Introduction: Objectives: To give a stable joint at Cranio-vertebral junction in a child with Rotatory torticolis and AAD, owing to a unilateral vertical C1-C2 facet joint.The author intends to assert the importance of changing the plane of articulation in a congenitally defective C0-C1-C2 complex,to achieve stable Cranio-vertebral joint with fusion.
Methods: We used posterior only technique (Atul Goel), did a trans-articular fixation of vertically oriented C1-C2 joint on the affected side,and C1-C2 Screw rod fixation on other side. We drilled the under surface of the occiput partially and superior surface of the C2 Lamina with a tricorticate bone block in between the two raw surfaces to achieve fusion. We presume it's a good edition to the posterior only technique wherein we can provide a lasting results owing to additional fusion.
Results: We have followed the patient for more than a year and there is good evidence of fusion at occipito-cervical region. No evidence of failure of the instrumentation or fusion is noted.
Conclusions: In a vertically oriented Occipito-cervical joint, the constant torsional force across vertical joint, and the applied instrument can cause future instability, thus may result in failure of instrumentation. Additionally it will also lead a surgeon to take up to possible Odontoidectomy, as many of mu colleagues believe. Not only it adds up to the cost of treatment, but subjects a child to more morbid two stage surgery, which is not even needed !
We propose addition of fusion surface, or a 'creation' of a new joint as an 'off-loader' between C0 and C2(or C1), which can be done easily and may save a child from dreaded and quiet often unwarranted Trans-oral surgery and posterior fixation.However we need a larger cohort to prove our point of view.
Patient Care: When discussed with teachers at my parent institute at All India institute of medical sciences New Delhi,immediately post op., many objected to the procedure saying it will fail within a year because Trans oral odontoidectomy has not been done ! But now I have more than a year of follow up with this new concept. If people know we can do this surgery in single posterior approach, patients will have less morbid surgeries instead of TOO+PF procedure, which in my view is entirely unnecessary anyways.
Learning Objectives: Many colleagues believe that such instrumentation across vertical joints fails eventually in a Paediatric patient with a torsional force at Occipito-Cervical region, soft bones and lack of fusion. Hence they must undergo Trans-oral Odontoidectomy and posterior fusion procedure.This procedure seems to break that thinking and gives a new insight to already well known entity. It treats the disease with only single stage surgery and achieves fusion reliably to give a stable Occipito-cervical joint.