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European Journal of Trauma and Emergency Surgery

Published in:

01-06-2021 | Original Article

Comprehensive treatment algorithm for atlanto-axial rotatory fixation (AARF) in children

Authors: Daniel Mahr, Viola Freigang, Himanshu Bhayana, Maximilian Kerschbaum, Borys Frankewycz, Markus Loibl, Michael Nerlich, Florian Baumann

Published in: European Journal of Trauma and Emergency Surgery | Issue 3/2021

Abstract

Background

Atlanto-axial rotatory fixation (AARF) is an uncommon condition in children presenting with torticollis. Many studies have elaborated on the diagnostic sequence of AARF. However, there is no consensus for the algorithm of management of AARF.

Methods

This study proposes to provide a comprehensive step-by-step guideline which aims to achieve and retain anatomic reduction of the atlanto-axial joint (AAJ). We recommend a ‘therapeutic crescendo’: closed reduction and immobilization in a rigid cervical collar (step I). In cases of re-dislocation, a second attempt of closed reduction and immobilization in a Halo-jacket (step II). Cases of recurrent dislocations due to persistent instability require open reduction and internal fixation. We present a new surgical technique of transverse suture transfixation (TSF) of C1/C2 (step III). Alternatively, a dorsal stabilization of C1/C2 is indicated after open reduction (step IV). 13 patients with radiologically confirmed AARF were included in this study. These patients were treated as per the above mentioned algorithm. All these patients were serially evaluated with a minimum follow-up of 1 year.

Results

Clinical data of 10/13 patients were available for follow-up evaluation at mean 4.6 years after the onset of symptoms. Two patients were managed surgically. We recorded good clinical results in all patients treated according to the algorithm.

Conclusions

AARF is a subacute pediatric emergency. Reduction and maintenance of joint congruency of the AAJ are the treatment goals. The comprehensive therapeutic algorithm presented in this study is applicable in patients with AARF to achieve excellent long-term results.

Level of evidence

IV, Retrospective cohort study.

Trial Registration Number

Clinical Trial Registry University of RegensburgZ-2014-0453-4. Registered 01 December 2014.

Ballock RT, Song KM. The prevalence of nonmuscular causes of torticollis in children. J Pediatr Orthoped. 1996;16(4):500–4.CrossRef

Grisel P. (1930) Enucleation de l`atlas et torticollis naso-pharyngien. La presse medicale (38): 50–53.

Astur N, Klimo P Jr, Sawyer JR, Kelly DM, Muhlbauer MS, Warner WC Jr. Traumatic atlanto-occipital dislocation in children: evaluation, treatment, and outcomes. J Bone Joint Surg Am. 2013;95(24):e194(191–198). https://doi.org/10.2106/JBJS.L.01295.CrossRef

Baumann F, Ernstberger T, Neumann C, Nerlich M, Schroeder GD, Vaccaro AR, Loibl M. Pediatric cervical spine injuries: a rare but challenging entity. J Spinal Disord Tech. 2015;28(7):E377–84. https://doi.org/10.1097/BSD.0000000000000307.CrossRefPubMed

Easter JS, Barkin R, Rosen CL, Ban K. Cervical spine injuries in children, part I: mechanism of injury, clinical presentation, and imaging. J Emerg Med. 2011;41(2):142–50. https://doi.org/10.1016/j.jemermed.2009.11.034.CrossRefPubMed

Fielding JW, Hawkins RJ. Atlanto-axial rotatory fixation (fixed rotatory subluxation of the atlanto-axial joint). J Bone Joint Surg Am. 1977;59(1):37–44.CrossRef

Hicazi A, Acaroglu E, Alanay A, Yazici M, Surat A. Atlantoaxial rotatory fixation-subluxation revisited: a computed tomographic analysis of acute torticollis in pediatric patients. Spine. 2002;27(24):2771–5. https://doi.org/10.1097/01.BRS.0000035723.17327.49.CrossRefPubMed

Landi A, Pietrantonio A, Marotta N, Mancarella C, Delfini R. (2012) Atlantoaxial rotatory dislocation (AARD) in pediatric age: MRI study on conservative treatment with Philadelphia collar—experience of nine consecutive cases. Eur Spine J 21(Suppl 1):S94–S99. https://doi.org/10.1007/s00586-012-2216-0.CrossRefPubMed

Pang D, Li V. Atlantoaxial rotatory fixation: part 2—new diagnostic paradigm and a new classification based on motion analysis using computed tomographic imaging. Neurosurgery. 2005;57(5):941–53 (discussion 941–953).CrossRef

10.

Varni JW, Seid M, Kurtin PS. PedsQL 4.0: reliability and validity of the Pediatric Quality of Life Inventory version 4.0 generic core scales in healthy and patient populations. Med Care. 2001;39(8):800–12.CrossRef

11.

Jeszenszky D, Fekete T, Kleinstuck F, Haschtmann D, Loibl M. Transoral closed reduction of fixed atlanto-axial rotatory-subluxation (AARS) in childhood and adolescence. Clin Spine Surg. 2017. https://doi.org/10.1097/BSD.0000000000000563.CrossRefPubMedCentral

12.

Harms J, Melcher RP. Posterior C1-C2 fusion with polyaxial screw and rod fixation. Spine. 2001;26(22):2467–71.CrossRef

13.

Magerl FSP. (1986) Stable posterior fusion of the atlas and axis by transarticular screw fixation. In: Society CSR, editor. Cervical spine. New York: Springer, pp. 322–7.

14.

Hadley MN, Walters BC, Grabb PA, Oyesiku NM, Przybylski GJ, Resnick DK, Ryken TC. Diagnosis and management of traumatic atlanto-occipital dislocation injuries. Neurosurgery. 2002;50(3 Suppl):105–13.

15.

Osiro S, Tiwari KJ, Matusz P, Gielecki J, Tubbs RS, Loukas M. Grisel’s syndrome: a comprehensive review with focus on pathogenesis, natural history, and current treatment options. Child’s Nerv Syst. 2012;28(6):821–5. https://doi.org/10.1007/s00381-012-1706-z.CrossRef

16.

Pang D, Li V. Atlantoaxial rotatory fixation: part 3-a prospective study of the clinical manifestation, diagnosis, management, and outcome of children with alantoaxial rotatory fixation. Neurosurgery. 2005;57(5):954–72 (discussion 954–972).CrossRef

17.

Subach BR, McLaughlin MR, Albright AL, Pollack IF. Current management of pediatric atlantoaxial rotatory subluxation. Spine. 1998;23(20):2174–9.CrossRef

18.

Tauchi R, Imagama S, Ito Z, Ando K, Hirano K, Muramoto A, Matsui H, Kato F, Yukawa Y, Sato K, Kanemura T, Yoshihara H, Kamiya M, Matsuyama Y, Ishiguro N. Complications and outcomes of posterior fusion in children with atlantoaxial instability. Eur Spine J. 2012;21(7):1346–52. https://doi.org/10.1007/s00586-011-2083-0.CrossRefPubMed

19.

Tauchi R, Imagama S, Ito Z, Ando K, Muramoto A, Matsui H, Matsumoto T, Yukawa Y, Kanemura T, Ishiguro N. Surgical treatment for chronic atlantoaxial rotatory fixation in children. J Pediatr Orthoped Part B. 2013;22(5):404–8. https://doi.org/10.1097/BPB.0b013e3283633064.CrossRef

20.

Glotzbecker MP, Wasser AM, Hresko MT, Karlin LI, Emans JB, Hedequist DJ. Efficacy of nonfusion treatment for subacute and chronic atlanto-axial rotatory fixation in children. J Pediatr Orthoped. 2014;34(5):490–5. https://doi.org/10.1097/BPO.0000000000000128.CrossRef

Title: Comprehensive treatment algorithm for atlanto-axial rotatory fixation (AARF) in children
Authors: Daniel Mahr
Viola Freigang
Himanshu Bhayana
Maximilian Kerschbaum
Borys Frankewycz
Markus Loibl
Michael Nerlich
Florian Baumann
Publication date: 01-06-2021
Publisher: Springer Berlin Heidelberg
Published in: European Journal of Trauma and Emergency Surgery / Issue 3/2021
Print ISSN: 1863-9933
Electronic ISSN: 1863-9941
DOI: https://doi.org/10.1007/s00068-019-01096-3

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Comprehensive treatment algorithm for atlanto-axial rotatory fixation (AARF) in children

Abstract

Background

Methods

Results

Conclusions

Level of evidence

Trial Registration Number

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

Level of evidence

Trial Registration Number

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