Chronic neglected irreducible atlantoaxial rotatory subluxation in adolescence

Atlantoaxial rotatory fixation (AARF) is a rare condition and delayed diagnosis. We report a case of chronic neglected atlantoaxial rotatory subluxation in adolescence child that was treated by serial skull traction followed by posterior fusing by method pioneered by Goel et al. A 15-year-old male presented with signs of high cervical myelopathy 2 years after trauma to neck childhood. There was upper cervical kyphosis, direct tenderness over C2 spinous process, atrophy of both hand muscles with weakness in grip strength. Reflexes in upper and lower extremities were exaggerated. Imaging showed Type 3 (Fielding and Hawkins) rotatory atlantoaxial dislocation (AAD). Treatment options available were 1. Staged anterior Transoral release & reduction followed by posterior fusion described by Govender and Kumar et al, 2. Posterior open reduction of joint and fusion, 3. Occipitocervical fusion with decompression. Our case was AARF presented to us with almost 2-year post injury. Considering complications associated with anterior surgery and posterior open reduction, we have opted for closed reduction by serially applying weight to skull traction under closed neurological monitoring. We have serially increased weight up to 15 kg over a period of 1 week before. We have achieved some reduction which was confirmed by traction lateral radiographs and computerized axial tomography scan. Residual subluxation corrected intra-operatively indirectly by using reduction screws in Goel et al. procedure. Finally performed for C1-C2 fusion to take care of Instability. We like to emphasis here role of closed reduction even in delayed and neglected cases.