Is Transoral Surgery Still a Relevant Procedure in Atlantoaxial Instability?

RAMACHANDRAN GOVINDASAMY; VEERAMANI PREETHISH-KUMAR; SWAROOP GOPAL; SATISH RUDRAPPA

doi:10.14444/7096

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Figure 1
(A–G) Scenario 1: (A) X-ray of 67-year-old woman with occipito-cervical wiring and bone grafting done outside. (B–D) Preoperative computed tomography of the spine shows well-fused C1-C2 (arrows), making a posterior approach practically impossible. Atlantoaxial dislocation with narrowing of the spinal canal is also observed. (E) T2 MRI sagittal section of cervical spine with high cervical cord compression, myelomalacia, and signal changes. (F) Preoperative image showing decompressed spinal cord after excising odontoid and C1 arch by the transoral approach. (G) Postoperative x-ray shows removal of wires with absent resected odontoid.
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Figure 2
(A–E) Scenario 3: (A, B) Flexion and extension x-ray revealing unstable atlantoaxial dislocation secondary to os odontoideum (C) Preoperative computed tomography of the spine shows dystopic os odontoideum ossicle lying between C1 arch and C2 vertebra, making the joint irreducible (arrows). (D) T2 MRI sagittal section of cervical spine with high cervical cord compression. (E) Postoperative x-ray shows occipito-cervical fusion with wires and iliac bone grafting.
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Figure 3
(A–F) Scenario 4: (A, B) Preoperative computed tomography of the spine (sagittal and coronal) demonstrates normal joint C1-C2 joint space, but the odontoid process is hitching against C1, making it irreducible (arrow). (C) T2 MRI of the sagittal section of cervical spine shows a fractured odontoid with mild hemorrhage (arrow) and normal cerebrospinal fluid space and cord. (D, E) eIntra-operative images demonstrating double incision; transoral approach for reduction of the fragment and transcervical approach through C5-C6 for the screw placement. (F) Follow-up computed tomography scan shows well-reduced and united odontoid with screw in situ (arrow).
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Figure 4
(A–D) Scenario 5: (A, B) Flexion and extension x-ray showing unstable atlantoaxial dislocation. (C) Preoperative computed tomography of the spine shows vertical alignment of C1-C2 joint space (arrows), assimilated C1, and basilar invagination of the bone. (D) T2 MRI of the sagittal section of cervical spine pinching the brain stem and high cervical cord (arrow).