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Anterior transoral atlantoaxial release and
posterior instrumented fusion for irreducible
congenital basilar invagination
...
Transoral Odontoidectomy
or
Posterior C1-C2 distraction
Irreducible C1 C2 dislocation
Irreducible atlanto-axial dislocation
Disadvantages of Transoral odontoidectomy
• Invaginated odontoid requires extended t...
Irreducible atlanto-axial dislocation
Disadvantages of Posterior C1-C2 distraction
• Technical very difficult procedure
• ...
Rationale
Ant. release C1-C2 + Post. Instrumented reduction
Displacements
Vertical translation
Basilar invagination
Retrov...
Rationale
Structures preventing reduction
Vertical displacement
Anterior structures shortened
 ALL
 Longus muscles
 Ant...
Rationale
Release of anterior contracted structures
Reduction of vertical translation
Excision of predental
Tissue + Ant. ...
Methods
• Prospective study
• Consecutive series of 15 patients (2007-2010)
• Average Age = 21 years Follow up = 12.4 mo (...
Pathologies
• Congenital basilar invagination (n=15)
• C1 assimilation (14), condylar hypoplasia (10), C2-3 fusions
(8), C...
Cervicomedullary angle
pB-C2 (mm)
Procedure
• Nasotracheal intubation & GA with muscle relaxation
• Reassessment of C1-C2 alignment on traction under GA
Lon...
C1 anterior arch
excisionJoint distraction
Releases intraarticular adhesions n=8
Posterior Reduction maneuver
Under contoured rod fixed to C2
Cantilever force to approximate plate
to the occiput
Correcti...
Results – Clivus Canal Angle
p<0.05
Results – Cervico medullary angle
p<0.05
110º±
11.4
146º±
6.8
Results
• Avg. Recovery rate =
98%
JOA myelopathy score
p<0.0001
11.5±
2.6 15.4±
1.9
Results
• Persistent Nasal Phonation (n=1)
• Superficial wound infection (n=1)
Complications (n=2)
Congenital Basilar Invagination
KF Syndrome
Post op
Traumatic AAD Rotatory
Conclusion
• Preliminary study – Encouraging results
• May be a safer and superior alternative to
transoral odontoid resec...
References
• Wang et al. Open reduction of irreducible atlantoaxial dislocation by transoral
anterior atlantoaxial release...
Anterior transoral atlantoaxial release and posterior instrumented fusion for irreducible congenital basilar invagination
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Anterior transoral atlantoaxial release and posterior instrumented fusion for irreducible congenital basilar invagination

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Paper presented at the Western Regional Orthopedic Conference in Mumbai in 2010 by Dr. Kshitij Chaudhary
The paper was subsequently published in European Spine Journal in 2015 with a longer follow up on these patients
http://bit.ly/1SvAivp

This is a short retrospective series that describes a novel method of treating irreducible congenital basilar invaginations. This procedure was first described by Dr. Wang from China.

Published in: Health & Medicine
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Anterior transoral atlantoaxial release and posterior instrumented fusion for irreducible congenital basilar invagination

  1. 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. 2. Transoral Odontoidectomy or Posterior C1-C2 distraction Irreducible C1 C2 dislocation
  3. 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. 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. 5. Rationale Ant. release C1-C2 + Post. Instrumented reduction Displacements Vertical translation Basilar invagination Retroversion of the odontoid Delta angle anterior C1 arch
  6. 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. 7. Rationale Release of anterior contracted structures Reduction of vertical translation Excision of predental Tissue + Ant. C1 arch Correction of Delta angle (Retroversion)
  8. 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. 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
  10. 10. Cervicomedullary angle pB-C2 (mm)
  11. 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. 12. C1 anterior arch excisionJoint distraction Releases intraarticular adhesions n=8
  13. 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
  14. 14. Results – Clivus Canal Angle p<0.05
  15. 15. Results – Cervico medullary angle p<0.05 110º± 11.4 146º± 6.8
  16. 16. Results • Avg. Recovery rate = 98% JOA myelopathy score p<0.0001 11.5± 2.6 15.4± 1.9
  17. 17. Results • Persistent Nasal Phonation (n=1) • Superficial wound infection (n=1) Complications (n=2)
  18. 18. Congenital Basilar Invagination
  19. 19. KF Syndrome
  20. 20. Post op
  21. 21. Traumatic AAD Rotatory
  22. 22. Conclusion • Preliminary study – Encouraging results • May be a safer and superior alternative to transoral odontoid resection • Technically easier procedure • Anatomical restoration possible
  23. 23. 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

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