Posterior revision surgery using an intraarticular distraction technique with cage grafting to treat atlantoaxial dislocation associated with basilar invagination

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OBJECTIVE

The treatment of atlantoaxial dislocation (AAD) and basilar invagination (BI) is challenging, especially in symptomatic patients with a history of previous surgery. Although seldom reported, posterior revision surgery to revise prior constructs can be advantageous over an anterior or combined approach. The authors describe their experience in performing posterior revision surgery using Goel’s technique.

METHODS

The authors reviewed patients with AAD and BI who had undergone previous posterior surgery at the cranio-cervical junction between January 2016 and September 2017. All of these patients underwent revision surgery from a posterior approach. The Japanese Orthopaedic Association (JOA) score was used to assess clinical symptoms before and after surgery. The distance from the tip of the odontoid to Chamberlain’s line, atlantodental interval (ADI), and clivus-canal angle (CCA) were used for radiographic assessment before and after surgery.

RESULTS

Twelve consecutive patients were reviewed. Prior surgeries were as follows: 4 patients (4/12) with posterior osseous decompression without fusion, 7 (7/12) with reduction and fusion without decompression, and 1 (1/12) with posterior osseous decompression and reduction and fusion. With the use of Goel’s technique for revision in these cases, distraction using facet spacers afforded release of the anterior soft tissue from a posterior approach. The occiput was fixated to C2 using a cantilever technique, and autologous cancellous bone was grafted into the intraarticular joints. In all 12 patients, complete reduction of BI and AAD were achieved without injury to nerves or vessels. All patients had evidence of bony fusion on CT scans within 18 months of follow-up.

CONCLUSIONS

Posterior revision surgery using Goel’s technique is an effective and safe revision salvage surgery for symptomatic patients with AAD and BI.

ABBREVIATIONS AAD = atlantoaxial dislocation; ADI = atlantodental interval; BI = basilar invagination; CCA = clivus-canal angle; JOA = Japanese Orthopaedic Association; SF-36 = 36-Item Short-Form Health Survey.

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Article Information

Correspondence Zan Chen: Xuanwu Hospital, Capital Medical University, Beijing, China. chenzan66@163.com.

INCLUDE WHEN CITING Published online July 5, 2019; DOI: 10.3171/2019.4.SPINE1921.

Disclosures Zan Chen is a consultant of Wego company, Shandong, China. He received financial support from a Beijing Municipal Administration of Hospital Grant (TX2017002) and a Beijing Natural Science Foundation Grant (7172091). Dean Chou is a consultant for Medtronic and Globus and receives royalties from Globus.

© AANS, except where prohibited by US copyright law.

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Figures

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    A 57-year-old woman presented with neck pain for 10 years. The prior operation was reduction and posterior fusion with an occipital plate and C2 fixation. The symptoms improved but recurred 2 weeks after the index surgery. A: CT obtained 12 months after the revision surgery demonstrating solid bony fusion in the atlantoaxial facet joint. B and C: Dynamic radiographs demonstrating no instability between the occiput and cervical spine.

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    A 27-year-old man presented with gait instability for 1 year. The prior surgery was posterior atlantoaxial reduction and occipital–C2 (translaminar screw) fusion. The patient’s symptoms persisted after the index operation. A: Preoperative CT scan (parasagittal view) showing loosening of the C2 translaminar screw. B: Postoperative CT (parasagittal view) showing interfacet spacer placement and occipital condyle screws with C2 pedicle screws. C: Preoperative CT (midsagittal view) showing AAD and BI with a large defect in the occiput. D: Postoperative CT showing complete reduction of both BI and AAD. E: Three-dimensional CT reconstructive image showing the large defect on the occipital bone. F: Intraoperative image demonstrating the occipital condyle and C2 pedicle fusion following Goel’s technique. Figure is available in color online only.

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    A 31-year-old man presented with progressive neck pain and gait instability for 5 years. The prior operation was posterior atlantoaxial reduction with occipital–C2 pedicle screw fusion. The symptoms worsened after the index operation. A: CT before the first operation (parasagittal view) demonstrating abnormal facet joints. B: CT after the index operation (parasagittal view). C2 pedicle screws and occipital plate were placed. C: CT after revision surgery (parasagittal view). C2 screws were replaced with new placement of C3 lateral mass screws. D: CT before the index surgery (midsagittal view) showing BI and AAD with an assimilated C1. E: CT after the index operation (midsagittal view) demonstrating inadequate reduction of AAD with no change in BI. F: CT after the revision operation (midsagittal view) demonstrating complete reduction of AAD and BI. G: MR image indicating syringomyelia from C2 to C6. H: MR image after the index operation showing slight enlargement of the syrinx. I: MR image after the revision surgery showing shrinkage of the syrinx.

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    A 57-year-old woman presented with neck pain for 10 years (the same patient shown in Fig. 1). The index operation was reduction and posterior fusion with an occipital plate and C2 fixation. The symptoms improved but reappeared 2 weeks after the prior surgery. A: CT scan before the index operation (parasagittal view). B: CT scan 1 week after the index operation (parasagittal view) indicating C2 pedicle screws and occipital plate were implanted. C: CT 3 months after the index operation (parasagittal view) indicating that the rod shifted due to implant loosening. D: CT after revision surgery (parasagittal view). Larger occipital screws were placed, and C3 screws were implanted to strengthen the fixation. E: CT before the index operation (midsagittal view) indicating BI and AAD with an assimilated C1. F: CT obtained 3 days after the index operation (midsagittal view) showing that complete reduction was achieved. G: CT 3 months after the index operation (midsagittal view) showing that AAD and BI reappeared. H: CT obtained 6 months after the revision surgery (midsagittal view) indicating that reduction was achieved for both AAD and BI. I: MR image before the index operation indicating ventral compression of the spinal cord and edema in the medulla. J: MR image 3 months after the first operation indicating not much change in spinal cord compression. K: MR image 3 months after the revision surgery indicating complete decompression and resolution of the edema.

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    A 51-year-old woman presented with gait instability and had undergone a posterior decompression without fusion 20 years prior to revision. The symptoms had worsened gradually. A: Preoperative CT (parasagittal view) indicating an assimilated C1 and small C2 pedicles. B: Postoperative CT (parasagittal view) showing interfacet cage placement. An occipital plate and C2 translaminar screws were placed for instrumentation. C: Preoperative CT (midsagittal view) indicating AAD and BI with an occipital defect. D: Postoperative CT indicating complete reduction of both BI and AAD. E: Preoperative MR image indicating edema in the brainstem. F: Postoperative MR image indicating good spinal cord decompression and resolution of edema.

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