Craniovertebral Junction – Pathology and SurgeryTraumatic Atlantoaxial Spondyloptosis Associated with Displaced Odontoid Fracture: Complete Reduction via Posterior Approach Using “Joint Remodeling” Technique
Introduction
Atlantoaxial dislocation (AAD) is a common phenomenon observed in both congenital and traumatic situations. However, atlantoaxial spondyloptosis (AAS), which is defined as complete displacement of the facets of atlas anterior to the facets of axis such that there is no contact between the 2 articulating surfaces,1 is an extremely rare manifestation of atlantoaxial instability. This extreme rarity is probably attributable to the severity of trauma that leads to AAS, which is usually incompatible with life. It represents the most severe form of AAD, and complete reduction in such a case presents a real technical challenge because of the interlocking of C1-C2 facets. Even cranial traction fails to achieve reduction in such cases.
We encountered a case of traumatic odontoid fracture associated with AAS. The patient was managed via posterior approach, and complete reduction was achieved with joint remodeling and manipulation with good clinical outcome.
Section snippets
Case Description
An 11-year-old male child suffered from a road traffic accident with an injury to his neck followed by quadriparesis. He presented to us 4 months later with dysphagia to solid foods, neck pain, and spastic quadriparesis (power bilateral upper and lower limbs: 3/5 Medical Research Council UK). On evaluation, he was found to have grossly displaced type II odontoid fracture, and the displaced fracture segment was lying in a horizontal plane between the body of atlas and C1 anterior arch (Figure 1B
Operative Details
The patient was positioned prone. Cranial traction was applied using Gardner well traction tongs. The pins of traction tongs were positioned ∼5 cm above the pinna at the level of the superior temporal line and ∼1.0 cm anterior to the external auditory meatus. An initial weight of 2.0 kg was applied, and weights were then gradually increased with an increment of 2.0 kg until a total weight of 10.0 kg was applied. However, as expected, no significant movement could be appreciated on lateral
Discussion
It is estimated that one third to half of all cervical spine injuries involve the craniovertebral junction (CVJ),2, 3 and odontoid fractures account for 10%−20% of all cervical spine fractures.4 In most of the cases AAD associated with these fractures is reducible, but in some, the reduction is not possible even with cranial traction.5 Several factors are responsible for irreducibility, and one of these factors is interlocking of C1-C2 facets with consequent AAS.1, 5, 6 The literature on AAS is
Conclusion
The current case presented a unique surgical challenge in terms of achieving reduction in a case of complex traumatic CVJ deformity. The “joint manipulation” and “joint remodeling” techniques can be used to achieve excellent deformity correction even in cases of displaced odontoid fractures associated with AAS, which is one of the most severe forms of dislocation involving the CVJ.
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Reduction of cervicothoracic spondyloptosis in an ambulatory patient: when traction fails
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2022, JBJS Case Connector
Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.