A Rare Complication of Sequential Bilateral Posterior Knee Dislocation Following Bilateral Robotic Assisted Primary Knee Replacement: Case Report.

INTRODUCTION: The International Headache Society divides headaches into primary (vascular and muscular) and secondary (inflammatory). Secondary headaches include headaches secondary to inflammation caused by injuries to the head and neck. Cervicogenic headache (CGH) is thought to be referred pain arising from irritation caused by cervical structures innervated by spinal nerves C1, C2, and C3; therefore, any structure innervated by the C1-C3 spinal nerves could be the source of a CGH. Pain from the lateral atlanto-axial joint (AAJ) is one of several causes of CGH. The pain is perceived in the upper neck and can be referred to the occiput, ear, vertex, and forehead.

CASE REPORT: Patients who attended our pain clinic were presented with complaints of pain in the upper cervical, occipital, and sometimes periorbital and retro-orbital area and around the post-auricular area. On the numerical rating pain scale, patients had pain score of 8-9/10. Three patients had a history of trauma to the cervical region and 2 had a history of rheumatoid arthritis (RA). Patients suffering from RA also had pain in bilateral wrist joints along with neck pain. On examination, there was tenderness along the facet joint line on both sides, when the site of maximum tenderness was checked under the C-Arm machine, it was found at the AAJ on both sides. Patients having a history of trauma first had conservative treatment with analgesics while rheumatoid patients with analgesics and disease-modifying anti-rheumatoid drugs. When patients had no satisfactory pain relief with conservative treatment then patients were considered for fluoroscopy (C-Arm) and 0.5-1 mL Iohexol 300 guided AAJ steroid injection with dexamethasone. After steroid injection, all patients had good-to-excellent results and were followed up for 4 months. Trauma patients got complete relief whereas patients having a history of RA had only mild pain.

CONCLUSION: AAJ steroid injection with dexamethasone is an effective pain-relieving procedure for acute pain relief in patients having severe pain due to cervical trauma or due to RA involving AAJ.