Management of pediatric patients with irreducible atlantoaxial dislocation: transoral anterior release, reduction, and fixation

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OBJECTIVE

Although transoral atlantoaxial reduction plate (TARP) surgery has been confirmed to be safe and effective for adults who have irreducible atlantoaxial dislocation (IAAD) with or without basilar invagination or upper cervical revision surgery, it is rarely used to treat these disorders in children. The authors of this study aimed to report on the use of the anterior technique in treating pediatric IAAD.

METHODS

In this retrospective study, the authors identified 8 consecutive patients with IAAD who had undergone surgical reduction at a single institution in the period between January 2011 and June 2104. The patients consisted of 5 males and 3 females. Three had os odontoideum, 2 had basilar invagination, and the other 3 experienced atlantoaxial rotatory fixed dislocation (AARFD). They were all treated using transoral anterior release, reduction, and fusion with the TARP. Preoperative and postoperative CT scans and MR images were obtained. American Spinal Injury Association (ASIA) Impairment Scale grades were determined.

RESULTS

All symptoms were relieved in all 8 patients but to varying degrees. Intraoperative loose reduction and fixation of C1–2 were achieved in one stage. The 4 patients with preoperative neurological deficits were significantly improved after surgery, and their latest follow-ups indicated that their ASIA Impairment Scale grades had improved to E. Postoperative pneumonia occurred in 1 patient but was under complete control after anti-infective therapy and fiber optic–guided sputum suction.

CONCLUSIONS

One-stage transoral anterior release, reduction, and fixation is an effective, reliable, and safe means of treating pediatric IAAD. The midterm clinical results are satisfactory, with the technique eliminating the need for interval traction and/or second-stage posterior instrumentation and fusion.

ABBREVIATIONS AAD = atlantoaxial dislocation; AARFD = atlantoaxial rotatory fixed dislocation; ADI = atlantodental interval; ASIA = American Spinal Injury Association; IAAD = irreducible AAD; TARP = transoral atlantoaxial reduction plate.

Article Information

Correspondence Hong Xia: Southern Theater General Hospital of People’s Liberation Army, Guangzhou, China. gzxiahong2@126.com.

INCLUDE WHEN CITING Published online June 14, 2019; DOI: 10.3171/2019.4.PEDS1928.

C.Z. and and J.W. contributed equally to this work and share first authorship.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    The reduction procedures for AAD using the TARP system on a 3D-printed model (A–H) and the intraoperative photographs (N and O) and fluoroscopic images (I, J, L, and M). The 3D-printed model reveals AAD (A and B). The C1 screw is inserted to fix the TARP on the atlas, and the temporary reduction screw is fixed onto the C2 vertebra through the open section in the central part of the TARP (C, D, and J). The reduction forceps are then installed between the TARP crossbar and the reduction screw (E, L, M, and N). Note the mechanical direction during use of the reduction forceps as indicated by arrows (K). Closure of the hand grips imparted a local distraction force between C1 and C2, as indicated by arrows numbered 1. The nut on the forceps arm is turned to push the C1 backward relative to C2, as indicated by arrows numbered 2. The C2 screws were inserted through the lower holes in the TARP after the reduction was held in an ideal position (G, H, and O). Figure is available in color online only.

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    Case 2. A 13-year-old boy with os odontoideum and IAAD. Preoperative lateral (A), extension (B), and flexion (C) cervical radiographs showing a typical case of os odontoideum (dystopic os). Lateral radiograph after skull traction (D) showing IAAD. Compared with a preoperative sagittal CT scan (E), the postoperative scan (F) shows anatomical atlantoaxial reduction. Compared with a preoperative sagittal T2-weighted MR image (G), the postoperative scan (H) indicates that ventral compression on the spinal cord has been totally relieved. Postoperative lateral (I) and anteroposterior (J) radiographs show the position of the hardware. A postoperative coronal CT scan (K) obtained at the 4-month follow-up, showing complete bony fusion. Postoperative 3D CT scan (L). Figure is available in color online only.

References

  • 1

    Anderson RCRagel BTMocco JBohman LEBrockmeyer DL: Selection of a rigid internal fixation construct for stabilization at the craniovertebral junction in pediatric patients. J Neurosurg 107 (1 Suppl):36422007

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Brockmeyer DApfelbaum RTippets RWalker MCarey L: Pediatric cervical spine instrumentation using screw fixation. Pediatr Neurosurg 22:1471571995

  • 3

    Brockmeyer DLYork JEApfelbaum RI: Anatomical suitability of C1-2 transarticular screw placement in pediatric patients. J Neurosurg 92 (1 Suppl):7112000

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Crockard HA: Anterior approaches to lesions of the upper cervical spine. Clin Neurosurg 34:3894161988

  • 5

    Desai RStevenson CBCrawford AHDurrani AAMangano FT: C-1 lateral mass screw fixation in children with atlantoaxial instability: case series and technical report. J Spinal Disord Tech 23:4744792010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Dickman CACrawford NRParamore CG: Biomechanical characteristics of C1-2 cable fixations. J Neurosurg 85:3163221996

  • 7

    Fielding JWHawkins RJ: Atlanto-axial rotatory fixation. (Fixed rotatory subluxation of the atlanto-axial joint.) J Bone Joint Surg Am 59:37441977

  • 8

    Gluf WMSchmidt MHApfelbaum RI: Atlantoaxial transarticular screw fixation: a review of surgical indications, fusion rate, complications, and lessons learned in 191 adult patients. J Neurosurg Spine 2:1551632005

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Goel ABhatjiwale MDesai K: Basilar invagination: a study based on 190 surgically treated patients. J Neurosurg 88:9629681998

  • 10

    Gradl GMaier-Bosse TPenning RStäbler A: Quantification of C2 cervical spine rotatory fixation by X-ray, MRI and CT. Eur Radiol 15:3763822005

  • 11

    Kerschbaumer FKandziora FKlein CMittlmeier TStarker M: Transoral decompression, anterior plate fixation, and posterior wire fusion for irreducible atlantoaxial kyphosis in rheumatoid arthritis. Spine (Phila Pa 1076) 25:270827152000

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 12

    Ma XYin QXia HWu ZYang JLiu J: The application of atlantoaxial screw and rod fixation in revision operations for postoperative re-dislocation in children. Arch Orthop Trauma Surg 135:3133192015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Rahimi SYStevens EAYeh DJFlannery AMChoudhri HFLee MR: Treatment of atlantoaxial instability in pediatric patients. Neurosurg Focus 15(6):ECP12003

  • 14

    Tauchi RImagama SIto ZAndo KMuramoto AMatsui H: Surgical treatment for chronic atlantoaxial rotatory fixation in children. J Pediatr Orthop B 22:4044082013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Wang SYan MPassias PGWang C: Atlantoaxial rotatory fixed dislocation: report on a series of 32 pediatric cases. Spine (Phila Pa 1976) 41:E725E7322016

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 16

    Wei GWang ZAi FYin QWu ZMa XY: Treatment of basilar invagination with Klippel-Feil syndrome: atlantoaxial joint distraction and fixation with transoral atlantoaxial reduction plate. Neurosurgery 78:4924982016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Xia HYin QAi FMa XWang JWu Z: Treatment of basilar invagination with atlantoaxial dislocation: atlantoaxial joint distraction and fixation with transoral atlantoaxial reduction plate (TARP) without odontoidectomy. Eur Spine J 23:164816552014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Yang JMa XXia HWu ZAi FYin Q: Transoral anterior revision surgeries for basilar invagination with irreducible atlantoaxial dislocation after posterior decompression: a retrospective study of 30 cases. Eur Spine J 23:109911082014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Yang SYBoniello AJPoorman CEChang ALWang SPassias PG: A review of the diagnosis and treatment of atlantoaxial dislocations. Global Spine J 4:1972102014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Yin QAi FZhang KChang YXia HWu Z: 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 (Phila Pa 1976) 30:E375E3812005

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 21

    Yin QXia HWu ZMa XAi FZhang K: Surgical site infections following the transoral approach: a review of 172 consecutive cases. Clin Spine Surg 29:E502E5082016

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 22

    Yin QSAi FZZhang KMai XHXia HWu ZH: Transoral atlantoaxial reduction plate internal fixation for the treatment of irreducible atlantoaxial dislocation: a 2- to 4-year follow-up. Orthop Surg 2:1491552010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23

    Zhang YHShao JChou DWu JFSong JZhang J: C1-C2 pedicle screw fixation for atlantoaxial dislocation in pediatric patients younger than 5 years: a case series of 15 patients. World Neurosurg 108:4985052017

    • Crossref
    • Search Google Scholar
    • Export Citation

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