Distraction, Compression, Extension, and Reduction Combined With Joint Remodeling and Extra-articular Distraction: Description of 2 New Modifications for Its Application in Basilar Invagination and Atlantoaxial Dislocation: Prospective Study in 79 Cases.

Abstract

Recent strategies for treatment of basilar invagination (BI) and atlantoaxial dislocation (AAD) are based on simultaneous posterior reduction and fixation. To describe new modifications of the procedure distraction, compression, extension, and reduction (DCER), ie, joint remodeling (JRM) and extra-articular distraction (EAD) in patients with "vertical" joints, and to quantify the improvement in joint indices, ie, sagittal inclination (SI), craniocervical tilt (CCT), and coronal inclination. Prospective study (May 2010 to September 2014). Joint indices measured included (normal values): SI (87.15 ± 5.65°), CCT (60.2 ± 9.2°), and coronal inclination (110.3 ± 4.23°). Surgical procedures included DCER alone (performed in SI <100°, group I) or JRM with DCER (in SI: 100-160°, group II), or EAD with DCER in severe BI with almost vertical joints (SI >160°, group III). Seventy-nine patients were selected (mean, 22.5 years of age). All conventional indices improved significantly (P < .001). CCT improved in all groups (P < .01); group I (n = 32): 54 ± 8.7° (preoperative 80.71 ± 12.72°); group II (n = 40): 58 ± 7.0° (preoperative 86.5 ± 14°); group III (n = 7): 62 ± 10.0° (preoperative 104 ± 11.2°). SI improved in both group I and II, P < .01 (cannot be measured in group III). At long-term follow-up (n = 64, 29 ± 8 months, range 12-39 months), the Nurick grade improved to 1.5 ± 0.52 (preoperative: 3.4 ± 0.65; P < .001). DCER seems to be an effective technique in reducing both BI and AAD. JRM and EAD with DCER are useful in moderate to severe BI and AAD (with SI >100°). Joint indices provide useful information for surgical strategy and planning.