• HPI: The patient is a 41 year old man with Down syndrome that frequently bangs his head against the wall when frustrated. He presented with complaints of central neck pain. He denied radicular pain, numbness, tingling, weakness, or bowel and bladder symptoms. Participates actively in Special Olympics. 

    PMH: 
    Down syndrome 

    Family Hx: 
    Noncontributory 

    Medications: 
    None 

    Social History: 
    Patient lives in a group home. He has a long history of tobacco abuse (1/2 pack / day). 

    Neurological Exam: 
    Strength in bilateral upper and lower extremities is 5/5 deltoids, biceps, triceps, intrinsic, hip flexion, knee flexion/extension, dorsiflesion, and plantarflexion. Sensation to light touch is intact throughout. Reflexes are 1 and symmetric throughout. Toes are downgoing toes bilaterally. Hoffman and Rhomberg are negative. 

    Figure 1 & 2 (below) Both images demonstrate an abnormal atlas-dens interval of 8.5 cm. MRI of the cervical spine was not useful secondary to patient movement during scanning but did not demonstrate obvious cervical spinal cord injury. 

    Figure 3 & 4 (below) Flexion/extension plain films demonstrate an atlas-dens interval of 2 mm in extension and 11 mm in flexion indicative and C1-C2 instability.

    Figure 1. Axial noncontrast CT of the cervical spine

    Figure 2. Sagittal noncontrast CT of the cervical

    Figure 3. Lateral plain film of the cervical spine in extension

    Figure 4. Sagittal plain film of the cervical spine in flexion

    1. What treatment option would you choose given the isolated symptom of neck pain and a nonfocal neurological exam?

    2. Provided that there were no anatomic restrictions and you selected to fuse C1 and C2, what method would you use?

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

    • Would elect to fuse given amount of instability and patient's desire to participate in Special Olympics.
    • test
    • Pt supposed to have Hoffman pisitive with uphoing planters .
    • In developing counties---- C1-2 interlaminar wire and H bone graft
    • First I would remove the posterior arch of C1 after Occipital to c4 fusion using mass screws and rods
    • 8.5mm, not cm
    • C1 lateral mass screws+ C2 pedicle screw(Translamina screw) with bone graft
    • C1C2 transarticular screws should be done in combination with Dickman/Sonntag. OC fusion is an option, but would take away mobility.
    • Harms modification of Goel's C1-2 instrumentation with pedicle screws at C2 supplemented by any of the available posterior element wire-graft fusion types (Gallie, Sonntag or Brooks-Jenkins).
    • A more extensive procedure could be complicate and with a more simplified technique would be enough.
    • transarticular screws and interspinous fusion
    • Don't think pt. would tolerate collar. Not likely to modify head banging activity either. Best to fix before defecit develops.

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