Long-Term Outcomes of Atlantoaxial Rotatory Fixation in Children Without Halo Vest

Atlantoaxial rotatory fixation (AARF) in children can be managed successfully over the long term using prolonged external immobilization and traction without general anesthesia or halo vest procedures, according to a case study published regarding an eight-year-old boy. The patient achieved full recovery and stable cervical alignment five years after initial presentation, demonstrating that conservative treatment remains a viable path for selected pediatric cases.

Clinical Presentation and Initial Evaluation of Pediatric Torticollis

The patient, a Japanese boy standing 120 cm and weighing 24.1 kg, awoke with sudden neck pain, restricted cervical motion, and acute torticollis, with no preceding trauma or infection reported. Initial treatment with a cervical collar at two local orthopedic clinics failed to relieve symptoms, prompting referral to the hospital two weeks after onset. According to initial hospital evaluations, the boy exhibited marked torticollis without upper or lower extremity motor weakness, sensory disturbances, or spasticity. Plain radiographs and three-dimensional computed tomography (CT) scans confirmed rotatory subluxation with deformity of the left C2 facet, classified as Fielding type II. Measurements cited by the hospital team included a right lateral atlanto-dental interval (LADI) of 1.6 mm, a left LADI of 9.0 mm, an atlanto-dental interval (AADI) of 3.6 mm, a retropharyngeal space (RS) of 9.9 mm, and an atlantoaxial rotation angle (ARA) of 13 degrees. Brain and cervical spine MRI scans were performed to rule out intracranial or intraspinal pathologies—such as posterior fossa or brainstem tumors—which emergency department data associates with approximately 1.2 percent of pediatric torticollis presentations, according to research by Raucci et al.

Remodeling Strategy Using Traction and Cervicothoracic Orthosis

Because initial cervical collar immobilization proved insufficient, the patient was admitted for 1.5-kg Glisson traction therapy. While traction temporarily improved alignment, torticollis repeatedly recurred whenever traction was discontinued and replaced with a standard collar. Traction was resumed multiple times across the treatment timeline. On hospital day 35, the medical team transitioned the patient’s external immobilization to a cervicothoracic orthosis (Adfit UD Brace, manufactured by Advanfit Inc. in Yatsushiro, Japan) to secure better rotational control. Progressive sitting, standing, and gait training followed. The patient was discharged home on hospital day 78. He continued wearing the cervicothoracic orthosis throughout the day, removing it only for bathing and sleeping, until it was switched to a cervical collar on day 238. The collar was finally discontinued on day 315.

Five-Year Radiographic and Clinical Outcomes

Follow-up CT scans performed six months after onset showed that neutral cervical alignment was maintained and clival asymmetry had nearly resolved, despite persistent mild deformity of the left C2 facet. At that stage, the patient resumed sports activities and unrestricted school attendance. At the five-year follow-up examination, the patient measured 171 cm in height and weighed 63.0 kg. CT imaging demonstrated only slight residual facet deformity without bony ankylosis, progression, or degenerative arthritic changes. The patient reported no neck pain, maintained full and symmetric cervical range of motion with normal bilateral rotation, and showed no neurological sequelae or recurrent torticollis during daily activities.

Frequently Asked Questions

What is atlantoaxial rotatory fixation (AARF)?

AARF is a condition characterized by persistent pathological rotation of the atlas relative to the axis, typically resulting in painful torticollis, a cock-robin head posture, and restricted neck movement. It primarily affects children and adolescents.

Why was halo vest immobilization avoided in this case?

Halo vest immobilization requires invasive pin insertion. Because neutral cervical alignment was successfully achieved and maintained using non-invasive traction followed by a cervicothoracic orthosis, the patient and his family avoided general anesthesia and invasive surgical or halo procedures.

Are there alternatives to conservative orthotic management for refractory AARF?

Yes. While prolonged nonoperative management with bracing and traction works for selected patients, other approaches include closed reduction under general anesthesia combined with halo vest immobilization, or surgical stabilization when alignment cannot be sustained.