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Singh DK, Kumar R, Pathak V, Kaif M, Yadav K. C1-C2 coronal and sagittal joint angle based treatment algorithm for the need of transoral odointectomy in complex craniovertebral junction anomalies with Clinico-Radiological outcome analysis. Br J Neurosurg 2023; 37:1594-1603. [PMID: 36073850 DOI: 10.1080/02688697.2022.2118232] [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: 02/14/2021] [Accepted: 08/23/2022] [Indexed: 11/02/2022]
Abstract
OBJECTIVE Craniovertebral junction (CVJ) pathology by virtue of its complexity is a surgical challenge in the realm of neurosurgery. We analyzed the need for transoral odointectomy in view of their C1-C2 joint coronal and sagittal angle of 58 patients with complex CVJ anomalies treated surgically. The clinical and radiological outcome of the patients was assessed and a treatment algorithm is proposed. METHODS A total of 58 cases were included in the Prospective study over the period of 2 years. Patients were evaluated clinically, investigated, and operated with reduction and rigid internal fixation with screws and rod. The clinical outcome was measured by Modified Japanese orthopedic association score(mJOA) and radiologically by conventional craniometrics indices. Paired 't' test used for statistical analysis. RESULTS Mean age of patients: 30 years, with mean, follow up: 20.5 months. 46(80%) patients were operated by posterior and 12(20%) by combined approach (anterior transoral with posterior). Occipitocervial fixation was done in 15(25.8%) cases and C1-C2 fixation in 43(74.2%) cases. As compared to patients with low coronal angle, the patient with coronal angle >65° needed anterior decompression (87.5%) and all (100%) had Occipitocervical fixation. Clinical outcome analysis showed significant improvement in mean mJOA score (preop 11.9 Vs postop 14.6) after surgery. All craniometrics indices were significantly improved after surgery. The overall complication rate was 10% with a mortality of 1.7%. 6 months follow up completed in all patients with a 100% fusion rate. CONCLUSION Occipitocervical fixation and anterior decompression is required in increased C1-C2 joint CA (>65°) for bony realignment and adequate decompression. Measurement of C1-C2 joint coronal and sagittal angle in complex CVJ anomalies will easily anticipate the surgeon regarding the need for anterior decompression inform of transoral odointectomy.
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Affiliation(s)
- Deepak Kumar Singh
- Department of Neurosurgery, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, India
| | - Rakesh Kumar
- Department of Neurosurgery, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, India
| | - Vipul Pathak
- Department of Neurosurgery, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, India
| | - Mohd Kaif
- Department of Neurosurgery, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, India
| | - Kuldeep Yadav
- Department of Neurosurgery, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, India
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Dastagirzada YM, Kurland DB, Hankinson TC, Anderson RCE. Craniovertebral Junction Instability in the Setting of Chiari Malformation. Neurosurg Clin N Am 2023; 34:131-142. [DOI: 10.1016/j.nec.2022.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Malikov A, Secen AE, Divanlioglu D, Gunerhan G, Ocal O, Gunduz UK. The feasibility of creating Image-Based Patient-Specific Drill Guides for the Atlantoaxial Instabilities using open-source CAD software and desktop 3D printers. World Neurosurg 2022; 163:e377-e383. [PMID: 35390495 DOI: 10.1016/j.wneu.2022.03.137] [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: 01/22/2022] [Revised: 03/29/2022] [Accepted: 03/30/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVE C1/2 cervical pedicle screw fixation is a well-known procedure for treating severely damaged and unstable C1/2 fractures. On the other hand, C1/C2 screw fixation is not safe and can lead to potentially disastrous consequences. The importance of personalized 3D printed navigational guides in avoiding these consequences cannot be overstated. MATERIALS AND METHODS We retrospectively reviewed the neuroimaging data of 16 patients who had undergone fixation for treatment of C1/2 diseases. We created patient-specific C1/2 models and drill guide models using open-source 3D editing software and a desktop 3D printer. The drill guides were then placed over the respective vertebrae models and fixated with 3.5 mm screws. Following fixation, the parts were scanned with a thin-slice (01 mm) CT scan, and the screw trajectories in the transverse and sagittal planes were measured at each level. RESULTS Of the total of 62 screws, 58 were type I (93.54%), 4 were type II (6.45%), and no screws were type III (Tab 2). The results showed that there was no significant deviation in the screw trajectories and the accuracy of the drill guides was 93.54% (Table 3). In our study, type I and type II screws were deemed acceptable, and the acceptable rates of C1/2 screw fixation were 100%. CONCLUSIONS In this preclinical study, we demonstrated that it is possible to create patient-specific pedicle drill guides using open source editing software and a commercially available desktop PLA printer, resulting in high accuracy rates in pedicle screw placement in C1/2 patient models.
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Affiliation(s)
- Azad Malikov
- Department of Neurosurgery, Ankara City Hospital, Ankara, Turkey.
| | - Ahmet Eren Secen
- Department of Neurosurgery, Ankara City Hospital, Ankara, Turkey
| | | | - Goksal Gunerhan
- Department of Neurosurgery, Ankara City Hospital, Ankara, Turkey
| | - Ozgur Ocal
- Department of Neurosurgery, Ankara City Hospital, Ankara, Turkey
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Abstract
Occipitocervical fusion (OCF) is indicated for instability at the craniocervical junction (CCJ). Numerous surgical techniques, which evolved over 90 years, as well as unique anatomic and kinematic relationships of this region present a challenge to the neurosurgeon. The current standard involves internal rigid fixation by polyaxial screws in cervical spine, contoured rods and occipital plate. Such approach precludes the need of postoperative external stabilization, lesser number of involved spinal segments, and provides 95-100% fusion rates. New surgical techniques such as occipital condyle screw or transarticular occipito-condylar screws address limitations of occipital fixation such as variable lateral occipital bone thickness and dural sinus anatomy. As the C0-C1-C2 complex is the most mobile portion of the cervical spine (40% of flexion-extension, 60% of rotation and 10% of lateral bending) stabilization leads to substantial reduction of neck movements. Preoperative assessment of vertebral artery anatomical variations and feasibility of screw insertion as well as visualization with intraoperative fluoroscopy are necessary. Placement of structural and supplemental bone graft around the decorticated bony elements is an essential step of every OCF procedure as the ultimate goal of stabilization with implants is to provide immobilization until bony fusion can develop.
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Rehman L, Bokhari I, Afzal A, Ahmad S. Posterior occipito cervical decompression with fixation and fusion in Cranio vertebral junction compression. Pak J Med Sci 2017; 33:1194-1198. [PMID: 29142563 PMCID: PMC5673732 DOI: 10.12669/pjms.335.12988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2017] [Revised: 05/10/2017] [Accepted: 10/04/2017] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To find out the clinical outcome of posterior decompression with occipitocervical fixation and fusion in patients with Craniovertebral junction instability. METHODS Eighty consecutive patients of cranio vertebral junction (CVJ) compression were treated in the department of neurosurgery, Jinnah Postgraduate Medical Centre (JPMC), Karachi over a period of 05 years from 1st January 2012 till 31st August 2016. All patients underwent posterior decompression with occipitocervical fusion (OCF) and fixation. The clinical outcome was assessed by Japanese Orthopedic Association (JOA) score and grading. RESULTS Out of 80 patients with CVJ instability, 64 (80%) were due to non traumatic causes, while 16 (20%) were secondary to trauma. All 80 patients(100%) showed post operative relief in pain. Sixty four (80%) patients showed improvement in power post operatively while six (7.5%) had no change, four (5%) showed deterioration and six (7.5%) patients expired. Sixty four (80%) patients had improvement of the JOA scores at last follow-up. According to etiology, the JOA score for patients with trauma improved in 12(75%) patients and 52(81.25%) for non traumatic causes while six patients (7.5%) expired. Fusion was achieved in 64 (80%) patients at last follow-up. CONCLUSION Posterior decompression with occipitocervical fusion and fixation is safe and can be recommended in cases of CVJ compression.
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Affiliation(s)
- Lal Rehman
- Dr. Lal Rehman, FCPS. Department of Neurosurgery, Jinnah Postgraduate Medical Center, Karachi, Pakistan
| | - Iram Bokhari
- Dr. Iram Bokhari, FCPS. Department of Neurosurgery, Jinnah Postgraduate Medical Center, Karachi, Pakistan
| | - Ali Afzal
- Dr. Ali Afzal, MBBS. Department of Neurosurgery, Jinnah Postgraduate Medical Center, Karachi, Pakistan
| | - Shakeel Ahmad
- Dr. Shakeel Ahmed, MBBS. Department of Neurosurgery, Jinnah Postgraduate Medical Center, Karachi, Pakistan
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Jiang L, Dong L, Tan M, Qi Y, Yang F, Yi P, Tang X. A Modified Personalized Image-Based Drill Guide Template for Atlantoaxial Pedicle Screw Placement: A Clinical Study. Med Sci Monit 2017; 23:1325-1333. [PMID: 28301445 PMCID: PMC5365048 DOI: 10.12659/msm.900066] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background Atlantoaxial posterior pedicle screw fixation has been widely used for treatment of atlantoaxial instability (AAI). However, precise and safe insertion of atlantoaxial pedicle screws remains challenging. This study presents a modified drill guide template based on a previous template for atlantoaxial pedicle screw placement. Material/Methods Our study included 54 patients (34 males and 20 females) with AAI. All the patients underwent posterior atlantoaxial pedicle screw fixation: 25 patients underwent surgery with the use of a modified drill guide template (template group) and 29 patients underwent surgery via the conventional method (conventional group). In the template group, a modified drill guide template was designed for each patient. The modified drill guide template and intraoperative fluoroscopy were used for surgery in the template group, while only intraoperative fluoroscopy was used in the conventional group. Results Of the 54 patients, 52 (96.3%) completed the follow-up for more than 12 months. The template group had significantly lower intraoperative fluoroscopy frequency (p<0.001) and higher accuracy of screw insertion (p=0.045) than the conventional group. There were no significant differences in surgical duration, intraoperative blood loss, or improvement of neurological function between the 2 groups (p>0.05). Conclusions Based on the results of this study, it is feasible to use the modified drill guide template for atlantoaxial pedicle screw placement. Using the template can significantly lower the screw malposition rate and the frequency of intraoperative fluoroscopy.
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Affiliation(s)
- Lianghai Jiang
- Department of Spinal Surgery, China-Japan Friendship Hospital, Beijing, China (mainland).,Graduate School of Peking Union Medical College, Beijing, China (mainland)
| | - Liang Dong
- Department of Spinal Surgery, Hong Hui Hospital, Xi'an, Shanxi, China (mainland)
| | - Mingsheng Tan
- Department of Spinal Surgery, China-Japan Friendship Hospital, Beijing, China (mainland).,Graduate School of Peking Union Medical College, Beijing, China (mainland)
| | - Yingna Qi
- Department of Spinal Surgery, China-Japan Friendship Hospital, Beijing, China (mainland)
| | - Feng Yang
- Department of Spinal Surgery, China-Japan Friendship Hospital, Beijing, China (mainland)
| | - Ping Yi
- Department of Spinal Surgery, China-Japan Friendship Hospital, Beijing, China (mainland)
| | - Xiangsheng Tang
- Department of Spinal Surgery, China-Japan Friendship Hospital, Beijing, China (mainland)
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Shkarubo AN, Andreev DN, Konovalov NA, Zelenkov PV, Lubnin AJ, Chernov IV, Koval KV. Surgical Treatment of Skull Base Tumors, Extending to Craniovertebral Junction. World Neurosurg 2017; 99:47-58. [DOI: 10.1016/j.wneu.2016.11.147] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Revised: 11/28/2016] [Accepted: 11/29/2016] [Indexed: 11/30/2022]
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Liao SX, Wang JH, Zheng YQ, Zheng G, Wei GJ, Xia H, Chen XH. Three-dimensional finite element analysis of a newly developed aliform internal fixation system for occipitocervical fusion. Med Eng Phys 2016; 38:S1350-4533(16)30188-6. [PMID: 28029426 DOI: 10.1016/j.medengphy.2016.08.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2016] [Revised: 08/06/2016] [Accepted: 08/30/2016] [Indexed: 11/15/2022]
Abstract
For patients with occipital malformation, it is difficult to obtain reliable stability using three screws on the midline. A new aliform occipitocervical internal fixation system was designed. The occiput was fixed with 3, 7, or 11 screws, and a three-dimensional finite element model of the system was established. A compressive preload of 40N combined with a pure moment of 1.5Nm was applied to simulate normal flexion, extension, lateral bending, and axial rotation. The stress distribution across the screws on the occiput and the occipital displacement produced by the newly developed system were compared with those produced by the DePuy SUMMIT system. Compared with the SUMMIT system (control group), in the new system, the maximum stress on the occiputs fixed with 3 screws (group A) and 7 screws (group B) increased by 16.5% and 15.0%, respectively. In contrast, the maximum stress on the occiput fixed with 11 screws (group C) decreased by 15.6%. In addition, the maximum occipital displacements under extension decreased by 10.0%, 11.4%, and 11.8% in the A, B, and, C groups, respectively. Our results indicate that both group A and the control group exhibited sufficient strength and instant stability; however, group C exhibited the highest stability and the lowest maximum von Mises stress.
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Affiliation(s)
- Sui-Xiang Liao
- Southern Medical University, 1063 South Road of Jinxishatai, 510515 Guangzhou, PR China; Department of Orthopedics, Panyu Central Hospital, 8 Fuyu East Road, Southbridge Street, Panyu, Guangzhou 511400, PR China
| | - Jian-Hua Wang
- Hospital of Orthopedics, Guangzhou General Hospital of Guangzhou Military Command, 111 Liuhua Road, Guangzhou 510010, PR China.
| | - Yong-Qiang Zheng
- Southern Medical University, 1063 South Road of Jinxishatai, 510515 Guangzhou, PR China; Department of Orthopedics, Jinjiang Municipal Hospital, 392 Xinhua Street, Jinjiang 362200, PR China
| | - Guan Zheng
- Southern Medical University, 1063 South Road of Jinxishatai, 510515 Guangzhou, PR China; Hospital of Orthopedics, Guangzhou General Hospital of Guangzhou Military Command, 111 Liuhua Road, Guangzhou 510010, PR China
| | - Ge-Jing Wei
- Southern Medical University, 1063 South Road of Jinxishatai, 510515 Guangzhou, PR China; Hospital of Orthopedics, Guangzhou General Hospital of Guangzhou Military Command, 111 Liuhua Road, Guangzhou 510010, PR China
| | - Hong Xia
- Southern Medical University, 1063 South Road of Jinxishatai, 510515 Guangzhou, PR China; Hospital of Orthopedics, Guangzhou General Hospital of Guangzhou Military Command, 111 Liuhua Road, Guangzhou 510010, PR China.
| | - Xiao-Hua Chen
- Department of Orthopedics, Panyu Central Hospital, 8 Fuyu East Road, Southbridge Street, Panyu, Guangzhou 511400, PR China
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Kukreja S, Ambekar S, Sin AH, Nanda A. Occipitocervical Fusion Surgery: Review of Operative Techniques and Results. J Neurol Surg B Skull Base 2015; 76:331-9. [PMID: 26401473 DOI: 10.1055/s-0034-1543967] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2014] [Accepted: 10/29/2014] [Indexed: 02/03/2023] Open
Abstract
Objective Varying types of clinicoradiologic presentations at the craniovertebral junction (CVJ) influence the decision process for occipitocervical fusion (OCF) surgery. We discuss the operative techniques and decision-making process in OCF surgery based on our clinical experience and a literature review. Material and Methods A total of 49 consecutive patients who underwent OCF participated in the study. Sagittal computed tomography images were used to illustrate and measure radiologic parameters. We measured Wackenheim clivus baseline (WCB), clivus-canal angle (CCA), atlantodental distance (ADD), and Powers ratio (PR) in all the patients. Results Clinical improvement on Nurick grading was recorded in 36 patients. Patients with better preoperative status (Nurick grades 1-3) had better functional outcomes after the surgery (p = 0.077). Restoration of WCB, CCA, ADD, and PR parameters following the surgery was noted in 39.2%, 34.6%, 77.4%, and 63.3% of the patients, respectively. Complications included deep wound infections (n = 2), pseudoarthrosis (n = 2), and deaths (n = 4). Conclusion Conventional wire-based constructs are superseded by more rigid screw-based designs. Odontoidectomy is associated with a high incidence of perioperative complications. The advent of newer implants and reduction techniques around the CVJ has obviated the need for this procedure in most patients.
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Affiliation(s)
- Sunil Kukreja
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, United States
| | - Sudheer Ambekar
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, United States
| | - Anthony H Sin
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, United States
| | - Anil Nanda
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, United States
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Yang J, Ma X, Xia H, Wu Z, Ai F, Yin Q. Transoral anterior revision surgeries for basilar invagination with irreducible atlantoaxial dislocation after posterior decompression: a retrospective study of 30 cases. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2014; 23:1099-108. [DOI: 10.1007/s00586-014-3169-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2013] [Revised: 01/02/2014] [Accepted: 01/04/2014] [Indexed: 11/29/2022]
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Clarke MJ, Toussaint LG, Kumar R, Daniels DJ, Fogelson JL, Krauss WE. Occipitocervical fusion in elderly patients. World Neurosurg 2011; 78:318-25. [PMID: 22120562 DOI: 10.1016/j.wneu.2011.10.037] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2010] [Revised: 08/24/2011] [Accepted: 10/21/2011] [Indexed: 11/16/2022]
Abstract
BACKGROUND Occipitocervical disease (OCD) in elderly patients will become increasingly common as the population ages. Our experience with occipitocervical fusions (OCF) in this population suggests mixed outcomes. METHODS Twenty consecutive patients over 65 years old underwent OCF between 1995 and 2005. A retrospective review of demographic, presentation, surgical and outcome data was performed. RESULTS Twenty patients averaging 75.3 years of age (range 65 to 91) were identified. All patients had evidence of myelopathy; however, the primary surgical indications were progressive spinal cord dysfunction (15), brainstem compression (3), and pain (2). Surgical approach was isolated posterior (9), or anterior transoral odontoidectomy followed by posterior stabilization (11). Overall, surgery improved function modestly; average modified Japanese Orthopedic Association functional score (improved 0.9 grades), average Ranawat Myelopathy Score (improved 0.4 grades), and average Nurick Myelopathy Grade (improved 0.6 grades). However, patients with poor preoperative functional assessment (Ranawat grade ≥ III) had greater neurologic improvement than those with good preoperative function, measured by Nurick grade improvement (1 vs. -0.28; P = .03) and Ranawat grade improvement (0.7 vs. -0.2; P = .03). Additionally, the posterior approach demonstrated significant improvement in Japanese Orthopedic Association functional assessment over patients with anterior/posterior approaches (2.2 vs. -0.3; P = .03), with fewer complications (posterior: 1 minor; anterior/posterior: 1 death, 2 major, 8 minor). Perioperative mortality occurred in 5%, and major morbidity in 10% of patients. CONCLUSIONS Preventing or stabilizing neurologic deficit in patients with OCD may require OCF, despite the patient's age. In the elderly population, our data favor using the posterior approach when possible, and demonstrate greater neurologic improvement in patients with poor preoperative function.
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Affiliation(s)
- Michelle J Clarke
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA.
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Buks Y, Snelling SR, Yates GD. Ventral fixation of chronic atlanto-occipital luxation in a dog. J Small Anim Pract 2011; 52:497-500. [PMID: 21824148 DOI: 10.1111/j.1748-5827.2011.01100.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
A 4·5-year-old male Australian Kelpie was presented for evaluation of ambulatory tetraparesis and neck pain of five weeks duration. Atlanto-occipital luxation was diagnosed by computed tomography. The joint was unstable following closed reduction, and a ventral surgical approach to the cranial cervical spine and occiput permitted manual reduction and stabilisation of the atlanto-occipital joint. The thickened joint capsule and articular cartilage were removed to promote AO arthrodesis. Eight cortical screws, inserted into the occipital condyles and C1, were embedded in polymethylmethacrylate to stabilise the atlanto-occipital articulation. The dog recovered uneventfully after it was placed in a neck brace and rested for six weeks. Neurologic examination at six weeks was normal and the dog returned to normal farm work 12 weeks after surgery.
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Affiliation(s)
- Y Buks
- Advanced Vetcare, Level 1, 26 Robertson Street, Kensington 3031, Victoria, Australia
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