Atlanto-axial subluxation with cervical myelopathy operated with occipital C2 fusion: A case report

Krutarth Shah,Rahul Kadam,Sunil Yadav,Vishal Bauva

doi:10.15419/jmri.3

Abstract

Background: Atlantoaxial subluxation with cervical myelopathy is a rare condition that can occur mainly by trauma followed by Rheumatoid arthritis, Grisel syndrome, Down’s syndrome and various other metabolic disorders. It is characterized by excessive movement of atlas (C1) over axis (C2) either by bony or ligamentous abnormality. Due to its laxity the spinal cord may get damaged and cause neurologic symptoms. Reduction and fixation is needed for such instability. Case Report: This 55-year-old gentleman was apparently all right 4 years back when he gradually developed difficulty in walking and imbalance. Bilateral Babinski sign was positive, All deep tendon reflexes were brisk; muscle tone was increased with clasp-knife spasticity present in all four limbs. Ankle and patellar clonus was present bilaterally. His X-ray cervical spine showed C1-C2 subluxation in flexion and extension views. Magnetic resonance imaging (MRI) of Cranio-vertebral junction. Mild subluxation of atlantoaxial joint (3.1 mm) with posterior displacement of dens causing narrowing of bony cervical spinal canal with reduced distance between posterior aspect of dens of C2 and anterior aspect of posterior arch of C1 vertebrae was noticed. Atlas was also slightly displaced anteriorly in relation to baso-occiput. We managed this patient with occipital cervical fusion after reduction from a posterior approach using screws and rods construct and fusion with bone graft from iliac crest. Post operatively the patient was able to walk without any support and tone of the muscles in lower limb decreased, no tingling or numbness are present, no signs of local infection or inflammation. Conclusion: We suggest to operate atlanto-axial subluxation and cervical myelopathy with occipital C2 fusion.

Highlights

Atlantoaxial subluxation (AASL) is rare and mostly follows trauma but in our case the etiology was a degenerative cause to the cranio-vertebral junction (CVJ) [1]
We describe a patient with isolated ligamentous injury, without any fractures at CVJ and with neuro deficit managed with occipital cervical fusion
It is a rare case as most of the subluxation are a cause of trauma, Grisel syndrome or RA but this is a case of chronic degeneration of the transverse ligament leading to subluxation eventually leading to myelopathy of cervical spine

Summary

Introduction

Atlantoaxial subluxation (AASL) is rare and mostly follows trauma but in our case the etiology was a degenerative cause to the cranio-vertebral junction (CVJ) [1]. Closed reduction and collar immobilization has been reported to be successful in a few cases though intact transverse axial ligament (TAL) is a prerequisite for conservative management [1,3]. We describe a patient with isolated ligamentous injury, without any fractures at CVJ and with neuro deficit managed with occipital cervical fusion.

Results

Conclusion