Atlanto-axial rotation dislocation (case report)

The authors present a female patient 45 years old, who had a car accident as a driver of a passenger car. Her car was hit from the left side by another car and the women hurt her head, neck and left shoulder. Due to pain in the region of the head and neck she was taken to the respective surgical out-patient department where they diagnosed the concussion of the brain of II degree and distortion of the cervical spine. The patient was treated conservatively by bed rest with the cervical spine fixed in the soft Schanz collar. After ten days she was discharged from the hospital and further followed up by a neurologist in the out-patient department. She underwent physical therapy focussed on the relaxation of muscles in the region of the cervical spine. Due to persisting pain in the region of upper cervical spine the patient was sent to the department of the first author six weeks after the injury. On clinical examination the head was inclined to the right and rotated to the left with pain in the region of the occipitocervical passage. Radiographs were made in the lateral and Sandberg projection. In the lateral projection the atlantodental distance was normal, the Sandberg projection showed an evidently asymmetrical location of the dens between the lateral masses of the atlas, asymmetrical size of the lateral masses and inclination of the head to the left. These basic projections alone showed an evident rotational atlantoaxial dislocation of I degree according to Fielding. The authors further added CT examination which showed rotation of C1 against C2 and asymmetrical location of the dens without dislocation from the anterior arch of the atlas. A conservative physical therapy was not successful and the patient felt worse. Twelve months after the injury a pre-operative traction by Glisson sling was introduced for five days with a gradual weight bearing up to 5 kg. A reduction followed from the dorsal approach and fixation of C1-C2 after Magerl combined with Gallie technique. The surgery was without complications and the post-operative radiographs showed a good position of the C1-C2 complex and a correct insertion of screws through atlantoaxial joints. The patient wore for six weeks a Philadelphia collar and another six weeks the Schanz collar. Standard and functional radiographs in flexion and extension made 12 weeks after the surgery showed bone bridging between C1-C2 arches and a stable atlantoaxial fusion. At the check one year after the surgery the patient had a limited rotation of the head by 25%, however, she was without pain and the inclination and rotation of the head was compensated. In the authors' view the use of Magerl technique of C1-C2 fixation is possible in case of a rotational atlantoaxial dislocation but difficult with regard to the changed anatomical conditions.