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Abstract: The patient in this case presented with neck pain six months ago, accompanied by pain that increased with activity and decreased at rest, etc. At first, the patient did not pay attention to and treat the condition. Until recently, the pain symptoms had seriously affected the patient’s daily life, so the patient was persuaded by his family to come to our hospital for consultation, and through relevant examinations, the patient was diagnosed with atlantoaxial instability. The patient was then given symptomatic surgery, and after six months of outpatient follow-up, the patient has now basically returned to normal life.
Basic information】Male, 45 years old
Disease Type】Atlantoaxial instability
Hospital】The First Affiliated Hospital of Zhengzhou University
Time of consultation】December 2021
【Treatment plan】Surgical treatment (posterior approach atlantoaxial dislocation reset, occipito-cervical fusion, internal fixation and extraction of the iliac bone, cranial traction)
Treatment period】2 weeks of inpatient treatment and 6 months of outpatient follow-up
Treatment effect】The patient has returned to normal life
I. Initial consultation
The patient developed neck pain without any cause six months ago. The specific pain was dull and radiating to the upper limbs, aggravated by rotation of the head, and reduced after rest. The long-term dull pain caused the patient to lose his appetite and even to suffer from poor sleep quality and depression, which seriously affected his daily life and work quality.
After the patient was admitted to the hospital, he was given the relevant examinations and was examined. The patient’s current condition was clear and in good spirits. The final results of the cervical spine CT examination suggested atlantoaxial instability, congenital circumoccipital fusion deformity, and skull base depression.
II. Treatment history
Combining the patient’s symptoms and examination, it was diagnosed that the patient had congenital circumoccipital fusion, skull base depression and atlantoaxial instability. After completing other preoperative tests, including routine blood, urine and liver and kidney functions, and excluding contraindications to surgery, the patient underwent a posterior approach to atlantoaxial dislocation, occipito-cervical fusion, internal fixation, iliac extraction and cranial traction. After the operation, the patient was instructed to wear a cervical brace for 3-5 weeks after the operation, and to keep regular dressing changes of the wound.
III. Treatment results
Two weeks after the patient underwent posterior approach atlantoaxial dislocation, occipito-cervical fusion, internal fixation, iliac extraction, and cranial traction, the imaging was reviewed again, and the results indicated that the internal fixation was in good position. Immediately after the operation, the patient’s neck pain and upper limb numbness were greatly improved, and there were no signs of infection in the surgical incision, and the patient had no other discomfort, so the patient was discharged from the hospital to recuperate. After the patient went home to recuperate for 2 months, he came back for a follow-up visit and complained that the symptoms such as weakness of the lower limbs and the feeling of stepping on cotton had basically all been relieved. The patient was followed up for six months afterwards and was informed that the patient had returned to normal life.
IV. Notes
I was very pleased to see the patient’s symptoms gradually reduced, but for the sake of the patient’s future health, I still need to remind the patient to pay attention to some matters in the treatment process.
1.I instructed the patient to wear a neck brace for 3 months after the operation, and to pay attention to less head-down work in general, as well as to avoid keeping a single movement of the neck for a long time, and not to use a pillow too high for sleeping, so as not to aggravate the disease.
2. Pay attention to the warmth of the neck and avoid getting cold, especially in autumn and winter.
3, diet should pay attention to strengthen nutrition, reasonable diet, eat more fresh vegetables and fruits, avoid spicy and stimulating food, eat more high-protein food, such as dairy products, soy products, fish, etc.
V. Personal insight
The common clinical symptoms of patients with atlantoaxial instability include neck pain, headache, head swelling, restricted movement, dizziness, blurred vision, etc., which may seriously affect the patient’s life, as well as the quality of work, similar to the case in which the patient presented with symptoms for six months before seeking medical attention is not desirable.
Atlantoaxial instability may put the high cervical medulla at risk for a long time, which may not only develop into high cervical medulla compression, but also acute spinal cord injury under external force, thus threatening the patient’s life. Therefore, for the patient’s case in this case, the stability of the upper cervical spine needs to be maintained through relevant surgical treatment as soon as possible.