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Katsuyama Y, Okuda Y, Kanamura H, Sasaki K, Saito T, Nakamura S. Management of Adult Atlantoaxial Rotatory Fixation: Case Series with Literature Review. THE IOWA ORTHOPAEDIC JOURNAL 2023; 43:96-105. [PMID: 38213850 PMCID: PMC10777696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/13/2024]
Abstract
Background Atlantoaxial rotatory fixation (AARF) is extremely rare in adults, and there is no consensus on the ideal treatment of adult AARF because of its rarity. We presented a case series of three adult AARFs and reviewed the literature on adult AARFs. We suggest treatment guidelines for the injury based on the literature review. Methods We compiled a series of three adult AARFs seen in our hospital. We also utilized the NCBI library to retrieve literature on adult AARF from 2000 to 2021. We included articles on adult AARF, which described the number of days from injury to diagnosis, Fielding classification, occurrence of associated cervical injuries, and details of treatment and the results. Results Thirty adult AARFs reports fulfilled the criteria and 32 patients were analyzed. Eighteen patients had Fielding Type 1 AARF and were diagnosed within 1 month of injury. Among them, 13 cases healed with conservative treatment. Patients with acute AARF of Fielding Type 1 who underwent manual reduction healed successfully. All patients that required more than 1 month from injury to diagnosis underwent surgery. All cases with AARF Fielding Types 2, 3, and 4 failed conservative treatment. Conclusion The case series and literature review suggest that early diagnosis of adult AARF is essential for successful closed reduction, and the Fielding classification may help determine treatment strategy. Furthermore, this study showed that not only traction but also manual reduction may be a useful treatment for early diagnosed AARF Fielding Type 1 without complications. Level of Evidence: III.
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Affiliation(s)
- Yusei Katsuyama
- Department of Orthopaedics, Fukuchiyama City Hospital, 231 Atsunaka-cho, Fukuchiyama, Kyoto 620-8505, Japan
| | - Yoshiki Okuda
- Department of Orthopaedics, Fukuchiyama City Hospital, 231 Atsunaka-cho, Fukuchiyama, Kyoto 620-8505, Japan
| | - Hitoshi Kanamura
- Department of Orthopaedics, Fukuchiyama City Hospital, 231 Atsunaka-cho, Fukuchiyama, Kyoto 620-8505, Japan
| | - Kentaro Sasaki
- Department of Orthopaedics, Fukuchiyama City Hospital, 231 Atsunaka-cho, Fukuchiyama, Kyoto 620-8505, Japan
| | - Tomoki Saito
- Department of Orthopaedics, Fukuchiyama City Hospital, 231 Atsunaka-cho, Fukuchiyama, Kyoto 620-8505, Japan
| | - Shinichiro Nakamura
- Department of Orthopaedics, Fukuchiyama City Hospital, 231 Atsunaka-cho, Fukuchiyama, Kyoto 620-8505, Japan
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de Meldau Benites V, da Costa MDS, Cavalheiro S. Posterior C1-C2 fusion for atlantoaxial rotatory fixation after posterior fossa craniotomy in a 4-year old: a case report. Childs Nerv Syst 2023; 39:1647-1651. [PMID: 36705687 DOI: 10.1007/s00381-023-05862-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 01/22/2023] [Indexed: 01/28/2023]
Abstract
INTRODUCTION This study aimed to highlight that atlantoaxial rotatory fixation (AARF) can be related to neurosurgery procedures in children, with an afterward demonstration of good results after halo-gravity traction and C1-C2 stabilization using the Harms technique. CASE DESCRIPTION To the best of our knowledge, this is the first case to report a 4-year-old boy who presented with AARF after a posterior fossa craniotomy to treat a cerebellar astrocytoma. At our medical facility, AARF was diagnosed using plain radiography and computed tomography imaging. The patient was treated with continuous cranial traction for 14 days. Initially, we detected that the patient had no C1 posterior arch or C2 spinous process; therefore, the best option was to perform the Harms technique. Postoperatively, the patient was placed in a cervical collar for 4 weeks. At the 4-year postoperative follow-up, the patient was doing well and had not developed any complications. CONCLUSION Herein, we report a case in which AARF can be developed after neurosurgical procedure. Surgical techniques used for atlantoaxial subluxation should be carefully selected. In our case, the Harms technique after cranial traction was an excellent option for correcting and stabilizing the abnormal neck position. However, further studies are required to determine the best technique to use in the pediatric population.
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Affiliation(s)
| | | | - Sergio Cavalheiro
- Department of Neurology and Neurosurgery, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
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Does alar ligament injury predict conservative treatment failure of atlantoaxial rotatory subluxation in adults: Case report and review of the literature. Spinal Cord Ser Cases 2021; 7:103. [PMID: 34862363 DOI: 10.1038/s41394-021-00464-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 10/28/2021] [Accepted: 11/02/2021] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION The alar ligament is an important structure in restraining the rotational movement at the atlantoaxial joint. While bony fractures generally heal, rupture of ligaments may heal poorly in adults and often requires surgical stabilization. Atlantoaxial rotatory subluxation (AARS) is a rare injury in adults, and the prognostic importance of the presence of alar ligament injury with regard to the success of nonoperative management is unknown. CASE PRESENTATION A 28-year-old woman presented after a traumatic Type I AARS without evidence of osseous injury, but MRI demonstrated evidence of unilateral alar ligament disruption. Initial conservative management with closed reduction and maintenance in a rigid cervical collar proved unsuccessful, with worsening pain and failure to maintain reduction. She subsequently underwent open reduction and surgical fixation of C1-C2, resulting in resolution of her pain and maintenance of alignment. DISCUSSION Alar ligament rupture may be a negative prognostic indicator in the success of nonoperative management of type I atlantoaxial rotatory subluxation. Additional study is warranted to better assess whether the status of the alar ligament should be considered an important factor in the management algorithm of type I AARS.
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Tobing SDAL, Abubakar I, Karda IWAM. Recurrent traumatic atlantoaxial rotatory subluxation: Case report. Ann Med Surg (Lond) 2020; 54:65-70. [PMID: 32382411 PMCID: PMC7198983 DOI: 10.1016/j.amsu.2020.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 04/01/2020] [Accepted: 04/10/2020] [Indexed: 12/03/2022] Open
Abstract
Introduction Atlantoaxial rotatory subluxation (AARS) is not uncommon in paediatric emergencies, however, the complications might be fatal. Long onset before presentation is correlated with higher recurrence and persistent deformity. There is no consensus on the treatment of AARS yet. Selected patients may benefit from conservative approaches; however, retention might be difficult, and subluxation may recur. Presentation of case A 6-year-old boy was admitted to our institution with AARS for three months before admission. Typical Cock-Robin position was observed. Computed tomography (CT) indicated AARS Fielding and Hawkins grade III. We treated the case conservatively by closed reduction and cervical traction using Gardner-Wells tongs. However, poor compliance resulted recurrence of subluxation, so we decided to fuse the atlantoaxial joint using transarticular screws, posterior wiring, and autologous bone grafting. Posterior fusion resulted in a satisfactory outcome, in which the wound healed accordingly. Six months of follow up examination revealed normal motoric and sensory function. The patient was able to perform daily activities with no significant issues. Discussion Patients with fixed deformity of more than three weeks have a higher rate for recurrence or persistent deformity, as reduction is harder and difficult to maintain. The use of posterior wiring alone is limited in maintaining reduction, while using transarticular screws alone is considered better in maintaining reduction; however, not providing it. Conclusion The use of posterior cervical fusion using C-wire, transarticular screws, and autologous bone grafting may be applied in recurrent case of AARS to ensure adequate reduction and fixation of the atlantoaxial joint. AARS is not uncommon in the paediatric setting as the biomechanical property of the paediatric spine introduces more risk for dislocation. A 6-year-old boy was admitted with AARS for three months before admission. After treated conservatively, the subluxation reoccurred. We decided to fuse the atlantoaxial joint. Posterior cervical fusion using C-wire, transarticular screws, and autologous bone grafting may be applied in recurrent case of AARS to ensure adequate reduction and fixation of the atlantoaxial joint.
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Affiliation(s)
- Singkat Dohar Apul Lumban Tobing
- Department of Orthopaedics and Traumatology, Cipto Mangunkusumo General Hospital – Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
| | - Irsan Abubakar
- Department of Orthopaedics and Traumatology, Cipto Mangunkusumo General Hospital – Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
- Department of Orthopaedics and Traumatology, University of Syiah Kuala, Aceh, Indonesia
| | - I Wayan Arya Mahendra Karda
- Department of Orthopaedics and Traumatology, Cipto Mangunkusumo General Hospital – Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
- Corresponding author. Jalan Diponegoro No. 71, Central Jakarta, Jakarta, 10430, Indonesia.
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Rahimizadeh A, Williamson W, Rahimizadeh S. Traumatic Chronic Irreducible Atlantoaxial Rotatory Fixation in Adults: Review of the Literature, With Two New Examples. Int J Spine Surg 2019; 13:350-360. [PMID: 31531285 DOI: 10.14444/6048] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Atlantoaxial rotatory fixation (AARF) is a rare condition in adults and is almost always due to an accompanying trauma. The first example of traumatic AARF in adults was reported by Corner in 1907 and since then only 55 adult cases with this rare traumatic scenario have been published so far. Approximately 80% of adults with traumatic AARF are diagnosed soon after the traumatic events. However, in the remaining casualties, the condition might be missed with some delay from the diagnosis to treatment. If this pathology is diagnosed early enough, the conservative attempts for a closed reduction are usually effective. After closed reduction, external immobilization is required to prevent recurrence of the dislocation. However, with delayed diagnosis, the condition may remain refractory to traction on manipulation and require an open reduction instead. In the literature, such irreducible chronic AARFs are rarely reported, being confined to only 14 adult examples, in whom surgical intervention for correction of the deformity will be required. In such cases, release of the atlantoaxial facet joints is the first surgical step. In the subsequent step, reduction of the dislocated facet joints can be done via one of the already described maneuvers. As the final step, C1-C2 fixation will be necessary for prevention of re-dislocation. Herein, 2 adult patients with chronic rotatory atlantoaxial dislocation of traumatic origin are presented. In both cases, cranial traction and manipulations were ineffective and therefore an open reduction procedure was proposed and accomplished via the posterior midline corridor. The transverse rod technique was implemented subsequent to the atlantoaxial facet release. After correction of the deformity, a C1-C2 fixation was accomplished followed by arthrodesis. In addition to the outlined procedure, an historical review of the literature on this subject from the beginning of 20th century is demonstrated.
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Affiliation(s)
- Abolfazl Rahimizadeh
- Pars Advanced and Minimally Invasive Manners Medical Research Center, Pars Hospital Affiliated to Iran University of Medical Sciences, Tehran, Iran
| | - Walter Williamson
- Pars Advanced and Minimally Invasive Manners Medical Research Center, Pars Hospital Affiliated to Iran University of Medical Sciences, Tehran, Iran
| | - Shahayegh Rahimizadeh
- Pars Advanced and Minimally Invasive Manners Medical Research Center, Pars Hospital Affiliated to Iran University of Medical Sciences, Tehran, Iran
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Barimani B, Fairag R, Abduljabbar F, Aoude A, Santaguida C, Ouellet J, Weber M. A missed traumatic atlanto-axial rotatory subluxation in an adult patient: case report. Open Access Emerg Med 2019; 11:39-42. [PMID: 30697088 PMCID: PMC6339448 DOI: 10.2147/oaem.s149296] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background Traumatic atlanto-axial rotatory subluxation (AARS) in an adult is a rare condition, which if left untreated can be fatal. In addition to this, many symptoms experienced such as neck pain and stiffness are non-specific which often leads to misdiagnosis, thus delaying definitive treatment. AARS can be divided into traumatic and non-traumatic causes with the latter generally encompassing congenital cervical spine abnormalities. Case presentation We present a case of a 66-year-old female with traumatic rotatory AARS, which was initially misdiagnosed in the emergency department. This patient was subsequently recalled to the hospital when the misdiagnosis was spotted the following day from imaging results. The patient was initially managed conservatively as an inpatient using head halter cervical traction which proved to give good clinical reduction allowing discharge with Miami J upon ambulation. Upon follow up the patient was experiencing continuous pain but remained neurovascularly intact. She thus opted for definitive management with C1–C2 stabilization with an open reduction and internal fixation. Conclusion This case demonstrates the importance of having a high index of suspicion to diagnose AARS in cervical spine trauma presenting to the emergency department, until exclusion can be made using imaging and clinical examination.
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Affiliation(s)
- Bardia Barimani
- McGill Scoliosis and Spine Centre, McGill University Health Centre, Montreal, QC, Canada,
| | - Rayan Fairag
- McGill Scoliosis and Spine Centre, McGill University Health Centre, Montreal, QC, Canada, .,Department of Orthopedic Surgery, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Fahad Abduljabbar
- McGill Scoliosis and Spine Centre, McGill University Health Centre, Montreal, QC, Canada, .,Department of Orthopedic Surgery, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Ahmed Aoude
- McGill Scoliosis and Spine Centre, McGill University Health Centre, Montreal, QC, Canada,
| | - Carlo Santaguida
- McGill Scoliosis and Spine Centre, McGill University Health Centre, Montreal, QC, Canada,
| | - Jean Ouellet
- McGill Scoliosis and Spine Centre, McGill University Health Centre, Montreal, QC, Canada,
| | - Michael Weber
- McGill Scoliosis and Spine Centre, McGill University Health Centre, Montreal, QC, Canada,
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Pavlova OM, Ryabykh SO, Burcev AV, Gubin AV. Anomaly-Related Pathologic Atlantoaxial Displacement in Pediatric Patients. World Neurosurg 2018; 114:e532-e545. [DOI: 10.1016/j.wneu.2018.03.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 03/02/2018] [Accepted: 03/05/2018] [Indexed: 11/30/2022]
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Robles LA, Mundis GM, Cuevas-Solórzano A. Atlanto-Occipital Rotatory Dislocation: A Case Report and Systematic Review. World Neurosurg 2017; 110:106-114. [PMID: 29133003 DOI: 10.1016/j.wneu.2017.11.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 10/31/2017] [Accepted: 11/02/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Atlanto-occipital rotatory dislocation (AORD) has rarely been reported in the literature; for this reason, the clinicoradiologic characteristics of this injury are not well described. METHODS We describe the case of a 67-year-old man who sustained a cervical spine trauma. He reported only neck pain and was neurologically intact. A computed tomography scan showed a rotatory displacement of the atlanto-occipital joints associated with a widened condylar-C1 interval; in addition, magnetic resonance imaging showed injuries to the stabilizing ligaments of this area. A systematic literature review was also performed to identify previous cases of patients with AORD. RESULTS The patient was treated with craniocervical fixation from occipital to C1, achieving a good outcome. The literature review yielded 9 cases of patients with AORD. Compared with patients with atlanto-occipital dislocation, patients with rotatory dislocations have a less severe degree of displacement of the atlanto-occipital joints and better clinical outcome. CONCLUSIONS Compared with previously classified atlanto-occipital dislocations, AORD is an independent and unique variation. AORD presents with different biomechanical, clinicoradiologic, and prognostic characteristics and represents an important addition to the spectrum of atlanto-occipital dislocation injuries.
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Affiliation(s)
- Luis A Robles
- Section of Neurosurgery, Hospiten, Puerto Vallarta, Jalisco, Mexico.
| | - Greg M Mundis
- San Diego Center for Spinal Disorders, La Jolla, California, USA
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Miyao Y, Sasaki M, Umegaki M, Yonenobu K. Adult Case of Atlantoaxial Rotatory Fixation Treated with In Situ Fixation Using an Unusual Posterior Instrumentation Construct. NMC Case Rep J 2017; 4:63-66. [PMID: 28840080 PMCID: PMC5566685 DOI: 10.2176/nmccrj.cr.2016-0270] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2016] [Accepted: 12/02/2016] [Indexed: 11/20/2022] Open
Abstract
Atlantoaxial rotatory fixation (AARF) occurs commonly in children who have undergone trauma. It is usually corrected with conservative therapy. In this report, however, the patient was an adult with AARF who was treated surgically. A 64-year-old woman presented with a 1-year history of spastic gait and hand clumsiness. Imaging studies revealed the presence of AARF, os odontoideum, and severe spinal cord compression at that spinal level. As the AARF had not been responded to head traction with a halo device, we decided to treat the patient with in situ posterior fixation. Because the rigid dislocation was present between the atlas and the axis, we were forced to make an unusual instrumentation construct. Neurological symptoms other than hand numbness diminished after the surgery, and arthrodesis was obtained between the occiput and the axis. It should be noted that surgical planning for posterior instrumentation construct is required when rigid AARF is treated surgically.
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Affiliation(s)
- Yasuyoshi Miyao
- Department of Neurosurgery, Suita Municipal Hospital, Suita, Osaka, Japan
| | - Manabu Sasaki
- Department of Neurosurgery, Iseikai Hospital, Osaka, Osaka, Japan
| | - Masao Umegaki
- Department of Neurosurgery, Iseikai Hospital, Osaka, Osaka, Japan
| | - Kazuo Yonenobu
- Graduate School of Health Care Sciences, Jikei Institute, Osaka, Osaka, Japan
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Traumatic atlantoaxial rotatory fixation in an adult patient. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2017; 28:284-289. [PMID: 28078473 DOI: 10.1007/s00586-016-4916-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Revised: 11/24/2016] [Accepted: 12/05/2016] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Atlantoaxial rotational fixation (AARF) is a rare entity in adults, with only a few cases reported in the English literature and often associated with a traumatic mechanism. It is an underdiagnosed condition that must be taken into account in the initial assessment of all craniocervical trauma. Both diagnostic and therapeutic delay may be a potential cause of severe neurological damage or even death of the patient. The therapeutic management is controversial given the difficulty of achieving optimum stability and permanent reduction. METHODS AND RESULTS A 28-year-old woman was involved in a traffic accident a week before coming to the emergency with rotation and irreducible cervical flexion from trauma and severe neck pain. CT and MRI column were performed and showed a cervical spinal AARF with transverse and alar ligaments intact and preserved atlantoaxial distance (Fielding I). The patient was treated by progressive cervical traction with 5 kg and manual reduction was completed in 24 h. Subsequently, an external immobilization was performed by cervical rigid collar for 16 weeks. The clinical course was good, with the patient regaining full mobility with cervical neck pain improvement. CONCLUSIONS The purpose of this paper is to show a case of a young woman with a posttraumatic AARF successfully treated conservatively. This case delineates the difficulties in diagnosing this pathology, as well as the challenges encountered in its management.
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Peyneau PD, Roque-Torres GD, Godolfim LR, Costa EDD, Almeida SMD, Ambrosano GMB. Rotation of the second cervical vertebra in pediatric patient. EINSTEIN-SAO PAULO 2016; 14:575-576. [PMID: 28076609 PMCID: PMC5221388 DOI: 10.1590/s1679-45082016ai3631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Accepted: 04/12/2016] [Indexed: 11/22/2022] Open
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It is the lateral head tilt, not head rotation, causing an asymmetry of the odontoid-lateral mass interspace. Eur J Trauma Emerg Surg 2015; 42:749-754. [DOI: 10.1007/s00068-015-0602-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Accepted: 11/16/2015] [Indexed: 12/13/2022]
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Kim JH, Kim JH, Jang SY, Kong MH. Combined Chronic Occipito-atlantal and Atlanto-axial Rotator Fixation with Cerebral Palsy. KOREAN JOURNAL OF SPINE 2014; 10:192-4. [PMID: 24757487 PMCID: PMC3941761 DOI: 10.14245/kjs.2013.10.3.192] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Revised: 09/12/2013] [Accepted: 09/14/2013] [Indexed: 11/19/2022]
Abstract
Occipito-atlantalrotatory subluxation that occurs in conjunction with atlanto-axial rotator fixation is extremely rare. The common clinical characteristics are painful torticollis and cock robin position presented with the head tilted to one side and rotated to the other side. The object of this report is to emphasize that AARF combined with OARF may be caused by a variety of conditions, to be must need algorithm for proper management, apparently. A torticollis patient who had cerebral palsy presented with severe nuchal pain and wryneck for a long period. The patient had a history of fallen down 16 years ago which caused severe nuchal pain. The conservative management had failed to correct the deformity and instability. we decided to operate using occiput-C1-C2 arthrodesis and C3-4-5 bilateral screw fixation for reinforcement. Now he doesn't have neurologic deficit and shows good outcome enough to sustain his head, not using his hands, in his daily life.
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Affiliation(s)
- Jae Hong Kim
- Department of Neurosurgery, Seoul Medical Center, Seoul, Korea
| | - Jung Hee Kim
- Department of Neurosurgery, Seoul Medical Center, Seoul, Korea
| | - Se Youn Jang
- Department of Neurosurgery, Seoul Medical Center, Seoul, Korea
| | - Min Ho Kong
- Department of Neurosurgery, Seoul Medical Center, Seoul, Korea
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