Normal Range of Movement During Rotation Stress Testing for the Alar Ligaments: An Observational Study.

OBJECTIVE: The purpose of this study was to determine the normal range of rotation occurring during rotation stress testing for alar ligament integrity and to ascertain whether rotation range on testing is affected by an individual's age. METHOD: In this observational study, 88 people aged 18 to 86 years old with no current neck problems or known risk factors for craniocervical instability underwent rotation stress testing for the alar ligaments. The test was performed in each direction in neutral, flexion, and extension, with the participant both sitting and supine. Rotation range was recorded using an electromagnetic movement tracking system. Range was assessed overall and then compared by 10-year age groups using analysis of variance. Reliability of measurements was assessed by intraclass correlation coefficient(2,1) and standard error of measurement. RESULTS: Mean angles of upper cervical rotation ranged between 10.91° (standard deviation 3.38°) to 16.12° (standard deviation 5.13°). Overall measured rotation ranged from 1.37° to 33.22°. Participants in older age groups generally displayed reduced rotation; however, the reduction was less than 4°. Reliability of rotation measurements was good to excellent, with the intraclass correlation coefficient ranging from 0.80 to 0.99. CONCLUSIONS: Normal range of rotation measured during stress testing for the alar ligament varied widely but did not exceed 33o. All values measured in this study fell below recommendations for ligament integrity. Age-related change was not clinically significant in the interpretation of this test in this asymptomatic population.

Supplementation of Screw-Rod C1-C2 Fixation With Posterior Arch Femoral Head Allograft Strut.

BACKGROUND: Numerous C1-C2 fixation techniques exist for the treatment of atlantoaxial instability. Limitations of screw-rod and sublaminar wiring techniques include C2 nerve root sacrifice and dural injury, respectively. We present a novel technique that utilizes a femoral head allograft cut with a keyhole that rests posteriorly on the arches of C1 and C2 and straddles the C2 spinous process, secured by sutures. OBJECTIVE: To offer increased fusion across C1-C2 without the passage of sublaminar wiring or interarticular arthrodesis. METHODS: A total of 6 patients with atlantoaxial instability underwent C1-C2 fixation using our method from 2015 to 2016. After placement of a C1-C2 screw/rod construct, a cadaveric frozen femoral head allograft was cut into a half-dome with a keyhole and placed over the already decorticated dorsal C1 arch and C2 spinous process. Notches were created in the graft and sutures were placed in the notches and around the rods to secure it firmly in place. RESULTS: The femoral head's shape allowed for creation of a graft that provides excellent surface area for fusion across C1-C2. There were no intraoperative complications, including dural tears. Postoperatively, no patients had sensorimotor deficits, pain, or occipital neuralgia. 5 patients demonstrated clinical resolution of symptoms by 3 mo and radiographic (computed tomography) evidence of fusion at 1 yr. One patient had good follow-up at 1 mo but died due to complications of Alzheimer disease. CONCLUSION: The posterior arch femoral head allograft strut technique with securing sutures is a viable option for supplementing screw-rod fixation in the treatment of complex atlantoaxial instability.

Systematic review of the nonsurgical management of atlantoaxial rotatory fixation in childhood.

OBJECTIVE: Atlantoaxial rotatory fixation (AARF) is an acquired fixed abnormality of C1-2 joint rotation associated with torticollis in childhood. If the condition is left uncorrected, patients are at risk for developing C1-2 fusion with permanent limitation in the cervical range of movement, cosmetic deformity, and impact on quality of life. The management of AARF and the modality of nonsurgical treatment are poorly defined in both primary care and specialized care settings, and the optimal strategy is not clear. This systematic review aims to examine the available evidence to answer key questions relating to the nonsurgical management of AARF. METHODS: A systematic review was performed using the following databases: PubMed, MEDLINE, Healthcare Management Information Consortium (HMIC), EMCare, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), British Nursing Index (BNI), and Allied and Complementary Medicine Database (AMED). Search criteria were created and checked independently among the authors. All articles with a radiological diagnosis of AARF and primary outcome data that met the study inclusion criteria were included and analyzed by the authors. RESULTS: Search results did not yield any level I evidence such as a meta-analysis or randomized controlled trial. The initial search yielded 724 articles, 228 of which were screened following application of the core exclusion criteria. A total of 37 studies met the full criteria for inclusion in this review, consisting of 4 prospective studies and 33 retrospective case reviews. No articles directly compared outcomes between modalities of nonsurgical management. Six studies compared the outcome of AARF based on duration of symptoms before initiation of treatment. Comparative analysis of studies was hindered by the wide variety of treatment modalities described and the heterogeneity of outcome data. CONCLUSIONS: The authors did not identify any level I evidence comparing different nonsurgical management approaches for AARF. There were few prospective studies, and most studies were uncontrolled, nonrandomized case series. Favorable outcomes were often reported regardless of treatment methods, with early treatment of AARF tending to yield better outcomes independent of the treatment modality. There is a lack of high-quality data, and further research is required to determine the optimal nonsurgical treatment strategy.

Recurrent Stroke in a Child With Atlantoaxial Instability Following Chiropractic Manipulation.

Pediatric stroke presents with a variety of signs and symptoms. Correct modality of imaging is essential in decreasing the time from symptom onset to appropriate management. Evaluation of pediatric stroke should include both blood work as well as imaging in a parallel rather than a sequential matter. We report a case of a child with a bow hunter's stroke that was challenging to diagnose. This type of stroke happens when the vertebral artery is occluded at the atlantoaxial or subaxial level during neck rotation. This case demonstrates that workup of stroke should be comprehensive to include all mechanical and anatomic possibilities before investigating rarer hypercoagulable disorders.

Torticollis and Atlantoaxial Rotatory Subluxation after Chiropractic Therapy

Torticollis is an abnormal, asymmetric head or neck position which usually caused by imbalance of paracervical muscles. The traumatic torticollis can be caused by following events; atlantoaxial rotatory subluxation, atlantoaxial dislocation, cervical vertebral fractures, and injury to the cervical musculature. Especially, acute traumatic atlantoaxial rotatory subluxation usually presents limitation of cervical range of motion without pain or neurologic deficit. We report a case of a 58 year-old man who developed the acute atlantoaxial rotatory subluxation right after the chiropractic therapy, which induced the limitation of cervical range of motion to 52.5% of normal range. The magnetic resonance image revealed the facture of the odontoid process and the partial injury in transverse ligaments of the atlas. He underwent intramuscular botulinum toxin injection and 10 days of continuous cervical traction 15 hours a day using a 5 kg weight. The range of the cervical motion restored up to 90.2% of normal range.

Additional Surgical Method Aimed to Increase Distractive Force during Occipitocervical Stabilization : Technical Note

OBJECTIVE: Craniovertebral junctional anomalies constitute a technical challenge. Surgical opening of atlantoaxial joint region is a complex procedure especially in patients with nuchal deformity like basilar invagination. This region has actually very complicated anatomical and functional characteristics, including multiple joints providing extension, flexion, and wide rotation. In fact, it is also a bottleneck region where bones, neural structures, and blood vessels are located. Stabilization surgery regarding this region should consider the fact that the area exposes excessive and life-long stress due to complex movements and human posture. Therefore, all options should be considered for surgical stabilization, and they could be interchanged during the surgery, if required.METHODS: A 53-year-old male patient applied to outpatients’ clinic with complaints of head and neck pain persisting for a long time. Physical examination was normal except increased deep tendon reflexes. The patient was on long-term corticosteroid due to an allergic disease. Magnetic resonance imaging and computed tomography findings indicated basilar invagination and atlantoaxial dislocation. The patient underwent C0–C3–C4 (lateral mass) and additional C0–C2 (translaminar) stabilization surgery.RESULTS: In routine practice, the sites where rods are bound to occipital plates were placed as paramedian. Instead, we inserted lateral mass screw to the sites where occipital screws were inserted on the occipital plate, thereby creating a site where extra rod could be bound. When C2 translaminar screw is inserted, screw caps remain on the median plane, which makes them difficult to bind to contralateral system. These bind directly to occipital plate without any connection from this region to the contralateral system. Advantages of this technique include easy insertion of C2 translaminar screws, presence of increased screw sizes, and exclusion of pullout forces onto the screw from neck movements. Another advantage of the technique is the median placement of the rod; i.e., thick part of the occipital bone is in alignment with axial loading.CONCLUSION: We believe that this technique, which could be easily performed as adjuvant to classical stabilization surgery with no need for special screw and rod, may improve distraction force in patients with low bone density.

Additional Surgical Method Aimed to Increase Distractive Force during Occipitocervical Stabilization : Technical Note

OBJECTIVE: Craniovertebral junctional anomalies constitute a technical challenge. Surgical opening of atlantoaxial joint region is a complex procedure especially in patients with nuchal deformity like basilar invagination. This region has actually very complicated anatomical and functional characteristics, including multiple joints providing extension, flexion, and wide rotation. In fact, it is also a bottleneck region where bones, neural structures, and blood vessels are located. Stabilization surgery regarding this region should consider the fact that the area exposes excessive and life-long stress due to complex movements and human posture. Therefore, all options should be considered for surgical stabilization, and they could be interchanged during the surgery, if required. METHODS: A 53-year-old male patient applied to outpatients’ clinic with complaints of head and neck pain persisting for a long time. Physical examination was normal except increased deep tendon reflexes. The patient was on long-term corticosteroid due to an allergic disease. Magnetic resonance imaging and computed tomography findings indicated basilar invagination and atlantoaxial dislocation. The patient underwent C0–C3–C4 (lateral mass) and additional C0–C2 (translaminar) stabilization surgery. RESULTS: In routine practice, the sites where rods are bound to occipital plates were placed as paramedian. Instead, we inserted lateral mass screw to the sites where occipital screws were inserted on the occipital plate, thereby creating a site where extra rod could be bound. When C2 translaminar screw is inserted, screw caps remain on the median plane, which makes them difficult to bind to contralateral system. These bind directly to occipital plate without any connection from this region to the contralateral system. Advantages of this technique include easy insertion of C2 translaminar screws, presence of increased screw sizes, and exclusion of pullout forces onto the screw from neck movements. Another advantage of the technique is the median placement of the rod; i.e., thick part of the occipital bone is in alignment with axial loading. CONCLUSION: We believe that this technique, which could be easily performed as adjuvant to classical stabilization surgery with no need for special screw and rod, may improve distraction force in patients with low bone density.

Relationship between craniocervical orientation and center of force of occlusion in adults.

OBJECTIVE: Clinical observation and anecdotal reports suggest changes can occur to dental occlusion following intervention with the National Upper Cervical Chiropractic Association (NUCCA) procedure. This case controlled study discerned if occlusion changes are measurable using a dental force plate (T-Scan®) following an adjustment to the craniocervical junction (CCJ). METHODS: A degree of case control was established by active patients being assessed twice prior to and following intervention. Before-after intervention assessment included posture evaluation and dental occlusion (T-Scan®). RESULTS: Findings suggest that changes in posture and occlusion can be observed after the NUCCA chiropractic procedure. Not all patients demonstrated a more balanced contact pattern following the adjustment, indicating a need for further investigation. DISCUSSION: These findings may suggest interconnectivity between the CCJ and an individual's occlusal contacts and support the need for further integration between chiropractors and dentists seeking to co-manage temporomandibular joint disorders.

An 11-Year Review of the TARP Procedure in the Treatment of Atlantoaxial Dislocation.

STUDY DESIGN: Retrospective study. OBJECTIVE: The aim of the study was to introduce the surgical techniques and evaluate the clinical outcomes of transoral atlantoaxial reduction plate (TARP) for the treatment of atlantoaxial dislocation. SUMMARY OF BACKGROUND DATA: Researchers have reported on transoral plate internal fixation for the treatment of irreducible atlantoaxial dislocation (IAAD) without long-term follow-up and detailed clinical experience. METHODS: The clinical records of 388 patients with atlantoaxial dislocation (IAAD, 340 cases; fixed atlantoaxial dislocation [FAAD], 48 cases) who received the TARP procedure from April 2003 to September 2014 were retrospectively reviewed. They were treated separately with TARP-I or TARP-II (82 cases), TARP-III (248 cases), or TARP-IV (58 cases). X-ray and magnetic resonance imaging were used to evaluate the efficacy of reduction and the degree of decompression, respectively. The long-term clinical outcome was evaluated by Japanese Orthopaedic Association scoring and the Symon and Lavender standard. RESULTS: Immediate reduction was achieved for all the patients with IAAD (340/340), whereas anatomical reduction was achieved for 98.2% of patients (334/340). Anatomical reduction was achieved in 87.5% of patients with FAAD (42/48). The average degree of spinal cord decompression ranged from 75% to 100% with an average of 88.4%. The clinical data of 106 patients were evaluated in the latest follow-up (12-108 mo, average 60.5 mo). The average spinal cord improvement rate by Japanese Orthopaedic Association scoring was 62.1%. According to the Symon and Lavender standard, there were 85 cases rated as markedly effective, 104 cases as effective, and 2 cases as noneffective. The overall markedly effective rate was 80% and the effective rate was 98%. CONCLUSION: The TARP procedure showed good anterior atlantoaxial release, reduction, decompression, and internal fixation for patients with IAAD and FAAD through a single anterior approach. It has the advantages of three-dimensional immediate atlantoaxial reduction and sufficient decompression. LEVEL OF EVIDENCE: 3.

Atlanto-axial infection after acupuncture.

A 67-year-old man presented with neck cellulitis following acupuncture for cervical spondylosis. Blood cultures were positive for methicillin-sensitive Staphylococcus aureus Increased neck pain and bacteraemia prompted MRI, which showed atlanto-axial septic arthritis without signs of infection of the tissues between the superficial cellulitic area and the atlanto-axial joint, thus making direct extension of infection unlikely. It is more likely that haematogenous spread of infection resulted in seeding in the atlanto-axial joint, with the proximity of the arthritis and acupuncture site being coincidental. Acupuncture is a treatment option for some indolent pain conditions. As such, acupuncture services are likely to be more frequently utilised. A history of acupuncture is rarely requested by the admitting doctor and seldom offered voluntarily by the patient, especially where the site of infection due to haematogenous spread is distant from the needling location. Awareness of infectious complications following acupuncture can reduce morbidity through early intervention.

A Case of Atlanto-Axial Joint Subluxation Following Tonsillectomy in Patient of Tonsillar Cancer with Preoperative Radiotherapy: Grisel's Syndrome / 대한이비인후과학회지

Grisel's syndrome, defined as the atlanto-axial joint subluxation not associated with a trauma or bone disease, is a rare complication following operative procedure and/or infections of the upper aerodigestive tract. Pathogenetically, it may occur in association with any condition that results in hyperemia and pathological relaxation of the transverse ligament of the atlanto-axial joint. When an inflammation heals, Grisel's syndrome can probably result in a fixation in the rotated position. It is diagnosed by physical and radiological findings. Early management, consisting of cervical immobilization and medical treatment, is considered a key factor for satisfactory outcome. Inappropriate treatment can result in a catastrophic consequence. Recently, we experienced a case of Grisel's syndrome following tonsillectomy in a patient with left palatine tonsillar cancer with preoperative radiotherapy. We report this case with a literature review.

Atlanto-axial infection after acupuncture.

A 67-year-old man presented with neck cellulitis following acupuncture for cervical spondylosis. Blood cultures were positive for methicillin-sensitive Staphylococcus aureus. Increased neck pain and bacteraemia prompted MRI, which showed atlanto-axial septic arthritis without signs of infection of the tissues between the superficial cellulitic area and the atlanto-axial joint, thus making direct extension of infection unlikely. It is more likely that haematogenous spread of infection resulted in seeding in the atlanto-axial joint, with the proximity of the arthritis and acupuncture site being coincidental. Acupuncture is a treatment option for some indolent pain conditions. As such, acupuncture services are likely to be more frequently utilised. A history of acupuncture is rarely requested by the admitting doctor and seldom offered voluntarily by the patient, especially where the site of infection due to haematogenous spread is distant from the needling location. Awareness of infectious complications following acupuncture can reduce morbidity through early intervention.

Closed manual reduction maneuver of atlantoaxial rotatory dislocation in pediatric age.

PURPOSE: The purposes of this study were to characterize the clinical and radiological features of type 1 and type 2 atlantoaxial rotatory dislocations (AARD) and to evaluate the outcome of the manual reduction maneuver for these types of dislocations in pediatric patients. METHODS: This study considered 12 pediatric patients with AARD who were treated between January 2003 and March 2013. The diagnosis was established by clinical findings and 3D-CT. All of the patients were treated by closed manual reduction and then a cervical orthosis was performed. All of the patients were followed up at regular intervals. RESULTS: The causes of the AARD were trauma (91.67 %) and infection (8.33 %). The time between onset of symptoms and admission to the hospital ranged from 16 days to 6 months. In radiological evaluation, the mean rotational angulation of the patients was 30.58°. The 3D-CT examination showed that six patients (50 %) had type 1 dislocation and six patients (50 %) had type 2 dislocation. All of the patients were treated by closed manual reduction and then a cervical orthosis was performed. For 11 patients (91.67 %), dislocation was successfully reducted and maintained. One patient (8.33 %) underwent surgery, following recurrence of the second closed reduction maneuver. CONCLUSION: This preceding treatment method has successfully produced a fast and recurrence-free alignment on all except one of our patients. This technique can be a useful treatment alternative in carefully selected AARD cases. Future research is encouraged to improve decision making in the application of this treatment method and provide additional validation of the current findings.

The influence of age, sex, and posture on the measurement of atlantodental interval in a normal population.

OBJECTIVE: The atlantodental interval (ADI) is used in assessing atlantoaxial stability. This measurement may potentially be affected by several features encountered during patient examination. This study examined the influence of 3 features: age, sex, and posture, on the measurement of ADI in a normal population. METHODS: The ADI was measured sequentially on 269 lateral cervical radiographs of adults with no demonstrated bony injury. Images were stratified by age and sex with equal representation in each age group. A further 25 asymptomatic adults were assessed for posture using craniovertebral angle measured from digital lateral photographs. The ADI was then measured from a lateral radiograph. The data were examined for correlation between age, craniovertebral angle, and ADI using Spearman rank correlation. The ADI of age groups was compared by Kruskal-Wallis test. The relationship between ADI and sex was examined using Wilcoxon rank sum test. Interaction between age and sex was explored using an interaction term in regression analysis. RESULTS: The ADI decreased with age, median measurements reducing from 2.07 to 0.85 mm across age groups (P < .01). No significant relationship was demonstrated between ADI and sex. No significant interaction was demonstrated between age and sex. Measurements of craniovertebral angle did not correlate with ADI (ρ = 0.03, P = .90). CONCLUSION: The magnitude of ADI decreases with advancing age. Age should be considered a modifying factor when interpreting measurement of ADI, particularly in consideration of potential minor instabilities. Patient sex does not appear to influence ADI, either independently or in interaction with age. Craniocervical posture variation does not influence ADI in an asymptomatic adult population.

Atlantoaxial rotatory subluxation after surgical relocation of Sprengel deformity: a case report.

We report a case of atlantoaxial rotatory subluxation developed after scapular relocation for Sprengel deformity in a 5-year-old girl. Scapular relocation descended the scapula by 60%, and achieved a normal shoulder joint motion. However, atlantoaxial rotatory subluxation developed, probably by pulling force of the tightened anterior fibers of upper trapezius muscle. Atlantoaxial joint was reduced easily under general anesthesia and muscle relaxant, along with surgical release of the tight band at the anterior part of trapezius muscle, which was maintained by halovest immobilization.

Upper cervical manipulation combined with mobilization for the treatment of atlantoaxial osteoarthritis: a report of 10 cases.

OBJECTIVE: This study presents the outcomes of patients with idiopathic degenerative and posttraumatic atlantoaxial osteoarthritis who were treated with upper cervical manipulation in combination with mobilization device therapy. CLINICAL FEATURES: A retrospective case review of 10 patients who were diagnosed with either degenerative or posttraumatic atlantoaxial arthritis based on histories, clinical symptoms, physical examination, and radiographic presentations was conducted at a multidisciplinary integrated clinic that used both chiropractic and orthopedic services. All 10 patients selected for this series were treated with a combination of upper cervical manipulation and mechanical mobilization device therapy. Outcome measures were collected at baseline and at the end of the treatment period. Assessments were measured using patients' self-report of pain using a numeric pain scale (NPS), physical examination, and radiologic changes. Average premanipulative NPS was 8.6 (range, 7-10), which was improved to a mean NPS of 2.6 (range, 0-7) at posttreatment follow-up. Mean rotation of C1-C2 at the end of treatment was improved from 28° (±3.1) to 52° (±4.5). Restoration of joint space was observed in 6 patients. Overall clinical improvement was described as "good" or "excellent" in about 80% of patients. Clinical improvements in pain and range of motion were seen in 80% and 90% of patients, respectively. CONCLUSION: Chiropractic management of atlantoaxial osteoarthritis yielded favorable outcomes for these 10 patients.

Resolution of whiplash-associated allodynia following cervicothoracic thrust and non-thrust manipulation.

Whiplash injuries of the cervical spine comprise 30% of injuries reported following motor vehicle accident (MVA) and often progress to chronic painful conditions. The purpose of this case report is to describe the management of a 37-year-old female referred to physical therapy with neck and shoulder pain after whiplash injury. The patient demonstrated limited cervical and shoulder active range of motion as well as quantitative sensory testing (QST) results consistent with central nervous system sensitization. She was treated for 11 visits over a 6-week period with manual therapy and specific exercise directed to the cervicothoracic spine. Her pain decreased from 9/10 to 2/10 by the end of treatment and remained improved at 1/10 at the 6-month follow-up. Her Copenhagen Neck Functional Disability Scale decreased from 23/30 to 4/30 by the 11th visit. In addition, she demonstrated clinically significant increases in cervical active range of motion and normal somatosensation. Manual therapy of the cervicothoracic spine may be a beneficial adjunct to the standard care of patients with signs and symptoms of central sensitization after whiplash-associated disorder and primary report of neck and shoulder pain.

Brain stem compression and atlantoaxial instability secondary to chronic rheumatoid arthritis in a 67-year-old female.

OBJECTIVE: This case study describes a patient with long-standing rheumatoid arthritis of the cervical spine who presented with significant bone destruction, gross joint derangement, and a potentially life-threatening complication, basilar invagination with brain stem compression. The pathophysiology, clinical presentation, imaging, and surgical management are discussed. CLINICAL FEATURES: A 67-year-old female presented to a chiropractic clinic with chronic neck pain of 30 years of duration complicated by rheumatoid arthritis. Her neck pain had recently exacerbated and was radiating into her trapezius muscle and shoulders. She also reported a recent onset of mild dysphagia. The patient was referred to a neurosurgeon for consultation and management. INTERVENTION AND OUTCOME: Computed tomography and magnetic resonance imaging of the cervical spine demonstrated significant bone destruction, gross joint derangement, and basilar invagination. There was moderate stenosis of the foramen magnum secondary to basilar invagination with significant brain stem compression. The patient underwent surgical stabilization fusion from the occiput to T2 using a posterior approach. Her pain severity was lessened after surgery, and the dysphagia had not progressed suggesting stabilization of brain stem compression. CONCLUSION: Patients with long-standing rheumatoid arthritis of the cervical spine often present with chronic neck pain. Cervical spine instability may arise from rheumatoid osteolysis and is also secondary to horizontal or vertical subluxation of the atlantoaxial and occipitoatlantal regions, respectively. High-velocity, low-amplitude manipulation of the upper cervical spine is an absolute contraindication in cases of atlantoaxial instability. A timely diagnosis and favorable surgical outcome provided relief from a potentially life-threatening disorder. This case exemplifies the clinical caution necessary for managing patients with chronic cervical spine pain complicated by rheumatoid arthritis.