Rotation of the second cervical vertebra in pediatric patient

Priscila Dias Peyneau Gina Delia Roque-Torres Luiz Roberto Godolfim Eliana Dantas da Costa Solange Maria de Almeida Gláucia Maria Bovi Ambrosano About the authors

Rotatory instability is characterized by the rotation between two vertebral bodies, and it constitutes the most common cause of torticollis in children.(11. Gradl G, Maier-Bosse T, Penning R, Stäbler A. Quantification of C2 cervical spine rotatory fixation by X-ray, MRI and CT. Eur Radiol. 2005;15(2):376-82.

2. Tachibana A, Imabayashi H, Yato Y, Nakamichi K, Asazuma T, Nemoto K. Torticollis of a specific C1 dislocation with split atlas. Spine (Phila Pa 1976). 2010;35(14):E672-5.

3. Meza Escobar LE, Osterhoff G, Ossendorf C, Wanner GA, Simmen HP, Werner CM. Traumatic atlantoaxial rotatory subluxation in an adolescent: a case report. J Med Case Rep. 2012;6:27.

4. Min Han Z, Nagao N, Sakakibara T, Akeda K, Matsubara T, Sudo A, et al. Adult traumatic atlantoaxial rotatory fixation: a case report. Case Rep Orthop. 2014;2014:593621.
-55. Missori P, Marruzzo D, Peschillo S, Domenicucci M. Clinical remarks on acute post-traumatic atlanto-axial rotatory subluxation in pediatric-aged patients. World Neurosurg. 2014;82(5):e645-8.) This prevalence occurs because of specific anatomic characteristics of childhood, such as disproportion between head-neck, underdeveloped cervical musculature, laxity of the joint capsule, ligament elasticity and horizontal shape of the articular facets between atlas and axis vertebrae.(33. Meza Escobar LE, Osterhoff G, Ossendorf C, Wanner GA, Simmen HP, Werner CM. Traumatic atlantoaxial rotatory subluxation in an adolescent: a case report. J Med Case Rep. 2012;6:27.

4. Min Han Z, Nagao N, Sakakibara T, Akeda K, Matsubara T, Sudo A, et al. Adult traumatic atlantoaxial rotatory fixation: a case report. Case Rep Orthop. 2014;2014:593621.

5. Missori P, Marruzzo D, Peschillo S, Domenicucci M. Clinical remarks on acute post-traumatic atlanto-axial rotatory subluxation in pediatric-aged patients. World Neurosurg. 2014;82(5):e645-8.

6. Maida G, Marcati E, Sarubbo S. Posttraumatic atlantoaxial rotatory dislocation in a healthy adult patient: a case report and review of the literature. Case Rep Orthop. 2012;2012:183581.
-77. Bellil M, Hadhri K, Sridi M, Kooli M. Traumatic atlantoaxial rotatory fixation associated with C2 articular facet fracture in adult patient: case report. J Craniovertebr Junction Spine. 2014;5(4):163-6.) This condition can occur due to inflammation/infection(22. Tachibana A, Imabayashi H, Yato Y, Nakamichi K, Asazuma T, Nemoto K. Torticollis of a specific C1 dislocation with split atlas. Spine (Phila Pa 1976). 2010;35(14):E672-5.,66. Maida G, Marcati E, Sarubbo S. Posttraumatic atlantoaxial rotatory dislocation in a healthy adult patient: a case report and review of the literature. Case Rep Orthop. 2012;2012:183581.,77. Bellil M, Hadhri K, Sridi M, Kooli M. Traumatic atlantoaxial rotatory fixation associated with C2 articular facet fracture in adult patient: case report. J Craniovertebr Junction Spine. 2014;5(4):163-6.) or trauma,(11. Gradl G, Maier-Bosse T, Penning R, Stäbler A. Quantification of C2 cervical spine rotatory fixation by X-ray, MRI and CT. Eur Radiol. 2005;15(2):376-82.,22. Tachibana A, Imabayashi H, Yato Y, Nakamichi K, Asazuma T, Nemoto K. Torticollis of a specific C1 dislocation with split atlas. Spine (Phila Pa 1976). 2010;35(14):E672-5.,44. Min Han Z, Nagao N, Sakakibara T, Akeda K, Matsubara T, Sudo A, et al. Adult traumatic atlantoaxial rotatory fixation: a case report. Case Rep Orthop. 2014;2014:593621.,66. Maida G, Marcati E, Sarubbo S. Posttraumatic atlantoaxial rotatory dislocation in a healthy adult patient: a case report and review of the literature. Case Rep Orthop. 2012;2012:183581.) or because of neurogenic or idiopathic origin.(22. Tachibana A, Imabayashi H, Yato Y, Nakamichi K, Asazuma T, Nemoto K. Torticollis of a specific C1 dislocation with split atlas. Spine (Phila Pa 1976). 2010;35(14):E672-5.)

The diagnosis includes clinical and imaging exam.(77. Bellil M, Hadhri K, Sridi M, Kooli M. Traumatic atlantoaxial rotatory fixation associated with C2 articular facet fracture in adult patient: case report. J Craniovertebr Junction Spine. 2014;5(4):163-6.,88. Mönckeberg JE, Tomé CV, Matías A, Alonso A, Vásquez J, Zubieta JL. CT scan study of atlantoaxial rotatory mobility in asymptomatic adult subjects: a basis for better understanding C1-C2 rotatory fixation and subluxation. Spine (Phila Pa 1976). 2009;34(12):1292-5.) Among imaging exams of bone tissue, radiographies in anteroposterior and lateral projections are of limited use because they do not enable a precise visualization of this alteration, due to difficulties in positioning patients (head offset or source of X-rays, and overlap of structures), leading to radiographic interpretation challenges.(11. Gradl G, Maier-Bosse T, Penning R, Stäbler A. Quantification of C2 cervical spine rotatory fixation by X-ray, MRI and CT. Eur Radiol. 2005;15(2):376-82.,66. Maida G, Marcati E, Sarubbo S. Posttraumatic atlantoaxial rotatory dislocation in a healthy adult patient: a case report and review of the literature. Case Rep Orthop. 2012;2012:183581.,77. Bellil M, Hadhri K, Sridi M, Kooli M. Traumatic atlantoaxial rotatory fixation associated with C2 articular facet fracture in adult patient: case report. J Craniovertebr Junction Spine. 2014;5(4):163-6.) Computed tomography is considered the gold standard procedure.(11. Gradl G, Maier-Bosse T, Penning R, Stäbler A. Quantification of C2 cervical spine rotatory fixation by X-ray, MRI and CT. Eur Radiol. 2005;15(2):376-82.,66. Maida G, Marcati E, Sarubbo S. Posttraumatic atlantoaxial rotatory dislocation in a healthy adult patient: a case report and review of the literature. Case Rep Orthop. 2012;2012:183581.,77. Bellil M, Hadhri K, Sridi M, Kooli M. Traumatic atlantoaxial rotatory fixation associated with C2 articular facet fracture in adult patient: case report. J Craniovertebr Junction Spine. 2014;5(4):163-6.) Images of tridimensional reconstruction provides a global visualization of rotation, therefore helping to establish the diagnosis.(22. Tachibana A, Imabayashi H, Yato Y, Nakamichi K, Asazuma T, Nemoto K. Torticollis of a specific C1 dislocation with split atlas. Spine (Phila Pa 1976). 2010;35(14):E672-5.,33. Meza Escobar LE, Osterhoff G, Ossendorf C, Wanner GA, Simmen HP, Werner CM. Traumatic atlantoaxial rotatory subluxation in an adolescent: a case report. J Med Case Rep. 2012;6:27.,77. Bellil M, Hadhri K, Sridi M, Kooli M. Traumatic atlantoaxial rotatory fixation associated with C2 articular facet fracture in adult patient: case report. J Craniovertebr Junction Spine. 2014;5(4):163-6.) In addition, the magnetic resonance image can also be requested to evaluate the risk of vascular-nervous bundle compromising and injuries of the ligaments adjacent to vertebrae.(11. Gradl G, Maier-Bosse T, Penning R, Stäbler A. Quantification of C2 cervical spine rotatory fixation by X-ray, MRI and CT. Eur Radiol. 2005;15(2):376-82.,55. Missori P, Marruzzo D, Peschillo S, Domenicucci M. Clinical remarks on acute post-traumatic atlanto-axial rotatory subluxation in pediatric-aged patients. World Neurosurg. 2014;82(5):e645-8.

6. Maida G, Marcati E, Sarubbo S. Posttraumatic atlantoaxial rotatory dislocation in a healthy adult patient: a case report and review of the literature. Case Rep Orthop. 2012;2012:183581.
-77. Bellil M, Hadhri K, Sridi M, Kooli M. Traumatic atlantoaxial rotatory fixation associated with C2 articular facet fracture in adult patient: case report. J Craniovertebr Junction Spine. 2014;5(4):163-6.)

A 12-year-old boy was referred to our radiologic clinic to undergo a cone beam computed tomography for orthodontic purposes. We carried out a tridimensional, axial, coronal and sagittal reconstruction (Figures 1 to 5). During imaging assessment, we observed 5° of rotation of the second cervical vertebra in relation to medium line and a space between atlanto-axial vertebrae of 5.1mm (right side) and 7.6mm (left side) (Figure 5). In anamnesis, the patient reported trauma experienced 1 year earlier and, after the incident, presence of constant torticollis.

Figure 1
Tridimensional reconstruction of first three cervical vertebrae (posterior view). Rotation of the second cervical vertebra can be observed (green). The yellow line highlights the median sagittal plane; red line represents the rotation of second vertebra; white line indicates latero-lateral inclination of the second vertebra

Figure 2
Tridimensional reconstruction of first three cervical vertebrae (transversal view). A rotation of the second vertebra is observed (green). Red arrow indicates the rotation of the second vertebra

Figure 3
Coronal reconstruction of cervical vertebrae. Red arrows indicating latero-lateral inclination of the second vertebra

Figure 4
Axial reconstruction. Yellow line showing medium sagittal plan; Red line indicating rotation of the second cervical vertebra

Figure 5
Cone beam computed tomography showing 5º of axial rotation in relation to medium line (A), atlanto-axil space of 5.1 and 7.6mm (B)

Correct diagnosis is crucial for adequate management. Treatment can be conservative using immobilization,(33. Meza Escobar LE, Osterhoff G, Ossendorf C, Wanner GA, Simmen HP, Werner CM. Traumatic atlantoaxial rotatory subluxation in an adolescent: a case report. J Med Case Rep. 2012;6:27.

4. Min Han Z, Nagao N, Sakakibara T, Akeda K, Matsubara T, Sudo A, et al. Adult traumatic atlantoaxial rotatory fixation: a case report. Case Rep Orthop. 2014;2014:593621.
-55. Missori P, Marruzzo D, Peschillo S, Domenicucci M. Clinical remarks on acute post-traumatic atlanto-axial rotatory subluxation in pediatric-aged patients. World Neurosurg. 2014;82(5):e645-8.,77. Bellil M, Hadhri K, Sridi M, Kooli M. Traumatic atlantoaxial rotatory fixation associated with C2 articular facet fracture in adult patient: case report. J Craniovertebr Junction Spine. 2014;5(4):163-6.,99. Fuentes S, Bouillot P, Palombi O, Ducolombier A, Desgeorges M. Traumatic atlantoaxial rotatory dislocation with odontoid fracture: case report and review. Spine (Phila Pa 1976). 2001;26(7):830-4.) traction or manual reduction,(33. Meza Escobar LE, Osterhoff G, Ossendorf C, Wanner GA, Simmen HP, Werner CM. Traumatic atlantoaxial rotatory subluxation in an adolescent: a case report. J Med Case Rep. 2012;6:27.,44. Min Han Z, Nagao N, Sakakibara T, Akeda K, Matsubara T, Sudo A, et al. Adult traumatic atlantoaxial rotatory fixation: a case report. Case Rep Orthop. 2014;2014:593621.,77. Bellil M, Hadhri K, Sridi M, Kooli M. Traumatic atlantoaxial rotatory fixation associated with C2 articular facet fracture in adult patient: case report. J Craniovertebr Junction Spine. 2014;5(4):163-6.,99. Fuentes S, Bouillot P, Palombi O, Ducolombier A, Desgeorges M. Traumatic atlantoaxial rotatory dislocation with odontoid fracture: case report and review. Spine (Phila Pa 1976). 2001;26(7):830-4.) with the use of analgesic,(33. Meza Escobar LE, Osterhoff G, Ossendorf C, Wanner GA, Simmen HP, Werner CM. Traumatic atlantoaxial rotatory subluxation in an adolescent: a case report. J Med Case Rep. 2012;6:27.) physiotherapy(11. Gradl G, Maier-Bosse T, Penning R, Stäbler A. Quantification of C2 cervical spine rotatory fixation by X-ray, MRI and CT. Eur Radiol. 2005;15(2):376-82.,99. Fuentes S, Bouillot P, Palombi O, Ducolombier A, Desgeorges M. Traumatic atlantoaxial rotatory dislocation with odontoid fracture: case report and review. Spine (Phila Pa 1976). 2001;26(7):830-4.) or surgery.(33. Meza Escobar LE, Osterhoff G, Ossendorf C, Wanner GA, Simmen HP, Werner CM. Traumatic atlantoaxial rotatory subluxation in an adolescent: a case report. J Med Case Rep. 2012;6:27.,77. Bellil M, Hadhri K, Sridi M, Kooli M. Traumatic atlantoaxial rotatory fixation associated with C2 articular facet fracture in adult patient: case report. J Craniovertebr Junction Spine. 2014;5(4):163-6.,99. Fuentes S, Bouillot P, Palombi O, Ducolombier A, Desgeorges M. Traumatic atlantoaxial rotatory dislocation with odontoid fracture: case report and review. Spine (Phila Pa 1976). 2001;26(7):830-4.)

REFERENCES

  • 1
    Gradl G, Maier-Bosse T, Penning R, Stäbler A. Quantification of C2 cervical spine rotatory fixation by X-ray, MRI and CT. Eur Radiol. 2005;15(2):376-82.
  • 2
    Tachibana A, Imabayashi H, Yato Y, Nakamichi K, Asazuma T, Nemoto K. Torticollis of a specific C1 dislocation with split atlas. Spine (Phila Pa 1976). 2010;35(14):E672-5.
  • 3
    Meza Escobar LE, Osterhoff G, Ossendorf C, Wanner GA, Simmen HP, Werner CM. Traumatic atlantoaxial rotatory subluxation in an adolescent: a case report. J Med Case Rep. 2012;6:27.
  • 4
    Min Han Z, Nagao N, Sakakibara T, Akeda K, Matsubara T, Sudo A, et al. Adult traumatic atlantoaxial rotatory fixation: a case report. Case Rep Orthop. 2014;2014:593621.
  • 5
    Missori P, Marruzzo D, Peschillo S, Domenicucci M. Clinical remarks on acute post-traumatic atlanto-axial rotatory subluxation in pediatric-aged patients. World Neurosurg. 2014;82(5):e645-8.
  • 6
    Maida G, Marcati E, Sarubbo S. Posttraumatic atlantoaxial rotatory dislocation in a healthy adult patient: a case report and review of the literature. Case Rep Orthop. 2012;2012:183581.
  • 7
    Bellil M, Hadhri K, Sridi M, Kooli M. Traumatic atlantoaxial rotatory fixation associated with C2 articular facet fracture in adult patient: case report. J Craniovertebr Junction Spine. 2014;5(4):163-6.
  • 8
    Mönckeberg JE, Tomé CV, Matías A, Alonso A, Vásquez J, Zubieta JL. CT scan study of atlantoaxial rotatory mobility in asymptomatic adult subjects: a basis for better understanding C1-C2 rotatory fixation and subluxation. Spine (Phila Pa 1976). 2009;34(12):1292-5.
  • 9
    Fuentes S, Bouillot P, Palombi O, Ducolombier A, Desgeorges M. Traumatic atlantoaxial rotatory dislocation with odontoid fracture: case report and review. Spine (Phila Pa 1976). 2001;26(7):830-4.

Publication Dates

  • Publication in this collection
    Oct-Dec 2016

History

  • Received
    1 Feb 2016
  • Accepted
    12 Apr 2016
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