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Table of Contents    
LETTER TO EDITOR
Year : 2013  |  Volume : 61  |  Issue : 2  |  Page : 197-199

Report of an unusual upper cervical spine injury: Traumatic atlantoaxial rotatory subluxation with vertical odontoid fracture in a child


Department of Neurosurgery, Celal Bayar University, School of Medicine, Turkey

Date of Submission22-Jan-2013
Date of Decision11-Feb-2013
Date of Acceptance06-Mar-2013
Date of Web Publication29-Apr-2013

Correspondence Address:
Mesut Mete
Department of Neurosurgery, Celal Bayar University, School of Medicine
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.111158

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How to cite this article:
Mete M, ▄nsal ▄▄, Duransoy YK, Barutšuoglu M, Selšuki M. Report of an unusual upper cervical spine injury: Traumatic atlantoaxial rotatory subluxation with vertical odontoid fracture in a child. Neurol India 2013;61:197-9

How to cite this URL:
Mete M, ▄nsal ▄▄, Duransoy YK, Barutšuoglu M, Selšuki M. Report of an unusual upper cervical spine injury: Traumatic atlantoaxial rotatory subluxation with vertical odontoid fracture in a child. Neurol India [serial online] 2013 [cited 2019 Dec 15];61:197-9. Available from: http://www.neurologyindia.com/text.asp?2013/61/2/197/111158


Sir,

A 14-year-old male was admitted to the emergency department after a fall from 15 meter height. Neurological examination was normal. He had a linear vertex injury with torticollis. Cervical X-rays [Figure 1] and cranial computed tomography (CT) were normal. Axial upper cervical CT demonstrated suspicion of type I atlantoaxial rotatory subluxation (AARS) with fracture line in odontoid process [Figure 2]. Coronal reconstruction CT clearly demonstrated vertical odontoid fracture [Figure 3]. Three dimensional CT (3D CT) scan directly define the relation of the atlantoaxial joint and vertical odontoid fracture [Figure 4]. In order to decide the treatment option, cervical magnetic resonance imaging (MRI) was taken. There were no hyperintensities in the alar ligaments and C1-2 articular capsules in T2-weighted and short TI-inversion recovery (STIR) MRI. On the basis of these findings we opted for conservative treatment with rigid cervical collar and in one month he had improvement of torticollis.
Figure 1: (a) Open mouth X - ray did not determined dens clearly because of superposition of skull base on upper cervical spine. (b - d) shows lateral neutral and functional X - rays, which were normal, and there was no findings of pathology

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Figure 2: (a) Axial upper cervical CT determined suspicious fracture line in odontoid process (white arrow) with (b) Type I AARS (black arrow)

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Figure 3: (a) While sagittal reconstruction of cervical CT was normal (b) Coronal reconstruction demonstrated vertical odontoid fracture clearly (black arrow)

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Figure 4: Three dimensional CT scan showing the right lateral translatory subluxation of the  Atlas More Details over the axis (white arrows) and vertical odontoid fracture (black arrow)

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Pediatric upper cervical spine injuries are rare and constitute between 0.6% and 9.5% of all cervical spine injuries. [1],[2] The pathophysiology of AARS is still unclear. It is believed that muscle contracture following upper respiratory tract infection might be a factor for AARS. [3] Sinigaglia et al. suggested that disruption of the facet joints followed by both alar ligamental disruption causes AARS. [4] AARS has been divided into four sub-types: [3],[4] Type I_ rotatory fixation (RF) with no anterior displacement; Type II-RF with anterior displacement of the atlas by 3_5 mm; Type III_RF with anterior displacement of the atlas >5 mm; and Type IV_RF with posterior displacement. [1],[3] Type I and II are the most common and also most difficult to diagnose. [3]

Dens fractures account approximately 9% of all fractures of the cervical spine [5] and are classified into three types: Type I- an oblique fracture through the upper part of the odontoid process itself; Type II- fracture at the junction of the odontoid process with the vertebral body of the axis; and Type III-total fracture through the body of the atlas. [6] Vertical fracture is an uncommon type of fracture affecting odontoid process, the fourth type of odontoid fracture and its incidence is unknown. The mechanism for vertical dens fracture is probably due to extension and axial loading. [5] Our patient had Type-I AARS with vertical dens fracture, probably due to axial loading on the anterior lip of the foramen magnum striking the apex of the dens and AARS due to rotatory forces during the injury.

Diagnosis of both Type I AARS and vertical odontoid fractures is difficult. Rotatory subluxation Type I does not have widened atlantodental interval so, the diagnosis is not completely accurate and may be suspicious or missed diagnosis with roentgenographic examination. [3],[7] Not only in AARS, but also in vertical odontoid fractures, plain X-ray may not always determine fracture because of skull superposition on the upper cervical spine. [8] Castillo et al. reported that they were not able to identify the vertical fractures on plain radiographs, [5] but these are clearly seen in CT scans. [3],[5],[7],[8] According to Duan et al. three dimensional (3D) CT clearly and directly define the spatial relation of the atlantoaxial joint. [7] Three dimensional CT images give a global view of the cervical deformity and aid in demonstrating subluxation. [8] While AARS and dens fracture could be seen in axial plane, we determined dens fracture in coronal reconstruction clearly, because fracture line was perpendicular to axial plane and parallel to sagittal plane. MRI helps to direct visualize tear or avulsion of the transverse ligament. [8] Our patient's cervical MRI determined intact transverse ligament, which means stable injury.

Treatment of AARS include immobilization with conservative care, traction, manual reduction, and surgery. [8],[9] Conservative treatment is the first step if transverse ligament is intact. [9] Surgical approach is needed for cases of AARS with unstable spinal injuries, neurological involvement, and failure to maintain reduction by conservative treatment. [8],[9] Rahimi et al. reported that AARS most often spontaneously reduces with the use of a rigid cervical collar or with 48-72 hours of traction followed by using of a cervical collar. [10] According to functional cervical X-rays and cervical MRI findings, our patient's injury was stable. Considering the patient's normal neurological status, we decided to manage his injury with rigid cervical collar.

Published cases with odontoid vertical fracture in literature are all found in adults; it is interesting to see this pathology in a child with combination of AARS. For suspected upper cervical spine injuries, CT scans and 3D CT reconstructions can diagnose AARS and vertical odontoid fractures. In combination of Type I AARS and vertical odontoid fracture, conservative treatment should be the option if transverse ligament is intact.

 
 ╗ References Top

1.Pancyzkowski D, Andrew BS, Nemecek N, Selden NR. Traumatic type III odontoid fracture and severe rotatory atlantoaxial subluxation in a 3-year old child. J Neurosurg Pediatr 2010;5:200-3.  Back to cited text no. 1
    
2.Dickerman RD, Morgan JT, Mittler M. Circumferential cervical spine surgery in an 18-month-old female with traumatic disruption of the odontoid and C3 vertebrae. Pediatric Neurosurg 2005;41:88-92.  Back to cited text no. 2
    
3.Fielding JW, Hawkins RJ. Atlanto axial rotatory fixation. J Bone Joint Surg Am 1977;59:37-44.  Back to cited text no. 3
    
4.Sinigaglia R, Bundy A, Monturemici DA. Traumatic atlantoaxial rotatory dislocation in adults. Chir Narzadow Ruchu Ortop Pol 2008;73:149-54.  Back to cited text no. 4
    
5.Castillo M, Mukherji SK. Vertical fractures of the dens. AJNR Am J Neuroradiol 1996;17:1627-30.  Back to cited text no. 5
    
6.Anderson LD, D'Alonzo RT. Fractures of the odontoid process of the axis. J Bone Joint Surg Am 1974;56;1663-74.  Back to cited text no. 6
    
7.Duan S, Huang X, Lin Q, Chen G. Clinical significance of articulating facet displacement of Lateral atlantoaxial joint on 3D CT diagnosing atlantoaxial subluxation. J Formos Med Assoc 2007;106:840-6.  Back to cited text no. 7
    
8.Jeon SW, Jeong JH, Moon SM, Choi SK. Atlantoaxial rotatory fixation in adults patients. J Korean Neurosurg Soc 2009;5:246-8.  Back to cited text no. 8
    
9.Oh JY, Chough CK, Cho CB, Park HK. Traumatic atlantoaxial rotatory fixation with accompanying odontoid and C2 articular facet fracture. J Korean Neurosurg Soc 2010;48:452-4.  Back to cited text no. 9
    
10.Rahimi SY, Stevens EA, Yeh DJ, Flannery AM, Choudhri HF, Le MR. Treatment of atlantoaxial instability in pediatric patients Neurosurg Focus 2003;15:ECP1.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

This article has been cited by
1 Atlantoaxial Rotatory Subluxation in Children
Kevin M. Neal,Ahmed S. Mohamed
Journal of the American Academy of Orthopaedic Surgeons. 2015; 23(6): 382
[Pubmed] | [DOI]



 

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