Journal of Anesthesia

, Volume 24, Issue 4, pp 598–602 | Cite as

Significance of prevention and early treatment of a postoperative twisted neck: atlantoaxial rotatory subluxation after head and neck surgery

  • Byeoknyeon Kim
  • Keiko Iwata
  • Kenji Sugimoto
  • Shogo Suzuki
  • Yoshiaki Ema
  • Hironaka Tsunobuchi
  • Kimitoshi Nishiwaki
Clinical Report


Atlantoaxial rotatory subluxation (AARS) is an infrequent condition that occurs most commonly in children for unknown reasons. Pediatric surgery, otopharyngeal inflammation, general anesthesia, and extreme rotation of the head are risk factors for development of postsurgical AARS, but AARS can often occur unnoticed, and the syndrome is not well known. We encountered three cases of postoperative AARS that occurred within 7 months; therefore, we have developed guidelines for prevention and early treatment of postoperative AARS. Postoperative AARS cannot be eliminated completely, but informed consent, a preoperative check, an appropriate surgical position, and a postoperative check may reduce the risk and damage related to this condition.


Preanesthetic assessment Torticollis Neck position Postoperative recovery 


  1. 1.
    Pang D, Li V. Atlantoaxial rotatory fixation: part 1––biomechanics of normal rotation at the atlantoaxial joint in children. Neurosurgery. 2004;55:614–25 (discussion p 625–626).CrossRefPubMedGoogle Scholar
  2. 2.
    Phillips WA, Hensinger RN. The management of rotatory atlanto-axial subluxation in children. J Bone Joint Surg Am. 1989;71:664–8.PubMedGoogle Scholar
  3. 3.
    Wilson BC, Jarvis BL, Haydon RC 3rd. Nontraumatic subluxation of the atlantoaxial joint: Grisel’s syndrome. Ann Otol Rhinol Laryngol. 1987;96:705–8.PubMedGoogle Scholar
  4. 4.
    Parke WW, Rothman RH, Brown MD. The pharyngovertebral veins: an anatomical rationale for Grisel’s syndrome. J Bone Joint Surg Am. 1984;66:568–74.PubMedGoogle Scholar
  5. 5.
    Jayakrishnan VK, Teasdale E. Torticollis due to atlanto-axial rotatory fixation following general anaesthesia. Br J Neurosurg. 2000;14:583–5.CrossRefPubMedGoogle Scholar
  6. 6.
    Karkos PD, Benton J, Leong SC, Mushi E, Sivaji N, Assimakopoulos DA. Grisel’s syndrome in otolaryngology: a systematic review. Int J Pediatr Otorhinolaryngol. 2007;71:1823–7.CrossRefPubMedGoogle Scholar
  7. 7.
    Pang D, Li V. Atlantoaxial rotatory fixation: part 3. A prospective study of the clinical manifestation, diagnosis, management, and outcome of children with atlantoaxial rotatory fixation. Neurosurgery. 2005;57:954–72 (discussion p 972).CrossRefPubMedGoogle Scholar
  8. 8.
    McGuire KJ, Silber J, Flynn JM, Levine M, Dormans JP. Torticollis in children: can dynamic computed tomography help determine severity and treatment. J Pediatr Orthop. 2002;22:766–70.CrossRefPubMedGoogle Scholar
  9. 9.
    Dasen KR. Atlantoaxial rotatory subluxation after a pediatric tonsillectomy. Anesth Analg. 1999;89:917–9.CrossRefPubMedGoogle Scholar
  10. 10.
    Naruo Y, Yamaoka H, Uchida M, Matsumoto K, Inatsugu H. Atlanto-axial rotary subluxation following pharyngoplasty: a case report (author’s transl). Masui. 1978;27:1623–6.PubMedGoogle Scholar
  11. 11.
    Audenaert SM, Schmidt TE. The cervical spine: additional considerations regarding atlanto-axial subluxation. Can J Anaesth. 1991;38:415–6.CrossRefPubMedGoogle Scholar
  12. 12.
    Locke GR, Gardner JI, Van Epps EF. Atlas-dens interval (ADI) in children: a survey based on 200 normal cervical spines. Am J Roentgenol Radium Ther Nucl Med. 1966;97:135–40.PubMedGoogle Scholar
  13. 13.
    Brisson P, Patel H, Scorpio R, Feins N. Rotary atlanto-axial subluxation with torticollis following central-venous catheter insertion. Pediatr Surg Int. 2000;16:421–3.CrossRefPubMedGoogle Scholar
  14. 14.
    Miyoshi Y, Tokunaga K, Date I. Sequentially occurred bilateral atlantoaxial rotatory subluxation following craniotomy: a case report. No Shinkei Geka. 2005;33:73–8.PubMedGoogle Scholar
  15. 15.
    Roche CJ, O’Malley M, Dorgan JC, Carty HM. A pictorial review of atlanto-axial rotatory fixation: key points for the radiologist. Clin Radiol. 2001;56:947–58.CrossRefPubMedGoogle Scholar
  16. 16.
    Pang D, Li V. Atlantoaxial rotatory fixation: part 2. New diagnostic paradigm and a new classification based on motion analysis using computed tomographic imaging. Neurosurgery. 2005;57:941–53 (discussion p 953).CrossRefPubMedGoogle Scholar
  17. 17.
    Fielding JW, Hawkins RJ. Atlanto-axial rotatory fixation. (Fixed rotatory subluxation of the atlanto-axial joint). J Bone Joint Surg Am. 1977;59:37–44.PubMedGoogle Scholar
  18. 18.
    Kawabe N, Hirotani H, Tanaka O. Pathomechanism of atlantoaxial rotatory fixation in children. J Pediatr Orthop. 1989;9:569–74.PubMedGoogle Scholar
  19. 19.
    Subach BR, McLaughlin MR, Albright AL, Pollack IF. Current management of pediatric atlantoaxial rotatory subluxation. Spine. 1998;23:2174–9.CrossRefPubMedGoogle Scholar
  20. 20.
    Eadie PA, Moran R, Fogarty EE, Edwards GE. Rotatory atlantoaxial subluxation following pharyngoplasty. Br J Plast Surg. 1989;42:722–3.CrossRefPubMedGoogle Scholar
  21. 21.
    Feldmann H, Meister EF, Kuttner K. From the expert’s office. Atlanto-axial subluxation with spastic torticollis after adenoidectomy resp. tonsillectomy in Rose position––malpractice of the surgeon or the anaesthesiologist? Laryngorhinootologie. 2003;82:799–804.CrossRefPubMedGoogle Scholar

Copyright information

© Japanese Society of Anesthesiologists 2010

Authors and Affiliations

  • Byeoknyeon Kim
    • 1
  • Keiko Iwata
    • 1
  • Kenji Sugimoto
    • 1
  • Shogo Suzuki
    • 1
  • Yoshiaki Ema
    • 1
  • Hironaka Tsunobuchi
    • 1
  • Kimitoshi Nishiwaki
    • 1
  1. 1.Department of AnesthesiologyNagoya University Graduate School of MedicineNagoyaJapan

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