Under the heading of “continuing to learn” every day…comes a new case.
A patient of mine who is 4 years old was playing with his brother the other morning while his mother was making their breakfast. He was a “well child” and woke up in a good mood, ready to eat and go to preschool. She could see the boys playing while she was cooking and then suddenly the 4 year old started to scream and cry that his “neck hurt”. At first she thought “he was pretending or over reacting” as there did not overtly seem to be anything wrong. The only thing she noticed is that he refused to turn his neck and held his head in an awkward position.
He continued to cry and actually scream - so she tried to calm him down and gave him some ibuprofen as well. Despite this he would not move his neck and was unconsolable, to the point that she almost took him to the ER but instead she brought him to the office. He was noted to be crying and seemed uncomfortable and refused to move his neck at all. His exam was otherwise normal. Even with careful questioning there was no history of trauma. He had slept through the night before this had occurred. He had a cold several weeks before, but had since improved. He did not have a fever.
He seemed to be in such pain that he was sent for neck X-rays which were read as normal. But he continued to be miserable….so who do you call??
I spoke to a pediatric orthopedic surgeon and he said he really did not have any ideas. Next call, the pediatric neurosurgeon. After hearing the symptoms he immediately said that he thought this little boy had “rotatory dislocation/subluxation” of the two upper cervical vertebrae in his neck (C-1 and C-2). He explained to me that in most cases the displacement resolves spontaneously, but in some cases the child continues to be uncomfortable as there is associated spasm of the sternocleidomastoid muscle, which causes the torticollis. (twisted neck).It may be seen in children after a recent upper respiratory infection and is then called Grisel Syndrome.
Treatment for the acute condition…pain control and muscle relaxation. This was all news to me and I had to go to textbook (online of course) to even read about the condition. The neurosurgeon walked me through treatment and the child was sent home on a very low dose of valium and continued ibuprofen. When I spoke to the mother later that evening the child was already more comfortable and had started to move his neck.
I called her the following morning and she said that he had not required any further valium and slept well and was actually on his way to preschool! WOW….I was thrilled he was better so quickly and that I was that much “smarter”. Wonder if I will ever see rotatory subluxation of the cervical vertebra again? I’ll be ready.