Case Report
Copyright ©The Author(s) 2023. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Cases. May 16, 2023; 11(14): 3351-3355
Published online May 16, 2023. doi: 10.12998/wjcc.v11.i14.3351
Iatrogenic atlantoaxial rotatory subluxation after thyroidectomy in a pediatric patient: A case report
Woo-Joon Hong, Jung-Kil Lee, Jong-Hwan Hong, Moon-Soo Han, Shin-Seok Lee
Woo-Joon Hong, Jung-Kil Lee, Jong-Hwan Hong, Moon-Soo Han, Department of Neurosurgery, Chonnam National University Hospital & Medical School, Gwangju 61469, South Korea
Shin-Seok Lee, Department of Rheumatology, Department of Internal Medicine, Chonnam National University Medical School & Hospital, Gwangju 61469, South Korea
Author contributions: Author contributions: Lee JK performed the operation and evaluated the patient; Hong WJ wrote the manuscript; Lee SS and Lee JK provided writing assistance; Hong JH and Han MS evaluated and reviewed the chart.
Supported by The Chonnam National University Hospital Biomedical Research Institute, No. BCRI22023.
Informed consent statement: Informed written consent was obtained from the patient’s legal guardian for the publication of this case report and any accompanying images.
Conflict-of-interest statement: The authors declare that they have no potential or actual conflicts of interest with regard to this article.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Jung-Kil Lee, MD, PhD, Professor, Department of Neurosurgery, Chonnam National University Hospital & Medical School, 42, Jebong-ro, Dong-gu, Gwangju 61469, South Korea.
Received: February 23, 2023
Peer-review started: February 23, 2023
First decision: March 28, 2023
Revised: April 2, 2023
Accepted: April 10, 2023
Article in press: April 10, 2023
Published online: May 16, 2023

Atlantoaxial rotatory subluxation (AARS) is an uncommon disease with a greater prevalence among children than adults, and it is mostly associated with trauma. Iatrogenic spinal injury accounts for a low percentage of injuries. However, in AARS, 20%-40% of cases are associated with surgery, and 48% are caused by infection. Here, we describe our experience with a case of iatrogenic AARS after general anesthesia.


A 12-year-old girl presented with right-sided torticollis and cervical motion limit. The patient had undergone thyroidectomy 2 mo ago. Computed tomography revealed AARS with bilateral locked facets. Following the failure of repeated external reduction under general anesthesia, the patient underwent an open surgical reduction. The patient gained atlantoaxial alignment without any complications. Follow-up radiographs showed a normal appearance without instability. The cervical spine of children is more predisposed to injury due to anatomical and biomechanical differences. AARS secondary to infection and surgery is known as Grisel’s syndrome, which involves non-traumatic AARS. Several cases of AARS after surgery and other procedures with no evidence of inflammation have been reported. Our experience shows that surgery requiring hyperextension of the neck after general anesthesia should also be included as a risk factor.


Surgeons and anesthesiologists should be careful not to excessively extend the neck during pediatric surgery. Moreover, clinicians caring for pediatric patients with recent head and neck procedures must be aware of common AARS presentations.

Keywords: Atlantoaxial joint, Joint subluxation, Adolescent, Grisel’s syndrome, Case report

Core Tip: Atlantoaxial rotatory subluxation (AARS) is a rare condition with a higher prevalence in children, often associated with trauma or infection, and occasionally surgery. This case highlights iatrogenic AARS after general anesthesia and the importance of caution during surgery for AARS in pediatric patients.