Treatment of irreducible atlantoaxial dislocation using one-stage retropharyngeal release and posterior reduction

Ren, Xianfeng; Gao, Feng; Liu, Siyuan; Yang, Jing; Xi, Yongming

doi:10.1177/2309499019870465

Cited by 11 publications

(13 citation statements)

References 19 publications

(38 reference statements)

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“…However, the transoral approach has a high risk of infection [15,21]. The anterior submandibular retropharyngeal approach is entirely extraoral and extramucosal, which reduces the rate of infection, while it may be difficult for patients with a big body habitus and short neck [20]. In our present study, the anterior release and posterior reduction and internal fixation were performed in 5 AAS patients without good reduction.…”

Section: Discussionmentioning

confidence: 80%

“…For AAS without good reduction with the utility of skull traction under general anesthesia, sufficient release of the dislocated atlantoaxial joint is of key importance for successful treatment. In order to achieve good reduction, various methods had been used for IAAD patients, including transoral odontoidectomy and posterior fixation [15], transoral atlantoaxial reduction plate internal fixation [16,17], transoral atlantoaxial release and posterior internal fixation [18,19], and anterior submandibular retropharyngeal approach and posterior internal fixation [20]. All these procedures had advantages and disadvantages.…”

Section: Discussionmentioning

confidence: 99%

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Surgical treatment of atlantoaxial subluxation by intraoperative skull traction and C1-C2 fixation

Guo

et al. 2020

BMC Musculoskelet Disord

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Background: Atlantoaxial subluxation (AAS) is a not rare abnormality between the atlas (C1) and axis (C2). For AAS patients with persistent neck pain and neurologic symptoms, surgical intervention is a good choice. Nevertheless, there were still few reports about the use of intraoperative skull traction and different fixation methods in treatment of AAS. Methods: From January 2012 to December 2018, a total of 86 cases were admitted to our hospital and diagnosed as AAS. All the patients received atlantoaxial reduction with the help of intraoperative skull traction and C1-C2 fixation. Clinical and radiological parameters were collected through chart review. Results: There were 86 cases included in this study. The mean operative time was 153.9 ± 73.9 min, and the mean amount of intraoperative blood loss was 219.1 ± 195.6 ml. 81 patients underwent posterior reduction, internal fixation and fusion. 5 patients underwent anterior release, followed by posterior internal fixation and fusion. 82 patients got satisfactory postoperative outcomes while complications occurred in 4 patients. Significant neurologic improvement was observed in these patients. Bone fusion was achieved on the midline sagittal reconstructed CT images at the latest follow-up in all these patients except 1 case. All the patients were followed up for 34.84 ± 15.86 months at average (range 12-60 months). The mean ADI value was 7.55 ± 1.67 mm at average preoperatively, and improved to 4.03 ± 1.21 mm postoperatively, and to 4.21 ± 0.99 mm at the latest follow-up. The mean A-A angle was 15.48 ± 9.82 degrees at average preoperatively, and improved to 21.61 ± 10.43 degrees postoperatively, and to 19.73 ± 8.13 degrees at the latest follow-up. The mean A-A height was 35.61 ± 7.66 mm at average preoperatively, and improved to 40.08 ± 8.5 mm postoperatively, and to 38.83 ± 6.97 mm at the latest follow-up. There were complications in 4 patients, including pedicle misplacement, pedicle screw fracture, infection and one death. Conclusion: Intraoperative skull traction can effectively facilitate the surgical procedures for ASS caused by different etiologies. Further research will be needed to investigate the safety and effectiveness of this method in the future.

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Section: Discussionmentioning

confidence: 80%

Section: Discussionmentioning

confidence: 99%

Surgical treatment of atlantoaxial subluxation by intraoperative skull traction and C1-C2 fixation

Guo

et al. 2020

BMC Musculoskelet Disord

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“…Operative release and the pedicle screw technique have been able to achieve reduction in the dislocated atlantoaxial joint when traction reduction has been unsuccessful. [13][14][15] Therefore, considering operative release, the technique of three-dimensional CT and traumatic factors, we should distinguish atlantoaxial dislocations that can be reduced surgically from the others. In the present study, our TOI classification system is able to do that.…”

Section: Discussionmentioning

confidence: 99%

New Classification and Its Value Evaluation for Atlantoaxial Dislocation

Tan

Long

et al. 2020

Orthopaedic Surgery

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Objective To introduce the TOI classification system (the Traction reduction type [T type], Operation reduction type [O type], and Irreducible type [I type] classification system) and to determine the interobserver and intraobserver reliability of the TOI classification system. Methods Based on the characteristics of atlantoaxial dislocation (AAD), AAD was divided into Traction reduction type (T type), Operation reduction type (O type), and Irreducible type (I type). The analysis of interobserver and intraobserver agreements was done using kappa statistics. From July 2016 to January 2019, 213 AAD patients were retrospectively studied at four hospitals. Plain radiographs including extension and flexion views and three‐dimensional CT images were obtained. Twenty independent observers, including eight experienced spine specialists and 12 orthopaedic fellows from four different residency training hospitals, completed the survey. Results The classification of the TOI system was based on etiology, the course of the disease, flexion–extension X‐rays, three‐dimensional CT reconstruction, and curative effects of skull traction. Flexion–extension X‐rays demonstrating a successful reduction of the dislocated atlantoaxial joint and three‐dimensional CT images showing osseous fusion of atlantoaxial facet joints and cervical traction reveal characteristics of T‐type. Furthermore, this type can be divided into two subtypes, T1 and T2, according to the etiology and course of the disease. Unsatisfactorily reduction after 1–2 weeks of strict cervical traction, no reduction shown on flexion–extension X‐rays, and no destruction or boneless fusion of atlantoaxial facet joints demonstrated in three‐dimensional CT images are characteristics of type O. Atlantoaxial facet joint showing bone fusion or failure of reduction after cervical traction or three‐dimensional CT images showing failure of surgical release are characteristics of type I. Interobserver and intraobserver reliability of the TOI classification system were moderate (κ = 0.543) and substantial (κ = 0.658), respectively. Interobserver and intraobserver reliability of the treatment choice were moderate (κ = 0.568) and substantial (κ = 0.675), respectively. There were no significant differences in the interobserver and intraobserver reliability between experienced spine specialists and fellows for all κ‐values (P > 0.05). Conclusions The TOI classification system had satisfactory reliability and, therefore, can be applied clinically and used by less experienced surgeons. We believe TOI can help surgeons choose appropriate treatment strategies.

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“…Wang et al [17] demonstrated that the one-stage anterior transoral release and posterior internal xation were safe and reliable for treating IAAD. Ren et al [18] demonstrated the e cacy of anterior submandibular retropharyngeal release and posterior reduction and xation as the optimal treatment for patients with IAAD. In their study, all patients achieved satisfactory clinical outcomes without apparent complications including, pharyngeal or chest infection, deep vein thrombosis, or dyspnea postoperatively.…”

Section: Discussionmentioning

confidence: 99%

“…In their study, they determined that the majority of IAAD cases could become reducible after anterior release without odontoid resection. Thus, the clinical outcome of traditional treatments for IAAD was relatively satisfactory [18][19][20].…”

Section: Discussionmentioning

confidence: 99%

Retropharyngeal Reduction Plate for Treatment of Irreducible Atlantoaxial Dislocation: A Cadaveric Test and Finite Element Analysis

Zhao

et al. 2020

Preprint

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Background: Clinical studies have shown that irreducible atlantoaxial dislocation (IAAD) can achieve reduction, decompression, fixation and fusion by transoral, posterior, and other traditional approaches. The present study aims to introduced a newly designed reduction plate through the retropharyngeal approach and evaluate its feasibility by cadaveric test and finite element analysis.Methods: A cadaveric specimen and a 45-year-old postoperative female patient diagnosed with IAAD who underwent the traditional posterior fixation were enrolled in this scientific study. The retropharyngeal approach involved placing the reduction plate into a cadaveric specimen’s cervical spine. Spiral CT thinly scanning (0.05 mm) from the base of the occipital bone to C7 vertebrae was performed and reconstructed for three-dimensional (3D) finite element analysis using Mimics software based on the Dicom data of two different fixations. Biomechanical distribution was compared between two fixations under different stress conditions, including flexion, extension, bending and rotation, respectively.Results: There was no significant difference in maximum stress between the retropharyngeal reduction plate system and the posterior atlantoaxial pedicle screw fixation system during flexion. Under states of extension, bending and rotation, the maximum stress of the reduction plate system was significantly lower than that of the posterior atlantoaxial pedicle screw fixation system. Both of the maximum stresses between two fixations were far lower than the maximum yield strength (795-827 MPa) and ultimate strength (860-896 MPa) of the titanium alloys. There was no significantly stress concentration between retropharyngeal reduction plate system and the posterior atlantoaxial pedicle screw fixation system under different movement.Conclusions: The cadaveric test showed that it is feasible to place the reduction plate using the retropharyngeal approach. The finite element analysis indicated that the retropharyngeal reduction plate system may provide relatively reliable fixation compared with traditional posterior fixation. A new choice of designing a surgical plan for treating atlantoaxial dislocation is presented.

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Treatment of irreducible atlantoaxial dislocation using one-stage retropharyngeal release and posterior reduction

Cited by 11 publications

References 19 publications

Surgical treatment of atlantoaxial subluxation by intraoperative skull traction and C1-C2 fixation

Surgical treatment of atlantoaxial subluxation by intraoperative skull traction and C1-C2 fixation

New Classification and Its Value Evaluation for Atlantoaxial Dislocation

Retropharyngeal Reduction Plate for Treatment of Irreducible Atlantoaxial Dislocation: A Cadaveric Test and Finite Element Analysis

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