Non-traumatic Atlantoaxial Subluxation Research Articles

Adult Atlantoaxial Subluxation in Post COVID-19 Recovery: A Case Series

Background: Non-traumatic atlantoaxial subluxation in adults is a rare condition usually common in patients with rheumatoid arthritis, and infection of the upper respiratory tract is also considered to be a trigger of inflammation and laxity of ligaments and further subluxation. to date there have been some reported cases of atlantoaxial as complication of COVID-19. Diagnosis and management of atlantoaxial subluxation is currently based on x-ray with special views. Therefore, it is important to early diagnosis and treating adult patients suffering from neck pain and stiffness as a suspected case of nontraumatic atlantoaxial subluxation. Case reports: In this case series, we reported 17 healthy elderly patients (11 male and 6 female) who had atlantoaxial subluxation after a mild (8 patients 4 male and 4 female) and 9 moderate cases (6 males with 3 females) of COVID-19. The patients had neck pain (pain score ranged 6 to9 wit mean 7,5), occipital headache (7 patient with severe and moderate occipital headache with only 3 with mild), and stiffness with different levels of limitation of cervical movements after recovering from Covid-19 in varying periods between 3 and 7 months. Conservative treatment included antibiotics; non-steroid anti-inflammatory agents, short course of corticosteroids, and immobilization with soft cervical collar followed by physiotherapy after pain subsided was done for the patients, and the clinical recovery observed within 8-10 weeks with good results in 10 patients with relieving pain and restoring the cervical motion to the normal, and 7 patients with acceptable result of treatment with slight limitation of cervical movements. Conclusion: As atlantoaxial subluxation in adult patients may be a late complication of COVID-19, more research is needed to determine the specific association between COVID-19 and atlantoaxial subluxation in adults.

Torticollis in an 8-year-old child due to Grisel’s syndrome - A case report

Grisel's syndrome is a nontraumatic atlantoaxial subluxation resulting from an ongoing local inflammatory process. An 8-year-old male presented to the emergency department with neck pain which was sudden in onset without any history of any significant fall or trauma. On physical examination, the patient had torticollis with a head tilt to the left side and the chin rotated to the right. The CT scan confirmed atlantoaxial subluxation with C1 rotated to the right on the odontoid process without anterior displacement. The patient was managed conservatively with antibiotics, anti-inflammatory agents, and head-halter traction. As Grisel's syndrome can have catastrophic outcomes, early diagnosis and treatment are critical. It must be considered in patients presenting with acute torticollis following an infection or prior surgery.

A Case of Grisel’s Syndrome Following Tonsillectomy and Adenoidectomy

Grisel’s syndrome is a non-traumatic atlantoaxial rotatory subluxation for which the underlying mechanism has not yet been identified. It is known to occur following upper respiratory infections, tonsillitis, ear, nose, and throat (ENT) surgeries such as tonsillectomy and adenoidectomy. The diagnosis of Grisel’s syndrome can be made by plain x-ray, CT scanning, and/or MRI scanning. The first choice of treatment is conservative therapy such as bed rest, muscle relaxation, analgesic therapy, antibiotics, and simple traction. While Grisel’s syndrome occurs rarely, delayed treatment may lead to neurological complications or requires surgical treatment. Early diagnosis and treatment are important in preventing fatal outcome. We report the case of a 9-year-old male who developed Grisel’s syndrome after tonsillectomy and adenoidectomy.

Non-Surgical Treatment in Acute and Chronic Grisel’s Syndrome: Two Case Reports and Literature Review

Grisel’s syndrome, which involves non-traumatic atlantoaxial rotatory subluxation, is a rare disease that occurs primarily in children. Herein, we present two cases of chronic and acute Grisel’s syndrome that were successfully treated with traction and medication as non-surgical management. A 10-year-old male patient was diagnosed with chronic Grisel’s syndrome after surgery to remove cholesteatoma in his left ear 6 months previously (Case 1), and a 5-year-old female patient was diagnosed with acute Grisel’s syndrome after acute pharyngitis (Case 2). Both patients were treated with pain control and halo traction, which corrected torticollis and relieved their symptoms.

Surgical management of Grisel syndrome in the adult patient: illustrative case.

BACKGROUNDGrisel syndrome describes an infectious soft tissue process that destabilizes the cervical bony elements and ligamentous complexes. This nontraumatic atlantoaxial rotary subluxation occurs in children primarily. This case illustrates a rare case presentation of an adult with Grisel syndrome: infectious destruction of the right atlantoaxial facet joint caused the occiput-C1 vertebra (head) to rotate rightward with lateral horizontal displacement off the C2 vertebra.OBSERVATIONSBecause the infection destroyed the C1 bony arch and atlantoaxial facet joints with epidural extension, the rotated head and atlas pulled the brainstem–cervical spinal cord junction against a fixed odontoid process, resulting in a cord contusion. Because of the highly unstable craniocervical junction, the patient presented with torticollis and left upper extremity weakness.LESSONSTreatment entailed closed reduction under general anesthesia followed by occipitocervical fusion with an occipital plate, C1 lateral mass screws, and C2-C5 pedicle screws. This case describes the unique surgical pearls necessary for occipitocervical fusion of an unstable craniocervical junction, including tips with neuronavigation, trajectories of the cervical pedicle screws, aligning the lateral mass and pedicle screws with the occipital plate, and nuances with occipitocervical distraction.

Magnetic Resonance Imaging as the Primary Imaging Modality in Children Presenting with Inflammatory Nontraumatic Atlantoaxial Rotatory Subluxation.

Inflammatory nontraumatic atlantoaxial rotatory subluxation (AAS) in children is an often-missed diagnosis, especially in the early stages of disease. Abscess formation and spinal cord compression are serious risks that call for immediate surgical attention. Neither radiographs nor non-enhanced computed tomography (CT) images sufficiently indicate inflammatory processes. Magnetic resonance imaging (MRI) allows a thorough evaluation of paraspinal soft tissues, joints, and ligaments. In addition, it can show evidence of vertebral distraction and spinal cord compression. After conducting a scoping review of the literature, along with scientific and practical considerations, we outlined a standardized pediatric MRI protocol for suspected inflammatory nontraumatic AAS. We recommend contrast-enhanced MRI as the primary diagnostic imaging modality in children with signs of torticollis in combination with nasopharyngeal inflammatory or ear nose and throat (ENT) surgical history.

Síndrome de Grisel como Complicação de Abcesso Parafaríngeo

INTRODUÇÃO: A síndrome de Grisel é uma entidade rara que corresponde a uma subluxação rotatória atlanto-axial não-traumática, por norma secundária a infeção das vias aéreas superiores ou a cirurgia da cabeça e pescoço. Os pacientesapresentam-se com torcicolo, e um grau de suspeição elevado é necessário para o diagnóstico.CASO CLÍNICO: Criança do sexo masculino, 6 anos, admitida por odinofagia, febre e torcicolo. Exame objetivo revelava flexão cervical com rotação para a direita. Tomografia computorizada cervical demonstrava abcesso parafaríngeo e subluxação anterior atlanto-axial de 3 mm, configurando uma subluxação tipo II de Fielding. A criança foi internada para realização de antibioterapia endovenosa, vigilância e imobilização cervical.DISCUSSÃO: A síndrome de Grisel é um diagnóstico a considerar numa criança com torcicolo e infeção cervical. Os otorrinolaringologistas devem relembrar-se das possíveis apresentações e fatores de risco para esta síndrome. O tratamento conservador é muitas vezes suficiente, e a identificação precoce com imobilização parecem levar a melhores outcomes.

Grisel\u2019s syndrome: a case report on this rare pediatric disease and its anesthetic challenges

BackgroundGrisel’s syndrome is a non-traumatic atlantoaxial subluxation associated with inflammatory conditions of the head and neck, which occurs primarily in children. Increased flexibility of the ligaments during inflammation is implicated in the pathogenesis of the subluxation between the axis and atlas. The potential sequelae may be severe, and early diagnosis and treatment of Grisel’s syndrome can prevent tragic outcomes.Case presentationWe present a case of torticollis in an 8-year-old child. She had a two-week history of a streptococcal throat infection. The patient was treated with several different methods of conservative care, including muscle relaxation, cervical halter traction, and Halo application. However, the torticollis persisted. The patient then required surgical correction involving cervical spine fusion. She had no complications and experienced no reoccurrence of the torticollis to date.ConclusionGrisel’s syndrome is a pathology for which conservative management is successful in most cases. Cases requiring surgical intervention are rarely documented in the literature. Our case is significant, as in spite of aggressive conservative management, the patient required surgical correction. Patients requiring surgical management of Grisel’s syndrome may require additional anesthetic exposure for diagnostic interventions like magnetic resonance imaging or neck manipulations for closed reduction. We discuss the features of Grisel’s syndrome and specific anesthetic management considerations for procedures such as magnetic resonance imaging, application of cervical traction, and surgical correction of torticollis.

Grisel's Syndrome in an Adult After Endoscopic Nasopharyngectomy.

BackgroundGrisel's syndrome is rare in adults, and is characterized by nontraumatic atlanto‐axial subluxation secondary to infection. Here, we report a case of Grisel's syndrome occurring after endoscopic nasopharyngectomy.MethodsA 67‐year‐old man complained of fever and neck pain with reduced lateral rotation after an endoscopic nasopharyngectomy for recurrent nasopharyngeal carcinoma. Flexion and extension X‐rays of the cervical spine demonstrated atlanto‐axial subluxation, and magnetic resonance imaging showed infective changes with cervical osteomyelitis. A diagnosis of Grisel's syndrome with cervical spine osteomyelitis was made. A later computed tomography (CT) scan demonstrated subluxation of C1 on C2, as well as the occipital‐C1 joint.ResultsThe patient was treated with intravenous antibiotics and offered surgery for spinal stabilization, but declined. He remained well 15 months post‐op on a cervical collar with minimal pain and no neurologic deficits.ConclusionA high index of suspicion for Grisel's syndrome is suggested in patients who have neck pain with reduced range of motion postnasopharyngectomy, and imaging is useful in clinching the diagnosis.Level of Evidence4

Conservative Treatment in Grisel’s Syndrome Following Tonsillectomy

Grisel’s syndrome is a rare complication that is characterized by non-traumatic atlantoaxial subluxation. It is most commonly seen in children after an upper respiratory tract infection or neck surgery, such as an adenoidectomy, tonsillectomy and mastoidectomy. Grisel’s Syndrome is characterized by torticollis and a limited range of motion of the neck with pain. Here the authors report a case of a Malian 5-year-old girl with Grisel’s syndrome following tonsillectomy. The patient’s complaints were fully resolved after 2 weeks of conservative treatment.

56. Grisel’s syndrome (Non-traumatic atlantoaxial rotatory subluxation), a rare but serious complication of Ehlers Danlos Syndrome

56. Grisel’s syndrome (Non-traumatic atlantoaxial rotatory subluxation), a rare but serious complication of Ehlers Danlos Syndrome

A Case of Grisel Syndrome Showing No Underlying Laxity of the Atlanto-axial Joint.

Grisel syndrome is a rare, non-traumatic atlanto-axial subluxation associated with an inflammatory or infectious process in the upper neck. According to the two-hit hypothesis, which is widely accepted for the pathogenesis of Grisel syndrome, preexisting ligamentous laxity of the atlanto-axial joint is regarded as the first hit. An inflammatory or infectious process of the atlanto-axial joint acts as the second hit, resulting in non-traumatic atlanto-axial subluxation. We report on a 6-year-old girl with atlanto-axial subluxation following retropharyngeal and cervical lymphadenitis. She was diagnosed with Grisel syndrome, for which an initial computed tomography did not show any preexisting ligamentous laxity of the atlanto-axial joint. A literature review found only 4 case reports on Grisel syndrome with an initially normal atlanto-axial joint. The present case offers some evidence that a single hit, such as inflammatory changes in the atlanto-axial joint, might cause Grisel syndrome, even without underlying ligamentous laxity.

Grisel’s syndrome, a rare cause of anomalous head posture in children: a case report

BackgroundAnomalous head posture (AHP) or torticollis is a relatively common condition in children. Torticollis is not a diagnosis, but it is a sign of underlying disease. Grisel’s syndrome (GS) is a rare condition of uncertain etiology characterized by a nontraumatic atlanto-axial subluxation (AAS), secondary to an infection in the head and neck region. It has not been considered, in ophthalmological papers, as a possible cause of AHP.Case presentationA case of AAS secondary to an otitis media is studied. The children showed neck pain, head tilt, and reduction in neck mobility. The patient had complete remission with antibiotic and anti-inflammatory therapy and muscle relaxants. Signs of GS should always be taken into account during ophthalmological examination (recent history of upper airway infections and/or head and neck surgeries associated to a new onset of sudden, painful AHP with normal ocular exam). In such cases it is necessary to require quick execution of radiological examinations (computer tomography and/or nuclear magnetic resonance), which are essential to confirm the diagnosis.ConclusionGS is a multidisciplinary disease. We underline the importance of an accurate orthoptic and ophthalmological examination. Indeed, early detection and diagnosis are fundamental to achieve proper management, avoid neurological complications and lead to a good prognosis.

Non-traumatic Atlanto-axial Rotatory Subluxation- Grisel’s Syndrome Case Report and Literature Review

Study design: Case report of conservatively treated non-traumatic Atlanto-axial rotatory sublaxation. Objective: To report our case with this rare condition (non-traumatic Atlanto-axial rotatory subluxation-Grisel Syndrome) in a 9-year old girl presenting with torticollis and neck pain and literature review. Summary of background data: Atlanto-axial rotatory fixation or non-traumatic atlanto-axial subluxation which is usually secondary to an infection or an inflammation at the head and neck region is a rare subtype of subluxation in which a pathologic fixation of the atlas on the axis is present. It is most common in paediatric patients and it can be managed conservatively in the acute stage. In contrast, cases of chronic non-traumatic atlanto-axial rotatory subluxation are usually treated with operative reduction, according to literature data. Although high success rates have been achieved with operative reduction in chronic cases, a significant reduction in neck motion occurs due to the atlanto-axial fusion. Methods: A 9-year-old girl developed torticollis established longer than 10 weeks as a result of an upper respiratory tract infection. Computed tomography showed a type 1 rotatory subluxation of the Atlanto-axial joint according to the classification of Fielding and Hawkins. The patient was treated by manual reduction according to Jeszenszky (Jeszenszky transoral Citation Nr 22) under general anaesthesia and fluoroscopy control, and then a halo vest had been applied for 6 weeks. Results: We successfully treated this patient with chronic non-traumatic Atlanto-axial rotatory subluxation with manual reduction and immobilisation by applying a halo-body-jacket. She showed full recovery of neck motion and normal Atlanto-axial angle on clinical and radiological follow-up after 1 month and 3 months respectively. Conclusion: Chronic non-traumatic Atlanto-axial rotatory subluxation is a rare condition which can easily escape the attention of physicians especially in children. Conservative treatment with complete reduction under anaesthesia and subsequent immobilisation via halo-body-jacket for at least 6 weeks is a viable option as presented in this case report. Surgical treatment should be reserved only for cases of failure of conservative management (recurrence or irreducible subluxation).

Non-traumatic atlanto-axial rotatory subluxation: A rare cause of neck stiffness

Atlanto-axial rotatory subluxation is a rare condition in childhood. A sudden onset of pain and limitation in neck movements are the most common presenting features. Usually, a previous trauma history exists. This study presents a case of an 18-month-old male with neck stiffness and pain in neck through palpation without trauma in his history but with rotatory subluxation of 30° in atlanto-axial joint observed in his cervical imaging. With this case, the aim was to emphasize the necessity for considering the atlanto-axial subluxation in patients less than five years old diagnosed with neck stiffness in differential diagnosis even if a trauma is not available in their histories.

A Case of Prolonged Neck Pain Diagnosed with Grisel's syndrome as a Differential Diagnosed with Juvenile Idiopathic Arthritis

Grisel’s syndrome is an important cause of torticollis. The syndrome is a non-traumatic atlantoaxial subluxation that follows upper respiratory infection disease, surgery or romatologic disease. Subluxation occurs as a result of inflamed transverse and alar ligament, which stabilizes atlantoaxial joint. This case report focuses on the diagnosis of Grisel’s syndrome of a six –years old girl patient. She was consulted to pediatric rheumatology for having painfull toticollis for two months. It is found that the symptom started after having respiratory infection disease. She was diagnosed of Grisel’s syndrome following radiologic examination. She responded to conservative treatment, that included bed rest, external fixation, antibiotic therapy, muscle relaxants, and anti-inflammatory therapy. The case is reported to point out that one of the ethiology of painfull tortocollis through making differantial diagnoses of juvenile rheumatoid arthritis, that is itself diagnosed with radiologic examination should be considered.

Grisel's Syndrome: A Rare Complication following Adenotonsillectomy.

Grisel's syndrome is a nontraumatic atlantoaxial subluxation which is usually secondary of an infection or an inflammation at the head and neck region. It can be observed after surgery of head and neck region. Etiopathogenesis has not been clearly described yet, but increased looseness of paraspinal ligament is thought to be responsible. Patients typically present with painful torticollis. Diagnosis of Grisel's syndrome is largely based on suspicion of the patient who has recently underwent surgery or history of infection in head and neck region. Physical examination and imaging techniques assist in diagnosis. Therefore, clinicians should be aware of acute nontraumatic torticollis after recently applied the head and neck surgery or undergone upper respiratory tract infection. In this paper, a case of an eight-year-old male patient who had Grisel's syndrome after adenotonsillectomy is discussed with review of the literature.

Grisel's Syndrome as a Sequela of a Complicated Acute Mastoiditis

Grisel's syndrome is a rare complication of ENT area infections. It consists of a non-traumatic atlantoaxial subluxation after an infectious process. Its characteristic symptom is persistent torticollis despite a resolved infection. The knowledge of this condition helps early diagnosis and treatment. We therefore present the case of a patient with Grisel's syndrome as a sequela of an acute mastoiditis complicated by a Bezold's abscess.

Early descriptions of Grisel's syndrome

Dear Editor: We read with great interest the comprehensive review paper of Osiro et al. presenting Grisel's syndrome [1]. Apart from the introduction of this rare syndrome, the authors discussed recent developments on the pathogenesis of the syndrome along with treatment options. In the introduction, Sir Charles Bell (1774–1842 CE) was introduced as the first to explain nontraumatic atlantoaxial subluxation due to pharyngitis which ultimately led to death of the patient from spinal cord compression [1, 2]. Grisel's syndrome was named after Pierre Grisel (1869–1959 CE), a French surgeon who described the syndrome characterized by dislocation of the C1–C2 joint mostly in patients with pharyngitis and torticollis [1, 3]. Based on the historical evidence, we believe that the syndrome was known to the Greek and Persian physicians much earlier than thought. Among the ancient Greek scholars, Aetius of Amida (fifth–sixth century of the Common Era) seems to be the first to indicate the association between inflammation of the vertebrae caused by retropharyngeal abscess and vertebral luxation in his section on diphtheria [4]. The syndrome was later described by Rhazes (865–925 CE) in his Kitab al-Hawi (Liber Continens) quoting from Hippocrates' Of The Epidemics [5]. In the tenth century of the Common Era, Akhawayni Bukhari (Fig. 1), a prominent Persian physician, compiled the oldest extant treatise on medicine in new Persian, Hidayat al-Muta`allemin fi al-Tibb (The Students' Handbook of Medicine) [6, 7]. Being relatively short and simplified, the Hidayat was dedicated to the author's son and other students of medicine [8]. The second part of the book contains a chapter on the diphtheria describing different etiologies of suffocation, with a particular emphasis on a complication associated with neck pain and anterior subluxation of the cervical vertebrae. In addition to his description of this clinical entity, Akhawayni recommends novel life-saving approaches to the disease. Briefly, he advised application of either tongs or especially designed reins for applying pressure to reduce the subluxated vertebra [9]. The disease appears in the medical writings of the following centuries such as Avicenna's The Canon of Medicine and Jorjani's The Treasure of Khwarazm Shah, none of which have discussed the disease as detailed and instructive as that of Akhawayni's [10–12]. Altogether, descriptions of Grisel's syndrome and its associated symptoms are not limited to the recent centuries and date back to the earlier periods. S. E. J. Golzari Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran

Grisel Syndrome: Pathophysiological Evidence from Magnetic Resonance Imaging Findings

Grisel syndrome is a condition of uncertain etiology characterized by a non-traumatic atlantoaxial subluxation following an infection in the head and neck region. Although first described in 1830, the exact pathophysiology of Grisel syndrome remains unclear. We present a case of atlantoaxial subluxation after acute lymphadenitis diagnosed with a dynamic computed tomography (CT) and magnetic resonance imaging (MRI). A previously healthy 9-year-old male patient presented with torticollis of sudden onset. Dynamic CT and MR imaging showed rotary atlantoaxial subluxation and inflammation surrounding the cervical spinal ligaments. A follow-up MRI of the cervical spine, taken 3 weeks after the onset of symptoms, showed a complete resolution of subluxation and inflammation surrounding the cervical spinal ligaments. In this case report, we support the hypothesis that an inflammation-induced laxity of the cervical ligaments is the pathologic key to Grisel syndrome using radiologic findings.