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Galzio a,c a Neurosurgery, Department of Health Sciences, University of L’Aquila, Piazza Salvatore Tommasi, Coppito, 67100 L’Aquila, Italy b Maxillofacial Surgery, Department of Health Sciences, University of L’Aquila, L’Aquila, Italy c Department of Neurosurgery, ‘‘San Salvatore’’ City Hospital, L’Aquila, Italy article info Article history: Received 18 October 2011 Accepted 14 March 2012 Keywords: Grisel’s syndrome Transoral biopsy Neuronavigation abstract Grisel’s syndrome is a disease characterized by an atlanto–axial rotatory subluxation following acute inflammation of the upper respiratory tract. The syndrome has a good prognosis as it usually heals with antibiotics, despite the delayed serious complications that have been reported. When neuroradiological investigation does not allow an accurate differential diagnosis between a tumor and osteomyelitis, an image-guided transoral biopsy is a safe, fast, minimally invasive, as well as effective, procedure. Ó 2012 Elsevier Ltd. All rights reserved. 1. Introduction Grisel’s syndrome 1 is a relatively common disease that usually occurs in children. It is characterized by an atlanto–axial rotatory subluxation following an acute inflammation of the upper respira- tory tract or, rarely, otorhinolaryngological surgery. The most fre- quent symptoms of this condition are neck pain and a stiff neck, with the head fixed in the ‘‘cock robin’’ position. Usually, con- trast-enhanced MRI of the cervical spine is the gold standard for diagnosis, showing inflammation of both the dens and periodon- toid tissue. The syndrome has a good prognosis as it usually heals with antibiotics, despite the reported possibilities of delayed seri- ous complications. We report a very young boy with suspected Grisel’s syndrome, whose MRI scan showed an altered and not clearly defined signal in the dens. We decided to perform a neuronavigation-assisted, transoral biopsy of the dens to clearly define the lesion and to pro- vide adequate treatment. 2. Case report A 6-year-old boy was admitted to the San Salvatore City Hospital after 2 days of neck pain and a ‘‘cock robin’’ head position, with the head rotated to the right; the medical history revealed a recent pharyngitis (about 10 days before admission) that was resolved with broad-spectrum antibiotics, while the examination was other- wise negative. MRI of the cervical spine, before and after the addi- tion of gadolinium contrast (Fig. 1), showed an altered, and not clearly defined, signal in the apex of the dens. The dens apex, as well as the surrounding soft tissue, seemed to have an irregular mor- phology: this area of altered signal, together with the adjacent dura mater, showed intense contrast enhancement. The transverse liga- ment was not affected. In addition, both brain and dorsolumbar contrast-enhanced MRI were performed, with no evidence of further lesions. Plain radiographs of the cervical spine and a thin- ⇑ Corresponding author. Tel./fax: +39 0862 368233. E-mail address: dicolafran@gmail.com (F. Di Cola). Case Reports / Journal of Clinical Neuroscience 20 (2013) 901–903 901