Occipitocervical fusion with relief of odontoid invagination: atlantoaxial distraction method using cylindrical titanium cage for basilar invagination—case report

Abstract

A 65-year-old woman presented with basilar invagination manifesting as neck pain, dysesthesia around the lips, and truncal ataxia. The radiological findings demonstrated invagination of the odontoid process into the medulla oblongata and vertical atlantoaxial subluxation with C1 assimilation. The clivo-axial angle was 88° and the cervicomedullary angle was 115°, indicating severe basilar invagination. We planned occipitocervical fusion with atlantoaxial distraction using a cylindrical titanium cage. C2 pedicle screws were inserted, and the atlantoaxial joint was opened to translocate the odontoid process downward. A cylindrical titanium cage packed with local bone graft was inserted into the opened facet joint space. Occipital-C2 fusion was completed by fastening the occipital bone plates with pedicle screws using titanium rods. Postoperatively, the apex of the odontoid process descended by 7 mm, and the clivo-axial and cervicomedullary angles opened to 112° and 125°, respectively. Invagination of the odontoid process into the medulla oblongata was relieved. The preoperative symptoms improved, and she remained symptom-free without requiring anterior decompression over 2 years. Bone fusion of the atlantoaxial joints was completed with sustained facet distraction 12 months after the surgery, and adequate relief of the basilar invagination was maintained. The atlantoaxial distraction method using a cylindrical titanium cage can be a useful option in posterior fusion surgery for basilar invagination.

Neurological and spinal manifestations of the Ehlers–Danlos syndromes

“…Indications for surgery include severe headache, symptoms which constitute the cervical medullary syndrome, neurological deficits referable to the brainstem and upper spinal cord, radiological findings of CCI, and failure of a reasonable course of non‐operative therapy. Though there are no established criteria for treatment of CCI in EDS, there is abundant literature addressing the diagnosis of CCI [White and Panjabi, ; Harris et al, ; Batzdorf et al, ], and the treatment of CCI with craniocervical stabilization in various congenital or degenerative connective tissue disorders [Nagashima et al, ; Goel and Sharma, ; Henderson et al, ; Milhorat et al, ; Tubbs et al, ; Klekamp, ; Yoshizumi et al, ].…”

Biomechanical comparison of a novel transoral atlantoaxial anchored cage with established fixation technique - a finite element analysis

“…Similarly, Kao et al [ 46 ] also concluded that subsidence was not associated with clinical and radiological outcomes but associated with more disc height change. Spacer or cage has been used to reduce the BI and achieve atlantoaxial fusion through posterior approach [ 1 , 2 , 10 ], however, the authors did not investigate spacer or cage subsidence. Yoshizumi et al [ 10 ] treated a patient with BI using a cylindrical titanium cage packed with bone graft for atlantoaxial distraction and fusion and suggested that clinical observation about alignment change and cage subsidence would be continued over the long follow-up.…”

“…Spacer or cage has been used to reduce the BI and achieve atlantoaxial fusion through posterior approach [ 1 , 2 , 10 ], however, the authors did not investigate spacer or cage subsidence. Yoshizumi et al [ 10 ] treated a patient with BI using a cylindrical titanium cage packed with bone graft for atlantoaxial distraction and fusion and suggested that clinical observation about alignment change and cage subsidence would be continued over the long follow-up. The C2 endplate in the Cage + Plate model, which sustained 2.2 to 8.3 times greater stress than in Cage + TARP model, had higher stress than that in Cage + TARP model in all motions (Fig.…”

“…The selection of the surgical approach depends mainly on the reducibility of the atlantoaxial dislocation [ 4 – 6 ], as for the cases of BI with IAAD, which can not be reduced in traction before surgery, several authors of clinical studies have shown that transoral anterior atlantoaxial release followed by transoral atlantoaxial reduction plate (TARP) fixation can achieve reduction, decompression, fixation and fusion of C1–C2 through a transoral-only approach [ 4 , 7 – 9 ]. Although spacer or cage has been used to reduce the BI through posterior approach [ 1 , 2 , 10 ], there are no studies referred to the cage through transoral approach for C1-C2 fusion. The atlantoaxial fusion cage with TARP (Cage + TARP) device may increase stability and fusion rates, maintain or improve atlantoaxial fusion angle and prevent bone graft collapse, extrusion, resorption and micromotion; however, the Cage + TARP device may also be associated with potential disadvantages and complications, including dysphagia, load shielding of the bone graft.…”

Delayed neurological deterioration following atlantoaxial facet joint distraction and fixation in a patient with Chiari malformation type I

“…We adopted Goel's atlantoaxial distraction/fixation technique in the present case because foramen magnum decompression was not successful, and another report stated that his technique provides relief. 19 Notably, we also included the occipital bone for fixation, although Goel criticized this as unnecessary and unfavorable to implant strength. We respect Goel's opinion and his unique and original surgical intervention for CM-I, but since only transient neurological relief was achieved, his technique likely rescued our patient and initially allowed us to avoid performing the technically demanding odontoidectomy.…”