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Jian Q, Bo X, Jian F, Chen Z. The role of clivus and atlanto-occipital lateral mass height in basilar invagination with or without atlas occipitalization. Neurosurg Rev 2024; 47:404. [PMID: 39103656 DOI: 10.1007/s10143-024-02598-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Revised: 07/14/2024] [Accepted: 07/20/2024] [Indexed: 08/07/2024]
Abstract
Basilar invagination (BI) is a common deformity. This study aimed to quantitatively evaluate the height of clivus and atlanto-occipital lateral mass (LM) in patients with BI with or without atlas occipitalization (AOZ). We evaluated 166 images of patients with BI and of controls. Seventy-one participants were control subjects (group A), 68 had BI with AOZ (group B), and 27 had BI without AOZ (group C). Parameters were defined and measured for comparisons across the groups. Multiple linear regression analysis was used to test the relationship between Chamberlain's line violation (CLV) and the clivus height ratio or atlanto-occipital LM height. Based on the degree of AOZ, the lateral masses in group B were classified as follows: segmentation, incomplete AOZ, complete AOZ. From groups A to C, there was a decreasing trend in the clivus height and clivus height ratio. There was a linear negative correlation between the clivus height ratio and CLV in the three groups. Generally, the atlanto-occipital LM height followed the order of group B < group C < group A. The atlanto-occipital LM height was included only in the equations of groups B. There were no cases of atlantoaxial dislocation (AAD) in group C. There was a decreasing trend in LM height from the segmentation type to the complete AOZ type in group B. BI can be divided into three categories: AOZ causes LM height loss; Clivus height loss; Both clivus and LM height loss. The clivus height ratio was found to play a decisive role in both controls and BI group, while the atlanto-occipital LM height loss caused by AOZ could be a secondary factor in patients with BI and AOZ. AOZ may be a necessary factor for AAD in patients with congenital BI. The degree of AOZ is associated with LM height in group B.
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Affiliation(s)
- Qiang Jian
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45, Changchun Street, Xicheng District, Beijing, 100053, China
- Spine Center, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Xuefeng Bo
- School of Biomedical Engineering, Capital Medical University, Beijing, 100069, China
- Beijing Key Laboratory of Fundamental Research on Biomechanics in Clinical Application, Capital Medical University, Beijing, 100069, China
| | - Fengzeng Jian
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45, Changchun Street, Xicheng District, Beijing, 100053, China
| | - Zan Chen
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45, Changchun Street, Xicheng District, Beijing, 100053, China.
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Wang J, Yang H, Chen Y, Liu G, Xie N, Zhang S, Qiao G. A Method to Evaluate the Reduction Difficulty of Atlantoaxial Dislocation Based on Computed Tomography Quantitative Analysis. World Neurosurg 2024; 185:e283-e290. [PMID: 37683914 DOI: 10.1016/j.wneu.2023.08.136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 08/31/2023] [Indexed: 09/10/2023]
Abstract
BACKGROUND To evaluate the difficulty of reduction of congenital atlantoaxial dislocation with or without os odontoideum or basilar invagination based on computed tomography (CT) quantitative analysis. METHODS From March 2018 to December 2022, the CT features of 108 patients with atlantoaxial dislocation with or without os odontoideum or basilar invagination were analyzed. Quantitative scores were defined according to imaging features, including sloping of the lateral mass; osteophyte between the lateral mass joint; ball-and-socket deformity of the lateral mass joint; vertical interlocking of the lateral mass joint; callus between the lateral mass joint; and atlanto-odontoid joint hyperplasia, blocking, or fusion. Grades were calculated according to the sum of points of the atlanto-odontoid joint and lateral mass joints, as follows: I, 0-1 points; Ⅱ, 2-3 points; Ⅲ, 4-6 points; IV, 7-10 points. After 1 week of bidirectional cervical traction, CT scans were performed, and atlantodens interval and vertical distance from dens to Chamberlain line were measured. The vertical reduction rate, horizontal reduction rate, and overall reduction rate of atlantoaxial dislocation were calculated. RESULTS The vertical distance from dens to Chamberlain line values after traction were significantly reduced compared with before traction, including grades I, II, III, and IV. The overall reduction rates were 85.1% ± 11.8%, 65.8% ± 8.3%, 45.0% ± 8.5%, and 38.4% ± 13.0% respectively, after 1 week of bidirectional cervical traction. CONCLUSIONS The CT quantitative score system is an effective noninvasive evaluation to judge the reduction difficulty of atlantoaxial dislocation with or without os odontoideum or basilar invagination.
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Affiliation(s)
- Jianhua Wang
- Department of Orthopedics, General Hospital of Southern Theatre Command, Guangzhou, China; Southern Medical University, Guangzhou, China.
| | - Haozhi Yang
- Department of Orthopedics, General Hospital of Southern Theatre Command, Guangzhou, China
| | - Yuyue Chen
- Department of Orthopedics, General Hospital of Southern Theatre Command, Guangzhou, China
| | - Guoqiang Liu
- Department of Orthopedics, General Hospital of Southern Theatre Command, Guangzhou, China; Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Ningling Xie
- Department of Orthopedics, General Hospital of Southern Theatre Command, Guangzhou, China
| | - Shuang Zhang
- Department of Orthopedics, General Hospital of Southern Theatre Command, Guangzhou, China
| | - Guoqing Qiao
- Department of Orthopedics, General Hospital of Southern Theatre Command, Guangzhou, China
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Chinea AG, Pressman E, Flores-Milán G, Krafft PR, Alikhani P. C1-C2 intraarticular distraction with anterior cervical cages for basilar invagination realignment: Operative technique nuances and review of literature. NEUROCIRUGIA (ENGLISH EDITION) 2024; 35:51-56. [PMID: 36934973 DOI: 10.1016/j.neucie.2023.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 03/04/2023] [Indexed: 03/19/2023]
Abstract
Neurosurgical management of basilar invagination (BI) has traditionally been aimed at direct cervicomedullary decompression through transoral dens resection or suboccipital decompression with supplemental instrumented fixation. Dr. Goel introduced chronic atlantoaxial dislocation (AAD) as the etiology in most cases of BI and described a technique for distracting the C1-C2 joint with interfacet spacers to achieve reduction and anatomic realignment. We present our modification to Goel's surgical technique, in which we utilize anterior cervical discectomy (ACD) cages as C1-C2 interfacet implants. A young adult male presented to our institution with BI, cervicomedullary compression, occipitalization of C1, and Chiari 1 malformation. There was AAD of C1 over the C2 lateral masses. This reduced some with preoperative traction. He underwent successful C1-C2 interfacet joint reduction and arthrodesis with anterior cervical discectomy (ACD) cages and concomittant occiput to C2 instrumented fusion. BI can be effectively treated through reduction of AAD and by utilizing ACD cages as interfacet spacers.
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Affiliation(s)
- Angel G Chinea
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Elliot Pressman
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Gabriel Flores-Milán
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Paul R Krafft
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Puya Alikhani
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, Florida, USA.
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Jian Q, Zhao X, Hou Z, Wang Y, Fan T. Modified interfacet technique using shaped autologous occipital bone mass for basilar invagination. Clin Neurol Neurosurg 2023; 232:107848. [PMID: 37419081 DOI: 10.1016/j.clineuro.2023.107848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 06/18/2023] [Accepted: 06/21/2023] [Indexed: 07/09/2023]
Abstract
PURPOSE In economically undeveloped areas, surgery for basilar invagination (BI) is still a serious economic burden for people. This study introduces a modified interfacet technique for the treatment of BI using shaped autologous occipital bone mass to reduce BI and to save economical expenditure. METHODS The data of 6 patients with BI who underwent modified interfacet technique using shaped autologous occipital bone mass in our hospital from April 2020 to February 2021 were retrospectively analyzed. During the operation, osteotomy at the external occipital protuberance was performed using ultrasonic osteotome, followed by interfacet release and implantation of shaped autologous occipital bone mass to complete vertical reduction. The atlantodental interval (ADI), Chamberlain's line violation (CLV), clivo-axial angle (CXA) and cervico-medullary angle (CMA) were compared before and after surgery. Additionally, we observed implant stability during the follow-up period to assess the long-term success of the modified interfacet technique. RESULTS The surgical procedure was successful in all six patients, with no reported incidents of vascular injury, spinal cord injury, or dural tear. Following the operation, improvements were observed in the ADI, CLV, CXA, and CMA. Throughout the follow-up period, the implants remained stable, demonstrating no complications such as bone resorption of the autologous occipital bone mass, implant fracture, or displacement. CONCLUSION The utilization of shaped autologous occipital bone mass in atlantoaxial interfacet bone grafting has demonstrated effectiveness and feasibility. This technique offers simplicity, ease of preparation, and cost-effectiveness, making it a viable option for treating BI.
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Affiliation(s)
- Qiang Jian
- Spine Center, Sanbo Brain Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Xingang Zhao
- Spine Center, Sanbo Brain Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Zhe Hou
- Spine Center, Sanbo Brain Hospital, Capital Medical University, Beijing, People's Republic of China; Department of Neurosurgery, Beijing Luhe Hospital, Capital Medica University, Beijing, People's Republic of China
| | - Yinqian Wang
- Spine Center, Sanbo Brain Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Tao Fan
- Spine Center, Sanbo Brain Hospital, Capital Medical University, Beijing, People's Republic of China.
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Chang CC, Wu JC, Ko CC, Chang HK, Kuo YH, Kuo CH, Tu TH, Huang WC. Measurement of Deformity at the Craniovertebral Junction: Correlation of Triangular Area and Myelopathy. Neurospine 2022; 19:889-895. [PMID: 36597625 PMCID: PMC9816601 DOI: 10.14245/ns.2244786.393] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 08/28/2022] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE Diseases of the craniovertebral junction (CVJ) are commonly associated with deformity, malalignment, and subsequent myelopathy. The misaligned CVJ might cause compression of neuronal tissues and subsequently clinical symptoms. The triangular area (TA), measured by magnetic resonance imaging/images (MRI/s), is a novel measurement for quantification of the severity of compression to the brain stem. This study aimed to assess the normal and pathological values of TA by a comparison of patients with CVJ disease to age- and sex-matched controls. Moreover, postoperative TAs were correlated with outcomes. METHODS Consecutive patients who underwent surgery for CVJ disease were included for comparison to an age- and sex-matched cohort of normal CVJ persons as controls. The demographics, perioperative information, and pre- and postoperative 2-year cervical MRIs were collected for analysis. Cervical TAs were measured and compared. RESULTS A total of 201 patients, all of whom had pre- or postoperative MRI, were analyzed. The TA of the CVJ deformity group was larger than the healthy control group (1.62 ± 0.57 cm2 vs. 1.01 ± 0.18 cm2, p < 0.001). Moreover, patients who had combined anterior odontoidectomy and posterior laminectomy with fixation had the greatest reduction in the TA (1.18 ± 0.58 cm2). CONCLUSION In CVJ deformity, the measurement of the cervical TA could indicate the severity of brain stem compression. After surgery, the TA had a varying degree of improvement, which could represent the efficacy of surgery.
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Affiliation(s)
- Chih-Chang Chang
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan,School of Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan,Department of BioMedical Engineering, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
| | - Jau-Ching Wu
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan,School of Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
| | - Chin-Chu Ko
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan,School of Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
| | - Hsuan-Kan Chang
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan,School of Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
| | - Yi-Hsuan Kuo
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan,School of Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
| | - Chao-Hung Kuo
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan,School of Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan,Department of BioMedical Engineering, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
| | - Tsung-Hsi Tu
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan,School of Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan,Corresponding Author Tsung-Hsi Tu Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Room 525, 17F, No. 201, Shih-Pai Road, Sec. 2, Beitou, Taipei 11217, Taiwan
| | - Wen-Cheng Huang
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan,School of Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
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He Q, Cao J, Tian H, Chen B, Fan X, Wang S, Zhao Y, Wei J, Nie L, Pan X, Cheng L. The Classification of Axial Deformity in Patients with Basilar Invagination. Orthop Surg 2022; 14:3150-3158. [PMID: 36222216 PMCID: PMC9732616 DOI: 10.1111/os.13487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 07/21/2022] [Accepted: 08/10/2022] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE To summarize the variation types of the axis in patients with basilar invagination (BI), then propose a classification scheme of the axis deformity. METHODS From December 2013 to September 2020, 92 patients (male 42, female 50) who were diagnosed with BI were studied retrospectively. Based on the imaging data of CT, the width and height of the axis pedicle and the sagittal diameter of the lateral mass were measured in each patient. According to the development of axis pedicle and lateral mass, the types of axis variation were summarized, and then the classification scheme of axis deformity was put forward. RESULTS All cases were analyzed and axis deformities were divided into four types. Type I: the axis is basically normal (53 cases, 57.6%). Type II: axis lateral mass is dysplasia (eight cases, 8.7%), which includes two subtypes: type IIA, the axis unilateral lateral mass is dysplasia (three cases); type IIB, the axis bilateral lateral masses are all dysplasia (five cases). Type III: axis pedicle is dysplasia (11 cases, 12%), which is subdivided into two subtypes: type IIIA, the axis unilateral pedicle is dysplasia (six cases); type IIIB, the axis bilateral pedicles are all dysplasia (five cases). Type IV: axis pedicle and lateral mass are all dysplasia (20 cases, 21.7%), this type contains the following four subtypes: type IVA, the unilateral axis pedicle and unilateral lateral mass (contralateral or ipsilateral) are all hypoplasia (four cases); type IVB, the unilateral axis pedicle and bilateral lateral masses are all hypoplasia (five cases); type IVC, the bilateral axis pedicles and unilateral lateral mass are all dysplasia (seven cases); type IVD, the bilateral axis pedicles and bilateral lateral masses are all dysplasia (four cases). The left and right abnormal lateral mass sagittal diameter (Type II) was (7.23 ± 1.39) mm and (5.96 ± 1.37) mm, respectively, the left and right abnormal pedicle width (Type III) was (2.61 ± 1.01) mm and (3.23 ± 0.66) mm, respectively, left and right abnormal pedicle height (Type III) was (5.43 ± 2.19) mm and (4.92 ± 1.76) mm, respectively. Moreover, the classification scheme has good repeatability and credibility. CONCLUSIONS The classification about axis deformity could provide personalized guidance for axis screw placement in the BI and other upper cervical surgery, and axis screw placement errors would be effectively avoided.
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Affiliation(s)
- Qiting He
- Department of Orthopedic Surgery, Qilu Hospital of Shandong University, Cheeloo College of MedicineShandong UniversityJinanChina
| | - Jiankang Cao
- Department of Pain, Qilu Hospital of Shandong University, Cheeloo College of MedicineShandong UniversityJinanChina
| | - Huichao Tian
- Department of Orthopedic SurgeryLiaocheng People's HospitalLiaochengChina
| | - Bin Chen
- Department of Orthopedic Surgery, Qilu Hospital of Shandong University, Cheeloo College of MedicineShandong UniversityJinanChina
| | - Xincheng Fan
- Department of Orthopedic Surgery, Qilu Hospital of Shandong University, Cheeloo College of MedicineShandong UniversityJinanChina,Department of Orthopedic SurgeryTaian City Central HospitalTaianChina
| | - Shaoyi Wang
- Department of Orthopedic Surgery, Qilu Hospital of Shandong University, Cheeloo College of MedicineShandong UniversityJinanChina
| | - Yunpeng Zhao
- Department of Orthopedic Surgery, Qilu Hospital of Shandong University, Cheeloo College of MedicineShandong UniversityJinanChina
| | - Jianlu Wei
- Department of Orthopedic Surgery, Qilu Hospital of Shandong University, Cheeloo College of MedicineShandong UniversityJinanChina
| | - Lin Nie
- Department of Orthopedic Surgery, Qilu Hospital of Shandong University, Cheeloo College of MedicineShandong UniversityJinanChina
| | - Xin Pan
- Department of Orthopedic Surgery, Qilu Hospital of Shandong University, Cheeloo College of MedicineShandong UniversityJinanChina
| | - Lei Cheng
- Department of Orthopedic Surgery, Qilu Hospital of Shandong University, Cheeloo College of MedicineShandong UniversityJinanChina
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Niu G, Cheng J, Liu L, Li C, Zhou G, Chen H, Liu T, Nie H, Sun Z, Jiang W, Zhou Q, Zhao B, Zhu J, Yu R, Guo Y, Yang Y, Bai J. Individualized 3D printed navigation template-assisted atlantoaxial pedicle screws vs. free-hand screws for the treatment of upper cervical fractures. Front Surg 2022; 9:932296. [PMID: 36225218 PMCID: PMC9549244 DOI: 10.3389/fsurg.2022.932296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 08/22/2022] [Indexed: 11/13/2022] Open
Abstract
Objective This study aims to compare the efficacy and safety of freehand atlantoaxial pedicle screws against custom 3D printed navigation template screws in the treatment of upper cervical fractures. Methods In our institution from 2010 to 2020, a retrospective cohort analysis of 23 patients with upper cervical fractures was done. These patients were separated into two groups: group A (N = 12), which received customized 3D printed navigation template-assisted screws with virtual reality techniques, and group B (N = 11), which received freehand screws assisted by intraoperative fluoroscopy. Every patient was monitored for more than 1 year. The two groups were contrasted in terms of screw implant accuracy, cervical spine Japanese Orthopaedic Association (JOA) score, American Spinal Injury Association (ASIA) score, visual analogue scale (VAS) score, surgical time, fluoroscopy times, and intraoperative blood loss. Results A total of 88 atlantoaxial pedicle screws in all, 46 in group A and 42 in group B, were implanted. In group A, the screw insertion accuracy rate was 95.7%, compared to 80.0% in group B (P < 0.05). When compared to group B, group A had shorter surgery times, less blood loss, fewer fluoroscopies, a higher short-term JOA score, and overt pain reduction (P < 0.05). However, there was no discernible difference between the two groups' VAS scores, long-term JOA scores, or ASIA scores (sensory and motor), at the most recent follow-up. Conclusion Individualized 3D printed guide leads to significant improvement in the screw safety, efficacy, and accuracy, which may be a promising strategy for the treatment of upper cervical fractures.
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Affiliation(s)
- Guoqi Niu
- Department of Orthopedics, The Second Affiliated Hospital of Bengbu Medical College, Bengbu, China
- Digital Orthopedics Technology R/D and Application Innovation Team
- Correspondence: Guoqi Niu Jianzhong Bai
| | - Jiawei Cheng
- Department of Orthopedics, The Second Affiliated Hospital of Bengbu Medical College, Bengbu, China
- Digital Orthopedics Technology R/D and Application Innovation Team
| | - Lutan Liu
- Department of Orthopedics, The Second Affiliated Hospital of Bengbu Medical College, Bengbu, China
- Digital Orthopedics Technology R/D and Application Innovation Team
| | - Chao Li
- Department of Orthopedics, The Second Affiliated Hospital of Bengbu Medical College, Bengbu, China
- Digital Orthopedics Technology R/D and Application Innovation Team
| | - Gong Zhou
- Department of Orthopedics, The Second Affiliated Hospital of Bengbu Medical College, Bengbu, China
- Digital Orthopedics Technology R/D and Application Innovation Team
| | - Hui Chen
- Department of Orthopedics, The Second Affiliated Hospital of Bengbu Medical College, Bengbu, China
- Digital Orthopedics Technology R/D and Application Innovation Team
| | - Tao Liu
- Department of Orthopedics, The Second Affiliated Hospital of Bengbu Medical College, Bengbu, China
- Digital Orthopedics Technology R/D and Application Innovation Team
| | - Hu Nie
- Department of Orthopedics, The Second Affiliated Hospital of Bengbu Medical College, Bengbu, China
- Digital Orthopedics Technology R/D and Application Innovation Team
| | - Zheng Sun
- Department of Orthopedics, The Second Affiliated Hospital of Bengbu Medical College, Bengbu, China
- Digital Orthopedics Technology R/D and Application Innovation Team
| | - Weili Jiang
- Department of Orthopedics, The Second Affiliated Hospital of Bengbu Medical College, Bengbu, China
- Digital Orthopedics Technology R/D and Application Innovation Team
| | - Qiankun Zhou
- Department of Orthopedics, The Second Affiliated Hospital of Bengbu Medical College, Bengbu, China
- Digital Orthopedics Technology R/D and Application Innovation Team
| | - Baoyin Zhao
- Department of Orthopedics, The Second Affiliated Hospital of Bengbu Medical College, Bengbu, China
- Digital Orthopedics Technology R/D and Application Innovation Team
| | - Jun Zhu
- Department of Orthopedics, The Second Affiliated Hospital of Bengbu Medical College, Bengbu, China
- Digital Orthopedics Technology R/D and Application Innovation Team
| | - Ruochen Yu
- Department of Orthopedics, The Second Affiliated Hospital of Bengbu Medical College, Bengbu, China
- Digital Orthopedics Technology R/D and Application Innovation Team
| | - Yalong Guo
- Department of Orthopedics, The Second Affiliated Hospital of Bengbu Medical College, Bengbu, China
- Digital Orthopedics Technology R/D and Application Innovation Team
| | - Yi Yang
- Department of Orthopedics, The Second Affiliated Hospital of Bengbu Medical College, Bengbu, China
- Digital Orthopedics Technology R/D and Application Innovation Team
| | - Jianzhong Bai
- Department of Orthopedics, The Second Affiliated Hospital of Bengbu Medical College, Bengbu, China
- Digital Orthopedics Technology R/D and Application Innovation Team
- Correspondence: Guoqi Niu Jianzhong Bai
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Li T, Du YQ, Yin YH, Xing SL, Qiao GY. Treatment of Reducible Atlantoaxial Dislocation and Basilar Invagination Using the Head Frame Reduction Technique and Atlantoaxial Arthrodesis. Global Spine J 2022; 12:909-915. [PMID: 33138641 PMCID: PMC9344496 DOI: 10.1177/2192568220970164] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Retrospective case series. OBJECT To evaluate the outcomes of a head frame reduction and atlantoaxial arthrodesis technique for the treatment of reducible basilar invagination (BI) and atlantoaxial dislocation (AAD). METHODS Seventy-two reducible BI and AAD cases who were treated with the head frame reduction and atlantoaxial arthrodesis technique from June 2015 to December 2018 were retrospectively analyzed. Radiological measurements including the atlantodental interval (ADI), the height of odontoid process above Chamberlain line, Wackenheim line, clivus-canal angle (CCA) and JOA score were evaluated. RESULTS There was no death in this series. The follow-up period ranged from 6 to 32 months (mean: 21.2 months). Radiological, complete or 90% reduction was attained and complete decompression was demonstrated in all patients. The CCA increased from 123.22 ± 8.36 preoperatively to 143.05 ± 8.79 postoperatively (P < 0.01). There was no patient found postoperative dysphagia. Neurological improvement was observed in all patients, with the JOA scores increasing from 12.53 ± 1.93 preoperatively to 16.13 ± 1.23 postoperatively (P < 0.01). Solid bony fusion was demonstrated in 69 patients at follow-up (95.8%). CONCLUSION Head frame reduction technique is a simple and effective treatment which could relief neurologic compression and adjust the CCA in patients with reducible AAD and BI with lower potential risks. Atlantoaxial fixation with short segmental fixation, strong purchase and low shearing force could maintain superior stabilization. The safety and long-term efficacy of such fixation and reduction technique were favorable, which illustrated that it could be a promising treatment algorithm for such kind of disease.
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Affiliation(s)
- Teng Li
- Department of Neurosurgery, The
First Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Yue-Qi Du
- Department of Neurosurgery, The
First Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Yi-Heng Yin
- Department of Neurosurgery, The
First Medical Centre, Chinese PLA General Hospital, Beijing, China,Guang-Yu Qiao and Yi-Heng Yin, Department of
Neurosurgery, The First Medical Center, Chinese PLA General Hospital, 28 Fuxing
Road, Haidian District, Beijing 100853, China.
;
| | - Shao-Ling Xing
- Department of Anesthesia and
Operative Services, The First Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Guang-Yu Qiao
- Department of Neurosurgery, The
First Medical Centre, Chinese PLA General Hospital, Beijing, China,Guang-Yu Qiao and Yi-Heng Yin, Department of
Neurosurgery, The First Medical Center, Chinese PLA General Hospital, 28 Fuxing
Road, Haidian District, Beijing 100853, China.
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Shi L, Xue D, Wang Y, Chou D, Zhao Y, Zhang S, Zhang M, Wang L, Li P, Liu Y. Efficacy of a Lateral Mass Fusion Device Combined with a Three-Dimensional-Printed Model in the Treatment of Craniovertebral Junction Abnormalities. World Neurosurg 2021; 159:e120-e129. [PMID: 34896663 DOI: 10.1016/j.wneu.2021.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Revised: 12/02/2021] [Accepted: 12/03/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To investigate the efficacy of a lateral mass fusion device combined with a three-dimensional-printed model in treatment of craniovertebral junction abnormalities. METHODS This retrospective study comprised 56 patients with irreducible atlantoaxial dislocation who underwent posterior fixation between January 2016 and December 2019. Patients were divided into 2 groups according to whether or not cages were used-cage group and autograft group. Visual analog scale score, Japanese Orthopaedic Association score, health-related quality of life, American Spinal Injury Association spinal cord injury grade, atlas-dens interval, space available for the cord, cervicomedullary angle, and fusion rate were compared between groups. RESULTS Medical follow-up was >1 year. There was no statistical difference between groups in preoperative visual analog scale score, Japanese Orthopaedic Association score, 12-Item Short Form Health Survey score, American Spinal Injury Association grade, atlas-dens interval, space available for the cord, and cervicomedullary angle, and these indexes significantly improved after surgery (P < 0.05). Visual analog scale score and atlas-dens interval were lower in the cage group than in the autograft group (P < 0.05). Japanese Orthopaedic Association score, 12-Item Short Form Health Survey score, space available for the cord, and cervicomedullary angle were significantly higher in the cage group than in the autograft group (P < 0.05). Fusion rate of the cage group 4-6 months after surgery was higher than that of the autograft group (P = 0.068). American Spinal Injury Association grade was significantly higher in the cage group than in the autograft group (P < 0.05). CONCLUSIONS During 1-year follow-up, neurological function improvement and atlantoaxial joint reduction were satisfactory. The lateral mass fusion device combined with a three-dimensional printed model may be a clinically useful technique.
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Affiliation(s)
- Landa Shi
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Deng Xue
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yuqiang Wang
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Dean Chou
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Yao Zhao
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Shuhao Zhang
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Min Zhang
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Limin Wang
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Pengfei Li
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yilin Liu
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.
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10
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Chaudhary A, Chopra S, Sinha VD. Role of Three-dimensional Printing in Neurosurgery: An Institutional Experience. Asian J Neurosurg 2021; 16:531-538. [PMID: 34660365 PMCID: PMC8477846 DOI: 10.4103/ajns.ajns_475_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 02/01/2021] [Accepted: 03/16/2021] [Indexed: 11/23/2022] Open
Abstract
Background: Recent advancements in three-dimensional (3D) printing technology in the field of neurosurgery have given a newer modality of management for patients. In this article, we intend to share our institutional experience regarding the use of 3D printing in three modalities, namely, cranioplasty using customized 3D-printed molds of polymethylmethacrylate, 3D-printed model-assisted management of craniovertebral (CV) junction abnormalities, and 3D model-assisted management of brain tumors. Materials and Methods: A total of 55 patients were included in our study between March 2017 and December 2019 at S. M. S Medical College, Jaipur, India. 3D-printed models were prepared for cranioplasty in 30 cases, CV junction anomalies in 18 cases, and brain tumors in 7 cases. Preoperative and postoperative data were analyzed as per the diagnosis. Results: In cranioplasty, cranial contour and approximation of the margins were excellent and esthetic appearance improved in all patients. In CV junction anomalies, neck pain and myelopathy were improved in all patients, as analyzed using the visual analog scale and the Japanese Orthopedic Association Scale score, respectively. Our questionnaire survey revealed that 3D models for brain tumors were useful in understanding space interval and depth intraoperatively with added advantage of patient education. Conclusion: Rapid prototyping 3D-printing technologies provide a practical and anatomically accurate means to produce patient-specific and disease-specific models. These models allow for surgical planning, training, simulation, and devices for the assessment and treatment of neurosurgical disease. Expansion of this technology in neurosurgery will serve practitioners, trainees, and patients.
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Affiliation(s)
- Ankit Chaudhary
- Department of Neurosurgery, Sawai Man Singh Medical College, Jaipur, Rajasthan, India
| | - Sanjeev Chopra
- Department of Neurosurgery, Sawai Man Singh Medical College, Jaipur, Rajasthan, India
| | - Virendra Deo Sinha
- Department of Neurosurgery, Sawai Man Singh Medical College, Jaipur, Rajasthan, India
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11
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Zhou S, Yuan B, Liu W, Tang Y, Chen X, Jia L. Three-dimensional reduction method with a modified C2 isthmus screw in irreducible atlantoaxial dislocation: a technical note. BMC Surg 2021; 21:324. [PMID: 34384414 PMCID: PMC8362247 DOI: 10.1186/s12893-021-01321-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 07/25/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Three-dimensional reduction plays a vital role in surgical reduction of irreversible atlantoaxial dislocation (IAAD). However, the most commonly used combination of C1 pedicle screw (PS) or lateral mass screw (LMS) and C2 PS or isthmus screw often fails to achieve satisfactory reduction at one time. The difficulty is usually caused by short anteroposterior and vertical distance between heads of C1 and C2 screws, which lack enough space for reduction operation. The objective of this study is to describe a three-dimensional reduction method with a modified C2 isthmus screw and to illustrate its advantage and effectiveness for IAAD. METHODS Twelve patients with IAAD underwent reduction and fixation with modified C2 isthmus screw combined with C1 PS or LMS, fusion with autologous bone graft. The insertion point was lateral to the intersection of caudal edge of C2 lamina and lateral mass, with a trajectory towards C2 isthmus, via lateral mass. The three-dimensional reduction was achieved through pulling and distracting. Radiographic evaluation included anteroposterior and direct distance between different insertion points, the occipitoaxial angle (O-C2A), clivus-canal angle (CCA) and cervicomedullary angle (CMA). Clinical outcomes evaluation included the Japanese Orthopaedic Association (JOA) score, Visual analog scale (VAS) and Neck Disability Index (NDI). RESULTS All the patients maintained effective reduction during the follow-up. The anteroposterior and direct distance was significantly higher in modified C2 isthmus screw than C2 PS whether combined with C1 PS or LMS (P < 0.05). The degree of O-C2A, CCA and CMA, JOA score, NDI, and VAS were significantly improved after the surgery (P < 0.05). CONCLUSIONS Three-dimensional reduction method with a modified C2 isthmus screw is effective and safe in managing IAAD. It can increase the anteroposterior and vertical distance between the heads of C1 and C2 screws, which is benefit for the three-dimensional reduction operation of IAAD.
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Affiliation(s)
- Shengyuan Zhou
- Spine Center, Department of Orthopedics, Shanghai Changzheng Hospital, Naval Medical University (Second Military Medical University), Shanghai, 200003, People's Republic of China
| | - Bo Yuan
- Spine Center, Department of Orthopedics, Shanghai Changzheng Hospital, Naval Medical University (Second Military Medical University), Shanghai, 200003, People's Republic of China
| | - Weicong Liu
- Department of Orthopedics, the Second Affiliated Hospital, Hunan Normal University, Changsha, People's Republic of China
| | - Yifan Tang
- Spine Center, Department of Orthopedics, Shanghai Changzheng Hospital, Naval Medical University (Second Military Medical University), Shanghai, 200003, People's Republic of China
| | - Xiongsheng Chen
- Spine Center, Department of Orthopedics, Shanghai Changzheng Hospital, Naval Medical University (Second Military Medical University), Shanghai, 200003, People's Republic of China.
| | - Lianshun Jia
- Spine Center, Department of Orthopedics, Shanghai Changzheng Hospital, Naval Medical University (Second Military Medical University), Shanghai, 200003, People's Republic of China
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12
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Salunke P, Karthigeyan M, Singh A. The enigma of acute worsening after a latent interval in post-operative patients of craniovertebral junction instability. Clin Neurol Neurosurg 2021; 207:106741. [PMID: 34144465 DOI: 10.1016/j.clineuro.2021.106741] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 03/22/2021] [Accepted: 05/24/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE For reasons that are poorly understood and still undocumented, few patients of craniovertebral junction (CVJ) anomalies with instability/atlantoaxial dislocation (AAD) in our practice have been seen to suffer unprecedented acute neurological deterioration with respiratory compromise about 48-72 h post-surgery. This has been specifically observed after an uneventful, stable clinical condition in the immediate postoperative period. This study attempts to elucidate the factors and outcomes related to such latent worsening. PATIENTS AND METHODS The 4-year surgical data of 268-patients with CVJ instability (AAD/basilar-invagination) who underwent C1-C2 fixation were retrospectively studied. The relevant factors of 17 patients who showed such deterioration were compared with that of the remaining in a multivariate model. RESULTS Seventeen patients had acute neurological worsening with respiratory arrest after a latent period. Ten improved at follow-up. Contrary to the general expectation, poor preoperative neurological score or severe dislocation that needed considerable manipulation did not influence such worsening. Dural injury in patients with associated Chiari malformation and vertebral arterial (VA) injury emerged as independent factors (p < 0.01) associated with this pattern of delayed neurological decline. CONCLUSIONS We report our management and outcomes of a unique subset of AAD with neurological worsening in the postoperative period after 48-72 h. Such a subgroup was not previously identified in literature. Dural lacerations in AAD with Chiari, and VA injury seem to predispose to such complications and should be prevented at best. Close observation, and caution regarding early extubation (<72 h) is recommended in this subset despite an apparently uneventful immediate postoperative neurological status.
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Affiliation(s)
- Pravin Salunke
- Department of Neurosurgery, Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh, India.
| | - Madhivanan Karthigeyan
- Department of Neurosurgery, Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh, India.
| | - Apinderpreet Singh
- Department of Neurosurgery, Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh, India.
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13
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Ma F, Liao Y, Tang Q, Tang C, Luo N, He H, Yang S, Wang Q, Zhong D. Morphometric Analysis of the Lateral Atlantoaxial Joints in Patients with an Old Type II Odontoid Fracture and Atlantoaxial Dislocation: A Study Based on CT Analysis. Spine (Phila Pa 1976) 2021; 46:726-733. [PMID: 33337679 DOI: 10.1097/brs.0000000000003894] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
MINI The morphological features of the lateral atlantoaxial joints (LAJs) in patients with old type II odontoid fractures and atlantoaxial dislocation have not been fully analyzed. Our study found the changes in morphological features of the LAJs in some patients, and revealed the causes and consequences of the changes in morphological features of the LAJs.
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Affiliation(s)
- Fei Ma
- Department of Orthopaedics, The Affiliated Hospital of Southwest Medical University, Luzhou, China
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14
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A novel surgical protocol for safe and accurate placement of C1 lateral mass screws in patients with atlas assimilation, basilar invagination and atlantoaxial instability: technical details, accuracy assessment and perioperative complications. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2021; 30:1585-1595. [PMID: 33704580 DOI: 10.1007/s00586-021-06780-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 10/23/2020] [Accepted: 02/16/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE To introduce a novel surgical protocol for safe and accurate placement of C1 lateral mass screws in patients with atlas assimilation, basilar invagination and atlantoaxial instability, and to categorize the screw accuracy and perioperative complications regarding this technique in a large case series. METHODS Between January 2015 and January 2020, patients who had atlas assimilation, basilar invagination and atlantoaxial instability, and underwent atlantoaxial fixation using C1 lateral mass screws were reviewed. C1 lateral mass screws were placed with a novel surgical protocol following a series key steps, including posterior para-odontoid ligament release, panoramic exposure of the invaginated lateral mass, and diligent protection of the abnormal VA. Screw accuracy and related complications were specifically evaluated. RESULTS A total of 434 C1 lateral mass screws were placed. Fifteen screws (3.5%) were classified as unacceptable, 54 screws (12.4%) were classified as acceptable, and 365 screws (84.1%) were classified as ideal. Overall, 96.5% of screws were deemed safe. There were no cases of vascular injury or permanent neurological defects. One patient with an unacceptable screw presented with hypoglossal nerve paralysis and recovered after an immediate revision surgery. Thirty-seven patients complained about occipital neuralgia and were successfully managed with medication. CONCLUSION Placement of C1 lateral mass screws in patients with atlas assimilation, basilar invagination and atlantoaxial instability following this surgical protocol is safe and accurate. Thorough para-odontoid ligamental release, wide exposure of the invaginated lateral mass, and diligent protection of the vertebral artery are critical to maximize the chances of successful screw placement.
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15
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Hong JT, Kim IS, Lee HJ, Park JH, Hur JW, Lee JB, Lee JJ, Lee SH. Evaluation and Surgical Planning for Craniovertebral Junction Deformity. Neurospine 2020; 17:554-567. [PMID: 33022160 PMCID: PMC7538356 DOI: 10.14245/ns.2040510.255] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Accepted: 09/16/2020] [Indexed: 11/22/2022] Open
Abstract
Craniovertebral junction (CVJ) deformity is a challenging pathology that can result in progressive deformity, myelopathy, severe neck pain, and functional disability, such as difficulty swallowing. Surgical management of CVJ deformity is complex for anatomical reasons; given the discreet relationships involved in the surrounding neurovascular structures and intricate biochemical issues, access to this region is relatively difficult. Evaluation of the reducibility, CVJ alignment, and direction of the mechanical compression may determine surgical strategy. If CVJ deformity is reducible, posterior in situ fixation may be a viable solution. If the deformity is rigid and the C1–2 facet is fixed, osteotomy may be necessary to make the C1–2 facet joint reducible. C1–2 facet release with vertical reduction technique could be useful, especially when the C1–2 facet joint is the primary pathology of CVJ kyphotic deformity or basilar invagination. The indications for transoral surgery are becoming as narrow as a treatment for CVJ deformity. In this article, we will discuss CVJ alignment and various strategies for the management of CVJ deformity and possible ways to prevent complications and improve surgical outcomes.
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Affiliation(s)
- Jae Taek Hong
- Department of Neurosurgery, Eunpyeong St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Il Sup Kim
- Department of Neurosurgery, St. Vincent's Hospital, The Catholic University of Korea, Suwon, Korea
| | - Ho Jin Lee
- Department of Neurosurgery, St. Vincent's Hospital, The Catholic University of Korea, Suwon, Korea
| | - Jong Hyuk Park
- Department of Neurosurgery, Incheon St. Mary's Hospital, The Catholic University of Korea, Incheon, Korea
| | - Jeong Woo Hur
- Department of Neurosurgery, Eunpyeong St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Jong Beom Lee
- Department of Neurosurgery, Chungbuk National University, Cheongju, Korea
| | - Jeong Jae Lee
- Department of Neurosurgery, GangNeung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Sang Hyo Lee
- Department of Neurosurgery, Eunpyeong St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
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Technique of C2 Subfacetal Screw in Patients with High-Riding Vertebral Artery. World Neurosurg 2020; 144:59. [PMID: 32791217 DOI: 10.1016/j.wneu.2020.08.045] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 08/04/2020] [Accepted: 08/05/2020] [Indexed: 11/23/2022]
Abstract
A C2 pedicle screw provides robust construct for fixation in atlantoaxial dislocation.1-5 However, inserting a C2 pedicle screw with the standard technique in cases with narrow pedicle and high-riding vertebral artery (VA) may endanger the artery.6 A pars screw is also risky and biomechanically inferior.3-5 This video demonstrates the technique of safe insertion of subfacetal screws, directly into the C2 body while safeguarding the VA in a patient with atlantoaxial dislocation/basilar-invagination with cervicomedullary compression (Video 1). Computed tomography angiography showed a high-riding VA with a thin pedicle. The patient underwent posterior C1-C2 joint manipulation and fixation.1,2 After the joints were exposed, the VA was dissected from the medial border of the C2 transverse foramen and a subfacetal screw was inserted directly into the C2-body, safeguarding the artery.7 The screw trajectory is similar to that described by Goel et al8 (15-20 degrees cranial and 30-40 degrees medial). The entry point in the Goel technique is 2 mm below the medial portion of C2 superior articular surface. However, with a high-riding VA, the entry point needs to be shifted medially. C1 lateral mass screws were inserted according to the standard technique and fixed to C2 screws with rods. Postoperatively, the patient improved and radiology showed satisfactory reduction with good flow across the VA on angiography. There is a minimal risk of arterial injury/spasm due to its handling. Nevertheless, the benefit of a strong construct clearly outweighs this risk. Alternatively, one may insert a C2 laminar screw. However, the biomechanical considerations are better with the C2 pedicle screws and the overall construct may be not ideal as the fixation is away from the C1-C2 joint.3-5,9.
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Ma F, He H, Liao Y, Tang Q, Tang C, Yang S, Wang Q, Zhong D. Classification of the facets of lateral atlantoaxial joints in patients with congenital atlantoaxial dislocation. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2020; 29:2769-2777. [PMID: 32728804 DOI: 10.1007/s00586-020-06551-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 07/22/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE To investigate the morphological characteristics and para-positions of the facets of lateral atlantoaxial joints (FLAJs) in patients with congenital atlantoaxial dislocation (CAAD) and to propose a classification system for the FLAJs. METHODS A total of 93 cases of CAAD were included in this retrospective study. The obliquity and slippage of the FLAJs in the sagittal and coronal planes were measured and observed in the CT images of all of the cases. The obliquity and slippage of the FLAJs represented the morphological characteristics and the para-positions, respectively, and were used as classification parameters. Accordingly, a classification system for the FLAJs was established. We additionally investigated the correlation between the classifications of the FLAJs and various types of CAAD. The classifications of the FLAJs in 34 patients with irreducible AAD (IAAD) were also investigated. RESULTS One hundred eighty-six FLAJs in 93 patients were classified into 6 types (namely, A, B1, B2, C, D1, and D2) for obliquity and 3 types (namely, S0, S1, and S2) for slippage. Among the 186 FLAJs, type B1 and type S0 were the most common obliquity and slippage types, respectively. There were 11 combination types for obliquity and 5 combination types for slippage of bilateral FLAJ in 93 patients. Most of the patients (69.7%, 47/70) with anteroposterior AAD had accompanying slippage and anteversion of the FLAJ in the sagittal plane. Rotational AAD was found in 10 patients with asymmetrical slippage in both FLAJs in the sagittal plane. Lateral translational AAD was found in 6 patients with an S1-type FLAJ in the coronal plane. In 5 patients with lateral angular AAD, FLAJs of types D1 and S2 were observed on one side. Among the 34 patients with IAAD, 31 patients had both obliquity and slippage in the FLAJs on one or both sides. CONCLUSION The morphological characteristics and para-positions of the FLAJs on both sides largely determine the types of AAD in patients with CAAD. The types of obliquity and slippage of the FLAJ are related to the reducibility of AAD.
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Affiliation(s)
- Fei Ma
- Department of Spine Surgery, Affiliated Hospital of Southwest Medical University, No. 25 Taiping Street, Luzhou City, 646000, China
| | - Hongchun He
- Department of Spine Surgery, Affiliated Hospital of Southwest Medical University, No. 25 Taiping Street, Luzhou City, 646000, China
| | - Yehui Liao
- Department of Spine Surgery, Affiliated Hospital of Southwest Medical University, No. 25 Taiping Street, Luzhou City, 646000, China
| | - Qiang Tang
- Department of Spine Surgery, Affiliated Hospital of Southwest Medical University, No. 25 Taiping Street, Luzhou City, 646000, China
| | - Chao Tang
- Department of Spine Surgery, Affiliated Hospital of Southwest Medical University, No. 25 Taiping Street, Luzhou City, 646000, China
| | - Sheng Yang
- Department of Spine Surgery, Affiliated Hospital of Southwest Medical University, No. 25 Taiping Street, Luzhou City, 646000, China
| | - Qing Wang
- Department of Spine Surgery, Affiliated Hospital of Southwest Medical University, No. 25 Taiping Street, Luzhou City, 646000, China
| | - Dejun Zhong
- Department of Spine Surgery, Affiliated Hospital of Southwest Medical University, No. 25 Taiping Street, Luzhou City, 646000, China.
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Dong C, Yang F, Wei H, Tan M. Anterior release without odontoidectomy for irreducible atlantoaxial dislocation: transoral or endoscopic transnasal? EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2020; 30:507-516. [PMID: 32654012 DOI: 10.1007/s00586-020-06527-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 04/30/2020] [Accepted: 07/01/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE To compare transoral and endoscopic transnasal anterior release without odontoidectomy and posterior reduction and fixation to treat irreducible atlantoaxial dislocation (IAAD). METHODS From June 2006 to January 2017, 35 consecutive patients with IAAD underwent transoral (Tr-Oral group) or endoscopic transnasal (Tr-Nasal group) release and posterior fixation and fusion in our department. Clinical neurological recovery (Japanese Orthopedic Association (JOA) score) and radiological reduction parameters including atlantodontoid interval (ADI), space available for the cord (SAC) and cervicomedullary angle (CMA) were analyzed and compared. The operation duration, blood loss, length of intensive care unit (ICU)/hospital stay and complications were recorded. RESULTS All 35 patients (18 and 17 patients in the Tr-Oral and Tr-Nasal groups, respectively) were followed up for a mean of 36.4 months (range, 21-60 months). All patients achieved excellent anatomical reduction and clinical neurological recovery, with no significant differences between the two groups. The JOA score, ADI, SAC and CMA were not significantly different between the two groups at various postoperative points. Although the Tr-Oral group had shorter operation time and less blood loss than the Tr-Nasal group, the Tr-Nasal group tended to have a significantly shorter hospital/ICU stay, earlier extubation and earlier oral intake than the Tr-Oral group. CONCLUSION The transoral and endoscopic transnasal approaches can achieve equivalent release and reduction effects when treating IAAD. Compared to the transoral approach, the endoscopic transnasal route is less invasive with earlier extubation and oral intake, shorter hospital/ICU stays and lower medical costs, which is conducive to enhanced recovery after surgery.
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Affiliation(s)
- Chunke Dong
- Beijing University of Chinese Medicine, 11 North Third Ring Road East, Chaoyang District, Beijing, 100029, China
- Department of Orthopaedic Surgery, China-Japan Friendship Hospital, 2 Yinghuadong Road, Chaoyang District, Beijing, 100029, China
| | - Feng Yang
- Department of Orthopaedic Surgery, China-Japan Friendship Hospital, 2 Yinghuadong Road, Chaoyang District, Beijing, 100029, China
| | - Hongyu Wei
- Department of Orthopaedic Surgery, China-Japan Friendship Hospital, 2 Yinghuadong Road, Chaoyang District, Beijing, 100029, China
| | - Mingsheng Tan
- Department of Orthopaedic Surgery, China-Japan Friendship Hospital, 2 Yinghuadong Road, Chaoyang District, Beijing, 100029, China.
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Duan W, Chou D, Jian F, Chen Z. Posterior intra-articular distraction with cage placement to treat congenital atlantoaxial dislocation associated with basilar invagination. NEUROSURGICAL FOCUS: VIDEO 2020; 3:V2. [PMID: 36285121 PMCID: PMC9542379 DOI: 10.3171/2020.3.focusvid.191001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Accepted: 03/31/2020] [Indexed: 06/16/2023]
Abstract
Congenital atlantoaxial dislocation (AAD) associated with basilar invagination (BI) is a complex congenital malalignment at the craniovertebral junction. The olisthesis, atlantoaxial facet joint arthropathy, and the contraction of the anterior soft tissue make the treatment challenging. Our video demonstrates the surgical technique for posterior intra-articular distraction with cage placement to treat congenital atlantoaxial dislocation associated with basilar invagination. The video can be found here: https://youtu.be/7EQqW96HhN8.
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Affiliation(s)
- Wanru Duan
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China; and
| | - Dean Chou
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Fengzeng Jian
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China; and
| | - Zan Chen
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China; and
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Chryssikos T, Pratt N, Howie B, Mushlin H, Sansur C. Open Reduction and Decompression of Atlantoaxial Subluxation with Basilar Impression Due to Grisel Syndrome Using the Cervical Management Base Unit. World Neurosurg 2020; 138:129-136. [PMID: 32147559 DOI: 10.1016/j.wneu.2020.02.165] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 02/24/2020] [Accepted: 02/25/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Intraoperative manipulation of the craniocervical junction with the Cervical Management Base Unit (CMBU) has been used as an adjunct for achieving optimal anatomic alignment during instrumented fusion procedures in a variety of disease settings. Here, we present our experience using the CMBU as a supplement to achieving a successful reduction and fixation of a reducible craniocervical subluxation with associated basilar impression/medullary compression in the setting of Grisel syndrome. CASE DESCRIPTION Under fluoroscopy and neuromonitoring guidance, the elevator and axial translation mechanisms of the CMBU safely allowed for presurgical assessment of reducibility and facilitated complete reduction of the deformity with restitution of a normal atlantodental interval, spinolaminar line, and clivoaxial angle. Magnetic resonance imaging acquired 1 month after surgery and antibiotic therapy showed resolution of a large epidural abscess in the region of the dens and no evidence of residual neural impingement. Upright plain films at 9 months showed maintenance of the desired craniocervical alignment. CONCLUSIONS Intraoperative manipulation of the craniocervical junction using the CMBU, when implemented under fluoroscopy and neuromonitoring, can safely facilitate an enduring anatomic correction of craniocervical deformity in the setting of Grisel syndrome. The dynamic utility of the CMBU for translation of the head and neck obviated the need to apply forces directly to hardware-bone interfaces, and its utility may extend to craniocervical disorders of other etiologies, especially those of a reducible nature and in the setting of poor bone quality and joint laxity.
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Affiliation(s)
- Timothy Chryssikos
- Department of Neurosurgery, University of Maryland, Baltimore, Maryland, USA.
| | - Nathan Pratt
- Department of Neurosurgery, University of Maryland, Baltimore, Maryland, USA
| | - Benjamin Howie
- Department of Neurosurgery, University of Maryland, Baltimore, Maryland, USA
| | - Harry Mushlin
- Department of Neurosurgery, University of Maryland, Baltimore, Maryland, USA
| | - Charles Sansur
- Department of Neurosurgery, University of Maryland, Baltimore, Maryland, USA
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Salunke P, Karthigeyan M, Ahuja CK, Panchal C. An Unusual Cause of Vertebrobasilar Insufficiency in a Case of Atlantoaxial Dislocation with Anomalous Vertebral Artery. World Neurosurg 2020; 138:193-196. [PMID: 32145426 DOI: 10.1016/j.wneu.2020.02.144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Accepted: 02/23/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Posterior circulation stroke resulting from atlantoaxial dislocation (AAD), although uncommon, is a well-described entity. The normally coursed V3 segment of the vertebral artery (VA) is likely to be stretched because of C1-C2 dislocation and further compromised by the C1-C2 translational mobility. The persistent first intersegmental artery (PFIA), an anomalous variant does not course through the C1 transverse foramen, but rather crosses the posterior C1-C2 joints and is unlikely to be affected by the C1-C2 dislocation. Therefore, a patient with AAD and anomalous VA presenting with stroke should be evaluated for other etiologies of VA compromise. CASE DESCRIPTION We report a patient of AAD with PFIA who presented with posterior circulation stroke. Careful radiological evaluation revealed a loose body (LB) adjacent to the medial aspect of the left C1-C2 facet compressing the anomalous VA. Intraoperatively, there was a large LB on the posteromedial border of the joint, compressing the VA. The anomalous VA was mobilized, and the offending element removed followed by fixation of the C1-C2. CONCLUSIONS One should be aware of such an etiology of arterial compromise in cases of AAD with coexistent anomalous VA. An underlying LB or large osteophytes resulting from instability may be the offending cause, and needs to be dealt with, as fusion alone may not benefit the patient.
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Affiliation(s)
- Pravin Salunke
- Department of Neurosurgery, Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
| | - Madhivanan Karthigeyan
- Department of Neurosurgery, Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh, India.
| | - Chirag Kamal Ahuja
- Department of Neuroradiology, Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
| | - Chirag Panchal
- Department of Neurosurgery, Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
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Agarwal P, Chopra S, Sinha VD, Kataria R. Three-Dimensional-Printed Model-Assisted Management of Craniovertebral Junction Abnormalities: An Institutional Experience with Literature Review. Asian Spine J 2019; 14:204-211. [PMID: 31679320 PMCID: PMC7113469 DOI: 10.31616/asj.2019.0138] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 06/26/2019] [Indexed: 12/11/2022] Open
Abstract
Study Design Prospective study. Purpose To evaluate the utility and limitations of using three-dimensional (3D)-printed models for the management of craniovertebral (CV) junction abnormalities. Overview of Literature In comparison to other bony and vascular anomalies, CV junction abnormalities are difficult to treat. For cases of irreducible atlantoaxial dislocation (AAD), posterior reduction and stabilization have replaced anterior decompression as the standard management protocol. The use of 3D models, such as those described herein, can provide surgeons with in-depth knowledge of the vertebral artery course and bony anomalies associated with CV junction abnormalities. Methods Clinical and radiological features of 18 patients with CV junction abnormalities were analyzed between March 2017 and February 2019 at Sawai Man Singh Medical College, Jaipur, India. Dynamic computed tomography (CT) of the CV junction and CT angiographies of the neck with respect to the vertebral artery course at the C1–C2 joints were obtained and studied. Customized 3D models of the CV junction were then made based on the CT data, and rehearsal of the surgical procedure was performed using the 3D model one day prior to performing the actual procedure. Results Seventeen patients had congenital-type AAD, whereas one patient had posttraumatic AAD. Improvements in neck pain and myelopathy were seen in all patients at the follow-up, as analyzed using the Visual Analog Scale and the Japanese Orthopedic Association Scale score, respectively. There were no cases of malpositioning of screws or any direct vertebral artery injury, although in one patient, the distal flow in the dominant vertebral artery was cut off as it got compressed between the bony arch and the screw head. Conclusions Compared to computer-generated images, 3D-printed models are a more practical approach for dealing with complex CV junction abnormalities. They provide surgeons with deep insights into the complex bony anomalies as well as variations in the vertebral artery courses, thereby improving surgical outcomes.
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Affiliation(s)
- Prashant Agarwal
- Department of Neurosurgery, Sawai Man Singh Medical College, Jaipur, India
| | - Sanjeev Chopra
- Department of Neurosurgery, Sawai Man Singh Medical College, Jaipur, India
| | - Virendra Deo Sinha
- Department of Neurosurgery, Sawai Man Singh Medical College, Jaipur, India
| | - Rashim Kataria
- Department of Neurosurgery, Sawai Man Singh Medical College, Jaipur, India
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Tailored Posterior-Only Approach for C2 Vertebral Body Lesions: Our Surgical Experience in 10 Patients. World Neurosurg 2019; 133:e730-e738. [PMID: 31605844 DOI: 10.1016/j.wneu.2019.09.155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 09/26/2019] [Accepted: 09/27/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND C2 vertebral body (axis) lesions are often approached anteriorly and combined with posterior stabilization of the craniovertebral junction (CVJ). The anterior approach has its limitations. A posterolateral corridor is an alternative access to the C2 body lesions, and this alone may suffice in selected cases. We describe our experience with C2 body lesions, dealt primarily through a posterior approach, and propose an algorithm in the management of such cases. METHODS Ten patients with axis lesions were operated through a midline posterior approach followed by posterior stabilization of the CVJ in the same sitting. Their preoperative and follow-up clinico-radiologic details were reviewed. RESULTS The lesions included aneurysmal bone cysts (n = 2), fibrous dysplasia (n = 2), chordoma (n = 2), Ewing sarcoma (n = 1), metastases (n = 1), post-traumatic malunion (n = 1), and post-inflammatory deformity (n = 1). All patients presented with worsening neck pain. Five also had spastic quadriparesis. There were no perioperative complications. All showed clinical improvement at follow-up. Only 2 patients (chordoma: n = 1; aneurysmal bone cyst: n = 1) required an additional anterior procedure. CONCLUSIONS Adequate debulking or total excision of lesion, neural decompression, and stabilization of the CVJ for axis body lesions can be achieved through a single midline posterior approach in most cases. If required, an anterior approach may be later added depending on the final histopathology.
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Du YQ, Qiao GY, Yin YH, Li T, Tong HY, Yu XG. Usefulness of 3D Printed Models in the Management of Complex Craniovertebral Junction Anomalies: Choice of Treatment Strategy, Design of Screw Trajectory, and Protection of Vertebral Artery. World Neurosurg 2019; 133:e722-e729. [PMID: 31589981 DOI: 10.1016/j.wneu.2019.09.139] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 09/25/2019] [Accepted: 09/26/2019] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To evaluate the usefulness of 3-dimensional (3D) printed models as an aid for the treatment of complex CVJ anomalies. METHODS 3D printed models were fabricated for 21 patients with complex CVJ anomalies, including vertebral artery anomaly, thin C2 pedicle, vertical atlantoaxial facet joint, or rotational dislocation combined with atlantoaxial dislocation and basilar invagination. Preoperative planning, surgical simulation, and intraoperative reference were achieved using the 3D model during the surgical treatment. The usefulness of 3D printed models, and postoperative clinical and radiological outcomes were assessed. RESULTS Direct posterior reduction and atlantoaxial fixation were achieved in 19 patients. Transoral odontoidectomy followed by posterior fixation was implemented for 2 patients with vertical facet joint and rotational dislocation. All screws were safely inserted with no complication, and 90% patients achieved a >60% reduction of both horizontal and vertical dislocation. Clinical symptoms improved in all patients, with the averaged Japanese Orthopedic Association scores increasing from 11.14 to 14.43 (P < 0.01). CONCLUSIONS The patient-specific 3D printed model would be an effective tool for evaluation of the reducibility of the atlantoaxial dislocation and basilar invagination, decision making in choosing the optimal surgical approach and way of fixation, and precise placement of the screw while protecting the vertebral artery and spinal cord. The risk of neurovascular injury was minimized, and encouraging outcomes were achieved with the aid of this technique.
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Affiliation(s)
- Yue-Qi Du
- Department of Neurosurgery, Chinese PLA General Hospital, Haidian District, Beijing, China
| | - Guang-Yu Qiao
- Department of Neurosurgery, Chinese PLA General Hospital, Haidian District, Beijing, China
| | - Yi-Heng Yin
- Department of Neurosurgery, Chinese PLA General Hospital, Haidian District, Beijing, China.
| | - Teng Li
- Department of Neurosurgery, Chinese PLA General Hospital, Haidian District, Beijing, China
| | - Huai-Yu Tong
- Department of Neurosurgery, Chinese PLA General Hospital, Haidian District, Beijing, China
| | - Xin-Guang Yu
- Department of Neurosurgery, Chinese PLA General Hospital, Haidian District, Beijing, China
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Sardhara J, Behari S, Sindgikar P, Srivastava AK, Mehrotra A, Das KK, Bhaisora KS, Sahu RN, Jaiswal AK. Evaluating Atlantoaxial Dislocation Based on Cartesian Coordinates: Proposing a New Definition and Its Impact on Assessment of Congenital Torticollis. Neurosurgery 2019; 82:525-540. [PMID: 28472514 DOI: 10.1093/neuros/nyx196] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 03/21/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Conventional 2-dimensional (2-D) definition of atlantoaxial dislocation (AAD) is inadequate for coexisting 3-D displacements. OBJECTIVE To prospectively classify AAD and its related abnormalities along 3 Cartesian coordinates and assess their association with torticollis. METHODS One hundred and fifty-four patients with congenital AAD were prospectively classified according to their C1-2 displacement along 3 Cartesian coordinates utilizing 3-D multiplanar CT. The impact of this 3-D dislocation on occurrence of clinically manifest torticollis was also evaluated and surgical treatment was planned. RESULTS Three dimensional CT assessment detected the following types of C1-2 dislocations: I:translational dislocation (along Z coordinate, n = 37 [24%]); II: central dislocation (along Y coordinate, n = 10 [6.5%]); III: translational+central dislocation (along Z+Y coordinates, n = 42 [27.3%]); IV: translational dislocation+ rotational dislocation+coronal tilt (along Z+X coordinates, (n = 6 [3.9%]); V: central dislocation (basilar invagination)+rotational dislocation+coronal tilt (along Y+X coordinates, n = 11 [7.1%]); VI: translational dislocation+ central dislocation+ rotational dislocation+ coronal tilt (along all 3 axes, n = 48 [31%]). Assessing degree of relative C1-2 rotation revealed that 27 (37%) of 85 patients with <50 rotation and 54 (78%) of 69 patients with >5° rotation had associated torticollis. Translational dislocation had negative association (odds ratio [OR] 0.1, 95% confidence interval [CI; 0.47-0.32], P = .00), while type VI (OR 5.0, 95% CI [2.2-11.19], P = .00), type V (OR 4.44, 95% CI [0.93-21.26], P = .04), and type IV (OR 1.84, 95% CI [0.32-10.38], P = .48) dislocations had strong positive association with torticollis. Sixty-two (40%) patients improved, 68 (44%) remained unchanged, and 24 (16%) patients worsened postoperatively. Twenty-eight patients required second-stage transoral decompression following posterior distraction-fusion due to neurological nonimprovement. CONCLUSION Three-dimensional assessment of AAD including evaluation of culpable C1-2 facet joints addresses anomalous displacements in 3 Cartesian planes. This provides targets for adequate cervicomedullary decompression-stabilization, and helps in the management of accompanying torticollis.
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Affiliation(s)
- Jayesh Sardhara
- Department of Neurosurgery, Sanjay Ga-ndhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Sanjay Behari
- Department of Neurosurgery, Sanjay Ga-ndhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Pavaman Sindgikar
- Department of Neurosurgery, Sanjay Ga-ndhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Arun Kumar Srivastava
- Department of Neurosurgery, Sanjay Ga-ndhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Anant Mehrotra
- Department of Neurosurgery, Sanjay Ga-ndhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Kuntal Kanti Das
- Department of Neurosurgery, Sanjay Ga-ndhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Kamlesh Singh Bhaisora
- Department of Neurosurgery, Sanjay Ga-ndhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Rabi N Sahu
- Department of Neurosurgery, Sanjay Ga-ndhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Awadhesh K Jaiswal
- Department of Neurosurgery, Sanjay Ga-ndhi Postgraduate Institute of Medical Sciences, Lucknow, India
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Srivastava A, Sardhara J, Behari S, Pavaman S, Joseph J, Das K, Mehrotra A, Jaiswal AK, Bhaishora K. Knock and Drill Technique: A Simple Tips for the Instrumentation in Complex Craniovertebral Junction Anomalies without using Fluoroscopy. J Neurosci Rural Pract 2019; 8:14-19. [PMID: 28149076 PMCID: PMC5225702 DOI: 10.4103/0976-3147.193555] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Context: Existence of complex variable bony and vertebral artery (VA) anomalies at craniovertebral junction (CVJ) in subset of complex CVJ anomalies demands individualized instrumentation policy and placing screws in each bone requires strategic preoperative planning and intraoperative skills. Aim: To evaluate the clinical accuracy of knock and drill (K and D) technique for the screw placement in complex CVJ anomalies. Settings and Design: Prospective study and operative technical note. Materials and Methods: Totally 36 consecutive patients (16 - pediatrics, 20 - adult patients) of complex CVJ: Complete/partial occipitalized C1 vertebra; at least one hypoplastic (C1/C2) articular mass, rotational component, and variations in the third part of VA were included in this study. Preoperative detail computed tomography (CT) CT CVJ with three-dimensional reconstruction was done for the assessment of CVJ anatomy and facet joint orientation. The accuracy of novel technique was assessed with postoperative CT to evaluate cortical breach in between 5th and 7th postoperative day in all the patients. All patients were underwent clinico-radiological evaluation at 6-month follow-up. Results: Totally 144 screws were placed using K and D technique (pediatric group - 64 screws, adult patients - 80 screws). Total of 12 screws were placed in C1 lateral mass in both age group without any bony cortical breach and complication. Sixteen C2 pedicle screws and 12 C2 pars screw in pediatrics and 18 C2 pedicle screws in adult patients were placed without any bony breach or VA injury. Out of thirty subaxial lateral mass screws in pediatric group, the bony breach was encountered with one screw (3.3%). Total of 38 C2 pars screws was placed in adult group in which bony breach along with VA injury was encounter with 1screw (2.6%). Conclusion: A simple technique of K and D for placing a screw increases the accuracy and spectrum of bony purchase and has the potential to reduce the complication in patients with complex CVJ anomalies.
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Affiliation(s)
- Arun Srivastava
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Jayesh Sardhara
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Sanjay Behari
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Sindgikar Pavaman
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Jeena Joseph
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Kuntal Das
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Anant Mehrotra
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Awadhesh K Jaiswal
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Kamlesh Bhaishora
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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Duan W, Du Y, Qi T, Jiang B, Wang K, Liu Z, Guan J, Wang X, Wu H, Chen Z, Jian F. The Value and Limitation of Cervical Traction in the Evaluation of the Reducibility of Atlantoaxial Dislocation and Basilar Invagination Using the Intraoperative O-Arm. World Neurosurg 2019; 132:e324-e332. [PMID: 31476460 DOI: 10.1016/j.wneu.2019.08.160] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 08/22/2019] [Accepted: 08/23/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To assess the value and limitation of cervical traction in the evaluation of the reducibility of atlantoaxial dislocation (AAD) and basilar invagination (BI) using the intraoperative O-arm. METHODS A total of 22 patients with hyperextensive, irreducible AAD were included. The cervical traction test under general anesthesia was performed, and the degree of reduction was evaluated using the O-arm before the operation started. The traction effects both vertically and horizontally were evaluated. All cases then underwent modified direct posterior reduction and fixation. Clinical outcomes were evaluated using the Japanese Orthopaedic Association (JOA) scale. Radiologic measurements included the anterior atlantodental interval, the distance of odontoid tip above Chamberlain line, and the clivus-canal angle. Magnetic resonance imaging signal changes, size of syringomyelia, and the space ventral to medulla also were used to evaluate the postoperative reduction result. RESULTS After the cervical traction test, 7 patients achieved incomplete reduction, 5 achieved only vertical reduction, 6 achieved only horizontal reduction, and 4 achieved complete reduction in both horizontal and vertical orientations as assessed by the O-arm. All patients underwent a direct reduction technique. The mean JOA score increased from 11.1 to 14.5. Complete reduction of AAD and BI were achieved in 19 patients (86.4%), with partial reduction achieved in 3 (13.6%). Sufficient cerebrospinal fluid space anterior to the medulla with improved JOA score was achieved in the 3 partially reduced patients. CONCLUSIONS With the innovations of direct posterior reduction techniques, cervical traction under anesthesia may not sufficiently predict the reducibility of BI and AAD. Cervical traction still plays an important role during the direct posterior reduction procedure.
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Affiliation(s)
- Wanru Duan
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yueqi Du
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Tengfei Qi
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Bowen Jiang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kai Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Zhenlei Liu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jian Guan
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xingwen Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Hao Wu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Zan Chen
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Fengzeng Jian
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.
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Wang HW, Li XP, Yin YH, Li T, Yu XG. Change of Anatomical Location of the Internal Carotid Artery Relative to the Atlas with Congenital Occipitalization and the Relevant Clinical Implications. World Neurosurg 2019; 130:e505-e512. [PMID: 31254707 DOI: 10.1016/j.wneu.2019.06.138] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 06/16/2019] [Accepted: 06/17/2019] [Indexed: 11/25/2022]
Abstract
INTRODUCTION The occipitalization of the atlas (OA) is always associated with multiplanar dislocation and olisthy of the C1 over C2 facets, which may change the anatomical relationship between the internal carotid artery (ICA) and the atlas. The purpose of this current study is to identify the location of the ICA relative to the anterior aspect of the atlas in patients with OA and define the clinical implications for screw placement. METHODS We retrospectively reviewed the computed tomography angiography data of 86 patients with OA and 86 control subjects. Several parameters were also measured to quantitatively evaluate the mutual relationship. RESULTS In the OA group, 25.6% of ICAs were located in area 3 and 74.4% in area 2, whereas the percentages were 57.4% and 42.6%, respectively, in the control group. There were 73 (42.4%) ICAs in which the shortest distance between the dorsal surface of the ICA and the ventral cortex of the atlas was less than 4 mm in the OA group and only 50 (29.1%) in the control group. The ideal angulation of C1 screw trajectory was about 5 degrees more medial in the OA group than that in the control group (P < 0.01). CONCLUSIONS The risk of ICA injury is much higher in OA patients than in non-OA patients during the C1 screw placement. A mean medial angulation about 20 degrees will permit a long and safe screw purchase, but should be individualized. We recommend careful preoperative computed tomography angiography evaluation in all patients before surgery.
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Affiliation(s)
- Hua-Wei Wang
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Xue-Ping Li
- Department of Radiology, Chinese PLA General Hospital, Beijing, China
| | - Yi-Heng Yin
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Teng Li
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Xin-Guang Yu
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China.
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Salunke P, Karthigeyan M, Malik P. Foramen magnum decompression without bone removal: C1-C2 posterior fixation for Chiari with congenital atlantoaxial dislocation/basilar invagination. Surg Neurol Int 2019; 10:38. [PMID: 31528376 PMCID: PMC6743679 DOI: 10.25259/sni-38-2019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Accepted: 01/23/2019] [Indexed: 11/10/2022] Open
Abstract
Background: Atlantoaxial dislocation (AAD) and basilar invagination (BI) may coexist with Chiari malformations (CM) and a small posterior fossa volume. These are typically treated with craniovertebral junction fusion and foramen magnum decompression (FMD). Here, we evaluated whether C1–C2 posterior reduction and fixation (which possibly opens up the ventral foramen magnum) would effectively treat AAD and CM without additionally performing FMD. Methods: This is a retrospective analysis of 38 patients with BI, AAD, and CM who underwent C1–C2 posterior reduction and fusion without FMD. Baseline and follow-up clinical, demographic, and radiological data were evaluated. Results: The vast majority of patients (91.9%) improved both clinically and radiographically following C1–C2 fixation alone; none later required direct FMD. Notably, AAD was irreducible in 25 (65.8%) patients. Preoperatively, syringomyelia was present in 28 (73.7%) patients and showed resolution. In 3 (8.1%) patients, resolution of syrinxes did not translate into clinical improvement. Of interest, 5 patients who sustained inadvertent dural lacerations exhibited transient postoperative neurological worsening. Conclusions: Posterior C1–C2 distraction and fusion alone effectively treated AAD, BI, accompanied by CM. The procedure sufficiently distracted the dens, reversed dural tenting, and restored the posterior fossa volume while relieving ventral brainstem compression making FMD unnecessary. Surgeons should, however, be aware that inadvertent dural lacerations might contribute to unwanted neurological deterioration.
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Affiliation(s)
- Pravin Salunke
- Department of Neurosurgery, Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
| | - Madhivanan Karthigeyan
- Department of Neurosurgery, Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
| | - Puneet Malik
- Department of Neurosurgery, Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
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30
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Guan J, Chen Z, Wu H, Yao Q, Wang Q, Zhang C, Qi T, Wang K, Duan W, Gao J, Li Y, Jian F. Effectiveness of posterior reduction and fixation in atlantoaxial dislocation: a retrospective cohort study of 135 patients with a treatment algorithm proposal. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2019; 28:1053-1063. [PMID: 30604297 DOI: 10.1007/s00586-018-05869-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 12/21/2018] [Indexed: 02/08/2023]
Abstract
PURPOSE Surgical procedures on atlantoaxial dislocation remain controversial. The aim of this observational retrospective study was to investigate the treatment algorithm of surgical procedures. METHODS According to CT and intraoperative evaluation during direct posterior reduction, 135 AAD cases were categorized into three groups: Group I: reducible dislocation; Group II: irreducible dislocation (Group IIa: effective decompression achieved after posterior reduction; Group IIb: no effective decompression after posterior reduction); and Group III: fixed dislocation. Group III presented with extensive bony fusions. Group I and Group IIa were treated with direct posterior reduction and fixation. Group IIb underwent posterior fixation and transoral odontoidectomy. Group III underwent transoral odontoidectomy alone. Japanese Orthopedic Association scores (JOA) were assessed to evaluate clinical status before and 6, 12 months after surgery. RESULTS Our study included 118 Group I cases, 16 Group II cases (Group IIa: 11 cases; Group IIb: 5 cases), and one Group III case. Follow-up ranged from 12 to 36 months. PRIMARY OUTCOME Anatomic atlantoaxial reduction was achieved in 118 of 135 patients (87.4%). Clinical improvements were seen in 96.3% (130/135) all the patients. Solid atlantoaxial fusion was shown in 134 patients. Secondary outcome: The overall complication rate was 3.7% (5/135). For Group I, the mean postoperative 6-month JOA was 14.5 versus 12.2 in preoperative patients (paired Student's t test, P < 0.01). CONCLUSIONS This article proposes a clinical procedure that assists with therapeutic decision making and indicates the severity and difficulty of reduction of the atlantoaxial joint. These slides can be retrieved under Electronic Supplementary Material.
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Affiliation(s)
- Jian Guan
- Department of Neurosurgery, Division of Spine, China International Neurological Institute, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Beijing, 100053, People's Republic of China
| | - Zan Chen
- Department of Neurosurgery, Division of Spine, China International Neurological Institute, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Beijing, 100053, People's Republic of China
| | - Hao Wu
- Department of Neurosurgery, Division of Spine, China International Neurological Institute, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Beijing, 100053, People's Republic of China
| | - Qingyu Yao
- Department of Neurosurgery, Division of Spine, China International Neurological Institute, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Beijing, 100053, People's Republic of China
| | - Qu Wang
- Department of Neurosurgery, The People's Hospital of Guizhou Province, Guiyang, People's Republic of China
| | - Can Zhang
- Department of Neurosurgery, Division of Spine, China International Neurological Institute, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Beijing, 100053, People's Republic of China
| | - Tengfei Qi
- Department of Neurosurgery, Division of Spine, China International Neurological Institute, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Beijing, 100053, People's Republic of China
| | - Kai Wang
- Department of Neurosurgery, Division of Spine, China International Neurological Institute, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Beijing, 100053, People's Republic of China
| | - Wanru Duan
- Department of Neurosurgery, Division of Spine, China International Neurological Institute, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Beijing, 100053, People's Republic of China
| | - Jun Gao
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Yongning Li
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Fengzeng Jian
- Department of Neurosurgery, Division of Spine, China International Neurological Institute, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Beijing, 100053, People's Republic of China.
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Salunke P, Sahoo SK. Irreducible Posterior C1-2 Dislocation with Retrolisthesis of Dens: Hindsight from 10 Cases. World Neurosurg 2018; 123:e202-e210. [PMID: 30476658 DOI: 10.1016/j.wneu.2018.11.124] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 11/13/2018] [Accepted: 11/15/2018] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Posterior C1-2 dislocation secondary to fracture of the dens or os odontoideum is uncommon. Little is known about posterior dislocations in which close reduction fails, requiring intraoperative maneuvers. The objective of this retrospective study was to analyze clinical presentations, factors causing irreducibility, and nuances in the achievement of intraoperative reduction. METHODS The clinicoradiological features of 10 patients with irreducible posterior C1-2 dislocation were studied. Six were posttraumatic, with odontoid fractures, and 4 had os odontoideum. The radiologic images were studied to analyze the cause of irreducibility, and the operative management of these cases was discussed. RESULTS The patients with traumatic dislocation had persistent neck pain (n = 6) and early onset (n = 1) or delayed onset (n = 4) myelopathy. The fracture line was oblique, extending anterosuperiorly to posteroinferiorly in all except 1 patient, with fracture fragments distracted in 4 and interlocked in 2. There was associated lateral translation in 2. All patients had facet locking. Intraoperative reduction was achieved in all by unlocking the facets, intrafracture reduction, or both. All 4 patients with congenital posterior dislocations had retrolisthesis of dens with lateral translation. They presented with neck tilt (n = 4) and severe myelopathy (n = 3). They were easier to reduce intraoperatively, but the improvement lesser in comparison with the traumatic fractures. CONCLUSIONS The posterior C1-2 dislocation associated with fracture of the dens or os-odontoideum is a distinct entity. Lateral translation is often seen with retrolisthesis of the os odontoideum and occasionally in traumatic posterior dislocations. It is necessary to address the cause of irreducibility and achieve multiplanar realignment for a good outcome.
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Anomalous V3 Segment Aneurysm Associated with Congenital Atlantoaxial Dislocation: Case Report and Discussing the Challenges in Management. World Neurosurg 2018; 121:59-61. [PMID: 30312814 DOI: 10.1016/j.wneu.2018.09.231] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 09/28/2018] [Accepted: 09/29/2018] [Indexed: 11/20/2022]
Abstract
BACKGROUND An anomalous vertebral artery is not a deterrent for posterior C1-C2 joint manipulation and reduction of atlantoaxial dislocation (AAD). However, presence of an incidental aneurysm in the aberrant segment of artery with concurrent AAD adds to the surgical challenge. CASE DESCRIPTION A 30-year-old woman presented with neck pain and spastic quadriparesis. Her imaging revealed atlantoaxial dislocation and bony segmentation defects. Three-dimensional computed tomography angiography showed bilateral anomalous vertebral arteries (V3 segment) and an incidental aneurysm on the arterial segment that crossed the right C1-C2 joint posteriorly. Because the artery bearing the aneurysm was nondominant, it was ligated and successful C1-C2 posterior reduction and fusion could be performed. CONCLUSION The association of an incidental aneurysm with an anomalous vertebral artery in congenital AAD is unusual. The etiology could be an underlying collagen defect or repeated shearing trauma to the vessel wall due to C1-C2 instability. It would be less risky to proceed with endovascular embolization followed by occipitocervical fusion without opening the joints in case the aneurysm is present on the dominant aberrant V3 segment. Ventral decompression can be supplemented for irreducible AAD. On the contrary, if the aneurysm is present on the nondominant aberrant V3 segment, the C1-2 joint can be opened and manipulated following an initial endovascular treatment of the aneurysm. If the circumstances demand, the nondominant artery can be ligated and sacrificed, although there is a small risk of formation of stump aneurysm.
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Pros and Cons of C2 Nerve Sectioning/Preservation in Posterior Fusion for Congenital Atlantoaxial Dislocation. World Neurosurg 2018; 118:e925-e932. [DOI: 10.1016/j.wneu.2018.07.101] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 07/10/2018] [Accepted: 07/11/2018] [Indexed: 11/23/2022]
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Karthigeyan M, Salunke P, Kataria MS. Bilateral persistent 'second' intersegmental vertebral arteries: illustrated with a case. Acta Neurochir (Wien) 2018; 160:1621-1623. [PMID: 29934840 DOI: 10.1007/s00701-018-3601-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 06/14/2018] [Indexed: 11/28/2022]
Abstract
Congenital craniovertebral junction deformities can be associated with an anomalous vertebral artery (VA). At times, the artery crosses the joint posteriorly (i.e., persistent first intersegmental artery) and is at risk during posterior approach. We report a new variant, wherein the bilateral VA coursed medially after exiting the C3 transverse foramina to lie beneath C2 pars interarticularis and enter the foramen magnum (without passing through C2 transverse foramen anywhere along its course). This is possibly a result of bilateral persistent second intersegmental arteries. It is pertinent to recognize this unusual variant to avoid VA injury, especially while inserting C2 pars/transarticular screw.
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Affiliation(s)
- Madhivanan Karthigeyan
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research (PGIMER), Sector 12, Chandigarh, 160012, India.
| | - Pravin Salunke
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research (PGIMER), Sector 12, Chandigarh, 160012, India
| | - Mandeep Singh Kataria
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research (PGIMER), Sector 12, Chandigarh, 160012, India
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Improvise, adapt and overcome-challenges in management of pediatric congenital atlantoaxial dislocation. Clin Neurol Neurosurg 2018; 171:85-94. [DOI: 10.1016/j.clineuro.2018.05.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 05/23/2018] [Accepted: 05/29/2018] [Indexed: 11/18/2022]
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Pavlova OM, Ryabykh SO, Burcev AV, Gubin AV. Anomaly-Related Pathologic Atlantoaxial Displacement in Pediatric Patients. World Neurosurg 2018; 114:e532-e545. [DOI: 10.1016/j.wneu.2018.03.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 03/02/2018] [Accepted: 03/05/2018] [Indexed: 11/30/2022]
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Salunke P. Letter to the Editor. Thinking laterally: beyond transoral decompression for irreducible ADD with os odontodieum. J Neurosurg Spine 2018; 29:116-118. [PMID: 29701565 DOI: 10.3171/2017.11.spine171268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Sahoo S, Salunke P, Garg R. Unusual Case of C2 Subisthmic Vertebral Artery with Atlantoaxial Dislocation: Persistent Second Cervical Intersegmental Artery. World Neurosurg 2018; 115:154-156. [PMID: 29689387 DOI: 10.1016/j.wneu.2018.04.079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 04/12/2018] [Accepted: 04/13/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND The vertebral artery (VA) may have an anomalous course in patients with congenital atlantoaxial dislocation. In such cases, the artery crosses the C1-C2 joint posteriorly. These cases need thorough evaluation of the VA course to avoid its injury during posterior reduction and fusion of C1-C2. We describe for the first time an unusual subisthmic course of VA in a case of congenital irreducible atlantoaxial dislocation (AAD). The surgical implication and possible embryology of such an anomaly have been highlighted. METHODS A 25-year-male diagnosed with congenital AAD presented with spastic quadriparesis. Radiology showed irreducible AAD with oblique C1-C2 facet joints. The computed tomography angiogram showed the right VA traversing beneath the isthmus of atlas. The joint was opened, drilled, manipulated, and fused with a C1 lateral mass and C2 pedicle screw. RESULTS The C2 isthmus was defined, and the C2 pedicle screw was inserted to prevent injury to the VA. The patient gradually improved and was doing well at his 6-month follow-up. CONCLUSIONS The subisthmic variant of the VA may be the result of persistent C2 intersegmental artery. The presence of a subisthmic VA increases the chance of injury while inserting transarticular or C2 pars screw and warrants insertion of direct pedicle screw.
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Affiliation(s)
| | | | - Ravi Garg
- PGIMER, Neurosurgery, Chandigarh, India
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Turel MK, Kerolus MG, Traynelis VC. Machined cervical interfacet allograft spacers for the management of atlantoaxial instability. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2018; 8:332-337. [PMID: 29403245 PMCID: PMC5763590 DOI: 10.4103/jcvjs.jcvjs_87_17] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Background: The use of cervical interfacet spacers (CISs) to augment stability and provide solid arthrodesis at the atlantoaxial joint has not been studied in detail. The aim of this work is to report the outcomes with the use of machined allograft CISs at C1-2. Methods: A retrospective review of 19 patients who underwent an atlantoaxial fusion with the use of CISs was performed. All patients had instability documented with flexion and extension lateral radiographs. This instability was due to trauma, degenerative stenosis, symptomatic C1-2 arthropathy, and os odontoideum. Clinical and radiological outcomes were assessed. Fusion was determined based on a lack of hardware failure, absence of motion on flexion and extension plain X-ray films, and presence of bridging trabecular bone which was most often demonstrated by a computed tomography. Results: The mean age was 69.1 ± 12.9 years. Eight patients had traumatic fractures, six patients had degenerative stenosis, two patients had C2 neuralgia due to C1-2 arthropathy, two patients had C1-2 ligamentous subluxation, and one patient had an unstable os odontoideum. The occiput or subaxial spine was included in the arthrodesis in 10 patients. Rib autograft was utilized in most patients. No patient had postoperative neurological worsening, malposition of hardware, or vertebral artery injury and there were no mortalities. The fusion rate was 95%. The mean follow-up was 12.1 ± 5.5 months. Conclusions: CIS is a promising adjuvant for the treatment of atlantoaxial instability.
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Affiliation(s)
- Mazda K Turel
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
| | - Mena G Kerolus
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
| | - Vincent C Traynelis
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
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Sahoo SK, Salunke P. C2 Body as “Keystone” in Management of C1-C2-C3 Dislocation Secondary to Congenital Absence of C2 Posterior Elements. World Neurosurg 2018; 110:117-120. [DOI: 10.1016/j.wneu.2017.10.166] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 10/29/2017] [Accepted: 10/31/2017] [Indexed: 11/29/2022]
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Salunke P, Karthigeyan M, Sunil N, Rangan V. ‘Congenital anomalies of craniovertebral junction presenting after 50 years of age’: An oxymoron or An unusual variation? Clin Neurol Neurosurg 2018; 165:15-20. [DOI: 10.1016/j.clineuro.2017.12.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Revised: 12/08/2017] [Accepted: 12/17/2017] [Indexed: 10/18/2022]
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Deepak AN, Salunke P, Sahoo SK, Prasad PK, Khandelwal NK. Revisiting the differences between irreducible and reducible atlantoaxial dislocation in the era of direct posterior approach and C1–2 joint manipulation. J Neurosurg Spine 2017; 26:331-340. [DOI: 10.3171/2016.8.spine16408] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
The current management of atlantoaxial dislocation (AAD) focuses on the C1–2 joints, commonly approached through a posterior route. The distinction between reducible AAD (RAAD) and irreducible AAD (IrAAD) seems to be less important in modern times. The roles of preoperative traction and dynamic radiographs are questionable. This study evaluated whether differentiating between the 2 groups is important in today's era.
METHODS
Ninety-six consecutive patients with congenital AAD (33 RAAD and 63 IrAAD), who underwent surgery through a posterior approach alone, were studied. The preoperative and follow-up clinical statuses for both groups were studied and compared using Japanese Orthopaedic Association (JOA) scores. The radiological findings of the 2 groups were compared, and the intraoperative challenges described.
RESULTS
A poor preoperative JOA score (clinical status) was seen in one-fifth of patients with IrAAD, although the mean JOA score was nearly similar in the RAAD and IrAAD groups. There was significant improvement in follow-up JOA score in both groups. However, segmentation defects (such as an assimilated arch of the atlas and C2–3 fusion) and anomalous vertebral arteries were found significantly more often in cases of IrAAD compared with those of RAAD. Os odontoideum was commonly seen in the RAAD group. The C1–2 joints were acute in IrAAD compared with RAAD. Preoperative traction in IrAAD resulted in vertical distraction and improvement in clinical and respiratory status. Surgery for IrAAD required much more drilling and manipulation of the C1–2 joints while safeguarding the anomalous vertebral artery.
CONCLUSIONS
Bony and vascular anomalies were much more common in patients with IrAAD, which made surgery more challenging than it was in RAAD despite similar approaches. An irreducible dislocation seen on preoperative radiographs made surgeons aware of difficulties that were likely to be encountered and helped them to better plan the surgery. Distraction achieved through preoperative traction reaffirmed the feasibility of intraoperative reduction. This made the differentiation between the 2 groups and the use of preoperative traction equally important.
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Affiliation(s)
| | | | | | | | - Niranjan K. Khandelwal
- 2Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Salunke P. Delineate, Yet not Dread: Anomalous Vertebral Artery in Pediatric Congenital Atlantoaxial Dislocation and Basilar Invagination. J Pediatr Neurosci 2017; 12:227-231. [PMID: 29204196 PMCID: PMC5696658 DOI: 10.4103/jpn.jpn_64_17] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Introduction: The deformed joints seen in congenital atlantoaxial dislocation (CAAD) are often associated with vascular anomalies. It is important to identify these vascular anomalies and address them appropriately without compromising the manipulation and fusion of C1–C2 joints. The small bones in pediatric age group pose an additional challenge. Materials and Methods: Data of fifty-six children with CAAD operated in the last 4 years was analyzed. A computed tomography angiogram was obtained preoperatively to assess for the course of the third segment of vertebral artery (VA). The anomalous VA was dissected and safeguarded during drilling and manipulation of the C1–C2 joints. Results: Of the 112 VAs, 5 were aplastic, 21 crossed the joint posteriorly. Only one patient with reducible atlantoaxial dislocation (AAD) had anomalous VA crossing the joint posteriorly, the remaining VA anomalies were seen with irreducible AAD. Anomalous VA was seen on both sides in 2 patients. The most common anomaly was an inverted VA seen in seven sides. In all patients, the anomalous VA could be dissected and safeguarded without compromising the C1–C2 dissection and manipulation and fusion. In children, even the normal VA may occasionally pose difficulties while manipulation of joints. Challenges while addressing the anomalous and normal VA in pediatric age group have been described. Techniques to overcome these have been discussed. Conclusion: It is important to delineate the anomalous VA. However, the presence of such an artery is not a deterrent to the manipulation of C1–C2 joint, essential for best results. Special attention needs to be paid to the extent of distraction, medial C2 transverse foramen, and dissection/drilling of the area superior to the anomalous VA in the pediatric age group.
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Affiliation(s)
- Pravin Salunke
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Deepak AN, Salunke P, Kamble RP. Case of Atlantoaxial Dislocation with Assimilated C1, Absent Posterior C2, Butterfly C3, and Fused Subaxial Cervical Spine: Management Dilemma with Multiple Segmentation and Formation Defects. J Pediatr Neurosci 2017; 12:72-74. [PMID: 28553387 PMCID: PMC5437796 DOI: 10.4103/jpn.jpn_154_16] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Segmentation defects are often seen with congenital atlantoaxial dislocation (AAD) though an associated absence of posterior arch of C2 and butterfly C3 is rare. Apart from rarity, the combination of formation and segmentation defects adds to the management dilemma. We report a case of AAD with assimilated atlas, absent C2 posterior arch, C3 butterfly vertebra with floating posterior elements, and fused C4–C6. The child was managed by C1–C2 fusion alone with immediate symptomatic improvement. The presence of formation defects such as adjacent butterfly vertebra and absent posterior elements does not alter the management of AAD. Fusing the C1–C2 joints appears to be a balanced approach.
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Prasad PK, Salunke P, Sahni D, Kalra P. "Soft that molds the hard:" Geometric morphometry of lateral atlantoaxial joints focusing on the role of cartilage in changing the contour of bony articular surfaces. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2017; 8:354-358. [PMID: 29403249 PMCID: PMC5763594 DOI: 10.4103/jcvjs.jcvjs_109_17] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Purpose: The existing literature on lateral atlantoaxial joints is predominantly on bony facets and is unable to explain various C1-2 motions observed. Geometric morphometry of facets would help us in understanding the role of cartilages in C1-2 biomechanics/kinematics. Objective: Anthropometric measurements (bone and cartilage) of the atlantoaxial joint and to assess the role of cartilages in joint biomechanics. Materials and Methods: The authors studied 10 cadaveric atlantoaxial lateral joints with the articular cartilage in situ and after removing it, using three-dimensional laser scanner. The data were compared using geometric morphometry with emphasis on surface contours of articulating surfaces. Results: The bony inferior articular facet of atlas is concave in both sagittal and coronal plane. The bony superior articular facet of axis is convex in sagittal plane and is concave (laterally) and convex medially in the coronal plane. The bony articulating surfaces were nonconcordant. The articular cartilages of both C1 and C2 are biconvex in both planes and are thicker than the concavities of bony articulating surfaces. Conclusion: The biconvex structure of cartilage converts the surface morphology of C1-C2 bony facets from concave on concavo-convex to convex on convex. This reduces the contact point making the six degrees of freedom of motion possible and also makes the joint gyroscopic.
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Affiliation(s)
| | | | - Daisy Sahni
- Department of Anatomy, PGIMER, Chandigarh, India
| | - Parveen Kalra
- Department of Production and Industrial Engineering, PEC University of Technology, Chandigarh, India
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Salunke P, Sahoo SK, Deepak AN, Khandelwal NK. Redefining Congenital Atlantoaxial Dislocation: Objective Assessment in Each Plane Before and After Operation. World Neurosurg 2016; 95:156-164. [PMID: 27514697 DOI: 10.1016/j.wneu.2016.07.097] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 07/23/2016] [Accepted: 07/27/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND The C1-C2 joint has multiple degrees of freedom of movement and C1-C2 dislocation (AAD) is often multiplanar. The existing methodology to assess the dislocation is limited to few planes. The object of this study is to redefine and objectively assess congenital AAD in each possible plane, before and after the operation. METHODS This study consisted of 95 patients of irreducible congenital AAD operated on with the posterior approach alone. Preoperative and postoperative computed tomography imaging was studied in the axial, coronal, and sagittal planes. The relationship of C1-C2 along with the C1-C2 joint inclination was studied in each plane. The extent and type of dislocation was objectively assessed in each plane (newer indices) and compared with follow-up imaging for correction. The preoperative and postoperative Japenese orthopaedics association scores were compared. RESULTS The commonest variety (61 patients) was a combination of anteroposterior (AP) and vertical C1-C2 dislocation. Five patients had predominant APnteroposterior, 6 vertical, 4 axial rotational, 9 lateral angular tilt, and 3 had lateral transalational. Seven patients had a combination of dislocation in AP, vertical, and rotational planes. AP dislocation was seen with sagittal inclination of C1-C2 joints and vertical dislocation with coronal inclination. Asymmetry in the joint's sagittal inclination added to a rotational component, whereas asymmetry in the coronal angulation caused lateral angular tilt. Pure rotational or lateral translation dislocation had near-normal C1-C2 orientation. Preoperative Japenese orthopaedics association score was worst in the lateral tilt and the lateral translation. Correction in all planes was achieved in all patients. CONCLUSIONS The objective assessment of C1-C2 dislocation and joints in each plane was to determine its management and help in achieving multiplanar correction.
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Focusing on the delayed complications of fusing occipital squama to cervical spine for stabilization of congenital atlantoaxial dislocation and basilar invagination. Clin Neurol Neurosurg 2016; 145:19-27. [PMID: 27062686 DOI: 10.1016/j.clineuro.2016.04.001] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 03/21/2016] [Accepted: 04/01/2016] [Indexed: 11/21/2022]
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Salunke P, Sahoo SK, Futane S, Deepak AN, Khandelwal NK. 'Atlas shrugged': congenital lateral angular irreducible atlantoaxial dislocation: a case series of complex variant and its management. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2016; 25:1098-108. [PMID: 26758289 DOI: 10.1007/s00586-015-4370-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Revised: 12/26/2015] [Accepted: 12/28/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE The commonly described congenital atlanto-axial dislocation and Basilar-Invagination is antero-posterior or rotational or vertical plane. However, congenital dislocation in lateral plane has received scant attention. The purpose of this manuscript is to describe this unusual entity and discuss its management. MATERIALS AND METHODS The clinic-radiological feature of seven patients with congenital lateral angular AAD (CLAAAD) were studied and managed. The unilateral C1 facet had subluxed lateral to C2-3 complex. The C1 and C2 facets were drilled comprehensively and repositioned with distraction, placement of metallic spacers and facet manipulation after insertion of screws. The post operative outcome was studied. RESULTS The presentation is usually with neck tilt (progressive in 3) and/or progressive spastic quadriparesis. The mean C1-2 tilt was 25.2°. C1 was bifid in six patients. C1 lateral mass was assimilated with occipital condyle on dislocated side in and the other side was normal (6 patients). The dislocated C1-2 joint was abnormally oblique as compared to contralateral side. The relationship of occiput and C1 was normal. Correction of dislocation and lateral tilt was achieved in all patients with subsequent correction of neck tilt and deficits. One patient required reoperation. CONCLUSIONS The acute angulation of joint on one side and near normal on other side leads to differential vertical movement, further accentuated by splaying of bifid C1. The entity is seen in young patients and often present with neck tilt and spastic quadriparesis. Management requires reshaping the joints and facet manipulation. If the reshaping is inappropriate, the joint is likely to redislocate before fusion occurs.
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Affiliation(s)
- Pravin Salunke
- Department of Neurosurgery, PGIMER, Sector 12, Chandigarh, 1600l2, India.
| | - Sushanta K Sahoo
- Department of Neurosurgery, PGIMER, Sector 12, Chandigarh, 1600l2, India
| | - Sameer Futane
- Department of Neurosurgery, MGM Hospital & Medical College, Aurangabad, India
| | - A N Deepak
- Department of Neurosurgery, PGIMER, Sector 12, Chandigarh, 1600l2, India
| | - N K Khandelwal
- Department of Radiodiagnosis, PGIMER, Sector 12, Chandigarh, 1600l2, India
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Salunke P, Sahoo SK, Deepak AN, Garg R. Congenital C1-2 Lateral Translational Dislocation: Case Illustration with Pre- and Postoperative Imaging. Pediatr Neurosurg 2016; 51:218-20. [PMID: 27054833 DOI: 10.1159/000444939] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 02/20/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND Congenital atlantoaxial dislocation has been commonly described in the antero-posterior or vertical plane (basilar invagination). However, dislocation in the lateral translational plane due to congenital deformity is rare. CASE REPORT We present a case of a young male who presented with os odontoideum with C1-2 dislocation in the lateral plane along with antero-posterior dislocation. He was operated on through a midline posterior incision, and the C1-2 facet was manipulated so as to correct the dislocation in all planes. CONCLUSION With os odontoideum, the C1-2 joints can exhibit movements that are out of the ordinary, even in the lateral translational plane. It suggests that the ligaments and joint capsule may weaken with time. Careful radiological evaluation helps in diagnosing this rare condition. An understanding of 3D facetal anatomy is important to achieve complete correction.
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Affiliation(s)
- Pravin Salunke
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Salunke P, Sahoo S, Deepak A. Anomalous vertebral artery is not a deterrent to C1-2 joint dissection and manipulation for congenital atlantoaxial dislocation. Neurol India 2015; 63:1009-12. [DOI: 10.4103/0028-3886.170118] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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