Elsevier

World Neurosurgery

Volume 106, October 2017, Pages 355-358
World Neurosurgery

Doing More with Less
Management of Pediatric Atlantoaxial Rotatory Subluxation with a Simple Handmade Cervical Traction Device: Doing More with Less

https://doi.org/10.1016/j.wneu.2017.06.177Get rights and content

Objectives

To introduce a novel traction device for management of pediatric atlanto-axial rotatory subluxation (AARS) in source limiting areas.

Background

Atlanto-axial (C1–C2) joint is accountable for up to two third of total axial craniocervical rotation. Its major role in pivotal rotation of cervical spine makes it more vulnerable to a certain type of injury known as AARS. Management of AARS is based on the Fielding classification which includes closed reduction and immobilization and cervical fusion in unstable cases. There are several cervical traction devices including the Gardner-Wells tongs and halter traction device. All the available devices require insertion of pins into the calvarial periosteum which is a painful, invasive and intolerable procedure especially for the pediatric patients.

Methods

We designed a simple hand-made cervical traction device which is composed of 2 soft padded straps (40 × 4 cm) and 2 connecting strings which can be applied easily under the chin and occipital areas of the patients.

Results

We successfully treated a 9-year-old girl with AARS with the device. The advantage of the device is its available, inexpensive and non-invasive and the patient might tolerate it more easily compared to the previously designed instruments.

Conclusion

This hand-made simple cervical traction device in source limiting centers and hospitals is a good example of doing more with less. It was effective and the tolerance of the patient was acceptable. Further studies with larger series are required for providing appropriate evidence.

Introduction

The atlantoaxial (C1–C2) joint accounts for up to two thirds of instances of total axial craniocervical rotations to either side. Its major role in the pivotal rotation of the cervical spine makes it more vulnerable to a certain type of injury known as atlantoaxial rotatory subluxation (AARS). Rotatory subluxation of this joint is more prevalent in the pediatric age group.1 Although infections are the most common cause in the pediatric age group (known as Grisel syndrome),2 most cases of AARS in adults occur after trauma with injury to the transverse or alar ligaments or both.3, 4, 5 The most common presentation of AARS is torticollis, which is described as the “cock-robin” position of the neck, followed by suboccipital headache.

The management of AARS is based on the Fielding classification.6 Accordingly, patients with stable classes (I and II) can be treated with closed reduction and immobilization, whereas patients with unstable classes (III and IV) and those with neurologic deficits attributable to the injury should be treated with reduction and C1–C2 fusion.6 Regardless of the duration of symptoms and the type of AARS, benzodiazepines, muscle relaxants, steroids, and cervical traction are the primary constituents of treatment for achieving reduction. Better outcomes with the management of AARS in the acute stage show that early diagnosis and management of AARS merits certain attention. In areas with unavailable resources, a simple design of a traction device can be a reasonable substitute for halter traction for the management of AARS.1, 7

Section snippets

Case Report

A 9-year-old girl was referred from a rural center in southern Iran 3 weeks after she was in a car accident. She described having painful torticollis, and on physical examination her head was rotated to the right and laterally flexed to the left in the typical “cock-robin” posture. However, the results of her neurologic examination were unremarkable. Thin-cut computed tomographic (CT) scans showed type I atlantoaxial rotatory subluxation according to the Fielding classification6 (Figure 1).

With

Discussion

AARS is quite common in the pediatric age group.1 Upper respiratory tract infection (Grisel syndrome), trauma, and iatrogenic factors are the most common causes.2 The management of AARS is based on the Fielding classification and consists of closed reduction with a cervical traction device and stabilization.6 Several cervical traction devices are available for this purpose, including the Gardner-Wells tongs and the halter traction device.7 All the available devices require the insertion of pins

References (7)

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Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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