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Successful Conservative Treatment for Neglected Rotatory Atlantoaxial Dislocation

Chechik, Ofir MD*; Wientroub, Shlomo MD; Danino, Barry MD*; Lebel, David E. MD; Ovadia, Dror MD

Journal of Pediatric Orthopaedics: June 2013 - Volume 33 - Issue 4 - p 389–392
doi: 10.1097/BPO.0b013e318279c68c
Spine Trauma

Background: Rotatory atlantoaxial subluxation (RAS) is a rare condition that is often misdiagnosed and therefore incorrectly managed. We describe our experience and propose an algorithm for treating neglected RAS nonoperatively.

Methods: All consecutive children with neglected (>6 wk) RAS were treated in our department between 2005 and 2010 by cervical traction using a Gleason traction device and nonsteroidal anti-inflammatory drugs and muscle relaxants. When reduction was not achieved, the Gleason device was replaced by a halo device without manipulative reduction, and weight was added as necessary until reduction was successful. Fixation of reduction was either by a sternooccipital mandibular immobilizer or a halo vest for 3 to 4 months.

Results: All 5 children (4 boys and 1 girl, aged 4 to 11 y) were successfully treated for neglected RAS. The mean duration from symptom onset (eg, limited neck range of motion, discomfort) to treatment initiation was 11.6 weeks (range, 6 to 16 wk). Closed reduction was achieved by a Gleason or a noninvasive halo device within 1 to 2 weeks in 4 cases. The fifth case was reduced after 5 weeks of traction using a halo with a 5 kg weight. All children had symmetrical full range of motion, normal neurological examination, and were fully engaged in educational and sports activities without recurrent dislocations at final follow-up (mean, 30 mo; range, 18 to 49 mo).

Conclusions: Conservative treatment by gradual and prolonged traction without manipulative reduction in neglected RAS might be a successful method. Reduction can often be achieved within 2 weeks of treatment onset.

Level of Evidence: Level IV (retrospective case series).

Departments of *Orthopaedic Surgery

Pediatric Orthopaedics, Dana Children’s Hospital, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel

None of the authors received financial support for this study.

The authors declare no conflict of interest.

Reprints: Dror Ovadia, MD, Department of Pediatric Orthopaedics, Dana Children’s Hospital, Tel Aviv Medical Center, Sackler Faculty of Medicine, 6 Weizmann Street, Tel Aviv 64239, Israel. E-mail:

© 2013 by Lippincott Williams & Wilkins