Elsevier

World Neurosurgery

Volume 110, February 2018, Pages 609-613
World Neurosurgery

Craniovertebral Junction – Pathology and Surgery
Traumatic Atlantoaxial Spondyloptosis Associated with Displaced Odontoid Fracture: Complete Reduction via Posterior Approach Using “Joint Remodeling” Technique

https://doi.org/10.1016/j.wneu.2017.09.097Get rights and content

Background

Atlantoaxial spondyloptosis (AAS), which is defined as complete displacement of facets of atlas anterior to the facets of axis such that there is no contact between the 2 articulating surfaces, is an extremely rare manifestation of atlantoaxial instability. The reason for an extreme rarity of traumatic AAS is probably the severity of injury in traumatic AAS that is usually incompatible to life. It represents the most severe form of atlantoaxial dislocation, and complete reduction in such a case presents a real technical challenge because of the interlocking of C1-C2 facets. Cranial traction fails to achieve reduction in such cases.

Case Description

In this report, we describe a case of traumatic odontoid fracture associated with AAS and discuss our technique of complete reduction of deformity via posterior approach. An 11-year-old child presented to us 4 months after a road traffic accident with progressive spastic quadriparesis. On evaluation, displaced type II odontoid fracture with AAS was detected. The patient underwent surgery via posterior approach. The techniques of “joint manipulation” and “joint remodeling” were used to achieve complete reduction of spondyloptosis. Postoperative imaging showed complete reduction of deformity. The patient also improved neurologically after surgery.

Conclusion

This case report aims to present the ability of “joint manipulation” and “joint remodeling” techniques in achieving excellent reduction in even one of the most difficult post-traumatic deformities that affect the craniovertebral junction.

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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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.

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