{"id":71365,"date":"2023-04-26T09:59:12","date_gmt":"2023-04-26T07:59:12","guid":{"rendered":"https:\/\/www.revista-portalesmedicos.com\/revista-medica\/?p=71365"},"modified":"2024-02-28T10:14:29","modified_gmt":"2024-02-28T09:14:29","slug":"subluxacion-atlanto-axoidea-por-traumatismo-en-un-paciente-con-artritis-reumatoide","status":"publish","type":"post","link":"https:\/\/www.revista-portalesmedicos.com\/revista-medica\/subluxacion-atlanto-axoidea-por-traumatismo-en-un-paciente-con-artritis-reumatoide\/","title":{"rendered":"Subluxaci\u00f3n atlanto axoidea por traumatismo en un paciente con artritis reumatoide"},"content":{"rendered":"<p style=\"text-align: justify;\"><strong>Subluxaci\u00f3n atlanto axoidea por traumatismo en un paciente con artritis reumatoide<\/strong><\/p>\n<p style=\"text-align: justify;\">Autor principal: Juan Pablo Garc\u00eda Garc\u00eda<\/p>\n<p style=\"text-align: justify;\">Vol. XVIII; n\u00ba 8; 379<!--more--><\/p>\n<p style=\"text-align: justify;\"><strong>Atlantoaxoid subluxation due to trauma in a patient with rheumatoid arthritis<\/strong><\/p>\n<p style=\"text-align: justify;\">Fecha de recepci\u00f3n: 30\/03\/2023<\/p>\n<p style=\"text-align: justify;\">Fecha de aceptaci\u00f3n: 20\/04\/2023<\/p>\n<p style=\"text-align: justify;\">Incluido en Revista Electr\u00f3nica de PortalesMedicos.com Volumen XVIII. N\u00famero 8 Segunda quincena de Abril de 2023 \u2013 P\u00e1gina inicial: Vol. XVIII; n\u00ba 8; 379<\/p>\n<p style=\"text-align: justify;\"><strong>Autor: <\/strong>Juan Pablo Garc\u00eda Garc\u00eda<\/p>\n<p style=\"text-align: justify;\">Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado, Toluca M\u00e9xico.<\/p>\n<p style=\"text-align: justify;\"><strong>Declaraci\u00f3n de buenas pr\u00e1cticas<\/strong><\/p>\n<p style=\"text-align: justify;\">EL autor de este manuscrito declara que:<\/p>\n<p style=\"text-align: justify;\">Elabor\u00f3 el art\u00edculo del caso cl\u00ednico y no tienen conflictos de intereses<br \/>\nLa investigaci\u00f3n se ha realizado siguiendo las Pautas \u00e9ticas internacionales para la investigaci\u00f3n relacionada con la salud con seres humanos elaboradas por el Consejo de Organizaciones Internacionales de las Ciencias M\u00e9dicas (CIOMS) en colaboraci\u00f3n con la Organizaci\u00f3n Mundial de la Salud (OMS).<br \/>\nEl manuscrito es original y no contiene plagio.<\/p>\n<p style=\"text-align: justify;\">El manuscrito no ha sido publicado en ning\u00fan medio y no est\u00e1 en proceso de revisi\u00f3n en otra revista.<\/p>\n<p style=\"text-align: justify;\">Ha obtenido el permiso necesario para las im\u00e1genes y gr\u00e1ficos utilizados.<br \/>\nHa preservado la identidad del paciente.<\/p>\n<p style=\"text-align: justify;\"><strong>RESUMEN<\/strong><\/p>\n<p style=\"text-align: justify;\"><strong>Introducci\u00f3n: <\/strong>La subluxaci\u00f3n atlantoaxial o inestabilidad atlantoaxial, es un padecimiento que puede ser diagnosticado mediante estudio radiogr\u00e1fico o tomogr\u00e1fico, puede estar asociado a enfermedades como la espondilitis anquilosante, s\u00edndromes, traumatismos y enfermedades degenerativas como la artritis reumatoide, es una complicaci\u00f3n poco frecuente en pacientes con artritis reumatoide, ya que la mayor\u00eda son por causa traum\u00e1tica, sin embargo no hay estudios sobre su prevalencia o incidencia.<\/p>\n<p style=\"text-align: justify;\"><strong>Presentaci\u00f3n de Caso Cl\u00ednico: <\/strong>Femenina de 50 a\u00f1os de edad con artritis reumatoide que posterior a un accidente automovil\u00edstico inici\u00f3 con dolor cervical y limitaci\u00f3n en la fuerza, por tomograf\u00eda se diagnostic\u00f3 luxaci\u00f3n atlantoaxoidea. Se resolvi\u00f3 mediante cirug\u00eda cervical posterior con la colocaci\u00f3n de tornillos y barras a C1 y a las l\u00e1minas vertebrales de C2, con remoci\u00f3n del arco posterior del atlas.<\/p>\n<p style=\"text-align: justify;\"><strong>Discusi\u00f3n y conclusi\u00f3n: <\/strong>Este tipo fracturas pueden ser resueltas en un hospital de segundo nivel de atenci\u00f3n por un equipo multidisciplinario, sin necesidad de referir a un tercer nivel o centro m\u00e9dico nacional con la consecuente saturaci\u00f3n de los servicios, as\u00ed como la problem\u00e1tica para los pacientes y sus familiares al ser referidos generalmente muy lejos de sus lugares de residencia. La t\u00e9cnica quir\u00fargica que se determine debe evitar la p\u00e9rdida de la funci\u00f3n neurol\u00f3gica, obtener y mantener la estabilidad de la columna vertebral as\u00ed como lograr una recuperaci\u00f3n temprana del paciente.<\/p>\n<p style=\"text-align: justify;\"><strong>Palabras clave: <\/strong>Articulaci\u00f3n Atlantoaxoidea, Fractura por dislocaci\u00f3n, Inestabilidad Articular, Artritis Reumatoide.<\/p>\n<p style=\"text-align: justify;\"><strong>SUMMARY<\/strong><\/p>\n<p style=\"text-align: justify;\"><strong>Introduction: <\/strong>Atlantoaxial subluxation or atlantoaxial instability is a condition that can be diagnosed by radiographic or tomographic study, it can be associated with diseases such as ankylosing spondylitis, syndromes, trauma and degenerative diseases such as rheumatoid arthritis, it is a rare complication in patients with arthritis rheumatoid, since most are due to trauma, however there are no studies on its prevalence or incidence.<\/p>\n<p style=\"text-align: justify;\"><strong>Clinical Case: <\/strong>A 50-year-old female with rheumatoid arthritis that started with neck pain and strength limitation after a car accident. Atlantoaxial dislocation was diagnosed by tomography. It was resolved by posterior cervical surgery with the placement of screws and bars at C1 and the vertebral plates at C2, with removal of the posterior arch of the atlas.<\/p>\n<p style=\"text-align: justify;\"><strong>Discussion and conclusion: <\/strong>This type of fracture can be resolved by a second level care hospital with a multidisciplinary team without the need to refer to a third level or national medical center, thus alleviate the saturation of services, as well as problems for patients and their families when referred to a hospital far away from their places of residence.<\/p>\n<p style=\"text-align: justify;\">The surgical technique must avoid the loss of neurological function, obtain, and maintain the stability of the spine as well as achieve an early recovery of the patient.<\/p>\n<p style=\"text-align: justify;\"><strong>Keywords: <\/strong>Atlanto-Axial Joint, Dislocation Fracture, Instability, Joint, Rheumatoid Arthritis<\/p>\n<p style=\"text-align: justify;\"><strong>Introduction<\/strong><\/p>\n<p style=\"text-align: justify;\">Atlantoaxial instability, also known as atlantoaxial subluxation, it can only be identified radiologically due to increased mobility or laxity between the body of the atlas and the odontoid process.<sup>1<\/sup><\/p>\n<p style=\"text-align: justify;\">The association of atlanto axoid fracture, dislocation or subluxation with some pathologies such as rheumatoid arthritis <sup>2<\/sup> must be borne in mind, it may occur in some syndromes such as Down <sup>3<\/sup> or Grisel <sup>4<\/sup>, it is also associated with trauma from falls, sports accidents, traffic collisions <sup>5<\/sup> and habits that continually affect neck trauma.<\/p>\n<p style=\"text-align: justify;\">For instability of the cervical spine White and Panjabi suggest diagnostic criteria based on standard radiographs <sup>6<\/sup>. The presence of previously defined radiographic findings (anterior atlantodental interval&gt; 3 mm in adults,&gt; 5 mm in children) is a diagnosis of atlantoaxial instability or atlantoaxial subluxation.<\/p>\n<p style=\"text-align: justify;\">Tomography has been the study of choice for the diagnosis of instability of the atlanto axoid joint. <sup>7<\/sup><\/p>\n<p style=\"text-align: justify;\"><strong>Clinical case<\/strong><\/p>\n<p style=\"text-align: justify;\">A 50-year-old woman referred to a first-level care unit with a diagnosis of rheumatoid arthritis under treatment with an immuno modulator (rituximab), bilateral knee osteoarthritis, systemic arterial hypertension, and diabetes mellitus. She was assessed on April 19, 2016 by the rheumatology service of the second level of care hospital, where the patient reported that on April 2, 2016, after a car accident, she started with neck pain coupled with strength limitations 4\/5 on the Daniels scale, dynamic radiographic studies of the cervical spine were carried out in which an atlantoaxial subluxation was observed, which is why it is referred to the neurosurgery department. (Figure 1)<\/p>\n<p style=\"text-align: justify;\">In her initial assessment in the neurosurgery service, a patient was found with cervical pain and headache related to tension of the posterior cervical muscles; the rest of her physical examination did not show any neurological alterations to be highlighted, so a simple tomography of the cervical spine was performed with focus on the cervical junction.<\/p>\n<p style=\"text-align: justify;\">The diagnosis of atlantoaxial dislocation due to separation of the anterior border of the odontoid process and the posterior border of the anterior arch of the atlas of more than 7 mm in neutral position was determined through a tomography of the cranio-cervical junction, related to rheumatoid arthritis and accident vehicular. Therefore, the treatment carried out was posterior cervical surgery with the placement of screws and bars at C1 (Atlas) and the vertebral plates of C2 (Axis) and with removal of the posterior arch of the Atlas. Figure 2 shows the tomographic reconstruction with enhancement of post-surgical material.<\/p>\n<p style=\"text-align: justify;\"><strong>Pre-surgical tomographic video:<\/strong><\/p>\n<p style=\"text-align: justify;\">https:\/\/youtu.be\/DIO225wj3IQI<\/p>\n<p style=\"text-align: justify;\"><strong>Post-surgical tomographic video:<\/strong><\/p>\n<p style=\"text-align: justify;\"><iframe loading=\"lazy\" title=\"Control tomogr\u00e1fico instrumentaci\u00f3n C1 C2\" width=\"1200\" height=\"900\" src=\"https:\/\/www.youtube.com\/embed\/NtYynmKzRPY?feature=oembed\" frameborder=\"0\" allow=\"accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share\" allowfullscreen><\/iframe><\/p>\n<p style=\"text-align: justify;\"><strong>Discussion<\/strong><\/p>\n<p style=\"text-align: justify;\">Rheumatoid arthritis causes synovitis in the cervical spine and damages skeletal structures at any level.<\/p>\n<p style=\"text-align: justify;\">Transarticular screws are biomechanically superior to cabling techniques and equivalent to fixation of lateral mass C1 to pedicle C2 (C1LM-C2P). Recently, the C1 lateral to laminar C2 mass fixation (C1LM-C2L) has been shown to have similar flexibility to the C1LM-C2P fixation in flexion, extension, lateral flexion, and axial rotation. Compare the stiffness of C1LM-C2P with the C1LM-C2L threaded rod fixture.<\/p>\n<p style=\"text-align: justify;\">The C1-C2 screw and rod system provide stability and sufficient reduction of misalignment at the cranio-vertebral junction, thus preserves the mobility of the atlanto-occipital joints in the treatment of atlantoaxial dislocation. The main disadvantage is the difficulty in placing the screws.<sup>8<\/sup><\/p>\n<p style=\"text-align: justify;\">Data on the frequency of atlantoaxial dislocation cannot be mentioned since there are no prevalence or incidence data, only clinical case reports. <sup>9-11<\/sup><\/p>\n<p style=\"text-align: justify;\"><strong>Conclusions<\/strong><\/p>\n<p style=\"text-align: justify;\">The association of atlanto-axoid fracture, dislocation or subluxation with risk factors such as rheumatoid arthritis, ankylosing spondylitis, Down&#8217;s or Grisel&#8217;s syndromes, trauma from falls, sports accidents or traffic collisions, (as in the case of study) should be taken into account. Presented in which there was rheumatoid arthritis and after the car accident, the symptoms began, therefore, if there is any of the aforementioned antecedents, a physical examination should be performed and supplemented with the necessary imaging studies, this will allow a diagnosis to be made on time. In the atlantoaxial joint, 3 essential movements are involved, flexion, extension and axial rotation. The surgical technique to be determined must avoid the loss of neurological function, realign the spine, obtain and maintain the stability of the spine and achieve an early recovery.<\/p>\n<p style=\"text-align: justify;\">It is important to mention that it is not an exclusive procedure to be performed in a third level of care hospital or in a national medical center, since it can be carried out successfully (as in the case of study) in a second level of care hospital in the health sector, the recommendation is to work in a multidisciplinary manner with neurosurgery, traumatology and orthopedics, anesthesiology, as well as nursing services, which increases the benefit for the patient and their families, avoiding transfers (referrals) to places far from their residence, consequently \u00a0reducing the saturation of third care services and medical centers.<\/p>\n<h2 style=\"text-align: justify;\"><a href=\"https:\/\/www.revista-portalesmedicos.com\/imagenes\/publicaciones\/2023\/Subluxacion-atlanto-axoidea.pdf\" target=\"_blank\" rel=\"noopener\"><strong>Ver anexo<\/strong><\/a><\/h2>\n<p style=\"text-align: justify;\"><strong>References<\/strong><\/p>\n<ol style=\"text-align: justify;\">\n<li>Alcocer Maldonado Jos\u00e9 Luis, Dom\u00ednguez Gasca Luis Gerardo, Mora Constantino Jorge, Dom\u00ednguez Carrillo Luis Gerardo. Inestabilidad atlantoaxoidea. Acta m\u00e9d. Grupo \u00c1ngeles [Internet]. 2016 ;14(4):235-39. Recuperado a partir de: http:\/\/www.scielo.org.mx\/scielo.php?script=sci_arttext&amp;pid=S1870-72032016000400235<\/li>\n<li>Cabot A, Becker A. The cervical spine in rheumatoid arthritis. Clin Orthop Relat Res [Internet]. 1978 ;131:130\u2013140. Recuperado a partir de: https:\/\/www.ncbi.nlm.nih.gov\/pubmed\/657609<\/li>\n<li>Henales V, Palaz\u00f3n H, Jan\u00e9 M, Sal R, Herrera M. Inestabilidad occipito-Atlanto-Axoidea en el s\u00edndrome de Down. Bol Pediatr [Internet]. 1991;32:55-58. Recuperado a partir de: https:\/\/www.sccalp.org\/documents\/0000\/1382\/BolPediatr1991_32_055-058.pdf<\/li>\n<li>Dom\u00ednguez LG, Trujillo M, Segovia A. S\u00edndrome de Grisel, luxaci\u00f3n rotatoria atlanto-axoidea. Acta M\u00e9dica Grupo \u00c1ngeles [Internet]. 2005;3(2):103-107. Recuperado a partir de: https:\/\/www.medigraphic.com\/pdfs\/actmed\/am-2005\/am052e.pdf<\/li>\n<li>Chika A. Ndubuisi, Samuel C. Ohaegbulam, Wilfred C. Mezue. Impact of Active Leisure (Noncompetitive) Contact Sports Activities on the Space Available for the Cord of the Subaxial Cervical Spine of Asymptomatic Adults. World Neurosurgery [Internet]. 2017;108:705-710. Recuperado a partir de: https:\/\/pubmed.ncbi.nlm.nih.gov\/28927917\/<\/li>\n<li>White AA, Panjabi MM. The problem of clinical instability in the human spine: a systematic approach. En: White AA, Panjabi MM, editors. Clinical biomechanics of the spine. Philadelphia: JB Lippincott; 1990. p. 277\u2013378.<\/li>\n<li>Richards PJ. Cervical spine clearance: a review. Injury [Internet]. 2005;6(2):248\u2013269. Recuperado a partir de: https:\/\/www.injuryjournal.com\/article\/S0020-1383(04)00295-5\/ppt<\/li>\n<li>\u00c1lvarez Betancourt L. Comparaci\u00f3n de 4 T\u00e9cnicas Quir\u00fargicas para Manejo deLuxaci\u00f3n C1-C2 Secundaria a Artritis Reumatoide. J Bras Neurocirurg [Internet]. 2012 23(1):46-50. Recuperado a partir de:file:\/\/\/D:\/Users\/submed_edomex\/Downloads\/1087-Texto%20do%20artigo-974-1907-10-20180324.pdf<\/li>\n<\/ol>\n<ol style=\"text-align: justify;\" start=\"9\">\n<li>Ferrara P, Spaho N, Vecchi E. Subluxaci\u00f3n atlanto-axial anterior secundaria a osteoartritis: reporte de un caso. Rev. argent. neurocir [Internet]. 2006;20(1):45-49. Recuperado a partir de:https:\/\/aanc.org.ar\/ranc\/items\/show\/520<\/li>\n<\/ol>\n<ol style=\"text-align: justify;\" start=\"10\">\n<li>\u00c1balos Medina GM, Ruiz Villaverde G, Castellano Garc\u00eda MM, Raya \u00c1lvarez E. Fractura-luxaci\u00f3n atlantoaxoidea tras traumatismo craneoencef\u00e1lico leve en paciente con artritis reumatoide. Reumatol Clin [Internet]. 2009;5(2):80\u201382. Recuperado a partir de:https:\/\/www.reumatologiaclinica.org\/es-pdf-S1699258X09000369<\/li>\n<\/ol>\n<ol start=\"11\">\n<li style=\"text-align: justify;\">Alp\u00edzar Aguirre A, Lara Cano JG, Rosales Olivares LM, Miramontes Mart\u00ednez V, Reyes S\u00e1nchez AA. Resultado en el tratamiento quir\u00fargico de la inestabilidad atlantoaxoidea. Cir Ciruj [Internet].;77:101-105. Recuperado a partir de: https:\/\/www.redalyc.org\/pdf\/662\/66211459004.pdf<\/li>\n<\/ol>\n","protected":false},"excerpt":{"rendered":"<p>Subluxaci\u00f3n atlanto axoidea por traumatismo en un paciente con artritis reumatoide Autor principal: Juan Pablo Garc\u00eda Garc\u00eda Vol. XVIII; n\u00ba 8; 379<\/p>\n","protected":false},"author":620,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"footnotes":""},"categories":[202,207],"tags":[17417,909,692,17418,17419],"class_list":["post-71365","post","type-post","status-publish","format-standard","hentry","category-reumatologia","category-traumatologia","tag-articulacion-atlantoaxoidea","tag-artritis-reumatoide","tag-caso-clinico","tag-fractura-por-dislocacion","tag-inestabilidad-articular","no-featured-image-padding"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v26.6 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Subluxaci\u00f3n atlanto axoidea por traumatismo en un paciente con artritis reumatoide<\/title>\n<meta name=\"description\" content=\"Subluxaci\u00f3n atlanto axoidea por traumatismo en un paciente con artritis reumatoide Autor principal: Juan Pablo Garc\u00eda Garc\u00eda Vol. XVIII; 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