Treatment of basilar invagination by atlantoaxial joint distraction and direct lateral mass fixation

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Object. The author discusses the successful preliminary experience of treating selected cases of basilar invagination by performing atlantoaxial joint distraction, reduction of the basilar invagination, and direct lateral mass atlantoaxial plate/screw fixation.

Methods. Twenty-two patients with basilar invagination—in which the odontoid process invaginated into the foramen magnum and the tip of the odontoid process was above the Chamberlain, McRae foramen magnum, and Wackenheim clival lines—were selected to undergo surgery. In all patients fixed atlantoaxial dislocations were documented.

The 16 male and six female patients ranged in age from 8 to 50 years. A history of trauma prior to the onset of symptoms was documented in 17 patients. Following surgery, the author observed minimal-to-significant reduction of basilar invagination and alteration in other craniospinal parameters resulting in restoration of alignment of the tip of the odontoid process and the clivus and the entire craniovertebral junction in all patients. In addition to neurological and radiological improvement, preoperative symptoms of torticollis resolved significantly in all patients. The minimum follow-up period was 12 months and the mean was 28 months.

Conclusions. Joint distraction and firm lateral mass fixation in selected cases of basilar invagination is a reasonable surgical treatment for reducing the basilar invagination, restoring craniospinal alignment, and establishing fixation of the atlantoaxial joint.

Article Information

Address reprint requests to: Atul Goel, M.Ch., Department of Neurosurgery, King Edward Memorial Hospital and Seth G. S. Medical College, Mumbai–400012, India. email: atulgoel62@hotmail.com.

© AANS, except where prohibited by US copyright law.

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Figures

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    Imaging studies obtained in a 15-year-old boy. Upper Left: Preoperative T1-weighted image revealing basilar invagination, fixed atlantoaxial dislocation, and indentation of the brainstem. Os odontoideum can be observed. Upper Right: Preoperative CT scan demonstrating marked basilar invagination and fixed atlantoaxial dislocation. Fusion of the C2–3 vertebral bodies, occipitalization of the atlas, and os odontoideum are apparent. Lower Left: Postoperative CT scan revealing reduction of the basilar invagination and the atlantoaxial dislocation. Note the change in the osseous alignment of the CVJ. The alteration in the relationship of the anterior arch of the atlas and the clivus to the C-2 body and odontoid process can be appreciated. Metal artifacts can also be seen. Lower Right: Lateral plain radiograph demonstrating plate and screw fixation.

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    Preoperative and postoperative CT scans obtained in a 16-year-old boy. Left: Preoperative study demonstrating basilar invagination, fixed atlantoaxial dislocation, atlantal occipitalization, and C2–3 fusion. Right: Postoperative study revealing the changes in the alignment of the craniovertebral region. Note the alteration in the relationship of the odontoid process with the clivus. Atlantoaxial fixation was performed unilaterally and occipitoaxial fixation was conducted on the contralateral side.

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    Imaging studies obtained in a 36-year-old man. Upper Left: Preoperative MR image revealing severe basilar invagination, fixed atlantoaxial dislocation, and Chiari I malformation. Posterior decompression was undertaken at an earlier stage. Upper Center: Computerized tomography scan demonstrating basilar invagination and fixed atlantoaxial dislocation. Also evident is C2–3 fusion. Upper Right: Lateral sagittal cut obtained through the joint, revealing the dislocation. Lower Left: Postoperative CT scan demonstrating reduction of the basilar invagination and atlantoaxial dislocation. Lower Center: Postoperative CT scan demonstrating the plate and screw fixation as well as the distracted joint in which a metal spacer has been placed. Note the reduction of the dislocation. Lower Right: Postoperative radiograph demonstrating results after plate and screw fixation. A metal spacer can be seen between the screws.

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    Drawing showing the plates and screws used for atlantoaxial fixation.

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    Photograph showing the custom-made titanium plate spacers, which are coiled plates with multiple holes.

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