Mini-lecture for Grisel's syndrome. for the residents of PMR in Korea

1. A pain in the neck: Grisel’s syndrome
서울특별시 서울의료원
재활의학과
김 종 규

2. A pain in the neck: Grisel’s syndrome
2022. 3. 7. Stilwell, P. A., Fine, D., Roberts, J. & Goh, L. A pain in the neck: Grisel’s syndrome. Arch Dis Child 104, 610 (2019)
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3. • 7-year-old girl with severe neck stiff
ness and trismus on treatment for a
presumed throat infection
• Fixed torticollis with restricted neck
movements in all directions
• Erythematous tonsils and cervical ly
mphadenopathy
• Group A strep was cultured
• Diabetes mellitus, coincidentally
• CT neck with contrast
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2022. 3. 7.

4. 4
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5. • Initial management
• Soft neck collar
• Analgesia
• Diazepam
àUnsuccessful
• Manipulation under anesthesia
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2022. 3. 7.

6. Grisel’s syndrome
• Non-traumatic subluxation of atlant
o-axial joint (C1/C2)
• Caused by inflammation of adjacent
tissue
• Relaxed transverse ligament of A-A
joint
• Progressive throat and neck pain
• And/or neck stiffness
• Neck rotation LOM
• Unusual cause of acute torticollis
• Rare complication of adenoidectom
y and/or tonsillectomy
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2022. 3. 7.

7. Grisel’s syndrome - Diagnosis
• Imaging
• X-ray / CT / MRI
• Fielding & Hawkins classification of
C1-C2 rotatory subluxation
• Type I: rotatory fixation without anterior
displacement of atlas (≤ 3 mm)
• Type II: rotatory fixation with anterior di
splacement of atlas of 3-5 mm.
• Type III: rotatory fixation with anterior di
splacement of atlas of > 5 mm.
• Type IV: rotatory fixation with posterior
displacement of atlas.
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2022. 3. 7. Bocciolini C, Dall'Olio D, Cunsolo E, Cavazzuti PP, Laudadio P. Grisel's syndrome: a rare complication following adenoidectomy. Acta Otorhinolaryngol Ital. 2005;25(4):245-249.

8. Plane X-ray
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2022. 3. 7.

9. 9
2022. 3. 7. https://radiopaedia.org/cases/atlantoaxial-subluxation-1?lang=us

10. CT
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11. 11
2022. 3. 7. https://radiopaedia.org/cases/atlanto-axial-subluxationdislocation?lang=us

12. Dynamic CT
2022. 3. 7. Park, S.-H., Park, S.-H. & Lee, S.-H. Grisel Syndrome: Pathophysiological Evidence from Magnetic Resonance Imaging Findings. Ann Rehabilitation Medicine 37, 713–716 (2013)
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13. The initial T2-weighted magnetic
resonance imaging (MRI) study s
hows enhancement of atlantoden
tal interval (A) and superior articu
lar facet of axis (B). Repeated M
RI, 16 days later, shows disappe
arance of signal change in atlant
o-dental joint (C) and superior fa
cet articulation of axis (D).
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2022. 3. 7. Park, S.-H., Park, S.-H. & Lee, S.-H. Grisel Syndrome: Pathophysiological Evidence from Magnetic Resonance Imaging Findings. Ann Rehabilitation Medicine 37, 713–716 (2013)

14. 2022. 3. 7. Park, S.-H., Park, S.-H. & Lee, S.-H. Grisel Syndrome: Pathophysiological Evidence from Magnetic Resonance Imaging Findings. Ann Rehabilitation Medicine 37, 713–716 (2013)
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15. Treatment
• Protection
• Neck collar
• No excessive manipulation
• Early detection
• Adequate antibiotics
• Anti-inflammation treatment
• Halter traction (Cervical traction)
• Delayed treatment may lead
• Persistent torticollis
• Delayed external fixation
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2022. 3. 7.

16. 2022. 3. 7. Park, H.-J., Kwon, K., Kim, W.-K., Shim, Y.-J. & Kwon, S. Non-traumatic Atlanto-axial Rotatory Subluxation - A Case Report -. J Korean Soc Spine Surg 19, 59–63 (2011)
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17. 2022. 3. 7. Park, H.-J., Kwon, K., Kim, W.-K., Shim, Y.-J. & Kwon, S. Non-traumatic Atlanto-axial Rotatory Subluxation - A Case Report -. J Korean Soc Spine Surg 19, 59–63 (2011)
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18. Manipulation?
2022. 3. 7. Hill, C. S., Borg, A., Tahir, M. Z. & Thompson, D. N. P. Atlantoaxial rotatory fixation in childhood: a staged management strategy incorporating manipulation under anaesthesia.
Child’s Nerv Syst 37, 167–175 (2021).
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19. • General anesthesia
• Fluoroscopic guidance
• IOP monitoring
• Gentle traction
• Followed by rotation, counterwise
• Orthosis
• Miami J
• HBO body orthosis
• Surgical fixation for failed patients
• C1-2 lateral mass screw fixation
• Modified Gallie procedures with sublam
inar cables
• C-C2 fixation with C1 decompression
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2022. 3. 7. Hill, C. S., Borg, A., Tahir, M. Z. & Thompson, D. N. P. Atlantoaxial rotatory fixation in childhood: a staged management strategy incorporating manipulation under
anaesthesia. Child’s Nerv Syst 37, 167–175 (2021).

20. Prognosis
2022. 3. 7. Spinnato, P. et al. Atlantoaxial rotatory subluxation/fixation and Grisel’s syndrome in children: clinical and radiological prognostic factors. Eur J Pediatr 180, 441–447 (2021)
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21. Traumatic AARF
• AARF: atlanto-axial rotatory fixation
2022. 3. 7.
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22. 감사합니다.