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COMMENTARY
Year : 2018  |  Volume : 66  |  Issue : 1  |  Page : 151-152

“Fusing the appropriate” in complex craniovertebral junction anomalies


Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Web Publication11-Jan-2018

Correspondence Address:
Dr. Pravin Salunke
Department of Neurosurgery, PGIMER, Sector 12, Chandigarh - 160 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.222858

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How to cite this article:
Salunke P. “Fusing the appropriate” in complex craniovertebral junction anomalies. Neurol India 2018;66:151-2

How to cite this URL:
Salunke P. “Fusing the appropriate” in complex craniovertebral junction anomalies. Neurol India [serial online] 2018 [cited 2019 Oct 14];66:151-2. Available from: http://www.neurologyindia.com/text.asp?2018/66/1/151/222858




The authors have described rare yet complex cases of pan-cervical fusion with atlantoaxial dislocation (AAD). Undoubtedly, the management of these cases is challenging and requires expertise. AAD may be a result of excessive stress at the C1-2 level due to block cervical vertebrae or congenitally deformed C1-2 joints. The authors have elucidated the presence of a bifid arch of  Atlas More Details in combination with such pan-cervical fusion. The proposed idea of a bifid arch of atlas as a natural laminotomy providing space for the compressed cervicomedullary junction is quite intriguing.

Congenital AAD is often multiplanar and the deformity of C1-2 joints decides the plane of dislocation.[1] The combination of abnormal sagittal and coronal inclination leads to anteroposterior and vertical dislocation of C1 and C2.[1] The asymmetry of joints on either side adds angular/rotational component to the dislocation. Coronal asymmetry of the joints coupled with a bifid atlas leads to severe lateral angular dislocation.[2] It is important to study the preoperative radiology in coronal, sagittal, and axial planes to understand the multiplanar C1-2 dislocation and to plan surgical intervention.[1] The management of AAD usually is manipulation of the C1-2 joints with fusion in realigned position.[3],[4] The block cervical vertebrae or pan-cervical fusion is often associated with a bifid atlas apart from AAD.[5] A bifid atlas was seen in 3 out of 4 cases described by the authors. The lateral masses of such bipartite atlas are small and peg like.[5] A noteworthy aspect, which the authors have subtly described, is fusing the C1-2 vertebrae and not the occipital squama to the cervical spine. It is important to preserve mobility at the atlanto-occipital joint (OC1), which is relatively stable despite the bifid C1.[5] Fusing the occipital squama to the already fused cervical spine would lead to severe movement restrictions.[6] In addition, there are delayed complications of such a procedure.[6] However, the peg-like small lateral masses in bipartite atlas makes insertion of C1 screws relatively difficult.[5] Despite the challenges, C1-2 fusion is desirable.

The presence of bifid atlas is usually associated with each hemi-ring moving separately.[7] The two halves have a tendency to splay. This cannot be countered by fusing the C1-2 far away from the point where the forces act (using long screws- long lever arms) or by fusing the occipital squama to the cervical spine.[6] Converting the C1-2 into a single unit by fusing the C1-2 lateral masses close to the point where the forces act even prevents splaying of the hemi-rings of the bifid atlas. Goel's plate and screws fixation technique is most appropriate method to achieve such a fusion because it realigns C1-2 and acts as a compression plate as well. An alternative method is by inserting the screws so that tulips/screw heads are in close contact with the lateral masses.[4] Some amount of compression is necessary prior to fastening the rod to prevent any play between the polyaxial screws.[4]

Reaching up to the joints may pose a challenge, especially if the vertebral artery is anomalous. A preoperative CT angiogram is helpful.[8],[9],[10],[11] An anomalous artery is not a contraindication for fusion of C1-2 using facetal screws.[8] The artery can be dissected, mobilized, and safeguarded during drilling and manipulation of the C1-2 joint.[8],[9],[10],[11]

The decision making in such complex cases of AAD is as important as the operative nuances. It requires skill and considerable experience to decide the need and level of fusion. Fusing too much adversely affects the patient's mobility. This manuscript acts as a reference for young surgeons to strike the right balance between the use of implants for fusion and preserving the patient's quality of life.



 
  References Top

1.
Salunke P, Sahoo SK, Deepak AN, Khandelwal NK. Redefining congenital atlantoaxial dislocation: Objective assessment in each plane before and after operation. World Neurosurg 2016;95:156-64.  Back to cited text no. 1
    
2.
Salunke P, Sahoo SK, Futane S, Deepak AN, Khandelwal NK. 'Atlas shrugged': Congenital lateral angular irreducible atlantoaxial dislocation: A case series of complex variant and its management. Eur Spine J 2016;25:1098-108.  Back to cited text no. 2
    
3.
Salunke P, Sahoo SK, Deepak AN, Ghuman MS, Khandelwal NK. Comprehensive drilling of the C1-2 facets to achieve direct posterior reduction in irreducible atlantoaxial dislocation. J Neurosurg Spine 2015;23:294-302.  Back to cited text no. 3
    
4.
Salunke P, Sahoo S, Khandelwal NK, Ghuman MS. Technique for direct posterior reduction in irreducible atlantoaxial dislocation: Multi-planar realignment of C1-2. Clin Neurol Neurosurg 2015;131:47-53.  Back to cited text no. 4
    
5.
Salunke P, Sahoo SK, Mahajan A. Bipartite atlas with os odontoideum with block cervical vertebrae: A case report with emphasis on the “overlooked” C1 lateral masses. Turk Neurosurg 2015;25:814-7.  Back to cited text no. 5
    
6.
Salunke P, Sahoo SK, Sood S, Mukherjee KK, Gupta SK. Focusing on the delayed complications of fusing occipital squama to cervical spine for stabilization of congenital atlantoaxial dislocation and basilar invagination. Clin Neurol Neurosurg 2016;145:19-27.  Back to cited text no. 6
    
7.
Goel A, Nadkarni T, Shah A, Ramdasi R, Patni N. Bifid anterior and posterior arches of atlas: Surgical implication and analysis of 70 cases. Neurosurgery 2015;77:296-305.  Back to cited text no. 7
    
8.
Sardhara J, Behari S, Mohan B M, Jaiswal AK, Sahu RN, Srivastava A, Mehrotra A, Lal H. Risk stratification of vertebral artery vulnerability during surgery for congenital atlanto-axial dislocation with or without an occipitalized atlas. Neurol India 2015;63:382-91  Back to cited text no. 8
    
9.
Sindgikar P, Das KK, Sardhara J, Bhaisora KS, Srivastava AK, Mehrotra A, Jaiswal AK, Sahu RN, Behari S. Craniovertebral junction anomalies: When is resurgery required?. Neurol India 2016;64:1220-32  Back to cited text no. 9
    
10.
Yadav YR, Ratre S, Parhihar V, Dubey A, Dubey NM. Endoscopic technique for single-stage anterior decompression and anterior fusion by transcervical approach in atlantoaxial dislocation. Neurol India 2017;65:341-7  Back to cited text no. 10
    
11.
Salunke P, Sahoo S, Deepak AN. Anomalous vertebral artery is not a deterrent to C1-2 joint dissection and manipulation for congenital atlantoaxial dislocation. Neurol India 2015;63:1009-12.  Back to cited text no. 11
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