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Clinical Neurology and Neurosurgery Aug 2021For reasons that are poorly understood and still undocumented, few patients of craniovertebral junction (CVJ) anomalies with instability/atlantoaxial dislocation (AAD)...
OBJECTIVE
For reasons that are poorly understood and still undocumented, few patients of craniovertebral junction (CVJ) anomalies with instability/atlantoaxial dislocation (AAD) in our practice have been seen to suffer unprecedented acute neurological deterioration with respiratory compromise about 48-72 h post-surgery. This has been specifically observed after an uneventful, stable clinical condition in the immediate postoperative period. This study attempts to elucidate the factors and outcomes related to such latent worsening.
PATIENTS AND METHODS
The 4-year surgical data of 268-patients with CVJ instability (AAD/basilar-invagination) who underwent C1-C2 fixation were retrospectively studied. The relevant factors of 17 patients who showed such deterioration were compared with that of the remaining in a multivariate model.
RESULTS
Seventeen patients had acute neurological worsening with respiratory arrest after a latent period. Ten improved at follow-up. Contrary to the general expectation, poor preoperative neurological score or severe dislocation that needed considerable manipulation did not influence such worsening. Dural injury in patients with associated Chiari malformation and vertebral arterial (VA) injury emerged as independent factors (p < 0.01) associated with this pattern of delayed neurological decline.
CONCLUSIONS
We report our management and outcomes of a unique subset of AAD with neurological worsening in the postoperative period after 48-72 h. Such a subgroup was not previously identified in literature. Dural lacerations in AAD with Chiari, and VA injury seem to predispose to such complications and should be prevented at best. Close observation, and caution regarding early extubation (<72 h) is recommended in this subset despite an apparently uneventful immediate postoperative neurological status.
Topics: Adolescent; Adult; Aged; Arnold-Chiari Malformation; Atlanto-Axial Joint; Atlanto-Occipital Joint; Child; Female; Humans; Joint Dislocations; Male; Middle Aged; Platybasia; Postoperative Complications; Spinal Fusion; Young Adult
PubMed: 34144465
DOI: 10.1016/j.clineuro.2021.106741 -
World Neurosurgery Aug 2021To describe the foramen magnum angle (FMA) as a new parameter for basilar invagination (BI) type B.
OBJECTIVE
To describe the foramen magnum angle (FMA) as a new parameter for basilar invagination (BI) type B.
METHODS
The FMA was performed on sagittal slice of magnetic resonance imaging (MRI) as a line from the hard palate to the opisthion (angle vertex), and another line from the opisthion to the basion. The MRIs from 31 participants with BI type B and 96 controls were used. Intraclass correlation coefficient, descriptive data, and receiver operating characteristic (ROC) curve were used for statistical analysis at the 95% confidence interval.
RESULTS
The interobserver agreement of the FMA was 0.952. Patients with BI type B had a FMA significantly greater (25.9° ± 9.3°) than control participants (11.6° ± 4.9°) (P < 0.001). The area under the ROC curve showed a diagnostic value of 0.947. The FMA showed sensitivity 0.900 and specificity 0.854 for the cutoff criterion 17° (P < 0.001).
CONCLUSIONS
The FMA had an optimal diagnostic value that provided complementary evidence to investigate BI type B.
Topics: Adult; Aged; Female; Foramen Magnum; Humans; Magnetic Resonance Imaging; Male; Middle Aged; Observer Variation; Platybasia
PubMed: 34129970
DOI: 10.1016/j.wneu.2021.06.028 -
Neurology India 2021Vertebral artery (VA) may run an anomalous course in congenital craniovertebral junction anomalies. Anomalous VA, though rare, is challenging to handle. An anomalous VA...
INTRODUCTION
Vertebral artery (VA) may run an anomalous course in congenital craniovertebral junction anomalies. Anomalous VA, though rare, is challenging to handle. An anomalous VA can get injured during exposure of craniovertebral junction, even in the experienced hands.
OBJECTIVE
The objective of this article was to describe the technique of repairing the VA in case of its damage during exposure in the craniovertebral junction (atlantoaxial dislocation [AAD] with basilar invagination [BI]).
PROCEDURE
The authors describe a case of VA artery injury in a case of severe BI & AAD, which was anomalous and coursing over the joints. Following the repair of injured VA, we proceeded with the surgery (distraction, compression, extension, and reduction [DCER]).
CONCLUSION
To avoid injury, it is important to always perform a CT 3-D angiogram, perform meticulous dissection under the microscope while exposing the joints, use variable impedance bipolar to control venous bleeding and always expose the side with non-dominant VA first.
Topics: Atlanto-Axial Joint; Cervical Vertebrae; Humans; Joint Dislocations; Platybasia; Spinal Fusion; Vertebral Artery
PubMed: 33904442
DOI: 10.4103/0028-3886.314543 -
Journal of Neurological Surgery. Part... Feb 2021The video demonstrates the steps for an endoscopic transnasal approach for resection of the odontoid causing platybasia with basilar invasion. The video reviews...
The video demonstrates the steps for an endoscopic transnasal approach for resection of the odontoid causing platybasia with basilar invasion. The video reviews the clinical presentation, preoperative workup and imaging, patient positioning, technical nuances of the procedure, reconstruction, and clinical outcomes including postoperative imaging. The surgery was performed by a skull base team including otolaryngologists and neurological surgeons at a large regional tertiary care facility. A 59-year-old female with the Chiari I malformation with history of multiple revision cervical spinal surgeries presents with neck pain. Preoperative imaging showed a hypoplastic clivus and platybasia with basilar invasion. The main outcome measures consist of safely removing the odontoid with appropriate closure, reversal of the patient symptoms, and prevention of both operative complications and ventral compression of the brainstem. The patient's neck pain improved. There were no intraoperative or postoperative complications besides anterior rightward nasal septal deviation causing unilateral nasal obstruction. A septoplasty was performed to correct the septal deviation 6 months after the initial procedure. The endoscopic transnasal approach to the resection of odontoid is a safe and effective treatment to address basilar invasion and ventral compression of the brainstem. The link to the video can be found at: https://youtu.be/m_c3-Vn-l80 .
PubMed: 33717801
DOI: 10.1055/s-0040-1705161 -
The Journal of Spinal Cord Medicine Nov 2022Spinal-generated movement disorders are a complex group of medical conditions, frequently misdiagnosed, originating in the spinal cord or from combined peripheral and...
CONTEXT
Spinal-generated movement disorders are a complex group of medical conditions, frequently misdiagnosed, originating in the spinal cord or from combined peripheral and central nervous system involvement. In this case report, we describe a novel form of position-dependent dyskinesia due to severe craniocervical malformation.
FINDINGS
An 83-year-old woman with basilar invagination at the C2 vertebra above the line of Chamberlain, occipitocervical lordosis, platybasia with a short clivus, ankylosis of the C1-C2 complex and fusion of the C1 arch developed an unusual pattern of position-dependent left arm dyskinesia triggered by bending her neck forward with simultaneous contact of the flexed elbow with a flat surface. Symptoms did not improve with anticonvulsants and she progressed and died suddenly.
CONCLUSION/CLINICAL RELEVANCE
A newly described form of position-dependent arm dyskinesia can be associated with severe craniocervical malformation.
Topics: Humans; Female; Aged, 80 and over; Arm; Spinal Fusion; Spinal Cord Injuries; Platybasia; Dyskinesias
PubMed: 33705252
DOI: 10.1080/10790268.2021.1878341 -
Journal of Clinical Orthopaedics and... Feb 2021A Prospective Study.
STUDY DESIGN
A Prospective Study.
OBJECTIVE
To assess results of posterior occipito-cervical decompression and fusion operated with intra-operative traction/manipulation and instrumented reduction in cases of Basilar Invagination(BI).
METHODS
Total 22 patients of 8-65 years with diagnosed BI were operated for posterior occipito-cervical fusion by intra-operative traction/manipulation and instrumented reduction. Fusion was done using autologous bone graft taken from iliac crest. Immediate post-operative, first month and then every 3 months' follow-up examination were done for minimum period of 2 years.
RESULTS
22 patients (10 males,12 females) with mean age of 23.9 years having BI were included. 11 patients had C1 occipitalization, 4 had platybasia and 9 had atlanto-axial dislocation (AAD). 1 patient with os odontoideum with kyphotic deformity expired on 4th postoperative day due to respiratory insufficiency (mortality rate 4.54%). Neurological improvement by at least by one grade according to RANAWAT's and/or NURICK'S scale was observed in 17/21 patients (80.95%). 3 patients remained static and 1 had neuro-worsening. Mean mJOA score of 13.14 improved to 16.24. All had reduction of dens below foramen magnum according to McRae, chamberlain line and Ranawat index. Bone graft fused in all patients as confirmed with CT scan and dynamic X-rays. 1 wound dehiscence and 1 asymptomatic implant loosening were seen on follow-up.
CONCLUSION
Surgical treatment of BI with intra-operative traction/manipulation, instrumented reduction and posterior occipito-cervical fusion can achieve good correction of radiology, functional performance and clinical neurology as well as excellent fusion rates without adverse effects of trans-oral surgery.
PubMed: 33680811
DOI: 10.1016/j.jcot.2020.11.016 -
Operative Neurosurgery (Hagerstown, Md.) Mar 2021The management of atlantoaxial dislocation (AAD) associated with basilar invagination (BI) is challenging, and traditional posterior-only approaches lack the ability to...
A Safe and Effective Posterior Intra-Articular Distraction Technique to Treat Congenital Atlantoaxial Dislocation Associated With Basilar Invagination: Case Series and Technical Nuances.
BACKGROUND
The management of atlantoaxial dislocation (AAD) associated with basilar invagination (BI) is challenging, and traditional posterior-only approaches lack the ability to release the anterior soft tissue resulting in unsatisfactory reduction. Furthermore, vertebral artery anomalies and deformed anatomy increase surgical risks.
OBJECTIVE
To introduce a safe and efficient technique to reduce congenital AAD and BI through a single-stage posterior-only approach.
METHODS
A total of 65 patients with AAD and concomitant BI who had congenital osseous abnormalities were retrospectively analyzed. All patients had anterior soft tissue released through a posterior-only approach, followed by intra-facet cages implantation, cantilever correction, and instrumentation. Clinical results were measured using the Japanese Orthopedic Association (JOA) scale, and radiographic measurements included the atlanto-dental interval, the distance of odontoid tip above Chamberlain's line, clivus-canal angle (CCA), and syrinx length. Paired t-tests were used to compare preoperative and postoperative measurements.
RESULTS
The mean JOA score increased from 10.98 to 14.40 at 1-yr follow-up. Complete reduction of AAD and BI was achieved in 48 patients (73.8%). The mean CCA improved from 115° preoperatively to 129° postoperatively. Reduction of syrinx size was observed in 14 patients at 1 wk and in 35 patients 1 yr after surgery. All patients achieved bony fusion.
CONCLUSION
Posterior intra-articular distraction followed by cage implantation and cantilever correction can achieve complete reduction in most cases of congenitally anomalous AAD associated with BI.
Topics: Atlanto-Axial Joint; Humans; Joint Dislocations; Platybasia; Retrospective Studies; Spinal Fusion
PubMed: 33372978
DOI: 10.1093/ons/opaa391 -
Neurosurgery Jan 2021Occipital-cervical fusion (OCF) and ventral decompression (VD) may be used in the treatment of pediatric Chiari-1 malformation (CM-1) with syringomyelia (SM) as adjuncts...
Occipital-Cervical Fusion and Ventral Decompression in the Surgical Management of Chiari-1 Malformation and Syringomyelia: Analysis of Data From the Park-Reeves Syringomyelia Research Consortium.
BACKGROUND
Occipital-cervical fusion (OCF) and ventral decompression (VD) may be used in the treatment of pediatric Chiari-1 malformation (CM-1) with syringomyelia (SM) as adjuncts to posterior fossa decompression (PFD) for complex craniovertebral junction pathology.
OBJECTIVE
To examine factors influencing the use of OCF and OCF/VD in a multicenter cohort of pediatric CM-1 and SM subjects treated with PFD.
METHODS
The Park-Reeves Syringomyelia Research Consortium registry was used to examine 637 subjects with cerebellar tonsillar ectopia ≥ 5 mm, syrinx diameter ≥ 3 mm, and at least 1 yr of follow-up after their index PFD. Comparisons were made between subjects who received PFD alone and those with PFD + OCF or PFD + OCF/VD.
RESULTS
All 637 patients underwent PFD, 505 (79.2%) with and 132 (20.8%) without duraplasty. A total of 12 subjects went on to have OCF at some point in their management (PFD + OCF), whereas 4 had OCF and VD (PFD + OCF/VD). Of those with complete data, a history of platybasia (3/10, P = .011), Klippel-Feil (2/10, P = .015), and basilar invagination (3/12, P < .001) were increased within the OCF group, whereas only basilar invagination (1/4, P < .001) was increased in the OCF/VD group. Clivo-axial angle (CXA) was significantly lower for both OCF (128.8 ± 15.3°, P = .008) and OCF/VD (115.0 ± 11.6°, P = .025) groups when compared to PFD-only group (145.3 ± 12.7°). pB-C2 did not differ among groups.
CONCLUSION
Although PFD alone is adequate for treating the vast majority of CM-1/SM patients, OCF or OCF/VD may be occasionally utilized. Cranial base and spine pathologies and CXA may provide insight into the need for OCF and/or OCF/VD.
Topics: Arnold-Chiari Malformation; Child; Cohort Studies; Decompression, Surgical; Female; Humans; Male; Spinal Fusion; Syringomyelia; Treatment Outcome
PubMed: 33313928
DOI: 10.1093/neuros/nyaa460 -
BMC Musculoskeletal Disorders Dec 2020Transoral atlantoaxial reduction plate (TARP) fixation or occipitocervical fixation (OF) is an effective treatment for basilar invagination (BI) with irreducible...
BACKGROUND
Transoral atlantoaxial reduction plate (TARP) fixation or occipitocervical fixation (OF) is an effective treatment for basilar invagination (BI) with irreducible atlantoaxial dislocation (IAAD). But, all current clinical studies involved a single surgical procedure. The clinical effects of TARP and OF operation for BI with IAAD have yet to be compared. We therefore present this report to compare the treatment of TARP and OF procedure for BI with IAAD.
METHODS
Fifty-six patients with BI with IAAD who underwent TARP or OF operation from June 2011 to June 2017 were retrospectively analyzed. Among these, 35 patients underwent TARP operation (TARP group), and 21 patients underwent OF operation (OF group). We compared the difference of clinical, radiological, and surgical outcomes between the TARP and OF groups postoperatively.
RESULTS
Compared with OF group, the operative time and blood loss in TARP group were lower. There was no statistical difference in the atlantodental interval (ADI), clivus canal angle (CCA), cervicomedullary angle (CMA), distance between the top of the odontoid process and the Chamberlain line (CL) and Japanese Orthopaedic Association (JOA) score between the TARP and OF groups preoperatively, but the improvements of these parameters in the TARP group were superior to those in the OF group postoperatively. The fusion rates were higher in the TARP group than those in the OF group at the early stage postoperatively.
CONCLUSIONS
TARP and OF operations are effective surgical treatment for BI with IAAD, but the performance of reduction and decompression and earlier bone fusion rates of TARP procedure are superior to those of OF.
Topics: Atlanto-Axial Joint; Bone Plates; Decompression, Surgical; Humans; Joint Dislocations; Platybasia; Retrospective Studies; Spinal Fusion; Treatment Outcome
PubMed: 33292209
DOI: 10.1186/s12891-020-03838-6