International Journal of Surgery Case Reports 114 (2024) 109133

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International Journal of Surgery Case Reports

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Case report

Traumatic posterior dislocation of atlanto-axial joint with anterior arch

fracture in the patient of atlanto-occipital assimilation: A case report
Sungan Hong, Gang-Un Kim *
Department of Orthopaedic Surgery, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon, Republic of Korea

A R T I C L E I N F O A B S T R A C T

Keywords: Introduction and importance: Traumatic atlanto-axial dislocation (AAD) is relatively uncommon and can pose life-
Case report threatening risks. In this case, we describe a patient with a combination of AAD, an anterior arch fracture of the
Cervical spine dislocation atlas, and a rare congenital anomaly known as atlanto-occipital assimilation (AOA).
Atlanto-axial dislocation
Case presentation: A 70-year-old man presented with posterior neck pain and right-sided torticollis following an
Atlanto-occipital assimilation
accident that collision with a car while riding an electric scooter. Radiographic findings confirmed posterior AAD
Closed manual reduction
Neurologic deficit with anterior arch fracture of C1 in the inherent setting of AOA. The patient showed no neurologic deficit, so a
closed reduction technique using Gardner-Wells tongs was attempted in an awakened state, and successful
reduction could achieve without a neurologic deficit. After about three months of rigid brace application, head
and neck motion was allowed, and no recurrence of dislocation or cervical pain occurred during the follow-up
period of about one year.
Clinical discussion: Because the posterior AAD is usually accompanied by anterior arch fracture of atlas, the
transverse atlantal ligament remained intact. So nonoperative management after manual reduction was possible.
The presence of a C1 anterior arch fracture observed in our case can be regarded as an indicator predicting the
success of closed reduction of AAD.
Conclusion: Our case highlighted the successful nonoperative management of traumatic posterior AAD with an
accompanying anterior arch fracture of the atlas in a peculiar inherent combination of AOA through the closed
reduction technique and rigid cervical brace application.

1. Introduction traumatic condition based on congenital anomaly was successfully

Atlantoaxial dislocation (AAD) is a condition that causes a loss of
stability between the atlas and the axis [1,2]. Depending on the etiology
of AAD, it can be broadly categorized into traumatic, congenital, and
inflammatory causes [2–5]. Among them, traumatic AAD is a relatively
uncommon condition, often observed in association with life-
threatening circumstances [6–8]. Posterior AAD typically arises from a
traumatic mechanism involving hyperextension of the head and neck
and may be accompanied by an anterior arch fracture of the atlas [7].
In this case, we present a unique scenario where AAD, coupled with
an anterior arch fracture of the atlas, occurred in conjunction with a rare
congenital abnormality known as atlanto-occipital assimilation (AOA)
[9]. AOA can be defined as a state in which any part of the atlas is
completely or partially fused with the occiput of the skull [1]. A rare
treated through non-surgical techniques using manual reduction and
rigid brace application.
In the case of traumatic AAD, treatment strategies have not been
established because reported treatment cases are sporadic. Moreover,
when combined with a very rare congenital anomaly such as AOA, there
is no choice but to establish a treatment strategy tailored to each pa­
tient's condition. Through this case report, we attempt to provide a
comprehensive description of the clinical presentation, radiological
findings, treatment approach, and long-term results of posterior AAD
with anterior arch in the setting of AOA and to suggest conditions for
successful non-surgical treatment of AAD. The work has been reported in
line with the SCARE 2020 criteria [10].

Abbreviations: AAD, atlanto-axial dislocation; AOA, atlanto-occipital assimilation; CT, computed tomography; TAL, transverse atlantal ligament.
* Corresponding author at: Department of Orthopaedic Surgery, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 56 Dongsu-ro,
Bupyeong-gu, Incheon 21431, Republic of Korea.
E-mail address: yume14os@gmail.com (G.-U. Kim).

https://doi.org/10.1016/j.ijscr.2023.109133
Received 16 October 2023; Received in revised form 24 November 2023; Accepted 2 December 2023
Available online 13 December 2023
2210-2612/© 2023 The Authors. Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
S. Hong and G.-U. Kim
2. Case description
A 70-year-old man visited our clinic with posterior neck pain, right-
sided torticollis, and an inability to rotate his head. About 8 h before
visiting our clinic, the patient was involved in a collision with a car while
riding an electric scooter, during which he struck his forehead on the
ground, resulting in hyperextension of his neck. Initial neurological
examination just after arrival at the emergency department revealed no
motor deficits or sensory abnormalities in either the upper or lower
extremities. The patient's medical history included a stereotactic brain
surgery that was deep brain stimulation approximately three years ago
for the treatment of his essential tremor.
The radiographic imaging of the cervical spine taken at the emer­
gency department it revealed several notable findings, including right-
sided torticollis in the anteroposterior image and posterior displace­
ment of the C1 facet of the atlantoaxial joint in the lateral image, with its
position located superiorly to the C2 pars (Fig. 1a, b). The open-mouth
view showed a right-sided translation of the C1 lateral mass, along
with an indistinct visualization of the odontoid process of C2 (Fig. 1c).
Subsequent computed tomography (CT) imaging revealed incarceration
of the posterior margin of the C1 lateral mass with impingement of C2
pars (Fig. 2a, b). CT imaging also indicated complete bone union at the
atlanto-occipital joint and confirmed underlying atlanto-occipital
assimilation, as the C1 posterior arch was fused to the skull base
(Fig. 2a, b). Furthermore, it demonstrated an anterior arch fracture of C1
Fig. 1. Initial cervical spine radiograph showed right-sided torticollis (a) and posterior displacement of the C1 facet of the atlantoaxial joint (b, white arrowhead).
The open-mouth view showed a right-sided translation of the C1 lateral mass, and indistinct visualization of the odontoid process (c, white arrow).
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International Journal of Surgery Case Reports 114 (2024) 109133
(Fig. 2c), along with right-sided posterolateral displacement of the
lateral mass of C1 (Fig. 2d). CT Angiography revealed the preserved
continuity of the vertebral artery without evidence of vascular injury
(Fig. 2e).
The patient presented the incarcerated dislocation of the atlanto-
axial joint in the environment of the atlanto-occipital assimilation
without any neurological deficits or vascular damage. Given the clinical
presentation and radiographic findings, our treatment approach aimed
to achieve reduction and realignment of the atlantoaxial joint while
minimizing the potential risks associated with iatrogenic spinal cord
damage or cerebral ischemia resulting from arterial insufficiency during
the reduction process. We opted for a nonoperative approach to mini­
mize the potential risks associated with surgery, especially in a patient
with a history of deep brain stimulation. In the operating room with the
awakened patient, we initiated the reduction process using the Gardner-
Wells tongs under fluoroscopic guidance. Under continuous fluoroscopic
imaging guidance, gentle traction was attempted by pulling the handle
of Gardner-Wells tongs toward the cranial direction and a slight poste­
rior vector. The procedure was conducted with utmost care to prevent
any further injury to the spinal cord or vertebral arteries. Subsequently,
a clicking feeling was transmitted to the hand holding the tongs. At the
same time, fluoroscopy confirmed that the atlanto-axial joint had been
reduced to its normal position. Cervical spine radiograph taken imme­
diately after reduction showed that the surfaces of the C1–2 facet joint
remained in good contact, but the left-side lateral mass of C1 was a
S. Hong and G.-U. Kim International Journal of Surgery Case Reports 114 (2024) 109133

Fig. 2. Computed tomography revealed incarceration of the posterior margin of the C1 lateral mass with impingement of C2 pars (white arrowhead) with atlanto-
occipital assimilation (white asterisk) (a–b). Also, anterior arch fracture of C1 (black asterisk, c) and right-sided posterolateral displacement of both C1 lateral masses
were noted (white arrow, d). CT Angiography confirmed no vascular injury around the injured cervical spine.

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S. Hong and G.-U. Kim
slightly right-side translated feature (Fig. 3). No changes were observed
in the patient's neurologic status before and after reduction. Neverthe­
less, in magnetic resonance imaging taken after reduction, the spinal
cord at the C2 level showed focal high signal intensity C2 level (Fig. 4a),
with no evidence of transverse atlantal ligament (TAL) injury (Fig. 4b).
Following the successful reduction, we employed a 3-month appli­
cation of a rigid Miami cervical brace for immobilization and preventing
neck extension and accompanying posterior translation of the head. The
posterior part of the Miami brace, which has a broad and wide shape,
had the effect of pushing the occiput of the skull forward, which served
as an effective external device to prevent the reduced atlas from being
translated and dislocated back. Also, the brace allowed minimal neck
motion, ensuring the reduction remained stable during the initial heal­
ing period. In addition, we provided additional patient education while
wearing the brace, such as not extending the neck beyond looking
straight ahead and moving the torso instead of turning the head from
side to side. After discharge, regular follow-ups were conducted at
postreduction 1, 3, 6 months and 1 year. Radiographic assessments used
cervical plain radiograph to monitor the reduction and alignment sta­
bility, and serial radiography consistently demonstrated stable reduc­
tion of atlanto-axial joint. Cervical spine CT taken 3 months after
reduction showed that the C1–2 facet joint was maintained as a stable
construct, but the fracture gap at the C1 anterior arch remained (Fig. 5a,
b). The Miami brace was no longer worn three months after dislocation
reduction, and all head and neck motion was allowed to the extent
possible. Even without wearing a brace, symptoms such as recurrence of
dislocation or cervical pain did not occur during the follow-up period.
Also, a flexion-extension lateral radiograph of the cervical spine taken at
the post-reduction one year showed no evidence of atlanto-axial insta­
bility such as an increase of atlanto-dental interval (Fig. 5c, d).
Fig. 3. Cervical spine radiograph taken immediately after reduction.
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International Journal of Surgery Case Reports 114 (2024) 109133
3. Discussion
Atlanto-axial dislocation combined with fracture of the anterior arch
of the atlas is a rare and complex condition, mainly when it occurs in the
concomitant atlanto-occipital assimilation. This case report presents a
unique instance of traumatic posterior AAD with an accompanying
anterior arch fracture of the atlas in the environment of AOA that was
successfully treated by the closed reduction technique and rigid brace
application without surgical intervention.
Because approximately 70 % of AADs are anterior dislocations,
atlantodental distance (ADI) measurements are often used in the diag­
nosis and treatment planning of AAD [11]. The ADI is a small slitlike
space between the posterior aspect of the anterior atlas ring and the
anterior aspect of the odontoid process, and the measurement of ADI is
from a line projected superiorly along the anterior border to the axis
body to the anterior arch of the atlas [2]. However, in posterior AAD,
such as our patient's case, the lateral mass of the atlas is displaced
posteriorly, and the anterior arch remains alone in front of the dens due
to fracture. Therefore, the measurement of ADI either shows a negative
value or does not accurately reflect the status of the patient's dislocation.
Ghailane et al. mentioned the meaning of negative ADI as an indicator
that the dens of C2 migrate anteriorly and not posteriorly against the
spinal cord [6].
A previous report on AAD accompanied by AOA included a case
reported by Gnanadev et al. [12]. However, unlike this case, it was an
anterior AAD, and the patient arrived at the hospital without con­
sciousness or spontaneous breathing. Therefore, there was no evaluation
or treatment other than the initial lateral cervical spine radiograph. This
case was a case of posterior AAD accompanying C1 anterior arch frac­
ture in the peculiar inherent setting of AOA. The patient's vital signs
were normal, and there was no neurologic deficit or vascular compro­
mise. Therefore, a more careful reduction strategy and thoughtful
S. Hong and G.-U. Kim
Fig. 4. Post-reduction magnetic resonance imaging showed that the spinal cord at the C2 level showed focal high signal intensity C2 level (a), with no evidence of
transverse atlantal ligament (TAL) injury (b).
postreduction management plan were required.
Ghailane et al. [6] reported successful C1 anterior arch fracture
treatment accompanying posterior AAD using closed reduction and rigid
brace application. Unlike our case, in the report by Ghailane et al.,
congenital anomalies such as AOA were not accompanied, and the de­
gree of posterior translation of C1 observed on CT was limited to the
posterior margin of the C2 facet. In our case, the lateral mass of C1
completely deviated from the C2 facet joint. It showed an incarcerated
feature at the superior margin of the pars, so we had no choice but to
think more deeply about concerns such as reduction strategy, post­
reduction management, and the development of recurrent dislocation or
instability. Nevertheless, it was agreed that the hypothesis proposed in
the report by Ghailane et al. that posterior AAD was accompanied by
anterior arch fracture of atlas indicates that the TAL is intact [6].
Therefore, a maintenance plan was set with rigid cervical brace appli­
cation after successful manual reduction. In our case, although the
radiographic union of the C1 anterior arch was not confirmed after
wearing a rigid brace for three months, no recurrence of AAD or
occurrence of atlanto-axial instability was observed during the 1-year
follow-up period.
C1 anterior arch fracture accompanying posterior AAD can be
considered an indirect radiographic sign that tentatively indicates an
intact TAL. Also, we confirmed through MRI taken after reduction that
the TAL was intact without disruption. For that reason, even though the
displaced anterior arch of the atlas still exists after reduction, the patient
in our case can be classified as type II according to Wang's AAD classi­
fication, in which successful reduction is possible through skeletal
traction [13]. Therefore, if the anatomical construct can be restored
through manual reduction, the external immobilization procedure using
a brace will likely be successful. Jiang et al. [14] reported pure posterior
AAD without anterior arch fracture. In this case, reduction through the
closed reduction technique failed, and open reduction through partial
odontoidectomy was required. Conversely, the presence of a C1 anterior
arch fracture observed in our case can be regarded as an indicator pre­
dicting the success of closed reduction of AAD.
In our case, it is assumed that AOA acted further to concentrate
mechanical posterior force on the atlanto-axial joint, resulting in a more
severe form of AAD compared to previously reported cases. On the other
hand, after reduction, the AOA may have provided an environment in
which the external fixation effect could be concentrated on the atlanto-
axial joint due to the inherent stability of the atlanto-occipital joint.
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International Journal of Surgery Case Reports 114 (2024) 109133
4. Conclusion
In conclusion, this case highlights the successful nonoperative
management of traumatic atlanto-axial dislocation in a patient with
atlanto-occipital assimilation and an accompanying anterior arch frac­
ture of the atlas through the closed reduction technique and rigid cer­
vical brace application. Throughout the entire decision-making process,
including initial evaluation, reduction maneuver, postreduction man­
agement that resulted in successful outcome, we would use this report as
an appropriate example of handling unusual emergencies accompanied
by scarce patient environments.
Consent
Written informed consent was obtained from the patient for publi­
cation and any accompanying images. A copy of the written consent is
available for review by the Editor-in-Chief of this journal on request.
Ethical approval
This paper is a case report using already prepared medical records
and images, and therefore ethics approval is not required.
Funding
None.
CRediT authorship contribution statement
Sungan Hong: Writing the paper, preparing figures.
Gang-Un Kim: Study concept and design, data collection, data
interpretation, writing the paper.
Guarantor
Gang-Un Kim: Incheon St. Mary's Hospital, Republic of Korea.
Research registration number
Not applicable.
S. Hong and G.-U. Kim International Journal of Surgery Case Reports 114 (2024) 109133

Fig. 5. Cervical spine CT taken three months after reduction showed that the C1–2 facet joint was maintained as a stable construct (a), although the fracture gap at
the C1 anterior arch remained (b). Flexion-extension lateral radiograph of the cervical spine taken at the post-reduction one year showed no evidence of atlanto-axial
instability (c, d).

Declaration of competing interest Acknowledgements

No funds were received in support of this work. No benefits in any None.

form have been or will be received from a commercial party related
directly or indirectly to the subject of this manuscript.

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S. Hong and G.-U. Kim International Journal of Surgery Case Reports 114 (2024) 109133

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