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Bajaj J, Patidar J, Bajaj D, Vikram A, Yadav O, Yadav N, Sharma M, Hedaoo K, Sinha M, Ratre S, Parihar VS, Swamy MN, Yadav YR. The Rocker Technique for Atlantoaxial Dislocation With or Without Basilar Invagination: A Prospective Observational Study. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01249. [PMID: 38995047 DOI: 10.1227/ons.0000000000001214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Accepted: 03/26/2024] [Indexed: 07/13/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Atlantoaxial dislocation (AAD) poses a complex surgical challenge. Surgical approaches vary for reducible and irreducible cases. Challenges persist in reducing the atlantodental interval, especially in cases with oblique or vertical C1-C2 joints. The Rocker instrument (MJ Surgical), a less-explored technique, seeks to simplify instrumentation, reduce complexity, and enhance translation and retroflection reduction of AAD. METHODS This prospective observational study was conducted from January 2022 to July 2023 at a tertiary neurosurgical center. Inclusion criteria covered all age groups with AAD, with or without basilar invagination. Exclusions included medically unstable patients and severe osteoporotic spine conditions. Preoperative assessments included dynamic X-rays, magnetic resonance imaging, and computed tomography scans. The Rocker technique was used, and patients were followed up for 6 to 12 months. RESULTS Fifty-five patients (30 males, 25 females) underwent surgery. The mean age was 40.41 ± 15.01 years. Successful Rocker technique application was observed in 53 cases. Functional outcomes, assessed using Modified Ranawat grading, showed improvement postoperatively. Radiological outcomes revealed a significant reduction in the anterior atlantodental interval (7.21 ± 0.94 to 2.98 ± 0.78). Basilar invagination was reduced in all cases, whenever present. The technique exhibited versatility, applicability in various joint orientations, and cost-effectiveness. CONCLUSION The Rocker technique is a safe and effective alternative for managing both reducible and irreducible AADs, with or without basilar invagination. It simplifies the reduction process, offering advantages over established techniques. Further trials, especially in rotational deformities, are warranted for validation.
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Affiliation(s)
- Jitin Bajaj
- Department of Neurosurgery, Superspeciality Hospital, NSCB Medical College, Jabalpur, India
| | - Jayant Patidar
- Department of Neurosurgery, Superspeciality Hospital, NSCB Medical College, Jabalpur, India
| | - Diya Bajaj
- Department of Neuropathology, Superspeciality Hospital, NSCB Medical College, Jabalpur, India
| | - Aditya Vikram
- Department of Neurosurgery, Superspeciality Hospital, NSCB Medical College, Jabalpur, India
| | - Omprakash Yadav
- Department of Neurosurgery, Superspeciality Hospital, NSCB Medical College, Jabalpur, India
| | - Nishtha Yadav
- Department of Neuroradiology, Superspeciality Hospital, NSCB Medical College, Jabalpur, India
| | - Mukesh Sharma
- Department of Neurosurgery, Superspeciality Hospital, NSCB Medical College, Jabalpur, India
| | - Ketan Hedaoo
- Department of Neurosurgery, Superspeciality Hospital, NSCB Medical College, Jabalpur, India
| | - Mallika Sinha
- Department of Neurosurgery, Superspeciality Hospital, NSCB Medical College, Jabalpur, India
| | - Shailendra Ratre
- Department of Neurosurgery, Superspeciality Hospital, NSCB Medical College, Jabalpur, India
| | - Vijay S Parihar
- Department of Neurosurgery, Superspeciality Hospital, NSCB Medical College, Jabalpur, India
| | - M N Swamy
- Department of Neurosurgery, Superspeciality Hospital, NSCB Medical College, Jabalpur, India
| | - Y R Yadav
- Neurosciences, Apex Hospital & Research Center, Jabalpur, India
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Nguyen LH, Nguyen KM, Nguyen TLB, Do HM, Bui HM, Nguyen HV. Atlantoaxial dislocation due to Os odontoideum in down syndrome: Literature review and case reports. Int J Surg Case Rep 2024; 120:109888. [PMID: 38852555 PMCID: PMC11193034 DOI: 10.1016/j.ijscr.2024.109888] [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: 04/11/2024] [Revised: 06/02/2024] [Accepted: 06/04/2024] [Indexed: 06/11/2024] Open
Abstract
INTRODUCTION AND IMPORTANCE Os odontoideum is a rare condition commonly associated with atlantoaxial instability (AAI) and leading to atlantoaxial dislocation. The incidence of Os odontoideum is higher in patients with Down syndrome. Similar to odontoid fractures, atlantoaxial dislocation in patients with Os odontoideum can result in neurological deficits, disability, and even mortality. CASE PRESENTATION We present two cases of Os odontoideum accompanied by Down syndrome. Both patients were hospitalized due to progressive tetraparesis after falls several months prior. Upon examination, the patients exhibited myelopathy and were unable to walk or stand. MRI revealed spinal stenosis at the C1-C2 level due to atlantoaxial dislocation. C1-C2 fixation using Harms' technique was performed in both cases. One case experienced a complication involving instrument failure, necessitating revision surgery. CLINICAL DISCUSSION Due to the characteristics of transverse ligament laxity, low muscle tone, excessive joint flexibility, and cognitive impairment, children with both Down syndrome and Os odontoideum are at a high risk of disability and even mortality from spinal cord injury. Most authors recommend surgical management when patients exhibit atlantoaxial instability. Additional factors such as low bone density, cognitive impairment, and a high head-to-body ratio may increase the risk of surgical instrument failure and nonunion postoperatively in patients with Down syndrome. CONCLUSION Os odontoideum is a cause of AAI in patients with DS. Indication of surgery in the presence of AAI helps to resolve neurological injury and prevent further deterioration. The use of a cervical collar is considered to prevent instrument failure postoperatively.
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Affiliation(s)
- Long Hoang Nguyen
- Viet Duc University Hospital, Ha Noi, Viet Nam; University of Medicine and Pharmacy, Vietnam National University, Ha Noi, Viet Nam
| | - Khanh Manh Nguyen
- Viet Duc University Hospital, Ha Noi, Viet Nam; University of Medicine and Pharmacy, Vietnam National University, Ha Noi, Viet Nam
| | - Tien Le Bao Nguyen
- Viet Duc University Hospital, Ha Noi, Viet Nam; University of Medicine and Pharmacy, Vietnam National University, Ha Noi, Viet Nam
| | | | - Hoang Minh Bui
- Viet Duc University Hospital, Ha Noi, Viet Nam; University of Medicine and Pharmacy, Vietnam National University, Ha Noi, Viet Nam.
| | - Hoang Vu Nguyen
- Thai Nguyen University of Medicine and Pharmacy, Thai Nguyen, Viet Nam
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Li C, Tian Y, Ren Q, Ji X, Mao Z, Wu M. Treatment of Atlantoaxial Dislocation in Children with Down Syndrome Using Posterior Atlantoaxial Screw Fixation. Front Surg 2022; 9:877929. [PMID: 35693316 PMCID: PMC9178121 DOI: 10.3389/fsurg.2022.877929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 05/05/2022] [Indexed: 11/21/2022] Open
Abstract
Background To investigate the effect of posterior atlantoaxial screw fixation for the treatment of atlantoaxial dislocation in children with Down syndrome (DS). Methods Children diagnosed with DS who underwent posterior atlantoaxial screw fixation or occipitocervical fusion from January 2017 to January 2020 in Hebei Children’s Hospital were retrospectively included. Preoperative CT and MRI were performed to check the os odontoideum (OsO) and spinal cord compression, signal changes and spinal cord injury grade (ASIA grade). Results All 5 children have atlantoaxial dislocation and OsO. Among which 60% (3/5) of children had changes in spinal cord signals and 40% (2/5) had dural sac compression. Every child underwent posterior atlantoaxial screw fixation (3.5-mm diameter), and the average fusion level was 1.8 (1–2). All 5 cases wore the head-neck-chest brace for 3–6 months after the operation. 1 case had dural tear and recovered well after timely suturing. 1 case had internal fixation breakage of the prosthetic joint and underwent revision surgery. At the last follow-up, all cases were fused and the neurological function were all ASIA grade E. Conclusion After posterior atlantoaxial screw fixation, fusion and nerve recovery were achieved in all children with atlantoaxial dislocation and OsO. Postoperative head-neck-chest braces are necessary for children, especially those with occipitocervical fusion.
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Affiliation(s)
- Chengxin Li
- Department of Orthopedic, Beijing Children’s Hospital, Capital Medical University, Beijing, China
| | - Yiren Tian
- Department of Orthopedic, Children’s Hospital of Hebei Province,Shijiazhuang, China
- Correspondence: Yiren Tian
| | - Qiang Ren
- Department of Orthopedic, Children’s Hospital of Hebei Province,Shijiazhuang, China
| | - Xiangqian Ji
- Department of Orthopedic, Children’s Hospital of Hebei Province,Shijiazhuang, China
| | - Ziwei Mao
- Department of Orthopedic, Children’s Hospital of Hebei Province,Shijiazhuang, China
| | - Ming Wu
- Department of Orthopedic, Children’s Hospital of Hebei Province,Shijiazhuang, China
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Dahdaleh N, Cho S, Shlobin N. Os odontoideum: A comprehensive review. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2022; 13:256-264. [PMID: 36263339 PMCID: PMC9574117 DOI: 10.4103/jcvjs.jcvjs_71_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 07/31/2022] [Indexed: 11/10/2022] Open
Abstract
Os odontoideum (OO) is a rare craniocervical anomaly that is characterized by a round ossicle separated from the C2 vertebral body. With a controversial etiology and unknown prevalence in the population, OO may be asymptomatic or present in patients with myelopathic and neurological symptoms. In this literature review, we aimed to investigate epidemiology, embryology, pathophysiology, clinical presentation, and the role of diagnostic radiography in OO. By providing an overview of different management strategies, surgical complications, and postoperative considerations for OO, our findings may guide neurosurgeons in providing proper diagnosis and treatment for OO patients. A literature review was conducted using the PubMed, EMBASE, and Scopus databases. A search using the query “os odontoideum” yielded 4319 results, of which 112 articles were chosen and analyzed for insights on factors such as etiology, clinical presentation, and management of OO. The presentation of OO varies widely from asymptomatic cases to severe neurological deficits. Asymptomatic patients can be managed either conservatively or surgically, while symptomatic patients should undergo operative stabilization. Although multiple studies show different techniques for surgical management involving posterior fusion, the diversity of such cases illustrates how treatment must be tailored to the individual patient to prevent complications. Conflicting studies and the paucity of current literature on OO highlight poor comprehension of the condition. Further understanding of the natural history of OO is critical to form evidence-based guidelines for the management of OO patients. More large-center studies are thus needed to promote accurate management of OO patients with optimal outcomes.
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Bauer JM, Dhaliwal VK, Browd SR, Krengel WF. Repeat Pediatric Trisomy 21 Radiographic Exam: Does Atlantoaxial Instability Develop Over Time? J Pediatr Orthop 2021; 41:e646-e650. [PMID: 34171888 DOI: 10.1097/bpo.0000000000001884] [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: 02/07/2023]
Abstract
BACKGROUND Atlantoaxial instability (AAI) is common in pediatric patients with Trisomy 21 and can lead to spinal cord injury during sports, trauma, or anesthetized neck manipulation. Children with Trisomy 21 therefore commonly undergo radiographic cervical spine screening, but recommendations on age and timing vary. The purpose of this study was to determine if instability develops over time. METHODS We performed a retrospective review for all pediatric Trisomy 21 patients receiving at least 2 cervical spine radiographic series between 2008 and 2020 at our institution. Atlantodens interval (ADI) and space available for the cord at C1 (SAC) were measured; bony abnormalities such as os odontoidium, and age and time between radiographs were noted. AAI was determined by ADI ≥6 mm or SAC ≤14 mm based on our groups' prior study. Those who developed instability were compared with those who did not. RESULTS A total of 437 cervical spine radiographic series from 192 patients were evaluated, with 160 included. Mean age at first radiograph was 7.4±4.4 years, average ADI was 3.1 mm (±1.2), and SAC was 18.1 mm (±2.6). The average time between first and last radiographs was 4.3 years (±1.8), with average final ADI 3.2 mm (±1.4) and SAC 18.9 mm (±2.9). Seven patients (4%) had instability: 4 were unstable on their initial studies and 3 (1.6%) on subsequent imaging. Os odontoideum was found in 5 (71%) unstable spines and 3 (2%) stable spines (P<0.0001); only 1 patient that became unstable on subsequent radiograph did not have an os. There was no specific age cut-off or surveillance time period after which one could be determined no longer at risk. CONCLUSIONS Trisomy 21 patients have a 4.4% overall rate of AAI in our series with a 1.6% rate of progression to instability over ∼4 years. Given this nearly 1 in 23 risk of instability, we recommend initial surveillance radiograph for all children over 3 years with Trisomy 21; repeat asymptomatic surveillance should continue in those with os odontoideum given their high instability risk. LEVEL OF EVIDENCE Level II-diagnostic study.
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Affiliation(s)
- Jennifer M Bauer
- Seattle Children's Hospital Department of Orthopaedic Surgery, University of Washington Department of Orthopaedics and Sports Medicine
| | | | - Samuel R Browd
- Seattle Children's Hospital Department of Neurosurgery, University of Washington Department of Neurosurgery, Seattle, WA
| | - Walter F Krengel
- Seattle Children's Hospital Department of Orthopaedic Surgery, University of Washington Department of Orthopaedics and Sports Medicine
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Henderson FC, Francomano CA, Rowe PC. Letter to the editor regarding "Atlantoaxial dislocation due to os odontoideum in patients with Down's syndrome: literature review and case reports". Childs Nerv Syst 2021; 37:1041-1043. [PMID: 32940772 PMCID: PMC8009794 DOI: 10.1007/s00381-020-04886-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Accepted: 09/08/2020] [Indexed: 12/02/2022]
Affiliation(s)
- Fraser C Henderson
- Department Neurosurgery, University of Maryland Capital Region Health Center, Cheverly, MD, USA.
- Metropolitan Neurosurgery Group LLC, 1010 Wayne Avenue, Suite 420, Silver Spring, MD, 20910, USA.
| | - Clair A Francomano
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, 975 W. Walnut Street, IB 130, Indianapolis, IN, 46202, USA
| | - Peter C Rowe
- Department of Pediatrics, Johns Hopkins University School of Medicine, 200 N. Wolfe Street, #2077, Baltimore, MD, 21287, USA
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Evaluation of 2011 AAP cervical spine screening guidelines for children with Down Syndrome. Childs Nerv Syst 2020; 36:2609-2614. [PMID: 32778937 DOI: 10.1007/s00381-020-04855-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 07/30/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Atlantoaxial instability (AAI) has a higher incidence rate among individuals with Down syndrome (DS) than the non-DS population. In 2011, the American Academy of Pediatrics (AAP) updated its AAI screening guidelines for children with DS from radiographic screening to radiographs only if there are clinical symptoms suggestive of cervical spine pathology. An assessment of whether this alteration has been associated with an increase in AAI-associated spinal cord injury has not been undertaken. METHODS We provide the first neurosurgical review of a large experience implementing the 2011 AAP guidelines. We reviewed the courses of patients with DS seen at the Sie Center for Down Syndrome at Children's Hospital Colorado who were evaluated for cervical spine disease and determined whether screening radiographic imaging could have led to earlier diagnosis or prevented development of neurological deficits. We also report an illustrative case of a 5-year-old female with Down syndrome who presented with instability after normal screening radiographs per the pre-2011 guidelines. RESULTS The clinical experience of the Sie Center demonstrates that even when limiting imaging to patients who show signs or symptoms of spine pathology, the vast majority of x-rays are negative. Our exemplary patient presented to the emergency department for neck pain without a history of significant trauma. She was diagnosed and treated for atlantoaxial subluxation associated with os odontoideum. CONCLUSION Routine radiographic screening may not be sufficiently predictive of DS individuals at risk to develop AAI. This experience supports the appositeness of the de-escalation of care asserted by the guidelines.
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