Grisel Syndrome: Pathophysiological Evidence from Magnetic Resonance Imaging Findings
A 9-year-old male child was referred for evaluation of torticollis, and his recent medical history was significant for an episode of acute lymphadenitis on the neck 20 days ago, which was treated with intravenous antibiotics (ceftriaxone; Ceftriaxone, 2 g per day) and antiphlogistic therapy (diclofenac; Difexin, 45 mg per day) for 9 days. Otherwise, the parents reported no history of trauma or pre-existing health condition. He presented with torticollis of sudden onset 20 days after acute lymphadenitis of the neck.\nPhysical examination revealed limited cervical range of motion. His head was rotated to the right and tilted to the left. Nuchal spasm was present on the left side. No neurological impairment was observed.\nContrast CT of the neck was performed with side-to-side neck rotation, which revealed a significant rotary subluxation of C1 on C2 and an increased anterior atlantodental interval (), consistent with a Fielding type 2 rotatory subluxation. Contrast MRI of the neck revealed no neural involvement but demonstrated enhancement of the occipital condyle, C1 superior articular process, C1/C2 facet joint and atlantoaxial interval, indicating inflammation of those structures (, ). A Philadelphia neck brace was applied initially, and the patient was treated with halter traction for 14 days and antiphlogistic (morniflumate; Morniflu, 350 mg per day) therapy for 7 days. The torticollis resolved after three weeks, and the patient had complete return of cervical ranges of motion. Follow-up with dynamic CT and MRI scans taken 21 days from onset of the torticollis revealed complete resolution of the inflammation. He was discharged home with the Philadelphia neck brace and had no lasting limitation or deficits.