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  • The Internet Journal of Spine Surgery
  • Volume 10
  • Number 1

Case Study

Anterior Retropharyangeal Titanium Cage Distraction Of The Atlantoaxial Joints For Reducing Basilar Invagination: A First Report In The Literature

S Patkar

Keywords

anterior atlanto-axial joint fixation, atlanto-axial dislocation, atlanto-axial joint distraction, basilar invagination, chiari malformation syringomyelia

Citation

S Patkar. Anterior Retropharyangeal Titanium Cage Distraction Of The Atlantoaxial Joints For Reducing Basilar Invagination: A First Report In The Literature. The Internet Journal of Spine Surgery. 2015 Volume 10 Number 1.

DOI: 10.5580/IJSS.32469

Abstract

An adult male presented with spasticity in all 4 limbs and difficulty in walking of recent onset. No trauma was reported. He had no other systemic symptoms. Lateral X-ray and computerised axial tomography CT scan revealed atlanto-axial dislocation with basilar invagination. We describe the surgical procedure and outcome of this case.

 

Case Report

Clinical summary

An adult male presented with spasticity in all 4 limbs and difficulty in walking of recent onset. No trauma was reported. He had no other systemic symptoms.

Lateral X-ray and computerised axial tomography CT scan revealed atlanto-axial dislocation with basilar invagination (Figure 1 and Figure 2).

Figure 1
Plain X-rays lateral view flexion and extension showing basilar invagination with irreducible atlanto-axial dislocation.

Figure 2
CT scan with saggital view showing basilar invagination with atlanto-axial dislocation.

Procedure:  The atlanto-axial joints were exposed under general anaesthesia in supine position by an anterior extrapharyangeal approach. Joint cartilage was curetted and endplates were abraded. Special wedge titanium cages of 5 mm in height (Jayon Surgical Co India) were filled with bone substitute and impacted into the joints on both sides. Additionally, the lateral mass of the atlas (C1) was fixed to the body of the axis ( C2) using titanium plates and screws (Figure 3).

Figure 3
Implants: Wedge shaped cages of different heights, titanium plates 2 mm thickness and titanium screws 3.5 mm in diameter and 18 mm in length.

Postoperative CT scan and X-ray showed reduction of the basilar invagination and fixation of the atlantoaxial dislocation. (Figure 4, Figure 5, and Figure 6).

Figure 4
Postoperative CT scan showing downward migration of dens and reduction and fixation of the atlanto-axial dislocation.

Figure 5
Post-operative dynamic X-rays showing reduction of the basilar invagination and reduction with fixation of the atlanto-axial dislocation.

Figure 6
Post-operative coronal CT scans showing position of cages and plate screw construct.

Discussion:

Basilar invagination can be reduced by spacer insertion into the atlantoaxial joint1. Recently this technique has been recommended for syrinomyelia and Chiari malformation2. However, posterior surgery has inherent difficulties such as risk  vertebral artery injury, paravertebral venous plexus hemorrhage and necessity of sacrificing the C2 ganglion in most cases3.

The anterior  extrapharyangeal approach offers a  safe corridor to achieve all the aims of the posterior operation without all the problems of the posterior approach4. The surgery is performed in supine position with extension resulting in reduction of the atlanto-axial dislocation in most cases.

The anterior approach is using through muscle planes unlike the posterior approach which disrupts  the suboccipital and C2 spinous process muscle attachments which are so very essential for craniovertebral stability6.

A wedge shaped cage distracts the joint and reduces the atlantoaxial dislocation.  The large bone mass of the atlas and body of axis allow ample opportunity for easy, safe and rigid fixation of the atlanto-axial joint6.

This is the first report of a clinical case of basilar invagination reduced and fixed by anterior surgery.

References

1 Goel A. Craniovertebral anomalies: Role for craniovertebral realignment. Neurol India 2004;52:427-9
2 KimS, M.D., Hong JT , M.D. Sung JH, M.D., ByunJH, M.D . Vertical Reduction Using Atlantoaxial Facet Spacer in Basilar Invagination with Atlantoaxial Instability J Korean Neurosurg Soc. 2011 Dec; 50(6): 528–531.
3 Goel A Atlantoaxial joint jamming as a treatment for atlantoaxial dislocation: a preliminary report. Technical note. J NeurosurgSpine. 2007 Jul;7(1):90-4.
4 Goel A, Shah A. Atlantoaxial joint distraction as a treatment for basilar invagination: A report of an experience with 11 cases. Neurol India [serial online] 2008 [cited 2015 Sep 23];56:144-50
5 Patkar S Anterior Fixation of Atlanto-axial Joints : Techniqe and pitfalls. J Spinal Surg 2014;1(2):60-68.
6 Sakaura H1, Hosono N, Mukai Y, Fujimori T, Iwasaki M, Yoshikawa Preservation of muscles attached to the C2 and C7 spinous processes rather than subaxial deep extensors reduces adverse effects after cervical laminoplasty. Spine. 2010 Jul 15;35(16).

Author Information

Sushil Patkar
Associate Professor, Bhartividyapeeth Medical College & Hospital, Poona Hospital & Research Center
Pune, India
patneurosurgeon@gmail.com

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