• Unilateral facet subluxation with intact transverse ligament • Odontoid acts as a pivot point with 1 facet subluxating anteriorly, 1 facet subluxating posterioly. • Most common and benign type
• Unilateral facet subluxation with 3 to 5 mm of anterior displacement. • Injured Transverse ligament • 1 facet acts as pivot point and 1 lateral mass is displaced anteriorly
• Bilateral anterior facet displacement of > 5 mm. • Rare with higher risk of neurologic involvement or instantaneous death. • Both lateral masses are displaced
• Posterior displacement of atlas (C1) (with odontoid fracture, or hypoplastic dens) • Rare with higher risk of neurologic involvement or instantaneous death
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A 5-year-old boy develops spontaneous atlantoaxial rotatory subluxation shortly after an upper respiratory infection. No neurologic symptoms are present. He is initially treated with soft collar immobilization and rest. After a week, he continues to hold his head tilted and rotated with no change in his neurologic status. A current cervical radiograph is shown in Figure A. What is the next most appropriate treatment option for this patient?
Continued soft collar immobilization and rest
Halter traction, muscle relaxants and analgesics
Halo skeletal traction
Cervical stretching and immobilization in a stiff collar
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Spontaneous atlantoaxial rotatory subluxation can occur after an acute upper respiratory infection (Grisel Syndrome), and is felt to be caused by adjacent inflammation of the soft tissues in the neck. Initial treatment for this is soft collar immobilization and rest for 1 week. If subluxation persists, the patient should be transitioned to halter traction, and be given muscle relaxants and pain medications for up to 3 weeks. After a month of intractable symptoms, the patient can be placed in halo traction. If this is ineffective, a C1-C2 arthrodesis should be considered.
Copley and Dormans review the radiographic workup, symptoms, and treatment regimens for the various congenital and traumatic conditions of the pediatric cervical spine. They recommend NSAID therapy and soft cervical collar placement for initial treatment of patients with Grisel syndrome.
Illustration A demonstrates an example of Halter traction.
Copley LA, Dormans JP
J Am Acad Orthop Surg. 1998 Jul-Aug;6(4):204-14. PMID: 9682083 (Link to Abstract)
Copley, JAAOS 1998
Please rate question.
Average 4.0 of 22 Ratings
HPI - Insidious onset of neck pain and painful movement since 2 weeks.
What would be your next step in treatment for this patient?
HPI - The patient is a 23 yo male, college graduate and athlete, with no unusual recent history, that developed severe neck pain 3 days ago. He resports there has been no improvement, and he has difficulty moving his neck.
What do you think is the most likely diagnosis?