Objective: To present a case of Grisel’s syndrome (GS), highlighting challenges and the efficacy of botulinum toxin therapy in treatment.

Background: Grisel’s syndrome (GS) is a rare non-traumatic atlantoaxial rotatory subluxation (AARS) primarily affecting children aged 5–12 years. It often follows upper respiratory infections, otolaryngological surgeries, or inflammatory conditions that compromise the transverse ligament. Symptoms include progressive neck stiffness, pain, and torticollis, which can be mistaken for other pediatric conditions, delaying diagnosis.

A 9-year-old male presented with neck stiffness, pain, and limited movement persisting for several months. Symptoms worsened progressively without trauma history, but parents reported a preceding upper respiratory infection. Neurological exam revealed muscle hypertonia in the cervical region but no sensory or motor deficits.

Method: MRI demonstrated rotation of the atlas around the odontoid process with mild subcortical edema. CT confirmed subluxation with focal subcortical destruction at the apex of the odontoid process. These findings were consistent with Grisel’s syndrome (Fielding and Hawkins Type I).

The patient was managed using a multidisciplinary approach. Initial therapy included botulinum toxin injections under ultrasound and EMG guidance to address muscle spasticity. A total of 195 U of toxin was administered to the m. scalenus anterior, m. levator scapulae, m. splenius capitis, and m. semispinalis capitis. Physiotherapy, emphasizing gentle cervical mobilization and muscle strengthening, was initiated post-procedure.

Results: Over two months, the patient showed substantial improvement in pain and mobility. The patient achieved near-normal range of motion and reported significant reduction in muscle stiffness, and imaging confirmed stable alignment without progression. No adverse effects from botulinum toxin were observed.

Conclusion: Early recognition of GS is vital to prevent chronic pain and deformity. Botulinum toxin therapy effectively reduced muscle spasticity, accelerating recovery. Further research is needed to standardize its use in GS management.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/management-of-grisels-syndrome-with-botulinum-toxin-a-case-report/