or arthropathic changes caused by traction, reduction, the inciting insult, or immobilization. Conclusion When discussing treatment of childhood refractory AARF by traction, closed manipulation, and halo immobilization, the possibility of developing "spontaneous" ankylosis needs to be considered.

Successful conservative treatment for neglected rotatory atlantoaxial dislocation

BACKGROUND

Rotatory atlantoaxial subluxation (RAS) is a rare condition that is often misdiagnosed and therefore incorrectly managed. We describe our experience and propose an algorithm for treating neglected RAS nonoperatively.

METHODS

All consecutive children with neglected (>6 wk) RAS were treated in our department between 2005 and 2010 by cervical traction using a Gleason traction device and nonsteroidal anti-inflammatory drugs and muscle relaxants. When reduction was not achieved, the Gleason device was replaced by a halo device without manipulative reduction, and weight was added as necessary until reduction was successful. Fixation of reduction was either by a sternooccipital mandibular immobilizer or a halo vest for 3 to 4 months.

RESULTS

All 5 children (4 boys and 1 girl, aged 4 to 11 y) were successfully treated for neglected RAS. The mean duration from symptom onset (eg, limited neck range of motion, discomfort) to treatment initiation was 11.6 weeks (range, 6 to 16 wk). Closed reduction was achieved by a Gleason or a noninvasive halo device within 1 to 2 weeks in 4 cases. The fifth case was reduced after 5 weeks of traction using a halo with a 5 kg weight. All children had symmetrical full range of motion, normal neurological examination, and were fully engaged in educational and sports activities without recurrent dislocations at final follow-up (mean, 30 mo; range, 18 to 49 mo).

CONCLUSIONS

Conservative treatment by gradual and prolonged traction without manipulative reduction in neglected RAS might be a successful method. Reduction can often be achieved within 2 weeks of treatment onset.

LEVEL OF EVIDENCE

Level IV (retrospective case series).