Long-Term Outcomes of Prolonged Atlantoaxial Rotatory Fixation Managed Without Halo Vest Immobilization in a Child

Atlantoaxial rotatory fixation (AARF) in children usually responds to conservative treatment, including rest and cervical collar immobilization. However, some patients experience persistent or recurrent deformity and require prolonged immobilization or more intensive treatment. Long-term outcomes of prolonged AARF managed without halo vest immobilization have rarely been reported. We report the case of an eight-year-old boy who presented with acute neck pain and torticollis without an identifiable trigger. Initial treatment with a cervical collar at a local clinic failed to improve his symptoms, and he was referred to our hospital two weeks after symptom onset. He was admitted and treated with 1.5-kg Glisson traction. Although his symptoms and cervical alignment initially improved, neck pain and torticollis repeatedly recurred after attempts to discontinue traction and transition to a cervical collar. Traction was therefore resumed several times. On hospital day 35, immobilization was changed to a cervicothoracic orthosis to provide better rotational control. Progressive sitting, standing, and gait training were subsequently introduced, and the patient was discharged home on hospital day 78. The cervicothoracic orthosis was changed to a cervical collar on day 238, and the collar was discontinued on day 315. Follow-up CT performed at six months showed improvement in cervical alignment and facet morphology. At the five-year follow-up, the patient remained asymptomatic and had a full cervical range of motion. CT demonstrated slight residual facet deformity without progression, bony ankylosis, or degenerative changes. This case demonstrates a favorable long-term clinical outcome after prolonged AARF managed with traction and external orthoses without general anesthesia, manipulation, or halo vest immobilization. In carefully selected pediatric patients in whom corrected alignment can be achieved and maintained, prolonged nonoperative management may be a treatment option. However, the contributions of natural growth and the natural history of AARF cannot be excluded, and further studies are required to determine the appropriate indications and efficacy of this approach.