Open Reduction of Traumatic Atlanto-Axial Rotatory Dislocation with Use of the Extreme Lateral Approach. A Report of Two Cases*

Abstract

Irreducible rotatory injuries at the atlanto-axial level in children may result in torticollis and facial asymmetry4,10,22,25,35. The terminology associated with traumatic rotatory injuries at this level is somewhat confusing, and a clear distinction should be made between rotatory subluxation and rotatory dislocation, as the mechanisms of injury and the optimum management may differ. In this report, we use the term atlanto-axial rotatory dislocation to define a complete and persistent displacement of the adjacent articular surfaces at this level. Ideally, early closed manipulative reduction with use of distraction and derotation with spinal cord monitoring, followed by external bracing, restores both normal anatomical relationships and mobility in many patients. In some patients, however, the maneuver fails, and often the joint fuses spontaneously in malalignment. The exact cause of failure to achieve reduction is unclear. The purpose of this report is to describe our operative approach and findings in two patients who had atlanto-axial rotatory dislocation. These findings provide new information on the pathomechanics of irreducible atlanto-axial rotatory dislocation that distinguish it from rotatory subluxation. Furthermore, this approach allows for the correction of the deformity. The technique that we describe could potentially be associated with serious problems, such as damage to the neuraxis and vertebral artery, but it is the only method, to our knowledge, that allows restoration of normal anatomical relationships. The operation should not be performed by a surgeon who only occasionally operates on the cervical spine. CASE 1. A ten-year-old girl had a biopsy of a lymph node in the posterior triangle on the right side of the neck under general anesthesia in November 1990. She awoke with severe neck pain accompanied by dysesthesia over the occiput and neck and had torticollis; she had never had a previous episode of …