Traction for the treatment of traumatic atlantoaxial subluxation in adults / 中国骨伤

OBJECTIVE@#To observe the application of modified traction therapy in traumatic atlantoaxial subluxation in adults.@*METHODS@#The clinical data of 31 patients with atlantoaxial subluxation treated from March 2018 to June 2019 were restropectively analyzed. There were 15 males and 16 females, aged from 18 to 68 years old with an average of 39 years old, including 10 cases of 18-40 years, 15 cases of 41-60 years, 6 cases of 51-68 years. The main manifestations of the patients were limited neck movement, pain, and atlantoaxial CT scan showed different degrees of atlantoaxial subluxation. Three dimensional multifunctional traction bed was used for traction for 2 min, relaxation for 10 s. The traction angle starts from the rearward extension of 5°-10° and weight from 3-6 kg. The weight increased by 1 kg every two days until the symptoms were improved. Traction time was 30 min twice a day and 10 days for a course of treatment. One course of treatment was performed in patients with 1-2 mm left and right equal width of atlantoaxial space, and two courses of treatment were performed in patients with 3-4 mm left and right equal width of atlantoaxial space, and the course of treatment could be increased to 3 months in especially patients with serious problems, such as 4 mm left and right equal width of atlantoaxial space and no improvement after conventional treatment. The criteria to evaluate the clinical effect was cure:no pain in the neck, normal range of neck movement, CT showed normal atlantoaxial space and odontoid process was in the middle, patients with normal neck movement were followed up 1 month after the end of treatment;improvement:neck pain was significantly improved and CT showed that the left and right atlantoaxial space was less than 1 mm in equal width.@*RESULTS@#Among the 31 patients, 17 cases were cured by one course of treatment, 11 cases were cured by 2 courses of treatment, and 2 caseswere improved.@*CONCLUSION@#The modified traction therapy has obvious effect on adult traumatic atlantoaxial subluxation, especially the subluxation of 3-4 mm equal width in left and right atlantoaxial space, and this method is safe and reliable with good efficacy and the patients without discomfort.

Subluxación atloaxoidea. Emergencia en la atención clínico quirúrgica / Atlantoaxial subluxation. Emergency in clinical surgical care

Introducción: la subluxación atloaxoidea es un trastorno de la columna cervical, a nivel de las vértebras C1 y lC2 que causa deterioro en la rotación del cuello porque la faceta anterior de C1 se fija en la faceta de C2. Objetivo: enfatizar la importancia del diagnóstico temprano de la subluxación atlantoaxoidea en pacientes con o sin evidencia de trauma para que sea identificada como emergencia clínico quirúrgica. Desarrollo: en el presente trabajo se enfatiza en la necesidad de identificar eventos o complicaciones de la subluxación atloaxoidea que pongan en peligro la vida de los pacientes y requieran de la atención clínico quirúrgica de manera emergente por la compresión de médula espinal que puede ocasionar, de modo que en algunos reportes bibliográficos es clasificada como una emergencia. Conclusiones: existen muchas formas de presentación de la subluxación atloaxoidea, muchas de ellas pueden cursar con complicaciones que constituyan emergencias, así como variados tratamientos que deben ser valorados críticamente porque pueden ocasionar consecuencias mayores que la propia enfermedad, lo que habla a favor de lo imprescindible de un diagnóstico certero y de un enfoque multidisciplinar(AU)

Introduction: the atlantoaxial subluxation is a disorder of the cervical spine, at the level of the C1 and C2 vertebrae that causes deterioration in the rotation of the neck because the anterior facet of C1 is fixed on the facet of C2. Objective: To emphasize the importance of early diagnosis of atlantoaxial subluxation in patients with or without evidence of trauma to be identified as a surgical clinical emergency. Development: In the present work, emphasis is placed on the need to identify events or complications of atlantoaxial subluxation that endanger the life of patients and require surgical clinical attention in an emergent manner due to the compression of the spinal cord that may result from so that in some bibliographic reports it is classified as an emergency. Conclusions: There are many forms of presentation of atlantoaxial subluxation, many of them can present complications that constitute emergencies, as well as various treatments that must be critically evaluated because they can cause greater consequences than the disease itself, which speaks in favor of the essential of an accurate diagnosis and a multidisciplinary approach(AU)

Autogenic Rib Graft for Atlantoaxial and Occipitocervical Fixation in Pediatric Patients

STUDY DESIGN: Retrospective case series. PURPOSE: To evaluate surgical outcomes and effectiveness of an autogenic rib graft for upper cervical fixation in pediatric patients. OVERVIEW OF LITERATURE: Autogenic bone grafts have long been considered the ‘gold standard’ bone source for posterior cervical fusion in pediatric patients. However, there are some unsolved problems associated with donor-site morbidity and amount of bone grafting. METHODS: We studied five consecutive pediatric patients who underwent atlantoaxial fixation or occipitocervical fixation (OCF) using an autogenic rib graft with at least 2 years of follow-up (mean age, 9.8 years; mean follow-up period, 73.0 months). Two patients underwent OCF without screw-rod constructs and three patients with screw-rod constructs. Autogenic rib grafts were used in all patients. We evaluated the surgical outcomes including radiographic parameter, bony union, and perioperative complications. RESULTS: The atlantoaxial interval (ADI) was corrected from 11.6 to 6.0 mm, and the C1–2 angle was corrected −14.8° to 7.8°. The C2–7 angle was reduced from 31° to 9° spontaneously. Two patients with OCF required revision surgery due to loss of correction. Patients did not experience any complication associated with the donor sites (rib bone grafts). Six months postoperation X-rays clearly showed regeneration of the rib at the donor sites. Bony fusion was achieved in all patients; however, bony fusion occurred more slowly in patients without screw-rod constructs compared with patients with screw-rod constructs. Bone regeneration of the rib was observed in all patients with no complications at the donor site. CONCLUSIONS: Autogenic rib grafts have advantages of potential bone regeneration, high fusion rate, and low donor-site morbidity. In addition, a screw-rod construct provides better bony fusion in pediatric patients with OCF and atlantoaxial fixation.

Direct Intraoperative Reduction of Basilar Invagination Associated with Atlantoaxial Subluxation ­ Technical Note

In the present article, we describe a technique of direct intraoperative reduction of congenital atlantoaxial subluxation associated with severe basilar invagination and atlas assimilation. It consists of a wide dissection of the craniovertebral junction, exposing the region between the superior facet of C2 and the occiput (described as a "pseudoarticulation" by some authors). After exposure, a self-rotating small dissector or Kobe is used bilaterally, pushing C2 anteriorly and inferiorly, with reduction of the dislocation, followed by craniovertebral fixation. The technique is safe and eliminates the need for an anterior approach to the odontoid reduction, as well as the need to dissect the C1­2 joint.

Neste artigo, descrevemos a técnica de redução intraoperatória direta de subluxação atlantoaxial congênita associada a invaginação basilar grave e assimilação do atlas. Ela consiste em ampla dissecção da junção craniovertebral, expondo a região entre a face superior da C2 e o osso occipital (descrita como uma "pseudoarticulação" por alguns autores). Após exposição, um descolador pequeno ou Kobe é usado bilateralmente com rotação própria, deslocando C2 anterior e inferiormente, com redução da luxação, seguido de fixação craniovertebral. A técnica é segura e elimina a necessidade de uma abordagem anterior para a ressecção do odontoide, além de evitar a dissecação da junta C1­C2.

Clinical Observation on Combination of Muscle Tendon Manipulation and Sagittal Pull Method Modified with a Small Angle among 40 Atlantoaxial Subluxation Cases / 世界科学技术-中医药现代化

This study was aimed to investigate the clinical effect of atlantoaxial subluxation with the combination of the muscle tendon manipulation and the modified small angle sagittal pull and conventional Tuina therapy.A total of 80 atlantoaxial subluxation cases were randomly divided into two groups.The cure rate,rate of improvement,imaging and Xray space difference between two groups were observed and analyzed statistically.The results showed that the cure rate was 70.00％ in the treatment group,and 42.50％ in the control group;the total efficiency rate was 97.472％ in the treatment group,and 82.50％ in the control group.There was significant difference between two groups by x2 test.The image of atlanto odontoid anterior space and the side gap difference were significant before and after treatment (P ＜ 0.05).It was concluded that treatment of atlantoaxial subluxation with the combination of the muscle tendon manipulation and the modified small angle sagittal pull achieved better effect compared to the conventional Tuina therapy.This method should be further promoted in the clinical practice.

One case report of systemic onset juvenile idiopathic arthritis with atlantoaxial subluxation as the initial manifesta-tion / 临床儿科杂志

Objective To explore the clinical features of systemic onset of juvenile idiopathic arthritis (SoJIA) with atlantoaxial subluxation as the initial manifestation. Methods The clinical data from one SoJIA patient with atlantoaxial subluxation as the initial manifestation were retrospectively analyzed. Results A 9-year-old boy presented the head and neck movement disorder as the ifrst symptom, developed fever on the third day, then rapidly progressed on 23rd day, with a sharp decline in red blood cell, platelet, and hemoglobin, blood coagulation dysfunction, and a large number of bilateral pulmonary exudation. Ultrasonography showed excess lfuid in abdomen, chest, and pericardium. According to the 2001 version of the revised International College of Rheumatology standard, the diagnosis of SoJIA combined macrophage activation syndrome was conifrmed. Then treated with hemoperfusion, ifltration, and methylprednisolone combined with cyclosporine A, the disease was in remission. Conclusion For children with spontaneous atlantoaxial subluxation accompanied by the systemic symptoms, with no obvious skeletal deformity or acute inlfammation etc., should be alerted to the consideration of systemic juvenile idiopathic arthritis.

Risk Factors for the Development and Progression of Atlantoaxial Subluxation in Surgically Treated Rheumatoid Arthritis Patients, Considering the Time Interval between Rheumatoid Arthritis Diagnosis and Surgery

OBJECTIVE: Rheumatoid arthritis (RA) is a systemic disease that can affect the cervical spine, especially the atlantoaxial region. The present study evaluated the risk factors for atlantoaxial subluxation (AAS) development and progression in patients who have undergone surgical treatment. METHODS: We retrospectively analyzed the data of 62 patients with RA and surgically treated AAS between 2002 and 2015. Additionally, we identified 62 patients as controls using propensity score matching of sex and age among 12667 RA patients from a rheumatology registry between 2007 and 2015. We extracted patient data, including sex, age at diagnosis, age at surgery, disease duration, radiographic hand joint changes, and history of methotrexate use, and laboratory data, including presence of rheumatoid factor and the C-reactive protein (CRP) level. RESULTS: The mean patient age at diagnosis was 38.0 years. The mean time interval between RA diagnosis and AAS surgery was 13.6±7.0 years. The risk factors for surgically treated AAS development were the serum CRP level (p=0.005) and radiographic hand joint erosion (p=0.009). The risk factors for AAS progression were a short time interval between RA diagnosis and radiographic hand joint erosion (p<0.001) and young age at RA diagnosis (p=0.04). CONCLUSION: The CRP level at RA diagnosis and a short time interval between RA diagnosis and radiographic hand joint erosion might be risk factors for surgically treated AAS development in RA patients. Additionally, a short time interval between RA diagnosis and radiographic hand joint erosion and young age at RA diagnosis might be risk factors for AAS progression.

Successful Treatment of Occipital Radiating Headache Using Pulsed Radiofrequency Therapy

Rheumatoid arthritis (RA) is a chronic inflammatory disease involving multiple joints. The cervical spine is often affected, and cases involving atlantoaxial joint can lead to instability. Anterior atlantoaxial subluxation in RA patients can lead to posterior neck pain or occipital headache because of compression of the C2 ganglion or nerve. Here, we report the successful treatment of a RA patient with occipital radiating headache using pulsed radiofrequency therapy at the C2 dorsal root ganglion.

Congenital Anomaly of the Atlas Misdiagnosed as Posterior Arch Fracture of the Atlas and Atlantoaxial Subluxation

Partial or complete absence of the posterior arch of the atlas is a well-documented anomaly but a relatively rare condition. This condition is usually asymptomatic so most are diagnosed incidentally. There have been a few documented cases of congenital defects of the posterior arch of the atlas combined with atlantoaxial subluxation. We report a very rare case of congenital anomaly of the atlas combined with atlantoaxial subluxation, that can be misdiagnosed as posterior arch fracture.

Cervical Myelopathy Resulting From Non-Rheumatoid Atlantoaxial Subluxation

Degenerative pannus arising from the atlanto-axial articulation is a rare entity, which is associated with chronic atlanto-axial instability in degenerative arthropathies. Due to cervical instability and the mass effect on the spinal cord, it can produce severe neck pain and compressive myelopathy. We report a case of cervical myelopathy resulting from non-rheumatoid atlanto-axial subluxation. The posterior stabilization provided excellent neurological improvement and pannus regression. Early recognition of this condition is important as the clinical condition will deteriorate without surgical interventions.

Clinical, radiologic, and genetic features of Korean patients with Mucopolysaccharidosis IVA / 소아과

PURPOSE: Mucopolysaccharidosis IVA (MPS IVA; Morquio A syndrome) is rare lysosomal storage disorder caused by N-acetylgalactosamine-6-sulfatase (GALNS) deficiency. Only a few MPS IVA cases have been reported in the Korean literature; there is a paucity of research about clinical or radiologic findings for this disorder. Therefore, we studied clinical findings, radiological features, and genetic data of Korean MPS IVA patients for determining factors that may allow early diagnosis and that may thus improve the patients' quality of life. METHODS: MPS IVA was confirmed via assay for enzymatic activity of leukocytes in 10 patients. The GALNS gene was analyzed. Patients' charts were retrospectively reviewed for obtaining clinical features and evaluated for radiological skeletal surveys, echocardiography, pulmonary function test, and ophthalmologic test results. RESULTS: Nine patients had severe clinical phenotype, and 1 had an intermediate phenotype, on the basis of clinical phenotype criteria. Radiologic findings indicated skeletal abnormalities in all patients, especially in the hips and extremities. Eight patients had an odontoid hypoplasia, and 1 showed mild atlantoaxial subluxation and cord myelopathy. Genetic analysis indicated 10 different GALNS mutations. Two mutations, c.451C>A and c.1000C>T, account for 37.5% (6/16) and 25% (4/16) of all mutations in this samples, respectively. CONCLUSION: An understanding of the clinical and radiological features involved in MPS IVA may allow early diagnosis of MPS IVA. Adequate evaluations and therapy in the early stages may improve the quality of life of patients suffering from skeletal abnormalities and may reduce life-threatening effects of atlantoaxial subluxation.

The change of anterior atlanto-dense interval in atlantoaxial instability patients: preoperative vs postoperative

BACKGROUND: Atlantoaxial subluxation (AAS) is a frequent manifestation of rheumatoid arthritis (RA). The instability of the cervical spine caused by AAS is potentially fatal condition under intubation for surgery. Anterior atlanto-dens interval (AADI) is a mirror of the risk for neural injury. We evaluated the change of AADI in atlantoaxial instability patients, before and after surgery. METHODS: The present study included 56 patients who underwent surgical procedures by AAS. Lateral radiographs were checked at preoperative, postoperative, 1 month later and 6 month later. AADI was measured using picture archiving communication system (PACS) system in each lateral radiograph. RESULTS: The value of AADI is 8.40 +/- 2.29 mm in preoperative period, 2.72 +/- 0.53 mm in postoperative, 2.68 +/- 0.53 mm in 1 month, and 2.70 +/- 0.51 mm in 6 months later. After cervical fusion, AADI immediately decreased 5.68 +/- 2.24 mm. There were significant decreased in postoperative, 1 month and 6 months, when compared with preoperative AADI. CONCLUSIONS: After the cervical fusion of AAS, the neurological and radiological stability was achieved by decrement of AADI. We concluded that the cervical fusion of AAS provide more safety during endotracheal intubation by decreased AADI.

The Treatment of Traumatic Atlantoaxial Rotatory Subluxation (Fielding Type I) and the Correlation between the Clinical Progress and Radiological Reduction Parameter

STUDY DESIGN: This is a retrospective study. OBJECTIVES: We will discuss clinical outcomes of adult traumatic atlantoaxial rotatory subluxation (Fielding type I) and verify the correlation between the clinical outcomes and radiological reduction rate. SUMMARY OF LITERATURE REVIEW: Atlantoaxial rotatory subluxation which usually occur in children by non-traumatic sources or minor trauma has been discussed persistently. However, studies of atlantoaxial rotatory subluxation which occur in adults over 20 years old, especially by traumatic injury is rare. MATERIALS AND METHODS: From October 2004 to April 2011, thirty patients diagnosed of traumatic atlantoaxial rotatory subluxation with 6 months follow-up period were enrolled in the study. After diagnosis, we started treating Halter traction with 5 lbs. We discontinued traction when the patient recovered over 90% of ROM and applied Philadelphia collar to the patient. We measured visual analogue scale (VAS) for cervical pain and ROM. We measured atlanto-dens interval (ADI) and lateral mass-dens interval (LDI) difference using three-dimensional computed tomography (3D-CT) to validate radiological reduction rate. RESULTS: At the end of follow-up, none of the patients complained over pain and all recovered to full ROM. ADI was in normal range during the whole treatment period. LDI difference gradually decreased during treatment period, however, only 8 cases (26.7%) came back to normal range. CONCLUSIONS: In traumatic atlantoaxial rotatory subluxation (Fielding type I), satisfactory clinical outcomes such as pain relief or ROM improvement using traction and the radiological reduction rate was also improved but it failed to achieve a complete reduction of LDI difference in radiography.

Application and Prospective Randomized Control Study of Manipulative Reduction on Atlanto-axial Subluxation / 国际中医中药杂志

Objective To observe the clinical effect of treating atlanto-axial subluxation by manipulative reduction therapy. Methods 128 patients with atlanto-axial subluxation confirmed by cervical plain X ray were randomized into two groups: 64 in the treatment group treated by manipulative reduction therapy, and 64 in the control group treated by the routine cervical traction. The clinical effect was evaluated by both clinical and X-ray confirmation. Results The X-ray study showed that after treatment the reconstruction of excursion in odontoid process in the treatment group was better than that in the control group significantly (P<0.01). The improvement of vertebra basal artery blood flow in the treatment group was also better than that in the control group significantly (P<0.05). The total effective rate of the treatment group was 95.3%, while the control group was 78.1%. Conclusion The technique of manipulative reduction on atlanto-axial subluxation acts more directly on the cause of the disease than the routine traction, and exerts better results in restoring proper atlanto-axiai joint position and mechanics stability of cervical vertebra.. Thus it is the effective shortcut way with high safety and low cost.

Atlantoaxial Subluxation in Undifferentiated Spondyloarthropathy: A case report

Atlantoaxial subluxation in undifferentiated spondyloarthropathy is extremely rare and has not been reported. We describe a case of 27-year-old man who was diagnosed as undifferentiated spondyloarthropathy with atlantoaxial subluxation with an initial complaint of painful swelling of right 1st metatarsophalangeal joint and posterior neck pain. Roentgenograms showed sclerotic change and increased hazziness in right 1st metatarsophalangeal joint. Magnetic resonance images and roentgenograms of the cervical spine showed inflammation of odontoid process and atlantoaxial subluxation. Bone scan showed hot uptakes in left sacroiliac joint, right 1st & 4th metacarpophalangeal joints and 1st metatarsophalangeal joint. HLA-B27 gene was positive. Spontaneous atlantoaxial subluxation and undifferentiated spondyloarthropathy was diagnosed and conservatively treated with oral medication. Currently, there is no definite neurological sign. Early recognition and awareness of potential clinical complications is important in preventing compressive damage on central nervous system.

Indirect Decompression using Segmental Screw Fixation for Cervical Myelopathy Caused by C1-2 Subluxation: Technical Note / 대한정형외과학회잡지

The main aims of surgery for severe cord compression and myelopathy caused by atlantoaxial subluxation are decompression of the spinal cord and achievement of rigid fixation and fusion. Direct decompression by resecting the bony structures that compress the spinal cord includes transoral decompression and resection of the posterior arch of the atlas. The shortcomings of these procedures are a high complication rate and a relatively low rate of union. Indirect decompression can be performed by a reduction of the subluxation and fixation without bone resection. To the best of our knowledge, there are no domestic reports on the use of indirect decompression for severe cord compression and myelopathy for atlantoaxial subluxation. We report a case of a patient that had atlantoaxial subluxation and severe myelopathy; satisfactory reduction of the subluxation and decompression with an improvement in the myelopathy symptoms was achieved by indirect decompression using segmental screw fixation.

A Case of Rheumatoid Arthritis Presenting Initially as Atlantoaxial Subluxation / 대한류마티스학회지

We report here on a case of rheumatoid arthritis (RA) that progressed from the spine to the peripheral joints. In RA, the involvement of the cervical spine usually correlates with the progressive erosion of peripheral joints, such as the hand or foot, and the elevation of disease activity. Generally, it takes over 2 years of rheumatoid involvement of the cervical spine to cause laxity of the transverse ligament. The common types of rheumatoid cervical spine are anterior atlantoaxial subluxation, vertical subluxation and subaxial subluxation. We describe a 61-year-old woman with only neck pain initially. An MRI of the cervical spine showed atlantoaxial subluxation with features of the rheumatoid involvement. Arthritis later developed in both hands and symmetrically in other peripheral joints. She was diagnosed as having RA. This is the first case report of RA presenting initially as atlantoaxial subluxation.

Subluxación atlanto-axial anterior secundaria a osteoartritis: reporte de un caso / Anterior atlanto-axial subluxation secondary to osteoarthritis: a case report

Objetivo. Describir un caso de subluxación atlantoaxial anterior secundaria a una osteoartritis. Descripción. Un paciente masculino de 60 años de edad con una tetraparesia moderada, rápidamente progresiva, piramidalismo y trastornos sensitivos superficiales y profundos, de cuatro meses de evolución. Las radiografías de columna cervical frente y perfil muestraron una subluxación atlanto-axial anterior. La resonancia magnética mostró un tejido patológico periodontoideo con extensión a articulares y mielomalacia compresiva a nivel C1-C2 a expensas de elementos posteriores por la subluxación. Las radiografías del resto de la columna, manos, rodillas y hombros mostraron cambios degenerativos artrósicos. Se realiza una interconsulta con el servicio de reumatología que, luego del analizar los resultados serológicos, clínicos y radiológicos, arribó al diagnóstico de osteoartritis. Intervención. Consistió en un abordaje posterior, con apertura del foramen magno, laminectomía de C1 y osteosíntesis occipitocervical con la colocación de injertos óseos autólogos. Conclusión. La osteoartritis es una causa infrecuente de subluxación atlantoaxial anterior. Más allá de la patología causal, sabemos que el tratamiento quirúrgico es fundamental en los pacientes sintomáticos.

Objetive. To describe a new case of an anterior atlanto-axial suluxation caused by osteoarthritis. Dewscription. A 60-year-old male patient presented a 4 month history of progressive cuadriparesis, bipyramidalism and deep and superficial hipoestesia. The anterior and lateral radiographs showed an anterior C1-C2 subluxation and the magnetic resonance periodontoidal tissue mass that caused a compressive myelopathy. Intervention. Through a posterior approach, we openned theforamen magnum and performed a C1 laminectomy. After the decompression we performed an occipitocervical arthrodesis with an "Y" plate implant and autologous bone grafts. Conclusion. Osteoarthritis is an unusual cause of anterior atlantoaxial subluxation, that must be treated surgically in symptomatic patients.

Atlantoaxial Fixation using C2 Subarticular Screws and C1 Lateral Mass Screws : A Technical Report / 대한정형외과학회잡지

Segmental screw fixation is a useful procedure for the surgical treatment of atlantoaxial subluxation. Currently, C1 lateral mass screws and C2 pedicle screws are the standard screws used in this procedure. However, the C2 pedicle screw can cause serious complications such as vertebral artery injury. Recently we suggested a new trajectory for the C2 screw, the subarticular screw, which has a lower probability of vertebral artery injury compared with the pedicle screw, based on a study using 1 mm-sliced CT scan images and simulation software. We report the first case of segmental screw fixation using C2 subarticular screws along with C1 lateral mass screws. The patient had atlantoaxial subluxation and myelopathy and showed satisfactory results after surgery.

Atlantoaxial Subluxation due to Psoriatic Arthritis

Atlantoaxial subluxation causing spinal cord compression at the craniovertebral junction may develop in patients with rheumatoid or psoriatic arthritis. There have been only a few reports of atlantoaxial subluxation in patients with psoriatic arthritis in the world. The authors report a case of psoriatic arthritis with atlantoaxial subluxation accompaning periodontoid pannus formation. This 53-year-old man with a 3-year history of psoriatic skin lesion presented with nuchal pain and myelopathy. We performed decompression by C1 total laminectomy with transarticular screw fixation and obtained remarkable improvement in motor function and immediate postoperative stability.