Management of chronic atlantoaxial rotatory fixation

Clinical Results after Release of Sternocleidomastoid Muscle Surgery for Neglected Congenital Muscular Torticollis-Unipolar vs. Bipolar Release Surgery

BACKGROUND

Although the surgical release of the sternocleidomastoid muscle (SCM) is required for residual congenital muscular torticollis (CMT), the surgical outcomes between bipolar and unipolar SCM release remained unclear. The purpose of the present study was to assess surgical outcomes after bipolar and unipolar release of SCM in adolescent/adult patients with neglected CMT.

METHODS

Twenty-one consecutive adolescent/adult patients with neglected CMT who underwent surgical treatment were enrolled. Clinical and radiographic outcomes were evaluated at preoperative and final follow-up.

RESULTS

The bipolar release of SCM was performed in 3 patients (B group; males, n = 1, females, n = 2) and the unipolar release of SCM in 18 patients (U group; males, n = 6, females, n = 12). The mean age at surgery was 40.0 ± 17.0 years in Group B, and that was 32.3 ± 13.1 years in Group U (p = 0.47). The mean follow-up period was 16.0 ± 5.7 months in Group B and 10.4 ± 7.6 months in Group U (p = 0.22). Cervicomandibular angle correction rates were comparable at 75.4 ± 2.4% for the B group and 73.1 ± 11.7% for the U group (p = 0.62). There was no significant difference in clinical outcome according to the modified Cheng and Tang score between the two groups (p = 0.89). No major complications arose, although one patient exhibited a transient neurological deficit of the greater auricular nerve, and one patient developed a hematoma in the B group.

CONCLUSIONS

The unipolar SCM release appeared to be a non-inferiority and less invasive procedure, minimizing surgical scars and avoiding potential auricular nerve damage in adolescent/adult patients with neglected CMT.

Halo Traction Followed by Halo Vest Immobilization for the Treatment of Chronic Atlantoaxial Rotatory Fixation: A Case Report and Tips for Avoiding Complications in Pediatric Patients

CASE

A 4-year-old girl sustained a traumatic atlantoaxial rotatory subluxation. She presented at the treating facility 8 months after injury with cervical deformity, neck pain, gait instability, and decreased cervical motion. Her delay in presentation was partially because of international Corona Virus of 2019 (COVID-19) travel restrictions. The case was successfully treated with halo traction, followed by halo vest immobilization.

CONCLUSION

Chronic atlantoaxial rotatory fixation can be treated nonsurgically with closed reduction and halo traction, but is associated with operative risks. Optimal pin placement is challenging in the pediatric skull and may be improved with a preoperative or intraoperative computed tomography (CT) scan.

New Subtype of Atlantoaxial Rotatory Fixation (Type IIIa)

OBJECTIVE

Some atlantoaxial rotatory fixations (AARFs) cannot be classified according to the Fielding and Hawkins classification. This study aimed to introduce a new subtype of AARF (type IIIa AARF) with a C1 anterior displacement >5 mm, but with one lateral mass being displaced anteriorly and another posteriorly.

METHODS

Data from 10 cases of AARF with anterior C1 displacement of >5 mm were retrospectively reviewed. The exclusion criteria were as follows: 1) type I, II, or IV AARF according to the Fielding and Hawkins classification; 2) cases caused by trauma, tumor, or infection; 3) AARF with os odontoideum or odontoid fracture; and 4）age ≥18 years. Imaging features were analyzed. The atlanto-dental interval was measured to evaluate C1 anterior displacement.

RESULTS

Three cases that did not match type III AARF were classified under type IIIa AARF. They had the following common imaging features: 1) atlanto-dental interval of >5 mm, being similar to type III AARF; 2) one lateral mass of C1 displaced anteriorly and the other posteriorly (the most important feature distinguishing the type from type III AARF in which both C1 lateral masses displaced anteriorly); and 3) C1-C2 separation angle (mean 44.2 ± 2.9°) being larger than that in type III AARF.

CONCLUSIONS

AARF with anterior C1 displacement of >5 mm, but with one lateral mass displaced anteriorly and the other posteriorly, was defined as type IIIa AARF. It should not be confused with type III AARF because these 2 types differ in biomechanics and imaging parameters.

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.

Atlantoaxial rotatory dislocation: Surgical treatment in a pediatric patient cohort

•Surgical correction of AARD is an appropriate method of treatment after failed non-operative therapy.•The technique of surgical reduction and C1-C2 fixation using Harms/Goel technique provides excellent clinical outcomes.•In case of traumatic AARD we recommend to consider temporary fixation.

Surgical Treatment of Irreducible AcuteTraumatic Atlantoaxial Rotatory Subluxation in an Adult

Traumatic atlantoaxial rotatory subluxation (AARS) is a condition that is extremely rare in adults when compared to the pediatric population. The most common symptoms of this condition are torticollis and post-traumatic neck pain. Our patient is a 41-year-old male who presented to the emergency room within hours of the injury. He came by himself with his relative as a case of road traffic accident. He was the first passenger and had been restrained during the car accident, with no ejection or rollover. He presented with stiffness/pain and reduced range of motion in the neck. Computed tomography (CT) of the cervical spine showed rotatory subluxation of C1 over the C2 with a locked facet. Within 24 hours of the RTA and patient admission, we attempted cervical traction. The reduction was not successful. So, we decided to reduce AARS through a surgical approach. The patient was taken to the operating room for open reduction and fixation using the Harms technique for C1-C2 fusion. The patient recovered from the surgery uneventfully, without any complications, recovered cervical mobility, and improved torticollis. Surgical management through open reduction and internal fixation is recommended for AARD cases in which close reduction fails due to a locked facet.

A pediatric case of axial rotary fixation associated with severe head trauma requiring emergency craniotomy for hematoma removal

Background

Atlantoaxial rotatory fixation (AARF) causes the atlantoaxial joint to be fixed in a rotated position, resulting in painful torticollis. We report a case of pediatric AARF associated with severe head trauma requiring emergency craniotomy and was treated with conservative treatment.

Case presentation

A 10-year-old boy was struck by a van while walking across the street. Upon admission to our trauma care center, his Glasgow Coma Scale score was 11 points (E3V3M5), pupils were 4 mm bilateral regular circles, and other vital signs were stable. Plain computed tomography (CT) revealed left acute epidural hematoma, traumatic subarachnoid hemorrhage, cerebral contusion, pneumoencephalopathy, and rightward deviation of the axial vertebra. We performed an emergency craniotomy due to an enlarged hematoma on a repeat head CT scan and decreased level of consciousness. Based on imaging studies, rightward deviation of the axial vertebra was diagnosed as AARF; however, since the patient was already on ventilatory management and no physical findings were obtained, conservative treatment with cervical collar fixation was started. His condition improved, and he was extubated on day 3, released from the cervical collar on day 10, discharged from the hospital on day 17, and followed-up until day 32.

Conclusions

AARF is often caused by minor trauma or inflammation in children; however, we experienced a case complicated by severe head trauma, which was treated conservatively and showed a good clinical progress. Since AARF treatment depends on the length of time from onset, early diagnosis, in trauma care, carefully assessing factors other than major trauma, will lead to improved prognosis.

Clinical Features of Kawasaki Disease With Atlantoaxial Rotatory Fixation

PURPOSE

Atlantoaxial rotatory fixation (AARF) is a rare complication of acute Kawasaki disease (KD). Early diagnosis and intervention are important for AARF because delayed diagnoses may incur neurological sequelae. However, previous studies on AARF associated with KD are limited, and its clinical characteristics and course are unknown. This study aimed to examine the clinical features and treatment course of KD with AARF using a Japanese national inpatient database.

METHODS

Using the Diagnosis Procedure Combination database, we identified KD patients who received intravenous immunoglobulin (IVIG) treatment between July 2010 and March 2020. The clinical characteristics of KD patients with AARF and their risk factors were evaluated using multivariable logistic regression analysis. We also examined the relationship between AARF, the proportion of coronary artery abnormalities (CAAs), IVIG resistance, length of stay and medical costs.

RESULTS

We identified 71,913 patients with KD, 166 of whom had AARF. The AARF group had older age, heavier bodyweight and atypical KD. In multivariable analysis, AARF was associated with older age [odds ratio (OR): 1.24; 95% confidence interval (CI): 1.19-1.29], lower body mass index (OR: 0.89; 95% CI: 0.82-0.96) and atypical KD (OR: 1.95; 95% CI: 1.12-3.40). AARF was not associated with CAAs (OR: 0.73; 95% CI, 0.23-2.32) and IVIG resistance (OR: 1.05; 95% CI, 0.74-1.49). However, AARF was associated with higher medical costs (difference, US$1064; 95% CI: 346-1781) and longer hospital stay (difference, 3.1 days; 95% CI: 1.7-4.4).

CONCLUSION

AARF in patients with acute KD should be considered if cervical symptoms present in older patients with atypical KD.

C1-C2 Rotatory Subluxation in Adults “A Narrative Review”

The atlantoaxial joint C2 (axis) with the anterior arch of C1 (atlas) allows 50% of cervical lateral rotation. It is responsible for precise and important movements that allow us to perform precise actions, both in normal and working life. Due to low incidence in adults, this condition often goes undiagnosed, or the diagnosis is delayed and the outcome is worse. An early diagnosis and treatment are essential to ensure satisfactory neurological and functional outcomes. The aim of this review is to analyze C1-C2 rotatory subluxation in adults, given its rarity. The time between injury and reduction is key, as it is directly related to prognosis and the severity of the treatment options. Due to low incidence in adults, this condition often goes undiagnosed, or the diagnosis is delayed as a lot of cases are not related to a clear trauma, with a poor prognosis just because of the late diagnosis and the outcome is worse. The correct approach and treatment of atlantoaxial dislocation requires a careful study of the radiological findings to decide the direction and plane of the dislocation, and the search for associated skeletal anomalies.

Spontaneous Osseous Fusion after Remodeling Therapy for Chronic Atlantoaxial Rotatory Fixation and Recovery Mechanism of Rotatory Range of Motion of the Cervical Spine

We aimed to investigate the risk factors of spontaneous osseous fusion (SOF) of the atlantoaxial joint after closed reduction under general anesthesia followed by halo fixation (remodeling therapy) for chronic atlantoaxial rotatory fixation, and to elucidate the recovery mechanism of the rotatory range of motion (ROM) after halo removal. Twelve patients who underwent remodeling therapy were retrospectively reviewed. Five patients with SOF were categorized as the fusion group and seven patients without SOF as the non-fusion group. Three dimensional CT was used to detect direct osseous contact (DOC) of facet joints before and during halo fixation, while dynamic CT at neutral and maximally rotated head positions was performed to measure rotatory ROM after halo removal. The duration from onset to initial visit was significantly longer (3.2 vs. 5.7 months, p = 0.04), incidence of DOC during halo fixation was higher (0/7 [0%] vs. 4/5 [80%], p = 0.004), and segmental rotatory ROM of Occiput/C1 (Oc/C1) at final follow-up was larger (9.8 vs. 20.1 degrees, p = 0.003) in the fusion group. Long duration from the onset to the initial visit might induce irreversible damage to the articular surface of the affected facet, which was confirmed as DOC during halo fixation and resulted in SOF. Long duration from the onset to the initial visit and DOC during halo fixation could be used to suggest the risk for SOF. Nonetheless, rotatory ROM of Oc/C1 increased to compensate for SOF.

Chronic atlantoaxial rotatory fixation with neurofibromatosis type I: A case report

Background:

Atlantoaxial rotatory fixation (AARF) can be caused by infection, rheumatoid arthritis, surgery of head and neck, and congenital diseases. Type 1 neurofibromatosis (NF-1) is often associated with various musculoskeletal diseases, but few reports have described AARF with NF-1. Here, we report the success of a closed reduction and halo fixation utilized to treat chronic AARF with NF-1 in a 7-year-old female.

Case Description:

A 7-year-old female with NF-1 presented with a 2-month history of torticollis and neck pain. C2 facet deformity had previously been identified on computed tomography (CT) before the onset of neck pain. Cervical radiography and CT showed AARF classified Fielding’s Type I and Ishii’s Grade II. Following 2 weeks of cervical traction, a closed reduction was followed by halo fixation that was utilized for 2 months. The patient fully recovered cervical range of motion following halo vest removal 4 months later. Further, the follow-up CT documented a normal atlantoaxial joint despite residual C2 facet deformity. In addition, no recurrence was evident 2 years later.

Conclusion:

Halo fixation for chronic AARF with NF-1 proved effective. C2 facet deformity associated with NF-1 might have contributed to the onset of AARF.

Natural History, Neuroradiological Workup, and Management Options of Chronic Atlantoaxial Rotatory Fixation Caused by Drug-Induced Cervical Dystonia

Atlantoaxial rotatory fixation (AARF) resulting from drug-induced cervical dystonia (DICD) represents an extremely rare complication of antipsychotic treatment, requiring a comprehensive assessment of pharmacologic therapy and timely radiologic workup. We report a chronic case of Fielding type I, Pang type I AARF secondary to schizophrenia treatment in a 16-year-old girl, along with a review of the literature on the management challenges posed in this condition. In this scenario, torticollis may just represent the tip of the iceberg, and only an effective multidisciplinary approach increases the chances of satisfactory correction with closed reduction, hence avoiding the burden of more invasive treatment options.

Effectiveness of pediatric integrative manual therapy in cervical movement limitation in infants with positional plagiocephaly: a randomized controlled trial

BACKGROUND

Positional plagiocephaly (PP) is a cranial deformation frequent amongst children and consisting in a flattened and asymmetrical head shape. PP is associated with excessive time in supine and with congenital muscular torticollis (CMT). Few studies have evaluated the efficiency of a manual therapy approach in PP. The purpose of this parallel randomized controlled trial is to compare the effectiveness of adding a manual therapy approach to a caregiver education program focusing on active rotation range of motion (AROM) and neuromotor development in a PP pediatric sample.

METHODS

Thirty-four children with PP and less than 28 week-old were randomly distributed into two groups. AROM and neuromotor development with Alberta Infant Motor Scale (AIMS) were measured. The evaluation was performed by an examiner, blinded to the randomization of the subjects. A pediatric integrative manual therapy (PIMT) group received 10-sessions involving manual therapy and a caregiver education program. Manual therapy was addressed to the upper cervical spine to mobilize the occiput, atlas and axis. The caregiver educational program consisted in exercises to reduce the positional preference and to stimulate motor development. The control group received the caregiver education program exclusively. To compare intervention effectiveness across the groups, improvement indexes of AROM and AIMS were calculated using the difference of the final measurement values minus the baseline measurement values. If the distribution was normal, the improvement indexes were compared using the Student t-test for independent samples; if not, the Mann-Whitney U test was used. The effect size of the interventions was calculated using Cohen's d.

RESULTS

All randomized subjects were analysed. After the intervention, the PIMT group showed a significantly higher increase in rotation (29.68 ± 18.41°) than the control group (6.13 ± 17.69°) (p = 0.001). Both groups improved the neuromotor development but no statistically significant differences were found. No harm was reported during the study.

CONCLUSION

The PIMT intervention program was more effective in increasing AROM than using only a caregiver education program. The study has been retrospectively registered at clinicaltrials.gov, with identification number NCT03659032 . Registration date: September 1, 2018.

A Rare Case of Nontraumatic Atlantoaxial Rotatory Fixation in an Adult Patient Treated by a Closed Reduction: A Case Report

CASE

A 42-year-old woman presented with a severe neck pain and torticollis due to uncertain etiology. Because her radiographs and computed tomography revealed atlantoaxial rotatory fixation (AARF) that is an extremely rare condition in the adult population, a nonsurgical treatment was initially applied. Because 3 weeks of indirect traction failed, closed reduction was performed under general anesthesia at 2 months after onset, and her symptoms markedly improved without any complications and recurrence.

CONCLUSION

Closed reduction under general anesthesia for nontraumatic AARF in adult patients might be an effective treatment option, even for chronic cases or intractable cases by traction treatment.

New Simple 3-Dimensional Computed Tomogram Classification Leading to Successful Conservative Treatment in 51 Atlanto-Axial Rotatory Fixation Children

OBJECTIVE

to present a new and easy classification of atlanto-axial rotatory fixation (AARF) and to investigate the efficiency of conservative treatment of AARF.

BACKGROUND

Although there is a precise definition and diagnostic classification of AARF, there is still significant difficulty in measuring the atlas and axis angles because all of the atlas or axis cannot be seen in a certain 2-dimensional computed tomogram image. In addition, some recent case reports showed that long-term conservative treatment can reduce pediatric AARFs, even that are severe or chronic.

METHODS

Fifty-one children with AARF were analyzed retrospectively with new 3-dimensional computed tomogram (3DCT)-based AARF classification; the mean age was 72.7 ± 35.2 months (19-139 months). In the new AARF classification, type 1 was defined as that when the C1C2 angle is not 0° on midline and type 2 as that when the C1C2 angle is 0° on the midline.

RESULTS

All 7 children with AARF type 1 were treated successfully only with Halter tractions. Twenty among 44 children with type 2 did not show any difference in improvement compared with not-treated 24 children with type 2.

CONCLUSION

The first new AARF classification based on 3DCT appears to be easy to use and even the most severe children with AARF may be managed only with conservative treatment such as long-term Halter traction.

Systematic review of the nonsurgical management of atlantoaxial rotatory fixation in childhood

OBJECTIVE

Atlantoaxial rotatory fixation (AARF) is an acquired fixed abnormality of C1-2 joint rotation associated with torticollis in childhood. If the condition is left uncorrected, patients are at risk for developing C1-2 fusion with permanent limitation in the cervical range of movement, cosmetic deformity, and impact on quality of life. The management of AARF and the modality of nonsurgical treatment are poorly defined in both primary care and specialized care settings, and the optimal strategy is not clear. This systematic review aims to examine the available evidence to answer key questions relating to the nonsurgical management of AARF.

METHODS

A systematic review was performed using the following databases: PubMed, MEDLINE, Healthcare Management Information Consortium (HMIC), EMCare, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), British Nursing Index (BNI), and Allied and Complementary Medicine Database (AMED). Search criteria were created and checked independently among the authors. All articles with a radiological diagnosis of AARF and primary outcome data that met the study inclusion criteria were included and analyzed by the authors.

RESULTS

Search results did not yield any level I evidence such as a meta-analysis or randomized controlled trial. The initial search yielded 724 articles, 228 of which were screened following application of the core exclusion criteria. A total of 37 studies met the full criteria for inclusion in this review, consisting of 4 prospective studies and 33 retrospective case reviews. No articles directly compared outcomes between modalities of nonsurgical management. Six studies compared the outcome of AARF based on duration of symptoms before initiation of treatment. Comparative analysis of studies was hindered by the wide variety of treatment modalities described and the heterogeneity of outcome data.

CONCLUSIONS

The authors did not identify any level I evidence comparing different nonsurgical management approaches for AARF. There were few prospective studies, and most studies were uncontrolled, nonrandomized case series. Favorable outcomes were often reported regardless of treatment methods, with early treatment of AARF tending to yield better outcomes independent of the treatment modality. There is a lack of high-quality data, and further research is required to determine the optimal nonsurgical treatment strategy.

Current management of juvenile idiopathic arthritis affecting the craniovertebral junction

PURPOSE

Craniovertebral instability is a rare and serious problem. While previously treated surgically, better understanding of disease processes has permitted the field to move towards conservative management. Juvenile idiopathic arthritis (JIA) is one cause of pediatric craniovertebral instability. Early recognition and institution of appropriate medical therapy and bracing in a multidisciplinary fashion is critical to avoid long-term instability, joint abnormalities, or morbid surgical procedures. We seek to highlight cases of this rare problem and provide a principled approach to management decisions.

METHODS

We review 6 cases that have presented over the last 6 years and highlight 3 cases in particular regarding craniovertebral instability as a presentation of JIA. We reviewed the clinical records and radiographic features with particular emphasis of the stability of the craniovertebral junction.

RESULTS

Age range of the subjects was from 5 to 12. All patients presented with neck pain and abnormal head rotation. Four of the patients responded to medical management and/or cervical bracing with no long-term sequelae or instability. Two patients had refractory rotary subluxation, one that responded to manual reduction under pharmacological paralysis and bracing; the other had an incompetent transverse ligament requiring surgical reduction and fixation.

CONCLUSIONS

Neck pain and abnormal head rotation in an older child is rare finding but should prompt suspicion as a manifestation of JIA to the general pediatrician or initial provider. Appropriate serologic studies and MRI studies with contrast at the craniovertebral junction is necessary for evaluation. Early institution of medical management and cervical bracing under a multidisciplinary team of pediatric rheumatology and neurosurgery is key to avoiding surgical intervention and long-term abnormalities at the craniovertebral junction.

Trauma on the high seas: an overview of recreational water use injuries

Recreational water use (RWU) injuries span from superficial lacerations to even death. Given the global popularity of RWU, radiologists should be aware of the common mechanisms and key imaging findings related to injuries in this setting. The goal of this article is to depict common RWU injuries and their emergent radiographic findings, which may have both important surgical and management implications. We present a broad review with case illustrations of these injuries seen at our level 1 trauma center showing the breadth of injury that can occur, general mechanisms and sample imaging findings.

Traumatic Chronic Irreducible Atlantoaxial Rotatory Fixation in Adults: Review of the Literature, With Two New Examples

Atlantoaxial rotatory fixation (AARF) is a rare condition in adults and is almost always due to an accompanying trauma. The first example of traumatic AARF in adults was reported by Corner in 1907 and since then only 55 adult cases with this rare traumatic scenario have been published so far. Approximately 80% of adults with traumatic AARF are diagnosed soon after the traumatic events. However, in the remaining casualties, the condition might be missed with some delay from the diagnosis to treatment. If this pathology is diagnosed early enough, the conservative attempts for a closed reduction are usually effective. After closed reduction, external immobilization is required to prevent recurrence of the dislocation. However, with delayed diagnosis, the condition may remain refractory to traction on manipulation and require an open reduction instead. In the literature, such irreducible chronic AARFs are rarely reported, being confined to only 14 adult examples, in whom surgical intervention for correction of the deformity will be required. In such cases, release of the atlantoaxial facet joints is the first surgical step. In the subsequent step, reduction of the dislocated facet joints can be done via one of the already described maneuvers. As the final step, C1-C2 fixation will be necessary for prevention of re-dislocation. Herein, 2 adult patients with chronic rotatory atlantoaxial dislocation of traumatic origin are presented. In both cases, cranial traction and manipulations were ineffective and therefore an open reduction procedure was proposed and accomplished via the posterior midline corridor. The transverse rod technique was implemented subsequent to the atlantoaxial facet release. After correction of the deformity, a C1-C2 fixation was accomplished followed by arthrodesis. In addition to the outlined procedure, an historical review of the literature on this subject from the beginning of 20th century is demonstrated.

Morphological Characteristics of the Spinous Process of Axis: Clinical Implications for Cervical Spine Manipulation

OBJECTIVE

The purpose of this study was to evaluate the osseous variation of the axis spinous process as it may relate to palpation by clinicians.

METHODS

Morphologies of the bifid spinous process in the intact dry axis of 121 Chinese adult were investigated and classified. The angular deflection of the spinous processes, the bifid spinous processes (the bifid portions of the spinous processes), and the length of the bifid spinous processes were observed and measured.

RESULTS

The bifid spinous process morphologies were classified into 4 types: inverted-V shape (n = 49), inverted-U shape (n = 50), M shape (n = 18), and nonbifid spinous processes (n = 4). The direction of the spinous processes and bifid spinous processes were consistent because they depended on each other's direction of deviation. When the correlation between angular deflection of spinous processes and bifid spinous processes was analyzed, the right deviations of spinous process specimens (29 cases) showed that angular deflections of spinous processes were equal to bifid spinous processes and there was no statistically significant difference seen between them (t = 0.286, P > .05), whereas in the left deviations of spinous process specimens (49 cases), the angular deflection of spinous processes were not equal in length, but bigger than the bifid spinous processes, which was statistically significant (t = -3.079, P = .003 < .05).

CONCLUSION

The anatomical structure of the spinous processes and the bifid spinous processes vary from one another, but they exhibit some regularity. In clinical spinal manipulation practice, the anatomical characteristic of the axis should be taken into account during cervical static palpation, diagnostic imaging, and treatment.

Atlanto-axial rotatory fixation complicating ventriculo-peritoneal shunt surgery: a case report and literature review

INTRODUCTION

Atlanto-axial rotatory fixation (AARF) is a rare complication of ventriculo-peritoneal shunt (VPS) surgery.

CASE PRESENTATION

The authors present a unique case of AARF developing early after VP shunting, with persistent torticollis, a "cock-robin" head position, and a thick fibrous band along the catheter path. Due to refractoriness to conservative treatments, AARF, which can be an early-onset complication of VPS surgery, was resolved by removing the distal catheter along with the fibrous band encasing it.

CONCLUSION

Surgical removal of the fibrous band might be enough to solve such complication with no need of further surgical fusion procedures.

Rotatory Subluxation and Facet Deformity in the Atlanto-occipital Joint in Patients with Chronic Atlantoaxial Rotatory Fixation: Two Case Reports

Introduction:

The relationship between the morphometry of atlantoaxial joint and chronic atlantoaxial rotatory fixation (AARF) is well known, but disorders in the atlanto-occipital joint in chronic AARF are not fully elucidated. The authors report two rare cases of secondary deformities in the atlanto-occipital joint in chronic AARF.

Case Reports:

Two patients with chronic AARF were treated with closed manipulation, skull traction and halo-vest immobilization. Clinical outcomes and radiographs were reviewed retrospectively, focusing on pathological changes in the atlanto-occipital joint using multiplanar reconstruction computed tomography and three-dimensional computed tomography images. Case 1 (12-year-old girl) had rotatory subluxation with a superior facet deformity of the atlas in the atlanto-occipital joint before the initiation of treatment. After a series of conservative treatments, both atlantoaxial and atlanto-occipital rotatory fixation could not be reduced, and both the superior facet deformity of the atlas and osteoarthritic changes in the atlanto-occipital developed. She was monitored without surgery because the disorder progressed to the spontaneous fusion of the occipital bone to the axis. Case 2 (13-year-old boy) had rotatory subluxation without facet deformity of the atlas in the atlanto-occipital joint before the initiation of treatment. However, both the superior facet deformity of the atlas and osteoarthritic changes in the atlanto-occipital developed over time, and both atlantoaxial and atlanto-occipital rotatory fixation could not be reduced after a series of conservative treatments. He still had severe neck pain and severely restricted neck mobility and underwent spinal fusion.

Conclusion:

Atlanto-occipital rotatory subluxation and facet deformity in the atlanto-occipital joint may occur after prolonged AARF. It is necessary to pay attention to pathological changes not only in the atlantoaxial joint but also in the atlanto-occipital joint, when orthopedic surgeons treat patients with AARF.

Temporary Internal Fixation Using C1 Lateral Mass Screw and C2 Pedicle Screw (Goel-Harms Technique) without Bone Grafting for Chronic Atlantoaxial Rotatory Fixation

BACKGROUND

The primary treatment strategy for chronic atlantoaxial rotatory fixation (chro-AARF) is traction followed by bracing or application of a halo device. However, to complete these conservative therapies, patient cooperation is mandatory. If conservative therapy fails, surgery is required for reduction and prevention of recurrence. It has been considered that surgery for atlantoaxial rotatory fixation necessitates solid bony fusion. However, once bony fusion is achieved, loss of range of motion is problematic. Here, we report a patient with chro-AARF who was successfully treated with temporary internal fixation using a C1 lateral mass screw and C2 pedicle screw (Goel-Harms technique) without any grafting of bone or use of bone substitute materials.

CASE DESCRIPTION

A 9-year-old boy with chro-AARF was referred to our institution. He had a history of pervasive developmental disorders. He did not cooperate for the completion of conservative therapy and could not tolerate this therapy. Therefore, the orthopedic staff and his parents considered surgery. Under general anesthesia, reduction was easily performed. The Goel-Harms screw-rod construct was completed as a temporary internal fixator without any grafting of bone or use of bone substitute materials. After 6 months, the screw-rod construct was removed. Removal of the screw-rod construct was performed easily without complication. There was no ankylosis of the C1-2 joint, and cervical range of motion was maintained 2.8 years after removal of the construct.

CONCLUSIONS

When conservative therapy cannot be continued, Goel-Harms surgery as a temporary internal fixator without bone grafting might be a suitable alternative for selected patients with chro-AARF.

Traumatic atlantoaxial rotatory fixation in an adult patient

INTRODUCTION

Atlantoaxial rotational fixation (AARF) is a rare entity in adults, with only a few cases reported in the English literature and often associated with a traumatic mechanism. It is an underdiagnosed condition that must be taken into account in the initial assessment of all craniocervical trauma. Both diagnostic and therapeutic delay may be a potential cause of severe neurological damage or even death of the patient. The therapeutic management is controversial given the difficulty of achieving optimum stability and permanent reduction.

METHODS AND RESULTS

A 28-year-old woman was involved in a traffic accident a week before coming to the emergency with rotation and irreducible cervical flexion from trauma and severe neck pain. CT and MRI column were performed and showed a cervical spinal AARF with transverse and alar ligaments intact and preserved atlantoaxial distance (Fielding I). The patient was treated by progressive cervical traction with 5 kg and manual reduction was completed in 24 h. Subsequently, an external immobilization was performed by cervical rigid collar for 16 weeks. The clinical course was good, with the patient regaining full mobility with cervical neck pain improvement.

CONCLUSIONS

The purpose of this paper is to show a case of a young woman with a posttraumatic AARF successfully treated conservatively. This case delineates the difficulties in diagnosing this pathology, as well as the challenges encountered in its management.

Fusion Surgery Required for Recurrent Pediatric Atlantoaxial Rotatory Fixation after Failure of Temporary Fixation with Instrumentation

In cases of chronic irreducible and recurrent unstable atlantoaxial rotatory fixation (AARF), closed reduction and its maintenance are often unsuccessful, requiring surgical treatment. The purpose of the present report is to describe a rare case of pediatric AARF that required multiple treatments. A 6-year-old boy was diagnosed as having type 2 AARF. After conservative treatment, the patient was treated with temporary fixation surgery (C1-C2 Magerl) without a bone graft in consideration of motion preservation after screw removal. AARF recurred after the screw removal and required fusion surgery (Magerl–Brooks) with an iliac bone graft. Ultimately, bone union was achieved and the screws were removed 11 months after the surgery. We recommend surgeons be cautious when choosing temporary fixation surgery for AARF in small children. Further investigation is needed to determine the optimal time before screw removal.

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.

Anterior Retropharyngeal Reduction and Sequential Posterior Fusion for Atlantoaxial Rotatory Fixation With Locked C1-C2 Lateral Facet

STUDY DESIGN

Retrospective case series.

OBJECTIVE

To introduce a new type of atlantoaxial rotatory fixation (AARF) with a locked C1-C2 lateral facet and evaluate its therapeutic strategy.

SUMMARY OF BACKGROUND DATA

AARF presenting with torticollis and limited neck motion is commonly seen in teenagers. Fielding and Hawkins' classification is generally applied to AARF. Although conservative treatment is effective for acute AARF, it is often unsuccessful for chronic AARF, which ultimately requires surgery. We introduce a new type of chronic AARF with a locked C1-C2 lateral facet that does not fit into Fielding and Hawkins' classification and describe the appropriate treatment.

METHODS

Eight patients who had chronic AARF with a unilaterally locked C1-C2 lateral facet were referred to our clinic. Reduction had failed after traction for 3 to 4 weeks. After open release and reduction using the anterior retropharyngeal approach, we applied posterior C1-C2 transpedicular screw fixation with an autologous iliac bone graft for stage I or II.

RESULTS

The anterior retropharyngeal approach provided direct access to the C1-C2 locked lateral facet. The patient in an overall poor condition (stage II) underwent delayed posterior C1-C2 arthrodesis. The others (stage I) underwent immediate posterior C1-C2 arthrodesis. All patients were followed up for an average of 14.8 months (5-37 mo). Three-dimensional computed tomography revealed C1-C-2 arthrodesis bone graft fusion after an average of 3.1 months (2-4 mo). There was no recurrence of symptoms and no dislocations or internal fixation device loosening or breakage.

CONCLUSION

AARF with a locked C1-C2 lateral facet is a new type of AARF that cannot be classified using Fielding and Hawkins' classification. The anterior retropharyngeal approach for the release and reduction of AARF, followed by posterior C1-C2 arthrodesis is an effective therapeutic strategy for AARF with a locked C1-C2 lateral facet.

LEVEL OF EVIDENCE

4.

Current Trends in Management of Atlantoaxial Dislocation

Atlantoaxial dislocation (AAD), often caused by trauma, tumors or congenital malformations, is a challenging disorder of the craniocervical junction. Because of its deep location and intricate anatomic structure, the craniocervical junction is always a difficult region for spine surgery. With recent developments in medical science, great progress has been made in the diagnosis and treatment of AAD such that more instructive clinical classifications and efficacious treatment strategies, various novel operation techniques including innovative posterior or transoral anterior reduction, and novel fixation instruments are now widely used in clinical practice for managing AAD. However, surgeons continue to face more special characteristics and difficulty in carrying out upper cervical surgery than they encounter in other regions of the spine. Consequently, this high risk surgery should only be performed by extremely skilled and experienced surgeons and only when stringent indications have been met. Therefore, the aim of this course is to assist surgeons who are dealing with AAD by providing comprehensive information about AAD, including related anatomy, classification, clinical manifestations and diagnosis, imaging examinations and surgical techniques, thus decreasing the occurrence of complications and improving the level of diagnosis and treatment.

Atlantoaxial rotatory subluxation in children

Atlantoaxial rotatory subluxation is a rare condition in which patients present with the acute onset of torticollis. Atlantoaxial rotatory subluxation represents a spectrum of disease from muscle spasm to a fixed mechanical block to reduction of the atlantoaxial complex. If left untreated, some cases may resolve spontaneously; however, other cases may result in the development of secondary changes in the bony anatomy of the atlantoaxial joint, leading to persistent deformity. Diagnosis of the condition is largely clinical but can be aided by various imaging modalities, including radiographs, dynamic CT scanning, three-dimensional CT reconstructions, or MRI. Consideration should always be given to infection or other inflammatory disease as an underlying, precipitating cause. Treatments include observation, the use a cervical collar and analgesics, halter or skeletal traction, and posterior fusion of C1-C2. The most important factor for success of conservative treatment is the time from the onset of symptoms to recognition and the initiation of treatment.

A morphologically atypical case of atlantoaxial rotatory subluxation

A rare case of atlantoaxial rotatory subluxation occurred after pediatric cervical spine surgery performed to remove a dumbbell-shaped meningioma at the level of the C1/C2 vertebrae. This case is classified as a post-surgical atlantoaxial rotatory subluxation, but has a very rare morphology that has not previously been reported. Although there are several reports about post-surgical atlantoaxial rotatory subluxation, an important point of this case is that it might be directly related to the spinal cord surgery in C1/C2 level. On day 6 after surgery, the patient presented with the Cock Robin position, and a computed tomography scan revealed a normal type of atlantoaxial rotatory subluxation. Manual reduction was performed followed by external fixation with a neck collar. About 7 months after the first surgery, the subluxation became severe, irreducible, and assumed an atypical form where the anterior tubercle of C1 migrated to a cranial position, and the posterior tubercle of C1 and the occipital bone leaned in a caudal direction. The pathogenic process suggested deformity of the occipital condyle and bilateral C2 superior facets with atlantooccipital subluxation. A second operation for reduction and fixation was performed, and the subluxation was stabilized by posterior fixation. We encountered an unusual case of a refractory subluxation that was associated with an atypical deformity of the upper spine. The case was successfully managed by posterior fixation.

Combined Chronic Occipito-atlantal and Atlanto-axial Rotator Fixation with Cerebral Palsy

Occipito-atlantalrotatory subluxation that occurs in conjunction with atlanto-axial rotator fixation is extremely rare. The common clinical characteristics are painful torticollis and cock robin position presented with the head tilted to one side and rotated to the other side. The object of this report is to emphasize that AARF combined with OARF may be caused by a variety of conditions, to be must need algorithm for proper management, apparently. A torticollis patient who had cerebral palsy presented with severe nuchal pain and wryneck for a long period. The patient had a history of fallen down 16 years ago which caused severe nuchal pain. The conservative management had failed to correct the deformity and instability. we decided to operate using occiput-C1-C2 arthrodesis and C3-4-5 bilateral screw fixation for reinforcement. Now he doesn't have neurologic deficit and shows good outcome enough to sustain his head, not using his hands, in his daily life.

Atlantoaxial rotatory fixation in a child after bilateral otoplastic surgery

Atlantoaxial rotatory fixation (AARF), which is a dislocation or subluxation of the atlantoaxial joint, is a well-recognized condition in children. We present a case of AARF after otoplastic surgery for bilateral cryptotia performed by plastic surgeons. The pediatric patient presented with neck pain and torticollis after the surgery, and an orthopedic surgeon diagnosed AARF. The patient was treated successfully with conservative treatment incorporating mild manual manipulation, neck traction, and a collar for 1.5 months. Physicians should consider the possibility of AARF when a patient presents with neck pain and torticollis after otoplastic surgery; diagnosis and treatment should be started immediately.

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).

Atlantoaxial rotatory fixation--a cause of torticollis

BACKGROUND

A rare, but important cause of torticollis in children is atlantoaxial rotatory fixation. If the patient remains undiagnosed for more than three months, surgery is generally the only therapeutic alternative. In this article we present our experiences of surgical treatment of late-diagnosed atlantoaxial rotatory fixation in children.

MATERIAL AND METHOD

This article is based on a review of the case notes of patients who underwent surgery for atlantoaxial rotatory fixation in the Department for Neurosurgery at Oslo University Hospital, Rikshospitalet, during the period 2004-10.

RESULTS

The material sample consists of six children aged from seven to 14 years. Five had suffered minor trauma to the upper neck region, while one had had an upper respiratory tract infection. The diagnosis was made 5-36 months after the onset of symptoms. In three of the patients, an attempt was made at closed reduction without success. A CT scan one year postoperatively showed a normal position of the atlantoaxial joint in two patients and partial reduction in three. In the sixth patient there was bone fusion at the time of the operation, and open reduction was unsuccessful. All six patients had reduced rotational movement of the neck at the one-year check-up.

INTERPRETATION

All our patients were diagnosed more than five months after the onset of symptoms. Full or partial reduction was achieved in five of the six.