title: Grisel Syndrome Following Adenoidectomy: Surgical Management in a Case with Delayed Diagnosis.
abstract: BACKGROUND
  Grisel syndrome is a nontraumatic rotatory subluxation of the atlantoaxial joint, following nasopharyngeal inflammation or ear, nose, and throat (ENT) procedures. The syndrome should be suspected in cases of persistent neck pain and stiffness, especially after ENT surgical procedures. The primary treatment of early detected Grisel syndrome is conservative. If conservative treatment fails to achieve a stable reduction or it is followed by neurologic symptoms, arthrodesis of the first and second cervical vertebrae is indicated. We report the case of a 9-year-old boy who developed Grisel syndrome after adenoidectomy and was treated with C1-C3 internal fixation and fusion.
  
  
  METHODS
  A 9-year-old boy was referred to our hospital with a 3-month history of painful torticollis, which appeared 4 days after adenoidectomy. The patient underwent a neuroimaging study that documented the presence of atlantoaxial rotatory subluxation. The patient underwent C1-C3 internal fixation and fusion, using lateral masses and laminar and pars interarticularis screws. On the third postoperative day he was mobilized with a rigid collar. Postoperative computed tomography scans showed the resolution of rotational deformity and a solid fusion.
  
  
  CONCLUSIONS
  Early treatment of Grisel syndrome is of utmost importance to avoid neurologic complications and surgical intervention. In a patient with torticollis following ENT procedures, Grisel syndrome should be always suspected. In case of failure of conservative treatment or in case of delayed diagnosis, rigid C1-C2 or C1-C2-C3 fixation is a straightforward and valid surgical technique, even in children, because it provides immediate spinal stability in all planes at the atlantoaxial complex, avoiding the need for prolonged rigid external bracing.
authors.affiliation: Neurosurgery Department, AORN Santobono-Pausilipon-Annunziata Children's Hospital, Naples, Italy. Electronic address: pierospen@gmail.com.
authors.forename: Pietro
authors.initials: P
authors.lastname: Spennato
authors.affiliation: Neurosurgery Department, AORN Santobono-Pausilipon-Annunziata Children's Hospital, Naples, Italy.
authors.forename: Giancarlo
authors.initials: G
authors.lastname: Nicosia
authors.affiliation: Neurosurgery Unit, AORN Sant'Anna e San Sebastiano Hospital, Caserta, Italy.
authors.forename: Armando
authors.initials: A
authors.lastname: Rapanà
authors.affiliation: Neuroradiology Department, AORN Santobono-Pausilipon-Annunziata Children's Hospital, Naples, Italy.
authors.forename: Domenico
authors.initials: D
authors.lastname: Cicala
authors.affiliation: Radiology Department, AORN Santobono-Pausilipon-Annunziata Children's Hospital, Naples, Italy.
authors.forename: Tiziana
authors.initials: T
authors.lastname: Donnianni
authors.affiliation: Ear, Nose, and Throat Department, AORN Santobono-Pausilipon-Annunziata Children's Hospital, Naples, Italy.
authors.forename: Silvana
authors.initials: S
authors.lastname: Scala
authors.affiliation: Neurosurgery Department, AORN Santobono-Pausilipon-Annunziata Children's Hospital, Naples, Italy.
authors.forename: Ferdinando
authors.initials: F
authors.lastname: Aliberti
authors.affiliation: Neurosurgery Department, AORN Santobono-Pausilipon-Annunziata Children's Hospital, Naples, Italy.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Cinalli
mesh_terms: D000233:Adenoidectomy / Q000009:adverse effects*; D001174:Arthrodesis; D001268:Atlanto-Axial Joint / Q000293:injuries / Q000601:surgery; D002574:Cervical Vertebrae / Q000601:surgery; D002648:Child; D057210:Delayed Diagnosis; D006801:Humans; D016268:Internal Fixators; D004204:Joint Dislocations / Q000601:surgery*; D008297:Male; D019547:Neck Pain / Q000601:surgery; D059906:Neuroimaging; D011183:Postoperative Complications / Q000175:diagnosis* / Q000601:surgery*; D013123:Spinal Fusion; D013577:Syndrome; D014103:Torticollis / Q000175:diagnosis / Q000209:etiology* / Q000601:surgery*
keywords: Atlantoaxial fixation; Atlantoaxial instability; Atlantoaxial rotatory subluxation; Ear, nose, and throat complication