Posterior Fixation of the Craniovertebral Junction in Nontraumatic Instability

Abstract OBJECTIVE Tuberculous atlantoaxial dislocation is a rare disease entity. However, tuberculosis continues to be endemic in developing countries. Its earliest clinical presentation may be nonspecific, and delay in diagnosis may lead to irreversible neurological deficit. The management of tuberculous atlantoaxial dislocation includes ventral cervicomedullary decompression, occipitocervical arthrodesis, and administration of antituberculous medications. METHODS Eighteen patients with tuberculous atlantoaxial dislocation who presented with neck pain and/or occipital headache, restriction of neck movement, difficulty swallowing, and signs of myelopathy were studied. Four patients had evidence of associated pulmonary tuberculosis. Plain x-rays of the cervical spine, computed tomographic scans, and magnetic resonance images were obtained in all patients for diagnosis and to assess the degree of dislocation and cervicomedullary compression. Simultaneous anterior neural decompression, via a transcervical retropharyngeal approach, and posterior arthrodesis were performed on all patients while they remained under anesthesia. Antituberculous chemotherapy was continued for 18 months. RESULTS Histopathological analysis of excised tissue was consistent with tuberculosis in all patients. However, Ziehl-Neelsen staining for acid-fast bacilli was positive in two cases, and culture for Mycobacterium tuberculosis was negative in all patients. Patients with severe myelopathy experienced marked improvement. One patient died of fulminant resistant tuberculous meningitis. CONCLUSION The transcervical retropharyngeal approach to the craniovertebral junction provides direct access to the lesion and avoids the potential bacterial contamination of the oral and pharyngeal cavity. It also prevents the development of persistent fistulae. Posterior stabilization should be performed directly after anterior neural decompression, while the patient remains under anesthesia, to prevent neurological deterioration before subsequent posterior fixation. This technique also is helpful for early mobilization of patients. The aim of surgical treatment should be to obtain biopsy tissue and to perform radical excision of epidural granulation tissue/abscess and infected bone using microsurgical technique. Antituberculous medication must be continued for 18 months with four drug regimens, and continuous monitoring of drug toxicity should be performed throughout the course of treatment.

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Post-operative pulmonary complications in patients undergoing transoral odontoidectomy and posterior fixation for craniovertebral junction anomalies

Journal of Anaesthesiology Clinical Pharmacology ◽

10.4103/0970-9185.111720 ◽

2013 ◽

Vol 29 (2) ◽

pp. 200 ◽

Cited By ~ 8

Author(s):

MihirP Pandia ◽

GirijaP Rath ◽

ParmodK Bithal ◽

HariH Dash ◽

Manish Marda

Keyword(s):

Craniovertebral Junction ◽

Pulmonary Complications ◽

Posterior Fixation ◽

Transoral Odontoidectomy

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Endoscopic Endonasal Odontoidectomy Preserving Atlantoaxial Stability: a Pediatric Case

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0039-3402797 ◽

2020 ◽

Author(s):

Pierlorenzo Veiceschi ◽

Fabio Pozzi ◽

Francesco Restelli ◽

Tommaso Alfiero ◽

Paolo Castelnuovo ◽

...

Keyword(s):

Craniovertebral Junction ◽

Basilar Invagination ◽

Chiari I Malformation ◽

Lower Limbs ◽

University Hospital ◽

Third Ventriculostomy ◽

Posterior Fixation ◽

Endoscopic Endonasal ◽

Postoperative Mri ◽

Chiari I

Abstract Objectives We illustrate endoscopic endonasal odontoidectomy for the Chiari-I malformation respecting craniovertebral junction (CVJ) stability. Design Case report of a 12-year-old girl affected by the Chiari-I malformation. Magnetic resonance imaging (MRI) showed tonsillar herniation, basilar invagination, and dental retroversion, causing angulation and compression of the bulbomedullary junction. Patient underwent endoscopic third ventriculostomy (ETV) with reduction of ventricular size and resolution of gait disturbances, but she complained the Valsalva-induced headaches, hiccup, and dysesthesias in the lower limbs. Endoscopic endonasal odontoidectomy was chosen to decompress the cervicomedullary junction. Setting The research was conducted at University Hospital “Ospedale di Circolo,” Department of Neurosurgery at Varese in Italy. Participants Patients were from neurosurgical and ENT (ear, nose, and throat) skull base team. Main Outcome Measures A bilateral paraseptal approach was performed, using a four-hand technique. After resection of posterior edge of the nasal septum, the choana is entered and a rhinopharynx muscle–mucosal flap is dissected subperiosteal and transposed in oral cavity. The CVJ is exposed and, using neuronavigation and neuromonitoring, odontoidectomy is fulfilled until dura is reached, preserving the anterior arch of C1. Reconstruction is obtained suturing the flap previously harvested. Results Postoperative course was unremarkable and the patient experienced improvement of symptoms. Postoperative MRI documented the appearance of tight cerebrospinal fluid (CSF) film anterior to bulbomedullary junction and in retrotonsillar spaces, opening of the bulbomedullary angle, and slight tonsils reduction. No CVJ instability was occurred with any need of posterior fixation. Conclusion Endoscopic endonasal odontoidectomy is a feasible approach for CVJ malformation. In this case, bulbar decompression was achieved preserving CVJ stability and avoiding posterior fixation.The link to the video can be found at: https://youtu.be/VIobocHfCuc.

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Foramen magnum decompression without bone removal: C1–C2 posterior fixation for Chiari with congenital atlantoaxial dislocation/basilar invagination

Surgical Neurology International ◽

10.25259/sni-38-2019 ◽

2019 ◽

Vol 10 ◽

pp. 38 ◽

Cited By ~ 5

Author(s):

Pravin Salunke ◽

Madhivanan Karthigeyan ◽

Puneet Malik

Keyword(s):

Posterior Fossa ◽

Craniovertebral Junction ◽

Basilar Invagination ◽

Foramen Magnum ◽

Atlantoaxial Dislocation ◽

Posterior Fixation ◽

Foramen Magnum Decompression ◽

Radiological Data ◽

C2 Fixation ◽

Small Posterior Fossa

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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CRANIOVERTEBRAL JUNCTION TUBERCULOSIS

Neurosurgery ◽

10.1227/01.neu.0000327696.77814.1e ◽

2008 ◽

Vol 63 (5) ◽

pp. 946-955 ◽

Cited By ~ 27

Author(s):

Ramesh Teegala ◽

Pradyuth Kumar ◽

Shashank S. Kale ◽

Bhawani S. Sharma

Keyword(s):

Scoring System ◽

Performance Status ◽

Early Mobilization ◽

Craniovertebral Junction ◽

Neurological Deficits ◽

Posterior Fixation ◽

X Rays ◽

Halo Traction ◽

Management Protocol ◽

Grade 3

Abstract OBJECTIVE To establish a scoring system and management algorithm for patients with diagnosed craniovertebral junction tuberculosis. The specific goals were: 1) to avoid new neurological deficits; 2) to avoid morbidity and compromise in the quality of life associated with prolonged, rigid, cumbersome external immobilization, such as with a sternal occipital mandibular immobilizer brace and halo traction; and 3) to prevent sudden death. METHODS All patients diagnosed with craniovertebral junction tuberculosis were studied prospectively over a 3-year period. The initial severity of the disease was evaluated with clinicoradiological grading, and patients were divided into 3 grades. Overall performance status was assessed with disability scoring. Patients with Grade 1 and 2 severity were managed conservatively. Grade 3 patients underwent transoral decompression and posterior fixation. The patients' neurological recovery was evaluated every 4 weeks with disability scoring, along with x-rays, for the initial 3 months and every 2 months thereafter. RESULTS Of 71 patients, there were 27 Grade 1, thirty-six Grade 2, and 8 Grade 3 patients. Children and young adults comprised 70% of the study population. All Grade 3 patients underwent early surgery. Five Grade 1 and 2 patients (8%) required delayed surgery for reducible atlantoaxial dissociation. The remaining 58 patients (82%) were effectively managed conservatively. The mean follow-up duration was 18.5 ± 6.2 months. There was no mortality. CONCLUSION Use of our proposed scoring system and management protocol allowed both speedy recovery and early mobilization. All patients had good clinicoradiological outcomes regardless of the grade.

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The importance of atlantoaxial fixation after odontoidectomy

Journal of Neurosurgery Spine ◽

10.3171/2015.5.spine141249 ◽

2016 ◽

Vol 24 (2) ◽

pp. 300-308 ◽

Cited By ~ 10

Author(s):

Peng-Yuan Chang ◽

Yu-Shu Yen ◽

Jau-Ching Wu ◽

Hsuan-Kan Chang ◽

Li-Yu Fay ◽

...

Keyword(s):

Demographic Data ◽

Craniovertebral Junction ◽

Basilar Invagination ◽

Neurological Function ◽

Posterior Fixation ◽

Fusion Construct ◽

Before And After ◽

Atlantoaxial Fixation ◽

The Mean ◽

Triangular Area

OBJECT Although anterior odontoidectomy has been widely accepted as a procedure for decompression of the craniovertebral junction (CVJ), postoperative biomechanical instability has not been well addressed. There is a paucity of data on the necessity for and choice of fixation. METHODS The authors conducted a retrospective review of consecutively treated patients with basilar invagination who underwent anterior odontoidectomy and various types of posterior fixation. Posterior fixation included 1 of 3 kinds of constructs: occipitocervical (OC) fusion with atlantoaxial (AA) fixation, OC fusion without AA fixation, or AA-only (without OC) fixation. On the basis of the use or nonuse of AA fixation, these patients were assigned to either the AA group, in which the posterior fixation surgery involved both the atlas and axis simultaneously, regardless of whether the patient underwent OC fusion, or the non-AA group, in which the OC fusion construct spared the atlas, axis, or both. Clinical outcomes and neurological function were compared. Radiological results at each time point (i.e., before and after odontoidectomy and after fixation) were assessed by calculating the triangular area causing ventral indentation of the brainstem in the CVJ. RESULTS Data obtained in 14 consecutively treated patients with basilar invagination were analyzed in this series; the mean follow-up time was 5.75 years. The mean age was 53.58 years; there were 7 males and 7 females. The AA and non-AA groups consisted of 7 patients each. The demographic data of both groups were similar. Overall, there was significant improvement in neurological function after the operation (p = 0.03), and there were no differences in the postoperative Nurick grades between the 2 groups (p = 1.00). According to radiological measurements, significant decompression of the ventral brainstem was achieved stepwise in both groups by anterior odontoidectomy and posterior fixation; the mean ventral triangular area improved from 3.00 ± 0.86 cm2 to 2.08 ± 0.51 cm2 to 1.68 ± 0.59 cm2 (before and after odontoidectomy and after fixation, respectively; p < 0.05). The decompression gained by odontoidectomy (i.e., reduction of the ventral triangular area) was similar in the AA and non-AA groups (0.66 ± 0.42 cm2 vs 1.17 ± 1.42 cm2, respectively; p = 0.38). However, the decompression achieved by posterior fixation was significantly greater in the AA group than in the non-AA group (0.64 ± 0.39 cm2 vs 0.17 ± 0.16 cm2, respectively; p = 0.01). CONCLUSIONS Anterior odontoidectomy alone provides significant decompression at the CVJ. Adjuvant posterior fixation further enhances the extent of decompression after the odontoidectomy. Moreover, posterior fixation that involves AA fixation yields significantly more decompression of the ventral brainstem than OC fusion that spares AA fixation.

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