Atlantoaxial Rotatory Fixation Research Articles

Cervical vertigo due to rotational fixation of atlantoaxial joint combined with benign paroxysmal positional vertigo: A case report and literature review.

Vertigo is the most common clinical complaint, misdiagnosed patients are not rare, so it is very important to exclude and identify vertigo. For vertigo caused by multiple causes, including cervical vertigo with atlantoaxial rotation fixation combined with benign paroxysmal positional vertigo (BPPV), tuina can correct joint misalignment. The reduction technique will return the fallen otolith to the correct position. The use of massage and reduction can improve clinical symptoms and improve quality of life and may be a simple, safe, and effective treatment strategy for this disease. We report on a patient with both cervical vertigo due to atlantoaxial rotational fixation and BPPV, including his imaging examination, clinical manifestations, and treatment methods. Cervical vertigo (atlantoaxial rotatory fixation) and BPPV. Tuina combined with atlantoaxial directional inverted reduction technique and reduction manipulation. The patient's vertigo symptoms improved significantly, nystagmus disappeared, cervical occipital pain, nausea, head distension, and other symptoms disappeared, and cervical motion rotation reached 60°. This study proved the effectiveness of massage combined with a reduction in the treatment of cervical vertigo and BPPV, as well as the importance of vertigo diagnosis and differential diagnosis, and provided a new treatment idea for the future diagnosis and treatment of vertigo caused by a variety of causes.

Reliability and validity of the pediatric adaptation of the mJOA scale for evaluating cervical spine disorders.

The study aimed to evaluate the validity and reliability of the pediatric adaptation of the Japanese Orthopedic Association (mJOA) scale in pediatric patients with various cervical spine pathologies. Initial assessments were performed by a neurosurgeon, followed by an independent evaluation by a neurologist within 1-2days to test inter-rater reliability. The same clinician assessed the same group of children using the adapted mJOA scale at different point in time (between 1month and 1year after the initial assessment) to test intra-rater reliability. For known-groups validity, the pediatric mJOA scale assessments were compared between two groups of pathologies with different prognosis. Concurrent validity was assessed against the McCormick scale, and convergent validity was tested by reassessing patients using the adult mJOA scale two or more years after the initial assessment by pediatric one. A cohort of 169 pediatric patients aged 6months to 18years (mean age: 10 ± 4.6years) with various cervical spine pathologies was recruited. Pathologies included atlanto-axial rotatory fixation (AARF), Chiari type I anomaly, congenital cervical spine scoliosis, atlanto-axial dislocation (AAD) and instability (AAI), cervical spine stenosis and trauma, and congenital cervicothoracic dislocations. The majority of patients underwent cervical spine surgery and were followed up for an average of 6.9 ± 2.97years. The pediatric mJOA scale demonstrated high inter-rater reliability (r = 0.99, p < 0.0001) and strong intra-rater reliability (r = 0.82, p < 0.0001). Significant differences in pediatric mJOA scores were observed between patients with expected-intact neurological status and those with expected-pathological neurological status (p < 0.0001). The pediatric mJOA scale showed a strong correlation with the McCormick grading system (r = 0.97, p < 0.001) and good correlation with the adult mJOA scale during long-term follow-up (r = 0.82, p < 0.0001). The pediatric version of the mJOA scale is a reliable and valid tool for assessing pediatric patients with cervical spine disorders. Its high reliability and validity support its use in both clinical practice and research.

Traumatic atlantoaxial rotatory fixation in adults: a systematic review of published cases.

Atlantoaxial rotatory fixation (AARF) in adults is a rare and clinically challenging condition characterized by a spectrum of etiological factors, predominantly attributed to traumatic and inflammatory pathologies within the craniovertebral region. Trauma is the most frequently identified cause within the adult population, with the first case report published in 1907. This study aims to conduct a systematic review that addresses the clinical presentations and management strategies relating to traumatic atlantoaxial rotatory fixation in adults. A comprehensive search of the PubMed database was executed, adhering to the PRISMA guidelines. The inclusion criteria encompassed case reports and series documenting AARF cases in individuals aged 18 and above, spanning database inception to July 2022. Studies not published in the English language were excluded. A total of 61 articles reporting cases of AARF in the adult population were included in the study. The mean age of affected individuals was 36.1years (± 15.6), with a distribution of 46% females and 54% males. Predominant mechanisms of injury included motor vehicle accidents and falls, constituting 38% and 22% of cases, respectively. Among the classification systems employed, Fielding and Hawkins type I accounted for the majority at 63%, followed by type II at 10%, and type III at 4%. Conservative management was used for treatment in 65% of acute (65%) cases and 29% of chronic cases. Traumatic AARF is a rare phenomenon in the adult population, is more common in younger adults, and does not often present with neurologic deficits. Patients diagnosed acutely are more likely to be successfully treated with conservative management, while patients diagnosed chronically are less likely to be reduced with conservatively and often require surgical treatment. Surgery should be considered for patients with irreducible dislocations, ligamentous injuries, unstable associated fractures, and persistent pain resistant to conservative management.

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.

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. 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.

Retrospective analysis of atlantoaxial rotatory fixation describing age distribution and gender ratio in children and adolescents: A preliminary report

IntroductionAtlantoaxial rotatory fixation (AARF) in children presents with an acute onset of neck pain. Almost all cases heal within a few days of onset and are treated conservatively. Because few cases of AARF have been reported, the age distribution or gender ratio of AARF in the child population have not been described enough. In Japan, the social insurance system covers all citizens. Thus, we used insurance claims data to investigate the features of AARF. The aim of this study is to examine the age distribution, compare gender ratio and determine the recurrence proportion of AARF. MethodsWe used the JMDC database to search for claims data submitted between January 2005 and June 2017 for cases of AARF in patients aged <20 years. ResultsWe identified 1949 patients with AARF, of which 1102 (56.5%) were male. The mean age was 98.3 ± 42.2 months and 91.6 ± 38.4 months in males and females, respectively, and males with AARF were significantly older at onset than females with AARF (p < 0.001). In both sexes, the highest frequency of AARF occurred when the patient was 6 years old. There were 121 (6.2%) cases of recurrent AARF (male: 61, 5.5%; female: 60, 7.1%), but the age differences between the sexes in these cases were not statistically significant. ConclusionsThis is the first report to describe the characteristics of the study population of AARF. Males were more likely to suffer from AARF than females. Furthermore, age (in months) at AARF onset was significantly higher in males than in females. Recurrence rate was not significant in both sexes.

Comparison of surgical outcomes of C1-2 fusion surgery between O-arm-assistedoperation and C-arm assisted operation in children with atlantoaxial rotatory fixation.

Placement of the pedicle screw is technically challenging during C1-2 fusion surgery in children and different intraoperative image-guided systems have been developed to reduce the risk of screw malposition. The purpose of the present study was to compare surgical outcomes between C-arm fluoroscopy and O-arm navigated pedicle screw placement in the treatment of atlantoaxial rotatory fixation in children. We retrospectively evaluated charts of all consecutive children with atlantoaxial rotatory fixation who underwent C-arm fluoroscopy or O-arm navigated pedicle screw placement from April 2014 to December 2020. Outcomes including operative time, estimated blood loss (EBL), accuracy of screw placement (Neo's classification) and completed fusion time were evaluated. A total of 340 screws were placed in 85 patients. The accuracy of screw placement of the O-arm group was 97.4%, which was significantly higher than that of the C-arm group (91.8%). Both groups had satisfied bony fusion (100%). Statistical significance (230.0 ± 34.6 ml for the C-arm group and 150.6 ± 47.3 ml for the O-arm group, p < 0.05) was observed with respect to the median blood loss. There were no statistically significant difference (122.0 ± 16.5 min for the C-arm group and 110.0 ± 14.4 min for the O-arm group, p = 0.604) with respect to the median operative time. O-arm-assisted navigation allowed more accurate screw placement and less intraoperative blood loss. Both groups had satisfied bony fusion. O-arm navigation did not prolong the operative time despite the time required for setting and scanning.

Treating Pediatric Irreducible Atlantoaxial Rotatory Fixation (IAARF) by Unlocking Facet Joint Through Transoral Approach and Fixing With Slim-TARP Plate (15 Cases Series).

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. 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. 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. 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. Transoral release and fixation with slim-TARP plate by transoral approach is a feasible and safe method for treating pediatric irreducible atlantoaxial rotatory fixation.

One-Stage Anterior Retropharyngeal Release Followed by Posterior Open Reduction and Intra-Articular Cage Fusion for Treating Chronic Fixed Type III Atlantoaxial Rotatory Fixation

To verify the effectiveness of anterior retropharyngeal release followed by posterior open reduction using long arm reduction screws combined with intra-articular fusion with a cage filled with the local autologous bone for treating fixed Type III atlantoaxial rotatory fixation (AARF). Data from 6 children with fixed AARF were retrospectively reviewed. All patients underwent anterior retropharyngeal release followed by posterior open reduction using long-arm reduction screws combined with intra-articular fusion with a cage filled with local autologous bone. Outcomes were measured using the atlantodental interval value, the Japanese Orthopedic Association score and visual analog scale for neck pain. Patient age, sex, operation time, blood loss, and bone fusion time were recorded. Complications related to the operation were also recorded. All patients achieved complete reduction and solid bone fusion at follow-up. The atlantodental interval dropped to 2.1±0.5mm after the operation from a preoperative score of 15.3±3.1mm(P<0.05). Japanese Orthopedic Association score significantly improved from a preoperative score of 15.3±0.5 to 17±0 at the final follow-up (P<0.05). Visual analog scale for neck pain markedly decreased from preoperative 4.5±1.0 to 0.2±0.4 at the final follow-up (P<0.05). No complication related to the surgical approach or instrumentation was observed. One-stage anterior retropharyngeal release followed by posterior open reduction combined with intra-articular cage fusion is effective in treating chronic fixed type III AARF.

Clinical Features of Kawasaki Disease With Atlantoaxial Rotatory Fixation.

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

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.

上気道感染後に生じた環軸椎回旋位固定例

上気道感染後に生じた環軸椎回旋位固定例

Halter Traction for the Treatment of Atlantoaxial Rotatory Fixation.

Atlantoaxial rotatory fixation (AARF) comprises a spectrum of abnormal rotational relationships between C1 (atlas) and C2 (axis). We aimed to evaluate the efficacy and long-term clinical outcomes of halter traction in treating patients diagnosed with primary AARF. We included patients <18 years of age who presented with new-onset painful torticollis, neck pain, and sternocleidomastoid muscle spasm, had an AARF diagnosis confirmed by use of 3-dimensional dynamic computed tomography, received in-hospital cervical halter traction under our treatment protocol, and were followed for ≥12 months. Radiographic and long-term clinical outcomes were analyzed. A total of 43 patients (31 male and 12 female; average age of 7.9 years) satisfied the inclusion criteria. There were 5 acute, 6 subacute, and 32 chronic cases. The mean duration of initial symptoms prior to treatment was 12.1 weeks. Thirty-seven (86.0%) of the patients experienced previous minor trauma, and 6 (14.0%) had a recent history of upper-respiratory infection (Grisel syndrome). The mean duration of in-hospital traction was 17.6 days. The mean follow-up period was 8.5 years. Forty-two (97.7%) of the patients achieved normal cervical alignment after treatment. One patient (2.3%) had recurrence and received a second course of halter traction, with cervical alignment restored without any surgical intervention. No neurological deficits were noted during or after the treatment. No major complications were observed. Normal anatomy and restoration of cervical alignment can be achieved by cervical halter traction in most cases of AARF. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Feasibility and Safety of Goel-Harms Posterior C1-C2 Fusion in the Management of Pediatric Reducible Atlantoaxial Instability

Pediatric atlantoaxial instability (AAI) is not common and could be a serious clinical condition. The Goel-Harms technique is one of the most used techniques in adults and needs more evaluation in pediatric populations. This study reports the feasibility and safety of the Goel-Harms technique in the treatment of pediatric reducible AAI. In this retrospective cohort study we reported all pediatric patients who underwent Goel-Harms technique for AAI with a minimum 1-year follow up. Patients were clinically assessed using the Japanese Orthopedic Association (JOA) score and radiologically with plain radiographs, computed tomography scan, and magnetic resonance imaging of the craniocervical region. Postoperatively, patients were followed up according to our clinical and radiographic imaging protocol. The following parameters were recorded: JOA score, construct stability, fusion, and abnormal events. A total of 25 patients have completed a 1-year follow-up and fulfilled our criteria. The mean age was 10.68 ± 4.47 (range, 3-17) years. Fifteen patients were male and 10 were female. The final diagnosis included Down syndrome (DS) in 8, type II dens fracture in 7, os odontoideum in 3, and atlantoaxial rotatory fixation in 7. The mean follow-up was 21.76 ± 8.22 months. The preoperative JOA score improved from 15.96 ± 1.46 to 16.76 ± 1.92 at the last follow-up. Sound bone fusion was reported in 92% of patients. Our data suggest that the Goel-Harms technique is a safe, feasible, and effective procedure in managing pediatric reducible AAI. Special perioperative care should be offered to young AAI patients with DS.

Atlantoaxial Rotatory Fixation after Microtia Reconstruction Surgery.

Background:Nontraumatic atlantoaxial rotatory fixation after microtia reconstruction surgery is a rare complication. Intraoperative cervical hyperextension and/or excessive rotation and postoperative inflammation have been reported as causes of atlantoaxial rotatory fixation. We herein describe cases of atlantoaxial rotatory fixation after microtia reconstruction surgery.Methods:This was a retrospective study of 80 patients (165 surgeries) who underwent microtia reconstruction surgery in Dokkyo Medical University Hospital between April 2006 and December 2012. The patient- and operation-related variables were obtained from medical charts. Neck radiographs and computed tomography scans of patients with atlantoaxial rotatory fixation were evaluated to check for cervical spine abnormalities.Results:Five cases of atlantoaxial rotatory fixation after microtia reconstruction surgery were recorded. Three of these five cases were diagnosed with Klippel-Feil syndrome after the onset of atlantoaxial rotatory fixation. No significant difference was found in the operative duration and other variables between patients with atlantoaxial rotatory fixation and those without. All patients immediately underwent conservative treatment and showed complete recovery and no recurrences.Conclusions:Although atlantoaxial rotatory fixation is a rare complication, surgeons should consider it in patients with neck problems following microtia reconstruction surgery. A patient with microtia may have unrecognized Klippel-Feil syndrome. Patients with Klippel-Feil syndrome are more likely to develop atlantoaxial rotatory fixation, which may have severe consequences. Thus, it is crucial to preoperatively identify Klippel-Feil syndrome with neck radiography and to detect atlantoaxial rotatory fixation at the earliest.

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.

Successful Closed Reduction of Atlantoaxial Rotatory Fixation in Children-A Retrospective Study of 30 Patients.

Study Design:Retrospective cohort study.Objectives:To review our treatment experience and to investigate the process of this disease.Methods:Clinical data of AARF patients, who received closed reduction, was retrospectively reviewed. Patients were divided into 2 groups according to the length of delay (Group I: 1 month ≤ delayed time < 3 months), Group II (delayed time < 1 months). The correlation between the length of delayed time and clinical recovery (CR), radiological recovery (RR), and total recovery time were measured. The atlantodental interval (ADI), lateral mass-dens interval (LDI) and lateral joint space (LJS) were compared at admission and final follow-up.Results:30 children (12 girls and 18 boys) with AARF had received conservative treatment. The mean age at initial treatment was 8.13-year-old, ranging from 5 to 14. The mean follow-up time was 26.93 months (range, 6-87 months). The average length of delayed time was 28.53 days (range, 2-80 days). When the LDI, LJS, and ADI differences are compared at admission and the final visit, the differences are reduced significantly on LDI and LJS. A positive correlation is observed between the length of the delay and CR time and total recovery time (r = 0.63, p = 0.00 and r = 0.47, p = 0.01) respectively.Conclusions:Pediatric AARF patients who have a delay time < 3 months can be treated with closed reduction successfully. The longer the delayed time, the longer the traction time, but the cervical collar time is almost the same. The LDI and LJS on the anteroposterior of X-rays are convenient to estimate the progress of this condition during the treatment.

Primary treatment of atlantoaxial rotatory fixation in children: a multicenter, retrospective series of 125 cases.

The primary treatment for atlantoaxial rotatory fixation (AARF) remains controversial. The aim of this study was to investigate the primary treatment for AARF and create an algorithm for primary treatment. The authors analyzed the data of 125 pediatric patients at four medical institutions from April 1989 to December 2018. The patients were reported to have neck pain, torticollis, and restricted neck range of motion and were diagnosed according to the Fielding classification as type I or II. As a primary treatment, 88 patients received neck collar fixation, and 28 of these patients did not show symptom relief and required Glisson traction. Thirty-seven patients were primarily treated with Glisson traction. In total, 65 patients, including neck collar treatment failure patients, underwent Glisson traction in hospitals. The success rate of treatment was significantly higher in the Glisson traction group (97.3%) than in the neck collar fixation group (68.2%) (p = 0.0001, Wilcoxon test). In the neck collar effective group, Fielding type I was more predominant (p = 0.0002, Wilcoxon test) and the duration from onset to the first visit was shorter (p = 0.02, Wilcoxon test) than that in the neck collar ineffective group. Using multivariate logistic regression analysis with the above items, the authors generalized from the estimated formula: logit [p(success group by neck collar fixation group)|duration from onset to the first visit (x1), Fielding type (x2)] = 0.4(intercept) - 0.15x1 + 1.06x2, where x1 is the number of days and x2 = 1 (for Fielding type I) or -1 (for Fielding type II). In cases for which the score is a positive value, the neck collar should be chosen. Conversely, in cases for which the score is a negative value, Glisson traction should be the first choice. According to this formula, in patients with Fielding type I AARF, neck collar fixation should be allowed only if the duration from onset is ≤ 10 days. In patients with Fielding type II, because the score would be a negative value, Glisson traction should be performed as the primary treatment.

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

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. 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. 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. 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.

Atlantoaxial rotatory fixation in childhood: a staged management strategy incorporating manipulation under anaesthesia

AimsThe aims were to evaluate the safety of manipulation under anaesthesia (MUA) for atlantoaxial rotatory fixation (AARF) and the relative efficacy of rigid collar vs halo-body orthosis (HBO) in avoiding relapse and the need for open surgery.MethodsCases of CT-verified AARF treated by MUA were identified from a neurosurgical operative database. Demographic details, time to presentation and aetiology of AARF were ascertained through case note review. Cases were divided according to method of immobilisation after successful reduction, either rigid collar (group 1) or HBO (group 2). The primary outcome measure was relapse requiring open surgical arthrodesis.ResultsThirty-three patients (2.2–12.7 years) satisfied inclusion criteria. Time to presentation varied from 1 day to 18 months. There were 19 patients in group 1 and 14 in group 2. There were no adverse events associated with MUA. 9/19 (47%) patients in group 1 resolved without need for further treatment compared with 10/14 (71%) in group 2 (p = 0.15). Of the 10 patients who failed group 1 treatment, four resolved after HBO. A total of ten patients (30%) failed treatment and required open surgery.ConclusionsMUA is a safe procedure for AARF where initial conservative measures have failed. MUA followed by immobilisation avoids the need for open surgery in over two thirds of cases. Immobilisation by cervical collar appears equally effective to HBO as an initial management, and so a step-wise approach may be reasonable. Delayed presentation may be a risk factor for relapse and need for open surgery.

環軸椎後方固定術を施行した環軸椎回旋位固定（Fielding type IV）の1例

環軸椎後方固定術を施行した環軸椎回旋位固定（Fielding type IV）の1例