IJOCP | March 2015 | Volume 2015 | Issue 2015 | Page 3

Conference: 28th Annual Conference of Association of Spine Surgeons of India 2015, Pune. India [Click for Full details]  

Authors: Pravin Padalkar, Saurab Tanver, Varun Joshi, Vinod Laheri

Authors Affiliatoins: MGM Institute of Health Sciences

Address of correspondence: drpravinpadalkar@yahoo.com


Abstract
 
   
                                                                                                          

Introduction

Atlantoaxial rotatory fixation (AARF) is a rare condition and often under recognized, resulting in an incorrect or delayed diagnosis1.Because a clinical diagnosis of AARF is generally difficult, it is often made in the late stage. We report a case of Chronic Neglected atlantoaxial rotatory subluxation in adolescence child that was treated by serial skull traction followed by posterior fusing by method pioneered by Prof Laheri & Goel et

Material &Methods

Case Report : A 15 year old male presented with upper cervical kyphosis and signs of high cervical myelopathy almost 2yrs after initial trauma in childhood. On clinical evaluation there was upper cervical kyphosis, sub occipital pain and direct tenderness over C2 spinous process. The neurological evaluation showed atrophy of both hand muscles with weakness in grip strength.exaggerated reflexes in upper and lower extremities. Dagnosis of rotatory atlantoaxial dislocation corresponding to type 3 in the classification scheme developed by Fielding and Hawkins [4]. Reduction of this 2 yr old dislocation proved difficult and required 10 days of skull traction followed by gentle manipulation. To determine whether C2–C1 fusion was required, dynamic radiographs of the cervical spine were obtained (Fig. 5). There was evident instability, inform of recurrent subluxation from reduced position, and the atlas–dens interval was anormal (C1–C2, <3 mm). A magnetic resonance imaging (MRI) and reconstruction CT angiogram study was performed to look for post-traumatic spinal cord contusion and, above all, to evaluate the transverse ligament. In addition, the integrity of the medulla, cervical cord and the vertebral arteries can be demonstrated.5-7

Surgical Technique

The patient is positioned prone using a Mayfield head holder (OMI, Inc, Cincinnati, OH). The neck is kept neutral and the head is placed in the military tuck position. Goel’s C1 lateral mass screw with C2 pars/ pedicle screw fixation. The screw is placed with 15-25 degrees of medial angulations. The thick medial wall of the C2 pedicle will help redirect the screw if necessary and prevent medial wall break out and entry into the spinal canal. The trajectory of the C2 pedicle screw is 20 degrees up angle and 15-25 degrees medial from the entry point. The screws are tightened over a plate or rods are top loaded onto the screw heads

 Result

At the six months follow-up, he was free from the neck pain and resumed normal activities. These follow-up radiograph images confirmed the atlas and axis has been completely repositioned.  The ‘cockrobin’ posture disappeared and fusion was noted after four to seven weeks with normal alignment of the atlantoaxial joints and the atlantodental interval Rehabilitation therapy aimed at recovering mobility was started. Twelve months later, the range of motion of the neck was normal in all planes, and a dynamic lateral radiograph of the cervical spine confirmed that the atlantoaxial joint was stable.

 Conclusion

Rotatory atlantoaxial dislocation is relatively rare in adults but can be caused by neck injuries. Reduction is difficult if the diagnosis is delayed by more than 1 month. Prolonged Skull traction upto 15kg  is indicated, if necessary in association with direct manipulation of the neck. Stability is dependent on whether the transverse ligament is intact and can be evaluated by measuring the atlas–dens interval on dynamic cervical radiographs and the atlas–axis angle on CT scans in maximum rotation. When the atlanto-dental exceeds 5 mm, there is instability of the C1-C2 complex and posterior C1/2 fixation is indicated.

How to Cite this Abstract
Padalkar P, Tanver S, Joshi V, Laheri V. Chronic Neglected Irreducible Atlantoaxial Rotatory Subluxation In Adolescence: Case Report. International Journal of Conference Proceedings. March 2015;(2015):117