title: One-step fixation of atlantoaxial rotatory subluxation: technical note and report of three cases.
abstract: OBJECTIVE
  To describe a successful one-step intraoperative reduction of atlantoaxial rotatory subluxation (AARS) using neuromuscular blockade and intraoperative traction.
  
  
  METHODS
  While the patient was undergoing continuous somatosensory evoked potential monitoring, crown halo traction was applied under general anesthesia. A muscle relaxant was administered, and an intraoperative computed tomography scan was performed using the O-arm Surgical Imaging System in the supine position verifying adequate reduction. The patient was placed in the prone position, and a repeat image was obtained verifying persistent reduction in the position that the patient would undergo dorsal fixation. Occipitocervical fixation was then performed.
  
  
  RESULTS
  This technique was performed successfully in three pediatric patients with chronic AARS. There were no complications related to the procedure.
  
  
  CONCLUSIONS
  Intraoperative traction and neuromuscular blockade achieved a one-step reduction before fixation for subacute and chronic irreducible AARS. This one-step reduction obviates preoperative traction, which is often inconvenient and not tolerated by pediatric patients. Successful reduction is also demonstrated in detail intraoperatively with three-dimensional imaging.
authors.affiliation: Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA.
authors.forename: Nader S
authors.initials: NS
authors.lastname: Dahdaleh
authors.forename: Brian J
authors.initials: BJ
authors.lastname: Dlouhy
authors.forename: Arnold H
authors.initials: AH
authors.lastname: Menezes
mesh_terms: D001268:Atlanto-Axial Joint / Q000002:abnormalities / Q000293:injuries*; D002648:Child; D005073:Evoked Potentials, Somatosensory / Q000502:physiology; D005500:Follow-Up Studies; D005592:Fracture Fixation / Q000379:methods*; D006801:Humans; D007432:Intraoperative Period; D004204:Joint Dislocations / Q000000981:diagnostic imaging / Q000601:surgery*; D008297:Male; D019547:Neck Pain / Q000209:etiology; D009460:Neurologic Examination; D019148:Neuromuscular Blockade; D019637:Orthopedic Procedures; D011182:Postoperative Care; D014057:Tomography, X-Ray Computed; D014143:Traction; D016896:Treatment Outcome