- Department of Orthopaedics, Seth Gordhandas Sunderdas Medical College and King Edward Memorial Hospital, Mumbai, Maharashtra, India.
Sachin Mohana Khemkar, Department of Orthopaedics, Seth Gordhandas Sunderdas Medical College and King Edward Memorial Hospital, Mumbai, Maharashtra, India.
DOI:10.25259/SNI_790_2023Copyright: © 2023 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Tushar N. Rathod, Sachin Mohana Khemkar, Tapas Mohanty, Arjit Vashishtha, Arun Kale, Akshay Phupate. Functional and radiological outcomes following craniovertebral junction surgery. 10-Nov-2023;14:393
How to cite this URL: Tushar N. Rathod, Sachin Mohana Khemkar, Tapas Mohanty, Arjit Vashishtha, Arun Kale, Akshay Phupate. Functional and radiological outcomes following craniovertebral junction surgery. 10-Nov-2023;14:393. Available from: https://surgicalneurologyint.com/surgicalint-articles/12633/
Background: Craniovertebral junction (CVJ) pathologies include atlantoaxial instability/deformities resulting in myelopathy, respiratory failure, and even death. Here, we describe the indications, preoperative planning, and intra-operative/postoperative complications following surgical management of CVJ anomalies.
Methods: A prospective analysis of 34 patients with CVJ pathology was evaluated between 2015 and 2022. Their various etiologies included atlantoaxial instability, trauma, tuberculosis, Down’s syndrome, Morquio syndrome, os odontoideum, and atlantoaxial abnormalities. Clinical outcomes were assessed using the American spinal injury association (ASIA) impairment scale score and Benzel’s modified Japanese Orthopedic Association (mJOA) score. Surgical assessments included length of hospital stay, operative time, blood loss, and intraoperative postoperative complications. Radiological parameters included fusion (i.e., implant loosening/implant failure), preoperative/ postoperative atlanto-dens interval (ADI), clivus canal angle (CCA), and space available for cord (SAC).
Results: Five patients were managed conservatively, while 29 patients had surgery. Operations included occipitocervical fusion (14 patients), C1–2 fusion (10 patients), C1–2 transarticular screw fixation (four patients), and one patient underwent anterior corpectomy decompression/fusion. Seven patients had vertebral artery anomalies, and 13 patients had atlantoaxial abnormalities. At the final follow-up, atlantoaxial instability (i.e., mean preoperative ADI of 6.6 ± 2.3 mm) was restored to 4.2 ± 0.6 mm, significant cord compression (i.e., with mean SAC of 8.3 ± 2.9 mm) was relieved to 17.2 ± 1.6 mm, and the mean preoperative CCA (i.e., 130.2 ± 15.3) was improved to 143.3 ± 8.3°. There was also a statistically significant improvement in the ASIA scale and mJOA score.
Conclusion: Surgical management of CVJ abnormalities requires expertise and meticulous planning to avoid devastating complications such as wound dehiscence and catastrophic vertebral artery injury.
Keywords: Atlantoaxial instability, Clivus canal angle, Craniovertebral junction, Space available for cord, Vertebral artery abnormalities
Craniovertebral junction (CVJ) pathologies are commonly associated with atlantoaxial instability and deformities resulting in cervical myelopathy, respiratory failure, or even death.[
This was a prospective analysis of clinical, radiological, and surgical complications for 34 patients presenting with CVJ pathologies from 2015 to 2022 and is attributed to atlantoaxial instability, trauma, tuberculosis, Down’s syndrome, Morquito syndrome, os odontoideum, and atlantoaxial abnormalities [
Surgical indications were ADI >5 mm for adults and in children with one or more of the following: neurologic involvement, persistent anterior displacement with ADI >4 mm, deformity present >3 months, or recurrence of deformity following 6 weeks of immobilization. Preoperative CT scans also were used to assess the pedicles, while CTA identified vertebral artery anomalies [
The five patients undergoing conservative management were given custom-fit cervical orthoses. Those patients having CVJ tuberculosis underwent fluoroscopy-guided biopsy and were given antitubercular treatment for 18 months as per our protocol (4 months of intensive phase which included isoniazid, rifampicin, ethambutol, pyrazinamide, and 14 months of continuation phase with isoniazid, rifampicin, and ethambutol). There were 29 patients who underwent surgery: occipitocervical fusion (14 patients), C1–2 fusion (10 patients), C1–2 transarticular screw fixation (four patients), and one anterior corpectomy decompression and fusion. In the immediate postoperative period, all patients were treated with custom-fit cervical orthoses. Routinely, surgical patients received parenteral antibiotics for 5 postoperative days. Wound checks were done on days 3 and 7. Drain removal was done 48 h following surgery. Suture removal was performed on postoperative day 15. The braces were continued till fusion was documented on a CT scan.
Preoperative values of the visual analog scale score, mJOA, ADI, SAC, and CCA were compared with postoperative values using the Mann–Whitney U-test, Wilcoxon-matched paired t-test, and Z-test [
Surgical parameters were assessed using a mean operative time of 155.09 min, the mean intraoperative blood loss of 679.6 mL, and the length of stay in the hospital range from 15 to 30 days [
At the final follow-up, atlantoaxial instability was restored to 4.2 ± 0.6 mm, the mean SAC was 17.2 ± 1.6 mm, and the mean CCA was 143.3 ± 8.3°. Furthermore, fusion was achieved in 31 patients (91.17%).
Complications were seen in 3 patients (8.82%). One patient had an intraoperative massive bleed leading to death. Another patient died in the immediate postoperative period due to brainstem dysfunction. The third patient had a wound infection which led to a progressive neurological deficit requiring debridement and intravenous antibiotics.
Management of CVJ abnormalities should be based on the type of instability, the integrity of posterior cervical elements, individual anatomic variation, and the surgeon’s familiarity with the techniques. 7 patients with significant cervicomedullary compression and persistent AAI required posterior decompression/fusion. Shukla et al. reported 24 cases of CVJ tuberculosis: 5 patients underwent transoral biopsy only, 9 patients had transoral decompressions/ posterior fusions, and 6 patients underwent only posterior fusion.[
We had 1 patient with Down’s syndrome and os odontoideum with AAD managed by Goel/Harms fixation.[
Surgical management of CVJ abnormalities requires expertise at a tertiary center, with a mandatory CTA, and careful operative planning to avoid devastating complications.
Patients’ consent not required as patients’ identities were not disclosed or compromised.
There are no conflicts of interest.
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Journal or its management. The information contained in this article should not be considered to be medical advice; patients should consult their own physicians for advice as to their specific medical needs.
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