Antar Veysel, Turk Okan
Department of Neurosurgery, Istanbul Research and Training Hospital, Istanbul, Turkey.
J Korean Neurosurg Soc. 2018 Mar;61(2):277-281. doi: 10.3340/jkns.2017.0197. Epub 2018 Feb 28.
Craniovertebral junctional anomalies constitute a technical challenge. Surgical opening of atlantoaxial joint region is a complex procedure especially in patients with nuchal deformity like basilar invagination. This region has actually very complicated anatomical and functional characteristics, including multiple joints providing extension, flexion, and wide rotation. In fact, it is also a bottleneck region where bones, neural structures, and blood vessels are located. Stabilization surgery regarding this region should consider the fact that the area exposes excessive and life-long stress due to complex movements and human posture. Therefore, all options should be considered for surgical stabilization, and they could be interchanged during the surgery, if required.
A 53-year-old male patient applied to outpatients' clinic with complaints of head and neck pain persisting for a long time. Physical examination was normal except increased deep tendon reflexes. The patient was on long-term corticosteroid due to an allergic disease. Magnetic resonance imaging and computed tomography findings indicated basilar invagination and atlantoaxial dislocation. The patient underwent C0-C3-C4 (lateral mass) and additional C0-C2 (translaminar) stabilization surgery.
In routine practice, the sites where rods are bound to occipital plates were placed as paramedian. Instead, we inserted lateral mass screw to the sites where occipital screws were inserted on the occipital plate, thereby creating a site where extra rod could be bound. When C2 translaminar screw is inserted, screw caps remain on the median plane, which makes them difficult to bind to contralateral system. These bind directly to occipital plate without any connection from this region to the contralateral system. Advantages of this technique include easy insertion of C2 translaminar screws, presence of increased screw sizes, and exclusion of pullout forces onto the screw from neck movements. Another advantage of the technique is the median placement of the rod; i.e., thick part of the occipital bone is in alignment with axial loading.
We believe that this technique, which could be easily performed as adjuvant to classical stabilization surgery with no need for special screw and rod, may improve distraction force in patients with low bone density.
颅颈交界区畸形是一项技术挑战。寰枢关节区域的手术切开是一个复杂的过程，尤其是在患有诸如基底凹陷等颈部畸形的患者中。该区域实际上具有非常复杂的解剖和功能特征，包括多个提供伸展、屈曲和广泛旋转的关节。事实上，它也是一个骨骼、神经结构和血管所在的瓶颈区域。关于该区域的稳定手术应考虑到由于复杂运动和人体姿势，该区域承受过度且终身的应力这一事实。因此，应考虑所有手术稳定的选择，并且如果需要，它们可以在手术过程中相互替换。
一名53岁男性患者因长期头部和颈部疼痛前来门诊就诊。除了深腱反射增强外，体格检查正常。该患者因过敏性疾病长期服用皮质类固醇。磁共振成像和计算机断层扫描结果显示基底凹陷和寰枢椎脱位。该患者接受了C0-C3-C4（侧块）和额外的C0-C2（经椎板）稳定手术。
在常规操作中，杆与枕骨板连接的部位放置在旁正中。相反，我们在枕骨板上插入枕骨螺钉的部位插入侧块螺钉，从而创建了一个可以连接额外杆的部位。当插入C2经椎板螺钉时，螺钉帽留在正中平面，这使得它们难以与对侧系统连接。这些直接与枕骨板连接，而该区域与对侧系统没有任何连接。该技术的优点包括C2经椎板螺钉易于插入、螺钉尺寸增加以及排除颈部运动对螺钉的拔出力。该技术的另一个优点是杆的正中放置；即，枕骨的厚部与轴向负荷对齐。
我们认为，这种技术无需特殊的螺钉和杆，可轻松作为经典稳定手术的辅助操作来实施，可能会提高骨密度低的患者的牵张力。
