Grisel syndrome
Transcript of Grisel syndrome
Grisel Syndrome
Nontraumatic Atlantoaxila Rotatory Subluxation: Grisel Syndrome. Case Report and Literature Review
Alecio C. E. S. Barcelos Gustavo C. Pateriota Arlindo Ugulino Netto
Introduction
• Notraumatic rotatory atlantoaxial subluxation first describesd in 1830 by Charles bell, in syphillis
• Defines by Grisel in 1950
• Grisel syndrome: atlantoaxial rotatory subluxation, not triggered by trauma, affecting Pt with hx of H&N infection
• Rare
• 68% < 12 years
• 90% < 21 years
Case Report• 7 years old. Boy
• Torticollis, halitosis, cough, odynophagia for 1/52
• No fever
• PE:
– posture in right-sided head rotation
– Subtle flexion
– Ipsilateral SCM spasm
– Nuchal pain
– Hypertrophied tonsils, no abcess
– Normal Neuro exam
• Lab: N crp and WBC
• CT:
– Lt. atlantoaxial facet ant. Dislocation
– ADI normal
• Tx:
– Soft collar
– Analgesia,muscle relaxant,Abx.( ceftriaxone for 14 days)
– Partial relaxation occurred after 24 hrs.
– Larger collar to reduce the flexion
– Clinical reduction after 48 hrs. then Hard collar
– Improved odynophagia
– Reduction was confirmed by radiology.
– MRI| done 21 days later
• Odontoid was slightly shifted to Rt.
• Fluids in C1 C2 facet joints.
• ADI was Normal
• Pt was discharged after 3/52
• He wore hard collar for 6/52
• Return to daily activity including sports gradually
Discussion
• Grisel syndrome happens after head infection or otolaryngology procedures
• More in Peds.
– Weak ligaments and joints capsules ( down, marfan)
– Horizontal joint line
– Small supporting muscles.
– Kawasaki Disease is found related to Grisel s.
– More post adenectomy after monopolar catarycomparing to bipolar coagulation.
• KarKos et al :
– Systemic review 71 articles
– 96 Pt with C1 C2 subluxation
– All no hx. of trauma
– 48% had recent URTI
– 40% post neck procedures
– Clinical picture: torticollis,neck pain maily in nape
– Signs:– Palpable deviation spinous process of C2
– SCM sppasm
– Inability to turn head beyond midline
Pathphysiology
• Unknown
• Grisel emphasize the role of muscle spasm
• Tedesco et al– Cervical lympadenitis induce irritative spasm of
suboccipital and parvertebral muscles.
• Most accepted theory is by Parke et al.– Studied vascularization of c spine, cranial base and
peripharyngeal
– Posterior superior veinous drainage is connected to periodontoidal plexus via pharyngovertebral veins
– This transport septic oxidates
• C1 C2 subluxation can be seen in x-ray
– Asymmetry, increased in lateral mass of C1
– Difficult to obtain optimal view
• Gold standard is CT
• Fundamental issue in diagnosis is hx. Of URTI
• Dx after 3/52 is related to failure of conservative Tx. Including closed reduction. And recurrence and permanent deformity.
diagnosis
• Hx.
• Torticollis after few days fron URTI onset
• Anomalous rotation and mild flexion
• Pain with active or passive rotation
• Elevated CRP & WBC in first days.
• Xray:
• CT
Treatment
• Controversial
• Initially conservative
• Waiting period of spontaneous reduction is not established. However most reduced after 7 days.
• Authors recommends hard collar for 2/52 to avoi recurrence
• If susequent reduction did not happen, do closed reduction
• Traction in slight flexion followed by extension and reverse rotation deformity.
• Jeszenszky manuver
• Wetzel and La Rocca proposed Tx based on Feilding and Hawkin Classification
• Surgery in failed closed Tx. Or recurrence
• Craniocervical fusion– In children < 6 years????
– Menezes recommends small craniotomy and upper cervical laminectomy with interlaminar and occipital rib graft reinforced by titanium cables.
• > 6 years : screw
fixation