• This patient is an otherwise healthy 14 year old right handed white male who presents to the emergency room with a chief complaint of neck pain. This began as a “dull ache” in his mid cervical spine after football practice the night before. He had played on the offensive line and does not recall any specific injury or trauma during the practice. His neck pain persisted into the next school day, and the school nurse sent him to the ED after her evaluation. He denies any prior head or spine injury.

    On exam, he is afebrile and vital signs are normal. Cranial nerves are intact. Strength is 5/5 in all muscle groups in both upper and lower extremities. Sensation is intact to light touch and pin-prick throughout. Deep tendon reflexes are normal in upper and lower extremities bilaterally. Toes are down-going. There is mild tenderness to palpation in the mid-cervical spine.

    Cervical plain x-rays and flexion-extension films were ordered by the ER physician.

    The plain films revealed 4mm of subluxation of C1 on C2 (atlanto-dental interval of 1 to 5mm) on the flexion-extension films (Figure 4). The remainder of the C-spine was normal (Figures 1-4). A C-spine MRI was obtained which revealed no acute soft tissue injury. The transverse ligament appeared to be intact.

    Figure 1. Lateral C-Spine

    Figure 2. A-P C-Spine

    Figure 3. Open Mouth Odontoid View

    Figures 4. C-spine Extension-Flexion

    Figures 5. C-spine Extension-Flexion

    Figures 6. Sagittal MRI Views

    Figures 7. Sagittal MRI Views

    Figure 8. Axial MRI Views

    Figure 9. Axial MRI Views

    1. Is any further work-up warranted at this time?

    2. Are any further imaging studies needed?

    3. Are any other studies needed?

    4. Should this patient be offered treatment?

    5. What would be the best non-surgical treatment?

    6. What would be the best surgical treatment?

    7. When should the patient be allowed to play football again?

    8. Please add any suggestions or comments regarding this case:

    Period of cervical traction first. If reduction occurs immobilization. Consider c1-2 fusion No more football.

    Patient has had trauma to his neck which could lead to vertebral or carotid dissection. even a minimal dissectioncould lead to CVA. an MRA or CTA is indicated.

    Hello, The patient has typical "cock robin" head position. The lateral masses of the C1 are not symetrical. Atlanto-dental interval is just at the upper limit. On MRI there is medullary irritation by C2. I recommend the holo fixation for 3-4 weeks and if there is no change I prefer the C1-2 posterior wiring. The patient can play football after the fusion occured. Thank You Kudret Tureyen M.D University of Suleyman Demirel Department of Neurosurgery Isparta/Turkey

    Period of cervical traction first. If reduction occurs immobilization. Consider c1-2 fusion No more football.

    R/O grisel´s syndrome

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