Rotatory Subluxation Research Articles

C1 hypertrophic lateral mass resection and occiput-C2 fusion.

This case involved a 6-year-old boy with Down syndrome, left C1 lateral mass hypertrophy, C1–2 rotatory subluxation, and spinal cord compression. He presented after falling down some stairs at his home. Torticollis, dysphagia, and speech delay were noted on examination. Vascular imaging showed impingement on the left vertebral artery by the anomalous C1 lateral mass. Through a posterior approach, the hypertrophic C1 lateral mass was resected, and an occiput–C2 fusion was performed. Postoperatively, his torticollis and brainstem symptoms were resolved.The video can be found here: https://youtu.be/1U0GLdw6c70

Intraoperative Use of Cone-Beam Computed Tomography in the Treatment of Atlantoaxial Rotatory Subluxation

Atlantoaxial rotatory subluxation (AARS) is a rare pathological condition of the upper cervical spine. It can be caused by multiple mechanisms, including minor neck manipulations. Children are more prone owing to the weaker periarticular soft tissue and a steeper slant of the C1 facet plane against the vertical axis of the dens. If AARS does not resolve spontaneously, a normal position of the atlantoaxial joint must be achieved by reduction and stabilization. A 15-year-old girl had presented with a painful torticollis that had already been present for 4 weeks after trimaxillary jaw correction for skeletal class II malocclusion. A computed tomography (CT) scan of the cervical spine showed AARS Field and Hawkins classification type I. We first attempted 1 week of conservative treatment with a soft collar and the prescription of a muscular relaxant. However, because the AARS persisted, we performed transoral closed reduction with the patient under general anesthesia, as previously described. During the procedure, we used intraoperative cone-beam CT to evaluate the degree of reduction. After obtaining complete reduction, immobilization with a halo-vest was applied. Complete reduction of the AARS was achieved with closed intraoral reduction. We used intraoperative cone-beam CT to confirm complete reduction. We found cone-beam CT to be a very useful tool.

Navigation-Assisted Posterior Open Reduction and Internal Fixation in a C-CLAMP Fashion for an Isolated C1 Fracture.

C1 fractures with an intact transverse ligament are usually treated conservatively. Patients who present with a progressive diastasis of bone fragments and a progressive articular subluxation mainly attributed to progressive lengthening of the transverse ligament (TAL) fibers can be treated with a C1 “C-clamp” fusion.A 75-year-old male who sustained a motor vehicle accident was neurologically intact. A computed tomography (CT) imaging demonstrated a Jefferson's type-C1 fracture with a slight lateral displacement of the C1 left lateral mass (LM) and a rotatory subluxation on the right. MRI showed an intact TAL and demonstrated an isolated rupture of the left alar ligament. Conservative treatment was chosen. Radiographic follow-up showed, at 3 months, progressive lateral mass displacement, most likely due to elongation of the TAL fibers; this was also associated with a persistent mechanical neck pain. For this reason, we performed a posterior reduction and internal fixation in a C-clamp fashion by placement of C1 lateral mass screws and posterior compression sparing the C1–2 joint. Using navigation, a 3.5-mm screw was inserted into the LM bilaterally. The screw heads were then connected with a rod and compression was applied before tightening. Postoperative CT scan demonstrated a satisfying reduction and further imaging will be made during the follow-up. The patient had a considerable relief of neck pain. Simple lateral mass fixation with C-clamp technique is a reasonable option in case of isolated C1 fractures in patients who have failed conservative management while preserving the range of motion (ROM) at the atlanto–axial joint. The link to the video can be found at: https://youtu.be/x8bsVwzCt_M .

Atlantoaxial Rotatory Subluxation in a 10-Year-Old Boy

Atlantoaxial rotatory subluxation (AARS) is the loss of normal alignment and stability of the first (atlas) and second (axis) cervical vertebrae with respect to each other. We describe the clinical challenges of managing a 10-year-old boy who presented with repetitive episodes of torticollis. Open-mouth odontoid radiograph and computed tomographic (CT) scan gave a diagnosis in ARRS, based on its characteristic imaging findings. The child was admitted multiple times for continuous halter traction in the first 6 months after symptom onset. He also experienced a temporary complication from an overcorrection with correcting neck bracing. Seven months after symptom onset, this case was discussed by a multidisciplinary spine team and referred to chiropractic clinic. Despite persistent radiographic evidence of atlantoaxial instability, after 5 months of chiropractic treatment, the child was asymptomatic with nearly full range of neck movement. He also weaned off acetaminophen he had been taking over the past year. Incidentally, bilateral gynecomastia was discovered at the surveillance after treatment. The incidental finding of innocent gynecomastia, even if common in preteen boys, brings up the topic of acetaminophen’s effects on the regulation of sex hormones that was previously overlooked.

Halo-gravity traction for the treatment of pediatric cervical spine disorders.

Halo-gravity traction (HGT) is an effective and safe method for gradual correction of severe cervical deformities in adults. However, the literature is limited on the use of HGT for cervical spine deformities that develop in children. The objective of the present study was to evaluate the safety and efficacy of HGT for pediatric cervical spine deformities. Twenty-eight patients (18 females) whose mean age was 11.3 ± 5.58 years (range 2-24.9 years) underwent HGT. Common indications included kyphosis (n = 12), rotatory subluxation (n = 7), and basilar invagination (n = 6). Three children (11%) received traction to treat severe occipitocervical instability. For these 3 patients, traction combined with a halo vest, with bars attached rigidly to the vest, but with the ability to slide through the connections to the halo crown, was used to guide the corrective forces and moments in a specific and controlled manner. Patients ambulated with a wheelchair or halo walker under constant traction. Imaging was done before and during traction to evaluate traction efficacy. The modified Clavien-Dindo-Sink classification was used to categorize complications. The mean duration of HGT was 25 days (IQR 13-29 days), and the mean traction was 29% ± 13.0% of body weight (IQR 19%-40% of body weight). The mean kyphosis improved from 91° ± 20.7° (range 64°-122°) to 56° ± 17.6° (range 32°-96°) during traction and corresponded to a mean percentage kyphosis correction of 38% ± 13.8% (range 21%-57%). Twenty-five patients (89%) underwent surgical stabilization, and 3 patients (11%) had rotatory subluxation that was adequately reduced by traction and were treated with a halo vest as their definitive treatment. The mean hospital stay was 35 days (IQR 17-43 days).Nine complications (32%) occurred: 8 grade I complications (28%), including 4 cases of superficial pin-site infection (14%) and 4 cases of transient paresthesia (14%). One grade II complication (4%) was seen in a child with Down syndrome and a preexisting neurological deficit; this patient developed flaccid paralysis that rapidly resolved with weight removal. Six cases (21%) of temporary neck discomfort occurred as a sequela of a preexisting condition and resolved without treatment within 24-48 hours. HGT in children is safe and effective for the gradual correction of cervical kyphosis, atlantoaxial subluxation, basilar invagination, and os odontoideum. Cervical traction is an additional tool for the pediatric spine surgeon if uncertainties exist that the spinal alignment required for internal fixation and deformity correction can be safely achieved surgically. Common complications included grade I complications such as superficial pin-site infections and transient paresthesias. Halo vest gravity traction may be warranted in patients with baseline neurological deficits and severe occipitocervical instability to reduce the chance of catastrophic movement.

Current management of juvenile idiopathic arthritis affecting the craniovertebral junction.

Craniovertebral instability is a rare and serious problem. While previously treated surgically, better understanding of disease processes has permitted the field to move towards conservative management. Juvenile idiopathic arthritis (JIA) is one cause of pediatric craniovertebral instability. Early recognition and institution of appropriate medical therapy and bracing in a multidisciplinary fashion is critical to avoid long-term instability, joint abnormalities, or morbid surgical procedures. We seek to highlight cases of this rare problem and provide a principled approach to management decisions. We review 6 cases that have presented over the last 6years and highlight 3 cases in particular regarding craniovertebral instability as a presentation of JIA. We reviewed the clinical records and radiographic features with particular emphasis of the stability of the craniovertebral junction. Age range of the subjects was from 5 to 12. All patients presented with neck pain and abnormal head rotation. Four of the patients responded to medical management and/or cervical bracing with no long-term sequelae or instability. Two patients had refractory rotary subluxation, one that responded to manual reduction under pharmacological paralysis and bracing; the other had an incompetent transverse ligament requiring surgical reduction and fixation. Neck pain and abnormal head rotation in an older child is rare finding but should prompt suspicion as a manifestation of JIA to the general pediatrician or initial provider. Appropriate serologic studies and MRI studies with contrast at the craniovertebral junction is necessary for evaluation. Early institution of medical management and cervical bracing under a multidisciplinary team of pediatric rheumatology and neurosurgery is key to avoiding surgical intervention and long-term abnormalities at the craniovertebral junction.

Relationships between radiographic parameters and spinopelvic muscles in adult spinal deformity patients.

While the clinical impact of coronal and sagittal alignment in adult spinal deformity (ASD) patients (pts) is established, there is a paucity of data in terms of axial plane deformity and potential association between muscle degeneration and 3D deformity. The purpose of this study was to analyze spinopelvic muscles characteristics in association with the 3D deformity of ASD patients. This is a prospective cohort study; primary lumbar scoliosis patients (Cobb > 20°) were enrolled and sustained a low-dose X-rays with 3D spinal reconstructions and a fat/water separation MRI (from C7 to the knee). Volumetric 3D reconstructions and fat infiltration (FI) of 6 muscles groups were performed. Relationships between muscular data, radiographic parameters and health-related quality of life were investigated. Patients were stratified and compared based on the SRS classification, the odontoid-hip axis (ODHA) angle (> or < 6.1°) and occurrence of rotatory subluxation. Twenty-eight patients were enrolled with a mean age of 60 ± 16yo and mean body mass index of 26 ± 4kg/m2 without differences between groups. There were a moderate sagittal malalignment and a Cobb angle of 45 ± 11° (table). Muscular volume was smaller in patients with more severe deformity (p > 0.05). Pts with ODHA > 6.1° or pelvic incidence minus lumbar lordosis > 10° had significantly higher FI for the 6 muscular groups, patients with pelvic tilt > 20° had significantly higher FI for erector spinae, hip flexors and extensors (p < 0.05). SF36-PCS significantly correlated with the muscular volume; SRS and Oswestry disability index correlated with the erectors spinae volume (p < 0.05). This study analyzed for the first time the relationship between 3D radiographic parameters and muscular characteristics in ASD. Sagittal malalignment is associated with increased FI and decreased muscle volumes with poor outcomes. These slides can be retrieved under Electronic Supplementary Material.

Etiology-Based Classification of Adjacent Segment Disease Following Lumbar Spine Fusion.

Adjacent segment disease (ASDz) is a potential complication following lumbar spinal fusion. A common nomenclature based on etiology and ASDz type does not exist and is needed to assist with clinical prognostication, decision making, and management. The objective of this study was to develop an etiology-based classification system for ASDz following lumbar fusion. We conducted a retrospective chart review of 65 consecutive patients who had undergone both a lumbar fusion performed by a single surgeon and a subsequent procedure for ASDz. We established an etiology-based classification system for lumbar ASDz with the following six categories: "degenerative" (degenerative disc disease or spondylosis), "neurologic" (disc herniation, stenosis), "instability" (spondylolisthesis, rotatory subluxation), "deformity" (scoliosis, kyphosis), "complex" (fracture, infection), or "combined." Based on this scheme, we determined the rate of ASDz in each etiologic category. Of the 65 patients, 27 (41.5%) underwent surgery for neurogenic claudication or radiculopathy for adjacent-level stenosis or disc herniation and were classified as "neurologic." Ten patients (15.4%) had progressive degenerative disc pathology at the adjacent level and were classified as "degenerative." Ten patients (15.4%) had spondylolisthesis or instability and were classified as "instability," and three patients (4.6%) required revision surgery for adjacent-level kyphosis or scoliosis and were classified as "deformity." Fifteen patients (23.1%) had multiple diagnoses that included a combination of categories and were classified as "combined." This is the first study to propose an etiology-based classification scheme of ASDz following lumbar spine fusion. This simple classification system may allow for the grouping and standardization of patients with similar pathologies and thus for more specific pre-operative diagnoses, personalized treatments, and improved outcome analyses.

Pre-operative halo-gravity traction in severe neurofibromatosis type 1 and congenital scoliosis with thoracic rotatory subluxation

ObjectivesTo evaluate the efficacy and safety of pre-operative Halo-gravity traction in the treatment of severe neurofibromatosis type 1 and congenital scoliosis patients with thoracic rotatory subluxation. Patients and methodsPatients with neurofibromatosis type 1 and congenital scoliosis undergoing Halo-gravity traction were reviewed. Radiographic parameters were measured at pre-, post-traction and post-operation. The forced vital capacity and forced expiratory volume in 1 s were recorded at pre- and post-traction. The neurologic function were assessed according to the Frankel score. The complications during Halo-gravity traction, operation and post-operative follow-up were recorded. ResultsA total of 35 patients (21M and 14F) with rotatory subluxation including 18 neurofibromatosis type 1 and 17 congenital scoliosis patients were included, of whom the average age was 14.9 ± 4.8 years. The average duration of Halo-gravity traction was 72.3 ± 11.2 days, during which the average Cobb angle improved from 105.4 ± 34.2° to 81.7 ± 32.6° (P < 0.001), and the global kyphosis decreased from 79.2 ± 22.5° to 59.7 ± 23.0° (P = 0.003). At pre-traction, the values of coronal and sagittal rotatory subluxation were 9.3 ± 5.2 mm and 7.5 ± 3.5 mm, which significantly improved to 6.7 ± 3.6 mm (P < 0.001) and 4.9 ± 2.3 mm (P < 0.001), respectively. The average improvement in forced vital capacity and forced expiratory volume in 1 s were from 43.6% to 54.2% predicted and from 40.4% to 48.8% predicted, respectively. After Halo-gravity traction, the Frankel scores improved from C to D in 3 patients, from D to E in 2 patients. ConclusionHalo-gravity traction can improve the coronal and sagittal curvature, and the rotatory subluxation in neurofibromatosis type 1 and congenital scoliosis patients. The pre-operative Halo-gravity traction is a safe option for severe neurofibromatosis type 1 and congenital scoliosis patients with rotatory subluxation.

TORTICOLLIS SECONDARY TO A POSTERIOR FOSSA TUMOR: A CASE REPORT

Aims: Torticollis secondary to a posterior fossa tumor is a rare condition that is mostly seen in pediatric patients. In this case report, it is aimed to present a 23-month-old male patient with a posterior fossa tumor that presents the symptoms of torticollis. Case Report: A 23-month-old male patient was admitted to the hospital with a history of a restricted range of motion in his neck and leaning to his left side while sitting. Physical examination of the patient revealed acute onset of atlantoaxial rotatory subluxation findings therefore, the initial diagnosis was Grisel’s Syndrome. Later, a cranial magnetic resonance imaging revealed a mass which was seen in the posterior fossa. The mass was considered as the cause of the torticollis. Conclusion: This case report shows the importance of the differential diagnosis of torticollis. Posterior fossa tumors should not be overlooked while searching for the cause of torticollis. Keywords: Torticollis, posterior fossa tumors, infratentorial neoplasms

Interventional magnetic resonance imaging as a diagnostic and therapeutic method in treating acute pediatric atlantoaxial rotatory subluxation.

Atlantoaxial rotatory subluxation or fixation (AARF) is a rare condition, usually occurring in pediatric patients. It mimics benign torticollis but may result in permanent disability or death. The condition requires prompt diagnosis by thorough examination to avoid any treatment delays. Spiral computed tomography (CT) with three-dimensional reconstruction CT is recommended for identifying incongruence between C1 and C2 vertebrae, and magnetic resonance imaging (MRI) may be performed to exclude ligamentous injuries. In addition to static imaging, dynamic CT involves the reduction between C1 and C2 being confirmed using CT with the head turned maximally to the left and right. The present report (level of evidence, III) provides a method for treating AARF that has similar advantages as dynamic CT but avoids ionizing radiation by replacing CT with interventional MRI. The new method comprised simultaneous axial traction and manual closed reduction, performed under general anesthesia, and the use of interventional MRI to ensure that reduction was achieved and held. The head is turned maximally to the right and left during the manual reduction. A rigid cervical collar was used following reduction. Dynamic CT was not required but prior diagnostic static CT was performed in preparation. No further CT was required. There appears to be no previous studies on interventional MRI in AARF care. Being superior in its diagnostic soft-tissue visualization performance and lacking ionizing radiation, interventional MRI is a potential option for investigating and treating acute AARF in non-syndromic patients with no trauma history.

Do Curve Characteristics Influence Stenosis Location and Occurrence of Radicular Pain in Adult Degenerative Scoliosis?

Study DesignRetrospective cohort. ObjectiveThe aim of this study was to describe the various locations of spinal stenosis (LSS) in lumbar scoliosis and its related clinical symptoms. IntroductionAdults with lumbar scoliosis often present with pain and disability. Association of scoliosis and stenosis is not rare, but remains sparsely explored. Consequences of scoliosis on stenosis location and treatment remain debatable. MethodsPatients operated for symptomatic LSS with lumbar scoliosis (Cobb angle >20°) from 2015 to 2016 were included. All patients completed preoperative clinical and neurologic examination. Coronal and sagittal radiographic parameters, rotatory subluxation (RS), and spondylolisthesis were analyzed on full spine radiographs. Computed tomographic scan multiplanar reconstructions were performed to measure central, foraminal, and lateral recess stenosis, from T10 to the sacrum. ResultsA total of 76 patients were included (69 ± 9 years old, 77% female). Sixty percent had neurogenic claudication, and L5 was the most common radicular pain (41%). The mean Cobb angle was 33° ± 16°. Overall, 35 (46%) patients had coronal malalignment; in 69%, side of the coronal tilt corresponded to side of the concavity of the lumbosacral curve. Sixty patients had RS (most frequent level L3–L4). In 50% of the cohort, RS was located at the junction between the lumbar and lumbosacral curves. In 70% (n = 53) of the patients, central stenosis occurred at the junction between the lumbar and lumbosacral curves. Foraminal and lateral stenosis were most frequently observed in the concavity of the distal lumbosacral curve. L5 radicular pain was significantly more frequent in case of lumbosacral contra-curve and right coronal malalignment. ConclusionLSS is frequent in lumbar scoliosis. Relationships exist between curve characteristics and symptomatic LSS in lumbar scoliosis; especially, concavity of the lumbosacral contra-curve and the junctional level between the lumbar curve and the lumbosacral contra-curve. Therefore, accurate analysis of stenosis in ASD seems mandatory, to at least perform decompression because perfect planned treatment for stenosis and scoliosis correction might not always be possible because of the patient's general health status. Level of EvidenceLevel 4.

Traumatic Atlanto-Axial Rotary Subluxation (AARS) in a 6-Year-Old Child during Recreational Jūdō Practice: A Case Report and Mini-Review of Serious Neck Injuries in Jūdō

Introduction: Traumatic atlanto-axial rotational subluxations (AARS) represent a serious condition that is associated with neurological complications, and should be considered among jūdō sports injuries involving the neck. Case presentation: A 6-year-old Caucasian girl with approximately 1 year of recreational jūdō experience presented with neck and shoulder pain while holding her head in a “Cock-robin” sideways tilted position. During a children’s jūdō class while seated on “all fours” she had been subjected to an improperly executed turnover performed by a boy of similar age, body mass and experience. Because of increasing torticollis symptoms after class she was taken by her parents to a local hospital’s emergency department where X-rays showed a mid-clavicular fracture. It was not until 7 weeks post-accident that a CT scan was ordered and a type-III traumatic acute AARS causing her clinical symptoms was recognized. Differential diagnosis: Congenital cervical spine anomalies, Grisel’s syndrome, Juvenile rheumatoid arthritis, Odontoid fracture without atlanto-axial dislocation. Treatment: A halo crown traction brace connected to a cervical traction pulley with gradual increased weight (+0.5 kg every half day to a maximum of 6.5 kg) was used for reduction over a 17-day period, followed by 6 weeks of ambulant immobilization with a halo vest, and 8 weeks of wearing a stiff neck brace. The girl fully recovered but was advised not to return to practicing contact sports. Uniqueness of the study: AARS has not previously been described in association with jūdō practice in children. Conclusion: Traumatic AARS should be considered as a potential diagnosis in jūdōka, especially those of very young age and of female gender, when presenting with torticollis following mechanical impact or severe pressure on the head if blocked in a tilted position. Prompt diagnosis is crucial, preferably by open-mouth X-rays and CT scan, to ensure proper management and prevent neurological complications.

Rigid segmental cervical spine instrumentation is safe and efficacious in younger children.

The utilization of cervical spine instrumentation in the young pediatric patient is not well reported. This study presents outcomes and complications of cervical spine instrumentation in patients who underwent cervical spine fusion surgery before age 10. Radiographic and clinical data were collected on all patients who underwent cervical spine surgery with instrumentation at a single institution between January 1, 2006, and March 31, 2015. Patients were ≤ 10years of age at the time of surgery with any cervical spine deformity/injury diagnosis. Patient demographics, details on cervical spine diagnosis, procedural data, imaging data, and postoperative follow-up data were collected. Twenty children met the criteria and were included in the study with a mean follow-up of 10.6months (3months-2years). Initial indication for cervical spine correction surgery included deformity (7 cases), trauma (6 cases), instability (3 cases), stenosis (2 cases), rotary subluxation (1 case), and infection (1 case). Fifteen cases were treated with adult 3.5-mm cervical spine instrumentation, 3 with wiring (1 sublaminar and 2 spinous process), and 2 with cannulated screws. Postoperative immobilization included 16 halo fixation, 3 collars, and 1 CTO. Overall, there were five complications related to the surgery. Two patients who had wiring (1 sublaminar and 1 spinous process) developed a non-union and required revision surgery (1 with cannulated screws and 1 with 3.5-mm segmental cervical spine instrumentation). One patient developed a postoperative infection that required incision and drainage. Five patients developed superficial pin infections for their halo. Two deformity patients experienced neurological complications that were likely unrelated to the cervical instrumentation. Rigid segmental fixation can be safe and efficacious when used in pediatric cervical spine patients. Whether used with halo or orthosis, patients experience minimal to no complications from the instrumentation and achieve successful fusion. Cervical spine wiring had a high risk of non-union requiring revision surgery. The incidence of wound infection was low with one in 20 cases.

Ultrasound criteria for biomechanical component of local and regional level somatic dysfunction in case of myogenic torticollis

Introduction.Myogenic torticollis is the most common injury in children′s musculoskeletal system. Atlantoaxial rotatory subluxation is one of the main reasons for this pathology. In the newborn even a minor injury during pathological delivery can cause this. The ultrasound method allows you to conduct a real time examination and provide the physician by complete information about the state of pulpal nucleus, fi brous ring, and relative position of cervical vertebrae bodies, spinal canal and radicular canals. Also it allows you to estimate neck muscles thickness and area, which is an informative complementary method of osteopathic diagnosis.Goal of research— clarifi cation of the criteria for biomechanical component of local and regional level somatic dysfunction by ultrasound examination of the cervical spine Materials and methods. The paper presents the data of cervical spine ultrasound examination for 57 nursing infants, infants and preschoolers with myogenic torticollis due to birth injury (ICD code X: P 15.8).Results.An ultrasound examination of the cervical spine determined the quantitative parameters of the atlantoaxial joint and the spinal canal, which was 17,57±0,44 mm. By posterior approach, the asymmetric position of theCII odontoid bone with respect to lateral masses of the atlas was determined; a statistically signifi cant width difference in atlantoaxial joint space was revealed (p&lt;0,001). By muscles ultrasound examination, signifi cant thickness differences between left and right larger posterior straight muscles of the head (p&lt;0,05) were found. Signs of instability at theCII–CIII level were detected in all patients, with no instability signs at other levels.Conclusion.The established criteria for ultrasound examination are atlantoaxial joint state, hypermobility of spinal motor segments, as well as muscles thickness and area in region under study. This allows us to verify instrumentally biomechanical SD of both local and regional levels, thus dynamic control over osteopathic treatment effectiveness is possible.

Atlantoaxial Rotatory Instability in a Down Syndrome Patient with Aberrant Vertebral Artery Anatomy

Atlantoaxial instability (AAI) is a common deformity in Down syndrome (DS). Although often inconsequential, AAI can progress to atlantoaxial rotatory subluxation (AARS). In patients with DS, concomitant AAI often necessitate surgical fusion, but successful stabilization in this population can be challenging due to high complication rates. A 14-year-old male with DS presented with a 3-month history of spontaneous AARS. After failed closed reduction, the parents consented to surgical stabilization. Preoperative planning revealed a high-riding vertebral artery and thin C2 lamina; therefore, C1-C4 segmental posterior instrumented fusion was performed, resulting in a successful reduction maintained at 12 months’ follow-up. The development of rigid fixation for the treatment of AARS has improved fusion rates in children with DS. However, vascular and osseous anomalies in this population often dictate extension of the fusion constructs beyond C1 and C2. Careful preoperative planning is a prerequisite to safe and solid fixation.

Early diagnosis of Grisel's syndrome in children with favorable outcome.

The painful torticollis only itself may be a major sign for the diagnosis of Grisel's syndrome (GS). It is known as an inflammatory atlantoaxial rotatory subluxation following upper respiratory tract infections (URTI) and surgical otolaryngological procedures. The analysis of 16 pediatric GS patients were reviewed retrospectively by considering the diagnosis, the treatment modality, and the prognosis at the Department of Neurosurgery and Otorhinolaryngology in Mersin University, Faculty of Medicine between 2008 and 2018. In addition to the clinical cases, five cadavers were used to demonstrate atlantoaxial region, particularly the ligamentous complex and articulation of the atlas-axis, for the mechanism of these rare entities. The most common etiological factor of GS was URTI with 81.25% among 16 patients. Painful torticollis was the primary symptom of pediatric patients at admission. The X-Ray, computerized tomography (CT), and magnetic resonance imaging (MRI) investigations were used for the definitive diagnosis in the first week of admission, except one. No morbidity, mortality, and deformity were reported in this series. Early diagnosis is the principle of GS for avoiding of permanent neck deformity and complex surgical procedures. If GS can be diagnosed without any doubt by only considering patient's history and clinical examination, CT scan is not recommended due to harmful effects of radiation. The treatment was achieved by reduction, external fixation under analgesia, or sedoanalgesia accompanying with antibiotic and anti-phylogistic treatment.

Selective Thoracic Fusion for Adolescent Idiopathic Scoliosis: Long-Term Radiographic and Functional Outcomes*

IntroductionSelective thoracic fusions (STFs) were introduced by Moe to treat the structural thoracic curve when a more flexible lumbar component existed. It is unknown how the curves behave and how the patients function beyond 20 years after surgery. MethodsOf the 152 eligible patients with STF, 67 were traced and contacted and 40 completed outcome questionnaires (Oswestry Disability index [ODI], Scoliosis Research Society–30 [SRS-30]) and had follow-up standing radiographs. The preoperative, postoperative, 1-year, and follow-up films were compared, and the lumbar spine on follow-up assessed for signs of degeneration—disc space narrowing, osteophyte formation, rotatory subluxation, and lateral spondylolisthesis. ResultsThe average follow-up was 32.7 years. There were 27 Lenke 1C, 10 Lenke 2C, and 3 Lenke 1B curves. A posterior fusion was performed in 37, with a Harrington rod used in 28 and all-hook constructs in 12 with fusion to T10 (1), T11 (10), T12 (22), or L1 (7). The average preoperative right thoracic curves were 56.1°, 36.2° 1 year postoperation, and 38.6° at follow-up. The average preoperative lumbar curve was 44.6°, being 35.2° at 1 year postoperation, and 36.9° at follow-up. Five patients had additional surgery, 3 pseudarthrosis repairs (one with extension of the fusion to L4), 1 implant removal, and 1 microdiscectomy 35 years postoperatively. At follow-up, the average ODI was 8.7 (0–62) and the average SRS-30 3.8 (1.4–4.9). Nine patients took nonnarcotic medication, usually weekly or less, with only one taking daily narcotics. The most common lumbar radiographic finding was disc space narrowing at the apex of the lumbar curve, and osteophytes at L2–L3. There was no correlation of the lumbar changes to ODI, with a tendency to more medication use with longer follow-up (older subjects). ConclusionAt an average 33-year follow-up, the lumbar curve in STF is unchanged, with patients functioning well and mild radiographic changes in the lumbar spine.

The Grisel's syndrome: A non-traumatic subluxation of the atlantoaxial joint

IntroductionGrisel's syndrome consists in rotational subluxation of C1–C2 following ENT infection or surgery. There is no consensus on management. We present 2 cases requiring surgical treatment in our center. Case reportsTwo 10-year-old patients presented torticollis with cervical pain resistant to medical treatment, with onset a few months after tonsillectomy. In both cases, radiological assessment, comprising CT scan and MRI, showed Fielding–Hawkins type-3 C1–C2 rotational subluxation, without ligament lesion. After failure of conservative treatment, posterior reaming, realignment, C1–C2 arthrodesis using lateral masses and pars interarticularis screws and bone graft achieved good fusion and immediate spinal stability in all planes of the atlantoaxial complex. DiscussionGrisel's syndrome consists in non-traumatic subluxation of the atlantoaxial joint with intact atlantoaxial ligaments. Initial pharyngeal inflammation spreads to the prevertebral fascia via direct connections between the periodontoidal venous plexus and pharyngovertebral veins, inducing fasciitis that leads to abnormal relaxation of the atlantoaxial ligaments and reactional muscle contraction with ankylosis. This phenomenon, appearing gradually and insidiously over a period of a few weeks, creates a frozen joint with ankylosis. Medical treatment with NSAIDs, muscle relaxants, and immobilization is usually sufficient; cervical traction may be needed. Surgical treatment by C1–C2 arthrodesis is indicated in case of failure of medical management or onset of neurologic signs. ConclusionClose collaboration between pediatricians, ENT surgeons and neurosurgeons is essential for early diagnosis and management, which is the main prognostic factor for successful medical treatment, avoiding surgery.

Clinical significance of imaging findings for atlantoaxial rotatory subluxation in children

Background/aim: This study evaluated the usefulness of measuring the atlantodental interval (ADI) and lateral atlantodental spaces (LADSs) by retrospectively analyzing the imaging data of children of various ages with and without atlantoaxial rotatory subluxation (AARS). Materials and methods: The data of 495 children who underwent cranial computed tomography were collected. Among these children, 255 children were clinically diagnosed with AARS while 240 children were not. ADI and LADS values were measured. Results: The difference in mean ADI between children with and without AARS in all age groups was statistically significant (t-test, all P < 0.05). In children without AARS, the 95% reference range for ADI was <3.2 mm. The difference in the variance of bilateral lateral atlantodental spaces (VBLADSs) between children with and without AARS in all age groups was statistically significant (rank-sum test, all P < 0.05), with a 95% reference range of 0–2.20 mm (D-test). Conclusion: The ADI is a well-known and frequently used parameter and is not new, but there is little research about this in China and here we confirm its application in Chinese children. The LADS is not a frequently used parameter, but it does not significantly differ. The VBLADS parameter is new and significant in this manuscript. We concluded that VBLADSs of >2.2 mm are useful indicators for the diagnosis of AARS in patients ≤14 years old. Finally, it can be concluded that ADI of ≥3.2 mm and VBLADS of >2.2 mm are useful indicators for the diagnosis of AARS in patients ≤14 years old. Widened LADSs would not be helpful in the diagnosis of AARS in children.