Atul Goel

Atlantoaxial joint distraction for treatment of basilar invagination secondary to rheumatoid arthritis.

We present our experience of treating two cases of rheumatoid arthritis involving the craniovertebral junction and having marked basilar invagination by an alternative treatment method. In both the cases, the facets were osteoporotic and were not suitable for screw implantation. The patients were 66 and 72 years of age and both patients were females. Both the patients presented with complaints of progressively increasing spastic quadriparesis. Surgery involved attempts to reduce the basilar invagination and restore the height of the collapsed lateral mass by manual distraction of the facets of the atlas and axis and forced impaction of titanium spacers in the joint in addition to bone graft harvested from the iliac crest. The procedure also provided stabilization of the region. No other fixation procedure involving wires, screws, plate and rods was carried out simultaneously. Following surgery both the patients showed symptomatic improvement and partial restoration of craniovertebral alignments. Follow-up is of 2 and 24 months. Distraction of the facets of atlas and axis and impaction of metal implant and bone graft in the facet joint can assist in reduction of basilar invagination and fixation of the region in selected cases of rheumatoid arthritis involving the craniovertebral junction.

Is Only Stabilization the Ideal Treatment for Ossified Posterior Longitudinal Ligament? Report of Early Results with a Preliminary Experience in 14 Patients

BACKGROUND AND OBJECTIVEnSurgical treatment of ossified posterior longitudinal ligament (OPLL) continues to be wrought with confusion, debate, and arguments. We report our experience with an alternative form of treatment that involves only fixation of the involved spinal segments. We report and put on record our remarkably gratifying clinical experience in 13 of 14 patients having OPLL after surgery that involved only facetal fixation and aimed at arthrodesis of involved spinal segments. No direct bone, ligament, or disc resection was done for decompression of the spinal dural tube or root canal. The OPLL was not directly handled during the surgical procedure. The rationale of the proposed treatment is discussed.nnnMETHODSnDuring the period June 2012 to August 2014, 14 patients having OPLL were treated by facetal transarticular screw fixation technique. The Japanese Orthopaedic Association score, visual analogue scale, and Odoms criteria were used as indices to monitor the clinical status.nnnRESULTSnThe procedure resulted in firm stabilization and fixation of the spinal segments and provided a ground for arthrodesis. During an average follow-up period of 17 months, there was immediate postoperative and progressive recovery in symptoms in 13 patients. There were no surgery or implant-related mechanical or infective complications.nnnCONCLUSIONSnInstability could be the defining phenomenon in pathogenesis of clinical symptoms related to OPLL. The clinical outcome in our patients suggests that only fixation of the spinal segments can be a simple, safe, and rationale form of treatment for the complex pathology of OPLL.

Atlantoaxial Fixation for Basilar Invagination without Obvious Atlantoaxial Instability (Group B Basilar Invagination): Outcome Analysis of 63 Surgically Treated Cases

BACKGROUNDnWe discuss the rationale of surgical treatment of group B basilar invagination by atlantoaxial facet joint stabilization and segmental arthrodesis.nnnMETHODSnFrom January 2010 to April 2016, 63 patients with group B basilar invagination were surgically treated. All patients had varying degree of myelopathy-related functional disability. Fifty-two patients had both Chiari malformation and syringomyelia. All patients were treated by atlantoaxial plate and screw fixation with the techniques described by us in 1994 and 2004. Foramen magnum decompression or syrinx manipulation was not carried out in any patient. Occipital bone and subaxial spinal elements were not included in the fixation construct.nnnRESULTSnThree patients died in the immediate postoperative phase. In the remaining patients, there was clinical improvement and no patients neurologic function worsened after surgery. In 12 of 38 patients in whom postoperative magnetic resonance imaging was possible, at a follow-up of at least 3 months, there was reduction in the size of the syrinx.nnnCONCLUSIONSnThe pathogenesis of basilar invagination in group B is related to atlantoaxial instability. The clinical outcome suggests that the surgical treatment in these cases should be directed toward atlantoaxial stabilization and aimed at segmental arthrodesis. Inclusion of the occipital bone in the fixation construct is not necessary. Foramen magnum decompression and procedures involving manipulation of Chiari malformation and syringomyelia are not necessary.

Pathological crying as a manifestation of spontaneous haemorrhage in a pontine cavernous haemangioma.

A 53-year-old man presented with a sudden onset severe headache associated with ataxia. His family observed labile emotions and frequent episodes of crying. Investigations revealed a pontine cavernoma with evidence of bleeding. The lesion was treated conservatively. Over approximately 6 months, the patients ataxia improved and he recovered from the crying episodes. To our knowledge, pathological crying has not been previously associated with brainstem cavernoma.

Radiological Evaluation of 510 Cases of Basilar Invagination with Evidence of Atlantoaxial Instability (Group A Basilar Invagination)

OBJECTIVEnTo evaluate the musculoskeletal and soft tissue neural alterations in cases with group A basilar invagination.nnnMETHODSnBetween January 2007 and August 2016, 510 patients with group A basilar invagination were surgically treated. The radiologic images of these patients were reviewed retrospectively. The patients were divided into 4 groups: group A1, comprising 60 patients with syringomyelia; group A2, comprising 354 patients with external syrinx, marked by excessive cerebrospinal fluid (CSF) in the extramedullary space; group A3, comprising 51 patients with both syringomyelia and external syrinx; and group A4, comprising 45 patients with no abnormality of CSF cavitation in the spinal canal.nnnRESULTSnA number of musculoskeletal and neural parameters, including the extent of basilar invagination, degree of angulation of the odontoid process, and facet malalignment, were evaluated in each of the 4 groups. The degree of basilar invagination was 6-27.4 mm (average, 15.85 mm) in group A1, 4.3-24.5 mm (average, 12.56 mm) in group A2, 5.6-17.6 mm (average 10.8 mm) inxa0group A3, and 5.2-17.3 mm (average, 11.74 mm) in groupxa0A4. The angle of inclination of the odontoid process wasxa061.1-90.7 degrees (average, 71.4 degrees) in group A1,xa030.5-79.8 degrees (average, 60.05 degrees) in groupxa0A2, 68.5-78.3 degrees (average, 73.4 degrees) in groupxa0A3,xa0and 62.2-87.4 degrees (average, 71.2 degrees) in group A4.nnnCONCLUSIONSnThe nature of bone malformations directly influences the presence or absence of external syrinx and syringomyelia.

Extraspinal-Interdural Surgical Approach for C2 Neurinomas—Report of an Experience with 50 Cases

OBJECTIVEnWe report our experience with surgery in 50 patients with C2 neurinomas. The anatomic subtleties of these discrete forms of tumors and their surgical implications are analyzed.nnnMETHODSnDuring the period 2006-2016, we operated on 50 patients with 55 C2 neurinomas. Type A tumors were located within the spinal canal, type B tumors were located in the lateral gutter, and type C tumors had a paraspinal extension. By working within the dural confines of the tumor and appropriately angulating the microscope, the entire tumor bulk extending into 1 or all 3 compartments was resected. Follow-up duration ranged from 3 months to 10 years (mean 68 months).nnnRESULTSnThis series included 36 male and 14 female patients. Age range of patients was 14-70 years (mean age 36 years). Progressive symptoms of myelopathy were present in 41 patients. There were 16 type Axa0+ B tumors, 27 type B tumors, 10 type Bxa0+ C tumors, and 2 type Axa0+ Bxa0+ C tumors. All patients experienced symptom improvement after surgery and were able to resume their normal lifestyle.nnnCONCLUSIONSnC2 neurinomas arise in the region of the C2 ganglion, and despite the fact that some achieve a large size, they remain confined within the dura. Radical tumor resection can be achieved by working within the layers of the dural cover. Bone removal and opening of spinal dura for tumor exposure and resection can be avoided.

Atlantoaxial Fixation for Odontoid Fracture: Analysis of 124 Surgically Treated Cases

OBJECTIVEnThe authors analyze 124 cases with fracture of odontoid process. All patients were surgically treated by posterior atlantoaxial fixation.nnnMETHODSnThere were 96 male and 28 female patients. The ages of the patients ranged from 12 to 80 years. Apart from Anderson and DAlonzo type I (6 cases), type II (93 cases) and type III (25 cases), three sub-types of odontoid fractures were included in the classification. In type A (118 cases), there was vertical compression fracture that resulted in malalignment of the fractured odontoid process segments. Type B (49 cases) resulted when the fracture resulted in malalignment of the facets of atlas and axis. Type C (25 cases) included cases in which the fracture line involved the facet of axis. Fractures were divided into acute type when the injury was less than 3 months old (50 cases), delayed type when the injury was between 3 months to one year (34 cases) and chronic type when the injury was more than 1 year in duration (40 cases). All patients were treated with posterior atlantoaxial fixation with the techniques described in 1994 and 2004. Follow-up period ranged from 6 to 156 months (average 72 months).nnnRESULTSnAll patients improved in symptoms after surgery. There were no significant postoperative complications.nnnCONCLUSIONSnPosterior atlantoaxial stabilization forms a safe surgical strategy for all kinds of odontoid fractures. Additional characteristics of odontoid fractures further subclassified them and assisted in surgical decision-making and in formulating the surgical strategy.

Role of atlantoaxial and subaxial spinal instability in pathogenesis of spinal ‘degeneration’ related cervical kyphosis

BACKGROUNDSnThe role of subaxial and atlantoaxial instability in the pathogenesis of degeneration-related cervical kyphosis is evaluated.nnnMATERIAL AND METHODSnDuring the period 2013-2016, the authors treated 21 patients having cervical kyphosis that was related to degenerative spinal disease. The patients presented with symptoms related to cervical myelopathy. Kyphosis was diagnosed on the basis of described radiologic parameters. The patients were divided into 3 groups. Group A (10 patients) had manifest radiologic evidence of atlantoaxial dislocation, type 1 facetal instability, abnormal increase in atlantodental interval, and evidence of cord compression by the odontoid process. Group B (5 patients) had axial or central atlantoaxial facetal instability (type 2 or 3 atlantoaxial facetal instability) and subaxial spinal instability. Group C (6 patients) had subaxial spinal instability. The patients were treated by only stabilization. Group A patients underwent atlantoaxial fixation, group B patients underwent atlantoaxial and subaxial fixation, and group C patients underwent only subaxial spinal fixation. The operation was aimed at arthrodesis of the spinal segments. No bone or soft tissue decompression was done.nnnRESULTSnDuring the minimum follow-up period of 6 months, all patients improved in their neurologic symptoms and demonstrated evidence of spinal arthrodesis. There were no major surgical complications.nnnCONCLUSIONSnSpinal instability plays a major role in the generation of cervical spinal kyphosis. Atlantoaxial instability may form the primary and nodal site of development of the process of spinal degeneration in general and kyphosis in particular.

Voice quality affection as a symptom of Chiari formation

OBJECTIVEnVoice alteration as a presenting symptom in cases with Chiari formation is analyzed, as well as outcome after atlantoaxial fixation.nnnMETHODSnDuring the period January 2016 to June 2017, 25 cases of Chiari formation presented with associated or a major presenting symptom of voice or speech quality alteration related to inadequate breathing efforts. All patients underwent atlantoaxial fixation. No foramen magnum decompression was done.nnnRESULTSnIn all patients, the voice quality and volume and breathing disturbances improved in the immediate postoperative period after recovering from anesthesia. During the period of follow-up that ranged from 12 to 25 months, all patients continued to improve in their speech function.nnnCONCLUSIONSnSuch critical symptoms of voice disturbance and inadequate breathing and the possibility of rapid postoperative recovery have not been recorded earlier in the literature.

C1-2 and C2-3 Instability in the Presence of Hypoplastic Posterior Elements of C2 Vertebra: Report of 2 Cases

BACKGROUNDnWe present 2 cases involving a previously unreported clinical situation in which basilar invagination, atlantoaxial instability, and C2-3 instability were associated with a bifid posterior arch of the axis bone.nnnCASE DESCRIPTIONSnTwo young males presented with limb weakness, spasticity, and paresthesias. Both patients had altered voice quality, with reduced and thin volume, and difficulty sleeping supine. Radiologic imaging showed an absence of the posterior elements of the C2 vertebrae. The C3 spinous process mimicked the C2 spinous process in shape and size. C1-2 and C2-3 posterior fixations were performed.nnnCONCLUSIONSnC1-2 and C2-3 fixation resulted in firm fixation of the region and a remarkable clinical recovery. The most significant features were an immediate postoperative improvement in voice quality and the ability to sleep comfortably in the supine position.