Traumatic Atlantoaxial Rotatory Subluxation in Adult: Case Report

Traumatic atlantoaxial rotatory subluxation (AARS) is generally found in pediatric patients, rarely found in adults, being a life-threatening condition especially when early diagnosis is not possible, which can lead to severe late neurological deficits.We describe a 38-year-old patient, victim of physical aggression caused by strangulation attempt who developed AARS, an uncommontraumatic cause. During the hospital care, the early diagnosis allowed us to institute a conservative treatment, which made the case uncommon, since most of the time surgical treatment is imperative. With the patient awake and under analgesia, a closed reduction was performed that promoted immediate pain relief, followed by a prescription of wearing a Philadelphia-type collar for 8 weeks. During the follow-up, cervical spine radiographies demonstrated no subluxation after removing the cervical collar. The patient was asymptomatic after 6months of treatment. This case supports the importance of nonoperative management of AARS in selected cases.

The development and evaluation of individualized templates to assist transoral C2 articular mass or transpedicular screw placement in TARP-IV procedures: adult cadaver specimen study

OBJECTIVES: The transoral atlantoaxial reduction plate system treats irreducible atlantoaxial dislocation from transoral atlantoaxial reduction plate-I to transoral atlantoaxial reduction plate-III. However, this system has demonstrated problems associated with screw loosening, atlantoaxial fixation and concealed or manifest neurovascular injuries. This study sought to design a set of individualized templates to improve the accuracy of anterior C2 screw placement in the transoral atlantoaxial reduction plate-IV procedure. METHODS: A set of individualized templates was designed according to thin-slice computed tomography data obtained from 10 human cadavers. The templates contained cubic modules and drill guides to facilitate transoral atlantoaxial reduction plate positioning and anterior C2 screw placement. We performed 2 stages of cadaveric experiments with 2 cadavers in stage one and 8 in stage two. Finally, guided C2 screw placement was evaluated by reading postoperative computed tomography images and comparing the planned and inserted screw trajectories. RESULTS: There were two cortical breaching screws in stage one and three in stage two, but only the cortical breaching screws in stage one were ranked critical. In stage two, the planned entry points and the transverse angles of the anterior C2 screws could be simulated, whereas the declination angles could not be simulated due to intraoperative blockage of the drill bit and screwdriver by the upper teeth. CONCLUSIONS: It was feasible to use individualized templates to guide transoral C2 screw placement. Thus, these drill templates combined with transoral atlantoaxial reduction plate-IV, may improve the accuracy of transoral C2 screw placement and reduce related neurovascular complications. .

Traumatic atlantoaxial rotatory subluxation in adults: report of two cases and literature review / Subluxación atlantoaxial rotatoria traumática en adultos: reporte de dos casos y revisión de la literatura

Atlantoaxial subluxation is defined as an instability of the atlas (C1) over the axis (C2), due to failure or rupture of the ligament complex in the C1-C2 joint. It occurs most frequently in childhood, due to atlantoaxial ligament laxity, a common condition at this age group and may have traumatic or nontraumatic causes. The clinical features of this entity are the presence of upper cervical pain, limitation of neck mobility, torticollis and muscle spasm. The treatment of rotatory subluxation should be individualized because there is no evidence in the literature showing the superiority of a particular therapeutic proposal. In this study we describe two cases of atlantoaxial subluxation of traumatic origin in adults and review the literature regarding the main aspects of this entity.

Subluxación atlantoaxial se define a una inestabilidad del atlas (C1) sobre el axis (C2), debido a un fallo o rotura del complejo del ligamento de la articulación C1-C2. Es más frecuente en la infancia, debido a la laxitud del ligamento atlantoaxial, una condición común en este grupo de edad y puede tener causas traumáticas o no traumáticas. Las características clínicas de esta entidad son la presencia de dolor cervical superior, limitación de la movilidad del cuello, tortícolis y los espasmos musculares. El tratamiento de la subluxación rotatoria debe ser individualizado en porque no hay una evidencia en la literatura que muestra la superioridad de una propuesta terapéutica en particular. En este estudio se describen dos casos de subluxación atlantoaxial de origen traumático en adultos y se hace una revisión de la literatura respecto a los principales aspectos de esta entidad.

Application of spiral CT reconstruction in the forensic identification of atlantoaxial injuries / 法医学杂志

OBJECTIVE@#To evaluate diagnostic value of spiral CT reconstruction in atlantoaxial injuries.@*METHODS@#The images of 25 cases of spiral CT reconstruction were analyzed and compared with images of CT scan and X-ray.@*RESULTS@#In 7 cases of odontoid process fracture, X-ray demonstrated 4 cases and CT demonstrated 5 cases, whereas the spiral CT reconstruction diagnosed 7 cases, which could display the displacement of fracture clearly. The X-ray and CT showed asymmetric space between left and right gaps of atlantoaxial joint in 6 cases, while spiral CT reconstruction showed normal and excluded the possibility of atlantoaxial dislocation. There was one case of lateral atlantoaxial joint dislocation, which was demonstrated by the spiral CT reconstruction clearly but not by the X-ray and CT scan. There were 3 cases of atlantoaxial congenital deformity (1 case of absence of both posterior arch of atlas and odontoid process and 2 cases of maldevelopment of the odontoid process), which were displayed clearly by spiral CT reconstruction, but misdiagnosed as odontoid process fracture and atlantoaxial subluxation by X-ray and CT scan.@*CONCLUSION@#Spiral CT reconstruction can provide the most accurate and integrity imaging information and is very useful in the diagnosis of atlantoaxial injuries and deformity.

Fractura del ahorcado: antecedentes históricos / Hangmen's fracture: historical background

La fractura del ahorcado es la lesión traumática del arco neural del axis. El entendimiento de esta afección comenzó a desarrollarse a principios de este siglo, aunque el proceder del ahorcamiento judicial se utilizaba desde cientos de años con anterioridad. Este trabajo se propone revisar los antecedentes históricos hasta el momento actual en el conocimiento de dicha afección, su presentación natural, el diagnóstico imagenológico y las alternativas del tratamiento(AU)

Hangmans fracture is the traumatic injury of the neural arch of the axis. This affection started to be understood at the beginning of the last century, though the procedure of the judicial hanging had been used hundreds of years before. The objective of this paper is to review the historical antecedents of the knowledge of this affection, its natural presentation, the imaging diagnosis and the treatment alternatives up to now(AU)

Síndrome de Grisel: um alerta para o otorrinolaringologista / Grisel's syndrome: a warning for the otorhinolaryngologist

A Síndrome de Grisel consiste na subluxaçäo rotatória da articulaçäo atlantoaxial, comumente näo associada a trauma ou doença óssea. Possui etiologia variada. Os pacientes se queixam de dor cervical constante e progressiva, apresentando torcicolo e, em certos casos, compressäo da espinha cervical. O diagnóstico é clínico e radiológico. o tratamento deve ser o mais precose possível. Realiza-se revisäo bibliográfica do assunto, visando alertar os otorrinolaringologistas para esta possibilidade diagnóstica.

The biomechanical study of atlantoaxial fixation.

Recent studies of various C(1-2) constructs have confirmed superior stability with transarticular screw fixation. In the meantime, our study on the C2 morphology in Thai people found about 4 per cent of the pedicles were too small for the 3.5 mm. C(1-2) transarticular screw. In order to select a smaller screw to use in this operation, we performed a biomechanical testing of 2 sizes of screw (2.7 mm, 3.5 mm) for transarticular screw fixation and Gallie's wiring, comparison in terms of stiffness in flexion, extension, torsion, anterior and posterior shear loads. There were no statistical differences of the stiffness between 2.7 mm and 3.5 mm transarticular screw fixation in all directions, whereas there were significantly greater stiffness of transarticular screw over Gallie's wiring in various directions (P<0.05).

Posterior C1-C2 transarticular screw fixation for Atlanto-axial instability.

The objective of this study was to reveal that the treatment of C1-C2 instability by transarticular C1-C2 screw fixation with bone graft has a better result than conventional sublaminar wiring with bone graft by Gallie's technique. This technique, proposed by Magerl and Semann in 1987, produces a rigid three points fixation resulting in maximal bone fusion rate and does not require an orthosis post-operatively. This technique is performed in patients with fractured lamina of C1 or in patients who need a laminectomy of C1 for spinal cord decompression. This study revealed 10 patients having C1-C2 instability who were operated on by transarticular C1-C2 screw fixation with bone graft. No complication was encountered. No screw and bone graft slipping were noted. The patients were improved clinically and the average follow-up period was 7.7 months. There were 2 cases which had previously been operated on for sublaminar wiring but the operation was unsuccessful because there was a fractured lamina of C1. Both patients were sent to Prasat Neurological Institute & Hospital for transarticular C1-C2 screw fixation. Another 2 cases were operated on for sublaminar wiring with bone graft. The follow-up X-ray of both cases disclosed a displacement of C1-C2. Lost of C1 lamina was found in one case and there was slipping of wire in another case, because of this the patients were re-explored for transarticular C1-C2 screw fixation with bone graft. The conclusion is, this technique of transarticular C1-C2 screw fixation, is the best surgical treatment for C1-C2 instability, in the hands of experienced surgeons with an excellent knowledge of anatomy.

Atlanto-axial dislocation in children

The authors present 14 cases of C1 C2 dislocations in children (8 boys and 6 girls; mean age, 6.9 years) seen at the Orthopedics and Traumatology Institute of the University Hospital, Faculty of Medicine, University of Säo Paulo from 1978 to 1990. In view of the disappointing results obtained by conservative treatment in 6 of the 14 patients, the authors recommend early atlanto-axial arthrodesis in cases of C1 C2 dislocation in children

Subluxaçäo atlanto-axial e síndrome de Reiter: apresentaçäo de um caso e revisäo da literatura / Atlanto-axial dislocation and Reiter's syndrome: presentation of a case and review of literature

O presente relato descreve uma paciente com síndrome de Reiter e subluxaçäo atlanto-axial que desenvolveu compressäo da medula espinhal. A literatura sobre esse assunto é revisada

Hidrocefalia: uma complicaçäo rara da subluxaçäo atlanto-axial na artrite reumatóide / Hydrocephalus: a rare complication of atlanto-axial dislocation in rheumatoid arthritis

Os autores fazem uma revisäo das complicaçöes da subluxaçäo atlanto-axial na artrite reumatóide (AR), descrevendo quadro clínico e diagnóstico: relatam um caso de paciente com subluxaçäo C1-C que apresentou hidrocefalia como uma possível complicaçäo

Paciente com pelve espondilite anquilosante e subluxaçäo atlanto-axial / Patient pelvic with ankilosant spondylitis and atlanto-axial subluxation

É relatado o caso de um paciente de 14 anos de idade, do sexo masculino, com espondilite anquilosante e subluxaçäo atlanto-axial com quadro de tetraparesia, que foi submetido a traçäo halocraniana e fez uso de halo-gesso, obtendo melhora do quadro neurológico

Subluxaçäo atlanto-axial na artrite reumatóide / Atlanto-axial dislocation in rheumatoid arthritis

A subluxaçäo atlanto-axial é quadro complexo e de grande gravidade potencial, frente a danos neurológicos que pode acarretar em pacientes com artrite reumatóide. Após discorrer sobre os quatro tipos de deslocamentos (anterior, posterior, vertical e lateral), os autores descrevem o quadro clínico e o variável prognóstico visto nas séries da literatura. Cirurgia é indicada em casos de compressäo medular com sintomas neurológicos em progressäo, dor severa ou intratável

Sporadic Ehlers-Danlos syndrome with neurologic, cardiac and dental involvement.

A sporadic case of Ehlers-Danlos syndrome associated with atlantoaxial dislocation, mitral valve prolapse and dental abnormalities is presented. This case could not be assigned to any of the nine defined types of the syndrome.