Posttraumatic true irreducible C1–2 lateral dislocation is rare. The mechanism of injury is likely to be different for this kind of dislocation. The management of such an injury and the technique for direct posterior reduction remain unclear because of its rarity. The authors describe the case of a 34-year-old man who sustained injury in a vehicular accident, leading to neck pain. Radiological studies revealed fixed right lateral and posterior C1–2 dislocation. Direct posterior open reduction was achieved by distracting the facets and rotating them in a counterclockwise direction. Care was taken to avoid direct or indirect injury to the vertebral arteries. Segmental C1–2 fusion was performed. Distraction with lateral extension injury possibly gives rise to this unique fracture dislocation. Preoperative imaging including angiography for vertebral arteries helps in defining the cause of fixity and in surgical planning. Direct posterior reduction is possible in such fixed C1–2 lateral dislocation, circumventing transoral surgery—provided the facets are preserved.
Pravin Salunke, Sushanta K. Sahoo, Ramesh Doddamani, Chirag K. Ahuja, and Kanchan K. Mukherjee
Arsikere N. Deepak, Pravin Salunke, Sushanta K. Sahoo, Prashant K. Prasad, and Niranjan K. Khandelwal
The current management of atlantoaxial dislocation (AAD) focuses on the C1–2 joints, commonly approached through a posterior route. The distinction between reducible AAD (RAAD) and irreducible AAD (IrAAD) seems to be less important in modern times. The roles of preoperative traction and dynamic radiographs are questionable. This study evaluated whether differentiating between the 2 groups is important in today's era.
Ninety-six consecutive patients with congenital AAD (33 RAAD and 63 IrAAD), who underwent surgery through a posterior approach alone, were studied. The preoperative and follow-up clinical statuses for both groups were studied and compared using Japanese Orthopaedic Association (JOA) scores. The radiological findings of the 2 groups were compared, and the intraoperative challenges described.
A poor preoperative JOA score (clinical status) was seen in one-fifth of patients with IrAAD, although the mean JOA score was nearly similar in the RAAD and IrAAD groups. There was significant improvement in follow-up JOA score in both groups. However, segmentation defects (such as an assimilated arch of the atlas and C2–3 fusion) and anomalous vertebral arteries were found significantly more often in cases of IrAAD compared with those of RAAD. Os odontoideum was commonly seen in the RAAD group. The C1–2 joints were acute in IrAAD compared with RAAD. Preoperative traction in IrAAD resulted in vertical distraction and improvement in clinical and respiratory status. Surgery for IrAAD required much more drilling and manipulation of the C1–2 joints while safeguarding the anomalous vertebral artery.
Bony and vascular anomalies were much more common in patients with IrAAD, which made surgery more challenging than it was in RAAD despite similar approaches. An irreducible dislocation seen on preoperative radiographs made surgeons aware of difficulties that were likely to be encountered and helped them to better plan the surgery. Distraction achieved through preoperative traction reaffirmed the feasibility of intraoperative reduction. This made the differentiation between the 2 groups and the use of preoperative traction equally important.
Pravin Salunke, Sushanta K. Sahoo, Arsikere N. Deepak, Mandeep S. Ghuman, and Niranjan K. Khandelwal
The cause of irreducibility in irreducible atlantoaxial dislocation (AAD) appears to be the orientation of the C1–2 facets. The current management strategies for irreducible AAD are directed at removing the cause of irreducibility followed by fusion, rather than transoral decompression and posterior fusion. The technique described in this paper addresses C1–2 facet mobilization by facetectomies to aid intraoperative manipulation.
Using this technique, reduction was achieved in 19 patients with congenital irreducible AAD treated between January 2011 and December 2013. The C1–2 joints were studied preoperatively, and particular attention was paid to the facet orientation. Intraoperatively, oblique C1–2 joints were opened widely, and extensive drilling of the facets was performed to make them close to flat and parallel to each other, converting an irreducible AAD to a reducible one. Anomalous vertebral arteries (VAs) were addressed appropriately. Further reduction was then achieved after vertical distraction and joint manipulation.
Adequate facet drilling was achieved in all but 2 patients, due to VA injury in 1 patient and an acute sagittal angle operated on 2 years previously in the other patient. Complete reduction could be achieved in 17 patients and partial in the remaining 2. All patients showed clinical improvement. Two patients showed partial redislocation due to graft subsidence. The fusion rates were excellent.
Comprehensive drilling of the C1–2 facets appears to be a logical and effective technique for achieving direct posterior reduction in irreducible AAD. The extensive drilling makes large surfaces raw, increasing fusion rates.
Sushanta K. Sahoo, Sivashanmugam Dhandapani, Apinderpreet Singh, Chandrashekhar Gendle, Madhivanan Karthigeyan, Pravin Salunke, Ashish Aggarwal, Navneet Singla, Raghav Singla, Manjul Tripathi, Rajesh Chhabra, Sandeep Mohindra, Manoj Kumar Tewari, Manju Mohanty, Hemant Bhagat, Arunaloke Chakrabarti, and Sunil Kumar Gupta
COVID-19 has affected surgical practice globally. Treating neurosurgical patients with the restrictions imposed by the pandemic is challenging in institutions with shared patient areas. The present study was performed to assess the changing patterns of neurosurgical cases, the efficacy of repeated testing before surgery, and the prevalence of COVID-19 in asymptomatic neurosurgical inpatients.
Cases of non–trauma-related neurosurgical patients treated at the Postgraduate Institute of Medical Education and Research (PGIMER) before and during the COVID-19 pandemic were reviewed. During the pandemic, all patients underwent a nasopharyngeal swab reverse transcription–polymerase chain reaction test to detect COVID-19 at admission. Patients who needed immediate intervention were surgically treated following a single COVID-19 test, while stable patients who initially tested negative for COVID-19 were subjected to repeated testing at least 5 days after the first test and within 48 hours prior to the planned surgery. The COVID-19 positivity rate was compared with the local period prevalence. The number of patients who tested positive at the second test, following a negative first test, was used to determine the probable number of people who could have become infected during the surgical procedure without second testing.
Of the total 1769 non–trauma-related neurosurgical patients included in this study, a mean of 337.2 patients underwent surgery per month before COVID-19, while a mean of 184.2 patients (54.6% of pre–COVID-19 capacity) underwent surgery per month during the pandemic period, when COVID-19 cases were on the rise in India. There was a significant increase in the proportion of patients undergoing surgery for a ruptured aneurysm, stroke, hydrocephalus, and cerebellar tumors, while the number of patients seeking surgery for chronic benign diseases declined. At the first COVID-19 test, 4 patients (0.48%) tested were found to have the disease, a proportion 3.7 times greater than that found in the local community. An additional 5 patients tested positive at the time of the second COVID-19 test, resulting in an overall inpatient period prevalence of 1%, in contrast to a 0.2% national cumulative caseload. It is possible that COVID-19 was prevented in approximately 67.4 people every month by using double testing.
COVID-19 has changed the pattern of neurosurgical procedures, with acute cases dominating the practice. Despite the fact that the pandemic has not yet reached its peak in India, COVID-19 has been detected 3.7 times more often in asymptomatic neurosurgical inpatients than in the local community, even with single testing. Double testing displays an incremental value by disclosing COVID-19 overall in 1 in 100 inpatients and thus averting its spread through neurosurgical services.