Atlantoaxial manual realignment in a patient with traumatic atlantoaxial joint disruption

doi:10.1016/j.jocn.2009.09.023

Journal of Clinical Neuroscience

Volume 17, Issue 5, May 2010, Pages 672-673

https://doi.org/10.1016/j.jocn.2009.09.023 Get rights and content

Abstract

We report a patient with complex traumatic translatory atlantoaxial dislocation, who we treated by joint exposure and reduction of the dislocation by facet manipulation and subsequent plate and screw atlantoaxial fixation. A 28-year-old male had fallen 7.6 m (25 feet), and following the fall had severe neck pain but no neurological deficit. Investigations revealed a fracture at the base of the odontoid process and posterior displacement of the entire atlas over the axis, resulting in a translatory atlantoaxial dislocation. Head traction failed as he developed severe vertigo following its application. The patient was operated upon in a prone position. We opened the atlantoaxial joint and realigned the facets using distraction and manipulation techniques and secured the joint using a plate and screw interarticular method. The patient tolerated the treatment well and was symptom-free after 28 months. Postoperative images showed good craniovertebral alignment. Although technically challenging, direct manipulation of the facets of the atlas and axis can result in excellent craniovertebral realignment.

Introduction

Traumatic atlantoaxial dislocation can sometimes pose a therapeutic challenge due to the complexity of atlantoaxial misalignment. We report a patient who developed a translatory atlantoaxial dislocation following trauma. As the patient was neurologically intact this posed an additional therapeutic challenge.

Section snippets

Case report

A 28-year-old male fell 7.6 m (25 feet) while trekking in a mountain range. He was brought to the hospital with a cervical collar in an air ambulance. Investigations revealed a Type 2 odontoid fracture and posterior and left lateral translation of the atlas over the axis. The facets of the atlas and axis were not aligned, and their articular surfaces were no longer in direct contact with each other (Fig. 1). Aside from neck pain, the patient had no other symptoms. Neurological examination did

Discussion

We previously described a lateral mass plate and screw method of atlantoaxial fixation.¹ The procedure involved directly exposing the joint, denuding its articular cartilage, packing bone graft within the joint and, subsequently, plate and screw fixation of the region by implanting screws into the lateral mass of the atlas and pars of the axis. We further modified these direct exposure and manipulation of the joint techniques to reduce basilar invagination and for irreducible atlantoaxial

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Cited by (18)

Posterior-only approach for treatment of irreducible traumatic Atlanto-axial dislocation, secondary to type-II odontoid fracture; report of a missed case, its management and review of literature
2024, International Journal of Surgery Case Reports
Odontoid fracture (OF) is among the most common and challenging cervical spine fractures in regards to the treatment and surgical approach. Atlanto-axial dislocation (AAD) is considered a significant complication after failed non-surgical treatment of OF. Traditionally, it requires anterior odontoidectomy followed by posterior C1-C2 reduction and fusion. In latest studies, Atlanto-axial joint (AAJ) remodeling in a posterior-only approach has got attention.
We herein present a 30-year-old man with missed type-II OF, presenting with irreducible anterior AAD and progressive neurological deficit. Old non-united OF with dorsal callous formation, compressing spinal cord, was detected. The patient underwent correction of the deformity and reduction of the fracture utilizing the posterior-only approach. AAJ remodeling, callous release and C1-C2 fusion was performed in standard prone position, under fluoroscopic guide and intraoperative electrophysiological monitoring. The patient had uneventful surgery and postoperative course and was neurologically intact with appropriate alignment in 6-month follow-up.
The irreducible AAD following type-II OF could be successfully treated with posterior-only approach (C1-C2 fusion).
Type-II OF is considered unstable requiring surgical management. Close follow-up and appropriate patient education is mandatory in non-surgical treatment. Irreducible AAD has been managed with anterior odontoid resection and posterior fusion. Several complications of anterior surgery, makes posterior-only approach a noticeable choice.
Traumatic Posterolateral C1-C2 Dislocation Complicated with Locked Lateral Mass and Type II Odontoid Fracture—5-Year Follow-up
2018, World Neurosurgery
Citation Excerpt :
Pure traumatic atlantoaxial dislocation is an extremely rare condition. Most C1-C2 dislocations tend to happen in preexisting conditions, as in congenital abnormalities2,3 and rheumatoid arthritis.3,4 An epidemiologic study by Gleizes et al5 found 2 cases out of 116 cases of upper cervical spine injuries.
We sought to document our experience in managing a rare complex of traumatic posterolateral atlantoaxial dislocation combined with locked lateral mass and type II odontoid fracture.
A 30-year-old male patient was referred to the author's department. He complained of a decrease in neck range of motion following a traffic accident. Neurologic examination was normal. Computed tomography and open-mouth radiographs showed a type II odontoid fracture and a posterolateral dislocation with a laterally locked left lateral mass at the C1-C2 level. Considering the difficulty and risk in reduction, due to this rare instability and dislocation, a 2-staged treatment was performed. With up to 11 kg skull traction for 7 days before surgery, the locked lateral mass and the lateral dislocation was finally reduced without any neurologic deficit. And once closed reduction was confirmed by open-mouth and lateral X-ray views in the cervical spine, a second staged C1-C2 surgical fixation and fusion with iliac bone graft was performed to achieve a normal anatomic alignment with a better stability.
The patient showed significant amelioration of neck symptoms postoperatively, and a successful reduction and fixation of the C1-C2 articulation was achieved. At the 5-year follow-up, solid bone fusion was evident on the computed tomography scan.
For traumatic posterolateral atlantoaxial dislocation complicated with type II odontoid fracture, a closed reduction of the lateral dislocation before operation is both useful and safe because surgeons do not need to reduce the extremely rare lateral dislocation during the operation. Posterior atlantoaxial stabilization and fusion, rather than the occipitocervical fusion as reported previously, is biomechanically stable enough to achieve solid fusion in this rare trauma while not sacrificing the occipitoatlantal joint.
Atlantoaxial Fixation for Odontoid Fracture: Analysis of 124 Surgically Treated Cases
2018, World Neurosurgery
Citation Excerpt :
Bone graft was harvested from the iliac crest. Small bone chips were stuffed into the articular cavity, and manual facet manipulation was done wherever necessary (in types A and B) to bring them into alignment.12 In patients with type A1 odontoid fractures, the facets of atlas and axis were distracted before insertion of bone graft within the joint cavity.
The authors analyze 124 cases with fracture of odontoid process. All patients were surgically treated by posterior atlantoaxial fixation.
There were 96 male and 28 female patients. The ages of the patients ranged from 12 to 80 years. Apart from Anderson and D'Alonzo type I (6 cases), type II (93 cases) and type III (25 cases), three sub-types of odontoid fractures were included in the classification. In type A (118 cases), there was vertical compression fracture that resulted in malalignment of the fractured odontoid process segments. Type B (49 cases) resulted when the fracture resulted in malalignment of the facets of atlas and axis. Type C (25 cases) included cases in which the fracture line involved the facet of axis. Fractures were divided into acute type when the injury was less than 3 months old (50 cases), delayed type when the injury was between 3 months to one year (34 cases) and chronic type when the injury was more than 1 year in duration (40 cases). All patients were treated with posterior atlantoaxial fixation with the techniques described in 1994 and 2004. Follow-up period ranged from 6 to 156 months (average 72 months).
All patients improved in symptoms after surgery. There were no significant postoperative complications.
Posterior atlantoaxial stabilization forms a safe surgical strategy for all kinds of odontoid fractures. Additional characteristics of odontoid fractures further subclassified them and assisted in surgical decision-making and in formulating the surgical strategy.
Cervical spine injuries
2016, Orthopaedics and Trauma
Citation Excerpt :
Treatment options: traumatic atlanto-axial subluxation is rarely seen and its management mirrors much more common pathological atlanto-axial subluxation (in patients with rheumatoid arthritis, Down's syndrome etc.). Surgical management is favoured in patients with anterior or posterior subluxation,55 transverse ligament rupture57 (especially Dickman28 type I), odontoid fracture,56 neurological deficit, irreducibility and chronicity. The C1/C2 subluxation is reduced and arthodesis performed from either anterior or posterior approach.31
Amongst patients with cord injury following spinal fractures, the majority are due to cervical spine fractures. Knowledge of both immediate and definitive management of the cervical spine injuries is essential for emergency department doctors and spinal surgeons (orthopaedic and neurosurgery). This article focuses on the in-hospital management of these fractures. It discusses the presentation, evaluation, classification and management of common cervical spine fractures. Broadly speaking, the management of cervical spine injury is influenced by fracture displacement, associated disco-ligamentous injury and the neurological status of the patient. Undisplaced or minimally displaced fractures with no adverse features can be treated conservatively. For ligamentous injuries and significantly displaced fractures surgical management is favoured. This includes atlanto-occipital dislocation, C1 and C2 fractures with transverse atlantal ligament damage, displaced hangman's fracture with C2/3 disc injury and lower spine fractures with distraction or rotation injuries with accompanying disco-ligamentous damage.
Traumatic atlantoaxial rotatory fixation in adults: a systematic review of published cases
2024, Neurosurgical Review
Traumatic Posterior Atlantoaxial Dislocation With an Associated Fracture: A Systematic Review
2023, Clinical Spine Surgery

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Case ReportAtlantoaxial manual realignment in a patient with traumatic atlantoaxial joint disruption

Abstract

Introduction

Section snippets

Case report

Discussion

J Clin Neurosci

Plate and screw fixation for atlanto-axial dislocation (Technical report)

Acta Neurochir (Wien)

The surgical reduction of spondylolisthesis

Clin Orthop

Case Report
Atlantoaxial manual realignment in a patient with traumatic atlantoaxial joint disruption