Grisel Syndrome is a rare condition where there is non-traumatic atlantoaxial rotatory subluxation, typically affecting children under 21 years old with a history of head and neck infection. The case report describes a 7-year old boy who presented with torticollis, cough, and odynophagia after a recent upper respiratory tract infection. Imaging showed left atlantoaxial facet anterior dislocation. He was treated conservatively with analgesics, muscle relaxants, antibiotics, and cervical collars, with clinical and radiological reduction achieved after 48 hours. Grisel Syndrome is believed to occur due to an inflammatory response spreading from head and neck infection via pharyngovertebral veins, causing irrit

1. Grisel Syndrome
Nontraumatic Atlantoaxila Rotatory Subluxation:
Grisel Syndrome. Case Report and Literature Review
Alecio C. E. S. Barcelos Gustavo C. Pateriota Arlindo Ugulino Netto

2. Introduction
• Notraumatic rotatory atlantoaxial subluxation
first describesd in 1830 by Charles bell, in
syphillis
• Defines by Grisel in 1950

3. • Grisel syndrome: atlantoaxial rotatory
subluxation, not triggered by trauma, affecting
Pt with hx of H&N infection
• Rare
• 68% < 12 years
• 90% < 21 years

4. 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

5. • 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.

6. – 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

7. 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 catary
comparing to bipolar coagulation.

8. • 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

9. 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

10. • 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

11. • 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.

12. 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

13. 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

14. • 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

15. • 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