Atlantoaxial subluxation is a condition in which the anatomical position between the atlantoaxial spine and the pivot spine is imbalanced by internal and external forces and cannot return to a normal state after moving beyond the physiological limits, causing cervical pain and joint movement disorders as the main clinical manifestations. Severe cases may also cause compression of the spinal cord and/or vertebral artery, and the condition is more complicated.
I. Diagnosis based on.
1, history: acute onset, there may be no history of neck trauma, some pediatric patients may have a history of upper respiratory tract infection before the onset. 2. Symptoms: spontaneous neck pain, aggravated by neck rotation, and a sense of forward head drop; often combined with headache of varying severity. Some patients may suffer from vertigo due to the impact of vertebral artery blood flow, or even sudden collapse when the neck is rotated; a few patients with severe displacement may suffer from numbness and weakness of the upper limbs and unstable walking of the lower limbs due to the compression of the spinal cord.
3.Signs: Some patients have head and neck tilt, and physical examination reveals cervical muscle spasm and unfavorable movement, among which rotation or forward flexion function is the most prominent; cervical spine palpation can be palpated with cervical 1 and 2 articular and transverse synapses unevenness, distorted spinous processes and pressure pain, which is consistent with what is seen on X-ray. In case of spinal cord compression, there may be a characteristic of Lime, i.e. radioactive numbness or electric shock-like pain in the lower extremities of the collar and back when the head is low; in severe cases, cone signs appear in the upper and lower extremities.
4, basic examination basis: X-ray plain film is the basic technical basis for the diagnosis of the disease. The difference between the width of the odontoid and the lateral block gap on both sides of the orthopantomogram is more than 1.5mm, and more than 3mm has diagnostic value; the anterior arch of the atlantoaxial spine and the anterior gap of the odontoid spine on the lateral radiograph are in the shape of “V”, which is more than 3mm in adults and 4mm in children, and more than 5mm can diagnose the tear of the transverse atlantoaxial ligament.
5.Further examination measures: patients suspected of atlantoaxial instability, atlanto-occipital deformity, atlantoaxial fracture, high spine occupying lesion and spinal cord compression can take CT or MRI film of upper cervical spine. Patients with severe vertigo can be examined by TCD or DSA to observe the blood flow of vertebral artery.
Second, the classification of evidence.
1.Atlantoaxial joint disorder: seen in patients with cervical degenerative instability or invisible injury, usually without obvious oblique neck deformity, mild forward flexion and rotational movement disorder of the neck, without obvious signs and symptoms of C2 nerve root and spinal cord compression. x-ray orthopantomogram shows asymmetry of atlantoaxial joint space, but no obvious signs of atlantoaxial instability are seen in cervical lateral power film.
2, atlantoaxial instability: occurs after head and neck trauma, or in children after pharyngeal infection, resulting in injury or laxity of the transverse and accessory ligaments, which destabilizes the atlantoaxial spine and causes compression of the spinal cord and/or vertebral artery. In addition to the general symptoms of atlantoaxial joint injury, the prominent manifestation is the simultaneous appearance of signs and symptoms of C2 nerve root, spinal cord and vertebral artery compression such as radiating pain and numbness at the top of the occiput, numbness and weakness in the upper extremities, unstable walking in the lower extremities, vertigo and sudden collapse episodes during neck activities. x-ray examination shows significant structural instability, such as an anterior atlantoaxial gap greater than 5 mm in lateral films, or a significantly enlarged tendency during anterior flexion Atlantoaxial instability can be divided into the following two types: a. Instrumental instability: The distance from the tip of the atlas to the anterior edge of the foramen magnum is greater than 5 mm in adults and greater than 10 mm in children.
a, organic instability: including spontaneous atlantoaxial dislocation (mostly due to atlantoaxial ligament relaxation caused by inflammation in the pharynx), sequelae of traumatic atlantoaxial dislocation (inappropriate treatment or severe injury during the acute phase), congenital instability (such as skull base depression), and medically induced instability (mainly due to excessive manipulation and traction).
b. Dynamic instability: mainly due to laxity and instability of the transverse ligament, pterygoid ligament or odontoid apical ligament and surrounding joint capsule.
3.Atlantoaxial joint interlocking: This is one of the clinical causes of persistent oblique neck with impaired neck flexion and rotational motion. This disease is characterized by atlantoaxial fixation on the cardinal vertebrae, and the atlantoaxial and cardinal posterior arches move as a unit when the neck moves. X ray shows: open mouth film shows that the dentate process of the pivot is deviated or centered; the head is rotated 10-15 degrees from side to side, and the open mouth film shows that the dentate process is deviated and fixed on one side; the lateral cervical film shows that the atlantoaxial structure is normal. There are two types.
a. Simple functional interlocking: the patient often has no history of trauma, the head and neck are fixed in symmetrical position, the surrounding soft tissues have contracture, the head and neck are stiff during examination, there is great resistance to rotation, and there is some difficulty in manual correction.
b. Fixed oblique neck deformity: the head and neck are fixed in the oblique position, the head is skewed 10-20 degrees to one side, while turning to the opposite side, the head can have a little range of motion, the sternocleidomastoid muscle on the opposite side of the oblique neck is in a spastic state, the affected side of the face is flat. If the disease continues to develop, the atlantoaxial vertebrae will move forward progressively and the compensatory “gooseneck” deformity of the lower cervical vertebrae will appear.
Treatment plan:
1, identification and treatment: massage techniques are divided into three parts: relaxation techniques, rectification techniques and finishing techniques.
The relaxation techniques should be used under the relaxation of the neck with gentle stimulating techniques such as one-finger Zen pushing, rolling and thumb rubbing on the back of the neck, neck and shoulders, and the key stimulation points and areas are: Fengchi, the lower edge of the occipital bone, the cervical spine, the nodes after the transverse process, Tian Ding, the shoulder well, the medial edge of the scapula and Tian Zong. At the same time, the cervical vertebrae are gently rotated with small amplitude to adjust the small misshift of the cervical vertebrae.
The correct manipulation should be noted as follows: accurate positioning; gentle manipulation, avoiding excessive force, avoiding the pursuit of popping sound; minimizing the rotation of the head and neck in the manipulation; the doctor should pay high attention to the correct manipulation is absolutely safe and can produce miraculous effects. Sometimes can immediately relieve the patient’s pain, especially in the early stage of the disease can be more than once cured. However, it is important to realize that improper manipulation can also lead to accidents; it is safer to operate in the prone position, and it is advisable to operate in the prone position for instability-type dislocation and bilateral rotation dislocation of the atlantoaxial joint, and to operate in the sitting position for ordinary dislocation patients.
The finishing technique mainly adopts take method, point method to stimulate both sides of the Fengchi forehead, both sides of the cervical vertebrae and both sides of the shoulder well, and finally homeopathic with fingers, palms from the shoulder well to both sides of the push.
2, atlantoaxial joint disorder to sit operation is appropriate. The rehabilitation technique can be used as seated cervical spine rotation fine-tuning technique, cervical spine rotation positioning trigger method under extraction and extension and cervical spine rotation positioning method. The sign of successful correction is the significant relief of neck pain and accompanying headache and vertigo, the return of normal head and neck movements, and the disappearance of clinical signs.
3.Atlantoaxial joint instability It is appropriate to operate in the prone position. The correction technique can be used as lateral recumbent cervical cross rotation fine adjustment technique, lateral recumbent cervical anterior and posterior staggered rotation fine adjustment technique, and also can first use the recumbent rotation positioning trigger method. The sign of successful rehabilitation should not only achieve significant relief of neck pain, headache and vertigo, but more importantly, improvement of spinal cord compression symptoms and signs. For patients with organic instability, they should be fixed in a neck cast for 2 months after successful manipulation to maintain the reset state; for patients with dynamic instability, they should be stabilized in a neck brace for 2-3 weeks after successful manipulation to wait for the repair of the relaxed injured soft tissue.
4.Atlantoaxial joint interlock It is appropriate to operate in the prone position. Cervical traction, cervical hot compress, soft tissue release and other methods should be used to fully relax the contracted soft tissues before the revision, so as not to be too busy for immediate revision. The rehabilitation technique can be chosen from lateral lying cervical spine extraction and extension under the front and back staggered rotation fine-tuning technique, and can also be chosen from cervical spine extraction and extension under the rotation positioning trigger method. The sign of successful rehabilitation is the significant relief of neck pain, headache and vertigo, the obvious reduction of neck muscle tension, especially the sternocleidomastoid muscle, and the reduction or disappearance of compensatory gooseneck deformity. After the successful manual rehabilitation, the neck should be stabilized with a neck brace for 2-3 weeks to prevent the habitual oblique neck posture caused by long-term soft tissue contracture from pulling the repaired atlantoaxial joint back to the staggered position.
5, other therapies a, cervical traction mainly used for atlantoaxial instability and atlantoaxial interlocked patients, the acute stage can be used bedside cervical jaw occipital belt traction, chronic patients can be used in sitting or supine position mechanical traction.
b, head and neck supine postural rehabilitation is mainly used for atlantoaxial instability, especially atlantoaxial instability caused by upper respiratory tract infection, and some patients in the acute stage can reset themselves by supine postural rehabilitation.
c. Head and neck brace For children with atlantoaxial subluxation caused by respiratory tract infection, it is dangerous to blindly apply manipulation in the acute stage, first use neck brace support and actively treat the primary infection causing inflammation of joint capsule and synovium, most children can reset themselves, the rest can be manipulated after the soft tissue inflammation subsides, which is safer.
Fourth, the complications treatment:
1, spinal cord compression should be ruled out under the premise of contraindications to manipulation, and actively manipulate the rehabilitation, spinal cord decompression as the first choice, while using dehydration therapy and short-term hormone application to reduce soft tissue edema inside and outside the cervical spinal canal. If the atlantoaxial spine has been reset by manipulation and the spinal cord compression is still not improved, or if the manipulation is difficult, neurosurgery and other related departments should be consulted.
2, vertebral artery compression The vertebral artery compression is mainly caused by the rotational displacement of the atlantoaxial spine and the distortion of the stroke, which is usually released immediately after the correct reset.
V. Notes:
1.Dental fracture, atlantoaxial fracture, cranio-occipital deformity and other skeletal problems should be excluded in the diagnosis process.
2. Do not be rough in the correction technique, and those who have difficulty in the correction should be referred or asked to a higher-level physician in time.
3, for atlantoaxial instability and atlantoaxial interlocking type should be hospitalized, closely observe the changes of the condition.
6.Efficacy assessment 1.Cure: clinical symptoms and signs disappear, no obstacle to head and neck activities.
2.Improved: clinical symptoms improved, signs reduced, no obstacle to head and neck movement.
3.Invalid: clinical symptoms and signs are not reduced or there is no change, head and neck forward flexion and rotation still exist obstacles.