A case report of postoperative atlantoaxial rotatory subluxation following craniotomy for pilocytic astrocytoma in a pediatric patient.

Background: Pilocytic astrocytoma is a benign, slow-growing pediatric brain tumor, while Grisel's syndrome refers to nontraumatic atlantoaxial subluxation classically associated with infection or head-and-neck surgery. Postoperative atlantoaxial rotatory subluxation following intracranial surgery is rare and poses significant diagnostic and management challenges. Case Description: We report a 7-year-old girl who presented with progressive headaches, imbalance, and signs of obstructive hydrocephalus. Imaging revealed a large cystic pilocytic astrocytoma involving the left frontotemporo-parietal region. The patient underwent left fronto-temporo-parietal craniotomy with excisional biopsy and placement of an Ommaya reservoir. Two weeks postoperatively, she developed painful neck spasm and mild torticollis. Cervical imaging confirmed C1-C2 rotatory subluxation (Fielding Type II), likely related to surgical positioning, with Grisel's syndrome considered a possible inflammatory mechanism. Management included halo traction, closed reduction under general anesthesia, followed by halo vest immobilization and later application of a Miami-J cervical collar. The patient demonstrated good clinical and radiological recovery. Conclusion: This case highlights a rare postoperative complication of craniotomy with the development of atlantoaxial rotatory subluxation. Early recognition and multidisciplinary management are essential to prevent neurological sequelae. Surgical positioning may represent a contributing risk factor, and further research is required to establish preventive strategies.