Transoral release to realign postoperative loss of reduction following occipitocervical fixation for congenital basilar invagination

Abstract

Purpose

Revision surgery in an irreducible atlantoaxial dislocation (IAAD) previously operated with a posterior approach is challenging. Multiple modalities using anterior, posterior, and dual approaches have been described. We report a so far unreported technique of revision surgery by posterior implant removal and decompression with anterior transoral release followed by posterior instrumentation.

Methods

14-year male with basilar invagination (BI) with IAAD, previously operated with posterior decompression and instrumented occipitocervical fusion presented three months later with post-traumatic recurrence of myelopathy with quadriparesis with Di Lorenzo grade 4 and loss of reduction. He was operated with a posterior implant and early fusion mass removal with extended foramen magnum decompression (FMD), followed by anterior transoral release with a satisfactory reduction on traction, and finally, a posterior revision instrumented occipitocervical fusion.

Results

At 2-year follow-up, the patient was symptom-free with Di Lorenzo grade 1 and cervicomedullary angle improvement from 97.4° to 141.2°; achieving bony fusion.

Conclusion

Single-stage posterior-anterior transoral-posterior approach can be used to achieve satisfactory reduction for a revision BI with IAAD with prior posterior instrumentation.

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Acknowledgements

Dr Milind Bhise, Department of Anaesthesiology and Dr Kiran Sathe, Department of Pediatrics, Sir H.N. Reliance Foundation Hospital, Mumbai.

Funding

There was no financial support or sources of funding for this study.

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Contributions

AA: Substantial contributions to the conception and design of the work; the acquisition, analysis, and interpretation of data for the work, drafting the work and revising it critically for important intellectual content, final approval of the version to be published, contributed effort to the study. KC: Substantial contributions to the conception and design of the work; the acquisition, analysis, and interpretation of data for the work, drafting the work and revising it critically for important intellectual content, final approval of the version to be published, contributed effort to the study. AD: Substantial contributions to the conception and design of the work; the acquisition, analysis, and interpretation of data for the work, drafting the work and revising it critically for important intellectual content, final approval of the version to be published, contributed effort to the study. VK: Substantial contributions to the conception and design of the work; drafting the work and revising it critically for important intellectual content, final approval of the version to be published, contributed effort to the study. BH: Substantial contributions to the conception and design of the work; drafting the work and revising it critically for important intellectual content, final approval of the version to be published, contributed effort to the study.

Corresponding author

Correspondence to Arjun Dhawale.

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Ethics approval was waived by the Institutional Research Ethics Committee of Sir H.N. Reliance Hospital in view of the retrospective nature of the study and all the procedures being performed were part of the routine care.

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Written informed consent was obtained from the patient.

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Video depicting surgical steps during anterior transoral release

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Achalare, A., Chaudhary, K., Dhawale, A. et al. Transoral release to realign postoperative loss of reduction following occipitocervical fixation for congenital basilar invagination. Spine Deform (2021). https://doi.org/10.1007/s43390-021-00303-9

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Keywords

  • Irreducible
  • Atlantoaxial
  • Dislocation
  • Instability
  • IAAD
  • Revision