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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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Imamura H, Hamano Y, Kamijo H, Ichikawa M, Kashima Y, Oba H. Successful recovery from cardiac arrest due to atlantoaxial subluxation in Down syndrome: a case report. Spinal Cord Ser Cases 2024; 10:37. [PMID: 38796439 PMCID: PMC11127916 DOI: 10.1038/s41394-024-00649-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 05/02/2024] [Accepted: 05/09/2024] [Indexed: 05/28/2024] Open
Abstract
INTRODUCTION Down syndrome is the most common chromosomal abnormality associated with intellectual impairments. Unexpected deaths are common with this disease. There are certain difficulties in clarifying the cause of death because the manifestations may be quite diverse and involve many organ systems. Atlantoaxial subluxation is a dangerous complication of Down syndrome, as it may lead to cervical cord-medullary compression. CASE PRESENTATION Herein, we present a case of Down syndrome in a patient who completely recovered from cardiac arrest due to atlantoaxial subluxation. The neck was immobilized during post-cardiac arrest care, and the patient underwent surgery after 14 days. The patient could walk independently and was discharged 3 months later. At the last follow-up 5 years after surgery, the patient's general condition was good. DISCUSSION Physicians should be aware that atlantoaxial instability can cause cardiac arrest in patients with genetic syndromes.
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Affiliation(s)
- Hiroshi Imamura
- Department of Emergency and Critical Care Medicine, Shinshu University School of Medicine, Matsumoto, Japan.
| | - Yujiro Hamano
- Department of Emergency and Critical Care Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | - Hiroshi Kamijo
- Department of Emergency and Critical Care Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | - Michitaro Ichikawa
- Department of Emergency and Critical Care Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | - Yuichiro Kashima
- Department of Emergency and Critical Care Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | - Hiroki Oba
- Department of Orthopedic Surgery, Shinshu University School of Medicine, Matsumoto, Japan
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Kong W, Du Y, Li J, Shao J, Xi Y. The retropharyngeal reduction plate for atlantoaxial dislocation: a finite element analysis. Front Bioeng Biotechnol 2024; 12:1346850. [PMID: 38318194 PMCID: PMC10841548 DOI: 10.3389/fbioe.2024.1346850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 01/05/2024] [Indexed: 02/07/2024] Open
Abstract
Objective: To investigate the biomechanical properties of the retropharyngeal reduction plate by comparing the traditional posterior pedicle screw-rod fixation by finite element analysis. Methods: Two three-dimensional finite element digital models of the retropharyngeal reduction plate and posterior pedicle screw-rod fixation were constructed and validated based on the DICOM (Digital Imaging and Communications in Medicine) data from C1 to C4. The biomechanical finite element analysis values of two internal fixations were measured and calculated under different conditions, including flexion, extension, bending, and rotation. Results: In addition to the backward extension, there was no significant difference in the maximum von Mises stress between the retropharyngeal reduction plate and posterior pedicle screw fixation under other movement conditions. The retropharyngeal reduction plate has a more uniform distribution under different conditions, such as flexion, extension, bending, and rotation. The stress tolerance of the two internal fixations was basically consistent in flexion, extension, left bending, and right bending. Conclusion: The retropharyngeal reduction plate has a relatively good biomechanical stability without obvious stress concentration under different movement conditions. It shows potential as a fixation option for the treatment of atlantoaxial dislocation.
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Affiliation(s)
| | | | | | | | - Yongming Xi
- Department of Spinal Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
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Essa A, Khatib S, Beit Ner E, Smorgick Y, Mirovsky Y, Anekstein Y, Rabau O. Traumatic Posterior Atlantoaxial Dislocation With an Associated Fracture: A Systematic Review. Clin Spine Surg 2023; 36:323-329. [PMID: 36750437 DOI: 10.1097/bsd.0000000000001431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 12/01/2022] [Indexed: 02/09/2023]
Abstract
STUDY DESIGN Systematic review. OBJECTIVE To investigate the clinical presentation, mechanism of injury, patients' characteristics, diagnosis, treatment, and prognosis of traumatic posterior atlantoaxial dislocation with fracture (TPAD). BACKGROUND TPAD is an extremely rare entity, with a limited number of cases reported in the literature. Although rare, a thorough understanding of the pathogenesis and management of such cases is required due to the high risk of spinal cord compression and the severity of neurological deficits. We conducted a systematic review of all cases of TPAD with fractures reported in the literature. METHODS This systematic review was conducted following the Preferred Reporting Items for Systematic reviews and Meta-analysis guidelines. Relevant literature was retrieved from the Pubmed database. All published English-written studies involving human subjects with relevant data regarding TPAD were included. RESULTS Two case series and 20 case reports published between 1924 and 2021 describing 28 patients with TPAD were included. The median age at presentation was 51.5 years, with male predominance (83%). The most common fracture pattern was Anderson and D'alonzo type II odontoid fracture (78%). Neurological exam at presentation was intact in 52% of patients. The primary diagnostic imaging was computed tomography employed in 96% of cases. The management consisted of 2 stages protocol, initially, a temporary axial traction was employed (54%), and later definitive surgical treatment was employed (93%). The posterior surgical approach was favored in 82% of cases. CONCLUSION TPAD with fracture occurred in the majority of cases with Anderson and D'alonzo type II odontoid fracture, predominantly in males. Diagnosis is usually established based on computed tomography imaging; further imaging may not be indicated as it does not seem to alternate the patient's management course. Surgical intervention was employed in almost all cases, with favored results through posterior C1-C2 fusion. LEVEL OF EVIDENCE Level-IV.
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Affiliation(s)
- Ahmad Essa
- Department of Orthopedics, Shamir (Assaf Harofeh) Medical Center
- Faculty of Medicine, Tel Aviv University, Tel Aviv
| | - Salah Khatib
- Department of Orthopedics, Shamir (Assaf Harofeh) Medical Center
- Faculty of Medicine, Tel Aviv University, Tel Aviv
| | - Eran Beit Ner
- Department of Orthopedics, Shamir (Assaf Harofeh) Medical Center
- Faculty of Medicine, Tel Aviv University, Tel Aviv
| | - Yossi Smorgick
- Department of Orthopedics, Shamir (Assaf Harofeh) Medical Center
- Faculty of Medicine, Tel Aviv University, Tel Aviv
- Department of Orthopedic Surgery, Spine Unit, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
| | - Yigal Mirovsky
- Department of Orthopedics, Shamir (Assaf Harofeh) Medical Center
- Faculty of Medicine, Tel Aviv University, Tel Aviv
- Department of Orthopedic Surgery, Spine Unit, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
| | - Yoram Anekstein
- Department of Orthopedics, Shamir (Assaf Harofeh) Medical Center
- Faculty of Medicine, Tel Aviv University, Tel Aviv
- Department of Orthopedic Surgery, Spine Unit, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
| | - Oded Rabau
- Department of Orthopedics, Shamir (Assaf Harofeh) Medical Center
- Faculty of Medicine, Tel Aviv University, Tel Aviv
- Department of Orthopedic Surgery, Spine Unit, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
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Spiegl UJA, Keil H, Krause J, Osterhoff G, Scheyerer MJ, Schnake KJ, Perl M. Combined Odontoid (C2) and Atlas (C1) Fractures in Geriatric Patients: A Systematic Review and Treatment Recommendation. Global Spine J 2023; 13:22S-28S. [PMID: 37084349 PMCID: PMC10177310 DOI: 10.1177/21925682221127951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/23/2023] Open
Abstract
STUDY DESIGN Systematic review. OBJECTIVE The aim of this study was to conduct a systematic overview of the pathogenesis and the treatment options of combined odontoid and atlas fractures in geriatric patients. METHODS This review is based on articles retrieved by a systematic search in the PubMed and Web of Science databases for articles published until February 2021 dealing with combination fractures of C1 and C2 in geriatric patients. RESULTS Altogether, 438 articles were retrieved from the literature search. A total of 430 articles were excluded. The remaining eight original articles were included in this systematic review depicting the topics pathogenesis, non-operative treatment, posterior approach, and anterior approach. The overall level of evidence of the studies is low. CONCLUSION Combined odontoid and atlas fractures in the geriatric population are commonly caused by simple falls and seem to be associated with atlanto-odontoid osteoarthritis. Non-operative treatment with a cervical orthosis is a feasible treatment option in the majority of patients with stable C2 fractures. In case of surgery posterior C1 and C 2 stabilization and anterior triple or quadruple screw fixation are possible techniques. Some patients may also deserve an occipito-cervical fusion. A possible treatment algorithm is proposed.
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Affiliation(s)
- Ulrich J A Spiegl
- Department of Orthopaedics, Trauma Surgery and Plastic Surgery, University of Leipzig, Leipzig, Germany
| | - Holger Keil
- Department of Trauma and Orthopedic Surgery, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - Johannes Krause
- Department of Trauma and Orthopedic Surgery, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - Georg Osterhoff
- Department of Orthopaedics, Trauma Surgery and Plastic Surgery, University of Leipzig, Leipzig, Germany
| | - Max J Scheyerer
- Department of Orthopedics and Trauma Surgery, University hospital, Duesseldorf, Germany
| | - Klaus John Schnake
- Center for Spinal and Scoliosis Surgery, Malteser Waldkrankenhaus St. Marien gGmbH, Erlangen, Germany
- Department of Orthopedics and Traumatology, Paracelsus Private Medical University Nuremberg, Nuremberg, Germany
| | - Mario Perl
- Department of Trauma and Orthopedic Surgery, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
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Ma Z, Zhang YN, Ma X, Chen C, Feng HY. Comparison of the clinical efficacy of unilateral and bilateral pedicle screw short-segment fixation and fusion in the treatment of atlantoaxial fracture-dislocation. Technol Health Care 2023; 31:1619-1629. [PMID: 36970926 PMCID: PMC10578255 DOI: 10.3233/thc-220721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 01/16/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND Few studies have compared the clinical efficacy of unilateral and bilateral pedicle screw fixation and fusion in treating atlantoaxial fracture-dislocation. OBJECTIVE To compare the efficacy of unilateral and bilateral fixation and fusion for atlantoaxial fracture-dislocation and to explore the feasibility of the unilateral surgical procedure. METHODS Twenty-eight consecutive patients with atlantoaxial fracture-dislocation were included in the study from June 2013 to May 2018. They were divided into a unilateral fixation group and a bilateral fixation group (14 patients in each group with an average age of 43.6 ± 16.3 years and 51.8 ± 15.4 years, respectively). The unilateral group had a unilateral anatomical variation of the pedicle or vertebral artery, or traumatic pedicle destruction. All patients underwent atlantoaxial unilateral or bilateral pedicle screw fixation and fusion. Intraoperative blood loss and operation time were recorded. The visual analog scale (VAS) and Japanese Orthopedic Association (JOA) scoring systems were used to evaluate pre- and postoperative occipital-neck pain and neurological function. X-ray and computerized tomography (CT) were used to assess atlantoaxial stability, the implants' position, and bone graft fusion. RESULTS All patients were followed up for 39-71 months postoperatively. Intraoperatively, no spinal cord or vertebral artery injury was observed. At the last follow-up, occipital-neck pain and neurological function in the two groups were significantly improved (P< 0.05). The X-ray films and CT showed satisfactory atlantoaxial stability, implant position, and osseous fusion in all the patients at 6 months postoperatively. CONCLUSION Unilateral and bilateral pedicle screw fixation and fusion can restore atlantoaxial stability and improve occipital-neck pain and neurological function in patients with atlantoaxial fracture-dislocation. The unilateral surgical procedure can be a supplementary option for patients with unilateral abnormal atlantoaxial lesions.
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Affiliation(s)
- Zhuo Ma
- Department of Orthopedic Surgery, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, The Third Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Yan-Nan Zhang
- Department of Orthopedic Surgery, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, The Third Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Xun Ma
- Department of Orthopedic Surgery, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, The Third Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Chen Chen
- Department of Orthopedic Surgery, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, The Third Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Hao-Yu Feng
- Department of Orthopedic Surgery, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, The Third Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
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Muacevic A, Adler JR, Patel J, Jenson M, Rao D. Interrelationship Between Craniocervical Dissociation Spectrum Injuries and Atlantoaxial Instability on Trauma Cervical MRI Examinations. Cureus 2022; 14:e31238. [PMID: 36514650 PMCID: PMC9733797 DOI: 10.7759/cureus.31238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 11/08/2022] [Indexed: 11/09/2022] Open
Abstract
Background and purpose Craniocervical dissociation injuries encompass a spectrum of osteoligamentous injuries between the skull base and C1-C2 that may be treated via prolonged external immobilization versus occipital cervical fusion depending on the risk of persistent craniocervical instability. However, the presence of atlantoaxial instability (AAI) at C1-C2, as determined by transverse atlantal ligament (TAL) integrity with or without a C1 fracture, may guide the neurosurgical management of craniocervical dissociation spectrum injuries (CDSI) since it implies an overall greater degree of instability at the craniocervical junction (CCJ). Materials and methods Adult trauma patients who suffered a transverse atlantal ligament injury on cervical magnetic resonance imaging (MRI) were identified retrospectively. The cervical computed tomography (CT) and magnetic resonance imaging examinations for these patients were reviewed for additional traumatic findings. Demographic information, treatment, and outcome information were recorded. Results Twenty-nine trauma patients presented to the emergency department (ED) with an acute, midsubstance transverse atlantal ligament tear on cervical magnetic resonance imaging. Thirty-one percent of patients demonstrated a tear in at least one major craniocervical ligament (atlanto-occipital capsular ligaments, alar ligaments, and tectorial membrane {TM}) with 14% demonstrating a tear in two major craniocervical ligaments and no patients demonstrating a tear in all three major craniocervical ligaments. Minor craniocervical ligament injuries (anterior atlanto-occipital membrane complex {AAOMc} and posterior atlanto-occipital membrane complex {PAOMc}) were common and observed in 76% of patients. Conclusions Our study suggests that multiple major craniocervical junction ligamentous injuries on cervical magnetic resonance imaging are relatively uncommon in the setting of transverse atlantal ligament injury.
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Spirollari E, Beaudreault C, Ng C, Vazquez S, Chapman E, Clare K, Wang R, Naftchi A, Das A, Lui A, Sacknovitz A, Dominguez JF, Gandhi CD, Tyagi R, Houten JK, Kinon MD. Cervical fusion for adult patients with atlantoaxial rotatory subluxation. JOURNAL OF SPINE SURGERY (HONG KONG) 2022; 8:224-233. [PMID: 35875625 PMCID: PMC9263735 DOI: 10.21037/jss-22-19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 04/29/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Atlantoaxial rotatory subluxation (AARS) is a rare injury of the C1/C2 junction. It is often associated with trauma in adults. Treatment may depend on the duration of symptoms and clinical presentation, but there is no consensus regarding the ideal management of these injuries. Our objective is to ascertain the prevalence of neurological deficit, complications, and outcomes of patients diagnosed with AARS undergoing cervical fusion (CF) versus those treated without CF. METHODS The 2016-2019 National Inpatient Sample (NIS) was queried using International Classification of Diseases, 10th revision (ICD-10) for adult patients with C1/C2 subluxation. Patients undergoing CF were defined through ICD-10 procedure codes. Baseline health and acute illness severity was calculated using the 11-point modified frailty index (mFI-11). Presenting characteristics, treatment complications, and outcomes were evaluated of CF vs. non-CF patients. RESULTS Of 990 adult patients with AARS, 720 were treated without CF and 270 were treated with CF. CF patients were more often myelopathic. Patients that had undergone CF treatment were negatively associated with having had extensive trauma. Patients undergoing CF experienced significantly longer length of stay (LOS), increased healthcare resource utilization, and decreased inpatient mortality. Sepsis had a negative association with patients that underwent CF treatment while pneumonia had a positive association. CONCLUSIONS Adult patients undergoing CF for AARS demonstrated an increase in healthcare resource utilization but also a significant decrease in mortality. Extent of acute injury appears to have a strong influence on decision making for CF. Further study of decision making for treatment of this rare injury in adults is warranted.
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Affiliation(s)
| | | | | | | | - Emily Chapman
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | | | - Ankita Das
- New York Medical College, Valhalla, NY, USA
| | - Aiden Lui
- New York Medical College, Valhalla, NY, USA
| | | | - Jose F. Dominguez
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Chirag D. Gandhi
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Rachana Tyagi
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - John K. Houten
- Department of Neurosurgery, Maimonides Medical Center, Zucker School of Medicine at Hofstra-Northwell, Brooklyn, NY, USA
| | - Merritt D. Kinon
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
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SANTOS FRANCISCODESOUZA, COSTA LEANDROMEDEIROSDA. LOCKED-IN SYNDROME AFTER TRAUMATIC ATLANTOAXIAL SUBLUXATION: A CASE REPORT. COLUNA/COLUMNA 2022. [DOI: 10.1590/s1808-185120222103261273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
ABSTRACT Traumatic atlanto-axial subluxation is a rare and underdiagnosed condition due to its high rate – reported to be between 60 and 80% – of early mortality. Its diagnosis takes into account the trauma mechanism, precise analyses of the imaging tests and the clinical presentation of the patient. This article describes a rare presentation of atlanto-axial subluxation associated with craniocervical dislocation as a case of locked-in syndrome. Level of evidence V; Retrospective observational study – Case report.
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Does alar ligament injury predict conservative treatment failure of atlantoaxial rotatory subluxation in adults: Case report and review of the literature. Spinal Cord Ser Cases 2021; 7:103. [PMID: 34862363 DOI: 10.1038/s41394-021-00464-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 10/28/2021] [Accepted: 11/02/2021] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION The alar ligament is an important structure in restraining the rotational movement at the atlantoaxial joint. While bony fractures generally heal, rupture of ligaments may heal poorly in adults and often requires surgical stabilization. Atlantoaxial rotatory subluxation (AARS) is a rare injury in adults, and the prognostic importance of the presence of alar ligament injury with regard to the success of nonoperative management is unknown. CASE PRESENTATION A 28-year-old woman presented after a traumatic Type I AARS without evidence of osseous injury, but MRI demonstrated evidence of unilateral alar ligament disruption. Initial conservative management with closed reduction and maintenance in a rigid cervical collar proved unsuccessful, with worsening pain and failure to maintain reduction. She subsequently underwent open reduction and surgical fixation of C1-C2, resulting in resolution of her pain and maintenance of alignment. DISCUSSION Alar ligament rupture may be a negative prognostic indicator in the success of nonoperative management of type I atlantoaxial rotatory subluxation. Additional study is warranted to better assess whether the status of the alar ligament should be considered an important factor in the management algorithm of type I AARS.
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Dibble CF, Javeed S, Zhang JK, Pennicooke B, Ray WZ, Molina C. Extended tulip cervical reduction screws to restore alignment in traumatic atlantoaxial dislocation after type 3 odontoid fracture: illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2021; 2:CASE21414. [PMID: 35855058 PMCID: PMC9265201 DOI: 10.3171/case21414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Accepted: 08/17/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Traumatic atlantoaxial rotatory subluxation after type 3 odontoid fracture is an uncommon presentation that may require complex intraoperative reduction maneuvers and presents challenges to successful instrumentation and fusion. OBSERVATIONS The authors report a case of a 39-year-old female patient who sustained a type 3 odontoid fracture. She was neurologically intact and managed in a rigid collar. Four months later, she presented again after a second trauma with acute torticollis and type 2 atlantoaxial subluxation, again neurologically intact. Serial cervical traction was placed with minimal radiographic reduction. Ultimately, she underwent intraoperative reduction, instrumentation, and fusion. Freehand C1 lateral mass reduction screws were placed, then C2 translaminar screws, and finally lateral mass screws at C3 and C4. The C2–4 instrumentation was used as bilateral rod anchors to reduce the C1 lateral mass reduction screws engaged onto the subluxated atlantodental complex. As a final step, cortical allograft spacers were inserted at C1–2 under compression to facilitate long-term stability and fusion. LESSONS This is the first description of a technique using extended tulip cervical reduction screws to correct traction-irreducible atlantoaxial subluxation. This case is a demonstration of using intraoperative tools available for the spine surgeon managing complex cervical injuries requiring intraoperative reduction that is resistant to traction reduction.
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Affiliation(s)
| | - Saad Javeed
- Department of Neurological Surgery, Washington University, St. Louis, Missouri
| | - Justin K. Zhang
- Department of Neurological Surgery, Washington University, St. Louis, Missouri
| | - Brenton Pennicooke
- Department of Neurological Surgery, Washington University, St. Louis, Missouri
| | - Wilson Z. Ray
- Department of Neurological Surgery, Washington University, St. Louis, Missouri
| | - Camilo Molina
- Department of Neurological Surgery, Washington University, St. Louis, Missouri
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Abstract
Craniocervical injuries (CCJs) account for 10% to 30% of all cervical spine trauma. An increasing number of patients are surviving these injuries due to advancements in automobile technology, resuscitation techniques, and diagnostic modalities. The leading injury mechanisms are motor vehicle crashes, falls from height, and sports-related events. Current treatment with urgent rigid posterior fixation of the occiput to the cervical spine has resulted in a substantial reduction in management delays expedites treatment of CCJ injuries. Within CCJ injuries, there is a spectrum of instability, ranging from isolated nondisplaced occipital condyle fractures treated nonoperatively to highly unstable injuries with severely distracted craniocervical dissociation. Despite the evolution of understanding and improvement in the management of cases regarding catastrophic failure to diagnose, subsequent neurologic deterioration still occurs even in experienced trauma centers. The purpose of this article is to review the injuries that occur at the CCJ with the accompanying anatomy, presentation, imaging, classification, management, and outcomes.
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Affiliation(s)
- Catherine Olinger
- Harborview Medical Center, University of Washington Department of Orthopaedics and Sports Medicine, 908 Jefferson Street, Fifth Floor, Seattle, WA, USA.
| | - Richard Bransford
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, WA, USA; Department of Neurological Surgery, University of Washington, Seattle, WA, USA; Spine Fellowship Program, University of Washington Department of Orthopaedics and Sports Medicine, 908 Jefferson Street, Fifth Floor, Seattle, WA, USA
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Sánchez-Ortega JF, Vázquez A, Ruiz-Ginés JA, Matovelle PJ, Calatayud JB. Longitudinal atlantoaxial dislocation associated with type III odontoid fracture due to high-energy trauma. Case report and literature review. Spinal Cord Ser Cases 2021; 7:43. [PMID: 34035212 DOI: 10.1038/s41394-021-00407-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 05/11/2021] [Accepted: 05/12/2021] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION Traumatic upper cervical spine injuries are frequently associated with high-energy trauma. The potential injuries to vital organs associated to a possible neurological damage marks the severity of this pathology. The neurological structures can be affected by a primary injury, spinal cord, cranial nerves and spinal nerves; or secondary to a vascular compromise, mainly the vertebral arteries. The dislocation of the atlantoaxial joint causes an unstable cervical spine that could be often associated with fracture of the Atlas and Axis. Evidently, these have a high morbimortality rate. CASE PRESENTATION A young woman who suffered a severe polytrauma secondary to a motor vehicle collision was diagnosed with a sagittal plane atlantoaxial joint dislocation associated with a type III odontoid fracture, despite an adequate initial polytrauma management, the neurological damage was too critical, ultimately the decease of the patient. DISCUSSION The atlantoaxial joint dislocation is a rare condition of the upper cervical spine and is usually secondary to a high-energy traumatism. The disruption of the atlantoaxial ligaments originates the considered most unstable cervical spine lesion and with the highest mortality. Attributable to the kinetic the bone fracture of the Atlas and Axis are commonly related, specially the odontoid process. Early immobilization followed by surgical decompression and stabilization is primordial. Typically, these injuries have an ominous prognosis, that is aggravated if added a polytrauma affecting adjacent neurological structures and other vital organs.
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Affiliation(s)
- Juan F Sánchez-Ortega
- Department of Neurosurgery, Lozano Blesa University Clinical Hospital, Zaragoza, Spain.
| | - Alfonso Vázquez
- Department of Neurosurgery, Lozano Blesa University Clinical Hospital, Zaragoza, Spain
| | - Juan A Ruiz-Ginés
- Department of Neurosurgery, Lozano Blesa University Clinical Hospital, Zaragoza, Spain
| | - Patricio J Matovelle
- Department of Neurosurgery, Lozano Blesa University Clinical Hospital, Zaragoza, Spain
| | - Juan B Calatayud
- Department of Neurosurgery, Lozano Blesa University Clinical Hospital, Zaragoza, Spain
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Klepinowski T, Limanówka B, Sagan L. Management of post-traumatic craniovertebral junction dislocation: A PRISMA-compliant systematic review and meta-analysis of casereports. Neurosurg Rev 2020; 44:1391-1400. [PMID: 32797319 PMCID: PMC8121741 DOI: 10.1007/s10143-020-01366-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 07/14/2020] [Accepted: 08/03/2020] [Indexed: 12/23/2022]
Abstract
Although historically considered fatal, with the advent of improved pre-hospital care, traumatic dislocation of the craniovertebral junction (CVJ) has been increasing in prevalence in neurosurgical centers. As more survivors are reported each year, a timely review with meta-analysis of their management seems necessary. PRISMA checklist was followed step by step. PubMed and Web of Science databases were searched using words “craniovertebral junction dislocation” and their corresponding synonyms. Study eligibility criteria included research studies from 2015 onwards that delineated adult and pediatric patients with confirmed post-traumatic atlantooccipital dislocation (AOD) or atlantoaxial dislocation (AAD) who survived until proper treatment. Of 1475 initial records, 46 articles met eligibility criteria with a total of 141 patients with traumatic CVJ dislocation. Of the patients, 90 were male (63.8%). Mean age of the cohort was 33.3 years (range 1–99 years). Trauma that most often led to this injury was road traffic accident (70.9%) followed by falls (24.6%). The majority of authors support posterior instrumentation of C1-C2 (45.2%) especially by means of Goel-Harms method. At mean follow-up of 15.4 months (range 0.5–60 months), 27.2% of treated patients remained neurologically intact. Of initially symptomatic, 59% improved, 37% were stable, and 4% deteriorated. Instrumenting the occiput in cases of pure AAD was associated with lower chance of neurological improvement in chi-square test (p = 0.0013) as well as in multiple linear regression (β = − 0.3; p = 0.023). The Goel-Harms C1-C2 fusion is currently the most frequently employed treatment. Many survivors remain with no deficits or improve, rarely deteriorate. Involving the occiput in stabilization in cases of AAD without AOD might be related with worse neurological prognosis.
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Affiliation(s)
- Tomasz Klepinowski
- Department of Neurosurgery, Pomeranian Medical University Hospital No. 1, Szczecin, Poland.
| | - Bartosz Limanówka
- Department of Neurosurgery, Pomeranian Medical University Hospital No. 1, Szczecin, Poland
| | - Leszek Sagan
- Department of Neurosurgery, Pomeranian Medical University Hospital No. 1, Szczecin, Poland
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Kageyama H, Kakumoto K, Yasuoka H, Arimoto H, Ohara Y. Cardiopulmonary arrest induced by atlantoaxial dislocation with subarachnoid hemorrhage: a case report and review of the literature. Spinal Cord Ser Cases 2019; 5:100. [PMID: 31871765 PMCID: PMC6908628 DOI: 10.1038/s41394-019-0247-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Revised: 11/27/2019] [Accepted: 12/02/2019] [Indexed: 11/08/2022] Open
Abstract
Introduction Spinal cord injury (SCI) with atlantoaxial dislocation (AAD) is often fatal. We present the case of a resuscitated patient with AAD and traumatic subarachnoid hemorrhage (SAH) at the craniovertebral junction (CVJ). Case presentation We present the case of an 84-year-old man who suffered an observed cardiopulmonary arrest. Cardiopulmonary resuscitation was initiated and spontaneous circulation returned. In the emergency room, the patient's Glasgow Coma Scale was 3 (E1V1M1). No spontaneous respiration was noted. Neuroimaging revealed SAH at the CVJ. Contrast-enhanced computed tomography (CT) revealed a vessel running through the left C2/3 intervertebral foramen into the spinal canal. The ventral space of spinal cord revealed contrast enhancement. Angiography revealed extravasation from the spinal branch of the left vertebral artery, without venous filling. It did not appear to be a vascular malformation with an arteriovenous shunt, but rather a traumatic laceration of the artery. Plain CT and CT angiography suggested AAD. Magnetic resonance imaging revealed injury to the medulla oblongata and upper cervical spinal cord, with AAD and retrodental subligamentous hemorrhage. We embolized the branch of the left vertebral artery and performed a C1 laminectomy. The patient moved his extremities postoperatively. Discussion This was a case of injury to the medulla oblongata and upper cervical spinal cord due to AAD with SAH. This is the first report of resuscitated case of traumatic AAD with SAH in the CVJ. Traumatic AAD should be included in the differential diagnosis in case of SAH in CVJ, which may be misdiagnosed as intrinsic SAH.
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Affiliation(s)
- Hiroshi Kageyama
- Department of Neurosurgery, Shin-Kuki General Hospital, Kuki, Saitama, Japan
| | - Kousuke Kakumoto
- Department of Neurosurgery, Shin-Kuki General Hospital, Kuki, Saitama, Japan
| | - Hiroki Yasuoka
- Department of Orthopedic surgery, Tokorozawa Meisei Hospital, Tokorozawa, Saitama, Japan
| | - Hirohiko Arimoto
- Department of Neurosurgery, Shin-Kuki General Hospital, Kuki, Saitama, Japan
| | - Yukoh Ohara
- Department of Neurosurgery, Juntendo University, Tokyo, Japan
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