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Subluxación atlanto axoidea por traumatismo en un paciente con artritis reumatoide

Subluxación atlanto axoidea por traumatismo en un paciente con artritis reumatoide

Autor principal: Juan Pablo García García

Vol. XVIII; nº 8; 379

Atlantoaxoid subluxation due to trauma in a patient with rheumatoid arthritis

Fecha de recepción: 30/03/2023

Fecha de aceptación: 20/04/2023

Incluido en Revista Electrónica de PortalesMedicos.com Volumen XVIII. Número 8 Segunda quincena de Abril de 2023 – Página inicial: Vol. XVIII; nº 8; 379

Autor: Juan Pablo García García

Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado, Toluca México.

Declaración de buenas prácticas

EL autor de este manuscrito declara que:

Elaboró el artículo del caso clínico y no tienen conflictos de intereses
La investigación se ha realizado siguiendo las Pautas éticas internacionales para la investigación relacionada con la salud con seres humanos elaboradas por el Consejo de Organizaciones Internacionales de las Ciencias Médicas (CIOMS) en colaboración con la Organización Mundial de la Salud (OMS).
El manuscrito es original y no contiene plagio.

El manuscrito no ha sido publicado en ningún medio y no está en proceso de revisión en otra revista.

Ha obtenido el permiso necesario para las imágenes y gráficos utilizados.
Ha preservado la identidad del paciente.

RESUMEN

Introducción: La subluxación atlantoaxial o inestabilidad atlantoaxial, es un padecimiento que puede ser diagnosticado mediante estudio radiográfico o tomográfico, puede estar asociado a enfermedades como la espondilitis anquilosante, síndromes, traumatismos y enfermedades degenerativas como la artritis reumatoide, es una complicación poco frecuente en pacientes con artritis reumatoide, ya que la mayoría son por causa traumática, sin embargo no hay estudios sobre su prevalencia o incidencia.

Presentación de Caso Clínico: Femenina de 50 años de edad con artritis reumatoide que posterior a un accidente automovilístico inició con dolor cervical y limitación en la fuerza, por tomografía se diagnosticó luxación atlantoaxoidea. Se resolvió mediante cirugía cervical posterior con la colocación de tornillos y barras a C1 y a las láminas vertebrales de C2, con remoción del arco posterior del atlas.

Discusión y conclusión: Este tipo fracturas pueden ser resueltas en un hospital de segundo nivel de atención por un equipo multidisciplinario, sin necesidad de referir a un tercer nivel o centro médico nacional con la consecuente saturación de los servicios, así como la problemática para los pacientes y sus familiares al ser referidos generalmente muy lejos de sus lugares de residencia. La técnica quirúrgica que se determine debe evitar la pérdida de la función neurológica, obtener y mantener la estabilidad de la columna vertebral así como lograr una recuperación temprana del paciente.

Palabras clave: Articulación Atlantoaxoidea, Fractura por dislocación, Inestabilidad Articular, Artritis Reumatoide.

SUMMARY

Introduction: Atlantoaxial subluxation or atlantoaxial instability is a condition that can be diagnosed by radiographic or tomographic study, it can be associated with diseases such as ankylosing spondylitis, syndromes, trauma and degenerative diseases such as rheumatoid arthritis, it is a rare complication in patients with arthritis rheumatoid, since most are due to trauma, however there are no studies on its prevalence or incidence.

Clinical Case: A 50-year-old female with rheumatoid arthritis that started with neck pain and strength limitation after a car accident. Atlantoaxial dislocation was diagnosed by tomography. It was resolved by posterior cervical surgery with the placement of screws and bars at C1 and the vertebral plates at C2, with removal of the posterior arch of the atlas.

Discussion and conclusion: This type of fracture can be resolved by a second level care hospital with a multidisciplinary team without the need to refer to a third level or national medical center, thus alleviate the saturation of services, as well as problems for patients and their families when referred to a hospital far away from their places of residence.

The surgical technique must avoid the loss of neurological function, obtain, and maintain the stability of the spine as well as achieve an early recovery of the patient.

Keywords: Atlanto-Axial Joint, Dislocation Fracture, Instability, Joint, Rheumatoid Arthritis

Introduction

Atlantoaxial instability, also known as atlantoaxial subluxation, it can only be identified radiologically due to increased mobility or laxity between the body of the atlas and the odontoid process.1

The association of atlanto axoid fracture, dislocation or subluxation with some pathologies such as rheumatoid arthritis 2 must be borne in mind, it may occur in some syndromes such as Down 3 or Grisel 4, it is also associated with trauma from falls, sports accidents, traffic collisions 5 and habits that continually affect neck trauma.

For instability of the cervical spine White and Panjabi suggest diagnostic criteria based on standard radiographs 6. The presence of previously defined radiographic findings (anterior atlantodental interval> 3 mm in adults,> 5 mm in children) is a diagnosis of atlantoaxial instability or atlantoaxial subluxation.

Tomography has been the study of choice for the diagnosis of instability of the atlanto axoid joint. 7

Clinical case

A 50-year-old woman referred to a first-level care unit with a diagnosis of rheumatoid arthritis under treatment with an immuno modulator (rituximab), bilateral knee osteoarthritis, systemic arterial hypertension, and diabetes mellitus. She was assessed on April 19, 2016 by the rheumatology service of the second level of care hospital, where the patient reported that on April 2, 2016, after a car accident, she started with neck pain coupled with strength limitations 4/5 on the Daniels scale, dynamic radiographic studies of the cervical spine were carried out in which an atlantoaxial subluxation was observed, which is why it is referred to the neurosurgery department. (Figure 1)

In her initial assessment in the neurosurgery service, a patient was found with cervical pain and headache related to tension of the posterior cervical muscles; the rest of her physical examination did not show any neurological alterations to be highlighted, so a simple tomography of the cervical spine was performed with focus on the cervical junction.

The diagnosis of atlantoaxial dislocation due to separation of the anterior border of the odontoid process and the posterior border of the anterior arch of the atlas of more than 7 mm in neutral position was determined through a tomography of the cranio-cervical junction, related to rheumatoid arthritis and accident vehicular. Therefore, the treatment carried out was posterior cervical surgery with the placement of screws and bars at C1 (Atlas) and the vertebral plates of C2 (Axis) and with removal of the posterior arch of the Atlas. Figure 2 shows the tomographic reconstruction with enhancement of post-surgical material.

Pre-surgical tomographic video:

https://youtu.be/DIO225wj3IQI

Post-surgical tomographic video:

Discussion

Rheumatoid arthritis causes synovitis in the cervical spine and damages skeletal structures at any level.

Transarticular screws are biomechanically superior to cabling techniques and equivalent to fixation of lateral mass C1 to pedicle C2 (C1LM-C2P). Recently, the C1 lateral to laminar C2 mass fixation (C1LM-C2L) has been shown to have similar flexibility to the C1LM-C2P fixation in flexion, extension, lateral flexion, and axial rotation. Compare the stiffness of C1LM-C2P with the C1LM-C2L threaded rod fixture.

The C1-C2 screw and rod system provide stability and sufficient reduction of misalignment at the cranio-vertebral junction, thus preserves the mobility of the atlanto-occipital joints in the treatment of atlantoaxial dislocation. The main disadvantage is the difficulty in placing the screws.8

Data on the frequency of atlantoaxial dislocation cannot be mentioned since there are no prevalence or incidence data, only clinical case reports. 9-11

Conclusions

The association of atlanto-axoid fracture, dislocation or subluxation with risk factors such as rheumatoid arthritis, ankylosing spondylitis, Down’s or Grisel’s syndromes, trauma from falls, sports accidents or traffic collisions, (as in the case of study) should be taken into account. Presented in which there was rheumatoid arthritis and after the car accident, the symptoms began, therefore, if there is any of the aforementioned antecedents, a physical examination should be performed and supplemented with the necessary imaging studies, this will allow a diagnosis to be made on time. In the atlantoaxial joint, 3 essential movements are involved, flexion, extension and axial rotation. The surgical technique to be determined must avoid the loss of neurological function, realign the spine, obtain and maintain the stability of the spine and achieve an early recovery.

It is important to mention that it is not an exclusive procedure to be performed in a third level of care hospital or in a national medical center, since it can be carried out successfully (as in the case of study) in a second level of care hospital in the health sector, the recommendation is to work in a multidisciplinary manner with neurosurgery, traumatology and orthopedics, anesthesiology, as well as nursing services, which increases the benefit for the patient and their families, avoiding transfers (referrals) to places far from their residence, consequently  reducing the saturation of third care services and medical centers.

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References

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