Combined occipitoatlantoaxial rotatory fixation

Concomitant atlantoaxial and atlanto-occipital rotatory dislocation in children: Radiological features, diagnostic pitfalls, and long-term outcome

While the pathological manifestation of atlantoaxial rotatory dislocation has been well described in the medical literature, the combined dislocation of the atlantoaxial and atlanto-occipital joints, or OAARD - short for occipital-atlantoaxial rotatory dislocation - is a condition which has been poorly elucidated and probably underdiagnosed. We believe that the pathogenesis of combined atlantoaxial and atlanto-occipital dislocation is most likely a result of untreated atlantoaxial rotatory dislocation leading to chronic secondary compensation measures occurring at the occiput-C1 joints. Unique clinical and radiological features lead to difficulty in diagnosis, and conventional treatment algorithms may not apply. This paper describes a combination of clinical and radiological features which can help clinicians correctly diagnose and treat OAARD.

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.

Juvenile chronic arthritis and the craniovertebral junction in the paediatric patient: review of the literature and management considerations

INTRODUCTION

Juvenile chronic arthritis (JCA) is a systemic disease of childhood affecting particularly joints. JCA is a heterogeneous group of inflammatory joint disorders with onset before the age of 16 years and is comprised of 7 subtype groups. The pathogenesis of JCA seen in the cervical spine is synovial inflammation, hyperaemia, and pannus formation at the occipitoatlantoaxial joints resulting in characteristic craniovertebral junction findings. Treatment of craniovertebral junction instability as a result of JCA is a challenge. The best treatment strategy may be difficult because of various radiological and clinical severities. A review of the literature and management considerations is presented.

REVIEW

No randomised controlled trial or systematic review on this subject has been published. Only experts' opinions, case reports, and case series have been described. Thirty-four studies have been reviewed in this study. Involvement of the cervical spine in patients with JCA can lead to pain and functional disability. The subtypes that usually affect the cervical spine are the polyarticular type and systemic onset type and rarely the pauciarticular type. The most common cervical spine changes related to JCA are as follows: (1) apophyseal joint ankylosis at C2-C3, (2) atlantoaxial subluxation, (3) atlantoaxial impaction, (4) atlantoaxial rotatory fixation, and (5) growth disturbances of the cervical spine. The incidence of severe subluxations has decreased in the last decade as result of antirheumatoid drugs and biologicals. However, neurological compromise still occurs in JCA patients necessitating surgical treatment.

CONCLUSION

Whenever the cervical spine is involved in rheumatoid arthritis patients without neurological deficits, conservative treatment is legitimate. Once patients develop neurological signs and symptoms, surgical treatment should be considered with particular focus to age, severity of the disease, and general health condition. Skilled anaesthesia is crucial and the surgical procedure should only be carried out in centres with experience in craniovertebral junction abnormalities.

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.