Reversal of longstanding musculoskeletal changes in basilar invagination after surgical decompression and stabilization

Clinical article

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Object

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.

Methods

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.

Results

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.

Conclusions

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.

Abbreviation used in this paper: CVJ = craniovertebral junction.

Article Information

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

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Line drawing showing the measurements of craniovertebral and cervical heights. Line A is drawn from the tuberculum sellae to the confluence of sinuses. The distance from the midpoint of this line to the midpoint of the base of the C-5 vertebra (line B) measures the craniovertebral height. The distance from the tip of the odontoid process to the midpoint of the base of the C-5 vertebral body (VB) (line C) measures the cervical height.

  • View in gallery

    Line drawing showing the parameters for measurement of the modified omega angle to assess cervical lordosis. Line A is drawn along the hard palate. Line B is parallel to Line A and passes through the center of the C-3 VB base. Line C extends from the center of the C-3 base along the tip of the odontoid process. The angle between line B and line C is the modified omega angle.

  • View in gallery

    Line drawing demonstrating measurement of the craniospinal angle. Line A is drawn along the clivus and line B along the posterior surface of the C2–3 VBs. The angle between these lines is the craniospinal angle.

  • View in gallery

    Images obtained in an 11-year-old girl with basilar invagination. Preoperative T2-weighted (A) and T1-weighted (B) MR images, and CT scan (C) demonstrating basilar invagination, partial assimilation of the atlas, and C2–3 fusion. Lateral radiograph in flexion (D) and extension (E) showing hyperlordosis of the cervical spine. Postoperative CT scan (F) and radiographs in extension (G) and flexion (H). Note craniovertebral and cervical spinal realignment and increase in craniovertebral and neck height. Also note the recovery in posterior cervical lordosis and increase in neck length.

  • View in gallery

    Images obtained in a 55-year-old woman with basilar invagination. A: Preoperative CT scan showing basilar invagination and assimilation of the atlas. B: Preoperative T2-weighted MR image demonstrating basilar invagination and Chiari malformation. C: Postoperative CT scan showing realignment of CVJ and cervical spine.

  • View in gallery

    Images obtained in a 40-year-old man with basilar invagination. A: Preoperative CT scan demonstrating basilar invagination, C2–3 fusion, and assimilation of atlas. B: Magnetic resonance image through the C1–2 facet joint showing the joint at an angle. C: T1-weighted MR image showing basilar invagination, Chiari malformation Type I, and syringomyelia. D: T2-weighted MR image. E: Lateral cervical spine radiograph. F: Postoperative CT scan. Note the realignment of CVJ and the cervical spine. G: Computed tomography scan with sagittal cut traversing the atlantoaxial joint showing plate and screw interarticular fixation and metal spacer within the joint. The alteration in alignment of the facets of the atlas and axis when compared to the preoperative view (B) can be appreciated. H: Postoperative extension radiograph showing fixation.

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