Posttraumatic atlantoaxial rotatory dislocation in a healthy adult patient: a case report and review of the literature

Management of Adult Atlantoaxial Rotatory Fixation: Case Series with Literature Review

Background

Atlantoaxial rotatory fixation (AARF) is extremely rare in adults, and there is no consensus on the ideal treatment of adult AARF because of its rarity. We presented a case series of three adult AARFs and reviewed the literature on adult AARFs. We suggest treatment guidelines for the injury based on the literature review.

Methods

We compiled a series of three adult AARFs seen in our hospital. We also utilized the NCBI library to retrieve literature on adult AARF from 2000 to 2021. We included articles on adult AARF, which described the number of days from injury to diagnosis, Fielding classification, occurrence of associated cervical injuries, and details of treatment and the results.

Results

Thirty adult AARFs reports fulfilled the criteria and 32 patients were analyzed. Eighteen patients had Fielding Type 1 AARF and were diagnosed within 1 month of injury. Among them, 13 cases healed with conservative treatment. Patients with acute AARF of Fielding Type 1 who underwent manual reduction healed successfully. All patients that required more than 1 month from injury to diagnosis underwent surgery. All cases with AARF Fielding Types 2, 3, and 4 failed conservative treatment.

Conclusion

The case series and literature review suggest that early diagnosis of adult AARF is essential for successful closed reduction, and the Fielding classification may help determine treatment strategy. Furthermore, this study showed that not only traction but also manual reduction may be a useful treatment for early diagnosed AARF Fielding Type 1 without complications. Level of Evidence: III.

Does alar ligament injury predict conservative treatment failure of atlantoaxial rotatory subluxation in adults: Case report and review of the literature

INTRODUCTION

The alar ligament is an important structure in restraining the rotational movement at the atlantoaxial joint. While bony fractures generally heal, rupture of ligaments may heal poorly in adults and often requires surgical stabilization. Atlantoaxial rotatory subluxation (AARS) is a rare injury in adults, and the prognostic importance of the presence of alar ligament injury with regard to the success of nonoperative management is unknown.

CASE PRESENTATION

A 28-year-old woman presented after a traumatic Type I AARS without evidence of osseous injury, but MRI demonstrated evidence of unilateral alar ligament disruption. Initial conservative management with closed reduction and maintenance in a rigid cervical collar proved unsuccessful, with worsening pain and failure to maintain reduction. She subsequently underwent open reduction and surgical fixation of C1-C2, resulting in resolution of her pain and maintenance of alignment.

DISCUSSION

Alar ligament rupture may be a negative prognostic indicator in the success of nonoperative management of type I atlantoaxial rotatory subluxation. Additional study is warranted to better assess whether the status of the alar ligament should be considered an important factor in the management algorithm of type I AARS.

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.

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.

Multidetector Computed Tomography and Magnetic Resonance Imaging Evaluation of Craniovertebral junction Abnormalities

BACKGROUND

Craniovertebral junction (CVJ) abnormalities constitute an important group of treatable neurological disorders with diagnostic dilemma. Their precise diagnosis, identification of probable etiology, and pretreatment evaluation significantly affects prognosis and quality of life of patients.

AIMS

The study was to classify various craniovertebral junction disorders according to their etiology and to define the importance of precise diagnosis for pretreatment evaluation with multidetector computed tomography (MDCT) and magnetic resonance imaging (MRI).

MATERIALS AND METHODS

This is a prospective observational study of 62 patients referred to our department between October 2012 and September 2014. All patients suspected to have a craniovertebral junction disorder were included in the study, from all age groups and both genders. Detailed clinical history was taken. Radiographs of cervical spine were collected if available. All patients were subjected to MDCT and/or MRI.

RESULTS

In our study of 62 patients; 39 were males and 23 were females, with male to female ratio of 1.6:1. Most common age group was 2(nd) -3(rd) decade (19 patients, 30.64%). Developmental anomalies (33 patients, 53.22%) were the most common etiology group followed by traumatic (10 patients, 16.12%), degenerative (eight patients, 12.90%), infective (four patients, 6.45%), inflammatory and neoplastic (three patients each, 4.8%), and no cause found in one patient.

CONCLUSIONS

CVJ abnormalities constitute an important group of treatable neurological disorders, especially in certain ethnic groups and are approached with much caution by clinicians. Thus, it is essential that radiologists should be able to make a precise diagnosis of craniovertebral junction abnormalities, classify them into etiological group, and rule out important mimickers on MDCT and/or MRI, as this information ultimately helps determine the management of such abnormalities, prognosis, and quality of life of patients.

Traumatic atlantoaxial rotatory fixation associated with C2 articular facet fracture in adult patient: Case report

Traumatic atlantoaxial rotatory fixation is a very rare injury in adults which is often misdiagnosed initially. Its combination with C2 fractures is predominated by dens lesions. Therapeutic management is challenging because of the difficulty to achieve optimal reduction and permanent stability. We report a rare case of traumatic atlantoaxial rotatory fixation in a 56-year-old women associated with C2 articular facet fracture successfully treated by conservative means after patient-awake manual reduction with optimal functional and radiographic outcome.