Rotatory Subluxation Research Articles

The Sonographic Posterolateral Rotatory Stress Test for Elbow Instability: A Cadaveric Validation Study

BackgroundAlthough clinical tests can detect posterolateral rotatory instability (PLRI) of the elbow, the ability of ultrasound to evaluate PLRI has not been assessed. ObjectiveTo determine whether increasing stages of posterolateral rotatory subluxation of the elbow could be assessed accurately with a sonographic posterolateral rotatory stress test. DesignCadaveric study. SettingLaboratory. PatientsTen, unpaired, cadaveric upper limbs. MethodsPosterolateral ulnohumeral distance was measured by ultrasound at rest and during manual sonographic posterolateral rotatory stress testing at 4 stages of increasing instability: (1) intact elbow, (2) extensor carpi radialis brevis (ECRB) release, (3) ECRB release + lateral collateral ligament complex (LCLC) release to produce a positive posterolateral drawer test, and (4) ECRB release + LCLC and capsule release to produce a positive lateral pivot-shift test. Mean values for sonographic resting ulnohumeral distance, stressed ulnohumeral distance, and laxity were calculated for each stage and compared between stages. Main Outcome MeasuresPosterolateral ulnohumeral laxity. ResultsMean ulnohumeral laxities were 1, 3, 6, and 10 mm (P < .001) for stages 1-4, respectively. Pairwise comparison of mean laxity between the intact elbow (Stage 1) and each pathologic state (Stages 2-4) demonstrated differences of 2 mm (Stage 1 versus 2); 5 mm (Stage 1 versus 3); and 9 mm (Stage 1 versus 4) (P < .001). The minimal difference in ulnohumeral laxity noted between the intact elbow and an elbow with a clinically positive posterolateral rotatory drawer test (Stage 3) was 4 mm. ConclusionsThe sonographic posterolateral rotatory stress test detected increasing posterolateral ulnohumeral laxity as a function of increasing clinical PLRI. This test may be used as an adjunct to history, examination, and static imaging to assess ulnohumeral laxity in patients with lateral elbow pain syndromes. Within the limits of this investigation, sonographic posterolateral ulnohumeral laxity of >4 mm should raise suspicion of underlying instability. Level of EvidenceIV

Magerl technique for children atlantoaxial rotatory subluxation

Objective To discuss the feasibility and prognosis of magerl technique for children. Atlantoaxial Rotatory Subluxation. Methods 63 patients with Atlantoaxial Rotatory Subluxation were treated in our hospital, and 16 of whom were treated with bilateral C1, 2 posterior transarticular screw fixation and fusion. All cases aged from 8 to 14, with an average age of 11±2.3 years old. According to Fielding classification, 10 cases were in type II, and 6 in type III. 1 patient showed dizziness, 11 patients showed obvious appearance of deviation of head and neck; 14 patients showed varying degrees of occipito-cervical pain, and one patient showed incomplete paralysis. All patients had undergone Halo traction, then the Magerl surgery for atlantoaxial fixation fusion. Through follow-up and photograph of atlantoaxial mouth opening, lateral cervical X-ray and atlantoaxial 3D CT, the screw position and bone graft fusion were evaluated. The clinical and radiological outcomes were evaluated according to the Symon and Lavender clinical standard, the imaging index space available for the cord (SAC), and the atlas-dens interval (ADI). Results All cases were followed up for 3 to 98 months (mean 38±14.6 months). All patients had completed the bilateral UCSS screw fixation, and the symptoms were improved significantly, without neurological symptoms aggravated or complications such as neurovascular injury. All UCSS screw position through the atlantoaxial joint was accurate, without atlanto occipital joint activity limitation. All patients got bony fusion 3 to 6 months post-operation. The clinical recovery rate was 93.8%. The SAC of C1,2 segment increased by 6.06±1.29 mm postoperatively, which showed a significant difference compared with preoperative SAC. The SAC at the latest follow-up was 15.31±0.79 mm, showing no significant difference compared with that just postoperatively. The ADI at one month post-operatively decreased by 5.75±1.53 mm, showing a significant difference compared with preoperative SAC. The ADI at the latest follow-up was 1.94±0.57 mm, showing no significant difference compared with that just postoperatively. Conclusion Preoperative Halo-traction combined with Magerl surgery in treatment of children with atlantoaxial rotatory subluxation is a safe and effective method. Key words: Atlanto-axial joint; Dislocations; Child; Internal fixators; Spinal fusion

Traumatic Atlantoaxial Rotatory Fixation (AARF) with Odontoid Fracture, Case report

Introduction Atlantoaxial rotatory fixation (AARF) is also known as rotatory subluxation, rotatory displacement, rotary deformity, rotational subluxation, and is characterized by incomplete dislocation of the inferior atlantal and superior axial articular facets.1 AARF in combination with odontoid fracture is an extremely rare injury.2–6 Atlantoaxial injuries can be classified according to Fielding 1 or White and Panjabi7 classification. The management of this combination is a matter of debate. 1,8,9 Material and Methods We present a case of a 78 years old woman who sustained a fall on the ground from a couch directly on her forehead, resulting in atlantoaxial dislocation with type II odontoid fracture accompanied with left sided hemiparesis ASIA type C. Results After failure of closed reduction, the treatment plane was to achieve reduction under anesthesia and C1–2 fusion, but again reduction was not possible. Occipitocervical fusion to C3 was done to have better stability in osteoporotic bone. Successful reduction was achieved during rod reduction from the occiput to C2 pedicle screw and C3 lateral mass screw. Cervical collar was advised for 3 months, and good fusion and improvement of the neurological status to ASIA type D was achieved after 6 month. Conclusion AARF with Odontoid Fracture is a rare combination and reduction may be impossible. Occipitocervical fusion is a good option in such case as C1–2 reduction is a prerequisite for transarticular screw. C2 pedicle screw offers good purchase even in osteoporotic bone which enabled reduction after rod repositioning. References Fielding JW, Hawkins RJ. Atlanto-axial rotatory fixation. (Fixed rotatory subluxation of the atlanto-axial joint). J Bone Joint Surg Am 1977;59(1):37–44 Born CT, Mure AJ, Iannacone WM, DeLong WG Jr. Three-dimensional computerized tomographic demonstration of bilateral atlantoaxial rotatory dislocation in an adult: report of a case and review of the literature. J Orthop Trauma 1994;8(1):67–72 Jones RN. Rotatory dislocation of both atlanto-axial joints. J Bone Joint Surg Br 1984;66(1):6–7 Moore KR, Frank EH. Traumatic atlantoaxial rotatory subluxation and dislocation. Spine 1995;20(17):1928–1930 Robertson PA, Swan HA. Traumatic bilateral rotatory facet dislocation of the atlas on the axis. Spine 1992;17(10):1252–1254 Wise JJ, Cheney R, Fischgrund J. Traumatic bilateral rotatory dislocation of the atlanto-axial joints: a case report and review of the literature. J Spinal Disord 1997;10(5):451–453 White AA III, Panjabi MM. The clinical biomechanics of the occipitoatlantoaxial complex. Orthop Clin North Am 1978;9(4):867–878 Schmidek HH, Smith DA, Sofferman RA, Gomes FB. Transoral unilateral facetectomy in the management of unilateral anterior rotatory atlantoaxial fracture/dislocation: a case report. Neurosurgery 1986;18(5):645–652 Crockard HA, Rogers MA. Open reduction of traumatic atlanto-axial rotatory dislocation with use of the extreme lateral approach. A report of two cases. J Bone Joint Surg Am 1996;78(3):431–436

Morphological Differences in the Vertebrae of Scoliosis Secondary to Neurofibromatosis Type 1 With and Without Paraspinal Neurofibromas.

A retrospective study. Aim of the study was to investigate morphological differences in the vertebrae of scoliosis secondary to neurofibromatosis type 1 (NF1-S) with and without paraspinal neurofibromas and to identify the relationship between paraspinal neurofibromas and vertebral deformity. Scoliosis is the most common orthopedic manifestation of NF1. Erosion or infiltration of the bone by localized neurofibromas was suggested as one of the primary etiology for the vertebral deformity. One hundred fourteen patients with NF1-S were classified into spinal tumor (ST) group and nontumor (NT) group with respect to the presence of paraspinal neurofibromas. The curve pattern, curve magnitude, the shape and location of paraspinal neurofibromas, and various kinds of morphological changes of vertebrae were evaluated by complete radiographs were compared between the two groups to determine whether the presence of paraspinal neurofibromas could be associated with a more severe vertebral deformity. The ST and NT groups included 54 patients (age, 16.8 ± 5.5 years) and 60 patients (age, 17.3 ± 4.2 years), respectively. The Cobb angles of the main curve were 72.3° ± 20.6° and 65.4° ± 19.4° for the ST and NT groups, respectively. No significant differences were observed between the two groups in age, sex ratio, and Cobb angle. There were significant differences between the ST and NT groups in apical vertebral rotation (36.8° ± 7.2° vs. 27.5° ± 6.8°; P < 0.001) and the prevalence of rotatory subluxation (66.1% vs. 35.0%; P = 0.04). Most of the paraspinal neurofibromas (70.4%) developed within the apical region, with the majority (29/38) located on the concave side. The NF1-S patients with paraspinal neurofibromas had significantly higher prevalence of morphological changes of vertebrae. The paraspinal neurofibromas, most of which were located on the concave side of the apical region, could be associated with more severe vertebral deformities. 3.

How Reliable is the Surgeon's Ability to Differentiate between Idiopathic and Degenerative Deformity in Adults; What Parameters Help them Decide?

Introduction Adult spinal deformity (ASD) may be classified as idiopathic (I) or degenerative (D) (or other) based on classifier's perception, the reliability of and factors inherent to which remain unknown. Aim of study is to evaluate the inter and intraobserver reliability of surgeons' perception in differentiating I from D ASD and to identify the determinants of it. Material and Methods From a multicentric prospective database, 179 patients were identified with the diagnosis of I ( n = 103) or D ( n = 76); no previous surgery; and a lumbar coronal curve &gt; 20°. Standing AP and lateral X-Rays were sent to five experienced spine surgeons to be identified as D or I (or other); followed by a second round after reshuffling. Weighted Kappa statistics was used, after which the patients were stratified by number of agreements as perfect (10/10) and very good (≥8/10); these were further compared for additional radiological parameters. Results Four observers completed both rounds while the 5th did only the first (a total of 10 observations/pt including the record). Agreement levels were moderate to good for intra but fair to moderate for interobserver comparisons (Table 1). There were 42 perfect and 80 with very good agreements for I patients but only 6 perfect and 17 very good agreements for D. Upon comparison of these, it was seen that they were different for some coronal parameters such as lumbar Cobb angle (larger in I, p &lt; 0.001), CSVL modifier (C more common in I, p = 0.007) and presence of rotatory subluxation (less common in D, p = 0.017) but very different for sagittal parameters (lumbar lordosis, sagittal vertical axis, T2-sagittal tilt, pelvic tilt, sacral slope and global tilt; increased sagittal imbalance in D, all p≤0.001). Conclusion Surgeons in this study demonstrated reasonable intraobserver agreement but only fair agreement amongst them. These findings suggest that especially in patients with significant coronal curves, determination of curve etiology with only radiological data may not be accurate. In patients with good agreement, the most consistent radiologic determinant appeared to be the presence of sagittal imbalance.

Non-contiguous Cervical Spine Injury in a 14-month old Child; Case Report and Review of the Literature

Introduction Cervical spine injuries in children are relatively rare. Pattern, severity and level of these injuries are age dependant. Most of the available literature differentiates between two age groups, younger and older than 8 years. The incidence of upper cervical injuries is higher among children younger than 8 years. Most of the available literature is retrospective analysis of databases or case reports. Patients and Methods: a 14-month old child was presented to our emergency unit after involvement in a road-traffic accident. A stiff neck cervical collar was applied at the accident scene. The child was conscious, oriented. He had tendency to move the right upper and lower limb better than the left side. He had torticollis with the head rotated to the left side. Neurological examination revealed a left-sided hemiparesis. He had no other injuries. Under general anesthesia CT and MRI of the skull and the cervical spine were done. These investigations showed a fracture of the axis with a rotary subluxation of C1/2, cord edema at the level of C1 predominantly on the left side and a disco-ligamentous injury at the level of C3/4. Controlled closed reduction under image intensifier and Minerva cast was applied for 3 weeks, and then replaced with a modified Minerva-Hartmann orthosis for another 3 weeks. A review of the literature for patients below the age of 3 years with cervical spine injuries was done in a trial to define an algorithm to clear the cervical spine and to outline the management of this age group. Results The patient was followed for one year with normal MRI findings at 6 months and normal clinical findings at one year follow-up with complete improvement of the neurological deficits. Conclusion Clearance of the cervical spine after trauma in children below the age of 3 is challenging. Articulation and cooperation during clinical examination and imaging investigation is limited. Imaging should be done under general anesthesia. Immobilisation is also demanding and definitive immobilisation for conservative treatment is usually using custom-made orthoses. results of conservative treatment are excellent if closed reduction and immobilisation were achieved.

Analysis of the reliability of surgeons' ability to differentiate between idiopathic and degenerative spinal deformity in adults radiologically. What descriptive parameters help them decide?

Adult spinal deformity (ASD) may be classified as idiopathic (ID) or degenerative (DD) (or other) based on classifier's perception, the reliability of and factors inherent to which remain unknown. The aim of this study is to evaluate the inter- and intra-observer reliability of surgeons' perception in differentiating ID from DD and to identify the determinants of this differentiation. From a multicentric prospective database of ASD, 179 patients were identified with the diagnosis of ID (n=103) or DD (n=76); without previous surgery; and a lumbar coronal curve larger than 20°. Standing antero-posterior and lateral X-rays of these patients were sent to five experienced spine surgeons to be identified as DD or ID (or other); followed by a second round after reshuffling. Weighted kappa statistics were used, the strength of agreement for the kappa coefficient was considered as; 0.81-1=almost perfect, 0.61-0.8=substantial, 0.41-0.60=moderate, 0.21-0.40=fair, 0.01-0.20=slight, and≤0=poor. Patients were then stratified based on the number of agreements on a total of 10 rounds as excellent (10 out of 10), good (more than 7 out of 10) and fair/poor (7 and less). These excellent and good agreements were further compared for additional radiological parameters. Agreement levels were moderate to substantial for intra but mostly fair for inter-observer comparisons. For ID patients, there were 42 cases with excellent and 38 with very good agreement whereas for DD, there were no excellent and only 17 cases with very good agreement. Upon comparison of these (ID vs DD for at least very good cases), it was seen that they were different for some coronal parameters such as lumbar Cobb angle (larger in ID, p<0.001), central sacral vertical line (CSVL) modifier (C more common in ID, p=0.007) and presence of rotatory subluxation (less common in DD, p=0.017), but very different for sagittal parameters (lumbar lordosis, sagittal vertical axis, T2 sagittal tilt, pelvic tilt, sacral slope, and global tilt; increased sagittal imbalance in DD, all p≤0.001). Surgeons in this study demonstrated reasonable (moderate to substantial) intra-observer agreement, but only fair agreement amongst them. Alarming as it may appear, we should be cautious in interpreting these results based on only radiology and no clinical information. In patients with good agreement, the most consistent radiologic determinant of degenerative ASD appeared to be the presence of sagittal imbalance.

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).

Case Report of a Traumatic Atlantoaxial Rotatory Subluxation with Bilateral Locked Cervical Facets: Management, Treatment, and Outcome.

The aim was to report a rare case of isolated traumatic atlantoaxial rotatory subluxation without ligamentous injury. Management consisted of analgesia, sedation, and application of a halo skull traction device. After removing halo skull traction, full reduction and recovery were achieved without instability.

Surgical treatment of children with non-traumatic old atlanto-axial rotatory fixation

Atlanto-axial rotatory fixation (AORF) develops on the background of acute torticollis. Widely adopted terms such as C1 subluxation or atlantooccipital rotational subluxation do not reflect the core of this pathology and carry negative weight in the diagnostics and treatment of AORF. Retrospective analysis of the diagnostics and treatment outcome of 5 children with confirmed AORF diagnosis and literature review were performed. Clinical method, radiography and functional computer tomography were used to verify the diagnosis. De-rotational halo-traction and open correction with screw fixation were applied for treatment. Head position was managed to be improved in all patients. In one case the reduction was performed using correction in suboccipital segments and in other 4 cases the correction and fixation by Harms and de-rotational halo-traction allowed to correct torticollis. The pain syndrome had been arrested completely. Disease outcome resulted in formation of C1-C2 fibrous or bone fusion regardless the method of treatment. The patients with neglected AORF represent a great challenge for diagnostics and treatment. When conservative treatment fails it is necessary to involve de-rotational halo-traction with possible application of open reduction and posterior fusion. The purpose of treatment is to eliminate torticollis and pain using creation of proper C1-C2 alignment. The motions in atlantooccipital joint do not restore due to formation of the fibrous or bone fusion.

Clinical analysis of acute limited neck motion in 420 children

Objective To study the clinical features of acute limited neck motion in children and its differen-tial diagnosis, and to improve doctors' awareness and the early diagnosis of the disease. Methods A total of 420 patients with acute limited neck motion as the chief complaint and atlantoaxial rotary subluxation as the first diagnosis between January 2005 and January 2014 in Nanjing Children's Hospital Affiliated to Nanjing Medical University were enrolled.The clinical manifestations, imaging and consultation data of the 420 patients were retrospectively analyzed. Results There were totally 248 male patients and 172 female patients.The ages ranged from 2 to 14 years old(the mean age was 7.2 years old), the course ranged from 2 hours to 2 days.Among 420 patients, 353 patients were diagnosed as atlantoaxial rotatory subluxation.Forty-two patients were diagnosed as cervical intervertebral disc calcification.Seven patients were diagnosed as Tourette syndrome.Four patients were diagnosed as intracranial tumors.Three patients were diagnosed as cervical eosinophilic granuloma.Two patients were diagnosed as cervical spinal tuberculosis.Two patients were diagnosed as viral encephalitis.Two patients were diagnosed as benign paroxysmal torticollis.Two patients were diagnosed as Kawasaki disease.One patient was diagnosed as neuroblastoma.One patient was diagnosed as hemophilia A. One patient was diagnosed as drug adverse reaction of metoclopramide.According to Fielding clinical classification, 204 patients were type Ⅰ, 122 patients were type Ⅱ, 21 patients were type Ⅲ, and 6 patients were type Ⅳ. Conclusions Based on disease distribution of acute limited neck motion in children, atlantoaxial rotatory subluxation seems to be the predominant while non-atlantoaxial rotatory subluxation is not uncommon.Differential diagnoses should be considered to avoid misdiagnosis.For atlantoaxial rotatory subluxation, conservative treatment including continuous mandible occipital belt traction and brace has been proved to be very effective methods. Key words: Atlantoaxial rotatory subluxation; Acute limited neck motion; Differential diagnosis; Child

Imaging of Atlanto-Occipital and Atlantoaxial Traumatic Injuries: What the Radiologist Needs to Know.

Approximately one-third of all cervical spine injuries involve the craniocervical junction (CCJ). Composed of the occiput and the first two cervical vertebrae, this important anatomic landmark, in conjunction with an intricate ligamentous complex, is essential to maintaining the stability of the cervical spine. The atlantoaxial joint is the most mobile portion of the spine, predominantly relying on the ligamentous framework for stability at that level. As acute onsite management of trauma patients continues to improve, CCJ injuries, which often lead to death onsite where the injury occurred, are increasingly being encountered in the emergency department. Understanding the anatomy of the CCJ is crucial in properly evaluating the cervical spine, allowing the radiologist to assess its stability in the trauma setting. The imaging findings of important CCJ injuries, such as atlanto-occipital dissociation, occipital condyle fractures, atlas fractures with transverse ligament rupture, atlantoaxial distraction, and traumatic rotatory subluxation, are important to recognize in the acute setting, often dictating patient management. Thin-section multidetector computed tomography with sagittal and coronal reformats is the study of choice in evaluating the extent of injury, allowing the radiologist to thoroughly evaluate the stability of the cervical spine. Furthermore, magnetic resonance (MR) imaging is increasingly being used to evaluate the spinal soft tissues and ligaments, and to identify associated spinal cord injury, if present. MR imaging is also indicated in patients whose neurologic status cannot be evaluated within 48 hours of injury. .

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 rare case of Klippel-Feil syndrome associated with atlantoaxial rotatory subluxation, atlanto-occipital fusion, and spina bifida

A rare case of Klippel-Feil syndrome associated with atlantoaxial rotatory subluxation, atlanto-occipital fusion, and spina bifida

Clinical and stereoradiographic analysis of adult spinal deformity with and without rotatory subluxation

IntroductionIn degenerative adult spinal deformity (ASD), sagittal malalignment and rotatory subluxation (RS) correlate with clinical symptomatology. RS is defined as axial rotation with lateral listhesis. Stereoradiography, recently developed for medical applications, provides full-body standing radiographs and 3D reconstruction of the spine, with low radiation dose. Hypothesis3D stereoradiography improves analysis of RS and of its relations with transverse plane and spinopelvic parameters and clinical impact. Material and methodsOne hundred and thirty adults with lumbar ASD and full-spine EOS® radiographs (EOS Imaging, Paris, France) were included. Spinopelvic sagittal parameters and lateral listhesis in the coronal plane were measured. The transverse plane study parameters were: apical axial vertebral rotation (apex AVR), axial intervertebral rotation (AIR) and torsion index (TI). Two groups were compared: with RS (lateral listhesis>5mm) and without RS (without lateral listhesis exceeding 5mm: non-RS). Correlations between radiologic and clinical data were assessed. ResultsRS patients were significantly older, with larger Cobb angle (37.4° vs. 26.6°, P=0.0001), more severe sagittal deformity, and greater apex AVR and TI (respectively: 22.9° vs. 11.3°, P<0.001; and 41.0° vs. 19.9°, P<0.001). Ten percent of patients had AIR>10° without visible RS on 2D radiographs. RS patients reported significantly more frequent low back pain and radiculalgia. DiscussionIn this EOS® study, ASD patients with RS had greater coronal curvature and sagittal and transverse deformity, as well as greater pain. Further transverse plane analysis could allow earlier diagnosis and prognosis to guide management. Level of evidence4, retrospective study.

Conservative treatment for Landells and Van Peteghem type II atlas fracture accompanied with atlantoaxial rotatory subluxation

Conservative treatment for Landells and Van Peteghem type II atlas fracture accompanied with atlantoaxial rotatory subluxation

Pinless halo in the pediatric population: indications and complications.

The use of the conventional halo is accompanied by the possibility of serious complications, especially in the pediatric population. Complications could include penetration of pin into the skull, pin loosening, pin tract infection, cranial nerve palsies, and vest-related pressure sores. The noninvasive "pinless" halo was introduced in an attempt to mitigate these problems while retaining the effectiveness of the conventional halo. The purpose of this study is to determine the indications and complications related to pinless halo application. We retrospectively reviewed 61 patients, whose treatment included the use of a pinless halo device, presenting to our institution between 2004 and 2012. There were 35 male and 26 female patients with an average age of 6.04 years. Indications of pinless halo application included postoperative immobilization for congenital muscular torticollis in 38 cases, conservative management of atlantoaxial rotatory subluxation in 11 cases, postoperative immobilization following cervical fusion in 10 cases, and immobilization for occipital condyle fracture in 2 cases. The average duration of the pinless halo application was 32.68 days. Thirteen patients had complications, among which major complications were seen in 2 patients, each of whom developed a pressure sore; one on the scalp and the other on the chest. Both the pressure sores responded to local treatment; however, 1 resulted in permanent alopecia. The use of the noninvasive pinless halo was found to be safe with few complications in our study. The complications were infrequent and patients were compliant to treatment, indicating that this modality is patient-friendly. Effectiveness of this treatment in comparison with invasive halos and other cervical orthoses was not determined and is a limitation of this study. Level IV-Case series.

Atlantoaxial rotatory subluxation in children.

Atlantoaxial rotatory subluxation is a rare condition in which patients present with the acute onset of torticollis. Atlantoaxial rotatory subluxation represents a spectrum of disease from muscle spasm to a fixed mechanical block to reduction of the atlantoaxial complex. If left untreated, some cases may resolve spontaneously; however, other cases may result in the development of secondary changes in the bony anatomy of the atlantoaxial joint, leading to persistent deformity. Diagnosis of the condition is largely clinical but can be aided by various imaging modalities, including radiographs, dynamic CT scanning, three-dimensional CT reconstructions, or MRI. Consideration should always be given to infection or other inflammatory disease as an underlying, precipitating cause. Treatments include observation, the use a cervical collar and analgesics, halter or skeletal traction, and posterior fusion of C1-C2. The most important factor for success of conservative treatment is the time from the onset of symptoms to recognition and the initiation of treatment.

One-step reduction and fixation applying transposterior arch lateral mass screw of C1 combined with pedicle screw of C2 and rod system for pediatric acute atlantoaxial rotatory subluxation with injury of transverse ligament.

A retrospective case series. To describe a novel intraoperative reduction technique applying C1 transposterior arch lateral mass screw combined with C2 pedicle screw and rod system for pediatric acute atlantoaxial rotatory subluxation with injury of transverse ligament and evaluate outcomes of this technique. For atlantoaxial rotatory subluxation with disruption of transverse ligament or recurrent cases, initial posterior atlantoaxial fusion is a preference. It is an important prerequisite for successful surgery to achieve satisfactory reduction of atlantoaxial articulation after preoperative cranial traction. However, the placement of cranial tractor and persistent traction may be challenging due to a pediatric patient's noncompliance and unsuitable anatomic structure. Therefore, an intraoperative way to achieve reduction and to keep solid stability with only a single procedure is needed. The consecutive patients with atlantoaxial rotatory subluxation with injury of transverse ligament, including 4 males and 1 female, underwent intraoperative reduction and fixation applying C1 posterior arch lateral mass screw combined with C2 pedicle screw and rod system during a 2-year period. The surgical technique and procedure of treatment were intensively reviewed; the clinical outcomes were retrospectively investigated in the aspects of clinical symptoms and imaging appearance. Clinical follow-ups were obtained for an average of 29.4 (range, 24-30 mo) months. The clinical and radiological follow-up indicated a complete clinical relief and satisfactory reduction, stable arthrodesis of atlantoaxial articulation. No neural and vascular impairment related to this technique were observed. The primary outcome showed under sufficient preoperative imaging measurements, C1 transposterior arch lateral mass screw combined with C2 pedicle screw and rod system that obviated preoperative cranial traction provided reliable reduction and stability of atlantoaxial articulation for atlantoaxial rotatory subluxation with injury of transverse ligament. 4.

Traumatic Pediatric Atlantoaxial Rotatory Subluxation Successfully Reduced and Discharged from the Emergency Department: A Case Report

The incidence of atlantoaxial rotatory subluxation is fairly uncommon; however it is more common to be encountered in the pediatric population. It is usually seen in children after a retropharyngeal inflammation or after a minor trauma. Children have unique anatomical features such as inherent ligamentous laxity and shallower and more horizontally oriented facet joints that allow greater freedom of motion especially at the C1-2 joint making them prone to atlantoaxial subluxation. If recognized early it can be successfully managed nonsurgically before chronic inflammatory changes affect the ligaments and joint structure of the C1-2 complex. However, it is unclear in the literature if inpatient admission is necessary for treatment. Here we present a case of atlantoaxial rotatory subluxation in a child caused by forcefully throwing a ball that was successfully reduced and subsequently discharge from the pediatric emergency department all in the same visit.