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  • Applying the Law of Levers to Reduce Atlanto-Axial Dislocation and Basilar Invagination: The Technique of Distration, Compression, Extension and Reduction

    Final Number:
    387

    Authors:
    Sarat P Chandra MBBS, MCh; Nishant Goyal MBBS MCh; Ajay Garg; Manik Prabhu; Bhawani S. Sharma

    Study Design:
    Clinical Trial

    Subject Category:

    Meeting: Congress of Neurological Surgeons 2015 Annual Meeting

    Introduction: Recent strategies for treatment of BI (basilar invagination) and AAD (atlanto-axial dislocation) are based on simultaneous posterior reduction and fixation. A new innovative technique of Distraction, compression, extension and distraction is described with 2 modifications: Joint remodelling (JRM) and extra-articular distraction (EAD)

    Methods: Prospective study (May 2010-September 2014). Joint indices measured included (normal values): sagittal inclination, cranio-cervical tilt and coronal inclination. Surgical procedures included DCER alone (performed in SI <100 degrees, Group I) or JRM with DCER (in SI: 100-160 degrees, Group II) or EAD with DCER in severe BI with almost vertical joints (SI > 160 degrees, Group III). The technique was also applied for chronic displaced odontoid fractures (Group IV, n = 14)

    Results: N= 93 (mean 22.5 years). All conventional indices improved significantly in the congenital cases (n= 79, p<0.001). CCT improved in all (p<0.01); Group I (n=32): 54+8.7 degrees (pre-operative 80.71±12.72 degrees); Group II (n=40): 58+7.0 degrees (pre-operative 86.5+14 degrees); Group III (n=7): 62+10.0 degrees (pre-operative 104+11.2 degrees). SI improved in both Group I and II. Follow-up (n=64, 29+8 months, Nurick’s grade improved to 1.5+0.52 (pre-operative: 3.4+0.65; p<.0001). In patients with chronic displaced odontoid fractures (Group IV, n =14), all patients improved (mean Nurick's pre-operative: 4.07 +/- 0.8; post-operative score 1.3 +/- 0.4). Mean correction in effective canal diameter: 74.3 +/- 9.5 %; mean correction in actual canal diameter: 77 +/- 8.7%.

    Conclusions: DCER is effective technique in reducing both BI and AAD. JRM and EAD with DCER useful in moderate-severe BI and AAD (with SI>100 degrees).

    Patient Care: 1) Reduce operative time 2) Reduce morbidity 3) Reduce the total blood loss

    Learning Objectives: New technique to reduce BI and AAD from a posterior only techique

    References: Chandra PS. In reply. Neurosurgery. 2014;74(1):E148-50. 2. Chandra PS. In reply: distraction, compression, and extension reduction of basilar invagination and atlantoaxial dislocation. Neurosurgery. 2015;76(2):E240-2. 3. Chandra PS, Goyal N. In Reply: Facetal Orientation in Congenital Atlantoaxial Dislocation: There Are Angles and There Are "Angles". Neurosurgery. 2015. 4. Chandra PS, Goyal N. In reply: the severity of basilar invagination and atlantoaxial dislocation correlates with sagittal joint inclination, coronal joint inclination, and craniocervical tilt: a description of new indices for the craniovertebral junction. Neurosurgery. 2015;76(2):E235-9. 5. Chandra PS, Goyal N, Chauhan A, Ansari A, Sharma BS, Garg A. The severity of basilar invagination and atlantoaxial dislocation correlates with sagittal joint inclination, coronal joint inclination, and craniocervical tilt: a description of new indexes for the craniovertebral junction. Neurosurgery. 2014;10 Suppl 4:621-9; discussion 9-30. 6. Chandra PS, Kumar A, Chauhan A, Ansari A, Mishra NK, Sharma BS. Distraction, compression, and extension reduction of basilar invagination and atlantoaxial dislocation: a novel pilot technique. Neurosurgery. 2013;72(6):1040-53; discussion 53. 7. Chandra PS, Goyal N, Prabhu M, Garg A, Sharma BS. Distraction, Compression, Extension, Reduction (DCER) Combined With Joint Re-modeling And Extra-articular Distraction: Description Of 2 New Modifications For Its Application In Basilar Invagination And Atlanto-Axial Dislocation: Prospective Study In 79 Cases. Neurosurgery , 2015 (accepted for publication).

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