This 65-year-old woman presented with a 7-year history of classic trigeminal neuralgia. After a conservative therapeutic approach and because the pain had become unbearable, she was subjected to surgical treatment. Examinations revealed an ectatic basilar artery that indented deeply into the region of the root entry zone of cranial nerve V. Additionally, severe basilar invagination, the fusion of multiple cervical vertebrae, and partial agenesis of the clivus were observed. Foramen magnum decompression resulted in lasting relief from the pain. The authors discuss the pathogenesis of trigeminal neuralgia in a relatively rare clinical situation.
Atul Goel and Abhidha Shah
Atul Goel and Abhidha Shah
The authors report their experience with 14 children in whom acute torticollis or a fixed flexion neck deformity developed. Other than neck deformity, there was no other significant functional or neurological symptom. Although several possible pathogenetic factors have been speculated, the exact cause remains unknown. Conservative observation and/or attempts at closed reduction failed to effect deformity resolution. Investigations revealed “locking” of facets that resulted in rotatory or translatory atlantoaxial dislocation depending on the nature of facet dislocation. The management issues in such cases are evaluated. The authors discuss the validity of atlantoaxial facet distraction and manipulation/reduction and fixation under direct visualization. In all cases recovery from neck deformity was significant immediately after surgery. The deformity resolution was sustained during a mean follow-up period of 23 months (range 3–52 months), although the range of neck movements remained marginally restricted. The craniovertebral realignment is demonstrated by images and clinical photographs.
Atul Goel and Abhidha Shah
The authors investigated the changes in the bone architecture and the characteristics of the neck and craniovertebral region in selected cases of basilar invagination. The reversal in these changes that occurred after decompression and fixation are analyzed. The implications of such an analysis in understanding the pathogenesis of a number of features that are characteristically associated with basilar invagination are evaluated.
One hundred and seventy selected patients with basilar invagination who underwent atlantoaxial joint distraction-fixation surgery at the authors' institution between 1999 and April 2008 were reviewed. The study was prospective after June 2006. A variety of parameters were used for radiological and physical assessments. The evaluation was done on the basis of pre- and postoperative imaging studies and clinical photographs. In the 41 prospective cases, additional direct physical measurements of the neck were performed.
Prior to surgery there were several physical changes such as reduced neck length, torticollis, exaggerated lordosis of the cervical spine, and reduced craniospinal angulation. Other findings included reduced discspace height, significant posterior cervical osteophyte formation, assimilation of atlas (72%), single-level (29%) or multiple-level (3%) cervical fusions, and an increase in the spinal subarachnoid space both above and below the level of maximum neural compression at the tip of the odontoid process. After surgical decompression of the region, there was remarkable recovery in craniovertebral alignments, and an increase in neck length (maximum up to 42 mm) was obvious on physical and radiological examination in 85% of patients. The disc-space height increased and there was a reversal of altered cervical lordosis, craniospinal angulation (maximum up to 36°), and torticollis.
It appears that a number of physical spinal changes characteristically associated with basilar invagination such as a short neck, exaggerated neck lordosis, torticollis, cervical spondylotic changes and fusions are potentially reversible after decompression and stabilization of the craniovertebral junction.
Abhidha Shah, Sukhdeep Singh Jhawar and Atul Goel
Atul Goel and Abhidha Shah
The authors discuss their successful preliminary experience with 36 cases of cervical spondylotic disease by performing facetal distraction using specially designed Goel cervical facet spacers. The clinical and radiological results of treatment are analyzed. The mechanism of action of the proposed spacers and the rationale for their use are evaluated.
Between 2006 and February 2010, 36 patients were treated using the proposed technique. Of these patients, 18 had multilevel and 18 had single-level cervical spondylotic radiculopathy and/or myelopathy. The average follow-up period was 17 months with a minimum of 6 months. The Japanese Orthopaedic Association classification system, visual analog scale (neck pain and radiculopathy), and Odom criteria were used to monitor the clinical status of the patient. The patients were prospectively analyzed. The technique of surgery involved wide opening of the facet joints, denuding of articular cartilage, distraction of facets, and forced impaction of Goel cervical facet spacers into the articular cavity. Additionally, the interspinous process ligaments were resected, and corticocancellous bone graft from the iliac crest was placed and was stabilized over the adjoining laminae and facets after adequately preparing the host bone. Eighteen patients underwent single-level, 6 patients underwent 2-level, and 12 patients underwent 3-level treatment. The alterations in the physical architecture of spine and canal dimensions were evaluated before and after the placement of intrafacet joint spacers and after at least 6 months of follow-up.
All patients had varying degrees of relief from symptoms of pain, radiculopathy, and myelopathy. Analysis of radiological features suggested that the distraction of facets with the spacers resulted in an increase in the intervertebral foraminal dimension (mean 2.2 mm), an increase in the height of the intervertebral disc space (range 0.4–1.2 mm), and an increase in the interspinous distance (mean 2.2 mm). The circumferential distraction resulted in reduction in the buckling of the posterior longitudinal ligament and ligamentum flavum. The procedure ultimately resulted in segmental bone fusion. No patient worsened after treatment. There was no noticeable implant malfunction. During the follow-up period, all patients had evidence of segmental bone fusion. No patient underwent reexploration or further surgery of the neck.
Distraction of the facets of the cervical vertebra can lead to remarkable and immediate stabilization-fixation of the spinal segment and increase in space for the spinal cord and roots. The procedure results in reversal of several pathological events related to spondylotic disease. The safe, firm, and secure stabilization at the fulcrum of cervical spinal movements provided a ground for segmental spinal arthrodesis. The immediate postoperative improvement and lasting recovery from symptoms suggest the validity of the procedure.
Atul Goel, Abhidha Shah, Madan Jadhav and Santhosh Nama
The authors report their experience in treating 21 patients by using a novel form of treatment of lumbar degenerative disease that leads to canal stenosis. The surgery involved distraction of the facets using specially designed Goel intraarticular spacers and was aimed at arthrodesis of the spinal segment in a distracted position. The operation is based on the premise that subtle and longstanding facet instability, joint space reduction, and subsequent facet override had a profound and primary influence in the pathogenesis of degenerative lumbar canal stenosis. The surgical technique and the rationale for treatment are discussed.
Between April 2006 and January 2011, 21 cases of lumbar degenerative disease resulting in characteristic lumbar canal stenosis were treated in the authors' department with the proposed technique. The patients were prospectively analyzed. There were 15 men and 6 women who ranged in age from 48 to 71 years (mean 58 years). Nine patients underwent 1-level and 12 patients underwent 2-level treatment. Surgery involved wide opening of the articular joint, denuding of the articular capsule/endplate cartilage, distraction of the facets, and forced impaction of Goel intraarticular spacers. Bone graft pieces obtained by sectioning the spinous processes were placed within and over the joint and in the midline over the adequately prepared host area of laminae. The Oswestry Disability Index and visual analog scale were used to clinically assess the patients before and after surgery and at follow-up. The alterations in the physical architecture of spinal canal and intervertebral foramen dimensions were evaluated before and after placement of the intrafacet implant and after at least 6 months of follow-up.
All patients had varying degrees of relief from symptoms of local back pain and radiculopathy. Impaction of spacers within the facet joints resulted in an increase in the spinal canal and intervertebral root canal dimensions (mean 2.33 mm), reduction of buckling of the ligamentum flavum, and reduction of the extent of bulge of the disc into the spinal canal. The procedure resulted in firm stabilization and fixation of the spinal segment and provided a ground for arthrodesis. No patient worsened neurologically after treatment. During the follow-up period, all patients had evidence of segmental bone fusion. No patient underwent reexploration or further surgery of the lumbar spine.
Impaction of the spacers within the articular cavity after facet distraction resulted in reversal of several effects of spine degeneration that had caused spinal and root canal stenosis. The safe, firm, and secure stabilization at the fulcrum of lumbar spinal movements provided a ground for segmental spinal arthrodesis. The immediate postoperative and lasting recovery from symptoms suggests the validity of the procedure.
Atul Goel, Abhidha Shah and Sanjay Rajan
The authors' experience with treatment of 8 patients with “vertical mobile and reducible” atlantoaxial dislocation is reviewed. The probable pathogenesis, radiological and clinical features, and management issues in such cases are discussed.
Between January 2006 and March 2008, 8 patients who presented with vertical mobile and reducible atlantoaxial dislocations were treated at the Department of Neurosurgery at King Edward Memorial Hospital in Mumbai, India. The vertical atlantoaxial dislocation/basilar invagination reduced completely on extension of the neck, with no need of any cervical traction. According to the extent of superior migration of the odontoid process, and measurements based on the vertical atlantoaxial instability index, the dislocation was graded as mild, moderate, or severe. All patients were treated using the C-1 lateral mass and C-2 pars plate and screw method of fixation.
The study group was composed of 5 male and 3 female patients (mean age 24 years, age range 8–54 years). All patients presented with the physical features of short neck, torticollis, pain in the nape of the neck, and varying degrees of quadriparesis. In 6 patients there was a history of trauma prior to the onset of major neurological symptoms. The dislocation was mild in 3 cases, moderate in 1, and severe in 4. All patients had clinical neurological improvement following surgery. The follow-up duration ranged from 4 to 30 months (mean 18 months).
Vertical mobile and reducible atlantoaxial dislocation is a discrete clinical entity. Abnormal inclination and incompetence of the facet joint appears to be the primary causative factor that resulted in vertical dislocation or basilar invagination. Posterior fixation in the reduced dislocation position forms the basis of treatment.
Atul Goel, Abhidha H. Shah and Ram Menon
The authors report an extremely rare case of a patient with acromegaly who had unilateral enlargement of an atlas facet resulting in cord compression and progressive quadriparesis. Although unilateral atlas facet enlargement has been identified in the literature in cases of spondylosis and as a component of congenital malformation, its association with acromegaly has not previously been reported. Resection of the offending facetal bone and atlantoaxial fixation resulted in rapid neurological recovery.
Report of 3 cases
Amit Mahore, Abhidha Shah, Trimurti Nadkarni and Atul Goel
Craniofrontonasal dysplasia (CFND) is a rare developmental anomaly associated with an X-linked inheritance. It is predominantly expressed in females. A Chiari malformation (CM) has not been reported in such patients earlier. The authors report on a family with 3 female members who have marked and generalized CFND. The generalized bone dysplasia/hypertrophy resulted in reduction in the posterior cranial fossa volume in all 3 patients, and in a CM associated with syringomyelia in 2 of them. One of the 2 affected family members who had a CM and syringomyelia was symptomatic and was treated by foramen magnum decompression surgery. The 3 family members had remarkable similarity in their external facial features and in their radiologically revealed morphological features. A review of the relevant literature, genetic abnormalities, and pattern of inheritance is presented.
Atul Goel, Abhidha Shah and Sanjay Rajan Gupta
The authors retrospectively analyzed a series of 108 patients in whom was diagnosed atlantoaxial instability due to degenerative osteoarthritis of the atlantoaxial joints. The management issues in such cases are discussed.
One hundred eight patients with osteoarthritis of the atlantoaxial joints and resultant craniovertebral instability—diagnosed on the basis of presenting clinical features, radiological imaging, and direct observation of the joint status during surgery—were retrospectively analyzed. Between 1990 and 2008, these patients were treated with a C1–2 lateral mass plate and screw method of atlantoaxial fixation and joint distraction using bone graft with or without the assistance of metal spacers.
Patient ages ranged from 48 to 84 years (average 63 years). There was a history of mild to moderate head and/or neck trauma 2 months to 11 years prior to diagnosis in 40% of the cases. All patients had symptoms of neck pain, and 82% of the patients had progressive myelopathy. A reduction in the height of the atlantoaxial lateral mass complex (100%), mobile atlantoaxial dislocation (100%), basilar invagination (68%), and periodontoid degenerative tissue mass (90%) were the more frequently encountered radiological features. Two patients died in the immediate postoperative period. At an average follow-up of 64 months, all surviving patients remarkably improved to varying degrees in their neurological condition.
Atlantoaxial joint arthritis frequently leads to craniovertebral instability and cord compression. Treatment by joint distraction and lateral mass fixation can be an optimum form of treatment.