One-step fixation of atlantoaxial rotatory subluxation: Technical note and report of three cases

Objective: To describe a successful one-step intraoperative reduction of atlantoaxial rotatory subluxation (AARS) using neuromuscular blockade and intraoperative traction. Methods: While the patient was undergoing continuous somatosensory evoked potential monitoring, crown halo traction was applied under general anesthesia. A muscle relaxant was administered, and an intraoperative computed tomography scan was performed using the O-arm Surgical Imaging System in the supine position verifying adequate reduction. The patient was placed in the prone position, and a repeat image was obtained verifying persistent reduction in the position that the patient would undergo dorsal fixation. Occipitocervical fixation was then performed. Results: This technique was performed successfully in three pediatric patients with chronic AARS. There were no complications related to the procedure. Conclusions: Intraoperative traction and neuromuscular blockade achieved a one-step reduction before fixation for subacute and chronic irreducible AARS. This one-step reduction obviates preoperative traction, which is often inconvenient and not tolerated by pediatric patients. Successful reduction is also demonstrated in detail intraoperatively with three-dimensional imaging.