Updated: 3/2/2022

Atlantoaxial Rotatory Displacement (AARD)

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  • summary
    • Atlantoaxial Rotatory Displacement is a pediatric cervical spine rotatory instability caused by C1-C2 subluxation or facet dislocation
    • The most common presentation is a young child who presents with torticollis.
    • Diagnosis is made by dynamic CT scan of the cervical spine. 
    • Treatment can be a soft collar, halter traction, halo traction, or surgical fusion depending on the chronicity of the condition.
  • Etiology
    • Mechanism
      • spectrum of disease that ranges from mild subluxation to fixed facet dislocation
    • Pathophysiology
      • common causes include
        • infection (~35%)
          • may have history of pharyngitis or otitis media
          • Grisel's disease is the condition of AARD following a respiratory infection or retropharyngeal abscess
          • thought to be linked to lymphatic edema in area of cervical spine
        • trauma (~24%)
        • recent head or neck surgery (~20%)
        • idiopathic
        • associated conditions
          • Down's syndrome
          • rheumatoid arthritis
          • tumors
          • congenital anomalies
      • pathoanatomy
        • mechanism is thought to be related to ligamentous laxity
        • transverse ligament integrity
          • transverse ligament is intact
            • spinal canal stenosis can only occur with severe rotation and facet dislocation
          • transverse ligament is ruptured
            • and there is a component of anterolithesis (> 5mm), then spinal canal stenosis can occur with less rotation (45 degrees)
            • vertebral arteries may also be at risk
  • Anatomy
    • Axis Osteology
      • axis has odontoid process (dens) and body
      • embryology
        • develops from five ossification centers
        • subdental (basilar) synchondrosis is an initial cartilagenous junction between the dens and vertebral body that does not fuse until ~6 years of age
        • the secondary ossification center appears at ~ age 3 and fuses to the dens at ~ age 12
    • Occipital-C1-C2 ligamentous stability
      • provided by the odontoid process and its supporting ligaments
        • transverse ligament
          • limits anterior translation of the atlas
        • apical ligaments
          • limit rotation of the upper cervical spine
        • alar ligaments
          • limit rotation of the upper cervical spine
  • Classification
      • Fielding Classification of AARD
      • Type I
      • Unilateral facet subluxation with intact transverse ligament
      • Odontoid acts as a pivot point with 1 facet subluxating anteriorly, 1 facet subluxating posteriorly.
      • Most common and benign type
      • Type II
      • Unilateral facet subluxation with 3 to 5 mm of anterior displacement.
      • Injured Transverse ligament
      • 1 facet acts as a pivot point and 1 lateral mass is displaced anteriorly
      • Type III
      • Bilateral anterior facet displacement of > 5 mm.
      • Rare with a higher risk of neurologic involvement or instantaneous death.
      • Both lateral masses are displaced
      • Type IV
      • Posterior displacement of the atlas (C1) (with odontoid fracture, or hypoplastic dens)
      • Rare with a higher risk of neurologic involvement or instantaneous death.
  • Physical Exam
    • Symptoms
      • tilted head
      • neck pain
      • headache
    • Physical exam
      • ipsilateral rotation and contralateral tilt of the head in relation to the lateral mass of C1
        • chin rotated to the side opposite the facet subluxation (e.g. right sided facet subluxation will have chin rotated to the left)
      • contra-lateral sternocleidomastoid may be spastic
        • sternocleidomastoid (SCM) spasm occurs on the SAME side as the chin (e.g. right sided facet subluxation will have chin rotated to the left, and left SCM will be spastic)
          • this protective spasticity occurs to reduce further subluxation
          • C1-C2 subluxation (and resultant chin position) is primary, SCM spasm is secondary/reactive
        • in contrast to congenital muscular torticollis where the SCM spasm occurs on the OPPOSITE side of the chin (e.g. left SCM spasm will rotate the head to the right, and chin will be on the right)
          • SCM spasm is primary
      • reduced cervical rotation
  • Imaging
    • Radiographs
      • recommended views
        • AP, open-mouth odontoid
          • look for variation in size and distance from midline of C2 lateral masses (reflects rotation)
        • lateral
          • facet joint appears anterior and wedge shaped instead of normal oval shape
        • cervical flexion & extension views
          • may be useful to exclude instability
          • may be difficult due to position of head and resisted neck motion
    • Dynamic CT
      • is diagnostic gold standard
      • take CT with head straight forward, and then in maximal rotation to right and left
        • will see fixed rotation of C1 on C2 which does not change with dynamic rotation
    • MRI
      • of little value unless neurologic symptoms
  • Treatment
    • Nonoperative
      • soft collar, NSAIDs, exercise program
        • indications
          • subluxation present for < 1 week (traumatic or Grisel's disease)
          • many patients probably reduce spontaneously before seeking medical attention
      • head halter traction, NSAIDs, benzodiazepines, then hard collar x 3 months
        • indications
          • subluxation persists > 1 week
          • persistent torticollis in spite of soft collar (above) x 2 weeks
        • technique
          • small amount (5 lbs.) usually enough
          • either in hospital or at home
          • muscle relaxants and analgesics may be needed
      • halo traction, then halo vest x 3 months
        • indications
          • subluxation persists > 1 mos.
          • failed halter traction x 2 weeks (above)
    • Operative
      • posterior C1-C2 fusion
        • indications
          • subluxation persists > 3 mos
          • neurologic deficits present
          • failed halo traction x 2 weeks
          • recurrent subluxation
  • Complications
    • Missed diagnosis
      • diagnosis is often missed delayed

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(OBQ10.167) 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?

QID: 3260

C1-C2 arthrodesis



Continued soft collar immobilization and rest



Halter traction, muscle relaxants and analgesics



Halo skeletal traction



Cervical stretching and immobilization in a stiff collar



L 3 C

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(OBQ06.66) A 3-year-old girl developed torticollis eight months ago after a severe respiratory tract infection. A initial trial of halter traction was attempted without success. A trial of halo traction was then performed for 3 weeks and then a dynamic computed tomographic (CT) was obtained and shown in Figure A. Panel (a) shows an axial image with maximal rotation to the left. Panel (b) shows an axial image with maximal rotation to the right. What is the most appropriate next step in management?

QID: 177

No further treatment



Closed reduction under conscious sedation



Closed reduction under general anesthesia in the operating room with neurologic monitoring



Occipitocervical fusion



Posterior atlantoaxial fusion



L 4 D

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Evidence (16)
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