Vertical mobile and reducible atlantoaxial dislocation

Object The authors' experience with treatment of 8 patients with “vertical mobile and reducible” atlantoaxial dislocation is reviewed. The probable pathogenesis, radiological and clinical features, and management issues in such cases are discussed. Methods Between January 2006 and March 2008, 8 patients who presented with vertical mobile and reducible atlantoaxial dislocations were treated at the Department of Neurosurgery at King Edward Memorial Hospital in Mumbai, India. The vertical atlantoaxial dislocation/basilar invagination reduced completely on extension of the neck, with no need of any cervical traction. According to the extent of superior migration of the odontoid process, and measurements based on the vertical atlantoaxial instability index, the dislocation was graded as mild, moderate, or severe. All patients were treated using the C-1 lateral mass and C-2 pars plate and screw method of fixation. Results The study group was composed of 5 male and 3 female patients (mean age 24 years, age range 8–54 years). All patients presented with the physical features of short neck, torticollis, pain in the nape of the neck, and varying degrees of quadriparesis. In 6 patients there was a history of trauma prior to the onset of major neurological symptoms. The dislocation was mild in 3 cases, moderate in 1, and severe in 4. All patients had clinical neurological improvement following surgery. The follow-up duration ranged from 4 to 30 months (mean 18 months). Conclusions Vertical mobile and reducible atlantoaxial dislocation is a discrete clinical entity. Abnormal inclination and incompetence of the facet joint appears to be the primary causative factor that resulted in vertical dislocation or basilar invagination. Posterior fixation in the reduced dislocation position forms the basis of treatment.

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Posterior Reduction of Fixed Atlantoaxial Dislocation and Basilar Invagination by Atlantoaxial Facet Joint Release and Fixation: A Modified Technique With 174 Cases

Neurosurgery ◽

10.1227/neu.0000000000001026 ◽

2015 ◽

Vol 78 (3) ◽

pp. 391-400 ◽

Cited By ~ 23

Author(s):

Yi-heng Yin ◽

Huai-yu Tong ◽

Guang-yu Qiao ◽

Xin-guang Yu

Keyword(s):

Facet Joint ◽

Basilar Invagination ◽

Atlantoaxial Dislocation ◽

Modified Technique ◽

Japanese Orthopedic Association ◽

Neurological Improvement ◽

Transoral Odontoidectomy ◽

Cervical Traction ◽

Transoral Decompression

Abstract BACKGROUND: Treatment of fixed atlantoaxial dislocation (AAD) with basilar invagination (BI) is challenging. OBJECTIVE: To introduce a modified technique to reduce fixed AAD and BI through a posterior approach. METHODS: From 2007 to 2013, 174 patients with fixed AAD and BI underwent surgical reduction by posterior atlantoaxial facet joint release and fixation technique. RESULTS: There was 1 death in the series, and 3 patients were lost to follow-up. The follow-up period ranged from 12 to 52 months (mean: 35.2 months) for the remaining 170 patients. Neurological improvement was observed in 168 of 170 patients (98.8%), and was stable in 1 (0.06%) and exacerbated in 1 (0.06%), with the Japanese Orthopedic Association scores increasing from 11.4 preoperatively to 15.8 postoperatively (P < .01). Radiologically, complete or >90% reduction was attained in 107 patients (62.9%), 60% to 90% reduction was attained in 51 patients (30%), and <50% reduction was attained in 12 patients (7.1%), who underwent additional transoral decompression. Complete decompression was demonstrated in all 170 patients. Solid bony fusion was demonstrated in 167 patients at follow-up (98.2%). CONCLUSION: This series showed the safety and efficacy of the posterior C1-2 facet joint release and reduction technique for the treatment of AAD and BI. Most fixed AAD and BI cases are reducible via this method. In most cases, this method avoids transoral odontoidectomy and cervical traction. Compared with the occiput-C2 screw method, this short-segment C1-2 technique exerts less antireduction shearing force, guarantees longer bone purchase, and provides more immediate stabilization.

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Transoral intraarticular cage distraction and C-JAWS fixation for revision of basilar invagination with irreducible atlantoaxial dislocation

BMC Musculoskeletal Disorders ◽

10.1186/s12891-020-03792-3 ◽

2020 ◽

Vol 21 (1) ◽

Author(s):

Xiaobao Zou ◽

Binbin Wang ◽

Haozhi Yang ◽

Su Ge ◽

Bieping Ouyang ◽

...

Keyword(s):

Revision Surgery ◽

Odontoid Process ◽

Basilar Invagination ◽

Atlantoaxial Dislocation ◽

Atlantoaxial Instability ◽

Cervical Cord ◽

Atlantoaxial Joint ◽

Japanese Orthopedic Association ◽

Satisfactory Outcome ◽

Irreducible Atlantoaxial Dislocation

Abstract Background The revision surgery of basilar invagination (BI) with irreducible atlantoaxial dislocation (IAAD) after a previous occipitocervical fusion (OCF) is challenging. Transoral revision surgery has more advantages than a combined anterior and posterior approach in addressing this pathology. The C-JAWS is a cervical compressive staple that has been used in the lower cervical spine with many advantages. Up to now, there is no report on the application of C-JAWS in the atlantoaxial joint. We therefore present this report to investigate the clinical outcomes of transoral intraarticular cage distraction and C-JAWS fixation for revision of BI with IAAD. Methods From June 2011 to June 2015, 9 patients with BI and IAAD were revised by this technique after previous posterior OCF in our department. Plain cervical radiographs, computed tomographic scans and magnetic resonance imaging were obtained pre- and postoperatively to assess the degree of atlantoaxial dislocation and compression of the cervical cord. The Japanese Orthopedic Association (JOA) score was used to evaluate the neurological function. Results The revision surgeries were successfully performed in all patients. The average follow-up duration was 18.9 ± 7.3 months (range 9–30 months). The postoperative atlas-dens interval (ADI), cervicomedullary angle (CMA), distance between the top of the odontoid process and the Chamberlain line (CL) and JOA score were significantly improved in all patients (P < 0.05). Bony fusion was achieved after 3–9 months in all cases. No patients developed recurrent atlantoaxial instability. Conclusions Transoral revision surgery by intraarticular cage distraction and C-JAWS fixation could provide a satisfactory outcome for BI with IAAD after a previous unsuccessful posterior operation.

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Delayed Neurological Deficit after Traumatic Odontoid Fracture

Neurologico Spinale Medico Chirurgico ◽

10.15562/nsmc.v1i2.74 ◽

2018 ◽

Vol 1 (2) ◽

Author(s):

Yesaya Yunus ◽

Julius July ◽

Lutfi Hendriansyah

Keyword(s):

Neurological Deficit ◽

Significant Risk ◽

Odontoid Process ◽

Odontoid Fracture ◽

Atlantoaxial Dislocation ◽

Neurological Deficits ◽

Odontoid Fractures ◽

Neurological Improvement ◽

Cord Injury ◽

Cervical Traction

Fractures of the odontoid process can lead to gross instability of the atlantoaxial complex and present a significant risk for a potentially catastrophic spinal cord injury. Type II odontoid fractures are the most common odontoid fractures and are unstable that may displace anteriorly or posteriorly. If left untreated, the patient may develop atlantoaxial dislocation that causes neurological deficit also progressive myelopathy.We described the surgical management of four patients with a delayed neurological deficit after odontoid fracture with a history of trauma and after triggered by traditional massage. Traction several days before operation applied to achieve reduction of atlantoaxial dislocation.Posterior instrumentation and correction of atlantoaxial dislocation were performed with interarticular screw fixation (Harm technique) in all of the patients.All of the four patients showed a reduction of the atlantoaxial dislocation and also a neurological improvement. Cervical traction followed by posterior instrumented correction may be an effective alternative to treating delayed neurological deficits after traumatic odontoid fracture.

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Delayed Neurological Deficit after Traumatic Odontoid Fracture

Neurologico Spinale Medico Chirurgico ◽

10.15562/nsmc.v1i2.100 ◽

2018 ◽

Vol 1 (2) ◽

pp. 22

Author(s):

Yesaya Yunus ◽

Julius July

Keyword(s):

Neurological Deficit ◽

Significant Risk ◽

Odontoid Process ◽

Odontoid Fracture ◽

Atlantoaxial Dislocation ◽

Neurological Deficits ◽

Odontoid Fractures ◽

Neurological Improvement ◽

Cord Injury ◽

Cervical Traction

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Treatment of Reducible Atlantoaxial Dislocation and Basilar Invagination Using the Head Frame Reduction Technique and Atlantoaxial Arthrodesis

Global Spine Journal ◽

10.1177/2192568220970164 ◽

2020 ◽

pp. 219256822097016

Author(s):

Teng Li ◽

Yue-Qi Du ◽

Yi-Heng Yin ◽

Shao-Ling Xing ◽

Guang-Yu Qiao

Keyword(s):

Treatment Algorithm ◽

Odontoid Process ◽

Case Series ◽

Basilar Invagination ◽

Reduction Technique ◽

Atlantoaxial Dislocation ◽

Retrospective Case ◽

Neurological Improvement ◽

Atlantoaxial Arthrodesis

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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Atlantoaxial Dislocation: Surgical Outcome following Anterior Retropharyngeal Approach to Odontoid with or without Fixation

Indian Journal of Neurosurgery ◽

10.1055/s-0040-1721237 ◽

2021 ◽

Author(s):

Manpreet Singh Banga ◽

B.V. Sandeep ◽

Suniti Kumar Saha ◽

Kaushik Roy ◽

Sourabh Dixit ◽

...

Keyword(s):

Functional Disability ◽

Odontoid Process ◽

Cerebrospinal Fluid Leak ◽

Basilar Invagination ◽

Atlantoaxial Dislocation ◽

Lower Limbs ◽

Posterior Fixation ◽

Duration Of Symptoms ◽

Female Ratio ◽

Number Of Patients

Abstract Introduction Atlantoaxial dislocation (AAD) refers to a loss of stability between the atlas and axis vertebra. The conventional transoral approach and the anterior retropharyngeal approach (ARPA) are adequate for the upper cervical vertebral segments. This study was undertaken to evaluate the usefulness of the ARPA to the odontoid in patients of AAD. Materials and Methods The study was undertaken on 20 patients admitted in Nil Ratan Sircar Medical College and Hospital, Kolkata, India, with functional disability secondary to AAD. These patients underwent surgery through ARPA to odontoid with or without fixation. Patients were analyzed between October 2014 and September 2016. Results Maximum number of patients belonged to third decade of life. The male to female ratio was 1.5. The mean duration of symptoms was 10.86 months. Weakness of the upper and lower limbs predominated. About 65% patients had axial neck pain. Nine patients (45%) in total had difficulty in either bowel or bladder. Five patients presented with fracture odontoid and pannus formation of the odontoid process, while six had basilar invagination. One patient underwent anterior odontoid screw fixation and the other 19 patients underwent anterior retropharyngeal odontoidectomy with posterior fixation. Two patients expired in the present study. Most of the patients had improvement in Nurick grade during follow-up. Five patients had transient throat pain and dysphagia. Three patients had superficial surgical site infection. One patient had postoperative cerebrospinal fluid leak. Conclusion The ARPA to odontoid is a feasible approach for decompression and fixation of the odontoid in AAD cases.

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Surgical treatment for basilar invagination with irreducible atlantoaxial dislocation: transoral atlantoaxial reduction plate fixation vs occipitocervical fixation

BMC Musculoskeletal Disorders ◽

10.1186/s12891-020-03838-6 ◽

2020 ◽

Vol 21 (1) ◽

Author(s):

Xiaobao Zou ◽

Bieping Ouyang ◽

Haozhi Yang ◽

Binbin Wang ◽

Su Ge ◽

...

Keyword(s):

Surgical Treatment ◽

Early Stage ◽

Plate Fixation ◽

Japanese Orthopaedic Association ◽

Odontoid Process ◽

Basilar Invagination ◽

Atlantoaxial Dislocation ◽

Clinical Effects ◽

Occipitocervical Fixation ◽

Irreducible Atlantoaxial Dislocation

Abstract Background Transoral atlantoaxial reduction plate (TARP) fixation or occipitocervical fixation (OF) is an effective treatment for basilar invagination (BI) with irreducible atlantoaxial dislocation (IAAD). But, all current clinical studies involved a single surgical procedure. The clinical effects of TARP and OF operation for BI with IAAD have yet to be compared. We therefore present this report to compare the treatment of TARP and OF procedure for BI with IAAD. Methods Fifty-six patients with BI with IAAD who underwent TARP or OF operation from June 2011 to June 2017 were retrospectively analyzed. Among these, 35 patients underwent TARP operation (TARP group), and 21 patients underwent OF operation (OF group). We compared the difference of clinical, radiological, and surgical outcomes between the TARP and OF groups postoperatively. Results Compared with OF group, the operative time and blood loss in TARP group were lower. There was no statistical difference in the atlantodental interval (ADI), clivus canal angle (CCA), cervicomedullary angle (CMA), distance between the top of the odontoid process and the Chamberlain line (CL) and Japanese Orthopaedic Association (JOA) score between the TARP and OF groups preoperatively, but the improvements of these parameters in the TARP group were superior to those in the OF group postoperatively. The fusion rates were higher in the TARP group than those in the OF group at the early stage postoperatively. Conclusions TARP and OF operations are effective surgical treatment for BI with IAAD, but the performance of reduction and decompression and earlier bone fusion rates of TARP procedure are superior to those of OF.

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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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Endoscopic Endonasal Transclival Odontoidectomy for Basilar Invagination: Operative Video and Technical Nuances

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0040-1715522 ◽

2020 ◽

Author(s):

James K. Liu ◽

Vincent N. Dodson ◽

Kevin Zhao ◽

Jean Anderson Eloy

Keyword(s):

Odontoid Process ◽

Craniovertebral Junction ◽

Basilar Invagination ◽

Foramen Magnum ◽

Endoscopic Endonasal ◽

Motor Weakness ◽

Cervicomedullary Junction ◽

Unsteady Gait ◽

Cervical Traction ◽

Motor Strength

AbstractBasilar invagination is a congenital or acquired craniovertebral junction abnormality where the tip of the odontoid process projects through the foramen magnum which can cause severe symptomatic compression of the brainstem and spinal cord. If left untreated, patients can develop progressive quadriparesis. Traditionally, basilar invagination can be treated with cervical traction and posterior stabilization. However, in irreducible cases, anterior decompression via a transoral or endonasal approach may be necessary. In this operative video, we demonstrate an endoscopic endonasal transclival approach for odontoidectomy to successfully treat a 37-year-old female with severe basilar invagination causing symptomatic compression on the cervicomedullary junction resulting in unsteady gait and motor weakness. The patient had Klippel–Feil syndrome where the C1 arch was assimilated to the foramen magnum and transclival drilling was needed to adequately access the odontoid process for removal. A second-stage posterior occipitocervical stabilization and fusion was performed the following day. Immediate postoperative imaging showed excellent decompression of the cervicomedullary junction. Postoperatively, the patient had significant improvement in gait and motor strength in all extremities, and was ambulating independently without assistance at 1 year after surgery. The endoscopic endonasal transclival odontoidectomy is a useful strategy to treat severe irreducible basilar invagination causing symptomatic neural compression. The surgical technique and nuances are described in a step-by-step fashion in this illustrative operative video.The link to the video can be found at: https://youtu.be/HL4K7KqJEJM.

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