Primary treatment of atlantoaxial rotatory fixation in children: a multicenter, retrospective series of 125 cases

OBJECTIVE The primary treatment for atlantoaxial rotatory fixation (AARF) remains controversial. The aim of this study was to investigate the primary treatment for AARF and create an algorithm for primary treatment. METHODS The authors analyzed the data of 125 pediatric patients at four medical institutions from April 1989 to December 2018. The patients were reported to have neck pain, torticollis, and restricted neck range of motion and were diagnosed according to the Fielding classification as type I or II. As a primary treatment, 88 patients received neck collar fixation, and 28 of these patients did not show symptom relief and required Glisson traction. Thirty-seven patients were primarily treated with Glisson traction. In total, 65 patients, including neck collar treatment failure patients, underwent Glisson traction in hospitals. RESULTS The success rate of treatment was significantly higher in the Glisson traction group (97.3%) than in the neck collar fixation group (68.2%) (p = 0.0001, Wilcoxon test). In the neck collar effective group, Fielding type I was more predominant (p = 0.0002, Wilcoxon test) and the duration from onset to the first visit was shorter (p = 0.02, Wilcoxon test) than that in the neck collar ineffective group. Using multivariate logistic regression analysis with the above items, the authors generalized from the estimated formula: logit [p(success group by neck collar fixation group)vertical bar duration from onset to the first visit (x(1)), Fielding type (x(2))] = 0.4(intercept) - 0.15x(1) + 1.06x(2), where x(1) is the number of days and x(2) = 1 (for Fielding type I) or -1 (for Fielding type II). In cases for which the score is a positive value, the neck collar should be chosen. Conversely, in cases for which the score is a negative value, Glisson traction should be the first choice. CONCLUSIONS According to this formula, in patients with Fielding type I AARF, neck collar fixation should be allowed only if the duration from onset is <= 10 days. In patients with Fielding type II, because the score would be a negative value, Glisson traction should be performed as the primary treatment.