C1-C2 rotary subluxation following posterior stabilization for congenital atlantoaxial dislocation.
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The authors report a rare complication of C1-C2 rotary subluxation in two children following posterior stabilization for congenital atlantoaxial dislocation (AAD). A patient, with mobile AAD, underwent Brook's C1-C2 fusion while the other, with fixed AAD, underwent transoral decompression followed by Jain's occipitocervical fusion. A pre-existing ligamentous laxity associated with an asymmetrical wire tightening or slippage of the wires due to rotation of the neck in the former, and the drilling of the C1-C2 lateral joints during the transoral procedure in the latter, could have contributed to the rotary subluxation. Both patients presented with persistent torticollis due to fusion in an asymmetrical position with dislocated facet joints. Rotary C1-C2 subluxation, when coexisting with anterior dislocation, has the potential to cause severe and occasionally fatal cord compression. Well defined criteria to diagnose this entity by conventional radiology exist, however, due to the overlap of anatomy, the condition is often overlooked. In the present study, three dimensional reconstruction images using helical computerized tomography were very useful in delineating the subluxation and in planning its surgical reduction and arthrodesis. (+info)
Atlantoaxial immobilization in rheumatoid arthritis: a prophylactic procedure?
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Timing of surgical intervention in atlantoaxial instability due to rheumatoid arthritis is still controversial. An aim of this study was to investigate whether atlantoaxial fusion can prevent progression of instability and upward migration of the dens. Thirty-two patients with rheumatoid arthritis, who underwent posterior atlantoaxial fixation due to instability, were clinically and radiologically examined after a minimum follow-up of 5 years. The radiological measurements focussed on the extent of cranial vertical migration after atlantoaxial fusion. In none of the 20 patients available for follow-up examination was a vertical cranial migration observed, in spite of the ongoing course of the disease. These findings are in concordance with findings in the literature, and strongly suggest that, with atlantoaxial stabilization, the inflammatory process with destruction of the lateral masses of the atlas is able to prevent further deterioration with vertical cranial migration. (+info)
Traumatic vertical atlantoaxial instability: the risk associated with skull traction. Case report and literature review.
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Traumatic overdistraction between C1 and C2 may occur when all the ligaments connecting C2 to the skull are ruptured, and may be manifested when an attempt to reduce C1-C2 subluxation is made by means of traction. We describe here the case of a patient with traumatic anterior atlantoaxial dislocation, who developed atlantoaxial vertical dissociation after skull traction using a Gardner-Halo with lb 4.02 (1.5 kg) of weight. The identification of patients who are susceptible to this complication is difficult. In this case, it might have been prevented by avoiding spinal traction. The aim of this report was to show that vertical dissociation may occur in C -C2 anterior dislocation submitted to spinal traction, and that other forms of reduction must be considered to treat these pathologies and avoid this potentially fatal complication. (+info)
Combination drug therapy retards the development of rheumatoid atlantoaxial subluxations.
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OBJECTIVE: To compare the efficacy of combination therapy with disease-modifying antirheumatic drugs (DMARDs) versus single therapy with DMARDs in the prevention of early cervical spine changes in patients with rheumatoid arthritis (RA). METHODS: One hundred ninety-five patients with recent-onset RA (mean disease duration 8 months) were randomly assigned to receive a combination of DMARDs (sulfasalazine, methotrexate, hydroxychloroquine, and prednisolone) or a single DMARD with or without prednisolone. After 2 years of followup, cervical spine radiographs were taken of 176 of these patients (85 in the combination-therapy group and 91 in the single-therapy group). These radiographs were evaluated, and the findings were correlated with the therapy strategies as well as with peripheral joint destruction and clinical and laboratory variables describing the disease activity. RESULTS: Anterior atlantoaxial subluxation (aAAS), atlantoaxial impaction (AAI; i.e., vertical subluxation), and subaxial subluxation (SAS) were found in only 6 (3.4%), 2 (1.1%), and 5 (2.8%) of the patients, respectively. Interestingly, none of the patients in the combination-therapy group had aAAS or AAI. The incidences of aAAS and AAI in the single-therapy group were 6.6% and 2.2%, respectively. SAS was present in 2 patients (2.2%) in the single-therapy group and in 3 patients (3.5%) in the combination-therapy group. The difference in the incidence of aAAS between the treatment groups was statistically significant (P = 0.029). None of the patients with cervical spine changes achieved remission of RA during the study. CONCLUSION: In the present study, the incidence of cervical spine subluxations in patients treated with single-drug therapy was in accord with findings of previous studies. However, none of the patients in the combination-therapy group had aAAS or AAI. These findings suggest that early, aggressive combination-DMARD therapy with sulfasalazine, methotrexate, hydroxychloroquine, and prednisolone can prevent or retard the development of rheumatoid atlantoaxial disorders. (+info)
A case report of spondyloepiphyseal dysplasia congenita.
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Spondyloepiphyseal dysplasia congenita (SED) is a rare form of skeletal systemic disease, characterized by congenital dwarfism with a short trunk and epiphysial dysplasia in the long bones and vertebral bodies. Patients also frequently suffer from atlanto-axial instability due to os odontoideum. Compression of the spinal cord caused by atlanto-axial instability is a common, serious complication in SED patients, and causes severe spinal cord symptoms or occasionally sudden death. We present an SED patient who underwent a posterior fusion of the occiput to the cervical spine for severe spinal cord symptoms due to atlanto-axial instability. (+info)
A technique for frameless stereotaxy and placement of transarticular screws for atlanto-axial instability in rheumatoid arthritis.
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The aim of the present study was to outline a new surgical technique and describe how, in a clinical setting, computer-generated image-guidance can assist in the planning and accurate placement of transarticular C1/C2 screws inserted using a minimally invasive exposure. Forty-six patients with atlanto-axial instability due to rheumatoid arthritis underwent posterior stabilisation with transarticular screws. This was achieved with a minimal posterior exposure limited to C1 and C2 and percutaneous screw insertions via minor stab incisions. The Stealth Station (Medtronic Sofamor Danek, Memphis, Tenn., USA) was used for image guidance to navigate safely through C2. Reconstructed computed tomographic (CT) scans of the atlanto-axial complex were used for image guidance. It was possible to perform preoperative planning of the screw trajectory taking into account the position of the intraosseous portion of the vertebral arteries, the size of the pars interarticularis and the quality of bone in C2. Screws could be inserted percutaneously over K-wires using a drill guide linked to the image-guidance system. Preoperative planning was performed in all 46 patients and accurate registration allowed proposed screw trajectories to be identified. Thirty-eight patients had bilateral screws inserted and eight had a unilateral screw. A total of 84 screws were inserted using the Stealth Station. There were no neurovascular injuries. This technique for placing transarticular screws is accurate and safe. It allows a minimally invasive approach to be followed. Image guidance is a useful adjunct for the surgeon undertaking complex spinal procedures. (+info)
Atlantoaxial instability treated with transarticular screw fixation.
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We treated 11 patients with atlantoaxial instability using transarticular posterior screw fixation and lateral bone grafting. A posterior bone graft was added in eight patients. The results showed good reduction and a stable fixation. After 6 months ten patients had regained almost 70% of rotation and did not notice any significant limitation. (+info)
Delayed closed reduction of rotatory atlantoaxial dislocation in an adult.
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We report a case of rotatory atlantoaxial dislocation due to a rugby injury in an adult. The patient presented with torticollis 4 weeks after the injury. The neurological evaluation was normal. Reduction proved difficult to obtain and required 10 days of skull traction followed by gentle manipulation. After reduction, dynamic cervical radiographs showed no instability and magnetic resonance imaging (MRI) confirmed that the transverse ligament was intact. After 6 weeks of immobilization in a Minerva jacket, a dynamic rotatory computed tomography (CT) scan confirmed that the atlantoaxial joint was stable. Such cases of atlantoaxial joint dislocation in adults treated by traction after a considerable delay are rare. In our patient, demonstration by MRI that the transverse ligament was intact led to the decision to use conservative therapy, which proved successful. (+info)