Craniovertebral Junction Instability: Negotiating the Learning Curve
Background: The management of craniovertebral junction instability was initially associated with a high morbidity and mortality rate. Because of the inherent mobility of the craniovertebral junction, achieving rigid fixation was difficult, leading to a high rate of implant failure. Also, achieving r...
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| Main Authors: | , |
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| Format: | Article |
| Language: | English |
| Published: |
Wolters Kluwer Medknow Publications
2025-01-01
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| Series: | Indian Spine Journal |
| Subjects: | |
| Online Access: | https://doi.org/10.4103/isj.isj_76_23 |
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| Summary: | Background: The management of craniovertebral junction instability was initially associated with a high morbidity and mortality rate. Because of the inherent mobility of the craniovertebral junction, achieving rigid fixation was difficult, leading to a high rate of implant failure. Also, achieving reduction of the odontoid to relieve neurologic compression was not possible in many cases, necessitating a second surgery in the form of trans-oral odontoid resection, which is a morbid procedure requiring tracheostomy and nasogastric tube feeding for a long time. The technique of C1 lateral mass to C2 fixation, revolutionized the treatment of craniovertebral junction disorders. This technique provides a very stable and rigid fixation and allows manipulation of the lateral atlanto-axial joint to achieve reduction. This technique and its subsequent modifications have resulted in a higher rate of fusion and has reduced the need for a trans-oral odontoid resection. However, this procedure is technically demanding, with a steep learning curve. Materials and Methods: We retrospectively review the results of 131 cases of craniovertebral junction instability operated over the last 8 years. We discuss in detail the technique and nuances of this procedure, and the difficulties faced and the lessons learned during the learning curve. The records of 131 operated patients were reviewed. The preoperative neurologic status, radiologic findings, the surgical technique, the need for second stage trans-oral odontoid resection, neurologic outcome, and complications were reviewed. Those patients in which C1 screws could not be inserted because of inadequate size of lateral mass underwent Occiput-C2 fixation. Results: Of the 131 operated patients, 112 patients improved or had stabilization of the neurologic status after occiput/Cl lateral mass-C2 fixation. Eighteen patients required trans-oral odontoid resection during the same admission because of inadequate reduction and persistent neurologic compromise. Mortality was noted in eight patients. No patient till date has developed implant failure or recurrence of symptoms. Conclusion: Craniovertebral junction instability is best treated by C1 lateral mass to C2 fixation and its various modifications. It provides a rigid fixation and a high rate of fusion, with a very low complication rate once the learning curve is overcome. |
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| ISSN: | 2589-5079 2589-5087 |