Letter to the Editor: Treatment of craniocervical instability using a posterior-only approach

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  • State University of Campinas, Campinas, Brazil
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TO THE EDITOR: We found the article by Young et al.6 (Young RM, Sherman JH, Wind JJ, et al: Treatment of craniocervical instability using a posterior-only approach. Report of 3 cases. J Neurosurg Spine 21:239–248, August 2014) very interesting and well illustrated. The authors reported a posterior-only approach based on modern hardware instrumentation that allows intraoperative reduction techniques and avoids the need for an additional anterior approach to treat craniocervical junction instabilities. They also stated the important point that basilar invagination (BI) was harder to reduce with preoperative traction than cranial settling, because degeneration of the joints and ligaments can make reduction with traction easier in the latter.

We have some comments regarding intraoperative reduction using posterior-only approaches for craniocervical junction instabilities. In 2010, Jian et al. published a report of 29 patients with BI and atlantoaxial dislocation successfully treated with distraction between the occipital plate and C-2.2 They did not perform preoperative traction or the maneuver for anterior reduction of C-2 relative to the foramen magnum. Since the publication of that article, we have tried to apply intraoperative posterior reduction techniques without preoperative traction, using the maneuver suggested by Jian et al. (distraction between the occipital plate and C-2) and also adding in some cases the anterior dislocation of the axis (pushing the cervical spine anteriorly) as proposed by Young et al. in this current manuscript. However, some of our patients who underwent just intraoperative reduction presented with a mild degree of postoperative craniocervical kyphosis (the horizontal gaze was slightly displaced downward and there was a reduction of the clivus-canal angle) because these maneuvers may favor cranial flexion. Because of that, we strongly recommend that patients with craniocervical instabilities, except for those with BI secondary to clivus hypoplasia, should undergo preoperative traction in a neutral position or even mild extension, which allows a gentle and gradual reduction of craniocervical misalignment.3–5 Especially in developing countries where neurophysiological monitoring is not available for all patients, preoperative reduction can be safely performed with assessment of the patient's neurological status in real time and can also decrease the duration of surgery (because the alignment will already have been corrected). Although preoperative traction is uncomfortable, unstable injuries generally reduce in the first 24 hours, and our practice is to perform traction the day before surgery. Another point observed in our practice is that using C-2 laminar screws for intraoperative reduction maneuvers results in more craniocervical kyphosis than the use of C-2 pedicle screws, probably because the latter can reach the anterior portion of the axis. Finally, the use of C1–2 spacers, as proposed by Goel et al., is also an alternative to direct intraoperative reduction, which does not result in any degree of craniocervical kyphosis.1 However, this technique cannot be performed in all patients, because vertebral artery and bone anomalies are commonly found in patients with congenital craniocervical malformations, precluding the use of C-1 lateral mass or even C-2 pedicle screws.

We congratulate the authors for this outstanding manuscript.

References

  • 1

    Goel A: Basilar invagination, Chiari malformation, syringomyelia: a review. Neurol India 57:235246, 2009

  • 2

    Jian FZ, , Chen Z, , Wrede KH, , Samii M, & Ling F: Direct posterior reduction and fixation for the treatment of basilar invagination with atlantoaxial dislocation. Neurosurgery 66:678687, 2010

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  • 3

    Joaquim AF: Basilar invagination. J Neurosurg Pediatr 10:355356, 2012. (Letter)

  • 4

    Joaquim AF: Management of basilar invagination. J Bras Neurocirurg 24:5359, 2013

  • 5

    Joaquim AF, , Ghizoni E, , Almeida JPC, , Anderle DV, & Tedeschi H: Basilar invagination secondary to hypoplasia of the clivus—is there indication for craniocervical fixation?. Coluna 13:6970, 2014

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  • 6

    Young RM, , Sherman JH, , Wind JJ, , Litvack Z, & O'Brien J: Treatment of craniocervical instability using a posterior-only approach. Report of 3 cases. J Neurosurg Spine 21:239248, 2014

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  • George Washington University Medical Center, Washington, DC

Response

We would like to thank Dr. Joaquim for his thoughtful and accurate commentary on our paper. His observation that reduction maneuvers result in craniocervical kyphosis has also been observed in our experience. However, we will point out that for most patients, slight downward gaze is desirable for activities of daily living such as eating or going down stairs. Cervical sagittal alignment is becoming a topic of active research, but our feeling is that the C2–7 sagittal vertical axis1 is probably more important than slight craniocervical kyphosis.

Reference

1

Scheer JK, , Tang JA, , Smith JS, , Acosta FL Jr, , Protopsaltis TS, & Blondel B, : Cervical spine alignment, sagittal deformity, and clinical implications. A review. J Neurosurg Spine 19:141159, 2013

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Contributor Notes

DISCLOSURE The author reports no conflict of interest.

INCLUDE WHEN CITING Published online January 2, 2015; DOI: 10.3171/2014.9.SPINE14853.

  • 1

    Goel A: Basilar invagination, Chiari malformation, syringomyelia: a review. Neurol India 57:235246, 2009

  • 2

    Jian FZ, , Chen Z, , Wrede KH, , Samii M, & Ling F: Direct posterior reduction and fixation for the treatment of basilar invagination with atlantoaxial dislocation. Neurosurgery 66:678687, 2010

    • Search Google Scholar
    • Export Citation
  • 3

    Joaquim AF: Basilar invagination. J Neurosurg Pediatr 10:355356, 2012. (Letter)

  • 4

    Joaquim AF: Management of basilar invagination. J Bras Neurocirurg 24:5359, 2013

  • 5

    Joaquim AF, , Ghizoni E, , Almeida JPC, , Anderle DV, & Tedeschi H: Basilar invagination secondary to hypoplasia of the clivus—is there indication for craniocervical fixation?. Coluna 13:6970, 2014

    • Search Google Scholar
    • Export Citation
  • 6

    Young RM, , Sherman JH, , Wind JJ, , Litvack Z, & O'Brien J: Treatment of craniocervical instability using a posterior-only approach. Report of 3 cases. J Neurosurg Spine 21:239248, 2014

    • Search Google Scholar
    • Export Citation
  • 1

    Scheer JK, , Tang JA, , Smith JS, , Acosta FL Jr, , Protopsaltis TS, & Blondel B, : Cervical spine alignment, sagittal deformity, and clinical implications. A review. J Neurosurg Spine 19:141159, 2013

    • Search Google Scholar
    • Export Citation

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