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Traumatic atlantoaxial rotatory subluxation with remote cervical spinal cord contusion in a child.

A 10‐year‐old right‐handed boy was admitted 2 days after a fall from a train following which he had loss of power in his left upper limb and was unable to move his neck. He was complaining of severe neck pain. He was found to have a fixed torticollis with his face turned to the right. The left upper limb was flaccid, areflexic and with grade 0/5 power in all muscle groups. He was able to perceive pain and touch sensation, although this was less compared with the right upper limb. A computed tomography (CT) scan of the cervical spine showed rotatory subluxation of C1 on C2 with no fracture visualized either at the cranio–vertebral junction or in the subaxial spine [Figures 1 and 2]. Magnetic resonance imaging (MRI) of the cervical spine revealed a C1‐C2 rotatory subluxation with a tear of the transverse ligament of the atlas [Figure 3]. There was a cord contusion on the left side at the C3–C4 level, remote from the site of dislocation, with no evidence of ligamentous or disc disruption at that level [Figure 4]. The patient underwent a C1 and C2 fixation by the posterior cervical approach using the Goel's technique (C1 lateral mass to C2 pedicle) after achieving an intraoperative reduction of the dislocation by using polyaxial lateral mass screws and a rod construct [Figure 5]. He was immobilized on a Philadelphia collar post‐operatively and placed on limb physiotherapy. Over the next few weeks, he regained almost normal power in the left upper limb except for residual weakness in the left deltoid and supraspinatus muscles. Multilevel involvement of the spine, as in this case, has been reported to occur in 7–22% patients in various studies focusing on pediatric spinal injuries.[1] Our case was unique in that there was a demonstrable disruption of the osseo‐ligamentous complex without neural injury in the upper cervical spine, while a spinal cord injury without any bony involvement was seen lower down.