Revisiting the differences between irreducible and reducible atlantoaxial dislocation in the era of direct posterior approach and C1-2 joint manipulation.

Abstract

OBJECTIVE The current management of atlantoaxial dislocation (AAD) focuses on the C1-2 joints, commonly approached through a posterior route. The distinction between reducible AAD (RAAD) and irreducible AAD (IrAAD) seems to be less important in modern times. The roles of preoperative traction and dynamic radiographs are questionable. This study evaluated whether differentiating between the 2 groups is important in today's era. METHODS Ninety-six consecutive patients with congenital AAD (33 RAAD and 63 IrAAD), who underwent surgery through a posterior approach alone, were studied. The preoperative and follow-up clinical statuses for both groups were studied and compared using Japanese Orthopaedic Association (JOA) scores. The radiological findings of the 2 groups were compared, and the intraoperative challenges described. RESULTS A poor preoperative JOA score (clinical status) was seen in one-fifth of patients with IrAAD, although the mean JOA score was nearly similar in the RAAD and IrAAD groups. There was significant improvement in follow-up JOA score in both groups. However, segmentation defects (such as an assimilated arch of the atlas and C2-3 fusion) and anomalous vertebral arteries were found significantly more often in cases of IrAAD compared with those of RAAD. Os odontoideum was commonly seen in the RAAD group. The C1-2 joints were acute in IrAAD compared with RAAD. Preoperative traction in IrAAD resulted in vertical distraction and improvement in clinical and respiratory status. Surgery for IrAAD required much more drilling and manipulation of the C1-2 joints while safeguarding the anomalous vertebral artery. CONCLUSIONS Bony and vascular anomalies were much more common in patients with IrAAD, which made surgery more challenging than it was in RAAD despite similar approaches. An irreducible dislocation seen on preoperative radiographs made surgeons aware of difficulties that were likely to be encountered and helped them to better plan the surgery. Distraction achieved through preoperative traction reaffirmed the feasibility of intraoperative reduction. This made the differentiation between the 2 groups and the use of preoperative traction equally important.