A Rare Cause of Torticollis: Grisel Syndrome

A Rare Cause of Torticollis: Grisel Syndrome Abstract Painful torticollis in children requires specific attention. Grisel syndrome is diagnosed on suspicion in patients with recent or history of ongoing upper respiratory tract infections and in patients with restriction of movement or deformity following oto-rhino-laryngologic surgery. Pediatricians should be aware of this condition because early diagnosis and intervention are critical for prognosis in Grisel syndrome. torticollis, atlantoaxial joint, diagnosis INTRODUCTION Grisel syndrome is a non-traumatic atlantoaxial rotatory subluxation (AARS), which is seen in children with inflammatory conditions of the head and neck region. Pathogenesis depends on increased elasticity of structures crossing the atlantoaxial complex because of inflammation around the head and neck region. Diagnosis is based on clinical and radiologic findings. This syndrome has been rarely described in pediatric literature. Our aim is to present two cases with Grisel syndrome to raise attention among pediatricians. Case 1: Seven-year-old male patient was admitted to emergency department with painful wryneck. The patient was diagnosed with tonsillitis for which oral medications were given 5 days earlier in an urban hospital and was sent to our institution because of painful wryneck that started 2 days before the admission. At physical examination, the neck was deviated to the left side with restricted range of motion. He also had oropharyngeal hyperemia and left cervical lymphadenomegalia. Neurologic and systemic physical examinations were normal. Leucocyte count was 10 900/ml, hemoglobin concentration was 11.8 g/dl and platelets were found to be 389 000/ml. Sixty-eight percent neutrophils, 22% lymphocytes and 10% monocytes were found in the peripheral smear. Also, erythrocyte sedimentation rate of 62 mm/h and C-reactive protein value of 1.47 mg/dl (0–0.34) were found. Rotation of the head on radiographs (Fig. 1) and asymmetric position of odontoid process between lateral masses of atlas on computerized tomographic (CT) scans (Fig. 2) were documented after the orthopedic consultation. The clinical and radiologic findings were indicating AARS. Antibiotics and anti-inflammatory drugs were given and mento-occipital head-halter traction with 1 kg was performed in the orthopedic clinic of our institution to eliminate muscle spasm. The patient’s complaints were fully resolved and the patient gained full cervical spine range of motion after 1 week of treatment. Fig. 1. View largeDownload slide (A) Open-mouth view, (B) Anteroposterior and (C) lateral views of the upper cervical spine in Case 1. Fig. 1. View largeDownload slide (A) Open-mouth view, (B) Anteroposterior and (C) lateral views of the upper cervical spine in Case 1. Fig. 2. View largeDownload slide (A) Axial and (B) coronal CT scans of the atlantoaxial complex in Case 1. Fig. 2. View largeDownload slide (A) Axial and (B) coronal CT scans of the atlantoaxial complex in Case 1. Case 2: Seven-year-old male patient was admitted to emergency department with swelling and pain in the neck for 1-month duration. The patient had a history of hospitalization in pediatric clinic because of elevation in acute phase values and cervical lymphadenitis 1 month earlier. The patient had been discharged after intravenous antibiotherapy. The patient had restriction in range of motion and pain in his neck that lasted for >1 month. Physical examination revealed scoliotic deformity and pain with cervical rotation, which were accompanied by bilateral, multiple small lymphadenomegalia at the cervical lymphatic chain (Fig. 3). Neurological and systemic physical examinations were normal. Acute phase reactants were normal. Cervical spine radiographs (Fig. 4) and CT (Fig. 5) were performed after orthopedic consultation. AARS was diagnosed after the radiologic workup. Muscle relaxants and anti-inflammatory drugs were given and mento-occipital head-halter traction with 1 kg was applied to the patient. The patient was discharged after 1 week of treatment with a partial resolution of torticollis and loss of pain and wearing a Minerva orthesis. Torticollis was found to have resolved at the 3rd week follow-up examination. Fig. 3. View largeDownload slide Photograph taken at admission showing painful torticollis in Case 2. Fig. 3. View largeDownload slide Photograph taken at admission showing painful torticollis in Case 2. Fig. 4. View largeDownload slide (A) Anteroposterior (B) lateral and (C) open-mouth view radiographs of the upper cervical spine in Case 2. Fig. 4. View largeDownload slide (A) Anteroposterior (B) lateral and (C) open-mouth view radiographs of the upper cervical spine in Case 2. Fig. 5. View largeDownload slide (A) Axial, (B) coronal and three-dimensional reconstruction CT scans of the atlantoaxial complex in Case 2. Fig. 5. View largeDownload slide (A) Axial, (B) coronal and three-dimensional reconstruction CT scans of the atlantoaxial complex in Case 2. DISCUSSION Torticollis is characterized by tilting of the head to one side and rotation of the head toward the opposite side [1]. Torticollis may have multiple etiologies such as congenital deformities, trauma or inflammation, infections, neoplasms, drug reactions and ocular, psychiatric and nervous system conditions [2–5]. The differential diagnosis of torticollis in children is wide and extensive and should include all systems [4]. In newborns or infants with torticollis, ultrasonography is the modality of choice for the evaluation of suspected congenital muscular torticollis. In older children with torticollis, CT and magnetic resonance imaging in addition to the neurologic examination and plain radiographs can be helpful in confirming the diagnosis [5]. Spontaneous and non-traumatic rotatory subluxation of the atlantoaxial joint following peripharyngeal inflammation or oto-rhino-laryngologic surgical procedures such as tonsillectomy, adenoidectomy and mastoidectomy is called Grisel syndrome [1, 6–8]. Pathogenesis of Grisel syndrome is still not quite clear, but there are two undeniable facts: first, there is a higher tendency of involvement in pediatric population (children have more ligamentous laxity in atlantoaxial complex), and second, patients usually present with acute and painful torticollis following serious infectious or inflammatory processes [9]. It is shown that retropharyngeal veins have connections with the periodontoidal venous plexus and the suboccipital epidural sinuses. These connections may serve as hematogenous routes for the transport of peripharyngeal septic exudates to the upper cervical structures and provide an anatomical explanation for the development of Grisel syndrome [10]. Inflammation around the atlantoaxial complex may cause involuntary muscle spasm, leading to acute and painful torticollis [8]. Fielding and Hawkins’ [11] classification describes the pathological anatomy on axial CT scans (Table 1). Types I and II are benign subluxations and >90% of patients present with Type I. Types III and IV lesions are atlantoaxial dislocations and therefore are potentially catastrophic [8]. Table 1. Fielding and Hawkins classification of Grisel’s syndrome (11) Type I  No subluxation. Fixed rotation of atlas and axis. Anterior displacement <3 mm.  Type II  Unilateral, atlantoaxial subluxation of one atlantoaxial joint. The contralateral joint is pivotal.  Type III  Ventral subluxation of C1 in both joints. Anterior displacement >5 mm.  Type IV  Dorsal subluxation of C1. Combination with fractured dens axis or congenital dens aplasia is possible.  Type I  No subluxation. Fixed rotation of atlas and axis. Anterior displacement <3 mm.  Type II  Unilateral, atlantoaxial subluxation of one atlantoaxial joint. The contralateral joint is pivotal.  Type III  Ventral subluxation of C1 in both joints. Anterior displacement >5 mm.  Type IV  Dorsal subluxation of C1. Combination with fractured dens axis or congenital dens aplasia is possible.  Table 1. Fielding and Hawkins classification of Grisel’s syndrome (11) Type I  No subluxation. Fixed rotation of atlas and axis. Anterior displacement <3 mm.  Type II  Unilateral, atlantoaxial subluxation of one atlantoaxial joint. The contralateral joint is pivotal.  Type III  Ventral subluxation of C1 in both joints. Anterior displacement >5 mm.  Type IV  Dorsal subluxation of C1. Combination with fractured dens axis or congenital dens aplasia is possible.  Type I  No subluxation. Fixed rotation of atlas and axis. Anterior displacement <3 mm.  Type II  Unilateral, atlantoaxial subluxation of one atlantoaxial joint. The contralateral joint is pivotal.  Type III  Ventral subluxation of C1 in both joints. Anterior displacement >5 mm.  Type IV  Dorsal subluxation of C1. Combination with fractured dens axis or congenital dens aplasia is possible.  The most common treatment modality in acute cases include cervical collar application for comfort and rest with use of analgesics [8]. Usually spontaneous reduction of atlantoaxial joint is seen with the help of rest and resolution of the inflammation. In delayed acute cases, spontaneous reduction of atlantoaxial complex does not always happen quickly; mento-occipital traction helps in reduction of the joint. In chronic cases, gradual reduction with halo-vest or wheelchair traction and often surgery with atlantoaxial or craniocervical fusion is required [12]. Both of our cases had clinically distinguishable cock robin postures with history of upper respiratory tract infection and clinical findings showing lymphadenomegalia. We classified both patients as Fielding and Hawkins Type I AARS according to their CT scans. Mento-occipital head halter tractions were applied to both cases; the orthopedic clinic in our institution routinely uses mento-occipital traction with small weights (1–2 kg) to eliminate muscle spasm in cases with AARS [13]. Ibuprofen and Baclofen were added to the treatment scheme for suppression of inflammation. Mento-occipital tractions were terminated when muscle spasms were resolved. Grisel’s syndrome can have catastrophic outcomes, and early diagnosis and intervention help to reduce bad outcomes. General practitioners and pediatricians are the first clinicians to see the children with upper respiratory tract infections. Starting anti-inflammatory treatment and requesting orthopedic consultation immediately on suspicion will reduce the need for surgery with risk of permanent morbidities. References 1 Barcelos ACES, Patriota GC, Netto AU. Nontraumatic atlantoaxial rotatory subluxation: Grisel syndrome. Case report and literature review. Global Spine J  2014; 4: 179– 86. Google Scholar CrossRef Search ADS PubMed  2 Beyazal MS, Demirok D, Capkin E, et al.   Grisel’s syndrome. a case report. Truk J Rheumatol  2011; 26: 243– 7. Google Scholar CrossRef Search ADS   3 Reichman EF, Shah J. Grisel syndrome: an unusual and often unrecognized cause of torticollis. Pediatr Emerg Care  2015; 31: 577– 80. Google Scholar CrossRef Search ADS PubMed  4 Per H, Canpolat M, Tumturk A, et al.   Different etiologies of acquired torticollis in childhood. Childs Nerv Syst  2014; 30: 431– 40. Google Scholar CrossRef Search ADS PubMed  5 Tumturk A, Kaya Ozcora G, Kacar Bayram A, et al.   Torticollis in children: an alert symptom not to be turned away. Childs Nerv Syst  2015; 31: 1461– 70. Google Scholar CrossRef Search ADS PubMed  6 Ombregt L, Applied anatomy of the cervical spine. In: Ombregt L (ed). A System of Orthopaedic Medicine . 3rd edn. London: Churchill-Livingstone publishing, 2013, e1– 12. 7 Spennato P, Nicosia G, Rapana A, et al.   Grisel syndrome following adenoidectomy: surgical management in a case with delayed diagnosis. World Neurosurg  2015; 84: 1494.e7– e12. Google Scholar CrossRef Search ADS   8 Neal KM, Mohamed AS. Atlantoaxial rotatory subluxation in children. J Am Acad Orthop Surg  2015; 23: 382– 92. Google Scholar CrossRef Search ADS PubMed  9 Ortega-Evangelio G, Alcon JJ, Alvarez-Pitti J, et al.   Eponym: Grisel syndrome. Eur J Pediatr  2011; 170: 965– 8. Google Scholar CrossRef Search ADS PubMed  10 Parke WW, Rothman RH, Brown MD. The pharyngovertebral veins: an anatomical rationale for Grisel's syndrome. J Bone Joint Surg Am  1984; 66: 568– 74. Google Scholar CrossRef Search ADS PubMed  11 Fielding JW, Hawkins RJ. Atlanto-axial rotatory fixation. (Fixed rotatory subluxation of the atlanto-axial joint). J Bone Joint Surg Am  1977; 59: 37– 44. Google Scholar CrossRef Search ADS PubMed  12 Crossman JE, David K, Hayward R, et al.   Open reduction of pediatric atlantoaxial rotatory fixation: Long term outcome study with functional measurements. J Neurosurg (Spine 3)  2003; 100: 235– 40. Google Scholar CrossRef Search ADS   13 Ciftdemir M, Copuroglu C, Ozcan M, et al.   Non-operative treatment in children and adolescents with atlantoaxial rotatory subluxation. Balkan Med J  2012; 29: 277– 80. Google Scholar PubMed  © The Author [2017]. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Tropical Pediatrics Oxford University Press

A Rare Cause of Torticollis: Grisel Syndrome

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Abstract

Abstract Painful torticollis in children requires specific attention. Grisel syndrome is diagnosed on suspicion in patients with recent or history of ongoing upper respiratory tract infections and in patients with restriction of movement or deformity following oto-rhino-laryngologic surgery. Pediatricians should be aware of this condition because early diagnosis and intervention are critical for prognosis in Grisel syndrome. torticollis, atlantoaxial joint, diagnosis INTRODUCTION Grisel syndrome is a non-traumatic atlantoaxial rotatory subluxation (AARS), which is seen in children with inflammatory conditions of the head and neck region. Pathogenesis depends on increased elasticity of structures crossing the atlantoaxial complex because of inflammation around the head and neck region. Diagnosis is based on clinical and radiologic findings. This syndrome has been rarely described in pediatric literature. Our aim is to present two cases with Grisel syndrome to raise attention among pediatricians. Case 1: Seven-year-old male patient was admitted to emergency department with painful wryneck. The patient was diagnosed with tonsillitis for which oral medications were given 5 days earlier in an urban hospital and was sent to our institution because of painful wryneck that started 2 days before the admission. At physical examination, the neck was deviated to the left side with restricted range of motion. He also had oropharyngeal hyperemia and left cervical lymphadenomegalia. Neurologic and systemic physical examinations were normal. Leucocyte count was 10 900/ml, hemoglobin concentration was 11.8 g/dl and platelets were found to be 389 000/ml. Sixty-eight percent neutrophils, 22% lymphocytes and 10% monocytes were found in the peripheral smear. Also, erythrocyte sedimentation rate of 62 mm/h and C-reactive protein value of 1.47 mg/dl (0–0.34) were found. Rotation of the head on radiographs (Fig. 1) and asymmetric position of odontoid process between lateral masses of atlas on computerized tomographic (CT) scans (Fig. 2) were documented after the orthopedic consultation. The clinical and radiologic findings were indicating AARS. Antibiotics and anti-inflammatory drugs were given and mento-occipital head-halter traction with 1 kg was performed in the orthopedic clinic of our institution to eliminate muscle spasm. The patient’s complaints were fully resolved and the patient gained full cervical spine range of motion after 1 week of treatment. Fig. 1. View largeDownload slide (A) Open-mouth view, (B) Anteroposterior and (C) lateral views of the upper cervical spine in Case 1. Fig. 1. View largeDownload slide (A) Open-mouth view, (B) Anteroposterior and (C) lateral views of the upper cervical spine in Case 1. Fig. 2. View largeDownload slide (A) Axial and (B) coronal CT scans of the atlantoaxial complex in Case 1. Fig. 2. View largeDownload slide (A) Axial and (B) coronal CT scans of the atlantoaxial complex in Case 1. Case 2: Seven-year-old male patient was admitted to emergency department with swelling and pain in the neck for 1-month duration. The patient had a history of hospitalization in pediatric clinic because of elevation in acute phase values and cervical lymphadenitis 1 month earlier. The patient had been discharged after intravenous antibiotherapy. The patient had restriction in range of motion and pain in his neck that lasted for >1 month. Physical examination revealed scoliotic deformity and pain with cervical rotation, which were accompanied by bilateral, multiple small lymphadenomegalia at the cervical lymphatic chain (Fig. 3). Neurological and systemic physical examinations were normal. Acute phase reactants were normal. Cervical spine radiographs (Fig. 4) and CT (Fig. 5) were performed after orthopedic consultation. AARS was diagnosed after the radiologic workup. Muscle relaxants and anti-inflammatory drugs were given and mento-occipital head-halter traction with 1 kg was applied to the patient. The patient was discharged after 1 week of treatment with a partial resolution of torticollis and loss of pain and wearing a Minerva orthesis. Torticollis was found to have resolved at the 3rd week follow-up examination. Fig. 3. View largeDownload slide Photograph taken at admission showing painful torticollis in Case 2. Fig. 3. View largeDownload slide Photograph taken at admission showing painful torticollis in Case 2. Fig. 4. View largeDownload slide (A) Anteroposterior (B) lateral and (C) open-mouth view radiographs of the upper cervical spine in Case 2. Fig. 4. View largeDownload slide (A) Anteroposterior (B) lateral and (C) open-mouth view radiographs of the upper cervical spine in Case 2. Fig. 5. View largeDownload slide (A) Axial, (B) coronal and three-dimensional reconstruction CT scans of the atlantoaxial complex in Case 2. Fig. 5. View largeDownload slide (A) Axial, (B) coronal and three-dimensional reconstruction CT scans of the atlantoaxial complex in Case 2. DISCUSSION Torticollis is characterized by tilting of the head to one side and rotation of the head toward the opposite side [1]. Torticollis may have multiple etiologies such as congenital deformities, trauma or inflammation, infections, neoplasms, drug reactions and ocular, psychiatric and nervous system conditions [2–5]. The differential diagnosis of torticollis in children is wide and extensive and should include all systems [4]. In newborns or infants with torticollis, ultrasonography is the modality of choice for the evaluation of suspected congenital muscular torticollis. In older children with torticollis, CT and magnetic resonance imaging in addition to the neurologic examination and plain radiographs can be helpful in confirming the diagnosis [5]. Spontaneous and non-traumatic rotatory subluxation of the atlantoaxial joint following peripharyngeal inflammation or oto-rhino-laryngologic surgical procedures such as tonsillectomy, adenoidectomy and mastoidectomy is called Grisel syndrome [1, 6–8]. Pathogenesis of Grisel syndrome is still not quite clear, but there are two undeniable facts: first, there is a higher tendency of involvement in pediatric population (children have more ligamentous laxity in atlantoaxial complex), and second, patients usually present with acute and painful torticollis following serious infectious or inflammatory processes [9]. It is shown that retropharyngeal veins have connections with the periodontoidal venous plexus and the suboccipital epidural sinuses. These connections may serve as hematogenous routes for the transport of peripharyngeal septic exudates to the upper cervical structures and provide an anatomical explanation for the development of Grisel syndrome [10]. Inflammation around the atlantoaxial complex may cause involuntary muscle spasm, leading to acute and painful torticollis [8]. Fielding and Hawkins’ [11] classification describes the pathological anatomy on axial CT scans (Table 1). Types I and II are benign subluxations and >90% of patients present with Type I. Types III and IV lesions are atlantoaxial dislocations and therefore are potentially catastrophic [8]. Table 1. Fielding and Hawkins classification of Grisel’s syndrome (11) Type I  No subluxation. Fixed rotation of atlas and axis. Anterior displacement <3 mm.  Type II  Unilateral, atlantoaxial subluxation of one atlantoaxial joint. The contralateral joint is pivotal.  Type III  Ventral subluxation of C1 in both joints. Anterior displacement >5 mm.  Type IV  Dorsal subluxation of C1. Combination with fractured dens axis or congenital dens aplasia is possible.  Type I  No subluxation. Fixed rotation of atlas and axis. Anterior displacement <3 mm.  Type II  Unilateral, atlantoaxial subluxation of one atlantoaxial joint. The contralateral joint is pivotal.  Type III  Ventral subluxation of C1 in both joints. Anterior displacement >5 mm.  Type IV  Dorsal subluxation of C1. Combination with fractured dens axis or congenital dens aplasia is possible.  Table 1. Fielding and Hawkins classification of Grisel’s syndrome (11) Type I  No subluxation. Fixed rotation of atlas and axis. Anterior displacement <3 mm.  Type II  Unilateral, atlantoaxial subluxation of one atlantoaxial joint. The contralateral joint is pivotal.  Type III  Ventral subluxation of C1 in both joints. Anterior displacement >5 mm.  Type IV  Dorsal subluxation of C1. Combination with fractured dens axis or congenital dens aplasia is possible.  Type I  No subluxation. Fixed rotation of atlas and axis. Anterior displacement <3 mm.  Type II  Unilateral, atlantoaxial subluxation of one atlantoaxial joint. The contralateral joint is pivotal.  Type III  Ventral subluxation of C1 in both joints. Anterior displacement >5 mm.  Type IV  Dorsal subluxation of C1. Combination with fractured dens axis or congenital dens aplasia is possible.  The most common treatment modality in acute cases include cervical collar application for comfort and rest with use of analgesics [8]. Usually spontaneous reduction of atlantoaxial joint is seen with the help of rest and resolution of the inflammation. In delayed acute cases, spontaneous reduction of atlantoaxial complex does not always happen quickly; mento-occipital traction helps in reduction of the joint. In chronic cases, gradual reduction with halo-vest or wheelchair traction and often surgery with atlantoaxial or craniocervical fusion is required [12]. Both of our cases had clinically distinguishable cock robin postures with history of upper respiratory tract infection and clinical findings showing lymphadenomegalia. We classified both patients as Fielding and Hawkins Type I AARS according to their CT scans. Mento-occipital head halter tractions were applied to both cases; the orthopedic clinic in our institution routinely uses mento-occipital traction with small weights (1–2 kg) to eliminate muscle spasm in cases with AARS [13]. Ibuprofen and Baclofen were added to the treatment scheme for suppression of inflammation. Mento-occipital tractions were terminated when muscle spasms were resolved. Grisel’s syndrome can have catastrophic outcomes, and early diagnosis and intervention help to reduce bad outcomes. General practitioners and pediatricians are the first clinicians to see the children with upper respiratory tract infections. Starting anti-inflammatory treatment and requesting orthopedic consultation immediately on suspicion will reduce the need for surgery with risk of permanent morbidities. References 1 Barcelos ACES, Patriota GC, Netto AU. Nontraumatic atlantoaxial rotatory subluxation: Grisel syndrome. Case report and literature review. Global Spine J  2014; 4: 179– 86. Google Scholar CrossRef Search ADS PubMed  2 Beyazal MS, Demirok D, Capkin E, et al.   Grisel’s syndrome. a case report. Truk J Rheumatol  2011; 26: 243– 7. Google Scholar CrossRef Search ADS   3 Reichman EF, Shah J. Grisel syndrome: an unusual and often unrecognized cause of torticollis. Pediatr Emerg Care  2015; 31: 577– 80. Google Scholar CrossRef Search ADS PubMed  4 Per H, Canpolat M, Tumturk A, et al.   Different etiologies of acquired torticollis in childhood. Childs Nerv Syst  2014; 30: 431– 40. Google Scholar CrossRef Search ADS PubMed  5 Tumturk A, Kaya Ozcora G, Kacar Bayram A, et al.   Torticollis in children: an alert symptom not to be turned away. Childs Nerv Syst  2015; 31: 1461– 70. Google Scholar CrossRef Search ADS PubMed  6 Ombregt L, Applied anatomy of the cervical spine. In: Ombregt L (ed). A System of Orthopaedic Medicine . 3rd edn. London: Churchill-Livingstone publishing, 2013, e1– 12. 7 Spennato P, Nicosia G, Rapana A, et al.   Grisel syndrome following adenoidectomy: surgical management in a case with delayed diagnosis. World Neurosurg  2015; 84: 1494.e7– e12. Google Scholar CrossRef Search ADS   8 Neal KM, Mohamed AS. Atlantoaxial rotatory subluxation in children. J Am Acad Orthop Surg  2015; 23: 382– 92. Google Scholar CrossRef Search ADS PubMed  9 Ortega-Evangelio G, Alcon JJ, Alvarez-Pitti J, et al.   Eponym: Grisel syndrome. Eur J Pediatr  2011; 170: 965– 8. Google Scholar CrossRef Search ADS PubMed  10 Parke WW, Rothman RH, Brown MD. The pharyngovertebral veins: an anatomical rationale for Grisel's syndrome. J Bone Joint Surg Am  1984; 66: 568– 74. Google Scholar CrossRef Search ADS PubMed  11 Fielding JW, Hawkins RJ. Atlanto-axial rotatory fixation. (Fixed rotatory subluxation of the atlanto-axial joint). J Bone Joint Surg Am  1977; 59: 37– 44. Google Scholar CrossRef Search ADS PubMed  12 Crossman JE, David K, Hayward R, et al.   Open reduction of pediatric atlantoaxial rotatory fixation: Long term outcome study with functional measurements. J Neurosurg (Spine 3)  2003; 100: 235– 40. Google Scholar CrossRef Search ADS   13 Ciftdemir M, Copuroglu C, Ozcan M, et al.   Non-operative treatment in children and adolescents with atlantoaxial rotatory subluxation. Balkan Med J  2012; 29: 277– 80. Google Scholar PubMed  © The Author [2017]. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

Journal

Journal of Tropical PediatricsOxford University Press

Published: Jul 18, 2017

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