Management of Atlanto-axial Dislocation, A Case Based Approach: An Institutional Experience

Vernon Velho and Sachin Ashok Giri

Department of Neurosurgery, Grant Medical College & Sir J. J. Group of Hospitals, India

^*Correspondance to: Sachin Ashok Giri 

 PDF  Full Text DOI: 10.25107/2474-1647.2274

Abstract

Introduction: Although many different techniques have been described for management of AAD, fixed or mobile varieties, no single technique is sufficient to manage all types of AADs as anatomical variations are many a times different in patients resulting in the tailoring the procedure for the associated deformity correction. Although radiological imaging allows diagnosis of abnormality, many times planned procedure is modified. In our series we describe the various techniques of management as well as rescue operations in case of failure of planned procedure.Methods: It is a retrospective study extended over a period of 10 years i.e. from January 2007 to December 2017. The clinical parameters which were used are demographics, visual analogue scale for assessment of pain & Nurick’s grading for neurological deficit. Apart from dynamic flexion & extension neck X-ray & CT scan, MRI craniovertebral junction, 3D CT angiogram of neck vessels was used for detailed anatomy & pathological assessment. In a patient with AAD associated with congenital anomalies, 3D print was used in perioperative period. Improvement in the neurological deficit is assessed & compared after 6 month follow up.Results: Total 154 patients of AAD are operated over a period of 10 years. Most of these patients were presented with neck pain and occipital headache (86.5%) followed by mono or hemi or quadriparesis (66.7%). In initial period of experience, most of these patients were managed by simple sub-laminar techniques like Gallie’s or Brooke’s fusion technique. But with gain in experience, there is gradual shift to more robust construct techniques like C1 lateral mass and C2 pedicle screw and rod technique or occipito C2-C3 fusion technique or Magerl’s technique. Vertebral artery injury occurred in two patients while placement of C1-C2 transarticular screw while one patient had a vertebral artery injury while placement of C2 pedicle screw. Though these techniques give more robust fixation, due to anatomical variation and intraoperative failure of planned procedure, other conventional and bailout techniques like occipitocervical fixation using Hartshill and sub-laminar wires or Writer’s technique or Brooke’s technique are used.Conclusion: Each case of AAD has to be evaluated with CT images with 3D reconstruction. 3D printing aids in decision making and also in cases with congenital anomalies like Klippel-Feil syndrome where there is high risk of vertebral artery injury due to anomalous course. Though there are many techniques described for the management of AAD, it is essential to have all basic techniques in an armamentarium as these procedures may be useful as bailout techniques.

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Cite the article

Velho V, Giri SA. Management of Atlanto-axial Dislocation, A Case Based Approach: An Institutional Experience. Clin Surg. 2018; 3: 2274.