- Department of Spine Surgery, Robert Jones and Agnes Hunt Orthopaedic Hospital, England, United Kingdom,
- Department of Spine Surgery, Apollo Hospital, Mumbai, Maharashtra, India.
Alok Gadkari, Fellow in Spinal Surgery, Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, United Kingdom.
DOI:10.25259/SNI_805_2022Copyright: © 2022 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Aashish Ghodke1, Alok Gadkari1, Rishi Trivedi1, Agnivesh Tikoo2, Ram Chaddha2. Torticollis in an 8-year-old child due to Grisel’s syndrome - A case report. 04-Nov-2022;13:502
How to cite this URL: Aashish Ghodke1, Alok Gadkari1, Rishi Trivedi1, Agnivesh Tikoo2, Ram Chaddha2. Torticollis in an 8-year-old child due to Grisel’s syndrome - A case report. 04-Nov-2022;13:502. Available from: https://surgicalneurologyint.com/surgicalint-articles/11983/
Background: Grisel’s syndrome is a nontraumatic atlantoaxial subluxation resulting from an ongoing local inflammatory process.
Case Description: An 8-year-old male presented to the emergency department with neck pain which was sudden in onset without any history of any significant fall or trauma. On physical examination, the patient had torticollis with a head tilt to the left side and the chin rotated to the right. The CT scan confirmed atlantoaxial subluxation with C1 rotated to the right on the odontoid process without anterior displacement. The patient was managed conservatively with antibiotics, anti-inflammatory agents, and head-halter traction.
Conclusion: As Grisel’s syndrome can have catastrophic outcomes, early diagnosis and treatment are critical. It must be considered in patients presenting with acute torticollis following an infection or prior surgery.
Keywords: Atlanto-axial subluxation, Grisels syndrome, Torticollis
Grisel’s syndrome is a nontraumatic atlantoaxial subluxation resulting from an ongoing local inflammatory process.[
Clinical and radiographic presentation
An 8-year-old male presented with the sudden onset of neck pain and torticollis characterized by a head tilt to the left side with the chin rotated to the right. He was neurologically intact. Open mouth cervical spine X-ray showed an asymmetric distance of C2 from the lateral masses. The CT scan confirmed atlantoaxial subluxation with C1 rotated to the right on the odontoid process in the absence of anterior displacement. The right and left side lateral atlantoaxial joints measured 3 mm and 6.4 mm, respectively. This was diagnosed as a Type I atlantoaxial rotatory subluxation (i.e., Fielding classification). The MRI verified the CT findings and demonstrated that the transverse ligament was intact. However, STIR and T2 images revealed hyperintensity of the pharyngeal and tonsillar tissues and lymph nodes, but there was minimal fluid in the bilateral atlantoaxial joints. The patient was immobilized in a Philadelphia collar and was kept in collar until after all the radiological studies were completed.
Treatment: Antibiotics, anti-inflammatory agents, traction, and bracing
The patient was put on head-halter traction, 2.5 kg weight was applied. The patient was started on antibiotics and anti-inflammatory agents for a presumed upper respiratory tract infection. Serial X-rays (admission, day 1 and day 2) confirmed further reduction of the torticollis. By day 3, the patient clinically improved and the torticollis had resolved. He was discharged with antibiotics/anti-inflammatory medications for 1 week and wore a Philadelphia collar for 6 weeks. Six weeks later, he was asymptomatic and the X-rays confirmed normal alignment.
Grisel’s syndrome is defined as a nontraumatic subluxation of atlantoaxial joint following nasopharyngeal inflammation. It was first described by Sir Charles Bell in 1830 in a patient with syphilis, pharyngitis, and lethal spinal compression.[
Radiological diagnosis and treatment options for Grisel’s syndrome
CT scans with 3D reconstructions are the gold standard for diagnosing Grisel’s syndrome. Typically, this should be supplemented with enhanced MR studies to better define the soft-tissue extent of neural and retropharyngeal pathology.
Early treatment of Grisel’s syndrome is straightforward and begins with the administration of antibiotics and anti-inflammatory agents and cervical bracing. If diagnosed later in the clinical course, surgery may be warranted to manage high-grade instability/subluxation.
The diagnosis of Grisel’s syndrome must be considered in patients presenting with acute torticollis following either an infection or operative procedure in upper aerodigestive tract. Early diagnosis and treatment are critical to avoid neurological sequelae.
Patient’s consent not required as patient’s identity is not disclosed or compromised.
There are no conflicts of interest.
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