Anterior Atlantoaxial Fixation Research Articles

A novel 3D-printed locking cage for anterior atlantoaxial fixation and fusion: case report and in vitro biomechanical evaluation

BackgroundTreatment of atlantoaxial dislocation is aimed at reduction and stabilization of the atlantoaxial joint. 3D printing refers to a process where additive manufacturing is achieved under precise computer control. Literature on its utilization in anterior atlantoaxial fixation and fusion is rare. This study is the first report on a 3D-printed locking cage used in the anterior procedure for atlantoaxial dislocation.MethodsA middle-aged male in his 40s presented with weakness and numbness of his extremities for 3 years and could only walk slowly with assistance. Imaging studies revealed severe anterior migration of C1, irreducible atlantoaxial dislocation, and severe cervical-medullary compression. A preoperative plan consisting of trans-oral soft tissue release and fixation using tailor-designed 3D-printed cages was devised. Following fluoroscopic confirmation of reduction of the atlantoaxial joints, two customized 3D-printed cages made of titanium alloy were inserted into the bilateral facet joints, which were then locked by six screws into the lateral masses of C1 and C2. The microstructure of the inserted cages was optimized for improved biomechanical stability and enhanced osseo-integration, without the need for bone grafting. In addition, a biomechanical test was performed on seven human cadaveric specimens comparing the novel implant with the conventional C1 lateral mass-C2 pedicle screw construct in three modes of motion (flexion-extension, lateral bending, axial rotation).ResultsImprovement of neurologic function in the patient was evident immediately after surgery. He was able to walk independently 1 month post-operatively. At the 12-month follow-up, coronal reconstruction of CT demonstrated properly-positioned 3D-printed cages, evidence of osseo-integration at the bone-implant interface, and no subsidence or displacement of the implant. Eighteen months out of surgery, the mJOA score improved to 15, and lateral X-ray confirmed reduction of atlanto-axial dislocation. Additionally, the new construct provided strong fixation comparable to that conferred by conventional constructs as there was no significant difference observed between the two groups in all three directions of motion.ConclusionsThe novel implant represents a new option in the treatment of irreducible atlantoaxial dislocation. It can provide strong anterior support for solid fixation and fusion with a low profile and a microstructure that obviates the need for bone grafting.

Anterior Retropharyngeal Cage Distraction and Fixation for Basilar Invagination: "The Wedge Technique".

ObjectiveSurgery is indicated for basilar invagination (BI) in symptomatic patients. In many patients, symptoms and signs occur due to an upward-migrated and malaligned odontoid with fixed or mobile atlantoaxial instability. Posterior distraction and fixation of the atlantoaxial joints has evolved to become the standard of care, but has some inherent morbidity. In this study, we propose that the unilateral anterior submandibular retropharyngeal approach with customized wedge-shaped titanium cages inserted into both atlantoaxial joints and anterior atlantoaxial fixation with a plate screw construct is a safer and easier option in many cases of BI. MethodsFrom February 2014 to February 2019, 52 patients (age range, 15–78 years; 40 males and 12 females) with symptomatic BI with atlantoaxial dislocation and minimal sagittal facetal inclination and only mild Chiari malformation without syringomyelia were offered anterior submandibular retropharyngeal atlantoaxial distraction and fixation surgery. ResultsNeurological improvement occurred in 80% of patients, while the neurological status of 20% remained unchanged. No patients worsened, and no major complications or mortality was observed. ConclusionIn properly selected cases of symptomatic BI, anterior wedge cage distraction with anterior atlantoaxial fixation is a safe and simple option.

P71. Biomechanical Evaluation of a Novel Anterior Atlanto-Axial Fixation Construct

BACKGROUND CONTEXT: Atlanto-axial fixation is a necessary treatment modality in a variety of pathologies, including cervical trauma, degenerative disease and neoplasm. Several posterior fixation techniques are currently in practice, including fixation of the C1 lateral masses to the C2 pars, pedicles or lamina. Simple interspinous wiring is also an option. Anterior atlanto-axial fixation may be associated with less risk to the neurovascular structures in the upper cervical spine, particularly the vertebral arteries.