Anterior transoral C1-C2 release and posterior fusion for irreducible congenital basilar invagination
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1) The document describes a surgical technique for treating irreducible atlantoaxial dislocation involving anterior transoral atlantoaxial release and posterior instrumented fusion. 2) The technique aims to address disadvantages of traditional transoral odontoidectomy or posterior C1-C2 distraction procedures. 3) Preliminary results from 15 patients found significant improvements in cervicomedullary angle and myelopathy scores after surgery with minimal complications.
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Anterior transoral C1-C2 release and posterior fusion for irreducible congenital basilar invagination
- 1. Anterior transoral atlantoaxial release and posterior instrumented fusion for irreducible congenital basilar invagination Laheri Vinod*, Chaudhary Kshitij*, Rathod Ashok*, Bapat Mihir^ *King Edward Memorial Hospital, Mumbai ^KDA Hospital, Mumbai
- 2. Transoral Odontoidectomy or Posterior C1-C2 distraction Irreducible C1 C2 dislocation
- 3. Irreducible atlanto-axial dislocation Disadvantages of Transoral odontoidectomy • Invaginated odontoid requires extended transoral approach • Technically difficult in severe BI • Non burrable ligamentous structures at the apex are difficult to excise • High complication/ morbidity rate • Swan Neck deformity subaxial cervical spine - fixed
- 4. Irreducible atlanto-axial dislocation Disadvantages of Posterior C1-C2 distraction • Technical very difficult procedure • Involves significant manipulation of C1C2 joint – Bleeding • Reduction not assured always. • Not reproducible
- 5. Rationale Ant. release C1-C2 + Post. Instrumented reduction Displacements Vertical translation Basilar invagination Retroversion of the odontoid Delta angle anterior C1 arch
- 6. Rationale Structures preventing reduction Vertical displacement Anterior structures shortened ALL Longus muscles Anterior C1-C2 capsule × Alar and transverse ligament Retroversion of Odontoid Predental tissue C1 anterior arch C1 arch
- 7. Rationale Release of anterior contracted structures Reduction of vertical translation Excision of predental Tissue + Ant. C1 arch Correction of Delta angle (Retroversion)
- 8. Methods • Prospective study • Consecutive series of 15 patients (2007-2010) • Average Age = 21 years Follow up = 12.4 mo (6-40 mo) • Inclusion Criteria – Irreducible atlantoaxial dislocation (IAAD) – Basilar invagination • Irreducibility criteria – Failure of reduction on Flex Ex Xrays – Failure of reduction on Traction Xray under GA
- 9. Pathologies • Congenital basilar invagination (n=15) • C1 assimilation (14), condylar hypoplasia (10), C2-3 fusions (8), C2-C4 fusion (1), Klippel-Feil syndrome (3), Chiari malformation (2), malformed odontoid (2), incomplete ring of C1 (1) • Cervical spine Flex-Ex radiographs • MRI CVJ • CT with vertebral art. Angiogram • Preoperative skeletal traction (2 days) • Max. wt less than one sixth the body weight Pre op Assessment
- 11. Procedure • Nasotracheal intubation & GA with muscle relaxation • Reassessment of C1-C2 alignment on traction under GA Longus Capitis Longus Colli ALL Capsule Release of tight anterior structures
- 12. C1 anterior arch excisionJoint distraction Releases intraarticular adhesions n=8
- 13. Posterior Reduction maneuver Under contoured rod fixed to C2 Cantilever force to approximate plate to the occiput Correction of retroversion of dens Excision of C1 ant. arch allows for this correction
- 15. Results – Clivus Canal Angle p<0.05
- 16. Results – Cervico medullary angle p<0.05 110º± 11.4 146º± 6.8
- 17. Results • Avg. Recovery rate = 98% JOA myelopathy score p<0.0001 11.5± 2.6 15.4± 1.9
- 18. Results • Persistent Nasal Phonation (n=1) • Superficial wound infection (n=1) Complications (n=2)
- 20. KF Syndrome
- 21. Post op
- 23. Conclusion • Preliminary study – Encouraging results • May be a safer and superior alternative to transoral odontoid resection • Technically easier procedure • Anatomical restoration possible
- 24. References • Wang et al. Open reduction of irreducible atlantoaxial dislocation by transoral anterior atlantoaxial release and posterior internal fixation. Spine (2006) vol. 31 (11) pp. E306-13 • Goto et al. Transoral joint release of the dislocated atlantoaxial joints combined with posterior reduction and fusion for a late infantile atlantoaxial rotatory fixation. A case report. Spine (1998) vol. 23 (13) pp. 1485-9 • Govender et al. Staged reduction and stabilisation in chronic atlantoaxial rotatory fixation. J Bone Joint Surg Br (2002) vol. 84 (5) pp. 727-31 • Yin et al. Irreducible anterior atlantoaxial dislocation: one-stage treatment with a transoral atlantoaxial reduction plate fixation and fusion. Report of 5 cases and review of the literature. Spine (2005) vol. 30 (13) pp. E375-81 • Crossman et al. Open reduction of pediatric atlantoaxial rotatory fixation: long- term outcome study with functional measurements. J Neurosurg (2004) vol. 100 (3 Suppl Spine) pp. 235-40