A novel technique to treat Grisel's syndrome: results of a simplified, therapeutical algorithm

Conservative approach for treatment of Grisel's syndrome after resection of lympahadenitis tuberculosis of the neck: A rare case report

INTRODUCTION

Grisel's syndrome is a rare condition characterized by nontraumatic rotatory subluxation of the atlantoaxial joint, which was caused by previous inflammation around the head and neck. It is usually seen in children and signed as torticollis. There was no consensus for management, yet early diagnosis and treatment is paramount.

PRESENTATION OF CASE

A 5-year-old girl came to outpatient clinic complaining of wry neck 1 day after surgical excision of her TB lymphadenitis and got worsen by time. There was no history of trauma around the neck. Examination under general anesthesia and CT scan revealed acquired severe torticollis consistent with Grisel's Syndrome Fielding type 3 accompanied by TB lymphadenitis, and TB myositis of the neck. Manipulation under general anesthesia and immobilization using Minerva cast followed by Lerman Cervicothoracal Osthosis was conducted.

DISCUSSION

This patient was diagnosed with Grisel's syndrome and underwent conservative treatment consisting of reduction under general anesthesia and immobilization using Minerva cast for 6 weeks. The patient was then applied Lherman Cervical Thoracic Orthosis (CTO) halo brace for another 3 months. Anti-tuberculous drug was given to control tuberculous infection. Eight months follow-up showed neither residual deformity, neck pain, nor movement limitation of the neck.

CONCLUSION

Grisel's syndrome has excellent result that is treated with conservative treatment using reduction under general anesthesia and Minerva cast.

New Simple 3-Dimensional Computed Tomogram Classification Leading to Successful Conservative Treatment in 51 Atlanto-Axial Rotatory Fixation Children

OBJECTIVE

to present a new and easy classification of atlanto-axial rotatory fixation (AARF) and to investigate the efficiency of conservative treatment of AARF.

BACKGROUND

Although there is a precise definition and diagnostic classification of AARF, there is still significant difficulty in measuring the atlas and axis angles because all of the atlas or axis cannot be seen in a certain 2-dimensional computed tomogram image. In addition, some recent case reports showed that long-term conservative treatment can reduce pediatric AARFs, even that are severe or chronic.

METHODS

Fifty-one children with AARF were analyzed retrospectively with new 3-dimensional computed tomogram (3DCT)-based AARF classification; the mean age was 72.7 ± 35.2 months (19-139 months). In the new AARF classification, type 1 was defined as that when the C1C2 angle is not 0° on midline and type 2 as that when the C1C2 angle is 0° on the midline.

RESULTS

All 7 children with AARF type 1 were treated successfully only with Halter tractions. Twenty among 44 children with type 2 did not show any difference in improvement compared with not-treated 24 children with type 2.

CONCLUSION

The first new AARF classification based on 3DCT appears to be easy to use and even the most severe children with AARF may be managed only with conservative treatment such as long-term Halter traction.

Grisel's Syndrome in Children: Two Case Reports and Systematic Review of the Literature

Background and Objective. Grisel's syndrome is a rare syndrome characterized by nontraumatic rotatory subluxation of the atlantoaxial joint. It usually affects children and typically presents with torticollis after ear, nose, and throat (ENT) surgery or head and neck infections. In the pediatric literature, there is only a small amount of available data; moreover, no systematic review has been previously done with focus on the pediatric population. We report our experience of two cases, and we provide a systematic review on Grisel's syndrome in children in order to offer a deeper insight about its clinical presentation, its current diagnosis, and principles of treatment. Case Reports and Review. We describe two boys of 9 and 8 years old, who developed atlantoaxial subluxation after adenoidectomy. Considering the early diagnosis, a conservative treatment was chosen, with no recurrence and no sequelae at follow-up. We identified 114 case reports, of which 90 describe children, for a total of 171 pediatric patients. Of the 154 cases in which cause was reported, 59.7% presented a head and neck infection and 35.7% had previous head and neck surgery. There is no sex prevalence (49.7% males versus 50.2% females). Mean delay in diagnosis is 33 days. Eight % of the patients had neurological impairment of the 165 cases which mentioned treatment, 96% underwent a conservative treatment, of whom the 8.8% recurred with the need of surgery. As a whole, 12% underwent surgery as a first- or second-line treatment. 3 6% of the patients whose follow-up was reported developed a sequela, minor limitation of neck movement being the most frequent. Conclusion. Grisel's syndrome should be suspected in children with painful unresponsive torticollis following ENT procedures or head and neck inflammation. CT scan with 3D reconstruction is the gold standard for diagnosis, allowing the identification of the subluxation and the classification according to the Fielding–Hawkins grading system. Surgical treatment is indicated in case of high-grade instability or failure of conservative treatment. Review of the literature shows how early diagnosis based on clinical and radiological evaluation is crucial in order to avoid surgical treatment and neurologic sequelae.

Rotational dislocation C1-C2 after otoplasty under local anesthesia

Non-traumatic rotational atlantoaxial subluxation (NTARS) is rare and mostly reported after infection of the upper respiratory tract and named Grisel's syndrome. NTARS has also been reported after head-and-neck surgery, but it is extremely rare after otoplasty. A case of NTARS after bilateral otoplasty is reported under local anesthesia, a 15-year-old female being presented with painful torticollis. The diagnosis of atlantoaxial rotatory subluxation was performed using radiographs and computed tomography 2 weeks after the surgery. Closed reduction was performed by traction of the head and transoral direct pressure over an anterior dislocated C1 mass. The reposition of the joint was achieved, but it was very unstable, and it was not possible to keep the reduction. Open posterior reduction and posterior C1–C2 arthrodesis were performed followed by the use of a soft collar during 3 months.

Complications of Halo Placement

BACKGROUND

The halo vest is widely used throughout the world to manage craniovertebral and cervical instabilities. It can be used for postoperative immobilization or as an alternative to surgical fixation.

METHOD

In this paper we present some cases of severe complications from our own practice and review the literature on halo complications.

RESULTS

Like any therapeutic manoeuvre, halo placement may be followed by various complications. In the meantime, modern techniques of fixation offer safe and immediate stabilization.

CONCLUSION

The halo vest remains a formidable method for cervical immobilization. However, it should not be used a priori instead of surgery.

Grisel's Syndrome: Non-traumatic Atlantoaxial Rotatory Subluxation-Report of Five Cases and Review of the Literature

BACKGROUND

In children, when unresponsive neck rigidity and distress are observed after ear, nose and throat (ENT) surgical treatment or nasopharyngeal inflammation, Grisel's syndrome should be suspected. This is a rare syndrome involving non-traumatic rotatory subluxation of the atlantoaxial joint. Conservative management with external cervical orthoses and empirical antibiotic, muscle relaxant and analgesic therapy should be the first choice of treatment. Surgical stabilization is indicated when high-grade instability or failure of stable reduction are observed. The instability is graded according to the classification system devised by Fielding and Hawkins. Several recommendations for treatment are available in the literature, but there are no common guidelines. In this paper, the authors discuss the need for prompt diagnosis and treatment considerations.

CASE DESCRIPTION

Five children with Fielding type I-III rotatory subluxation are reported. Three patients were treated with a cervical collar, and one patient was treated with skull traction and sternal-occipital-mandibular immobilizer (SOMI) brace application. Surgical treatment was necessary for one patient after failure of initial conservative management. The intervals between the onset of torticollis and radiological diagnosis ranged from 12 to 90 days. A relationship between an increased grade of instability and delayed diagnosis was observed.

CONCLUSION

In children with painful torticollis following ENT procedures or nasopharyngeal inflammation, Grisel's syndrome should always be suspected. Cervical magnetic resonance imaging (MRI) allows prompt and safe diagnosis, and a three-dimensional computed tomography (CT) scan provides better classification of the instability. Surgery, which is indicated in cases of high-grade instability or failure of conservative treatment, may be avoided with prompt diagnosis.

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

INTRODUCTION

Grisel'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 REPORTS

Two 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.

DISCUSSION

Grisel'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.

CONCLUSION

Close 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.

Painful torticollis following adenotonsillectomy: a cardinal sign of atlantoaxial subluxation

An 11-year-old boy with a history of autism spectrum disorder attended the emergency department with his mother 8 days after an adenotonsillectomy reporting postoperative bleeding. Detailed physical examination revealed no active bleeding, but a rigid neck posture was noted. A head and neck CT scan demonstrated unilateral rotatory atlantoaxial subluxation and possible damage to the anterior spinal ligament. He was reviewed by neurosurgeons who performed manipulation under anaesthetic and successfully realigned the occipital cervical tract. Non-traumatic atlantoaxial subluxation (Grisel's syndrome) is a rare but serious complication of routine ear, nose and throat (ENT) procedures. An awareness of this complication among paediatricians, otolaryngologists and emergency physicians, and a high index of suspicion in any patient presenting with torticollis following ENT surgery is essential in preventing significant neurological morbidity.

Grisel Syndrome: An Unusual and Often Unrecognized Cause of Torticollis

Torticollis can be due to many different etiologies. Torticollis is not a diagnosis, but a symptom of many conditions. We present a case of persistent torticollis in a child that was misdiagnosed during multiple visits to the pediatrician, otolaryngologist, and 3 different emergency departments. Grisel syndrome must be included in the differential diagnosis of any patient with torticollis after a head and neck infection, upper respiratory infection, or postoperative from head and neck surgery. Early diagnosis allows for appropriate management and can prevent significant morbidity.