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Jeffrey R. Leonard and Neill M. Wright

W hen instability of the atlantoaxial complex requires surgical stabilization, various procedures may be undertaken in adult patients. For atlantoaxial fixation, posterior wiring methods, such as the Brooks–Jenkins 3 and the Sonntag modified Gallie 4 approaches, are technically simple procedures but have been associated with high rates of fusion failure because of the absence of rotatory stabilization and because rigid postoperative immobilization is required. 18 The transarticular C1–2 screw technique introduced by Magerl 10 provides rigid fixation in

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Jerry Y. Du, Alexander Aichmair, Janina Kueper, Timothy Wright and Darren R. Lebl

to restore stability and prevent potentially life-threatening neurological deterioration have progressed rapidly in recent years. 11 , 45 Posterior wiring and graft techniques, such as the Gallie, Brooks-Jenkins, and Sonntag techniques, have been used for many decades to achieve arthrodesis. 4 , 6 , 12 The use of screw constructs for atlantoaxial fixation has emerged as a popular alternative. The technique described by Jeanneret and Magerl 21 involves placing a transarticular screw through the C1–2 articular surfaces. Other screw constructs for atlantoaxial

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Peng-Yuan Chang, Yu-Shu Yen, Jau-Ching Wu, Hsuan-Kan Chang, Li-Yu Fay, Tsung-Hsi Tu, Ching-Lan Wu, Wen-Cheng Huang and Henrich Cheng

craniovertebral junction . J Craniovertebr Junction Spine 1 : 44 – 48 , 2010 14 Goel A : Basilar invagination, Chiari malformation, syringomyelia: a review . Neurol India 57 : 235 – 246 , 2009 15 Goel A : Is atlantoaxial instability the cause of Chiari malformation? Outcome analysis of 65 patients treated by atlantoaxial fixation . J Neurosurg Spine 22 : 116 – 127 , 2015 16 Goel A : Occipitocervical fixation: is it necessary? . J Neurosurg Spine 13 : 1 – 2 , 2010 17 Goel A : Treatment of basilar invagination by atlantoaxial joint distraction

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Atul Goel

some special trick that he or she finds unique and superior. The very fact that no definite treatment strategy has convincingly found universal acceptance or has produced uniformly gratifying results suggests that the pathogenesis and pathophysiology of the disease process are still unclear and, to say the least, riddled with controversies and opinions. Here, the management of CM associated with or without basilar invagination and with or without syringomyelia is evaluated. All patients were treated primarily with atlantoaxial fixation. The surgical strategy was

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Go Yoshida, Mituhiro Kamiya, Hisatake Yoshihara, Tokumi Kanemura, Fumihiko Kato, Yasutugu Yukawa, Keigo Ito, Yukihiro Matsuyama and Yoshihito Sakai

A tlantoaxial fixation is the most popular treatment option for atlantoaxial instability, but it may cause a subaxial lesion and adjacent-segment degeneration. Unfortunately, we have encountered patients who develop cervical malalignment caused by cervical kyphosis or adjacent-segment degeneration after surgery, with resulting neurological symptoms and cervical pain, which ultimately require additional surgery. In patients with RA, postoperative subaxial alignment after atlantoaxial fixation is regulated by multiple factors: a fixed atlantoaxial angle

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Chih-Chang Chang, Wen-Cheng Huang, Tsung-Hsi Tu, Peng-Yuan Chang, Li-Yu Fay, Jau-Ching Wu and Henrich Cheng

and interpretation of data: Wu, CC Chang. Drafting the article: Wu. Critically revising the article: Wu. Reviewed submitted version of manuscript: Wu, CC Chang, Huang, Tu, PY Chang, Fay. Approved the final version of the manuscript on behalf of all authors: Wu. Statistical analysis: CC Chang. Administrative/technical/material support: Wu, Huang, Tu, PY Chang, Fay, Cheng. Study supervision: Wu, Huang, Cheng. References 1 Chang PY , Yen YS , Wu JC , Chang HK , Fay LY , Tu TH , : The importance of atlantoaxial fixation after odontoidectomy . J

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Gilbert Cadena, Huy T. Duong, Jonathan J. Liu and Kee D. Kim

significantly (*p < 0.05). Fig. 6. C1 lateral mass/C2 pars construct provides greater, but nonsignificant rigidity in flexion-extension, lateral bending, and axial rotation, as compared with the C1 PAS/C2 pars screw construct. Discussion Atlantoaxial instability presents a unique challenge to spine surgeons given the inherent high degree of mobility of this complex. Techniques for atlantoaxial fixation have evolved since Mixter and Osgood’s original description in 1910. 30 Gallie later popularized the posterior wiring technique in 1939. 11 Posterior wiring techniques 3 , 6

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Atul Goel, Apurva Prasad, Abhidha Shah, Survendra Rai, Abhinandan Patil and Ravikiran Vutha

include atlantoaxial and C2–3 fixation or C2–3 fixation alone. 7 , 11 , 13 We report 3 cases in which the absence of posterior elements of the C2 vertebra was associated with multiple other bone and neural abnormalities at the craniovertebral junction. Atlantoaxial fixation resulted in remarkable recovery in the clinical symptoms. Case 1 A 17-year-old boy presented to us with progressively increasing weakness and stiffness of all 4 limbs. The patient also had hesitancy during micturition and increased frequency of urination. He had difficulty in sleeping supine and was

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Roger Härtl, Robert H. Chamberlain, Mary S. Fifield, Dean Chou, Volker K. H. Sonntag and Neil R. Crawford

the VAs at risk of injury. Nevertheless, the TAIG procedure is considered the gold standard for atlantoaxial fixation. The anatomy of the C1–2 complex is not always suitable for TAIG fixation because of previous surgery, tumors, or congenital abnormalities. For example, in as many as 18% of cases, transarticular screws cannot be placed because the course of the VA is atypical. 20 The TAIG procedure also may not be feasible in patients who are obese or who have a cervical kyphotic deformity. 21 Goel and Laheri 8 have described an alternative technique for

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Andrew Jea

malformation? Outcome analysis of 65 patients treated by atlantoaxial fixation . J Neurosurg Spine [epub ahead of print Month Day, 2014. DOI: 10.3171/2014.10.SPINE14176] 5 Klekamp J : Surgical treatment of Chiari I malformation—analysis of intraoperative findings, complications, and outcomes for 371 foramen magnum decompressions . Neurosurgery 71 : 365 – 380 , 2012 6 Tubbs RS , Beckman J , Naftel RP , Chern JJ , Wellons JC III , Rozzelle CJ , : Institutional experience with 500 cases of surgically treated pediatric Chiari malformation Type