Cervical Spine Instability Research Articles

Prevalence and aggravation of cervical spine instabilities in rheumatoid arthritis during over 10 years: a prospective multicenter cohort study.

We designed a prospective multicenter cohort study to clarify along-term, > 10-year prevalence and aggravation of cervical spine instabilities in rheumatoid arthritis (RA). In 2001-2002, 634 outpatients were enrolled, and 233 (36.8%) were followed for > 10 years. Cervical spine instability was defined as atlantoaxial subluxation (AAS, > 3-mm atlantodental interval), vertical subluxation (VS, < 13-mm Ranawat value), and subaxial subluxation (SAS, ≥ 2-mm irreducible vertebral translation). The aggravation was determined as ≥ 2mm decrease of the Ranawat value in VS, ≥ 2-mm increase of slippage in SAS, and these new developments. The prevalence of VS and SAS increased during both the initial and last > 5 years (all, p ≤ 0.049). While VS aggravation was associated with pre-existing AAS (p = 0.007) and VS (p = 0.002), SAS aggravation correlated with pre-existing VS (p = 0.002). Multivariable analysis found hand mutilating changes (odds ratio [OR] = 4.048, p = 0.008), RA duration ≥ 5 years (OR = 3.711, p = 0.013), C-reactive protein (CRP) level ≥ 3.8mg/dL (OR = 2.187, p = 0.044), and previous joint surgery (OR = 2.147, p = 0.021) as predictors for VS aggravation. Pre-existing VS (OR = 2.252, p = 0.024) and CRP ≥ 1.0mg/dL (OR = 2.139, p = 0.013) were disclosed as predictors for SAS aggravation. Low disease activity and clinical remission before the development of VS and advanced peripheral joint destruction are essential to prevent progressive cervical spine instability in RA.

Understanding cervical spine instability: a finite element study on atypical hangman’s fractures

Recent reports have highlighted a notable prevalence of atypical hangman’s fractures, yet their biomechanical aspects remain underexplored. Using a validated finite element model, this study assesses changes in rotation-moment characteristics of the upper cervical spine due to fractures involving the superior and inferior articular process, pars interarticularis, and lamina. The results revealed that fractures affecting the superior articular process and pars interarticularis led to significant instability, particularly in axial rotation and extension. However, atypical hangman’s fractures did not necessarily produce greater instability than Levine-Edwards type II hangman’s fractures.

“Normal” Cervical Spine Radiographs and Computed Tomography Scans in the Emergency Department: Beware of Posttraumatic Instability of the Mobile Segment of the Lower Cervical Spine

The NEXUS criteria have been introduced in the 1990s to assist emergency department physicians to decide whether to perform radiographic work-up following cervical whiplash injury. Four criteria have been described on these profile radiographs of the cervical spine including angulation between cervical endplates, 3-mm listhesis, posterior facet joints overlap, and widened interspinous space. Although these criteria could help to detect patients suffering from unstable trauma of the mobile segment if the lower cervical spine, the radiographic signs may be so subtle that even specifically trained physicians like spine surgeons and neuroradiologists may miss them, especially during after-hour shifts. Hence, we present the striking case of a young female patient whose radiographs displayed slight but abnormal signs of lower cervical spine instability, but was nonetheless discharged home with dynamic X-rays of the cervical spine to be performed in a delayed setting. We hope that these striking features will help us remind the importance of radiologic semiology of posttraumatic unstable cervical spine.

Successful Anesthetic Management for Mandibular Neoplasm Resection in a Patient with Osteogenesis Imperfecta: A Case Report

Background: Osteogenesis imperfecta (OI) is a rare genetic disorder characterized by bone fragility and deformities. Patients with mandibular neoplasms and suspected OI require careful anesthetic management to avoid complications. This case report describes the successful anesthetic management of a patient with a mandibular neoplasm and suspected OI. Case presentation: A 33-year-old man presented with a large mandibular tumor causing airway obstruction and difficulty eating. He had physical features suggestive of OI, including short stature, bone deformities, and abnormal tooth growth. Preoperative evaluation revealed a difficult airway due to the tumor and potential cervical spine instability. Anesthesia was induced with propofol and atracurium after securing the airway via ultrasound-guided tracheostomy under local anesthesia. The tumor was resected successfully, and the patient recovered without complications. Conclusion: Anesthetic management in patients with suspected OI and mandibular neoplasms requires careful planning and execution. A multidisciplinary approach, including preoperative evaluation, airway management strategies, and close postoperative monitoring, is crucial for successful outcomes.

Normative Scores and Test-Retest Reliability of Neck Strength, Endurance, and Proprioception Tests in Children and Adolescents

OBJECTIVE: To determine normative scores, test-retest reliability, and minimal detectable change for the neck flexor endurance test (NFET), craniocervical flexion test (CCFT), and joint position error test (JPET) in children. DESIGN: Cross-sectional. METHODS: Two hundred typically developing children (10-15 years) were recruited. Participants were screened for cervical spine instability using the alar and transverse ligament tests prior to administering the NFET, CCFT, and JPET. Testing was performed twice on the same day, 6 hours apart. RESULTS: For the younger age group, average NFET scores were as follows: females = 9.1 seconds, males = 10.1 seconds. Mean CCFT scores decreased with an increase in pressure (22 millimeters of mercury [mmHg]: females = 6.1 seconds [1], males = 6.8 seconds [1]; 30 mmHg: females = 4.07 seconds [1.1], males = 4.1 seconds [0.9]). For the CCFT, reliability reduced as pressure increased. The JPET had moderate reliability (ICC2, k = 0.4-0.63) with the highest error in right rotation (females = 14.1 cm [5], males = 13.4 cm [4.7]). The NFET had excellent reliability (ICC2, k = 0.96 [0.94-0.97], P&lt;.001). CONCLUSION: The normative scores presented serve as a reference standard for future studies and for systematic screening and head and neck injury prevention. JOSPT Open 2024;2(4):348-353. Epub 20 May 2024. doi:10.2519/josptopen.2024.1135

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.

Co-occurrence of tethered cord syndrome and cervical spine instability in hypermobile Ehlers-Danlos syndrome.

The Ehlers-Danlos Syndromes (EDS) represent a group of hereditary connective tissue disorders, with the hypermobile subtype (hEDS) being the most prevalent. hEDS manifests with a diverse array of clinical symptoms and associated comorbidities spanning the musculoskeletal, neurological, gastrointestinal, cardiovascular, and immunological systems. hEDS patients may experience spinal neurological complications, including cervico-medullary symptoms arising from cranio-cervical and/or cervical instability/hypermobility, as well as tethered cord syndrome (TCS). TCS is often radiographically occult in nature, not always detectable on standard imaging and presents with lower back pain, balance issues, weakness in the lower extremities, sensory loss, and bowel or bladder dysfunction. Cervical instability due to ligament laxity can lead to headaches, vertigo, tinnitus, vision changes, syncope, radiculopathy, pain, and dysphagia. TCS and cervical instability not only share clinical features but can also co-occur in hEDS patients, posing challenges in diagnostics and clinical management. We present a review of the literature and a case study of a 20-year-old female with hEDS, who underwent surgical interventions for these conditions, highlighting the challenges in diagnosing and managing these complexities and underscoring the importance of tailored treatment strategies to improve patient outcomes.

Pediatric cervical spine instability: evolving concepts.

The pediatric cervical spine is structurally and biomechanically unique in comparison to adults. Guidelines to assess for cervical spine instability and standard of care treatments in the pediatric population have yet to be delineated. This is due to the rarity of the condition and the lack of multicenter data published on the topic. Our review explores the biomechanics of the pediatric cervical spine and highlights evolving concepts/research over the last several decades, with special attention to the Down syndrome and complex Chiari malformation cohorts.

Standalone Anterior Reconstruction Approach in Traumatic Cervical Spine Instability Lesions

Standalone Anterior Reconstruction Approach in Traumatic Cervical Spine Instability Lesions

Halo vest fixation effectively maintains cervical alignment through intraoperative repositioning in patients with cervical spine instability

IntroductionThe objective of this study was to examine if halo vest fixation provides sufficient stabilization of cervical spine alignment to endorse its use through intraoperative positional changes in patients with cervical spine instability. MethodsThe subjects of this study were 14 patients with cervical spine instability who were immobilized in halo vests until they underwent subsequent internal fixation surgery. After induction of anesthesia, the patients in halo vests were repositioned from the supine position to the prone position. The halo ring was fixed to the surgical table and the dorsal struts and vest were removed for surgery. Radiographs obtained in the preoperative sitting position and intraoperative prone position were compared for the following measures of cervical alignment: O–C2 angle, C2–C6 angle, pharyngeal inlet angle (PIA), atlantodental interval (ADI), Redlund-Johnell (R–J) value as a measure of O–C2 length, O–C6 length, and O–C2 length/O–C6 length (%). ResultsThere were no significant differences in O–C2 angle, C2–C6 angle, PIA, ADI, or O–C2 length/O–C6 length (%). However, the R–J value and O–C6 length were significantly higher in the intraoperative prone position than in the preoperative sitting position. None of the patients presented with any complications, including dysphagia or neurological deterioration. ConclusionsOur results suggest that when patients are repositioned to the prone position while immobilized in halo vests, the cervical spine is distracted in the cephalocaudal direction across all cervical segments but the cervical alignment is sufficiently maintained. Halo vests are a highly effective external fixation method for patients with cervical spine instability, allowing for a safe repositioning to the prone position for surgery while preserving cervical alignment and preventing neurological deterioration.

An Unknown Foreign laryngeal Object: an exotic complication of skull base osteoradionecrosis

BackgroundOsteoradionecrosis (ORN) of the skull base is a rare complication after head and neck radiation with a broad variety of subsequent complications.MethodsA 68-year-old woman with a complex oncological history (right-sided sphenoid meningioma; left-sided neck metastasis of a Cancer of Unknown Primary—CUP) was admitted with a right-sided epi—/ oropharyngeal mass and severe pain exacerbations for further evaluation. CT scan revealed an advanced ORN of the skull base with subsequent abruption of the ventral part of the clivus. This dislocated part of the clivus wedged in the oropharynx for 48 h and then moved towards the larynx, resulting in dyspnea and almost complete airway obstruction.ResultsDue to the dangerous airway situation, an urgent exploration and removal of the dislocated clivus was necessary. After a potential cervical spine instability was ruled out, the patient’s airway was initially secured with an awake tracheotomy and the clivus was removed transorally. The tracheostomy tube was removed during the ongoing inpatient stay, and the patient was discharged with significant pain relief.ConclusionsThe present case illustrates an orphan complication of skull base ORN resulting in a major airway emergency situation.

Imaging Characteristics of Nonrheumatoid Arthritis Patients With Retro-odontoid Pseudotumor: A Multicenter Case-control Study.

Multicenter case-control study. To identify imaging characteristics of the cervical spine in patients with retro-odontoid pseudotumor (ROP) without rheumatoid arthritis (RA) and determine the pathogenesis of ROP. ROP results from proliferative changes in the soft tissue of the atlantoaxial junction surrounding the region of the transverse ligament, and is commonly seen in RA patients. However, the pathogenesis of ROP caused by mechanical instability of the upper cervical spine in patients without RA is yet to be explained. We collected imaging data [preoperative radiographs, magnetic resonance imaging (MRI), and computed tomography (CT)] of patients who underwent surgery between April 2011 and March 2022 at the three university hospitals for ROP (cases) and cervical spondylotic myelopathy (as age, sex, and institution matched controls). The two groups were compared for different parameters on cervical dynamic radiographs, MRI, and CT. The ROP group consisted of 42 patients, and the control group comprised 168 patients. C2-C7 range of motion was significantly smaller in the ROP group (25.8 ± 2.6°) compared with the control group (33.0 ± 1.0°). C2-C7 sagittal vertical axis was significantly larger in the ROP group than the control group (39.3 ± 3.6 vs. 32.2 ± 1.3mm). MRI and CT assessment showed progressive degeneration at all intervertebral levels in the ROP group. A significant positive correlation was observed between the thickness of the soft tissue posterior to the dental process and the atlantodental interval in the flexion position ( r = 0.501). The development of ROP was associated with degeneration of facet joints and intervertebral disks in the middle and lower cervical spine. Our findings suggest that decreased mobility of the middle and lower cervical spine may cause instability in the upper cervical spine, leading to the formation of ROP.

Prevalence of anterior atlantoaxial subluxation and association with established rheumatoid arthritis.

Spinal involvement in rheumatoid arthritis (RA) is limited to the upper cervical spine, leading to cervical spine instability. This study aimed to evaluate the prevalence of anterior atlantoaxial subluxation (aAAS) and its associated risk factors in patients with RA. This single-centre cross-sectional study 240 patients consecutively were recruited. Radiographs of the cervical spine were obtained in the flexion and neutral neck positions and read by two blinded observers. The diagnosis of aAAS was based on the distance between the anterior aspect of the dens and the posterior aspect of the anterior arch of the atlas, which was >3mm during flexion. Statistical analysis was performed to determine the predictive factors of aAAS. Two hundred and forty patients with a mean±SD age of 56.4±11.4years were recruited, and 191 (78%) were female. The mean±SD duration of the disease was 10.2±8.5years. Of all 25 cases (10.4%) diagnosed with aAAS, the mean anterior atlantodental interval in patients with AAS was 4.19±1.20mm. One in three patients with aAAS had no neck pain. Patients with aAAS had longer disease duration, lower age at diagnosis, lower body mass index, higher anti-cyclic citrullinated peptide autoantibodies (anti-CCP), more frequent erosion, joint restriction, and joint prostheses. In the multivariate regression model, joint limitation, history of joint prostheses, low BMI, and higher anti-CCP levels were independent predictors of the aAAS. Thirty-three percent of patients with cervical involvement do not experience neck pain. Cervical involvement should be considered even without neck pain, particularly in established diseases.

Goldenhar syndrome: An ephialte for the anesthesiologist – What we saw was just the tip of the iceberg

Goldenhar syndrome, also called oculoauriculovertebral dysplasia, is characterized by craniofacial, central nervous system, cardiac, renal, and vertebral anomalies. It occurs due to the faulty unilateral development of vertebral arches. Patients presenting for surgery are usually in the pediatric age group. General anesthesia is the preferred mode of anesthesia considering the type of surgery, age of the patient, and vertebral anomaly in this patient group. The first and foremost consideration while anesthetizing these patients is the anticipated difficult airway. Frequently encountered airway abnormalities in these patients are micrognathia, retrognathia, mandibular dysplasia, craniovertebral anomalies leading to limited neck flexion and cervical spine instability, decreased thyromental distance, fascial asymmetry, cleft lip and palate, high arched palate, dental abnormalities, and temporomandibular joint abnormalities. Difficult airways often come disguised as syndromes, and thorough pre-operative evaluation along with preparation for the worst scenarios is a must. We have a myriad of alternative airway management equipment at our disposal. Adequate knowledge is a must for their best use.

Investigating the prevalence of cervical spine instability in patients with rheumatoid arthritis

IntroductionRheumatoid arthritis (RA) is a chronic, progressive, and systemic disease that broadly affects connective tissues, especially synovial joints. The aim of this study was to investigate the prevalence of cervical spine instability in patients diagnosed with RA.Material and methodsFifty patients with rheumatoid arthritis referred to Imam Khomeini Hospital in Urmia were selected by the census. After taking a history, the neck X-ray was taken from the lateral view in static, flexion, and extension.ResultsAmong 50 patients, 11 were male (22%) and 39 were female (78%). The average disease duration period was 5.63 ± 5.21 years. 43 patients (86%) had normal AADI, 5 patients (10%) had abnormal dynamic AADI, and 2 patients (4%) had abnormal AADI static. Basilar invagination instability was not found in the studied patients. There was no significant difference in terms of gender between normal and abnormal cases of AADI. Among normal AADI cases, 40 cases (93%) were taking drugs and among abnormal AADI cases, 4 cases (57.1%) were taking drugs and 3 patients (42.9%) were not receiving drug treatment. There is a significant difference between normal and abnormal cases of AADI in terms of drug use.ConclusionsIn our study, 7 cases of abnormal AADI were found among 50 patients, of which 2 had abnormal static AADI, which indicates the worsening of cervical spine instability. The study also found that those not treated with DMARDS were more likely to have cervical spine instability.

REHABILITATION OF PATIENTS WITH CERVICAL AND LUMBAR SPINE INSTABILITY USING TYMO ROBOTIC STABILOMETRICAL PLATFORM.

Introduction. The musculoskeletal system plays a vital role in maintaining posture and facilitating human movement, with the muscles often subjected to significant stress. Stabilometry can be used for evaluating postural balance and aiding in rehabilitation. This study aimed to assess the efficacy of the TYMO robotic stabilometric platform for the rehabilitation of patients with cervical and lumbar spine instability.Participants and methods. The study was conducted on the stable platform TYMO (Tyromotion). The study included 30 healthy students (group 1), 28 patients with instability of the cervical vertebra, who underwent standard rehabilitation treatment (group 2), 28 patients with instability of the cervical vertebra, who additionally used with a stabiloplatform (group 3), 29 patients with with instability of the lumbar spine, who received standard rehabilitation treatment (group 4), 29 patients with instability of the lumbar spine, who were additionally treated with a stabiloplatform (group 5). Groups 3 and 5, alongside with standard rehabilitation treatment, received a 10-day course involving stabiloplatform training. The parameters of the Center of Force (COF) section and load distribution were analyzed. Results and Discussion. When analyzing the respective indices across all groups in various functional positions prior to the treatment, the values were significantly increased. The use of the stabiloplatform proved to be effective in the treatment of patients, leading to the normalization of these indices. Notably, its application yielded a lasting therapeutic effect, whereas conventional physiotherapeutic methods fell short in achieving a lasting impact. Conclusions: Patients with cervical or lumbar spine instability demonstrate impaired balance test indicators. Following a 10-day treatment regimen with traditional rehabilitation methods, improvements are observed across all indicators, but they do not fully restore to the control levels in all functional positions. Furthermore, after one month, indicators deteriorate in nearly all functional positions. Training using a stabiloplatform is an effective approach in the treatment of patients with cervical or lumbar spine instability, and its use demonstrates a sustained therapeutic benefit.

Screening examination of the cervical spine in patients with Down syndrome

BACKGROUND: Among all the variety of orthopedic pathologies typical for patients with Down syndrome, pathology of the cervical spine, in our opinion, is the most important. Various types of atlantoaxial dislocations can cause significant neurological deficits and decrease patients quality of life.&#x0D; OBJECTIVE: To analyze the results of screening examination of patients with Down syndrome for the presence of cervical spine pathology.&#x0D; MATERIALS AND METHODS: As part of the screening examination, functional radiographs of the cervical spine in the lateral projection of 60 patients with Down syndrome were evaluated. Priorov NMIC will operate from May 2021 to January 2023.&#x0D; RESULTS: Nine of the 60 patients tested exhibited craniovertebral pathology. Three patients have Os odontoideum of the C2 vertebra. In five patients, different types of rotational atlantoaxial displacements were found, and one patient had hypoplasia of the occipital condyles associated with basilar invagination of the C2 vertebral dentition.&#x0D; CONCLUSION: The instability of the upper cervical spine is potentially the most dangerous manifestation of orthopedic pathology in Down syndrome. A screening examination with functional cervical spine lateral projection radiographs is recommended for this group of patients.

Diagnosis and Prevalence (1975-2010) of Sudden Death due to Atlantoaxial Subluxation in Cervical Rheumatoid Arthritis: A Literature Review.

Rheumatoid arthritis (RA), a chronic inflammatory disease primarily affecting synovial joints and tendons, can potentially impact various organs within the body. One notable complication associated with RA is upper cervical spine instability, medically termed atlantoaxial subluxation (AAS). This condition can lead to adverse consequences, including chronic myelopathy and acute mechanical compression of the medulla oblongata, with the potential for sudden death. While AAS may often remain asymptomatic, some nonspecific symptoms, such as neck pain, have been documented. Severe atlantoaxial subluxation can trigger more distinct symptoms, including delayed occipital pain attributed to the compression of the exiting C2 nerve root. Recent studies have elucidated a spectrum of symptoms preceding sudden death, encompassing vertigo, dizziness, convulsions, dysphagia, disorientation, and seizures. Remarkably, some cases have reported sudden death occurring during sleep. Historical data reveal a fluctuating incidence of this phenomenon, with eleven cases reported between 1969 and 1975 and six cases documented between 1990 and 2010. Notably, one of the most prevalent causes of sudden mortality in individuals with RA is the acute mechanical damage inflicted upon the medulla oblongata due to atlantoaxial subluxation.

Cervical Spine Instability Screening Tool Thai Version: Assessment of Convergent Validity and Rater Reliability.

Neck pain, dizziness, difficulty supporting the head for an extended period, and impaired movement are all symptoms of cervical spine instability, which may produce cervical spondylolisthesis in patients who have more severe symptoms. To avoid problems and consequences, early detection of cervical spine instability is required. A previous study created a Thai-language version of a cervical spine instability screening tool, named the CSI-TH, and evaluated its content validity. However, other characteristics of the CSI-TH still needed to be evaluated. The objective of the current study was to assess the rater reliability and convergent validity of the CSI-TH. A total of 160 participants with nonspecific chronic neck pain were included in the study. The Neck Disability Index Thai version (NDI-TH), the Visual Analog Scale Thai version (VAS-TH), and the Modified STarT Back Screening Tool Thai version (mSBST-TH) were used to evaluate the convergent validity of the CSI-TH. To determine inter- and intra-rater reliabilities, novice and experienced physical therapists were involved. The results showed that rater reliabilities were excellent: the intra-rater reliability was 0.992 (95% CI = 0.989 ± 0.994), and the inter-rater reliability was 0.987 (95% CI = 0.983 ± 0.991). The convergent validities of the VAS-TH, NDI-TH, and mSBST-TH when compared with the CSI-TH were 0.5446, 0.5545, and 0.5136, respectively (p < 0.01). The CSI-TH was developed for use by physical therapists and is reliable. It can be used by physical therapists, whether they are experienced or novices, and has an acceptable correlation to other neck-related questionnaires. The CSI-TH is concise, suitable for clinical use, and lower-priced when compared to the gold standard in diagnosis for patients with cervical spine instability.

Chronic Musculoskeletal Pain in a Case of Larsen Syndrome: Role of Myofascial Trigger Points

Background: Larsen syndrome is an extremely rare congenital disorder characterized by craniofacial anomalies and multiple skeletal deformities such as short stature, kyphoscoliosis of the spine, cervical spine instability, clubfeet, and joint dislocations especially of the knee and hip joints. Musculoskeletal pain in a case of Larsen syndrome signals red flags as these patients have various congenital anomalies. However, myofascial trigger points could be a cause of chronic musculoskeletal pain in these patients. Myofascial trigger points are easy to diagnose and treat. Case Report: We are presenting a 29-year-old man, diagnosed as a case of Larsen syndrome, who came to us with complaints of bilateral shoulder pain and right thigh pain for 4 years and 5 months, respectively. Examination of the patient revealed faulty joint mechanics along with the presence of trigger points in adjoining muscles. The trigger points were injected with local anesthetic followed by stretching and muscle-strengthening exercises, which led to pain relief. Conclusion: In the present case report, we wish to highlight that myofascial pain could be a cause of pain and functional limitation in patients suffering from Larsen syndrome. Key words: Larsen syndrome, myofascial trigger point