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Grisel’s Syndrome: Non-traumatic Atlantoaxial Rotatory Subluxation—Report of Five Cases and Review of the Literature

  • Corrado IaccarinoEmail author
  • Ormitti Francesca
  • Spennato Piero
  • Rubini Monica
  • Rapanà Armando
  • Pasquale de Bonis
  • Aliberti Ferdinando
  • Giorgio Trapella
  • Lorenzo Mongardi
  • Michele Cavallo
  • Cinalli Giuseppe
  • Servadei Franco
Chapter
Part of the Acta Neurochirurgica Supplement book series (NEUROCHIRURGICA, volume 125)

Abstract

Background: In children, when unresponsive neck rigidity and distress are observed after ear, nose and throat (ENT) surgical treatment or nasopharyngeal inflammation, Grisel’s syndrome should be suspected. This is a rare syndrome involving non-traumatic rotatory subluxation of the atlantoaxial joint. Conservative management with external cervical orthoses and empirical antibiotic, muscle relaxant and analgesic therapy should be the first choice of treatment. Surgical stabilization is indicated when high-grade instability or failure of stable reduction are observed. The instability is graded according to the classification system devised by Fielding and Hawkins. Several recommendations for treatment are available in the literature, but there are no common guidelines. In this paper, the authors discuss the need for prompt diagnosis and treatment considerations.

Case Description: Five children with Fielding type I–III rotatory subluxation are reported. Three patients were treated with a cervical collar, and one patient was treated with skull traction and sternal–occipital–mandibular immobilizer (SOMI) brace application. Surgical treatment was necessary for one patient after failure of initial conservative management. The intervals between the onset of torticollis and radiological diagnosis ranged from 12 to 90 days. A relationship between an increased grade of instability and delayed diagnosis was observed.

Conclusion: In children with painful torticollis following ENT procedures or nasopharyngeal inflammation, Grisel’s syndrome should always be suspected. Cervical magnetic resonance imaging (MRI) allows prompt and safe diagnosis, and a three-dimensional computed tomography (CT) scan provides better classification of the instability. Surgery, which is indicated in cases of high-grade instability or failure of conservative treatment, may be avoided with prompt diagnosis.

Keywords

Grisel’s syndrome Fielding classification Atlantoaxial instability Atlantoaxial rotatory subluxation 

Abbreviations

3D

Three-dimensional

ADI

Atlantodental interval

CT

Computed tomography

ENT

Ear, nose and throat

MIP

Maximum-intensity projection

MRI

Magnetic resonance imaging

SOMI

Sternal–occipital–mandibular immobilizer

Notes

Competing Interests

The authors declare that they have no competing interests.

Compliance with Ethical Standards

No financial support was received for this work.

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Copyright information

© Springer International Publishing AG, part of Springer Nature 2019

Authors and Affiliations

  • Corrado Iaccarino
    • 1
    • 2
    Email author
  • Ormitti Francesca
    • 3
  • Spennato Piero
    • 4
  • Rubini Monica
    • 5
  • Rapanà Armando
    • 6
  • Pasquale de Bonis
    • 7
  • Aliberti Ferdinando
    • 4
  • Giorgio Trapella
    • 7
  • Lorenzo Mongardi
    • 7
  • Michele Cavallo
    • 7
  • Cinalli Giuseppe
    • 4
  • Servadei Franco
    • 8
  1. 1.Neurosurgery–Neurotraumatology UnitUniversity Hospital of ParmaParmaItaly
  2. 2.Azienda USL-IRCCS di Reggio EmiliaReggio EmiliaItaly
  3. 3.Department of NeuroradiologyUniversity Hospital of ParmaParmaItaly
  4. 4.Neurosurgery DepartmentAzienda Ospedaliera di Rilievo Nazionale “Santobono-Pausilipon-Annunziata” Children’s HospitalNaplesItaly
  5. 5.Division of Paediatric General and Emergency Care UnitChildren’s Hospital of ParmaParmaItaly
  6. 6.Neurosurgery Unit, Lorenzo Bonomo HospitalAndriaItaly
  7. 7.Neurosurgery DepartmentUniversity Hospital of FerraraFerraraItaly
  8. 8.New YorkUSA

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