Úvod: V literatuře je Griselův syndrom popisován jako netraumatická rotační atlantoaxiální subluxace mezi C1 a C2 obratlem. Může vzniknout při zánětlivém onemocnění měkkých tkání v cervikokraniálním přechodu nebo po operacích v ORL oblasti. Pro častý výskyt Griselova syndromu po operačním výkonu se však kloníme k definici, která zahrnuje i traumatickou subluxaci jako příčinu vzniku a nedefinuje syndrom jen jako čistě netraumatický. Klinicky se nestabilita projevuje abnormálním držením hlavy, tzv. tortikolis. U mladistvých je častější z důvodu větší volnosti kloubních pouzder, většímu prokrvení v atlantoaxiální oblasti a delším alárním vazům. V článku je uvedena kazuistika dítěte s Griselovým syndromem, který vznikl po provedené adenotomii. Diskutována je patofyziologie, symptomatologie, diagnostika a léčba onemocnění.
Introduction: By definition from the literature, Grisel's syndrome is described as non-traumatic rotational atlantoaxial instability between C1 and C2 vertebrae. It can occur during an infection of a soft tissue in the cervicocranial region or after an operation in the ENT region. Because of the frequent occurrence after operations, we inclined to the definition which includes a traumatic subluxation as a cause of origin, and it's not defined as non-traumatic only. The instability manifests itself with abnormal head posture that is called torticollis. Increased incidence in adolescence is more common because of a greater ligamentous laxity of the joint capsules, increased perfusion of antlantoaxial regions and longer alar ligaments. In this article, the case of a child with Grisel's syndrome after adenotomy is described. The pathophysiology, symptomatology, diagnostic management and treatment are discussed.
- Klíčová slova
- Griselův syndrom,
- MeSH
- adenektomie škodlivé účinky MeSH
- atlantoaxiální kloub * zranění MeSH
- časná diagnóza MeSH
- externí fixátory MeSH
- imobilizace MeSH
- krční obratle diagnostické zobrazování patologie MeSH
- lidé MeSH
- nestabilita kloubu etiologie MeSH
- pooperační komplikace diagnóza etiologie terapie MeSH
- předškolní dítě MeSH
- syndrom MeSH
- tortikolis * diagnóza etiologie terapie MeSH
- výsledek terapie MeSH
- Check Tag
- lidé MeSH
- mužské pohlaví MeSH
- předškolní dítě MeSH
- Publikační typ
- kazuistiky MeSH
PURPOSE OF THE STUDY Atlantoaxial Rotatory Dislocation (AARD) mostly occurs in children and prevailing majority of cases are successfully managed by non-operative treatment. Surgical intervention is necessary in patients in whom non-operative treatment failed, in case of repeated dislocations and in patients with anatomical defects of the atlantoaxial complex. The purpose of the presented study is the radiological and clinical evaluation of patients with AARD surgically treated at our department. MATERIAL AND METHODS In the period from 2001 to 2017, altogether 15 patients with AARD were surgically treated at our department, namely 6 men and 9 women aged 5-72 years, with the mean age of 27.3 years. 8 patients were younger than 18 years of age. Apart from regular checks, all the patients were examined also at the end of the study, which means at a follow-up of 12-214 months, i.e. 112.1 months postoperatively on average. In the study, the anatomy of the atlantoaxial complex and craniocervical junction, course of the surgical procedure, correction of deformity, bone fusion, clinical condition of the patient and complications were monitored and evaluated. The clinical evaluation was performed using the Visual Analogue Scale (VAS) for neck pain and the Neck Disability Index (NDI). All the parameters were statistically evaluated at the p-level below 0.05. RESULTS In all 15 patients the surgery was preceded by unsuccessful non-operative treatment. The period between the rotation and the surgery was 4 days to 48 months, with the mean value of 11.3 months. All the patients included in the study showed an intact dens axis, the other patients were excluded from the study. In 10 patients their head was rotated to the left, in 5 patients to the right. The anterior atlantodental interval (ADI) was 2-7 mm with the mean value of 3.5 mm. In 13 cases the ADI was less than 5 mm, in 2 cases it was greater. According to the Fielding and Hawkins classification there were 9 cases of type I, 4 cases of type II and two cases of type III. According to the Ishii et al. classification, 2 cases of type I, 12 cases of type II and one case of type III were identified. In 9 patients predisposing factors were found in the history, namely 7 cases of trauma, 2 cases of infection. Mutual rotation of C1-C2 from 7.0° to 60.0° with the mean value of 27.3° was observed preoperatively, while after the correction it was from 1.0° to 7.0° with the mean value of 3.9° (p < 0.05). Lateral inclination was 3.4°-23.6° preoperatively with the mean value of 9.9°, and 0.7°-4.0° after the correction with the mean value of 2.2° (p < 0.05). The postoperative ADI ranged from 1 to 3 mm, with the mean value of 1.9 mm (p < 0.05). The bone fusion of C1-C2 or C1-C2-C3 was achieved in all the relevant cases (N = 13, 100%), in two patients a temporary fixation was used. The mean value of VAS for neck pain was 6.3 preoperatively, 1.0 (p < 0.05) at one year and 1.0 (p < 0.05) again at the final examination. The mean value of NDI was 50.4 % preoperatively, 9.3% (p < 0.05) at one year and 9.5% (p < 0.05) at the final examination. All patients that we operated on stated that they would undergo surgery again. DISCUSSION Compared to the other authors, our group of patients included surprisingly many adult patients (46.7%) with a high percentage of neurological defects (33.3%). In agreement with the literature, the cause of rotation was revealed in 60% of cases. At our department, correction is preferred in all the patients, while especially in paediatric patients in situ fixation causes the developmental deformities of the face and cervical spine. High success rate of bone fusion was confirmed (13/15, 13 = 100%) and also the transient atlantoaxial fixation was successfully used in two patients, both with traumatic etiology. CONCLUSIONS If non-operative treatment fails, surgical correction of AARD is a suitable treatment method which ensures favourable position of the atlantoaxial complex, improves the clinical condition of the patient and prevents the asymmetric development of the face in children. The Goel-Harm's fixation technique and C1-C2 fusion are considered by us the method of choice in older paediatric and adult patients. Key words: AARD, atlantoaxial rotatory dislocation, atlantoaxial rotatory subluxation, pediatric cervical spine, atlantoaxial fixation.
- MeSH
- atlantoaxiální kloub diagnostické zobrazování zranění chirurgie MeSH
- dislokace kloubu diagnostické zobrazování chirurgie MeSH
- dítě MeSH
- dospělí MeSH
- fúze páteře MeSH
- lidé středního věku MeSH
- lidé MeSH
- mladiství MeSH
- mladý dospělý MeSH
- předškolní dítě MeSH
- senioři MeSH
- výsledek terapie MeSH
- Check Tag
- dítě MeSH
- dospělí MeSH
- lidé středního věku MeSH
- lidé MeSH
- mladiství MeSH
- mladý dospělý MeSH
- mužské pohlaví MeSH
- předškolní dítě MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
Traumatic atlantooccipital dislocation is a rare injury in survivors with 15 % share in deaths due to spinal injury. The authors present a case of a patient with concurrent atlantooccipital and atlantoaxial instability of the upper cervical spine, which he suffered after a fall from height. Atlantooccipital dislocation in surviving patients is a rare injury, for which in some cases coincident bone injury is reported to upper cervical spine, such as occipital fracture or contingent odontoid (C2 dens) fracture. In our case, it is combined with atlantoaxial instability and this combined type of injury has not yet been described in the literature. We performed realignment of the dislocation and posterior occipitocervical (C0-C3) fusion. After the surgery, the patient manifested neurological improvement almost to a normal neurological outcome with persistent residual finding after subarachnoid hemorrhage.
- MeSH
- atlantoaxiální kloub zranění chirurgie MeSH
- atlantookcipitální kloub zranění chirurgie MeSH
- dislokace kloubu komplikace chirurgie MeSH
- dospělí MeSH
- fúze páteře MeSH
- kloubní ligamenta zranění MeSH
- krční obratle chirurgie MeSH
- lidé MeSH
- nestabilita kloubu etiologie chirurgie MeSH
- úrazy pádem MeSH
- Check Tag
- dospělí MeSH
- lidé MeSH
- mužské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- kazuistiky MeSH
PURPOSE OF THE STUDY Injuries to the upper cervical spine in children are rare and account for 0.6 to 9.5 % of all cervical spine injuries. We present a detailed analysis of the children and adolescents with unstable upper cervical spine injuries treated at our spinal centre. MATERIAL During 16 years of follow-up, unstable injury to the upper cervical spine was recorded in 23 children and adolescents. Two patients (8.7%) were treated conservatively and 21 (91.3 %) underwent surgery. The patients were allocated by age to three groups: 0-9 year, 10-14 year and 15-18 year categories. Twenty patients were seen at the final clinical and radiographic follow-up. One patient died at 62 months after surgery and two patients unfit for transport were evaluated on the basis of mailed interviews. The interval between injury and final evaluation ranged from 6 to 137 months, with an average of 53.4 months. METHODS The patients treated conservatively first wore a Philadelphia collar, then a custom-made brace, and eventually a soft Schanze cervical collar to finish the healing process. Application of a halo vest was considered a surgical procedure and was used only in very small children. In unstable odontoid fractures, direct osteosynthesis with two cannulated titanium screws was performed from the anterior approach in older children while, in small children, transoral or submandibular retropharyngeal decompression to treat spinal stenosis caused by bone fragments was carried out and a halo vest was applied. Hangman's fractures were treated by anterior cervical discectomy, fusion with bone graft and anterior plate fixation. The other types of unstable fractures were managed from the posterior approach by occipitocervical fixation, atlantoaxial fixation or instrumented fusion extended caudally. The patients characteristics included gender, age, mechanism of injury, type of injury, neurological findings, type of therapy or surgery, complications and treatment outcome. Neurological status was evaluated using the Frankel classification. RESULTS The patient group comprised 14 boys (60.9 %) and nine girls (39.1 %), which gave a gender ratio of 3 : 2. The age of patients at injury ranged from 2 to 18 years, with an average of 11 years and 6 months. The most frequent injuries included rotational or vertical atlantoaxial dislocation in eight (34.8%) and odontoid fractures in seven (30.4 %) patients; atlas fracture was recorded in three (13.0 %) and hangman's fracture also in three (13.0%) patients; occipitocervical displacement was found in one (4.3 %) and complex atlantoaxial fracture also in one patient (4.3%). At the time of injury, 17 patients (73.9 %) had no neurological deficit (Frankel grade E), three had Frankel grade A (one paraplegic with a concomitant T5 spinal cord injury) and three had Frankel grade D neurological deficits. Of the six patients with neurological deficit, two showed improvement by one or two Frankel grades. The method of dorsal atlantoaxial fixation was used in eight patients (Magerl fixation in 2 and Harms method in 6). Direct osteosynthesis of an odontoid fracture was performed in four patients, halo fixation was applied in four, C2-C3 discectomy with tricortical bone grafting and plating was carried out in three, occipitocervical fixation was used in three patients, and direct atlas osteosynthesis, simple decompression and simple non-instrumented dorsal spondylodesis each was performed in one patient. Neither intra-operative complications nor post-operative complications related to the surgical technique were recorded. Osteoarthritis or bone non-union, as late post-operative complications, were found in two patients. All other patients showed bone healing by first intention in the desired extent. Superficial or deep wound infections were not recorded. DISCUSSION In the first age category, the number of boys and girls with injuries to the upper cervical spine was equal while, in the third one, the boys outnumbered the girls more than twice. Of the 23 patients, 91.3 % were surgically treated; the anterior approach was used in approximately one third of the patients and the posterior approach in the rest of them. The high number of surgical interventions is due to the fact that the most serious paediatric spinal injuries are referred to our centre. CONCLUSIONS 1. Injuries to the upper cervical spine are most frequently found in the youngest children and in adolescents who, however, frequently have injury also to the lower cervical spine. 2. Neurological deficit is relatively frequent but has a better prognosis than in adults. The youngest children with mild deficits have the best prognosis. 3. The mortality rate in young children with upper cervical spine injuries is evidently high, mostly due to associated head, chest and abdomen trauma 4. Therapy, particularly in small children, is strictly individual.
Rotační atlantoaxiální nestabilita, jejímž následkem může být tortikolis, etiologicky vzniká z rozdílných příčin. Jednou z možností vzniku rotační atlantoaxiální nestability je Griselův syndrom. Jedná se o vzácnou komplikaci, jež se projevuje křečovitým stahem krčního svalstva s omezením hybnosti krku a hlavy. Vzniká po chirurgických výkonech vyžadujících specifickou polohu hlavy s hyperextenzí, nebo hyperextenzí s rotací, případně v souvislosti s bakteriální infekcí krčních prostor. Zvýšený výskyt u mladistvých je vysvětlován zvýšeným prokrvením atlantoaxiálního prostoru a zvýšenou vazivovou laxitou kloubních pouzder a delšími alárními vazy u dětí, při známé horizontální orientaci zygapofyzeálních kloubů mezi prvním a druhým krčním obratlem. Prezentovaná kazuistická sdělení popisují vznik Griselova syndromu v pooperačním období u dvou nemocných v dětském věku. Autoři upozorňují na důležitost včasné diagnózy, důraz kladou na mezioborovou spolupráci. Pozdní diagnóza může vést k vážným následkům kořenového deficitu, myelopatie, kosmetické deformity krční páteře. Klíčová slova: Griselův syndrom – atlantoaxiální nestabilita – tortikolis
Rotational atlantoaxial instability may lead to torticollis and has diverse aetiology. Grisel's syndrome is one of the potential causes of rotational atlantoaxial instability. Grisel's syndrome is a rare condition that manifests itself with spastic contraction of the neck muscles that limits movement of the head and neck. It may occur following a surgery, especially otorhinolaryngological, requiring a specific head position with hyperextension or hyperextension with rotation, or in connection with bacterial infections of the cervical area. Increased incidence in adolescence is explained by increased perfusion of the atlantoaxial space and increased ligamentous laxity of the joint capsules and allar ligament length in children with known horizontal orientation of zygapophyzeal joints between the first and the second cervical vertebrae. The presented case reports describe post-surgical development of Grisel's syndrome in two paediatric patients. The authors highlight the importance of early diagnosis, emphasising interdisciplinary cooperation. Late diagnosis can cause serious complications including root deficits, myelopathy or cosmetic deformity of the cervical spine. Key words: Grisel's syndrome – rotational atlantoaxial instability – torticollis
- Klíčová slova
- atlantoaxiální nestabilita,
- MeSH
- atlantoaxiální kloub * zranění MeSH
- časná diagnóza MeSH
- dítě MeSH
- externí fixátory MeSH
- imobilizace MeSH
- krční obratle patologie radiografie MeSH
- lidé MeSH
- mastoiditida chirurgie komplikace MeSH
- mezioborová komunikace MeSH
- nestabilita kloubu etiologie MeSH
- otorinolaryngologické chirurgické výkony MeSH
- pooperační komplikace * diagnóza etiologie terapie MeSH
- předškolní dítě MeSH
- rehabilitace MeSH
- syndrom MeSH
- tortikolis * diagnóza etiologie terapie MeSH
- tyreoidektomie MeSH
- Check Tag
- dítě MeSH
- lidé MeSH
- mužské pohlaví MeSH
- předškolní dítě MeSH
- Publikační typ
- kazuistiky MeSH
Traumatická atlantoaxiálna rotačná fixácia je definovaná ako nízkoenergetickým mechanizmom úrazu vzniknutá fixovaná subluxácia atlantoxiálneho komplexu, v dôsledku ktorej dochádza k miernej flexii hlavy, laterálnemu úklonu hlavy na jednu a rotácii hlavy na druhú stranu a bolestivému obmedzeniu hybnosti znemožňujúcemu vôľovo otočiť hlavu na kontralaterálnu stranu. Dôsledkom zriedkavosti tohto poranenia bývajú často jeho prehliadnutie, nesprávna liečba, dlhotrvajúca liečba, alebo trvalé následky. Prezentujeme kazuistiku 10-ročného pacienta ošetreného na našom pracovisku s akútnou traumatickou atlantoaxiálnou rotačnou fixáciou, ktorú utrpel pri páde. Diagnostikovaná bola na základe syntézy anamnestických údajov, klinického obrazu a statického CT vyšetrenia. Pacienta sme liečili úspešne konzervatívne. V diskusii sa stručne zaoberáme súčasným pohľadom na etiopatogenézu, diagnostiku i liečbu tohto poranenia. Jeho patogenéza nie je stále plne objasnená. Najspoľahlivejším diagnostickým vyšetrením je tu dynamické RTG resp. CT vyšetrenie. Podrobnejšie sa venujeme klinickej diagnostike a statickému RTG a CT vyšetreniu ako spôsobom, ktoré môžu viesť spolu s anamnestickým údajom o úraze k správnej diagnóze aj v prípade nedostupnosti akútneho dynamického CT resp. RTG vyšetrenia. V liečbe akútnej traumatickej atlantoaxiálnej rotačnej fixácie je zvyčajne indikovaný konzervatívny postup, a to s vynikajúcimi výsledkami. Inveterované stavy si väčšinou vyžadujú operačnú intervenciu. Liečba oneskorene rozpoznanej traumatickej atlantoaxiálnej rotačnej fixácie býva náročná a trvalo narúšajúca anatomické pomery rastúceho organizmu.
Traumatic atlantoaxial rotary fixation is defined as low-energy mechanism injury resulting in fixed subluxation of the atlantoxial complex expressing oneself as a slight head flexion, lateral tilt of the head to one side, head rotation to the other side and painful limitation of motion that makes it impossible to turn head to the contralateral side voluntary. As a result of the rarity of the injury it is often neglected, treated improperly, treated for the duration, or it has permanent consequences. We present a case report of a 10 year old patient treated in our department with acute traumatic atlantoaxial rotary fixation. The diagnosis was made on the basis of synthesis of anamnestic data, clinical picture and static CT examination. The patient was successfully treated conservatively. In the discussion we present a brief look at the etiopathogenesis, diagnosis and treatment of the injury. Its pathogenesis is still not fully understood. The most reliable diagnostic methods are dynamic X-ray and dynamic CT examinations. In our discussion, more is dedicated to clinical diagnostics, and static X-ray and CT examinations as a way likely to lead together with anamnestic data on the accident at the correct diagnosis even in the absence of acute dynamic CT or X-ray examinations. The treatment of acute traumatic atlantoaxial rotary fixation is usually indicated for conservative treatment, with excellent results. Neglected cases generally require surgical intervention. Treatment of neglected atlantoaxial rotary fixation is usually difficult and permanently distorting anatomical growing organism.
- MeSH
- atlantoaxiální kloub radiografie zranění MeSH
- dislokace kloubu diagnóza radiografie terapie MeSH
- dítě MeSH
- hlava - pohyby MeSH
- imobilizace MeSH
- klouby zranění MeSH
- krční obratle MeSH
- lidé MeSH
- rotace MeSH
- tortikolis MeSH
- úrazy pádem MeSH
- výztuhy MeSH
- Check Tag
- dítě MeSH
- lidé MeSH
- mužské pohlaví MeSH
- Publikační typ
- kazuistiky MeSH
- MeSH
- atlantoaxiální kloub radiografie zranění MeSH
- dislokace kloubu radiografie terapie MeSH
- dítě MeSH
- lidé MeSH
- muži MeSH
- Check Tag
- dítě MeSH
- lidé MeSH
- Publikační typ
- kazuistiky MeSH
- MeSH
- atlantoaxiální kloub chirurgie zranění MeSH
- dislokace kloubu diagnóza chirurgie MeSH
- dospělí MeSH
- externí fixátory MeSH
- fúze páteře metody MeSH
- lidé středního věku MeSH
- lidé MeSH
- poranění páteře diagnóza chirurgie MeSH
- trakce MeSH
- Check Tag
- dospělí MeSH
- lidé středního věku MeSH
- lidé MeSH
- ženské pohlaví MeSH
- Publikační typ
- kazuistiky MeSH
- MeSH
- atlantoaxiální kloub chirurgie patologie zranění MeSH
- dítě MeSH
- dopravní nehody MeSH
- fúze páteře metody normy přístrojové vybavení MeSH
- kostní šrouby MeSH
- lidé MeSH
- nestabilita kloubu diagnóza chirurgie MeSH
- poranění páteře chirurgie patologie MeSH
- předškolní dítě MeSH
- Check Tag
- dítě MeSH
- lidé MeSH
- předškolní dítě MeSH
- ženské pohlaví MeSH
- Publikační typ
- kazuistiky MeSH
